Step 2 CK

Contraindications to pulmonary surgery

FEV1 or DLC <40% (unable to do surgery due to high risk of postop lung failure --> if both are within the 30-60% range, perform exercise stress test to assess functional status)

Cause of achondroplasia

FGFR3 mutation (achondroplasia: caused by autosomal dominant/sporadic mutation in fibroblast growth factor receptor 3, which inhibits chondrocyte proliferation in long bones --> presents with shortening of extremities relative to trunk, genu varum, frontal bossing, macrocephaly, and midface hypoplasia)

Best next step in management for woman <40yo with primary ovarian insufficiency

FMR1 genetic mutation testing (due to strong association between fragile X premutation carriers and premature ovarian failure)

Best next step in management for young woman <30yo with painful cystic breast mass

FNA (fine-needle aspiration: performed for pain relief and determination of further management --> if bloody aspirate OR persistent palpable breast mass, pt requires core needle biopsy --> if nonbloody aspirate AND resolution of breast mass, repeat breast US in 4-6wks)

Triphasic abdominal CT: well-circumscribed 5cm liver lesion with central scar that appears hypodense on noncontrast imaging, but hyperdense with contrast

FNH (focal nodular hyperplasia: asymptomatic, benign regenerative liver nodule common in WOMEN AGE 20-50yo --> presents with small <5cm, well-circumscribed, solitary, liver lesion with central stellate scar that surrounds large congenital arterial anomaly that sends branches to periphery --> diagnosis: triphasic helical CT scan reveals hypodense lesion WITHOUT contrast but hyperdense lesion wITH contrast and central scar)

Renal biopsy: localized areas of mesangial sclerosis and basement membrane collapse

FSGS (focal segmental glomerulosclerosis)

What are the treponemal tests for syphilis?

FTA-ABS and TP-EIA (treponemal tests: detects antibody to treponemal antigens and provides QUALITATIVE data with reactive/nonreactive result --> used for diagnostic confirmation of syphilis --> HIGHER SENSITIVITY in early infection, but positive even after treatment)

Signs of GERD for an infant <1yo

FTT and Sandifer syndrome (FTT: poor wt gain, drop in growth percentiles, etc. --> Sandifer syndrome: intermittent opisthotonic posturing aka episodes of torticollis + abnormal arching of back, usually after meals)

Which network allows the spread of infection from face/sinuses/teeth to cause cavernous sinus thrombosis?

Facial venous system (since veins are VALVELESS, infection can spread contiguously from face to cavernous sinus)

Which coagulator factor is not exclusively synthesized by liver?

Factor 8 (therefore in liver disease, all factors will be decreased EXCEPT factor 8)

Indications for endometrial biopsy in woman <45yo with AUB

Failed COCP trial, obesity, PCOS, and Lynch syndrome (all of these indicate high risk for endometrial hyperplasia/cancer so need to rule out)

Indications for psychodynamic psychotherapy

High functioning personality disorders (psychodynamic psychotherapy: builds insight into unconscious conflicts and past relationships, uses transference, and breaks down maladaptive defenses)

Treatment for body dysmorphic disorder (BDD)

High-dose SSRI and CBT

Indication for whole blood transfusion

Severe hemorrhage (ex: major trauma --> whole blood includes pRBCs + plasma + clotting factors + O2-carrying capacity and used for patients requiring massive blood transfusions requiring volume expansion)

Which skin conditions are associated with HIV infection?

Severe psoriasis, severe seborrheic dermatitis, recurrent HSV, and molluscum contagiosum

Indication for hypertonic saline (3% saline)

Severe symptomatic hyponatremia (ACUTE hyponatremia <48hrs: give hypertonic saline to pts with serum Na+ <130 with any signs of elevated ICP such as HA, nausea, confusion, lethargy, and papilledema --> CHRONIC hyponatremia >48hrs: give hypertonic saline to pts with serum Na+ <120, seizures/coma/respiratory arrest, or concurrent intracranial pathology)

5-month-old girl presents with unresponsiveness, cyanosis, and flaccid paralysis Vitals: afebrile, SBP 45, HR 160, RR 5 PE: bilateral retinal hemorrhages CT head: bilateral cerebral edema and acute interhemispheric subdural hemorrhage

Shaken baby syndrome (form of child abuse in which baby is violently shaken, resulting in acceleration-deceleration head injury causing shearing of bridging veins and subdural bleeding, as well as coup-contrecoup injury as brain impacts skull --> presents with seizures, increasing head circumference, bulging/tense anterior fontanelle, and altered mental status --> diagnosis: fundoscopic exam shows bilateral retinal hemorrhages due to vitreoretinal traction --> management: hospitalization, CT head, skeletal survey, and contacting CPS)

Best next step in management of asymptomatic patient with elevated AlkPhos and positive AMA

UDCA (ursodeoxycholic acid: hydrophilic bile acid that decreases biliary injury from hydrophobic bile acids and increases biliary secretion --> delays histologic progression of PBC and improves survival)

Cause of sudden cardiac death in patients with prior MI and LV EF <30%

Ventricular arrhythmia (usually ventricular tachycardia degenerating to VFib --> prevent with placement of ICD)

Which post-MI complications occur within 24hrs of MI?

Ventricular arrhythmia, HF, cardiogenic shock, and reinfarction (usually occur within 24hrs of MI)

Diagnostic para: - Color: bloody - High protein - Low SAAG

TB ascites

Causes of low-SAAG ascites (<1.1g/dL)

TB, peritoneal carcinomatosis, chronic pancreatitis, and nephrotic syndrome (low SAAG/serum-ascites albumin gradient: indicates ABSENCE of portal HTN)

Which infections require airborne precautions?

TB, varicella, SARS, and measles (require airborne precautions because aerosolized particles >5 microns so stay suspended in air for prolonged periods of time)

Parkland formula

TBSA% x bodywt x 4mL (total fluid resuscitation for burn patients initially --> give 50% in first 8hrs, then other 50% in next 16hrs)

Treatment of alopecia areata

Topical or intralesional triamcinolone (steroid use to prevent autoimmune attack on hair bulb cells)

Treatment of scabies

Topical permethrin or oral ivermectin

Definition of status epilepticus

Seizure lasting >5mins or cluster of seizures without recovery in between

Indications for operative vaginal delivery

2nd stage arrest, maternal exhaustion, fetal distress, and contraindications to Valsalva (ex: HOCM, aortic stenosis, recent MI, glaucoma, and retinopathy)

Recommended folic acid intake for average-risk patients

0.4mg daily

Formula for 95% CI of mean

1.96*SE +/- mean (use to calculate 95% CI of mean --> 99% CI of mean = 2.58*SE +/- mean --> calculate SE = SD/sqrt of N)

Treatment of acute cluster headache

100% O2 or SQ sumatriptan (most common methods to abort active cluster headache --> prophylaxis for cluster headaches: verapamil or lithium)

Initial management of DKA

10ml/kg NS bolus over 1hr, regular insulin drip, and potassium (fluids: add D5W when serum glucose <200 --> insulin: switch to basal-bolus SQ insulin when pt can eat, glucose <200, anion gap <12, and serum HCO3 >15 --> potassium: give IV potassium if serum K+ <5.3 --> others: give IV bicarb for pH <6.9, and give IV phosphate for serum phos <1 + cardiac dysfunction + respiratory depression)

Ideal weight gain during pregnancy when BMI >30 (obese)

11-20lbs

When do children normally begin to walk?

12-15mo (if child cannot walk by 15mo, should be evaluated)

How long after last drink can alcohol withdrawal seizures + hallucinosis typically present?

12-48hrs since last drink

Ideal weight gain during pregnancy when BMI 25-29.9 (overweight)

15-25lbs

Normal CSF volume

150mL

When does initial maternal awareness of fetal movement typically occur?

16-20wks (and then monitoring of kick counts begins in 3rd trimester at 28wks)

Screening test for GDM (completed at 24-28wks)

1hr 50g GCT (1hr 50g glucose challenge test: patient drinks 50g glucose and BG checked 1hr later --> if positive >140, proceed with 3hr 100g GTT)

Most accurate method of determining gestational age

1st trimester US with crown-rump length (most accurate between 7-14wks gestation with +/- 3 to 5 days of variability, and used if LMP varies with 1st trimester US by >7 days --> in 2nd trimester, can use fetal abdominal circumference + biparietal diameter + femur length + head circumference to estimate gestational age but accuracy varies from +/- 1 to 2wks)

Management of esophageal variceal bleeding

2 large-bore IV catheters and fluid resuscitation, IV octreotide, IV ceftriaxone, and urgent endoscopy (if bleeding stops spontaneously, start beta-blockers and schedule endoscopic band ligation 1-2wks later --> if continued bleeding, put temporary balloon tamponade and proceed to TIPS/shunt surgery --> if early rebleeding, repeat endoscopy)

Indications for pediatric VCUG

2+ febrile UTIs, abnormal renal US, fever >102 with atypical bacteria, and signs of CKD

Diagnosis of dysthymia (persistent depressive disorder)

2+ years of chronic depressed moods (requires 2+ sx of SIGECAPS --> if 5+ sx, then dx with MDD)

How long after last drink can delirium tremens present?

2-4 days since last drink

Normal pupillary size

2-4mm in bright light

At what point in pregnancy can you diagnose gestational HTN and pre-eclampsia?

20wks (these must be diagnosed at the end of 2nd trimester)

When should you screen pregnant women for gestational diabetes mellitus?

24-28wks (screening test: 1hr 50g GCT/glucose challenge test and checking serum glucose 1hr late, positive if >140 --> diagnostic test: 3hr 100g GTT/glucose tolerance test and measuring glucose at 1, 2, and 3hrs afterwards and positive if 2+ values are elevated --> cutoffs: fasting glucose >95, 1hr glucose >180, 2hr glucose >155, and 3hr glucose >140)

Diagnosis of polyuria

24hr UOP >3L

Ideal weight gain during pregnancy when BMI 18.5-24.9 (normal)

25-35lbs

When should Rh-negative women receive Rhogam during pregnancy?

28-32wks and delivery (other indications: <72hrs after spontaneous abortion, threatened abortion, ectopic pregnancy, hydatidiform mole, chorionic villous sampling, amniocentesis, abdominal trauma, 2nd and 3rd trimester bleeding, and external cephalic version)

When does maternal monitoring of fetal movements (kick counts) usually occur?

28wks (at beginning of 3rd trimester --> normal FM is >10 movements in 2hrs)

Management for symptomatic ureteral stone <10mm

2L/day of fluids, straining urine, tamsulosin, and pain control

1st line treatment of acute psychosis

2nd gen antipsychotic (includes risperidone, aripiprazole, quetiapine, olanzapine, and ziprasidone --> can also try haloperidol --> give adjunctive benzos for agitation)

Indications for tympanocentesis and culture

3+ AOMs in 6mo or >3mo middle ear effusion with hearing loss

At how many weeks should a patient with PPROM be delievered?

34 weeks (if PPROM occurs <32wks, give betamethasone + magnesium + latency abx ampicillin and azithromycin --> if PPROM occurs 32-34wks, give betamethasone + latency antibiotics --> then delivery at 34wks when risk of complications outweights neonatal benefit of continuing pregnancy)

Diagnostic test for GDM (performed if 1hr 50g GCT >140 at 24-28wks)

3hr 100g GTT (3hr 100g glucose tolerance test: pt does overnight fast, drinks 100g glucose, and BG checked every hour --> positive if 2+ values are elevated: fasting BG >95, 1hr BG >180, 2hr BG >155, or 3hr BG >140)

1st line treatment of pediatric UTI

3rd gen cephalosporin (includes ceftriaxone, cefotaxime, cefpodoxime, and ceftaxidime --> covers serious gram-negative infections such as E coli)

How much should HCO3- rise/fall for every 10mmHg change in PaCO2 during metabolic compensation?

4 mEq/L (for respiratory acidosis: every 10 increase in PaCO2, should cause 4 increase in HCO3 --> for respiratory alkalosis: for every 10 decrease in PaCO2, should cause 4 decrease in HCO3)

Adequate antidepressant trial

4-6wks at therapeutic dose

Recommended folic acid intake for high-risk patients (prior pregnancy with NTD or on anticonvulsants)

4mg daily

Reversible causes of asystole/PEA

5 Hs and 5 Ts (5 Hs: hypovolemia, hypoxia, hydrogen ions aka acidosis, hypo- or hyperkalemia, and hypothermia --> 5 Ts: tension PTX, tamponade, toxins aka nacrotics/benzos, thrombosis from PE or STEMI, and trauma)

Causes of postop fever

5 Ws (wind/lungs: PE, pneumonia, or aspiration --> wound: surgical site infection from GAS/C. perfringes in <1mo postop --> water: UTI --> walk: DVT --> wonder drugs/products: drug fever, blood products, or central line infection)

Ideal time to examine breast

5-10 days after menses (aka while woman is in FOLLICULAR phase when there is minimal hormonal stimulation)

Normal ICP

5-15 (should be concerned when ICP >20)

12yo girl presents with 1-yr hx of progressive facial hair growth + acne and growth of 4in in last 4mo PE: breast at Tanner stage 1, pubic hair at tanner stage 3, dark hair over upper lip + cheeks + chin, acne vulgaris over cheeks, and 2cm vaginal canal with significant clitoromegaly + posterior labioscrotal fusion + no cervix/palpable uterus Abdominal US: bilateral gonads without follicles

5-alpha-reductase deficiency (autosomal recessive condition in 46XY MALES that causes inability to convert testosterone to DHT, resulting in prepubertal external ambiguous features until puberty when increased testosterone induces masculinization and growth of external genitalia --> presents with PHENOTYPICALLY female external genitalia at birth/prepuberty and then virilization at puberty with male-pattern facial/body hair, acne, clitoromegaly, labioscrotal fusion, and MALE INTERNAL GENITALIA --> labs: normal estrogen, testosterone, and LH --> diagnosis: abdominopelvic US shows no cervix/uterus and bilateral male gonads)

Normal daily CSF production

500mL

When should you introduce pureed foods to an infant's diet?

6 months (infants should be exclusively breastfed until age 6mo --> then introduce pureed fruits + veggies --> then introduce pureed proteins)

What percentage of values falls within 1 SD from mean?

68%

Appropriate tidal volume for a ventilated patient

6mL/kg of ideal body wt (ex: if pt weights 70kg, they should receive ~420mL tidal volume)

What is the maximum amount of weight that a newborn should lose in first 5 days of life?

7% of birth weight

Maximum rate of correction of hyponatremia

8 mEq/L in 24hrs (if exceeding this limit, risk of osmotic demyelination syndrome aka massive axonal demyelination in pontine white matter due to rapid osmotic changes --> "from low to high, your pons will die")

Up to how long will a postpartum patient present with lochia?

8 weeks (for postpartum patients, normal to have dark red/brown vaginal discharge for up to 8wks)

Normal CVP (central venous pressure)

8-12

What percentage of values falls within 2 SDs from mean?

95%

What percentage of values falls within 3 SDs from mean?

99.7%

Normal A-a gradient

<15 (patients with normal A-a gradient but low PaO2 caused by reduced FiO2 in high altitude or hypoventilation --> patients with elevated A-a gradient and low PaO2 indicate V/Q mismatch, diffusion limitation, or right-to-left shunt)

Definition of oliguria

<250mL urine in 12hrs

Normal urine albumin/creatinine ratio

<30 (therefore pts with T2DM with urine albumin/Cr ratio >30 AND hypertension should be started on ACE inhibitor to reduce progression of diabetic nephropathy)

Indications for oseltamivir therapy for influenza

<48hr of symptom onset, age >65, chronic medical problems, and pregnancy

Physiologic neonatal weight loss

<7% of birth wt in first 5 days (normal wt loss during neonatal period due to excretion of excess fluid acquired in utero and during labor --> neonates with >7% of wt loss of other signs of dehydration such as decreased wt diapers, absence of tears, sunken fontanelle, dry mucous membranes, decreased skin turgor, and delayed cap refill should be assessed for oromotor dysfunction + lactation failure and have daily wts)

Which Glasgow Coma Scale score indicates coma?

<8 (think "less than 8, may be too late")

Normal fetal movement in 3rd trimester (>28wks)

>10 movements in 2hrs

Cutoff for positive PPD induration size in healthy asymptomatic individuals with no history of TB exposure

>15mm (therefore any healthy person with <15mm induration after PPD is considered NEGATIVE for TB)

Treatment of postpartum endometritis

Clindamycin and gentamicin (provides coverage of mixed aerobes + anaerobes due to polymicrobial infection)

Diagnosis of manic episode

>1wk of elevated mood and 3+ sx of DIGFAST (D: distractibility --> I: impulsivity --> G: grandiosity --> F: flight of ideas/racing thoughts --> A: activity increase/psychomotor agitation --> S: sleep need decreased --> T: talkativeness/pressured speech)

Diagnosis of Tourette syndrome

>1yr of multiple motor and vocal tics (motor tics: include facial grimacing, blinking, head/neck jerking, shoulder shrugging, tongue protrusion, and sniffing --> vocal tics: includes grunting, snorting, throat clearing, barking, yelling, and coprolalia aka yelling obscenities --> treatment of Tourette syndrome: habit reversal training, tetrabenazine, haloperidol, fluphenazine, and guanfacine)

Definition of major burns

>20% total body surface area (major burns: should receive aggressive fluid resuscitation based on Parkland formula, then titrated to maintain adequate urine output >0.5mL/kg/hr)

Diagnosis of adequate contractions

>200 MVUs over 10mins

Diagnosis of prolonged PR interval

>200 msec (prolonged PR interval associated with AV block)

Size cutoff for solitary pulmonary nodule requiring biopsy/excision

>2cm (any pulm nodule >2cm requires surgical excision/biopsy due to 50% risk of malignancy --> other factors indicating malignancy include size >0.8cm with irregular borders, upper lobe location, spiculated appearance, elderly age, female sex, smoking history, and family hx of lung cancer)

Diagnosis of MDD

>2wks of depressed mood and 5+ sx of SIGECAPS (S: sleep issues --> I: interest loss --> G: guilt --> E: energy loss --> C: concentration problems --> A: appetite/weight changes --> P: psychomotor retardation or agitation --> S: suicidal ideation --> signs of atypical depression include increased appetite/wt gain, hypersomnia, leaden paralysis, mood reactivity, and hypersensitivity to rejection)

Diagnosis of hyperemesis gravidarium

>3 vomiting episodes/day with >5% wt loss and urinary ketones

Diagnosis of 2nd stage labor arrest (no further fetal descent)

>3hrs pushing in nulli, >2hrs pushing in mutli without epidural (or >4hrs pushing in nulli, >3hrs pushing in multi with epidural --> treatment: operative vaginal delivery --> complications: postpartum hemorrhage)

Diagnosis of prolonged QT interval

>460 msec

Diagnosis of uterine tachysystole

>5 contractions in 10mins (associated with fetal late decels due to transient decrease in placental perfusion during contractions and inadequate recovery time between contractions)

Indications for elective CABG

>50% stenosis of LCA, >70% stenosis in other coronary arteries, stenosis of proximal LAD and one other artery, stenosis of 3 coronary arteries, or mechanical obstruction

Diagnosis of high myopia

>6 diopters of correction (high myopia/nearsightedness: leads to stretching/thinning of sclera + choroid + retina --> increased risk of retinal detachment and macular degeneration)

Definition of massive hemoptysis

>600mL of expectorated blood for 24hrs, or bleeding rate >100mL/hr

Diagnosis of schizophrenia

>6mo of delusions, hallucinations, disorganized speech, disorganized behavior, and negative symptoms (neg sx include apathy and flat affect)

Indications for carotid endarterectomy

>70% carotid stenosis with TIA/stroke within 6mo (or in asymptomatic pts with >80% carotid artery stenosis)

Which etiology is associated with bronchiectasis of the lower lobes?

A1AT deficiency

Diagnosis of A1AT deficiency

A1AT level and liver biopsy (A1AT level: should be LOW --> liver biopsy: shows hepatocytes containing PAS-positive and diastase-resistant granules)

Diagnosis of occlusive peripheral artery disease (PAD)

ABI <0.9

32F with PMHx of asthma presents with 3-mo hx of progressive cough and 1-mo hx of productive cough thick yellow sputum tinged with blood and SOB Vitals: afebrile, BP 110/65, HR 88, RR 17, SaO2 93% on RA PE: mild respiratory distress and scattered end-expiratory wheezes b/l with coarse rhonchi at lung bases Labs: elevated eosinophils and IgE CXR: linear atelectasis at lung bases, thickened airways, and irregular cystic opacities primarily in central distribution

ABPA (allergic bronchopulmonary aspergillosis: hypersensitivity response to Aspergillus growing in lung mucus, especially in patients with ASTHMA and CYSTIC FIBROSIS --> presents with productive daily cough with occasional hemoptysis --> labs: eosinophilia, and elevated serum IgE --> diagnosis: CXR shows linear atelectasis aka bronchiectasis and cystic opacities due to mucus plugging, positive sputum culture, and positive anti-Aspergillus skin test --> treatment: oral steroids and itraconazole)

Which medications are associated with drug-induced lichen planus?

ACE inhibitors, thiazide diuretics, beta-blockers, and hydroxychloroquine (causes more diffuse presentation of LP --> treat with topical betamethasone +/- tacrolimus)

Which anti-HTN medications should be avoided in cirrhosis?

ACEIs and ARBs (block the RAAS, which is critical for BP normalization and renal perfusion in patients with liver cirrhosis --> causes organ hypoperfusion and AKI)

Which medications have been shown to reduce mortality in patients with HFrEF (systolic CHF)?

ACEIs, ARBs, beta-blockers, aldosterone antagonists, and hydralazine plus nitrates (ACEIs and ARBs: decrease heart remodeling --> beta-blockers: usually bisoprolol + carvedilol + metoprolol succinate that reduce myocardial O2 demand by decreasing HR and myocardial contractility --> aldosterone antagonists: include spironolactone, eplerenone, amiloride, and triamterene --> hydralazine plus nitrates aka BiDil: reduce mortality only in African-American patients)

Which medications improve long-term survival in patients with CHF with LV systolic dysfunction?

ACEIs, ARBs, beta-blockers, spironolactone, and eplerenone

Most common locations of berry aneurysms

AComm > PComm > MCA > verteberobasilar system

Most common locations of ruptured berry aneurysms

AComm and PComm (AComm RBA: compresses optic chiasm and presents with bitemporal hemianopia --> PComm RBA: compresses CN3 and presents with ipsilateral ptosis and fixed dilated "down and out" eye)

Indications for emergent hemodialysis

AEIOU (acidosis, electrolyte imbalance aka hyperkalemia, intoxication with ethylene glycol, overload of fluid, and uremia)

Diagnosis of acute liver failure (ALF)

AST and ALT >1000, hepatic encephalopathy, and INR >1.5 (causes of acute liver failure: acute viral hepatitis, acetaminophen toxicity, ischemia, autoimmune hepatitis, and Wilson disease --> NOTE: acute liver failure in Wilson disease associated with very low AlkPhos)

42M with PMHx of stable angina dx 6mo ago presents with 2wk hx of persistent nasal blockage, periodic difficulty breathing, and wheezing Meds: ASA, diltiazem, atorvastatin, and albuterol

AERD (aspirin-exacerbated respiratory disease: pseudoallergic reaction to NSAIDs caused by COX1/2 inhibition, resulting in arachidonic acid pathway shifting to increased LT production via 5-lipoxygenase pathway --> risk factors: asthma, chronic rhinosinusitis with nasal polypsosis, or chronic urticaria --> treatment: management of asthma + chronic rhinosinusitis and avoidance of NSAIDs, zileuton, and montelukast)

Diagnosis of oligohydramnios

AFI <5cm (causes of oligohydramnios: pre-eclampsia, abruptio placentae, uteroplacental insufficiency, renal anomalies, and NSAIDs --> complications: meconium aspiration, preterm delivery, and umbilical cord compression)

Diagnosis of polyhydramnios

AFI >24cm (causes of polyhydramnios: GDM, esophageal/duodenal atresia, anencephaly, multiple gestation, and congenital infection --> complications: fetal malposition, umbilical cord prolapse, preterm labor, and PPROM)

Which tumor marker is associated with HCC?

AFP (glycoprotein produced by fetal liver and yolk sac --> elevated in 50% of cases with HCC)

50F POD#0 s/p TAH and tumor debulking for metastatic ovarian cancer c/b ureteral laceration repaired intraop and 1u pRBC transfusion 10mins presents with sudden onset severe nausea, R flank pain, and pain + oozing along IV site Vitals: febrile 101.3F, BP 90/50, HR 130, RR 26 PE: tachycardia with weak pulses and dark red urine

AHTR (acute hemolytic transfusion reaction: rare but potentially fatal reaction due to transfusion of mismatched blood with ABO incompatibility, causing massive RBC destruction and intravascular hemolysis leading to toxic Hgb buildup in kidney and ATN with renal failure --> presents within mins-hrs after transfusion with fevers, chills, hypotension, flank pain, dark red urine 2/2 hemoglobinuria, and DIC --> diagnosis: high LDH, low haptoglobin, high indirect bili, and POSITIVE direct Coombs test --> treatment: aggressive IV fluids and supportive care)

5yo boy presents with 3wk hx of fatigue, fever, URI, poor appetite, and weight loss Vitals: febrile 103F, BP 100/70, HR 140 PE: pale conjunctivae and multiple petechiae, enlarged nontender palpable LNs in cervical + axillary + inguinal regions, splenomegaly, and tenderness with palpation to middle of bilateral thighs Labs: pancytopenia

ALL (acute lymphoblastic leukemia: most common childhood cancer with peak incidence at age 2-5yo characterized by unregulated bone marrow proliferation of LYMPHOBLASTS --> presents with fever, fatigue, wt loss, pallor and petechiae, bone pain, diffuse LAD, and hepatosplenomegaly --> labs: pancytopenia --> diagnosis: bone marrow biopsy shows >25% lymphoblasts, eval for TdT+ and CD10+ --> treatment: multidrug chemo --> note: t12;21 mutation indicates better prognosis)

47M presents with 6-mo hx of progressive weakness that began in right leg and gradually spread to other extremities, as well as difficulty swallowing solids + liquids PE: atrophy of R quadriceps and deltoid muscles b/l, fasciculations in quadriceps b/l, and Babinski sign b/l

ALS (amyotrophic lateral sclerosis/Lou Gehrig disease: combined UMN + LMN degeneration WITHOUT bowel/bladder deficits, resulting in pseudobulbar palsy and anterior horn damage --> presents with asymmetric limb weakness, fasciculations, atrophy, dysarthria, dysphagia, emotional lability, spastic gait, and exaggerated DTRs --> diagnosis: EMG shows fibrillation potentials in multiple muscles of multiple extremities --> treatment: riluzole, a glutamate inhibitor)

EMG: fibrillation potentials in multiple muscles of multiple extremities

ALS (amyotrophic lateral sclerosis/Lou Gehrig disease: combined UMN + LMN degeneration WITHOUT bowel/bladder deficits, resulting in pseudobulbar palsy and anterior horn damage --> presents with asymmetric limb weakness, fasciculations, atrophy, dysarthria, dysphagia, emotional lability, spastic gait, and exaggerated DTRs --> diagnosis: EMG shows fibrillations + fasciculations + chronic partial denervation --> treatment: riluzole, a glutamate inhibitor)

Diagnosis of PAI (primary adrenal insufficiency)

AM cortisol, plasma ACTH, and ACTH stimulation tests (should all be done at the SAME TIME to rapidly confirm diagnosis --> PAI: low AM cortisol + high ACTH + minimal response to cosyntropin --> central adrenal insufficiency: low AM cortisol + low ACTH + minimal or suboptimal response to cosyntropin --> normal response to cosyntropin will RULE OUT PAI)

Risk factors for amniotic fluid embolism

AMA, gravida >5, C-section, instrument delivery, placental previa, placental abruption, and pre-eclampsia (amniotic fluid embolism: entry of amniotic fluid into maternal circulation via endocervical veins/placental insertion site/areas of uterine trauma that causes massive inflammatory response and vasospasms --> presents with hypoxemic respiratory failure, cardiogenic shock, DIC, seizures, and coma --> treatment: intubation, pressors, and blood transfusion)

Which statistical test is used to compare 3+ means?

ANOVA (analysis of variance)

Which 3 views are recommended for workup of C-spine injury?

AP, lateral, and odontoid (aka anteroposterior, lateral, and open-mouth)

Calculating attributable risk perfect (ARP)

ARP = (RR - 1)/RR

73F with PMHx of hypothyroidism and knee OA presents with 1-year hx of dry eyes with sensation of dust/sand in eyes, and difficulty reading small-print books PE: dry mucosa with mild dental caries, normal eye exam Labs: normal, negative ANA

ARSS (age-related sicca syndrome/age-related dry eye syndrome: caused by age-related atrophy/fibrosis/ductal dilation of lacrimal + salivary glands, causing decreased exocrine output --> also associated with age-related decreased blink rates, oxidative damage, excessive evaporation of tears 2/2 meibomian dysfunction, and use of anticholinergic meds --> risk factors: ELDERLY FEMALE, thyroid disorder, and diabetes --> presents with dry eyes, ocular discomfort, impaired vision, dry mouth, and NEGATIVE ANA --> treatment: artificial tears or cyclosporine drops)

Initial stabilization of acute STEMI

ASA, clopidogrel, sublingual nitrate, metoprolol, statin, and anticoagulation (if pt presents with persistent pain/HTN/CHF and not hypotensive, give IV nitroglycerin --> if persistent severe pain, give IV morphine --> if unstable bradycardia, give IV atropine --> if flash pulmonary edema, give IV furosemide)

2nd line management of menopausal symptoms for women who fail paroxetine

Clonidine or gabapentin (well-tolerated but associated with side effects such as hypotension and headache/dizzinesss)

Patient with recent cardiac catheterization presents with mild swelling in right inguinal area with palpable thrill and continuous bruit

AV fistula (arteriovenous fistula: abnormal connection between artery and vein caused by accidental femoral vein puncture + inadequate femoral artery hemostasis, allowing bleeding from arterial puncture site to track into venous puncture site --> presents with localized inguinal swelling and tenderness, palpable thrill, CONTINUOUS bruit, and diminished distal pulses --> complication: high-output cardiac failure, higher risk with LARGER AVF)

64M with PMHx of arteriography thru right groin for eval of left calf claudication 3wks ago presents with palpable thrill and continuous machinery murmur at arteriography site PE: decreased pedal pulses on right Arteriogram: common femoral vein dilation

AV fistula (arteriovenous fistula: abnormal connection between artery and vein, sometimes caused iatrogenically from femoral catheterization with accidental femoral vein puncture + inadequate hemostasis leading to persistent bleeding from arterial puncture site to track into venous puncture site creating AVF --> presents with mild swelling/localized tenderness at site of entry, continuous bruit with palpable thrill, diminished distal pulses, and limb edema/ischemia --> diagnosis: duplex US/arteriogram shows AV fistula and femoral vein dilatation --> treatment: observation, US-guided compression, or surgical repair --> complication: high-output cardiac failure due to decreased arterial SVR and increased venous return/preload, with HIGHER RISK correlating to LARGER AVF)

25F presents with occasional episodes of acute onset fast regular heartbeats that feels like her "heart is racing in her chest," not related to any triggers. Cold water-immersion relieves her symptoms abruptly within several mins. Vitals during episode: BP 100/60, HR 185 and regular

AVNRT (AV nodal re-entrant tachycardia: most common form of PSVT caused by presence of BOTH slow and fast conduction pathways in AV node, with reentry mechanism occurring when atrial premature beat occurs when fast pathway in ERP but slow pathway is not, resulting in slow and fast pathways forming looped circuit --> presents in YOUNG ADULTS with episodes of palpitations, dizziness, SOB, or chest pain that are relieved with vagal maneuvers such as carotid sinus massage + cold-water immersion + Valsava + eyeball pressure which slow AV node conduction)

Which antiviral medication is contraindicated in patients with HLA-B5701 mutation?

Abacavir (NRTI: high risk of fatal SJS/TEN in patients with HLA-B5701 mutation --> other side effects: bone marrow suppression, peripheral neuropathy, and lactic acidosis)

Best next step in management for child/pregnant women with suspected appendicitis

Abdominal US (if non-diagnostic, obtain abdominal MRI)

Best imaging modalities to diagnose ureteral stone

Abdominal US and non-con spiral CT (abdominal US: preferred for pregnant pts and pts with low likelihood of alternate diagnoesis --> non-con spiral CT: used if potential alternative diagnosis or small stone)

Common causes of paralytic ileus

Abdominal surgery, retroperitoneal hemorrhage, pancreatitis, intestinal ischemia, hypokalemia, sepsis, and opiates

Cause of phase 1b ventricular arrhythmias during MI

Abnormal automaticity (phase 1b delayed ventricular arrhythmias: occurs 10-60mins after coronary occlusion --> due to abnormal automaticity)

46yo M presents on 5th day of ICU stay (admitted after major MVC) with diminished bowel sounds and facial grimacing with palpation of RUQ PE: NG tube shows retention of gastric contents Abdominal CT: gaseous distension of small and large bowels without air-fluid levels, distended gallbladder without gallstones, and small amount of pericholecystic fluid

Acalculous cholecystitis (occurs in ICU patients with multiorgan failure, severe trauma, surgery, burns, sepsis, or prolonged parenteral nutrition that results in cholestasis and gallbladder ischemia, leading to 2° infection by enteric organisms and eventual edema + necrosis of gallbladder --> presents with diminished bowel sounds, RUQ pain, and gastric retention --> imaging: gallbladder wall thickening + distension and presence of pericholecystic fluid --> treatment: antibiotics + percutaneous cholecystostomy with eventual cholecystectomy + abscess drainage)

Treatment of alcohol use disorder

Acamprosate and naltrexone (acamprosate: metabotropic glutamate receptor used as 1st line for AUD and safe for liver disease --> naltrexone: mu-opioid receptor antagonist but CONTRAINDICATED in pts with liver disease and those on prescribed opioid meds)

1st line treatment of IIH (idiopathic intracranial hypertension)

Acetazolamide (inhibits choroid plexus CA to decrease CSF production --> can add furosemide for pts with continued symptoms --> 2nd line tx for refractory pts/progressive vision loss includes optic nerve sheath decompression or lumoperitoneal shunting, use steroids or serial LPs as bridging therapy)

Prophylaxis for acute otitis externa

Acetic acid ear drops

Endoscopy: dilated esophagus and thickened LES muscle

Achalasia (failure of LES relaxation due loss of postganglionic inhibitory neurons containing NO + VIP, leading to to loss of myenteric plexus --> causes: idiopathic or 2° to Chagas disease/tumors compressing esophagus --> presents with progressive dysphagia to solids and liquids --> diagnosis: barium swallow shows dilated esophagus with distal stenosis aka "bird's beak," and manometry shows uncoordinated or absent peristalsis with high LES resting pressure)

52F presents with 1-year hx of progressive difficulty swallowing, intermittent vomiting of undigested food, and cough more severe night and 6-mo hx of 17lb wt loss Vitals and PE: normal CXR: air-fluid level in posterior mediastinum at level of cardiac silhouette Esophageal manometry: normal LE sphincter pressure and absent LES relaxation with swallowing

Achalasia (impaired peristalsis of distal esophagus and impaired relaxation of LES, preventing food/liquid from passing thru LES until hydrostatic pressure in esophageal column > closing pressure of sphincter --> presents with chronic dysphagia to both solids + liquids that improves in upright position, regurgitation, difficulty belching, heartburn, and mild wt loss --> diagnosis: manometry shows increased LES resting pressure + incomplete LES relaxation + decreased peristalsis of distal esophagus, barium swallow shows smooth "bird beak" narrowing at GE junction, and upper endoscopy rules out malignancy --> treatment: laparoscopic myotomy or pneumatic balloon dilation, botulinum injection, nitrates, and CCB)

Posterior heel pain on passive dorsiflexion of ankle

Achilles tendinopathy (presents with thickened Achilles tendon and posterior heel pain)

Which diseases are autosomal dominant?

Achondroplasia, ADPKD, Charcot-Marie-Tooth disease, FAP, HHT, hereditary spherocytosis, HOCM, Huntington, Marfan, MEN, myotonic MD, NF1, NF2, osteogenesis imperfecta, otosclerosis, tuberous sclerosis, and VHL

72M with PMHx of HLD, MI, MVP, and stroke 3yrs ago presents with 4-mo hx of progressive hearing loss, ringing in right ear, and unsteadiness when walking PE: decreased movement and sensation to temp on right face, unsteady gait, Weber localization to left ear, and Rinne showing air > bone b/l

Acoustic neuroma (vestibular schwannoma: benign tumor of CN8 Schwann cells that forms in internal auditory canal, resulting in cochlear + vestibular nerve compression and eventually expanding into cerebellopontine angle causing CN5 and CN7 compression --> presents in MIDDLE-AGED ADULTS ~50yo with unilateral sensorineural hearing loss + imbalance, facial numbness, and facial weakness --> diagnosis: audiogram and MRI with contrast of internal auditory canal --> treatment: surgical resection or radiation)

56yo M with PMH of cirrhosis is undergoing endoscopy for esophageal varices when after anesthesia, patient's SaO2 via pulse ox drops to 85% and does not improve with supplemental O2 PE: bluish discoloration of lips and fingers Labs: PaO2 142mmHg, SaO2 99%

Acquired methemoglobinemia (oxidization of iron in Hb from Fe2+ to Fe3+, which cannot bind O2 but has increased affinity for cyanide --> causes: topical anesthetics such as benzocaine, dapsone, and nitrates --> presents with cyanosis, hypoxia, pulse ox SaO2 ~85%, and LARGE SaO2 GAP aka large diff between SaO2 via pulse ox versus SaO2 via ABG, and normal PaO2 --> note: cyanosis occurs when methemoglobin >10% of total Hgb, hypoxia when >20% of total Hgb, and altered mental status/seizures/respiratory depression when >50% of total Hgb --> treatment: methylene blue and vitamin C for G6PD deficiency)

Skin exam: dry scaly flat papules with erythematous base on hands

Actinic keratosis (solar keratosis: pre-malignant lesions that can develop into SCC --> presents with dry scaly flat white/brown papules or plaques with erythematous base on sun-exposed areas --> treatment: 5FU cream)

Treatment of TCA overdose

Activated charcoal and IV sodium bicarb (charcoal: used for gastric decontamination --> IV sodium bicarb: overcomes Na+ channel blockage to prevent arrhythmias)

Indications for cholecystectomy within 72h of admission

Acute cholecystitis, choledocolithiasis, and gallstone pancreatitis (known as "complicate gallstone disease": require early cholecystectomy within 72h of admission to reduce disease duration, duration of hospitalization, and mortality)

Indications for emergent cholecystectomy

Acute cholecystitis, gallstone pancreatitis, and choledocholithiasis

Painful GI bleed in patient recently admitted to ICU

Acute colonic ischemia (caused by hypoperfusion to watershed areas in left colon such as splenic flexure/rectosigmoid junction --> presents <24hrs after episode of hypotension with crampy left-sided abdominal pain and overt hematochezia --> diagnosis: CTA and colonoscopy)

18M presents with 3day hx of progressive left testicular "dull and achy" pain PE: left testicle lower in scrotum with swelling/tenderness in area posterior to left testis that improves with elevation UA: 4-5 WBCs/hpf

Acute epididymitis (acute infection of epididymis caused by chlamydia/gonorrhea travel from urethra thru ejaculatory duct to ductus deferens and epididymis --> presents with posterior testicular pain and swelling that improves with elevation of testes, aka Prehn sign --> diagnosis: urine culture/NAAT testing positive for N gonorrhoeae or C trachomatis --> treatment: ceftriaxone + doxycycline or levofloxacin)

16yo M presents with 2-day hx of dysuria, foul-smelling urethral discharge, and severe persistent scrotal pain PE: tender right hemiscrotum with erythema and edema and pain relief with elevation of testis

Acute epididymitis (inflammation of epididymis caused by Chlamydia or Gonorrhea and occurs in sexually active males --> presents with localized pain and tenderness over POSTERIOR testis with dysuria, urethral discharge, and positive Prehn sign aka pain relief with scrotal elevation --> complication: progression to epididymo-orchitis)

36yo F presents with progressive painful red streaks around large abrasion over right ankle after falling off bike 3d ago Vitals: febrile 100.8F PE: 4cm abrasion superior to right lateral malleolus, several tender erythematous streaks extending proximally from wound to knee, and tender enlarged LNs in right popliteal fossa

Acute infectious lymphangitis (spreading of infection from cutaneous wound to deep dermis and lymphatic channels --> causes: group A strep and MSSA --> presents with tender erythematous streaks in linear longitudinal band appearance extending from wound toward draining LNs, regional tender LAD, and systemic symptoms such as fever/tachycardia --> treatment: cephalexin)

28F presents with 2-day hx of progressive weakness of upper extremities and 1-day hx of severe, diffuse, poorly localized abdominal pain Vitals: afebrile, BP 148/86, HR 112 PE: restless and diaphoretic appearance, decreased bowel sounds, weakness of proximal UE, and loss of biceps + triceps reflexes b/l Labs: low Na+ UA: positive urobilinogen

Acute intermittent porphyria (autosomal dominant disorder of heme synthesis pathway that causes reduced activity of porphobilinogen deaminase, resulting in buildup of neurotoxic heme pathway intermediates such as PBG and ALA --> exacerbating factors: progesterone, phenobarbital, carbamazepine, rifampin, tobacco, alcohol, fasting, surgery, and illness --> presents with 5 Ps: painful abdomen, port-wine colored uine that darkens with light/air exposure, polyneuropathy in proximal UE, psych disturbances such as hallucinations + anxiety + psychosis, and problematic autonomics with tachycardia + diaphoresis + HTN --> labs: hyponatremia --> diagnosis: elevated urinary PBG + ALA + porphyrins --> treatment: glucose and hemin)

4yo M presents with 4hr hx of nausea, vomiting, diarrhea, and abdominal pain after father notices several pill bottles were open Vitals: afebrile, BP 76/38, HR 160, RR 34 PE: only responsive to painful stimuli, dry mucous membranes, weak peripheral pulses with delayed cap refill, and hematemesis Labs: anion gap metabolic acidosis and pre-renal AKI Abdominal XR: several small opacities in stomach and duodenum

Acute iron poisoning (unintentional ingestion of prenatal vitamins or concentrated ferrous sulfate tablets, causing direct mucosal damage to intestinal tract and leading to massive GI losses causing hypovolemic shock --> presents in CHILDREN AGE <6yo with abdominal pain, vomiting w/ hematemesis, and diarrhea w/ melena --> labs: anion gap metabolic acidosis and pre-renal azotemia --> imaging: small opacities in stomach and intestines --> diagnosis: elevated serum iron levels --> treatment: deferoxamine chelation and whole bowel irrigation)

63yo M with PMH of HTN, HLD, and smoking presents with severe left leg pain and numbness, as well as intermittent palpitations Vitals: BP 130/80, HR 116 and irregular PE: sparse hair on both legs, absent distal pulses on left and diminished on right, decreased sensation on dorsum of left foot/leg, and weak ankle dorsiflexion on left

Acute limb ischemia (ALI: occlusion of artery perfusing a limb caused by arterial thrombus from PAD plaque rupture, cardiac/arterial embolus from AFib/LV thrombus/endocarditis, or iatrogenic/blunt trauma --> presents with 6 Ps of acute limb ischemia: pain, pallor, paresthesia, pulselessness, poikilothermia aka cool extremity, and paralysis --> treatment: immediate IV heparin and percutaneous thrombolysis versus surgical thrombectomy)

68yo M with PMH of HTN, T2DM, HLD, and recent anterior MI undergoing cardiac rehab presents with acute onset of severe right leg pain during rest PE: right leg appears pale and cool to touch, non-palpable distal pulses, loss of sensation over dorsum of right foot, and mild weakness with right dorsiflexion

Acute limb ischemia (acute arterial occlusion of lower extremity caused by either cardiac/arterial embolism, thrombosis, or iatrogenic/direct blunt trauma to artery --> causes of cardiac emboli: LA thrombus from AFib, LV thrombus from anterior MI, or septic emboli from IE/prosthetic valves --> presents with 6 Ps: pain, pallor, paresthesias, pulselessness, poikilothermia/cool extremity, and paralysis --> treatment: immediate IV heparin BEFORE diagnostic imaging, may need percutaneous alteplase/surgical thombectomy if no improvement)

72yo M POD#3 s/p CABG presents with dyspnea and worsening retrosternal pain despite morphine analgesia Vitals: febrile 101.5F, BP 112/52, HR 125 and irregularly irregular, RR 28 PE: cloudy fluid in sternal wound drain ECG: AFib with RVR CXR: widening of mediastinum Echo: small amount of pericardial fluid Labs: low Hb, elevated WBC, elevated platelets, and elevated Cr

Acute mediastinitis (infection of mediastinum occurring in 5% of sternotomies --> presents POSTOP <14 days with fever, tachycardia, chest pain, sternal wound drainage or purulent discharge, and leukocytosis --> diagnosis: clinically + CXR showing widened mediastinum --> treatment: surgical debridement with immediate closure + prolonged antibiotics --> mortality: 10-50%)

67yo M with PMH of T2DM, HTN, HLD, PUD, and CAD s/p PCI for acute MI 4wks ago presents with 3hr hx of nausea, vomiting, and increasing abdominal pain Vitals: fever 100F, BP 150/90, HR 110 and irregular, RR 22 PE: decreased bowel sounds and diffuse abdominal tenderness but greater in RLQ Labs: low bicarb and increased amylase

Acute mesenteric ischemia (abrupt mesenteric artery occlusion caused by cardioembolic events from AFib/valvular disease/CV aneurysms/IE or acute thrombosis from PAD/low CO states --> presents with rapid onset of severe periumbilical pain and abdominal pain out of proportion to physical exam --> labs: hemoconcentration, leukocytosis, elevated amlyase + phosphate + lactate, and metabolic acidosis --> diagnosis: CTA/MRA --> treatment: open embolectomy with vascular bypass or endovascular thrombolysis)

Complications of retropharyngeal abscess

Acute necrotizing mediastinitis, IJ vein thrombosis, and CN9-12 deficits

60M with PMHx of hearing loss tx with hearing aids presents with 2-day hx of R ear swelling/itchiness/pain and drainage that causes aid to become clogged PE: swollen R ear canal with erythema and purulent drainage

Acute otitis externa (skin and soft tissue infection of external auditory canal/EAC usually caused by Pseudomonas --> risk factors: swimming/water exposure, trauma with cotton swabs/ear candling, hearing aids, headphones, eczema, and contact dermatitis --> presents with unilateral ear pain + pruritis + swelling with discharge, pain with auricle manipulation, erythema + edema + debris within EAC, and NORMAL TM --> treatment: topical ciprofloxacin +/- topical steroid)

Which post-MI complication occurs 1-3 days after MI?

Acute pericarditis (post-MI fibrinous pericarditis: caused by extensive coagulative necrosis and acute inflammation with neutrophils within tissue surrounding infarct --> presents with sharp chest pain improved by sitting up/leaning forward and pericardial friction rub --> diagnosis: ECG shows diffuse ST elevation and/or PR depression --> treatment: NSAIDs, colchicine, and steroids)

Skin exam: pruritic rash with maceration and peeling between the toes b/l

Acute tinea pedis (athlete's foot: fungal infection of foot caused by Trichophyton rubrum caused by exposure to public places such as athletic facilities and swimming pools --> presents with INTERDIGITAL pruritic rash with maceration and peeling +/- burning pain and erythematous vesicles/bullae --> diagnosis: KOH prep of skin scrapings --> treatment: topical azoles, terbinafine, or tolnaftate)

37F with PMHx of orthotopic liver transplant for liver failure 2/2 hepatitis B 12days ago now on tacrolimus + prednisone presents with fever of 101F Labs: eosinophilia, high AlkPhos, and high AST Liver biopsy: mononuclear infiltrate with significant # of eosinophils in hepatic triads

Acute transplant rejection (occurs weeks-months after transplant and characterized by type 4 hypersensitivity reaction in which recipient CD4 and CD8 T cells activated against donor MHCs resulting in vasculitis of graft vessels with dense interstitial lymphocytic cellular infiltrate --> usually asymptomatic or can present with scleral icterus/mild ascites --> diagnosis: liver biopsy shows lymphocytic infiltrate with eosinophils within hepatic triad --> treatment: continue immunosuppression and add IV steroids)

At what age does bedwetting become abnormal/require interventino?

Age >5 (bedwetting is NORMAL before age 5, as most kids begin toilet-training at age 2-4yrs --> can also resolve spontaneously beyond age 5 but often require intervention due to family/child frustration)

Treatment of uncomplicated fracture of middle 1/3 of clavicle

Closed reduction with figure of 8 brace

30F presents with 4-day hx of worsening bilateral LE weakness + numbness and 1 episode of urinary incontinence today PE: decreased muscle strength and increased DTRs with extensor plantar response in bilateral LE, decreased sensation to pinprick below umbilicus, and absent vibratory sensation in toes

Acute transverse myelitis (immune-mediated disorder characterized by infiltration of inflammatory cells into segment of spinal cord, leading to neuro + oligodendrocyte cell death and demyelination, and usually involving THORACIC spinal cord --> causes: recent URI/GI infection, MS, and sarcoidosis --> presents in TEENS or YOUNG ADULTS 30-40yo with rapidly progress myelopathy: motor weakness progressing from flaccid to spastic paraparesis, autonomic dysfunction, and sensory dysfunction with pain + paresthesia + numbness at lowest spinal cord level with intact sensation --> diagnosis: MRI shows enhancement of affected cord segments without compression, LP shows CSF leukocytosis and elevated IgG --> treatment: high-dose IV steroids + plasmapheresis)

82yo M POD#2 s/p right hip surgery presents with tachycardia to 100, agitation, and confusion PMH: HTN, gout, BPH, and mild cognitive impairment PE: lower abdominal tenderness with exacerbation on palpation Labs: low Na+

Acute urinary retention (AUR: often post-op complication after abdominal surgery, pelvic surgery, or joint arthroplasty in which patient is unable to void --> risk factors: elderly males >80yo, history of BPH, history of neurologic disease, and use of precipitating meds such as anesthetics + opioids + anticholinergics --> presents with post-op agitation/confusion, tachycardia, and suprapubic tenderness --> diagnosis: bladder US showing >300mL urine --> treatment: Foley catheter and rule out UTI)

Management of pregnant patient with history of genital HSV

Acyclovir at 36wks until delivery (reduces risk of active lesions at delivery --> if active lesions present at time of delivery, C-section required)

Most common causes of crystal-induced AKI

Acyclovir, sulfa drugs, MTX, ethylene glycol, protease inhibitors, and tumor lysis syndrome

3yo girl presents 10mins after episode of syncope followed by generalized tonic-clonic movements lasting 30s, after which she is fully alert. On arrival, she stops talking and closes her eyes and has 3-4 rhythmic jerks of RUE. ECG: P waves at 80bpm with no QRS complexes, with return to normal sinus rhythm in 20s

Adams-Stokes attack (periodic fainting spell caused by intermittent complete heart block or other high-grade arrhythmia usually due to failure of one or more P waves to conduct to ventricles, resulting in loss of spontaneous circulation and inadequate blood flow to the brain --> presents with sudden-onset syncope or presyncope with twitching for 15-20s, followed by complete return to baseline within 2mins --> diagnosis: P waves without QRS complexes, aka high-grade AV block --> treatment: pacemaker)

Which type of esophageal cancer most commonly arises in the distal esophagus?

Adenocarcinoma (usually caused by Barret esophagus from longstanding GERD)

Which cancers are associated with Trousseau syndrome (migratory superficial thrombophlebitis)?

Adenocarcinoma (usually form pancreas, lung, prostate, stomach, and colon --> causes release of mucins that react with platelets to form platelet-rich microthrombi)

Which types of lung cancer most commonly occur PERIPHERALLY in the lung?

Adenocarcinoma and large cell carcinoma (adenocarcinoma: associated with NON-SMOKING, clubbing, and osteoarthropathy --> large cell carcinoma: associated with SMOKING, gynecomastia, and galactorrhea)

Which lung cancer is often NOT associated with smoking?

Adenocarcinoma of lung (most common lung cancer seen in NON-SMOKING WOMEN caused by activating mutations in KRAS + EGFR + ALK, usually arising in PERIPHERAL LUNG --> presents with chest pain, SOB, cough, and hemoptysis --> CXR: irregular pulmonary nodule located in lung PERIPHERY --> complications: clubbing and hypertrophic osteoarthropathy)

Which meds are used in pharmacologic stress testing?

Adenosine or dipyridamole (adenosine analogs: includes regadenoson which stimulate adenosine A2A receptors on vascular SM to cause coronary vasodilation --> dipyridamole: antiplatelet PDE inhibitor that increases cAMP in platelets resulting in inhibition of platelet aggregation and coronary vasodilation --> result of coronary vasodilation is augmentation of blood flow in NON-OBSTRUCTED coronary arteries, which will reveal ischemic defect on myocardial perfusion imaging --> indications for pharm stress test: LBBB, pacemaker, and pts unable to exercise --> contraindications: reactive airway disease, hypotension, and theophylline)

Shoulder pain with decreased PASSIVE and ACTIVE ROM

Adhesive capsulitis (frozen shoulder: fibrosis and contracture of glenohumeral joint capsule occurring in patients with underlying shoulder pathology --> presents with shoulder pain and decreased PASSIVE ROM)

Best next step in management for patient with PAC/PRA ratio >20 and plasma aldosterone >15

Adrenal suppression test (involves salt loading and documenting inability to suppress serum aldosterone --> if positive adrenal suppression test, pt should get abdominal CT to look for adrenal hyperplasia/adenoma)

Best next step in management for patient with primary hyperaldosteronism and normal abdominal CT

Adrenal vein sampling (recommended to differentiate between adrenal hyperplasia and adenoma --> if hyperplasia, recommend aldosterone antagonists such as spironolactone or eplenerone --> if adenoma, recommend SURGERY)

ECG: sinus rhythm with prolonged PR interval, prolonged QRS duration, normal QTc interval, and occasional PVCs

Advanced AV block (presents with intermittent episodes of lightheadedness and syncope --> diagnosis: ECG shows increased PR interval >0.2s with dropped QRS complexes or prolonged QRS >0.12s due to IV conduction delay --> treatment: electrophysiologic testing and eval for pacemaker)

At what age should speech be 100% intelligible?

Age 4

At what age is genu valgum considered physiologic?

Age 4-7 (due to normal LE alignment during childhood --> pt should have STRAIGHT LEGS by age >7yo)

Indications for high-risk STI screening in pregnancy

Age <25, prior STI, and high-risk sexual activity (require STI screening at both initial prenatal visit AND 3rd trimester --> STI screening during pregnancy: HIV, syphilis, HBV, gonorrhea, and chlamydia)

Indications for parathyroidectomy

Age >50, symptomatic, osteoporosis, nephrolithiasis, CKD, calcium >11.2, or urine calcium excretion >400mg/day (age >50: higher risk of complications during lifetime --> symptomatic: due to higher risk of complications --> osteoporosis: T-score less than -2.5 or fragility fracture --> nephrolithiasis: calcium oxalate stones --> CKD: GFR <60)

Indications for upper endoscopy in patient with suspected H. pylori

Age >60, GIB, significant weight loss, dysphagia, jaundice, palpable mass, or family history

Indications for sequential PCV13 + PPSV23 vaccines

Age >65, CSF leaks, cochlear implants, asplenia, sickle cell disease, immunocompromise, and CKD

Risk factors for osteoporosis

Age, low BMI, smoking, alcoholism, steroid use, Asian/White race, history of fracture, and family history

Main side effects of clozapine

Agranulocytosis, seizures, and myocarditis (clozapine: 2nd gen antipsychotic that is most effective for treatment-resistant schizophrenia and schizoaffective disorder --> serious side effects: agranulocytosis, seizures, and myocarditis)

Newborn boy presents with worsening biphasic stridor and multiple skin hemangiomas on face/chin

Airway hemangioma (enlarging subglottic hemangiomas in newborn that enlarges in first few weeks of life, then slowly regresses --> presents with worsening biphasic stridor and cervicofacial hemangiomas in "beard" distribution --> diagnosis: endoscopy)

Treatment of malignant hyperthermia

Airway support, cessation of trigger, and dantrolene

Treatment of ascariasis

Albendazole or mebendazole

Causes of sialadenosis (non-tender bilateral enlargement of parotid glands)

Alcoholism, bulimia, malnutrition, T2DM, and liver disease

Indications for thyroid FNA

All thyroid nodules >2cm or >1cm with microcalcifications, irregular margins, or internal vascularity

16F presents with few patches of hair loss on the scalp associated with mild itching just before loss PE: patchy, non-scarring hair loss with no scaling

Alopecia areata (autoimmune disorder involving attack on hair bulb cells, resulting in narrowing of hair shafts close to skin surface and patchy hair loss --> risk factors: autoimmune conditions such as vitiligo or hypothyroidism --> presents with painless patchy non-scarring hair loss, "exclamation point" hairs, and positive hair pull test with >5-6 hairs extracted --> treatment: topical or intralesional triamcinolone, with topical diphenylcyclopropenone or oral steroids for severe widespread hair loss)

Renal biopsy: thinning and splitting of GBM

Alport syndrome

Triad of sensorineural deafness, glomerulonephritis, and retinopathy

Alport syndrome (X-linked dominant disease caused by mutation in type 4 collagen, resulting in thinning + splitting of GBM --> presents with triad of SNHL, GN, and retinopathy/lens dislocation --> diagnosis: lamellated BM of inner ear, "basket-weave" appearance of glomerulus on EM)

PECARN high-risk TBI features for children age >2yo

Altered mental status, LOC, fall >5ft, high impact hit, serious MVC, vomiting, severe headache, and basilar skull fracture

36yo M who returned from Nepal 3mo ago presents with 1wk hx of progressive RUQ pain, malaise, anorexia, and fever Vitals: febrile 101.3F, BP 120/70, HR 96 PE: decreased breath sounds in right lung base and palpable liver 3cm below right costal margin with tender smooth edge Labs: elevated WBCs, AST 87, ALT 99, AlkPhos 320 Abdominal US: solitary hypoechoic lesion on right lobe of liver

Amebiasis (amoebic colitis: infection with protozoan Entamoeba histolytica endemic to developing countries and transmitted fecal-orally and sexually --> 90% of cases are asymptomatic, but 10% of causes cause bloody diarrhea and/or amebic liver abscess due to spread from colonic mucosa to portal vein to liver --> presents with diarrhea with bloody mucoid stools, low-grade fever, abdominal pain, anorexia, weight loss, cough, and RUQ pain/hepatomegaly --> workup: abdominal US shows single, subscapular, hypoechoic lesion in right hepatic lobe --> diagnosis: E histolytica serology or stool O&P --> treatment: metronidazole and intraluminal paromomycin --> complications: rupture of abscess to pleura/peritoneum)

1st line treatment for diabetic neuropathy

Amitriptyline, duloxetine, pregabalin, and gabapentin (amitriptyline: TCA that inhibits reuptake of serotonin + NE and inhibits pain signals, however not recommended for patients >65 or pre-existing cardiac disease --> duloxetine: SSRI + SNRI --> pregabalin and gabapentin: anticonvulsants that decrease depolarization of neurons in CNS)

Management of symptomatic polyhydramnios <37wks

Amnioreduction (use of amniocentesis to remove amniotic fluid)

Treatment of AOM

Amoxicillin (give to all infants <6mo and children >6mo with fever >102.2F + severe pain + bilateral disease --> 2nd line tx with Augmentin for refractory sx or recurrent AOM within 30 days)

Treatment of cryptococcal meningitis

Amphotericin B and flucytosine, then fluconazole

Treatment of TOA (tuboovarian abscess)

Ampicillin, gentamicin, and clindamycin (used to treat polymicrobial infection --> can also use metronidazole instead of clindamycin)

Causes of ESRD-related carpal tunnel syndrome

Amyloid accumulation, calcium phosphate deposits, and vascular steal phenomenon

Which type of necrosis is caused by acidic burns?

Coagulation necrosis

60F presents with progressively worsening fatigue, DOE, LE swelling, easy bruising, and significant proteinuria PE: JVD Echo: small pericardial effusion and concentric thickening of ventricular walls with diastolic dysfunction

Amyloidosis (abnormal aggregation of proteins into beta-pleated linear sheets causing extracellular deposition of insoluble protein fibrils, resulting in cellular damage and apoptosis in HEART + KIDNEYS + LIVER + BONE MARROW + MUSCLES + CNS + SKIN --> causes: plasma cell disorders cause AL, chronic inflammation causes AA, age/hereditary causes ATTR, and hemodialysis causes AB2M --> presents with asymptomatic proteinuria or nephrotic syndrome, RESTRICTIVE cardiomyopathy, hepatomegaly, macroglossia, peripheral/autonomic nephropathy, carpal tunnel syndrome, easy bruising, and waxy skin thickening --> diagnosis: abdominal fat pad/endomyocardial biopsy shows amyloid deposits visualized by Congo red stain and polarized light with apple-green birefringence)

Which cancers receive chemotherapy BEFORE surgical resection?

Anal cancer and small cell lung cancer

35yo M with PMH of chronic constipation presents with 1wk hx of excruciating pain on defecation and visible BRB on surface of stool PE: posterior mucosal tear of anus and skin tag

Anal fissure (longitudinal tears in anal canal DISTAL to dentate line, most commonly seen at posterior midline, caused by local trauma from constipation/diarrhea/anal sex, IBD, or cancer --> presents with severe pain on BMs, bright red blood on TP or stool surface, and external skin tag at distal end --> treatment: high-fiber diet with adequate fluid intake, stool softeners, sitz baths, and topical lidocaine + nifedipine + nitroglycerin)

Which mediations decrease TBG concentration, thus lowering required dose of levothyroxine?

Androgens, prednisone, anabolic steroids, and nicotinic acid

Labs: - Low H&H - Low serum iron - Low TIBC - High ferritin - Low transferrin saturation

Anemia of chronic disease (high ferritin due to iron storage within cells to prevent pathogens from acquiring circulating iron)

62F presents with acute-onset right-sided headache, ocular pain, nausea/vomiting, and decreased vision in R eye PE: right eye with red conjunctival flushing and mid-dilated pupil

Angle-closure glaucoma (ACG: narrowing and closure of the anterior chamber angle, leading to decreased aqueous outflow and elevated intraocular pressure --> presents with unilateral headache + ocular pain + decreased visual acuity, halos around lights, nausea/vomiting, conjunctival redness, corneal opacity/edema, palpable firmness of eyeball, and fixed mid-dilated pupil --> diagnosis: gonioscopy to visualize corneal angle and/or tonometry to measure IOP --> treatment: topical therapy with timolol + apraclonidine + pilocarpine and oral/IV acetazolamide, later laser iridotomy)

Screening guidelines for lung cancer

Annual low-dose helical chest CT for smokers age 55-80 (require >30 pack-year history and either currently smoke or quit within last 15yrs)

40yo M presents with several month hx of intermittent foul-smelling anal discharge, pruritus, and occasional pain during defecation PE: inflamed perianal skin, indurated pustule-like lesion close to anal verge, and mild rectal tenderness

Anorectal fistula (formation of sinus tract caused by rupture of perianal abscess, Crohn's disease, radiation proctitis, cancer, or lymphogranuloma venereum --> presents with chronic foul-smelling anal discharge and pruritus, pain on defecation, inflammatory perianal papule/pustule, and palpable fistula tract --> diagnosis: clinical or imaging with endoscopic sonogram, MRI, or fistulogram --> treatment: surgical fistulotomy)

Subacute medial knee pain PE: well-defined area of tenderness over anterior medial tibial plateau below joint line

Anserine bursitis (pes anserinus pain syndrome: tenderness DISTAL to joint line in region where conjoined tendon of semitendinosus, gracilis, and sartorius insert on tibia --> presents with pain and tenderness at MEDIAL knee below joint line --> treatment: placing pillow between knees during sleep)

20M presents after falling headfirst into hockey rink boards with inability to move arms/legs Vitals: BP 128/78, HR 102, RR 14 PE: appears anxious, pinprick and temp sensation absent below clavicles with intact vibratory sense, and inability to move BUE/BLE C-spine CT: burst fracture of C5 with impingement of posteriorly displaced fragments on spinal cord

Anterior cord syndrome (damage to anterior spinal artery, resulting in injury to spinothalamic tract and lateral cortical spinal tract with PRESERVATION of dorsal columns --> causes: thoracic cord ischemia from descending aortic dissection or severe neck flexion injury --> presents with paraplegia and loss of pain/temp sensation, but PRESERVATION of vibratory sense + proprioception)

Which tests are used to diagnose ACL injury?

Anterior drawer and Lachman tests (anterior drawer test: patient supine with knee flexed 90°, should feel laxity when pulling on tibia ANTERIORLY --> Lachman test: stabilize distal femur with 1 hand and flex knee at 30°, should feel laxity when pulling on tibia ANTERIORLY)

Patient appears hypovolemic Labs: low K+ and metabolic alkalosis Urine lytes: low urine Cl- and high urine Ca+

Bartter syndrome (autosomal recessive reabsorption defect in thick ascending LoH affecting Na+/K+/2Cl- cotransporter --> presents with hypovolemia/euvolemia and hypokalemia + metabolic alkalosis + HYPERCALCIURIA --> similar to chronic loop diuretic use)

69yo M presents a few hours after elective thoracic aortic aneurysm repair with flaccid paraplegia and loss of pain/temp sensation over LE and urinary retention. However preserved deep touch/pressure, vibration, and proprioception.

Anterior spinal artery syndrome (incomplete spinal cord injury caused by either burst fracture dislocation at C5 OR spinal cord infarction from decreased ASA perfusion in thoracic aortic surgery --> presents with paraplegia, loss of pain/temp sensation, bowel/bladder dysfunction, and signs of UMN later in disease course --> PRESERVED deep touch/pressure, vibration, and proprioception and preserved anal tone)

Most commonly injured ligament in ankle sprain

Anterior talofibular ligament (forceful inversion or supination of foot causes low ankle sprain, aka injury to ATL)

Which stress fracture sites are at a high risk for malunion?

Anterior tibial cortex and 5th metatarsal (usually managed with casting or internal fixation)

Which anti-Rhesus antibodies can cause hemolytic disease of the newborn?

Anti-D, anti-Kell, and anti-Duffy antibodies (need to be at critical titer level, usually >1:16 --> if mother tests positive for any of these antibodies, best next step is for PATERNAL antigen testing)

Which maternal antibodies are associated with development of fetal AV block?

Anti-SSA and anti-SSB (aka anti-Ro and anti-La antibodies: present in Sjogren syndrome and 30% of patients with SLE --> transferred to fetus via passive placental transfer and binds to fetal cardiac cells causing fetal AV block)

Which antibodies are associated with scleroderma?

Anti-centromere and anti-DNA topoisomerase (anti-centromere: associated with limited scleroderma/CREST syndrome associated with calcinosis cutis + Raynaud phenomenon + esophageal dysmotility + sclerodactyly + telangiectasias --> anti-DNA topoisomerase/anti-Scl-70: associated with diffuse scleroderma, also associated with anti-RNA polymerase III)

Treatment of acalculous cholecystitis

Antibiotics and percutaneous cholecystostomy (then can get definitive cholecystectomy once medical condition improves)

Management of elevated homocysteine levels

Anticoagulation, vitamin B6, and folate (can also add vitamin B12 if deficiency is documented)

35F with PMHx of depression who d/c paroxetine 3 days ago presents with anxiety, decreased energy, muscle pain and weakness, insomnia, and restlessness

Antidepressant discontinuation syndrome (withdrawal from serotonergic antidepressants due to abrupt cessation --> presents 2-4 days after medication stopped with dysphoria, fatigue, insomnia, myalgias, dizziness, flu-like and GI symptoms, tremor, and neurosensory disturbances such as "electric shock" and "rushing sensations in head + paresthesias + hypersensitivity to light and noise + vivid dreams --> treatment: restarting antidepressant and tapering dose gradually over 2-4wks or substituting fluoxetine and then taper)

Where is the aortic dissection located in a patient with UE pulse discrepancy?

Aortic arch dissection

Diagnosis of severe aortic stenosis (AS)

Aortic jet velocity >4.0 or mean transvalvular pressure gradient >40 (note: valve area usually <1.0 but not required)

Heart exam: diastolic murmur best heard along left/right sternal borders that is accentuated when patient sits up, leans forward, and puts hand behind head

Aortic regurgitation (loosened aortic valve caused by rheumatic heart disease, aortic root dilation, and congenital bicuspid valve --> presents with early decrescendo diastolic murmur accentuated with patient sitting up/leaning forward while holding breath in full expiration --> VALVULAR AR best heard along left sternal border at 3rd and 4th ICS --> AORTIC ROOT dilation best heard along right sternal border)

Which conditions are associated with pulses bisferiens (biphasic pulse: 2 pulses during systole)?

Aortic regurgitation and HOCM

Causes of pulsus bisferiens (biphasic pulse)

Aortic regurgitation, HOCM, and PDA (pulsus bisfereiens/biphasic pulse: 2 strong systolic peaks of aortic pulse caused by LV ejection separated by midsystolic dip)

Which condition is associated with pulsus parvus et tardus?

Aortic stenosis (pulsus parvus et tardus: slow-rising and low-amplitude pulse)

62M with PMHx of smoking presents with 1-year hx of pain in calves and thighs after walking more than 2 blocks and relieved by rest Vitals: afebrile, BP 140/80, HR 75, RR 16 PE: decreased femoral, popliteal, and pedal pulses b/l

Aortoiliac occlusive disease (Leriche syndrome: arterial occlusion at bifurcation of aorta into common iliac arteries --> risk factors: male smokers with atherosclerosis --> presents with TRIAD of bilateral hip/thigh/buttock claudication + absent or diminished femoral pulses with bilateral LE atrophy + impotence/erectile dysfunction)

Patient with sickle cell anemia presents with pallor Labs: - Normocytic anemia - DECREASED retic count - Normal WBC - Normal/low platelets

Aplastic crisis (transient arrest of erythropoesis that occurs in patients with sickle cell disease after infection, usually from Parvovirus B19 --> presents with pallor after Parvovirus B19 infection with flu-like sx and "slapped cheek" rash --> diagnosis: pancytopenia with DECREASED reticulocyte count)

Components of APGAR score

Appearance, pulse, grimace, activity, and respiration (appearance: usually 1pt for body pink + extremities blue --> pulse: usually 2pts for HR >100bpm --> grimace: usually 2pts for coughing + sneezing + crying --> activity: usually 2pts for active/spontaneous movement --> respiration: usually 2pts for regular good cry)

40M who builds outdoors fences presents with 1-mo hx of progressively worsening burning + tingling sensations in hands/feet and difficulty handling heavy tools PE: patchy areas of hyper- and hypopigmentation over skin of neck, hyperkeratoses and scaling on palms/soles, increased sensitivity to pinprick and light touch over fingers/toes, weakness of plantar flexion and dorsiflexion at ankles, weakness of interossei muscles + wrist flexors/extensors, and 1+ DTRs in UE and LE b/l Labs: low Hgb, low WBC, and elevated AST + ALT

Arsenic poisoning (poisoning with metalloid element arsenic, which binds to sulfhydryl groups to disrupt cellular respiration + gluconeogenesis --> risk factors: mining, pesticide/insecticide manufacturing, metalworking, pressure-treated wood, and contaminated well water --> ACUTE arsenic poisoning presents with garlicky breath, vomiting, watery diarrhea, and QTc prolongation --> CHRONIC arsenic poisoning presents with stocking-glove sensorimotor neuropathy, hypo and hyperpigmentation of skin, hyperkeratosis and scaling of palms + soles, and Mees lines aka horizontal striation of fingernails --> labs: pancytopenia and hepatitis --> diagnosis: elevated urine arsenic --> treatment: chelation with dimercaprol or DMSA)

53M with PMHx of PUD and smoking presents with 4mo hx of worsening SOB, decreased appetite, weight loss, and nagging epigastric discomfort PE: fingernail clubbing and bibasilar end-inspiratory crackles CXR: atelectasis and bilateral pleural plaques over diaphragm Chest CT: reticular opacities of lower lung fields, multiple pleural plaques, and round 6cm cavitary mass in RLL

Asbestosis and bronchogenic carcinoma (occurs in patients with occupational exposure to asbestos such as plumbers, electricians, carpenters, pipefitters, insulation workers, shipyard workers, and plastic/rubber manufacturing --> presents asymptomatic for 20-30yrs and then advanced disease presents with worsening SOB, fingernail clubbing and bibasilar end-inspiratory crackles --> CXR: bibasilar reticulonodular infiltrates, honeycombing, and bilateral pleural thickening/plaques --> complication: bronchogenic carcinoma)

Which 2 arteries supply the femoral head?

Ascending arteries and foveal artery (both lie within ligamentum teres)

Complications of mumps viral infection

Aseptic meningitis and sensorineural hearing loss

Which medications should be given to patients with known CAD?

Aspirin, clopidogrel, beta-blocker, ACEI, statin, and spironolactone (ASA + clopidogrel: dual antiplatelet therapy recommended for 12mo after drug-eluting stent placement --> beta-blocker: reduces mortality --> ACEI: reduces mortality --> statin: lowers cholesterol levels --> spironolactone: ONLY if EF <40% with CHF or T2DM, shown to reduce mortality)

Complicated diverticulitis

Associated with abscess, perforation, obstruction, or fistula

Signs of secondary Raynaud phenomenon (RP)

Asymmetric attacks, tissue ischemia, digital ulcers, and abnormal nail fold capillary exam (signs of secondary RP should prompt autoimmune workup: CBC and BMP, ESR, C3 and C4 levels, UA, ANA, and RF --> treat with nifedipine or amlodipine for persistent sx + ASA for patients at risk for digital ulceration)

Indications for platelet transfusion

Asymptomatic with platelet <10k, or bleeding with platelet <50k

Which cardiac arrhythmia is associated with DC electrocution (ex: lightning)?

Asystole

Ranson's criteria for assessing risk of mortality in pancreatitis

At presentation: age >55, WBC >16k, glucose >200, LDH >350, and AST >250 At 48hrs: HCT decrease by >10%, BUN increase by >5, calcium <8, PO2 <60, base deficit >4, and fluid sequestration >6000 (you get 1pt for each criteria --> pts with 0-2pts have 0-3% mortality --> pts with 3-4pts have 15% mortality --> pts with 5-6pts have 50% mortality --> pts with 7-11pts have almost 100% mortality)

Pap smear screening guidelines for HIV-positive women

At time of HIV diagnosis and every 6-12mo

CXR: bilateral linear densities in dependent portions of lungs

Atelectasis

CXR: unilateral lung white-out with mediastinal shift TOWARD affected lung and narrowed rib spacing

Atelectasis (unilateral alveolar collapse due to airway obstruction causing distal air trapping in alveoli --> causes: bronchial mucus plug, tumor, or foreign body --> presents with respiratory distress, hypoxemia, and unilateral dullness to percussion + absent breath sounds --> diagnosis: CXR shows opacification with mediastinal deviation TOWARD affected lung and narrowed intercostal spaces --> treatment: bronchoscopy to remove mucus plug)

Causes of lung white-out (hemithorax opacification)

Atelectasis, pleural effusion, consolidation, and post-pneumonectomy (atelectasis: presents with tracheal deviation TOWARD affected lung and narrowed intercostal spaces --> pleural effusion: presents with tracheal deviation AWAY from affected lung --> consolidation: presents with increased tactile fremitus + egophony + whispered pectoriloquy and NO tracheal deviation)

1st line treatment of ADHD for families that do not want stimulants

Atomoxetine (SNRI that is preferred ADHD tx for desire to avoid stimulants or hx of abuse --> 2nd line non-stimulant options: alpha-2 adrenergic agonists such as clonidine/guanfacine, bupropion, and TCA)

10-month-old girl presents with 5-day hx of itchy rash over cheeks and diaper area and 1-day hx of unwilling to stand PE: erythematous lichenified papules and plaques, excoriations on diaper area, and red lichenified plaques on cheek and chin

Atopic dermatitis (eczema: common skin condition caused by improper synthesis of stratum corneum components, leading to epidermal dysfunction and allergens entering disrupted skin barrier to generate inflammatory response --> risk factors: excessive bathing, dry environments, stress, overheating, and irritating detergents --> presents with itchy red scaly crusted lesions on extensor surfaces + trunk + cheeks + scalp, as well as lichenified plaques in flexural creases in children/adults --> treatment: thick bland emollients +/- topical hydrocortisone --> complications: eczema herpeticum and cellulitis/abscess)

Treatment of babesiosis

Atovaquone and azithromycin (take for 7-10 days --> for severe illness, give quinine and clindamycin)

Which high-risk animals require immediate rabies PEP if a patient is exposed?

Bat, raccoon, skunk, fox, and coyote

74F with PMHx of CLL, AFib, diverticulosis, HTN presents with acute onset abdominal pain and syncope during exercise class, followed by persistent nausea + dizziness + diffuse abdominal pain Vitals: afebrile, BP 80/54, HR 120, RR 14 PE: lethargic pale appearance, diffusely tender abdomen, decreased BS Labs: low Hgb, elevated WBC with 90% lymphocytes, elevated PT + INR

Atraumatic splenic rupture (occurs in settings of splenomegaly, derangement of splenic architecture, or thinning of splenic capsule --> causes: leukemia/lymphoma, infection with CMV/EBV/malaria, SLE, pancreatitis, splenic congestion from cirrhosis/pregnancy, and anticoagulation meds --> presents with diffuse or LUQ abdominal pain and peritonitis, referred left shoulder pain aka Kehr sign, and hemodynamic instability --> diagnosis: FAST or CT scan shows free intraperitoneal fluid --> treatment: catheter-based angioembolization in stable patients, splenectomy in unstable patients)

Which arrhythmia is most specific for digitalis toxicity?

Atrial tachycardia with AV block (digitalis toxicity: increases ectopy in atria or ventricles leading to atrial tachycardia, dx on ECG as abnormal P-waves with tachy 150-250bpm --> also increases vagal tone and decreases conduction thru AV node, causing AV block)

Treatment of organophosphate toxicity

Atropine and pralidoxime (atropine: competitive inhibitor of mACh receptors to resolve muscarinic sx aka DUMBELS --> pralidoxime: cholinesterase-reactivating agent that relieves both mACh and nACh effects)

Treatment of human bite wound

Augmentin (amoxicillin-clavulanate: provides excellent coverage of gram-positives such as Staph aureus/streptococci, gram-negatives such as Eikenella corrodens and H influenzae, and beta-lactamase producing oral anaerobes --> also need to provide tetanus booster --> wounds left open to drain and heal by 2° intention)

42F with PMHx of HTN presents for follow-up on abnormal LFTs Vitals: BP 146/80, HR 80 CBC: normal LFTs: high protein, normal albumin, and high AST + ALT >500 Coag panel: normal

Autoimmune hepatitis (autoimmune disorder caused by anti-smooth muscle or anti-liver/kidney microsomal type 1 antibodies causing liver injury, usually in WOMEN with comorbid AUTOIMMUNE DISEASE --> either asymptomatic or presents with fatigue, anorexia, nausea, and jaundice --> labs: elevated AST + ALT and LARGE PROTEIN GAP due to hypergammaglobulinemia --> diagnosis: positive serology for anti-smooth muscle or anti-liver/kidney microsomal type 1 antibodies, or positive biopsy with portal and periportal lymphoplasmacytic infiltration --> treatment: prednisone +/- azathioprine)

Which conditions are associated with vitiligo

Autoimmune thyroid disease (including Hashimoto and Graves disease --> vitiligo also associated with SLE, RA, Sjogren syndrome, alopecia areata, pernicious anemia, T1DM, and primary adrenal insufficiency)

Evaluation of fetal demise

Autopsy, karyotype, microscopic eval of placenta + membranes + cord, KB test, APLS antibodies, and coagulation studies (autopsy: look for dysmorphic features of fetus --> karyotype: determine chromosomal abnormalities, consider genetic studies --> microscopic eval of placenta/membranes/cord: look for signs of placental abruption or infection, nuchal cords, or true knots --> KB test: look for fetomaternal hemorrhage --> APLS antibodies: rule out APLS --> coagulation studies: only indicated in patients with hx of recurrent pregnancy loss, family/personal hx of VTE, or IUGR)

Hip XR: osteopenia, subchondral lucency, and flattening of femoral head

Avascular necrosis of hip (osteonecrosis of hip)

Management of vasovagal syncope

Avoid triggers and counterpressure maneuvers (ex: supine position with leg raising, leg crossing with tensing of muscles, and handgrip and tensing of arm muscles with clenched fists --> used to improve venous return during prodromal phase to increase CO and potentially abort syncopal episodes)

Best next step in management for patient with severe acne on antibiotics + topical retinoids

Avoidance of sun exposure (due to increased photosensitivity from doxycycline and retinoids)

Which structures are most commonly affected by surgical neck fractures of humerus?

Axillary artery and nerve (axillary nerve injury: presents with flattened deltoid, loss of arm abduction at shoulder >15°, and loss of sensation over deltoid/lateral arm)

Most commonly injured nerve in anterior shoulder dislocations

Axillary nerve (provides MOTOR innervation to teres minor and deltoid --> provides SENSORY innervation to skin over lateral shoulder --> damage to axillary nerve results in flattened deltoid, loss of arm abduction at shoulder >15°, and loss of sensation over lateral arm)

Treatment of cat-scratch disease (Bartonella henselae)

Azithromycin (disease is self-resolving, but treatment with azithromycin is recommended)

Treatment of confirmed chlamydia

Azithromycin (do not need to give empiric cetriaxone to cover gonorrhea as NAAT testing is very sensitive, so if gonorrhea ruled out you do not have to treat)

Treatment of Legionella

Azithromycin and levofloxacin (azithromycin: macrolide --> levofloxacin: respiratory quinolone)

Treatment of chancroid

Azithromycin or ceftriaxone (chancroid: caused by Haemophilus ducreyi infection --> presents with large deep PAINFUL ulcer with gray/yellow exudate and soft friable base, sometimes with tender suppurative lymphadenopathy)

Outpatient treatment of CAP in healthy adult

Azithromycin or doxycyline

Treatment of granuloma inguinale (donovanosis)

Azithromycin, doxycycline, or bactrim (granuloma inguinale: caused by Klebsiella granulomatis --> presents as PAINLESS beefy red friable genital ulcer without LAD)

Which antibiotics should be given to patients with acute COPD exacerbation?

Azithromycin, levofloxacin, or Augmentin (azithromycin: macrolide that covers upper respiratory pathogens + atypical pneumonias --> levofloxacin: respiratory fluoroquinolone that covers some GNRs and gram-positives --> Augmentin: penicillin/beta-lactamase inhibitor that covers gram-positives and upper respiratory GNRs)

Differential diagnosis for pediatric LATERAL neck mass

BCC, laryngocele, reactive adenopathy, and MAC lymphadenitis (BCC: branchial cleft cyst usually found ANTERIOR to SCM and INFERIOR to mandible, presents after URI with erythema + tenderness and mucopurulent drainage --> laryngocele: outpouching of laryngeal mucosa thru thyrohyoid that enlarges with Valsava, either congenital or acquired in glassblowers or trumpet players --> reactive adenopathy: usually presents with multiple firm tender nodules --> MAC lymphadenitis: presents with violaceous discoloration of skin, necrotic LN, and frequent fistula formation)

Management of shoulder dystocia

BE CALM (B: breathe and stop pushing --> E: elevate legs + flex hips/thighs against abdomen aka McRoberts maneuver --> C: call for help --> A: apply suprapubic pressure --> L: enLarge vaginal opening with episiotomy --> M: maneuvers including delivering posterior arm, Woods screw, Rubin maneuver, Gaskin maneuver, and Zavanelli maneuver to prepare for C-section)

Indications for bariatric surgery referral

BMI >40, BMI >35 with weight-related comorbidity, or BMI >30 with resistant T2DM or metabolic syndrome

Best next step in management for pregnant patient with non-reactive NST

BPP (biophysical profile: normal BPP score >8/10 indicates normal fetus and includes >3 fetal movements, >1 episode of flexion/extension of fetal limbs + spine, and >1 breathing episode for 30s --> if BPP 6/10, indicates "equivocal" test and need to repeat in 24hrs --> if BPP <4/10, indicates fetal hypoxia and requires urgent delivery)

32M with PMHx of splenectomy and recent camping trip in New England where he found 2 ticks on his legs presents with 5-day hx of intermittent high fever, chills, drenching sweats, malaise, fatigue, and dark urine Vitals: febrile 103F, BP 110/70, HR 116 PE: mild scleral icterus and mildly tender liver edge Labs: low Hgb with elevated reticulocytes, high total bili, high AlkPhos, high AST + ALT, and high LDH

Babesiosis (tick-borne protozoal illness endemic to northeastern USA transmitted via Ixodes scapularis tick bite 48-72hrs after attachment --> risk factors for severe infx: immunocompromise, age >50, and splenectomy --> presents with fever, fatigue, malaise, myalgias, and INTRAVASCULAR HEMOLYSIS with jaundice + dark urine --> labs: anemia, reticulocytosis, thrombocytopenia, indirect hyperbilirubinemia, transaminitis, and elevated LDH --> diagnosis: thin peripheral blood smear shows intraerythrocytic rings aka "Maltese cross" --> treatment: atovaquone + azithromycin OR quinine + clindamycin for 7-10 days)

Skin exam: several purple pedunculated lesions on face and extremities that are friable and bleed easily with palpation

Bacillary angiomatosis (systemic infection with gram-negative intracellular Bartonella transmitted via cat scratch or body/head lice in homeless populations, especially in advanced HIV with CD4 <100 --> presents with fever, night sweats, malaise, and vascular cutaneous lesions beginning as small reddish/purple papules that evolve into friable pedunculated/nodular lesions --> diagnosis: skin biopsy shows neutrophilic infiltrate --> treatment: doxycycline or erythromycin, followed by HAART 2-4wks later)

43M with PMHx of HIV with CD4 of 50/mm 3mo ago and homelessness presents with fever, night sweats, fatigue, and small reddish/purple papules that gradually enlarged to large nodules on face + arms + legs Vitals: febrile 100.4F, BP 116/70, HR 92 PE: cachectic appearance, white plaques on palate, hepatosplenomegaly, and several purple pedunculated lesions on face + extremities that are friable and bleed easily with palpation CT abdomen: hypodense liver lesions that enhance with IV contrast

Bacillary angiomatosis (widespread systemic infection caused by gram-negative intracellular bacteria Bartonella transmitted via cutaneous penetration after cat scratch or body/head lice, causing local dermal infection that then spreads to vascular endothelium and attacks RBCs --> risk factors: cat exposure, lice in homelessness, and advanced HIV with CD4 <100 --> presents with vascular cutaneous lesions beginning as small reddish/purple papules that evolve into friable pedunculated/nodular lesions, fever, malaise, night sweats, and involvement in liver + bone + CNS --> diagnosis: skin biopsy --> treatment: doxycycline or erythromycin, then starting HAART 2-4wks later)

Which medication has been shown to decrease alcohol cravings in patient with alcoholic liver disease?

Baclofen (GABA-B receptor antagonist normally used to treat muscle spacticity/dystonia and MS --> can also be used to decrease alcohol cravings ONLY in patients with alcoholic liver disease)

CSF analysis: - WBCs >1000, neutrophil predominant - Low glucose (<40) - High protein (>250)

Bacterial meningitis (inflammation of leptomeninges from bacteria such as Neisseria meningitidis or Strep pneumo --> CSF analysis: significant pleocytosis with neutrophil predominance, low glucose, and high protein --> diagnosis: CSF gram stain and culture --> treatment: IV antibiotics)

Most common cause of orbital cellulitis

Bacterial sinusitis (allows contiguous spread of GAS/Staph aureus from sinuses to orbital space, resulting in orbital cellulitis --> diagnosis: CT scan of orbit + sinuses)

1st line treatment of PCP (Pneumocystis pneumonia)

Bactrim (TMP-SMX, can add steroids if PaO2 <70 or A-a gradient >35 or SaO2 <92% on RA --> 2nd line treatment for mild/moderate PCP includes dapsone-TMP, primaquine with clindamycin, or atovaquone --> 2nd line treatment for moderate/severe PCP includes IV pentamidine or primaquine with IV clindamycin --> NOTE: need to delay initiation of antiretrovirals by 1-2wks until hypoxia improved due to risk of immune reconstitution syndrome)

Antibiotic prophylaxis for patients with HIV and CD4 <200

Bactrim (TMP-SMX: used to prevent PCP --> also useful in preventing Toxoplasmosis in patients with CD4 <100 and positive IgG antibody --> alternative PCP prophylaxis: dapsone, atovaquone, and pentamidine)

Which cancers cause primarily solitary brain mets?

Breast, colon, and renal cell carcinomas

Newborn male born at term via SVD weights 11 lbs 1 oz PE: large for gestational age, macroglossia, visceromegaly, and omphalocele

Beckwith-Wiedmann syndrome (overgrowth disorder caused by sporadic alteration of chromosome 11p15, leading to WT2 mutation and mutated insulin-like growth factor 2/IGFR2 --> presents with macroglossia, organomegaly, hemihyperplasia, omphalocele, and hypoglycemia 2/2 pancreatic hyperplasia causing hyperinsulinism --> management: monitoring for hypoglycemia, abdominal US + AFP every 3mo until age 4, and renal US every 3mo from age 4-8 --> complications: Wilms tumor and hepatoblastoma)

Treatment of Chagas disease

Benznidazole and nifurtimox (Chagas disease: caused by infection with protozoa Trypanosoma cruzi found in South America --> presents ACUTELY with unilateral periorbital swelling aka Romana sign, or CHRONICALLY with megacolon, achalasia/megaesophagus, and dilated CM with apical atrophy --> diagnosis: trypomastigote on blood smear)

Treatment of acute dystonia

Benztropine and diphenhydramine

Type of bias in which study only uses hospital patients

Berkson bias (type of selection bias that leads to low generalizability)

Management of Graves disease

Beta-blocker and methimazole (beta-blocker: used for symptomatic tx of hyperthyroidism --> methimazole: thionamide that blocks TPO to inhibit iodide oxidation + organification + coupling to inhibit T4/T3 synthesis --> use PTU in 1st trimester of pregnancy --> given these meds until patient is stabilized for more definitive treatment with RAI + steroids for exophthalmos)

Which anti-hypertensives are contraindicated in patients with myasthenia gravis?

Beta-blockers and CCBs (can trigger myasthenic crisis --> other meds contraindicated in MG: fluoroquinolones, aminoglycosides, macrolides, magnesium, and penicillamine)

Best method to control AFib with RVR in a postop patient s/p CABG

Beta-blockers and amiodarone (best method to rate control postop AFib --> only give anticoagulation and/or cardioversion if AFib lasts >24hrs after CABG)

Which medications are often causes of erectile dysfunction in men?

Beta-blockers, thiazide diuretics, spironolactone, and SSRIs

Hgb electrophoresis: - 5% HbA2 - 95% HbF

Beta-thalassemia major (caused by mutations in BOTH beta-globin genes, resulting in absent beta-globin expression resulting in only HbA2 and HbF --> presents at 6-12 MONTHS with fatigue, pallor, splenomegaly, jaundice, dark urine, and microcytic anemia --> diagnosis: Hgb electrophoresis shows HbA2 and HbF --> treatment: chronic transfusions and chelation therapy --> complications: marrow expansion with "crew cut" on skull XR, chipmunk facies, HSM, and increased risk of parvovirus B19-induced aplastic crisis)

Hgb electrophoresis: - 10% HbA2 - 90% HbA

Beta-thalassemia minor (caused by HETEROZYGOUS mutation in only 1 beta-globin gene, resulting in slightly elevated levels of HbA2 --> presents asymptomatically --> diagnosis: Hgb electrophoresis shows HbA2 >3.5%)

Most common causes of chronic aortic regurgitation

Bicuspid aortic valve, rheumatic heart disease, and aortic root dilation (bicuspid aortic valve: common congenital heart condition in young people --> rheumatic heart disease: more common in developing world --> aortic root dilation: associated with Marfan syndrome and syphilis)

Screening guidelines for breast cancer

Biennial screening MG for women age 50-74

25F presents with 1-year hx of numbness/dizziness and several days of intermittent double vision, dizziness, and unsteady gait PE: - On attempted left gaze, left eye abducts with horizontal nystagmus while right eye stationary - On attempted right gaze, right eye abducts with horizontal nystagmus while left eye stationary - Able to converge both eyes without nystagmus

Bilateral INO (bilateral internuclear ophthalmoplegia: disorder of conjugate horizontal gaze in which AFFECTED eye ipsilateral to lesion is unable to adduct and contralateral eye abducts with nystagmus, with preservation of convergence and pupillary light reflex --> caused by damage to MLF, a paired neural tract that mediates connection between CN3 and CN6 to allow for coordinated horizontal eye movements --> MS causes bilateral INO, lacunar stroke in pontine distribution causes unilateral INO)

Diagnosis of ARDS

Bilateral alveolar infiltrates, PaO2/FiO2 <200, and PCWP <18

Best next step in management for infant <4mo with limb-length discrepancy and asymmetric inguinal skin folds

Bilateral hip US (requires US to evaluate for DDH due to infant not yet ossifying femoral head + acetabulum)

Best next step in management for infant >4mo with limb-length discrepancy and asymmetric inguinal skin folds

Bilateral hip XR (after 4mo, infant has ossified femoral head + acetabulum --> XR preferred to evaluate acetabular development and positioning)

Definitive management of BRCA1-positive women

Bilateral mastectomy and oophorectomy

4wk-old M presents with decreased stool frequency with paler stools and progressive yellowing of eyes PE: scleral icterus and jaundice of face + chest and hepatomegaly Labs: total bili 12.5 RUQ US: absence of gallbladder and hepatomegaly

Biliary atresia (neonatal disorder caused by progressive fibro-obliterative destruction of extrahepatic bile ducts, resulting in cholestasis and decreased bile excretion into intestines --> asymptomatic at birth but presents at AGE 2-8WKS with jaundice, hepatomegaly, acholic stools, and dark urine --> labs: direct hyperbilirubinemia, elevated GGT, elevated AlkPhos, normal reticulocyte count --> RUQ US: shows triangular cord sign aka fibrous remnants above porta hepatis + small/absent gallbladder --> diagnosis: intraop cholangiography showing biliary obstruction OR liver biopsy showing intrahepatic bile duct proliferation, portal tract edema, and fibrosis --> treatment: Kasai procedure aka surgical hepatoportoenterostomy and liver transplant --> complications: progressive cirrhosis and portal HTN leading to splenomegaly)

1st line treatment for uterine atony

Bimanual fundal massage and high-dose oxytocin (if heavy bleeding persists, proceed to 2nd line meds --> 1. carboprost tromethamine: synthetic PGF2-alpha analog that stimulates uterine contractions, contraindicated in ASTHMA --> 2. methylergonovine: potent vasoconstrictor that stimulates contractions, contraindicated in HTN --> 3. tranexamic acid: antifibrinolytic that prevents clot breakdown if given within 3hrs of delivery, use with caution in hypergoaulability disorders)

Best next step in management for solitary pulmonary nodule >2cm with irregular borders

Biopsy or surgical excision (factors increasing malignant probability of SPN include: >2cm diameter, irregular borders, upper lobe location, spiculated appearance, advanced patient age, female sex, history of smoking, and FH of lung cancer)

Which physical exam finding is most commonly associated with subglottic stenosis?

Biphasic stridor (due to less flexibility of subglottic airway from support with cricoid cartilaginous ring --> causes minimal change in subglottic airway caliber in inspiration compared with expiration)

At what age is genu varum (bowlegs) considered physiologic?

Birth to age 2 (usually most noticable around age 12-15mo as child begins to walk around --> PHYSIOLOGIC if child has symmetric bowing, normal stature, no leg length discrepancy, and no lateral thrust when walking --> PATHOLOGIC if unilateral bowing with lateral thrust when walking aka Blount disease/tibia vara)

Which beta-blockers are indicated for CHF?

Bisoprolol, carvedilol, and metoprolol ("Beta-blockers Curb Mortality": bisoprolol and metoprolol: B1-selective antagonist with B1 > B2 blocking effects --> carvedilol: non-selective alpha and beta blocker)

Which medication should be given to perimenopausal women with chronic steroid use to prevent osteoporosis?

Bisphosphonates (includes alendronate, risedronate, zoledronate: pyrophosphate analogs that bind hydroxyapatite in bone to inhibit osteoclast activity --> used to treat/prevent osteoporosis, hypercalcemia, Paget disease of bone, metastatic bone disease, and osteogenesis imperfecta --> side effects: esophagitis, osteonecrosis of jaw, and atypical femoral stress fractures)

Treatment of hypercalcemia of immobilization

Bisphosphonates (inhibit osteoclastic bone resorption, thus reducing bone loss associated with immobilization)

25yo F who went camping yesterday and felt a bite on right arm presents with 1-day hx of nausea/vomiting, diffuse muscle pain/cramping and abdominal rigidity PE: diffuse muscle tenderness and acute abdomen

Black widow spider bite (toxin causes LOCAL and SYSTEMIC symptoms --> presents with nausea/vomiting within hours of bite, muscle pain + cramping, and abdominal rigidity)

Management of urge incontinence

Bladder training, oxybutynin, or mirabegron (bladder training: involves delaying micturition and resisting urge to void for progressively longer intervals to increase bladder capacity --> oxybutynin: antimuscarinic med that relaxes detrusor muscle --> mirabegron: beta-3 agonist that relaxes bladder)

36M with PMHx of seasonal allergies and works as agricultural irrigation mechanic in Wisconsin resents with large painless wartlike lesions on right forearm and back of neck, as well as 2mo hx of dry cough with mild malaise PE: 4-5cm warty, heaped-up skin lesions with violaceous hue and sharply demarcated border, with one lesion appearing crusted with small peripheral ulcer Wet prep of skin scrapings: yeast

Blastomycosis (infection with Blastomycoses dermatiditis endemic in Eastern + Midwestern USA, Great Lakes states, and Canadian provinces --> presents with acute/chronic pneumonia, heaped-up wart-like skin lesions with violaceous hue and ulcers, ostemyelitis, prostatitis, meningitis, and epidural/brain abscess --> can also form granulomatous nodules mimicking sarcoidosis --> diagnosis: culture/microscopy shows RBC-sized yeast with broad-based budding, or urine Ag testing --> treatment: oral itraconazole, severe disease treated with IV amphotericin B)

Causes of terminal hematuria

Bleeding from prostate, bladder neck, trigone, and posterior urethra

Which chemotherapeutic agents are associated with pulmonary fibrosis?

Bleomycin, busulfan, and methotrexate (therefore pts need baseline PFTs and repeat PFTs at regular intervals)

26F with PMHx of asymptomatic sarcoidosis presents with 1wk hx of photophobia and forceful contraction of eyelid muscles PE: frequent eye blinking, and shining light in eyes causes involuntary tonic closure of eyes b/l

Blepharospasm (type of focal dystonia characterized by recurrent forceful contraction of eyelid muscles --> causes: idiopathic, Parkinson disease, and antipsychotics --> presents with bilateral symmetric forceful eye closures triggered by bright lights and touching/brushing skin around the eyes --> treatment: dark glasses or botulinum toxin injection)

42F G5P4 at 14wks presents for routine prenatal visit PE: closed cervix and uterus c/w 6wk gestation US: normal uterus with gestational sac and no cardiac activity

Blighted ovum (pregnancy with no embryonic development likely due to early embryonic death with continued development of trophoblast --> presents asymptomatically or with vaginal spotting --> diagnosis: US at >6wks gestation shows empty hypoechoic gestational sac, aka gestational sac >25mm with no embryo or yolk sac)

24M presents after mountain bike fall with chest pain and wrist pain Vitals: BP 142/86, HR 110, RR 20 PE: sternal bruising with point tenderness, abrasions on both palms, deformed R wrist FAST: negative CT chest: hairline sternal fracture ECG: sinus tach with frequent PVCs

Blunt cardiac injury (BCI: damage to heart from rapid deceleartion or direct blow to precordium, resulting in shearing/compression/abrupt pressure change that can lead to myocardial edema + hemorrhage + necrosis --> presents with new-onset cardiac arrhythmia, ACS from coronary dissection/thrombosis, myocardial dysfunction, ruptured valve/septum/LV wall, or cardiac tamponade --> workup: ECG and TTE with 24-48hrs of continuous cardiac monitoring)

EEG: periodic sharp-wave complexes

CJD (Creutzfeldt-Jakob disease: prion disease caused by abnormally folded proteins --> presents with rapidly progressive dementia with startle myoclonus and ataxia --> diagnosis: EEG shows periodic sharp-waves, CSF positive for 14-3-3 regulatory proteins, and MRI shows caudate nucleus/putamen findings

Patient presents with chest pain and anxiety following blunt chest trauma CXR: widened mediastinum and enlarged aortic nob

Blunt thoracic aortic injury (BTAI: caused by fall >10ft followed by rapid deceleration, resulting in stretching + shearing + torsional forces capable of rupturing aorta --> presents with chest pain and possible HTN --> CXR: widened mediastinum or abnormal aortic contour aka enlarged aortic nob --> diagnosis: CTA for STABLE patients, intraop TEE for UNSTABLE patients)

Clinical signs of uterine atony

Boggy uterus and fundus >2cm above umbilicus

Best next step in management for girl <8 or boy <9 with precocious puberty

Bone age eval (if NORMAL bone age, dx with normal premature puberty --> if ADVANCED bone age and LOW LH/FSH, dx with adrenal or GU tumor --> if ADVANCED bone age and HIGH LH/FSH, dx with CNS tumor)

Most specific diagnostic test for osteomyelitis

Bone biopsy and culture (should be performed PRIOR to antibiotic initiation to identify causative pathogens --> can also perform wound base culture only after debridement + curettage)

Where are pressure ulcers most commonly found?

Bony prominences (includes sacrum, ischial tuberosities, malleoli, heels, and 1st or 5th metatarsal heads)

Causes of delayed bowel perforation after blunt abdominal trauma

Bowel contusion and mesenteric hematoma (bowel contusion: can present to full-thickness injury, dx via abdominal CT showing thickened/edematous proximal small bowel --> mesenteric hematoma: progresses to ischemia and necrosis)

Patient POD#1 s/p abdominal aortic aneurysm repair presents with fevers, abdominal pain, and bloody diarrhea

Bowel ischemia (complication of AAA repair caused by loss of IMA during aortic graft replacement, resulting in inadequate colonic collateral arterial perfusion to left and sigmoid colon --> presents with EARLY fever, abdominal pain, bloody diarrhea, and leukocytosis usually on POD1-2)

Management of uncomplicated diverticulitis

Bowel rest, oral antibiotics, and observation

Which 3 structures are at risk during fracture of middle 1/3 of clavicle?

Brachial plexus, subclavian artery, and subclavian vein (located in thoracic outlet)

Side effects of laprascopic CO2 insufflation of abdomen

Bradycardia and AV block (caused by peirtoneal stretch receptors sensing increased intraabdominal pressure, resulting in increased vagal tone --> presents with severe bradycardia, AV block, asystole, and sometimes elevated BP due to increased SVR)

Best next step in management for patient with new-onset CN6 palsy (medial gaze)

Brain MRI (abducens nerve/CN6 palsy usually caused by intracranial mass)

4yo boy presents with worsening ear pain after completing abx for AOM 2wks ago, as well as morning headaches with vomiting Vitals: febrile 100.4F, BP 100/60, HR 95, RR 18 PE: bulging erythematous opaque left TM, and tender erythematous swollen left mastoid Labs: elevated WBC

Brain abscess (caused by direct spread of bacterial infection in face/mouth, resulting in cerebral edema and increased ICP that stimulates medullary vomiting center and area postrema --> risk factors: AOM, mastoiditis, sinusitis, dental infection, and cyanotic heart disease --> mastoiditis, presents with fever, severe headache worse at night, nausea/vomiting, focal neuro deficits, and papilledema --> diagnosis: CT w/ contrast or MRI shows ring-enhancing lesion with surrounding edema --> treatment: IV antibiotics + needle aspiration and/or surgical excision)

MRI: multiple ring-enhancing lesions at grey-white junction

Brain metastases (treat with whole brain radiation)

12M presents with 1mo hx of left neck mass w/ fluid leakage after resolution of fever + URI PE: cystic left neck mass and small pit anterior to SCM leaking mucopurulent fluid

Branchial cleft cyst (BCC: usually associated with abnormality in 2nd branchial arch forming structures in face + upper neck --> presents after URI with erythematous, tender, lateral neck mass ANTERIOR to SCM and INFERIOR to mandible with mucopurulent drainage from sinus tract --> treatment: surgical resection)

COCPs increase the risk of which cancers?

Breast and cervical cancer (breast cancer: due to progestin component --> cervical cancer)

Contraindications to estrogen

Breast cancer, endometrial cancer, VTE, CAD, and liver disease

2-week-old infant presents with jaundice

Breast milk jaundice (occurs in breastfed infants whose physiologic jaundice persists beyond week 1 due to high levels of beta-glucuroidase in breast milk, which deconjugates intestinal bilirubin and increases enterohepatic circulation --> presents with isolated jaundice and NORMAL exam)

4-day-old boy who is exclusively breastfed since birth for 10mins on each breast every 4hrs presents with scleral icterus and jaundice of face/chest/abdomen Labs: elevated total bili, elevated indirect bili

Breastfeeding jaundice (insufficient intake of breast milk causing exaggerated INDIRECT hyperbilirubinemia in 1ST WEEK OF LIFE due to delayed stooling/delayed bilirubin elimination and increased enterohepatic circulation --> causes: delayed milk production >72hrs after birth, inadequate milk supply, infrequent feeding, cracked/clogging nipples, poor infant latch, ineffective suck, or falling asleep during feeds --> presents with scleral icterus/jaundice and dehydration with >7% wt loss and decreased UOP --> diagnosis: elevated INDIRECT bilirubin --> treatment: increase feeds to every 2-3h for 10-20mins)

Most important prognostic indicator in malignant melanoma

Breslow depth (distance from epidermal granular cell layer to deepest visible melanoma cells)

Knee XR: radiolucent, elongated lesion with surrounding reactive sclerosis

Brodie abscess (type of chronic osteomyelitis occurring in femoral/tibial metaphysis seen in TEENS age 10-20yo --> diagnosis: knee XR shows radiolucent elongated lesion with surrounding reactive sclerosis)

55F presents with 2yr hx of episodic cough productive of yellow sputum that improves after antibiotics but sx always recur, associated with blood-tinged sputum, SOB, and sinus congestion PE: diffuse rhonchi and wheezes with coarse crackles in base b/l CXR: linear atelectasis in mid and lower lung fields b/l

Bronchiectasis (disease of bronchial wall damage and airway dilation caused by combo of infectious insult and impaired bacterial clearance, resulting in recurrent cycles of infection + inflammation + tissue damage --> causes: immunocompromise, structural airway defect, CF, A1AT deficiency, hypogammaglobulinemia, RA, Sjogren syndrome, lung cancer, recurrent aspiration, and chronic lung infection with aspergillosis or Mycobacteria--> presents with chronic cough with large >100mL/day production of mucopurulent sputum, SOB, sinus congestion, fatigue, wt loss, hemoptysis, and coarse crackles and wheezing on lung exam --> CXR: linear atelectasis, dilated and thickened airways, and irregular peripheral opacities --> diagnosis: high-resolution CT chest shows thin-walled cystic spaces aka bronchial dilation, lack of airway tapering, and bronchial wall thickening --> workup: PFTs, CF testing, and sputum culture for bacteria + fungi + mycobacteria)

6-month-old girl presents with 2-day hx of cough, congestion, increased WOB, fussiness, and decreased appetite Vitals: afebrile, RR 65 PE: fussy, tachypneic with nasal flaring and subcostal retractions, and prolonged expiratory phase with diffuse crackles and end-expiratory wheezing

Bronchiolitis (lower respiratory tract infection caused by RSV, rhinovirus, influenza virus, and parainfluenza virus --> presents in CHILDREN <2yo with cough, congestion, rhinorrhea, diffuse wheezing/crackles, and respiratory distress which peaks on day 3-5 before gradually resolving --> treatment: supportive with nasal saline and suctioning --> complications: apnea in infants <2mo and respiratory failure --> prevention: palivizumab for preterm infants <29wks, infants <2yo with BPD, and hemodynamically significant congenital heart disease)

Differential diagnosis for middle mediastinal mass

Bronchogenic cyst, tracheal tumor, pericardial cyst, lymphoma, and aortic arch aneurysms

4-month-old born at 27wks 2/2 PPROM who spent 3mo in hospital for tx of sepsis and RDS requiring intubation + mechanical ventilation + umbilical artery catheterization. Currently receiving O2 and diuretic therapy at home. Vitals: afebrile, BP 78/45, HR 104, RR 32 PE: 5th percentile for wt and length, decreased breath sounds b/l, occasional wheezing, pronounced S2 and precordial heave, and hepatomegaly ECG: RA deviation and RV hypertophy

Bronchopulmonary dysplasia (BPD: chronic lung disease of the neonate caused by repeated insult to the neonatal lung from mechanical ventilation, prolonged O2 exposure, and inflammation --> risk factors: prematurity, low birth wt <2500g, RDS, and mechanical ventilation --> presents with persistent O2 requirement with tachypnea and rhonchi --> diagnosis: CXR shows bilateral haziness and decreased lung volumes --> treatment: self-resolves in 2-4mo --> complications: pulmonary arterial HTN presenting with pronounced S2, precordial heave, hepatomegaly, and ECG showing RA deviation + RV hypertrophy)

Treatment of massive hemoptysis (>600mL blood over 24hrs, or >100mL/hr bleeding rate)

Bronchoscopy (localizes bleeding site, provides suctioning ability to improve visualization, and can include other therapeutic interventions such as balloon tamponading or electrocautery)

25yo F who went camping yesterday and felt a bite on her right upper thigh presents with small ulcer on right upper thigh with increasing pain PE: erythematous and painful ulcer on lateral aspect of right thigh

Brown recluse spider bite (presents with deep skin ulcer at site of bite with erythematous halo and necrotic center that progresses to eschar --> treatment: basic wound management, debridement once lesion is stable, or skin grafting)

Which incomplete cord syndrome carries best prognosis?

Brown-Sequard syndrome (hemisection of spinal cord from penetrating trauma such as gunshot/stabbing, causing injury to CST + posterior columns + spinothalamic tracts --> presents with IPSILATERAL loss of motor function + touch/pressure sensation + proprioception, as well as CONTRALATERAL loss of pain/temp sensation)

Which diseases are X-linked recessive disorders?

Bruton agammaglobulinemia, muscular dystrophy, Fabry disease, G6PD deficiency, hemophilia, Hunter syndrome, hyper IgM syndrome, Lesch-Nyhan syndrome, ocular albinism, OTC deficiency, and Wiskott-Aldrich syndrome

Diagnostic para: - Color: straw-colored - Normal amylase - High protein (>2.5g) - High SAAG (>1.1)

Budd-Chiari syndrome (hepatic vein thrombosis/compression with centrilobular congestion and necrosis, leading to congestive liver disease --> causes: hypercoagulability, polycythemia vera, postpartum, HCC --> presents with severe RUQ pain with jaundice, hepatic encephalopathy, hepatomegaly, ascites, and varices --> diagnosis: para shows high protein and high SAAG due to normal albumin production AND portal HTN, liver appears mottled in appearance aka "nutmeg liver")

Contraindications to NOACs (oral factor Xa inhibitors)

CKD and cancer

Type of bias in which observers misclassify data due to diff in interpretation or preconceived expectations

Observer bias (type of observational bias)

42F presents with 4wk hx of vague worsening upper abdominal pain + distension and generalized pruritus worsened by water contact Vitals: afebrile, BP 152/80, HR 88, RR 16 PE: facial plethora and mild scleral icterus, distended abdomen with flank dullness to percussion, and tender hepatosplenomegaly Labs: elevated H&H, elevated platelets, elevated WBC, elevated total bili, elevated AlkPhos, elevated AST + ALT

Budd-Chiari syndrome (hepatic venous outflow obstruction caused by thrombosis from HCC/cirrhosis, MPD such as polycythemia vera, and OCP use/pregnancy --> presents with vague abdominal pain, jaundice, hepatosplenomegaly, ascites, and variceal bleeding --> labs: elevated transaminases, elevated total bili, prolonged INR + PTT --> diagnosis: abdominal US shows decreased hepatic vein flow)

Causes of high-protein ascites (para total protein >2.5g/dL)

Budd-Chiari syndrome, chronic pancreatitis, CHF, constrictve pericarditis, peritoneal carcinomatosis, and fungal infection

Treatment of microscopic colitis

Budenoside and loperamide (budenoside: steroid that decreases microscopic bowel inflammation --> loperamide: opioid agonist in GI tract that reduces bowel motility)

Most common location of urethral strictures

Bulbar urethra (found immediately distal to prostatic urethra under the scrotum within the perineum)

Which structures are involved in 2nd-degree perineal laceration?

Bulbocavernosus muscle and perineal body (2nd degree perineal laceration: heal quickly due to high vascularity of vaginal tissue and lack of extensive muscle damage --> usually no long-term sequelae)

Otoscopic findings associated with acute otitis media (AOM)

Bulging TM, pale yellow opaque TM, decreased TM mobility on pneumatic insufflation, and air-fluid levels (bulging TM: due to middle ear inflammation --> pale yellow opaque TM: suggestive of purulent effusion --> decreased TM mobility and air-fluid levels: due to middle ear effusion)

Skin biopsy: subepidermal blisters and linear IgG at basement membrane

Bullous pemphigoid (autoimmune skin disorder characterized by type II hypersensitivity reaction against hemidesmosomes, causing subepidermal cleavage and production of bullae --> presents in ELDERLY >60yo with prodrome of pruritic eczematous/urticarial lesions followed by tense bullae and plaques affecting flexural surfaces + groin + axilla --> diagnosis: skin biopsy shows subepidermal cleavage and linear IgG along basement membrane --> treatment: high-potency topical steroids)

Best next step in management for patient with arrest of active labor

C-section (decreases risk of intraamniotic infection and PPH)

Colonoscopy: pseudomembrane with erythema, edema, and ulceration of bowel wall

C. difficile colitis

What is the most common levels of cervical vertebral fracture?

C2 > C6 > C7 (approx 1/3 of all C2 fractures are odontoid fractures)

Which dermatome level supplies the shoulders?

C4

Which nerve root is responsible for biceps reflex?

C5-C6

Which nerve roots are involved in Erb-Duchenne palsy (waiter's tip)?

C5-C6 (aka UPPER TRUNK of brachial plexus)

Patient presents with neck pain and upper arm weakness in radial forearm + thumb PE: decreased biceps and brachioradialis reflex, and weak forearm flexion

C5-C6 disc herniation

What is the most common level of subluxation injury?

C5-C6 interspace (area of greatest flexion and extension in C-spine)

Which nerve root is responsible for brachioradialis reflex?

C6

Which dermatome level supplies the thumb?

C6 (thumbs up sign on left hand looks like a 6)

47M presents after falling down stairs with neck/shoulder pain and numbness + weakness of LUE PE: left-sided weakness of wrist extension, and numbness of forearm + thumb

C6 facet dislocation (C5/C6 facet dislocation: occurs after forced flexion of cervical spine resulting in anterior subluxation of C5 vertebral body relative to C6, causing radiculopathy of C6 nerve root --> presents with weakness of wrist extension and numbness of forearm + thumb)

Patient presents with neck pain and upper arm weakness extending to index + middle finger PE: decreased triceps reflex and weak forearm extension

C6-C7 disc herniation

Most common sites of cervical disc herniation

C6-C7, C5-C6, and C7-T1

Which nerve root is responsible for triceps reflex?

C7

47M presents after falling down flight of stairs with neck/shoulder pain and numbness + weakness of LUE PE: left-sided weakness of elbow extension and wrist flexion, and decreased sensation of index/middle fingers

C7 facet dislocation (C6/C7 facet dislocation: occurs with forced flexion of cervical spine resulting in anterior subluxation of C6 vertebral body relative to C7, causing radiculopathy of C7 nerve root --> presents with weakness in triceps extension + wrist flexion, and numbness of index + middle fingers)

Which nerve roots are involved in Klumpke's palsy (claw hand)?

C8-T1 (aka LOWER TRUNK of brachial plexus)

Best next step in management for postmenopausal woman with new ovarian cyst

CA-125 (tumor marker for epithelial ovarian cancer --> if pelvic US shows small size/simple cyst and CA-125 is normal, pt observed with periodic US --> if pelvic US shows large mass/solid components/septations and/or elevated CA-125, pt should undergo CT or MRI to assess extent of disease)

Lee's revised cardiac risk index's intermediate risk factors

CAD, CHF, stroke/TIA, insulin-dependent diabetes, Cr >2, and high-risk surgery (each factor gets 1 pt for total score from 0-6)

Which antibiotics are effective against Pseudomonas?

CAMPFIRE (C: carbapenems --> A: aminoglycosides --> M: monobactams --> P: polymyxins --> F: fluoroquinolones such as cipro or levo --> thIRd and 4th gen cephalosporins: ceftazidime and cefepeime --> E: extended-spectrum penicillins such as piperacillin or ticarcillin)

Which labs should be obtained during initial eval of hypertension?

CBC, CMP, TSH, HbA1c, lipid panel, UA, and ECG (CBC: evaluate H&H --> CMP: evaluate electrolytes and Cr --> TSH: evaluate thyroid disorder --> HbA1c: evaluate T2DM --> UA: exclude hematuria and proteinuria --> ECG: screen for LV hypertrophy or prior MI)

Management of suspected neonatal sepsis (for infants <90 days)

CBC, UA, blood and urine cultures, LP, and ampicillin plus gentamicin (make sure you get cultures BEFORE giving empiric abx)

1st line treatment of bulimia nervosa

CBT, nutritional rehab, and fluoxetine (need to have COMBO OF ALL 3 for effective tx of bulimia nervosa)

1st line treatment of diffuse esophageal spasm (DES)

CCB (calcium channel blockers: relieve pain and reduce dysphagia --> 2nd line tx include nitrates or TCAs)

Definition of cerebral perfusion pressure (CCP)

CCP = MAP - ICP (note: normal CCP >70)

Which scoring system is used to determine requirement for anticoagulation for patients with AFib/atrial flutter?

CHA2DS2VASC score (CHF: 1 pt --> HTN: 1 pt --> age >75: 2 pts --> T2DM: 1 pt --> stroke/TIA: 2 pts --> vascular disease: 1 pt --> age 65-74: 1 pt --> sex category female: 1 pt --> score 2+ in males, 3+ in females requires anticoagulation)

CXR: pulmonary vascular congestion and interstitial edema

CHF (congestive heart failure)

Contraindications to beta-blockers during acute STEMI

CHF and bradycardia

Biggest complications of total parenteral nutrition (TPN)

CLABSI (central-line associated bloodstream infection: infection of CVC usually due to Staph epidermidis, Staph aureus, Klebsiella, Pseudomonas, and Candida --> risk factors: poor patient hygiene, severe illness, and longer duration of therapy --> cholestasis only occurs for patients on TPN for >2wks)

65M with PMHx of T2DM, smoking, and 2 bronchitis episodes in last 4mo presents with 2-day hx of high fevers, confusion, and productive cough with green sputum Vitals: febrile 101.2F, BP 118/74, HR 98, RR 24, SaO2 92% on RA PE: enlarged nonpainful anterior cervical LNs, scattered rales at right lung base, and hepatosplenomegaly CXR: developing RLL infiltrate Labs: low Hgb and WBC 24k with lymphocyte predominance

CLL (chronic lymphocytic leukemia/small lymphocytic lymphoma aka CLL/SLL: most common adult leukemia caused by proliferation of CD20+, CD23+, CD5+ B-cells --> presents in ELDERLY >60yo with LAD, hepatosplenomegaly, mild thrombocytopenia and anemia, and SEVERE LYMPHOCYTOSIS --> diagnosis: peripheral smear shows smudge cells, flow cytometry shows mature B cell clonality --> treatment: alemtuzumab and rituximab --> complications: recurrent infections, warm or cold AIHA, and Richter transformation to DBCL)

Peripheral smear: abundance of mature-appearing lymphocytes with increased fragility

CLL (chronic lymphocytic leukemia: most common adult leukemia characterized by CD20/CD23/CD5 B-cell neoplasm --> presents in ELDERLY >60yo with anemia, thombocytopenia, recurrent infections, LAD, and hepatosplenomegaly --> labs: severe lymphocytosis >50k, peripheral smear shows SMUDGE CELLS --> diagnosis: flow cytometry shows monoclonal B lymphocytes --> treatment: CD20 inhibitor such as rituximab, CD52 inhibitor such as alemtuzumab --> complications: AIHA and Richter transformation to diffuse large B-cell lymphoma)

Labs: - WBC >100k - Myelocytes > metamyelocytes - Absolute basophilia - LOW leukocyte alkaline phosphatase

CML (chronic myeloid leukemia: caused by Philadelphia chromosome on t 9;22 with BCR-ABL hybrid gene, resulting in myeloid stem cell proliferation --> presents in MIDDLE-AGED ADULTS age 45-85yo with WBC >150K with EARLY NEUTROPHIL precursors, LOW LAP, and absolute BASOPHILIA --> treatment: BCR-ABL TK inhibitors such as imatinib + dasatinib)

Patient with AIDS (CD4 <50) presents with abdominal pain and frequent, small-volume, bloody diarrhea

CMV colitis (presents in patients with AIDS CD4 <50 with low-grade fevers, abdominal pain, weight loss, and frequent small-volume bloody stools --> treatment: valganciclovir and antiretroviral therapy)

35F with PMHX of HIV (CD4 <100) presents with 3-day hx of burning substernal chest pain and "excruciating" pain when swallowing PE: normal oral exam

CMV esophagitis (viral esophagitis that occurs in patients with HIV with CD4 <100 --> presents with severe odynophagia WITHOUT oral thrush --> diagnosis: upper GI endoscopy shows large linear distal esophageal ulcers, biopsy shows intranuclear + intacytoplasmic inclusions --> treatment: valganciclovir)

Fundoscopic exam: yellow-white exudates adjacent to fovea and retinal vessels

CMV retinitis (causes retinitis in patients with advanced AIDS with CD4 <100 --> presents with PAINLESS blurry vision, floaters, and photopsia aka sensation of flashing lights --> diagnosis: fundoscopic exam shows "fluffy" yellow-white hemorrhagic lesions adjacent to fovea + retinal vessels --> treatment: oral + intravitreal valganciclovir)

Which nerve is most commonly affected by increased ICP?

CN6 (abducens nerve: most commonly affected by increased ICP due to long course thru skull to lateral rectus/LR muscle --> CN6 palsy presents with diplopia and impaired eye abduction)

Triad of pons infarction (Millard-Gubler syndrome)

CN6 palsy, CN7 palsy, and contralateral hemiplegia

Which nerves are associated with the referred otalgia seen in HNSCC?

CN9 and CN10 (CN9: glossopharyngeal nerve that innervates both base of tongue and external auditory canal --> CN10: vagus nerve that innervates part of larynx/hypopharynx and external auditory canal)

47F found down in garage presents to ED obtunded Vitals: afebrile, BP 106/64, HR 108, RR 22 PE: does not follow commands, occasional wheezes, and decreased bowel sounds Labs: anion gap metabolic acidosis Brain MRI: bilateral hyperintensity of globus pallidus

CO poisoning (carbon monoxide poisoning: caused by smoke inhalation or car exhaust inhalation in an enclosed space , resulting in large reduction in O2-carrying capacity + left shift in Hb curve decreasing O2 unloading into tissues + disruption of OxPhos in mitochondria --> presents with signs of cerebral hypoxia such as headache, dizziness, confusion, malaise, dizziness, and nausea --> labs: anion gap metabolic acidosis due to lactic acidosis --> imaging: MRI shows bilateral hyperintensity of globus pallidus, indicating cerebral hypoxia --> diagnosis: ABG shows elevated carboxyhemoglobin level --> treatment: high-flow 100% O2)

Management of menopausal symptoms for women with intact uterus

COCPs (combined estrogen-progestin oral contraceptive pills --> decreases risk of endometrial cancer associated with unopposed estrogen)

Management of AUB in woman <45yo

COCPs (medical management for women <45yo due to low risk of endometrial hyperplasia/cancer --> estrogen regulates menstrual cycle to build up endometrium, and progestin sheds endometrium --> indications for endometrial biopsy in women <45yo: PERSISTENT AUB despite COCP trial, increased estrogen exposure from obesity/PCOS, and Lynch syndrome)

Most common cause of multifocal atrial tachycardia (MAT)

COPD exacerbation (also caused by RA enlargement, hypokalemia, and sepsis 2/2 catecholamine surge)

Causes of alveolar hypoventilation

COPD, chest wall abnormality, neuromuscular disease, drugs, and primary CNS disease (chest wall abnormality: OSA, obesity hypoventilation, scoliosis --> neuromuscular disease: myasthenia gravis, Lambert-Eaton syndrome, GBS --> drugs: anesthetics, narcotics, sedatives --> primary CNS dysfunction: brainstem lesions, infection, stroke)

Diagnosis of Kawasaki disease

CRASH and burn (C: conjunctival injection that is bilateral, nonexudative, and limbus-sparing --> R: rash that is polymorphous and desquamating --> A: adenopathy >1.5cm, usually cervical --> S: strawberry tongue aka oral mucositis + erythema + fissured lips --> H: hand-foot changes such as edema/erythema --> burn: high fever --> treatment: IVIG within 10d of fever onset and aspirin --> complication: coronary artery aneurysm leading to thrombosis/death)

Diagnosis of neurosyphilis

CSF levels of VDRL, FTA-ABS, and PCR

35F with persistent unilateral rhinorrhea that increases with BMs or bending over to pick something off floor

CSF rhinorrhea (drainage of CSF thru skull base usually occurring after trauma with fracture at cribriform plate/temporal bone, sinus surgery, or elevated ICP --> presents with unilateral watery rhinorrhea with salty/metallic taste that increases with BMs/bending over --> diagnosis: testing nasal discharge with CSF-specific proteins such as beta-2 transferrin or beta-trace protein, imaging with intrathecal contrast, or endoscopy with intrathecal fluorescein dye --> treatment: inpatient mgt with bed rest, HOB elevation, and frequent neuro evals --> complication: meningitis due to nasal flora contamination of CSF)

Best next step in management for patient with: 1) Elevated 24hr urine free cortisol 2) Elevated ACTH 3) No suppression with dexamethasone

CT CAP (CT chest/abdomen/pelvis: patient with high cortisol + ACTH and no suppression indicates ECTOPIC ACTH secretion, usually from small cell lung cancer --> need to pan scan to look for tumor + possible mets)

Best next step in management for non-pregnant adult with suspected appendicitis

CT abdomen/pelvis (normal appendix: evaluate for other dx --> non-visualized appendix: management depends on Alvarado score --> non-perforated appendicitis: antibiotics and appendectomy <12hrs --> perforated appendicitis: antibiotics, bowel rest, and percutaneous drainage for contained abscess vs. I&D with appendectomy for diffuse contamination)

Patient presents with blunt abdominal trauma and is hemodynamically stable. FAST exam shows intraperitoneal free fluid. Best next step in management?

CT abdomen/pelvis with contrast (ideal for visualizing extent of injury and diagnosing ongoing bleeding)

Best next step in management for patient with recurrent pneumonia in same anatomic location of lung

CT chest (looking for LUNG CANCER, LAD, vascular anomaly, bronchiectasis, bronchial stenosis, or endobronchial carcinoid tumor)

Management of diverticular abscess with >3cm fluid

CT-guided percutaneous drainage (if symptoms not controlled by 5th day, proceed to surgical drainage + debridement)

16yo M presents with left shoulder + hand pain after FOOSH injury in which he heard crunching sound and had intense pain in left shoulder PE: holding left arm with right hand, bruising around left shoulder and small hematoma at base of neck, and decreased left radial pulse XR: displaced fracture of clavicle Next step in management?

CTA (presence of "soft signs" after bone fracture indicates possible arterial injury, but need to do CTA to further investigate --> soft signs include diminished distal pulses, unexplained hypotension, stable hematoma, documented hemorrhage at time of injury, and associated neuro deficit --> "hard signs" that require immediate surgical intervention include distal limb ischemia, absent distal pulses, active hemorrhage or rapidly expanding hematoma, and bruit/thrill at site of injury)

Best next step in management with unilateral fixed, dilated pupil and "down and out" gaze

CTA of head (non-pupil-sparing CN3 palsy: usually caused by mass effect from PComm aneurysm or uncal herniation --> presents with ptosis, fixed dilated pupil, and "down and out" gaze --> requires immediate CTA/MRA of head for further eval)

Which tool is used to determine whether a patient with CAP should be hospitalized?

CURB65 (C: confusion --> U: urea >20 --> R: respirations >30 --> B: SBP <90 or DBP <60 --> 65: age >65yo --> if 1-2pts, likely inpatient tx --> if 3-4 pts, need urgent inpatient admission with possible ICU if score >4)

13yo with recurrent infections Labs: - Normal B cell count - Low IgG, IgM, and IgA

CVID (common variable immunodeficiency syndrome: defect in B-cell differentiation --> presents AFTER AGE 2 with recurrent sinopulmonary infections --> diagnosis: normal B cell count, low plasma cells, low IgG/IgM/IgA --> complications: increased risk of autoimmune disease, bronchiectasis, lymphoma)

Best next step in management for patient with suspected VAP

CXR (if positive for alveolar infiltrates, air bronchograms, or silhouetting of adjacent solid organs then you need to order lower respiratory tract sampling with culture, aka bronch brush --> also start pts on empiric antibiotics until culture susceptibility results)

8yo boy presents with 2mo hx of increasing pain in back of heels after starting basketball PE: unable to stand directly on heels without pain, mild swelling of heels b/l with bases tender to palpation, and reproducible pain on dorsiflexion of ankle

Calcaneal apophysitis (Sever disease: overuse injury caused by repetitive microtrauma to calcaneal apophysis aka heel growth plate, which is most susceptible to stress during periods of rapid growth --> risk factors: athletic children age 8-2yo participating in running/jumping sports --> presents with chronic heel pain worse with activity, heel swelling, tenderness on squeezing heel and palpating base of heel, and limited ankle dorsiflexion --> treatment: stretching, ice, NSAIDs, and heel cup insert for cushioning)

Heel pain when pressing at sides of the heel

Calcaneal stress fracture (caused by initiation of high-impact exercise --> presents with heel pain w/ weight-bearing and reproducible pain when pressing sides of heel)

Skin exam: painful violaceous SQ plaques with necrotic ulceration on bilateral LE

Calciphylaxis (calcific uremic arteriolopathy: arteriolar and soft tissue calcification that leads to local tissue ischemia and necrosis --> risk factors: ESRD on dialysis, kidney transplant, hypercalcemia, hyerphosphatemia, obesity, T2DM, and warfarin use --> presents with painful violaceous or purpuric SQ plaques + nodules that progress to ischemic/necrotic ulcers, usually on trunk + thighs --> labs: high PTH and hyperphosphatemia --> imaging: soft tissue calcifications --> skin biopsy: arterial calcification with thrombotic occlusion and subintimal fibrosis --> complication: sepsis)

Causes of elevated CVP

Cardiogenic and obstructive shock (cardiogenic shock: increases CVP due to back pressure from forward pump failure --> obstructive shock: increases CVP due to back pressure from obstructed cardiac filling)

67F with PMHx of T2DM and ESRD on hemodialysis presents with 2wk hx of painful skin lesions on LE Vitals: afebrile, BP 159/79, HR 97, RR 16 PE: diffuse violaceous SQ plaque on b/l LE with significant ulceration Labs: high BUN, high Cr, and normal Ca2+ Punch biopsy of skin lesion: calcification of middle layer of arterioles, subintimal fibrosis, and thrombotic occlusion without vasculitis

Calciphylaxis (calcific uremic arteriolopathy: systemic arteriolar calcification and soft-tissue calcium deposition leading to ischemia and necrosis, usually occurring in areas of high adiposity such as trunk/thighs --> risk factors: ESRD on hemodialysis, kidney transplants, hypercalcemia, hyperphosphatemia, obesity, T2DM, and warfarin use --> presents with painful SQ violaceous or purpuric plaques/nodules that form necrotic ulcers with INTACT peripheral pulses --> labs: high PTH and hyperphosphatemia --> imaging: soft tissue calcification --> diagnosis: skin biopsy shows arterial calcification/occlusion and subintimal fibrosis)

Causes of PTH-independent hypercalcemia

Cancer, vitamin D toxicity, granulomatous diseases, milk-alkali syndrome, thyrotoxicosis, vitamin A toxicity, thiazides, and immoblization

35F with PMHx of HIV (CD4 <100) presents with 3-day hx of burning substernal chest pain and difficulty swallowing PE: oral thrush in back of throat

Candida esophagitis (most common cause of esophagitis in patients with HIV --> presents with MILD DYSPHAGIA and ORAL THRUSH, without odynophagia --> diagnosis: upper GI endoscopy shows white plaques throughout esophagus, biopsy shows pseudohyphae --> treatment: fluconazole)

52F with PMHx of smoking, migraines, chronic diarrhea, and severe post-menopausal flushes presents with "pounding" sensation in neck, LE edema, and wt loss PE: 2/6 murmur at lower sternal border that increases with inspiration ECHO: retracted and immobile tricuspid valve leaflets with poor coaptation and severe tricuspid insufficiency

Carcinoid syndrome (presence of well-differentiated neuroendocrine tumor in distal small intestine, proximal colon, and bronchus with strong propensity for liver mets that secretes histamine + serotonin + VIP metabolized in liver --> from liver, travels to right heart and forms plaque-like deposits of fibrous tissue in right heart endocardium causing tricuspid regurgitation and right HF --> presents with episodic FLUSHING, cutaneous telangiectasias, secretory diarrhea, bronchospasms, and tricuspid regurgitation --> diagnosis: elevated 24hr urine 5-HIAA, CT/MRI of abdomen + pelvis to locate tumor, OctreoScan to detect mets, and echo to detect carcinoid heart disease --> treatment: octreotide prior to surgery)

ECHO: LA enlargement, concentric LV hypertrophy WITHOUT LV cavity dilation, and normal ejection fraction

Cardiac amyloidosis (type of restrictive cardiomyopathy caused by fibril deposition within heart, causing increased LV wall thickness with decreased cavity size and eventual LA enlargement --> presents with right heart failure with preserved EF --> diagnosis: ECHO shows concentric LV hypertrophy with non-dilated LV cavity

Complications of electrical burns

Cardiac arrhythmias, muscle necrosis, posterior shoulder dislocation, myoglobinuria, and renal failure (due to electrical burns following path of least electrical resistance via nerves, blood vessels, and fascia)

43F presents with acute onset of left-sided weakness. She has a 3mo hx of fatigue, low-grade fevers, occasional palpitations, and 13.2lb wt loss. PE: mid-diastolic rumble at apex and left-sided weakness Labs: low Hb, elevated ESR Head CT: multiple small, acute infarcts in right parietal and temporal lobes TTE: LA mass

Cardiac myxoma (benign cardiac tumor occurring in LEFT ATRIUM that obstructs blood flow from LA to LV, leading to mitral stenosis-like murmur and decreased CO --> presents with fever, wt loss, position-dependent SOB/lightheadedness/syncope, and mid-diastolic murmur at apex with "tumor plop" at end of diastole --> diagnosis: ECHO --> treatment: surgical resection --> complication: embolization of tumor fragments causing stroke/arterial ischemia)

Which parameter is estimated by central venous pressure/CVP?

Cardiac preload (due to CVP measuring pressure in SVC, which approximates RA pressure)

ECHO: diastolic collapse of RA and RV with plethora of IVC

Cardiac tamponade (accumulation of blood in pericardial space leading to increased diastolic pressure in chambers of heart and severely impaired venous return --> causes: aortic aneurysm, post-MI LV free wall rupture, postop CABG, myo/pericarditis, TB, cancer, radiation, and CT disease --> presents with Beck's triad of hypotension + JVD + muffled heart sounds, cardiogenic shock with reduced UOP + cool extremities, and pulsus paradoxus aka loss of radial pulse during inspiration --> diagnosis: PA cath shows elevated equalization of intracardiac diastolic pressures, ECG shows low-voltage QRS with electrical alterans, and ECHO shows RA and RV diastolic collapse + bowing of IV septum into LV during inspiration + IVC plethora --> treatment: pericardiocentesis)

43yo F with recent URI presents with 2wk hx of fatigue and SOB PE: BP 98/55, HR 105 PE: jugular venous distension CXR: enlarged cardiac silhouette

Cardiac tamponade (compression of heart by pericardial effusion, causing equilibration of diastolic pressure in all 4 chambers and decreased CO --> causes: preceding viral illness, bacterial/fungal infections, neoplasms, post-MI, trauma, uremia, autoimmune diseases, and hypothyroidism --> presents with Beck triad of hypotension + elevated JVP + distant heart sounds, along with tachycardia, pulsus paraxodus, and inability to find point of maximal apical impulse --> diagnosis: EKG shows low-voltage QRS and electrical alterans, CXR shows enlarged and globular cardiac silhouette with "water bottle" heart shape)

ECHO: RV diastolic collapse and bowing of IV septum into LV during inspiration

Cardiac tamponade (rapid accumulation of blood into pericardial space leading to elevated equalized diastolic pressure in all 4 chambers and severely impaired venous return --> presents with cardiogenic shock, hypotension, elevated JVD, distant muffled heart sounds, and pulsus paradoxus --> workup: ECG shows low-voltage QRS and electrical alterans, CXR shows enlarged cardiac silhouette with clear lungs --> dianosis: urgent echo shows RA + RV diastolic collapse, plethora of IVC, and bowing of IV septum into LV during inspiration --> treatment: immediate percutaneous or pericardial window drainage of pericardial fluid)

Causes of pulsus paradoxus (SBP drop >10 and/or loss of radial pulses during inspiration)

Cardiac tamponade, pericarditis, asthma, COPD, and croup (tamponade + pericarditis: due to increased venous return heart during inspiration causing leftward shift of IV septum, thus reducing LV EDV and overall SV --> asthma + COPD + croup: due to large drop in intrathoracic pressure in obstructive lung disease resulting in pooling of blood in lungs and decreasing LV preload + lung hyperinflation impinging on heart expansion during inspiration)

Shock parameters: - High CVP - High PCWP - Low CI - High SVR - Low SvO2

Cardiogenic shock (caused by inability for heart to pump due to acute MI, CHF, valvular dysfunction, or arrhythmia --> causes increased CVP/right-sided preload and INCREASED PCWP/left-sided preload due to increased SVR pushing blood into heart, but heart not being able to function causing low CO and low SvO2 --> ECHO: dilated LV with apical hypokinesis and engorgement of IVC)

Indications for emergency CABG in setting of STEMI

Cardiogenic shock, failed PCI, mechanical complications, or presentation >12h of initial insult

Workup of neck wound between mandible and cricoid cartilage

Carotid doppler US (Zone 2: between angle of mandible an cricoid cartilage --> location of carotid artery --> requires Carotid doppler US +/- exploratory surgery)

Type of study used to compare risk factor frequency

Case-control study (designed by selecting DISEASED and NON-DISEASED patients, then looking retrospectively to determine previous exposures)

Skin exam: localized nontender papule with adjacent tender, soft, freely mobile LAD with overlying erythema

Cat scratch disease (caused by Bartonella henselae, a fastidious gram-negative bacillus transmitted via cat scratch/bite --> presents with fever, localized nontender papule/nodule, and enlarged tender regional LAD with overlying erythema --> treatment: azithromycin)

75M with PMHx of T2DM, HTN, and smoking presents with 2mo hx of gradual blurry vision and difficulty reading, difficulty driving at night, and seeing halos around bright lights PE: decreased visual acuity b/l with normal visual field testing

Cataracts (opacification of lens due to oxidative damage from aging, resulting in progressive bilateral vision impairment --> risk factors: age >60yo, diabetes, smoking, chronic sunlight exposure, steroid use, and HIV --> presents with painless blurring of vision, glare + halos around bright lights at night, difficulty reading at night, and myopic shift aka improved near-sighted vision with decreased use of reading glasses --> diagnosis: fundoscopix exam shows visible opacity of lens, reduced clarity of rertinal detail, and loss of red reflex --> treatment: lens extraction with artificial lens implantation)

42yo M presents with 1-day hx of sharp shooting pain in lower back and buttons that radiates down back of legs after moving furniture yesterday, associated with weakness/numbness of legs and urinary straining PE: lower lumbar spine tenderness, decreased LE strength 4/5 bilaterally, absent ankle reflexes, decreased sensation in perineal region and buttocks, and positive straight leg raise

Cauda equina syndrome (injury to cauda equina containing L2-L5 and S1-S5 nerve roots caused by large central lumbar disc herniation at L4-S1, which bulges into lumbar cistern and compresses nerve roots --> presents with severe back pain radiating into legs, SADDLE ANESTHESIA, loss of LE motor strength + sensation + reflexes, bladder/rectal sphincter paralysis, and positive straight leg raise test --> diagnosis: MRI lumbosacral spine --> treatment: surgical decompression)

Strongest predictor of impending colonic perforation in Ogilvie syndrome

Cecal diameter >12cm (indication for IV neostigmine)

Most common sites of GI volvulus in adults

Cecum, proximal ascending colon, and sigmoid colon

Intrapartum antibiotic prophylaxis for patient with penicillin allergy with rash

Cefazolin (1st gen cephalosporin with GBS coverage)

1st-generation cephalosporins

Cefazolin and cephalexin (1st gen cephalosporins: provide coverage against gram-positive cocci such as group A strep/staph aureus, Proteus, E coli, and Klebsiella --> cefazolin used prior to surgery to prevent MSSA wound infections --> cephalexin used to treat lymphangitis and uncomplicated UTIs)

Antibiotic prophylaxis for SSI (surgical site infection)

Cefazolin, vancomycin, and clindamycin (note: vancomycin and clindamycin should only be given if there is severe penicillin or cephalosporin allergy)

Treatment of bacterial meningitis in patients with neurosurgery/shunt or skull trauma

Cefepime and vancomycin (cefepime: covers Staph epidermidis and Pseudomonas --> vancomycin: covers MRSA)

Treatment of bacterial meningitis in adults age >50 and immunocompromised

Cefepime, vancomycin, and ampicillin (cefepime: 4th gen cephalosporin that covers Strep pnemo, Neisseria, GBS, H flu, and Pseudomonas --> vacnomycin: covers MRSA --> ampicillin: covers Listeria)

Treatment of tertiary syphilis in patient with anaphylactic penicillin allergy

Ceftriaxone (give for 14 days --> if neurosyphilis present, requires penicillin desensitization and then IV penicillin G)

Treatment of confirmed gonorrhea

Ceftriaxone and azithromycin (need to give empiric treatment to cover chlamydia even if NAAT testing is negative)

Treatment of bacterial meningitis for children/adults age 2-50

Ceftriaxone and vancomycin (ceftriaxone: 3rd gen cephalosporin that covers Strep neumo, Neisseria, GBS, and H. flu --> vancomycin: covers MRSA)

Treatment of osteomyelitis in child with sickle cell disease

Ceftriaxone and vancomycin (need 3rd gen cephalosporin such as ceftriaxone or cefotaxime --> plus vancomycin or clindamycin for MRSA coverage --> if low likelihood of MRSA, can give nafcillin/oxacillin or cefazolin)

Postexposure prophylaxis for sexual assault

Ceftriaxone, azithromycin, metronidazole, HIV PReP, HBV vaccine and/or HBIG, and Plan B

Which medications decrease levothyroxine absorption?

Cholestyramine, iron, calcium, aluminum hydroxide, PPIs, and sucralfate

Which bone pathologies are found in the metaphysis?

Chondrosarcoma and osteosarcoma

Skin exam: anterior leg swelling, erythema with flat border, tenderness, and warmth to touch

Cellulitis (skin infection of deep dermis and SQ fat caused by GAS or Staph Aureus caused by skin disruption from insect bites/toe-web impetigo/stasis edema --> presents with fevers and slow-spreading poorly demarcated rash with warmth, tenderness, and erythema with flat indistinct borders --> diagnosis: leukocytosis with neutrophil predominance --> treatment: penicillin, nafcillin, oxacillin, or cephalosporin)

Labs: - Hypernatremia (>145) - Low urine osmolality (<300) after overnight fast - Increased urine osmolality after desmopressin

Central DI (decrease in ADH secretion from hypothalamus/posterior pituitary resulting in excess fluid loss --> causes: idiopathic, CNS disorder, head trauma, pituitary surgery, and ischemic encephalopathy --> presents with nocturia, dehydration, hypernatremia, and low urine specific gravity --> diagnosis: low urine osm <300 after water deprivation, but INCREASED urine osm after desmopressin)

62F with PMHx of HTN and OA presents with 3-day hx of UE weakness and numbness after being rear-ended by a truck PE: b/l weakness of hand grip, decreased triceps reflex, and decreased pinprick sensation of fingers C-spine XR: diffuse spondylotic changes

Central cord syndrome (incomplete spinal cord injury caused by hyperextension injury to neck in patients with preexisting cervical spondylosis, causing compression of spinal cord between hypertrophied ligamentum flavium POSTERIORLY and bulging disc/osteophyte complex ANTERIORLY --> presents with UE weakness/numbness, pain, sensory loss, and reflex loss --> diagnosis: cervical myelogram --> treatment: steroids and/or surgery)

Fundoscopic exam: whitened retina with attenuated vessels and "cherry-red" spot at fovea

Central retinal artery occlusion (CRAO: blockage of central retinal artery due to embolism from carotid artery atherosclerosis, cardiac vegetations, or PFO --> presents with acute painless monocular vision loss --> diagnosis: fundoscopic exam shows cloudy whitened retina with attenuated vessels and "cherry-red" spot at fovea --> workup: carotid imaging to evaluate stenosis --> treatment: anterior chamber paracentesis, ocular massage, and revascularization)

Fundoscopic exam: optic disc swelling, venous dilation and tortuosity, and retinal hemorrhages

Central retinal vein occlusion (CRVO: blockage of central retinal vein due to compression from nearby arterial atherosclerosis --> causes: coagulopathy, hyperviscosity, chronic glaucoma, and atherosclerosis --> presents with acute unilateral PAINLESS vision loss --> diagnosis: fundoscopic exam shows "blood and thunder appearance" aka optic disc swelling, venous engorgement and tortuosity, retinal hemorrhages, edema, and cotton wool spots --> treatment ONLY with significant macular edema: intravitreal injection of bevacizumab)

1-day-old girl born at 39wks via SVD presents with firm, non-fluctuant swelling confined to right side of skull

Cephalohematoma (collection of blood between skull and periosteum caused by rupture of subperiosteal blood vessels from birth trauma --> risk factors: vacuum- or forceps-assisted delivery --> presents hours after birth with firm, non-tender, non-fluctuant scalp swelling that does NOT cross suture lines --> management: observation, should resorb spontaneously within a month --> complication: hyperbilirubinemia tx with phototherapy)

Complication of rapid correction of hypernatremia

Cerebral edema (due to rapid movement of excess water from ECF into cells, causing cellular edema and possible lysis --> risk of brain herniation --> remember: "from high to low, your brains will blow")

Most common cause of death in acute liver failure

Cerebral edema (leads to coma and brainstem herniation)

10-month-old girl born at 32wks via SVD c/b pre-eclampsia with severe features presents with inability to stand. She can pull herself along the floor using arms but drags her legs behind her. PE: mild hypertonia of UE, hypertonia with significant resistance to passive extension in bilateral LE, brisk patellar reflexes, equinovarus deformities of feel b/l, and Babinski reflex b/l

Cerebral palsy (non-progressive motor dysfunction caused by prenatal insults to the brain such as periventricular leukomalacia, interventricular hemorrhage, and perinatal hypoxic-ischemic encephalopathy --> risk factors: prematurity and low birth wt --> presents with delayed gross motor milestones, hypertonia, dyskinesia, ataxia, hyperreflexia especially with spastic diplegia, equinovarus/clubfoot deformities of feet in which feet point down and inward, and contractures of lower limbs with "commando drawl" --> diagnosis: clinical by age 1-2, and MRI shows PVL and/or basal ganglia lesions --> treatment: PT/OT, speech therapy, nutritional support, and antispasmodics)

Diagnosis of protracted active labor

Cervical change <1cm every 2hrs (protracted active labor: most commonly caused by cephalopelvic disproportion --> risk factors: >41wks gestation, fetal anomaly, fetal malposition especially with occiput posterior, maternal obesity/excessive weight gain during pregnancy, nulliparity, AMA, and inadequate contractions --> management: IUPC to measure strength of contractions, IV oxytocin if <200MVUs over 10mins)

Treatment of CIN3

Cervical cone biopsy (cervical conization/excisional biopsy of cervix: both dx and tx procedure performed to remove entire lesion and examine full depth of invasion)

Management of CIN3

Cervical conization (via LEEP, cold knife conization, or cryoablation --> if POSITIVE surgical margins, require additional surgical excision with repeat conization or hysterectomy --> if NEGATIVE margins, require repeat Pap + HPV cotesting at 1 and 2yrs)

Normal rate of active phase of labor (6-10cm cervical dilation)

Cervical dilation >1cm every 2hrs

57M with PMH of HTN and HLD presents with several month hx of difficulty walking, weakness + stiffness in both legs, and numbness + tingling in arms and legs PE: mild weakness and atrophy of upper arm muscles with decreased triceps reflex, decreased strength 4/5 in bilateral LE, decreased vibratory + pain sensation in both hands and legs, and upgoing Babinski bilaterally

Cervical myelopathy (cervical cord compression caused by degenerative cervical spine/discs, causing canal stenosis and spinal cord compression --> presents in MIDDLE AGED ADULTS >55yo with gait dysfunction, extremity weakness + numbness, decreased proprioception + vibratory + pain sensation, LMN signs in arms aka muscle atrophy + hyporeflexia, and UMN signs in legs aka hyperreflexia and positive Babinski --> diagnosis: MRI or CT myelogram --> treatment: surgical decompression)

Sequelae of congenital toxoplasmosis

Chorioretinitis and obstructive hydrocephalus

62F with PMHx of depression and hypothyroidism presents with progressive gait unsteadiness due to leg stiffness, tingling/numbness in hands, and occasional electric shock-like sensation in spine PE: decreased UE muscle strength b/l with mild wasting of intrinsic hand muscles, and increased LE tone + reflexes b/l

Cervical spondylotic myelopathy (spinal cord compression in cervical spine caused by cervical spondylosis, a degenerative condition in which osteophytes in lateral vertebral bodies + ossification of posterior longitudinal ligament result in spinal canal narrowing --> presents with INSIDIOUS progressive neck pain radiating to shoulders/arms with LMN damage in UE + unsteady gait and UMN damage in LE, sometimes with Lhermitte sign --> diagnosis: MRI and myelopgraphy --> treatment: surgical decompression)

30yo M with recent dental surgery presents with enlarging face abscess exuding yellow granular pus

Cervicofacial actinomycosis (rare infection caused by Actinomyces, a gram-positive anaerobe that forms long branching filaments --> risk factors: dental carries/extraction, periodontal disease, poor oral hygiene, maxillofacial trauma, or radiation therapy --> presents with oral/facial abscesses with sinus tracts draining yellow "sulfur granule" pus --> treatment: penicillin)

Diagnosis of incidental shortened cervix

Cervix <2.5cm on US (treat with cerclage placement at 12-14wks + vaginal progesterone to decrease risk of preterm delivery)

25M presents with R eye discomfort and feels a mass PE: hard, painless nodule on upper eyelid of right eye

Chalazion (granulomatous reaction to occlusion of meibomian gland --> risk factors: rosacea or eyelid margin blepharitis --> presents with rubbery painless nodule on upper/lower eyelid --> treatment: self-resolving, improves with warm compresses to enhance drainage + speed healing)

62yo M with PMH of T1DM, HTN, HLD presents with several month hx of difficulty walking and mild pain in left foot PE: significantly deformed left ankle and mildly deformed left foot XR of left foot: bone loss, large osteophytes, and several extraarticular bone fragments

Charcot joint (neurogenic arthropathy: destruction and collapse of ankle joint + arch caused by impaired sensation and proprioception in foot, leading to altered weight bearing + mechanical stresses + recurrent trauma --> causes: diabetic neuropathy, peripheral neuropathy from B12 deficiency, syringomyelia, spinal cord injury, and tabes dorsalis/3° syphilis --> presents with difficulty in weight bearing/ambulation, mild pain with loss of sensation, foot/ankle deformities such as swelling + collapsed arch + decreased ROM, skin calluses, and neuropathic ulcers --> diagnosis: XR shows bony destruction, decreased bone mass, osteophyte formation, and loss of joint spaces --> management: casting/orthotics for mechanical offloading and correction of joint mechanics)

14yo boy with PMHx of high-arched feet and hammer toes presents with 10-mo hx of tripping and incoordination PE: mild weakness of hand musculature and weakness, wasting of anterior tibial + intrinstic foot muscles, absent DTRs at ankles and diminished elsewhere, and decreased sensation to vibration + proprioception over distal LE Nerve conduction study: markedly decreased motor nerve conduction velocities with prolonged distal motor latencies in extremities

Charcot-Marie-Tooth disease (hereditary motor and sensory neuropathy: typically autosomal dominant group of diseases caused by defective production of proteins involved in structure + function of PERIPHERAL nerves/myelin sheath --> presents with foot deformities such as pes cavus/hammer toe, LE weakness with foot drop, and sensory deficits)

Best next step in management after diagnosis of small cell lung cancer

Chemotherapy (SCLC is very chemosensitive so treat ONLY with chemo --> non-SCLC receives surgery and then chemo)

Best next step in management for patient with sternal wound drainage

Chest and sternal imaging (usually chest CT --> looking for mediastinal fluid collections or pneumomediastinum to diagnose mediastinitis)

Best next step in management for patient with circumferential chest burn and deteriorating respiratory status

Chest escharotomy (performed by incising constricting eschar to improve chest wall compliance and respiration)

Treatment of large pneumothorax >2cm in unstable patients

Chest tube thoracostomy

Which statistical test is used to compare categorical data/proportions?

Chi-square test

35F presents with 3-day hx of fever, malaise, and marked pain in hand/wrist joints after returning from Caribbean vacation Vitals: febrile 103F, BP 110/70, HR 98 PE: macular skin rash, mild cervical LAD, and swelling/tenderness of bilateral hand + wrist + ankle joints Labs: low WBCs with lymphopenia

Chikungunya fever (togavirus infection endemic to Central/South America + Caribbean + West Africa + Asia and is transmitted via Aedes mosquito --> presents 3-7 DAYS after mosquito bite with high fevers, severe polyarthalgias, headache, malaise, conjunctivitis, and maculopapular rash --> labs: LYMPHOPENIA, thrombocytopenia, and transaminitis --> diagnosis: serology --> treatment: resolves within 7-10 days, although chronic arthalgias/arthritis occurs in >50% and may require MTX)

1-hour-old boy born at 40wks via SVD to 22F G1P1 presents with blue tinge after 1min of feeding, with skin returning to normal after crying Vitals: HR 150, SaO2 87% PE: normal

Choanal atresia (failure of posterior nasal passage to canalize during 1st trimester that can be either unilateral or bilateral, causing bony/membranous obstruction in nasopharynx and inability to breathe thru nose --> causes: idiopathic or CHARGE syndrome aka coloboma, heart defects, atresia choanae, retardation, genital and ear abnormalities --> BILATERAL choanal atresia presents with hypoxia and cyanosis during feeding/pacifier that improves with crying --> diagnosis: inability to pass catheter thru nares, CT scan, or nasal endoscopy --> treatment: oral airway/intubation and orogastric tube feeds until surgery)

8yo with PMHx of recurrent AOM and tympanostomy tube placement at age 2 presents with 3mo hx of left-sided ear discharge despite completing 2 courses of antibiotics PE: hearing loss on left side, scarring on left TM with peripheral granulation and some skin debris

Cholesteatoma (benign growth of squamous epithelium with accumulation of keratin debris within middle ear --> causes: congenital or acquired 2/2 chronic middle ear disease, which forms retraction pocket in tM that can fill with granulation tissue and skin debris --> presents with continued ear drainage refractory to abx therapy, conductive hearing loss, CN palsies, and vertigo --> treatment: ENT referral --> complications: brain abscess and meningitis)

6-month-old boy presents with inability to sit, enlarging head, napping more frequently with vomiting at end of sleep PE: head circumference at 95th percentile with bulging anterior fontanelle MRI: ventriculomegaly with intraventricular mass

Choroid plexus papilloma (CPP: rare, slow-growing, benign overgrowth of choroid plexus resulting in increased CSF production, causing hydrocephalus --> presents with enlarging head circumference, poor feeding, bulging anterior fontanelle, and vomiting on waking --> diagnosis: head US shows enlarging ventricles with intraventricular mass, and MRI shows hydrocephalus with ventriculomegaly and intraventricular mass --> treatment: surgical resection)

47M with PMHx of smoking and working as traffic controller in underground parking garage presents with occasional daytime headaches, dizziness, and nausea Vitals: BP 140/90, HR 84, SaO2 97% on RA PE: grade 2/6 apical holosystolic murmur Labs: elevated HCT

Chronic CO poisoning (caused by chronic exposure to combusting organic matter--oil/gas/wood-- in enclosed or poorly ventilated areas, resulting in CO tightly binding to Hgb and forming carboxyhemoglobin with greater affinity for O2 --> presents with headaches, dizziness, nausea, malaise, confusion, seizures, syncope, MI, and arrhythmias --> labs: POLYCYTHEMIA --> imaging: MRI shows bilateral globus pallidus lesions --> diagnosis: ABG shows elevated carboxyhemoglobin --> treatment: high-flow 100% O2 and/or hyperbaric O2)

56M with PMHx of smoking presents with 1-day hx of right leg swelling and recent nosebleeds + occasional gum bleeding. Also reports 3mo hx of persistent nagging epigastric + back pain and 10lb wt loss. PE: mild epigastric tenderness and moderate asymmetric RLE edema

Chronic DIC (caused by secretion of TF into blood by mucin-producing tumors, which intermittently triggers coagulation cascade and leads to consumptive coagulopathy --> causes: pancreatic, gastric, ovarian, and breast cancer --> presents with periodic mucocutaneous bleeding, increased risk of DVT, and normal labs)

32M with FH of sudden death in maternal uncle at age 40 and cousin with heart surgery at a young age presents with occasional palpitations PE: decrescendo early diastolic murmur best heard at left sternal border when pt sits upright, leans forward, holds breath in full expiration, and firm pressure applied by stethoscope

Chronic aortic regurgitation (valvular disease of aortic valve usually caused by BICUSPID AORTIC VALVE, which can be sporadic or inherited in autosomal dominant fashion --> murmur caused by increased LV end-diastolic volume 2/2 backflow from aorta into LV in which LV initially compensates with eccentric hypertrophy to increase SV + CO, but eventually develops systolic LV dysfunction and CHF --> other causes: aortic root dilation from Marfan syndrome/syphilis best heard at RUSB, rheumatic heart disease with concomitant mitral stenosis, and infective endocarditis --> presents in YOUNG ADULTS age 30s-40s with decrescendo early diastolic murmur best heard at left sternal border with pt leaning forward and holding deep breath in expiration, widened pulse pressure, rapid rise-fall "water-hammer" pulse, "pistol-shot" femoral pulses, and abrupt carotid distension and collapse --> treatment: surgery)

30M with PMHx of multiple UTIs in last 4mo presents with 3-day hx of dysuria and urinary frequency. Also complains of pain with ejaculation. PE: smooth, nontender prostate UA: (+) leuk est and nitrites, many bacteria, 20-30 WBCs/hpf

Chronic bacterial prostatitis (caused by invasion of coliform bacteria such as E. coli into prostate from urethra via intraprostatic reflux --> risk factors: diabetes, smoking, urinary tract procedure --> presents in YOUNG/MIDDLE AGED MEN with recurrent UTIs, pain with ejaculation, and sometimes prostatic swelling/tenderness --> diagnosis: prostatic fluid bacteria > urine bacteria --> treatment: 6wks of ciprofloxacin)

Foot XR: punched-out erosions with overhanging rim of cortical bone

Chronic gout (XR shows "rat bite" lesion)

Cause of acne vulgaris

Chronic inflammation of pilosebaceous follicles

52yo M with PMH of T2DM, HTN, and right tibia open fracture s/p surgical tx 8mo ago presents with occasional fevers and clear drainage from wound requiring daily dressing PE: chronic wound with scant amount of serosanginous fluid, pain at fracture site, inability to bear full weight on right leg, and discomfort on dorsiflexion of right ankle Leg XR: bone fragmentation and ragged, irregular fracture lines

Chronic osteomyelitis (complication of incomplete bony infection tx or high-velocity tibial fractures, resulting in necrosis and fragmentation of bone --> risk factors: surgical hardware/instrumentation, T2DM, and impaired circulation or sensation in limb --> presents with nonunion of fracture, SINUS TRACT with persistently draining wound, and intermittent pain + swelling at fracture site --> XR: shows bone fragmentation and ragged, irregular fracture lines --> labs: elevated ESR and CRP --> diagnosis: open bone biopsy for culture or positive probe-to-bone test --> diagnosis: surgical debridement of infected and necrotic bone)

Diagnostic para: - Color: serosanguinous or straw-colored - High amylase (>1000) - High total protein (>2.5g) - Low SAAG (<1.1)

Chronic pancreatitis (caused by chronic alcohol use, cystic fibrosis, pancreatic duct/CBD obstruction, or autoimmune disorders --> presents with constant post-prandial epigastric pain that radiates to back and is RELIEVED BY LEANING FORWARD, abdominal distension with ascites, steatorrhea, vitamins ADEK deficiency, and diabetes --> workup: diagnostic para shows high amylase, high protein, and low SAAG --> diagnosis: CT or MRCP shows calcifications, dilated ducts, and enlarged or atrophic pancreas --> treatment: pain control, alcohol/smoking cessation, frequent small meals, and pancreatic enzyme supplement)

ECHO: concentric LV hypertrophy

Chronic pressure overload (usually due to systemic HTN or severe aortic stenosis)

Intrapartum antibiotic prophylaxis for patient with anaphylactic penicillin allergy

Clindamycin (however if GBS culture is resistant to clindamycin OR erythromycin, then give IV vancomycin)

Skin exam: PAINFUL bilateral symmetric LE dermatitis with red/brown discoloration, pitting edema with woody induration, and scaling/superficial erosions

Chronic stasis dermatitis (chronic venous stasis: due to increased intraluminal pressure on vessel wall tensile strength, leading to venous dilation + failure of venous valves causing backflow of blood and venous congestion --> high venous pressure results in increased vascular permeability and extravasation of fluid + plasma proteins + RBCs --> risk factors: obesity, advanced age, varicose veins, and history of DVT --> presents with bilateral leg pain/heaviness, pitting edema/woody induration, venous varicosities/telangiectasias, and pruritic dermatitis with dryness/scaling/superficial erosions + red/brown discoloration + weeping + irregular ulcers at medial malleolus --> diagnosis: venous duplex US to confirm venous HTN and reflux --> treatment: compression stockings, leg elevation, exercise, and avoiding long standing)

Causes of central (secondary) adrenal insufficiency

Chronic steroids, hypothalamic disease, and pituitary disease (chronic steroids >3wks: suppresses secretion of both CRH from hypothalamus and ACTH from pituitary gland, unable to meet metabolic demands for 6-12mo --> hypothalamic and pituitary disease: unable to produce CRH or ACTH --> diagnosis of secondary AI: low AM cortisol + low ACTH)

Skin exam: pruritic hyperkeratotic rash extending up sides of feet

Chronic tinea pedis (chronic athlete's foot: chronic fungal infection with Trochophyton rubrum, which is acquired from exposure to public places --> presents with pruritic/erythematous hyperkeratotic rash extending up sides of feet in "moccasin pattern," sometimes with scales/fissures/erosions --> diagnosis: KOH prep of skin scrapings --> treatment: topical azoles, terbinafine, or tolnaftate)

10-day-old girl presents with copious watery eye drainage PE: mild bilateral eyelid swelling with watery discharge and conjunctival hyperemia

Chyamydial conjunctivitis (most common cause of neonatal conjunctivitis caused by Chlamydia transmission from maternal genital secretions during delivery --> presents at 5-14 DAYS of life with mild bilateral eye, conjunctival hyperemia, and WATERY DISCHARGE that may be bloody --> treatment: ORAL azithromycin, monitor for pyloric stenosis --> complications: corneal scarring and blindness)

Diagnostic para: - Color: milky - Normal amlyase - High protein - Low SAAG - High triglycerides

Chylous ascites (usually caused by lymphoma-related lymphatic obstruction --> diagnostic para shows milky color due to presence of chyle --> high protein due to normal albumin synthesis, and low SAAG due to lack of portal HTN --> high TGs due to presence of these in lymphatic fluid)

Treatment of acute diverticulitis

Ciprofloxacin and metronidazole, IV fluids, and bowel rest (then follow-up colonoscopy 4-8wks later to rule out malignancy and evaluate extent of disease --> recommend high-fiber diet + avoidance of heavy meat/fat to prevent further complications)

Diagnostic para: - Color: straw-colored - Normal amylase - Low protein - High SAAG

Cirrhosis (causes LOW PROTEIN ascites due to lack of albumin production --> causes HIGH SAAG due to portal HTN)

Causes of low-protein ascites (para total protein <2.5g/dL)

Cirrhosis and nephrotic syndrome (cirrhosis: associated with LOW protein but HIGH SAAG --> nephrotic syndrome: associated with LOW protein and LOW SAAG)

Liver biopsy findings expected in A1AT deficiency

Cirrhosis and periportal eosinophilic inclusion bodies

Causes of high-SAAG ascites (>1.1g/dL)

Cirrhosis, Budd-Chiari syndrome, and CHF (high SAAG indicates presence of portal HTN)

Which chemotherapeutic agents are associated with ototoxicity?

Cisplatin and carboplatin (therefore need baseline audiometry prior to initiation)

Treatment of re-entrant and ectopic SVT and VT (ex: WPW syndrome)

Class 1A antiarrhythmics (moderate Na+ channel blockers: include quinidine, procainamide, and disopyramide --> increase AP duration and ERP in ventricular AP --> used to treat re-entrant and ectopic SVT and VT such as WPW syndrome --> side effects: thrombocytopenia, increased QT interval, SLE with procainamide, cinchonism with quinidine, and HF with disopyramide)

Treatment of post-MI ventricular arrhythmias

Class 1B antiarrhythmics (weak Na+ channel blockers: include lidocaine and mexiletine --> decreases AP duration and preferentially affects ischemic/depolarized Purkinje and ventricular tissue --> used to treat post-MI and digitalis-induced ventricular arrhythmias --> side effects: CNS stimulation/depression and CV depression)

Which class of antiarrhythmics is associated with use-dependent widened QRS?

Class IC antiarrhythmics (strong Na+ channel blockers: includes flecainide and propafenone --> inhibits depolarization in AV node and accessory bypass tracts with slow rate of drug binding and dissociation --> used to treat SVTs such as AFib in patients with structurally NORMAL hearts --> side effects: use-dependent wide QRS during rapid HR such as exercise)

Which class of anti-arrhythmics is associated with use-dependent prolonged PR interval?

Class IV antiarrhythmics (non-DHP calcium channel blockers: include verapamil and diltiazem --> prolong repolarization at AV node to increase ERP --> used for rate control for AFib and prevention of SVTs --> side effects: use-dependent increased PR interval during rapid HR, constipation, flushing, edema, and AV block/sinus node depression)

Contraindications to trial of labor after uterine surgery

Classical C-section and abdominal myomectomy with uterine cavity entry (classical C-section: includes vertical uterine incision --> abdominal myomectomy with uterine cavity entry: usually for extensive myomectomy or extraction of intramural/submucosal fibroids --> patients with these contraindications should be delivered via scheduled C-section at 36-37wks or urgent laparotomy + C-section)

Treatment of lung abscess

Clindamycin

Treatment of acute cervical lymphadenitis

Clindamycin (good coverage against group A strep, MRSA, and anaerobes --> can give Augmentin if low MRSA prevalence --> can give cefazolin if low likelihood of periodontal disease/dental carries)

Which pneumoconioses predominantly affect the upper lung lobes?

Coal, silica, and beryllium (coal workers pneumoconiosis: caused by prolonged coal dust exposure such as in coal miners --> silicosis: caused by sandblasting + foundries + and mines presents with upper lobe pneumoconiosis and "eggshell" calcification of hilar LNs, associated with increased risk of TB --> berylliosis: caused by aerospace + manufacturing and causes non-caseating granulomas in upper lobes, occasionally) responsive to steroids)

CXR: erosions of inferior intercostal surfaces and aortic indentation

Coarctation of aorta

Infant with new-onset CHF after closure of PDA

Coarctation of aorta

Heart exam: S4 gallop and continuous murmur best heard at left infraclavicular area

Coarctation of aorta (congenital narrowing of descending aorta just DISTAL to left subclavian artery, causing proximal arterial pressure load affecting upper body --> presents with asymptomatic HTN of UE, brachial-femoral pulse delay, left interscapular systolic/continuous murmur, epistaxis, headaches,and underdeveloped LE with claudication --> ECG: LV hypertrophy --> CXR: notching/erosions of inferior 3rd-8th ribs and "3" sign due to aortic indentation --> diagnosis: ECHO shows narrowing of descending aorta distal to left subclavian --> balloon angioplasty +/- stent placement or surgery)

3-day-old girl born via SVD at home presents with recent onset fussiness, poor feeding, and decreased UOP. She was normal first 2 days of life. Vitals: mildly hypertensive, tacycardiac, tachypneic, SaO2 96% in right hand and 85% in right foot on RA PE: systolic murmur heard at left paravertebral interscapular area Labs: high Na+, low HCO3-, and high lactic acid ABG: low pH and low PaO2

Coarctation of aorta (thickening of tunica media of aortic arch near junction of ductus arteriosus + aortic arch, with luminal narrowing causing mechanical obstruction in aortic blood flow that is dependent on PDA --> presents with HTN in UE, hypotension + hypoxia in LE, diminished/delayed femoral pulses, systolic ejection murmur at left interscapular area, and infantile CHF around DAY 3 OF LIFE with irritability + tachypnea + poor feeding + diaphoresis + lethargy --> labs: metabolic acidosis and AKI --> treatment: surgical repair)

Type of study used to compare disease incidence

Cohort study (designed by selecting EXPOSED vs. NON-EXPOSED patients and then comparing disease incidence --> can be either retrospective or prospective)

Which fracture is associated with elderly person FOOSH injury and displacement of distal radius?

Colles fracture (fracture of distal forearm in which broken end of radius is bent backwards --> presents with wrist deformity with extensive swelling + bruising, "dinner fork" deformity of wrist which makes a dome shape, and possible carpal tunnel syndrome with paresthesia of thenar muscles + impaired thumb abduction 2/2 median nerve compression)

Tumor marker analysis: - High CEA - High CA 19-9 - Normal AFP

Colon cancer and cholangiocarcinoma

Screening guidelines for CRC in patients with IBD (UC or Crohns with colonic involvement)

Colonoscopy 8yrs after initial diagnosis then every 1-3yrs

Screening guidelines for CRC in patients with classic FAP

Colonoscopy at age 10 then every year

Screening guidelines for CRC in patients with HNPCC (Lynch syndrome)

Colonoscopy at age 20 then every 1-2yrs

Screening guidelines for CRC in patient with family history of CRC/adenomatous polyps

Colonoscopy at age 40 or 10yrs before dx, then every 5yrs

Screening guidelines for colon cancer

Colonoscopy every 10yrs for adults age 50-75 (alternative: yearly FOBT/FIT)

Abdominal XR: constricting, apple-core, non-obstructing sigmoid mass

Colorectal carcinoma (CRC: stenosing annular subtype presents with apple-core lesion on abdominal XR)

65yo M with PMH of BPH and acute diverticulitis presents with 2wk hx of dysuria, turbid foul-smelling urine, and air bubble while urinating PE: mildly tender LLQ UA: elevated WBCs and bacteria Urine culture: positive for E. coli, Proteus, and Klebsiella

Colovesical fistula (connection between colon and bladder usually caused by acute diverticulitis, Crohn disease, or colon cancer --> presents with pneumaturia aka air in urine, fecaluria aka stool in urine, and recurrent UTIs with mixed flora --> diagnosis: abdominal CT with oral or rectal contrast showing contrast material in bladder with thickened colonic + vesicular walls --> treatment: surgery)

Best next step in management for pregnant woman with HSIL on Pap test

Colposcopy (used to look at abnormal cells with magnification --> looking for aceto-white changes and abnormal vessels at squamocolumnar junction --> if not visualized, endocervical curettage DEFERRED during pregnancy but still perform cervical biopsy)

22yo M presents after MVC POD#1 s/p left tibial and popliteal artery repair with increasing left leg pain that worsens with passive leg movement, and "pins and needles" sensation in leg PE: tense tender swelling of left calf, sensory loss between 1st and 2nd left toes, and palpable LE pulses bilaterally

Compartment syndrome (increased pressure within fascial compartment of limb, resulting in venous outflow obstruction and arteriolar collapse causing anoxia and necrosis of limb --> causes: long bone fractures, revascularization of acutely ischemic limb, and animal venoms --> presents with SEVERE limb pain out of proportion to injury, increased pain on PASSIVE stretch, paresthesia from sensory nerve ischemia, and rapidly increasing tense tender swelling of limb --> diagnosis: difference between compartment pressure and DBP <30mmHg --> treatment: emergent fasciotomy)

Pleural fluid analysis: pH <7.2 Glucose <60 WBC >50,000

Complicated parapneumonic effusion (caused by persistent bacterial invasion into pleural space, usually characterized by loculation/walling off of pleural fluid --> presents with EXUDATIVE effusion characterized by low pH <7.2 due to anaerobic utilization of glucose by neutrophils/bacteria, low glucose <60 due to high metabolic activity, high protein due to increased microvascular permeability and cell destruction, WBC >50k, and LDH >1000 --> diagnosis of EMPYEMA made by gross pus/bacteria on pleural gram stain and culture --> treatment: chest tube/pigtail cath drainage and IV antibiotics)

Cause of meralgia paresthetica

Compression of lateral femoral cutaneous nerve (compression occurs where LFCN passes under inguinal ligament --> presents with pain and paresthesia in lateral thigh)

Paradoxical improvement of hearing speech in noisy environments

Conductive hearing loss (CHL: associated with phenomenon known as paracusis of Willis due to CHL dampening competing background noise, allowing speech to be heard more clearly --> Weber test localizes to affected EAR --> Rinne test shows bone > air in affected ear)

Ear PE: - Tuning fork lateralizes to affected ear - Bone conduction > air conduction in affected ear

Conductive hearing loss (causes: cholesteatoma, Eustachian tube dysfunction, and otosclerosis --> presents with Weber test lateralizing to AFFECTED ear --> Rinne test showing BC > AC in affected ear --> ALSO presents with paradoxical improvement of hearing speech in noisy room)

Anal exam: fleshy, cauliflower-shaped mass at anal verge

Condyloma acuminata (anogenital warts)

Side effects of antipsychotic use in patients with Dementia with Lewy bodies (DLB)

Confusion, Parkinsonism, and autonomic dysfunction (patients with DLB have extreme antipsychotic hypersensitivity --> antipsychotics with strong DA receptor antagonism can cause confusion, rigidity, and orthostatic hypotension --> switch to lower-potency 2nd gen antipsychotics such as quetiapine)

Newborn baby presents with head circumference <3rd percentile, petechial rash, jaundice of face + trunk, and hepatosplenomegaly Head imaging: periventricular calcifications

Congenital CMV (most common congenital infection acquired via contact with urine/saliva of infected children and transmitted transplacentally --> newborn presents with PERIVENTRICULAR CALCIFICATIONS, growth restriction and microcephaly, jaundice, hepatosplenomegaly, thrombocytopenia with "blueberry muffin" and/or petechial rash, hearing loss, seizures, and chorioretinitis --> diagnosis: CMV PCR testing of urine/saliva --> treatment: valganciclovir for SYMPTOMATIC congenital CMV --> complication; most common cause of non-hereditary SENSORINEURAL hearing loss seen in 50% of symptomatic and 15% of asymptomatic newborns)

Newborn girl presents with ambiguous genitalia and elevated 17-hydroxyprogesterone

Congenital adrenal hyperplasia (CAH: autosomal recessive disorder characterized by 21-hydroxylase deficiency, resulting in decreased cortisol production and increased androgen production --> presents in newborn girls at birth with virilization, and boys age 1-2wks with salt-wasting syndrome aka hypotension + vomiting + dehydration --> labs: hyponatremia, hyperkalemia, and hypoglycemia --> diagnosis: elevated 17-OHP --> treatment: steroids + aldosterone analog, high-salt diet, genital reconstruction surgery for girls, and psychosocial support)

Newborn skin exam: poorly circumscribed flat gray-blue patch on lower back

Congenital dermal melanocytosis (Mongolian spot: more common in Asian and African-American populations --> presents as poorly-circumscribed flat gray-blue patches on lower back and sacrum)

Neonatal CXR: loops of bowel within hemithorax, displaced cardiac silhouette, and gasless abdomen

Congenital diaphragmatic hernia (CDH: incomplete fusion of pleuroperitoneal folds during development causes left-sided defect in diaphragm and protrusion of abdominal contents into thoracic cavity, leading to pulmonary hypoplasia and PPH --> presents with respiratory distress, unilateral absent breath sounds, barrel-shaped chest, and scaphoid abdomen --> diagnosis: CXR shows intrathoracic bowel loops, displaced cardiac silhouette, and gasless abdomen --> treatment: INTUBATION and gastric decompression with urgent surgical correction)

15-minute-old newborn girl presents born via SVD at 37wks presents with respiratory distress Vitals: afebrile, HR 176, RR 70, SaO2 82% on RA PE: grunting + subcostal and suprasternal retractions + cyanosis of lips and tongue, rounded chest, flat abdomen, absent breath sounds on left, and heart sounds loudest on right

Congenital diaphragmatic hernia (life-threatening diaphragmatic defect caused by incomplete fusion of pleuroperitoneal folds, resulting in herniation of bowel into chest which leads to pulmonary hypoplasia and pulmonary HTN --> presents within hours of birth with respiratory distress, absent unilateral breath sounds, deviation of heart into right thorax with right-sided heart sounds, concave abdomen, and barrel-shaped chest --> diagnosis: CXR shows intrathoracic bowel loops and displaced cardiac silhouette --> treatment: intubation, NG tube decompression, and surgical correction)

Fetal complications of maternal diabetes in 1st trimester

Congenital heart disease, NTD, small left colon syndrome, and spontaneous abortion

46yo F with PMH of gastric bypass surgery 5yrs ago presents with worsening LE tingling and numbness PE: gait ataxia with loss of vibration/position sensation in feet, mild LE edema, and scattered areas of skin depigmentation Labs: hypochromic microcytic anemia

Copper deficiency (caused by malabsorption from prior bariatric surgery, IBD, celiac disease, or excessive ingestion of zinc --> presents SIMILARLY to vitamin B12 deficiency + hypochromic microcytic anemia + skin depigmentation + hair fragility + hepatosplenomegaly + edema + osteoporosis --> diagnosis: low serum copper and ceruloplasmin levels)

12-week-old girl born via SVD at 38wks outside of USA presents with 3-wk hx of weakness, poor appetite, choking spells during feeding, excessive sleeping, constipation, and apathy PE: apathy, weakness, hypotonia, large tongue, sluggish movement, abdominal bloating, and umbilical hernia

Congenital hypothyroidism (85% caused by sporadic thyroid dysgenesis, 10% caused by inborn errors of thyroxin synthesis, and 5% caused by transplacental maternal thyrotropin-receptor blocking antibodies --> presents at 3-4 MONTHS with apathy, weakness, hypotonia, large tongue, sluggish movement, abdominal bloating, umbilical hernia, pathologic jaundice, difficulty breathing, noisy respiration, hypothermia, and refractory macrocytic anemia --> treatment: levothyroxine 10mcg/kg then titrated --> prevention: screening T4/TSH at birth)

Newborn skin exam: solitary hyperpigmented lesion with overlying hair on upper back

Congenital melanocytic nevus (CMN: benign proliferation of melanocyte cells within first few months of life --> presents with solitary hyperpigmented lesion with increased density of overlying dark coarse hairs --> 5% risk of transformation to melanoma, so often surgically removed)

2-month-old girl born via C-section for breech presentation presents with right-sided head flattening PE: flattening of right occiput with anterior displacement of right ear + forehead, preference to tilt head to left while rotating chin to right, and firm mass in inferior portion of left SCM that does not transilluminate

Congenital muscular torticollis (CMT: postural deformity in neck in which SCM muscle is tight and contracted, usually caused by fibrosis of SCM --> risk factors: intrauterine crowding from breech positioning, multiple gestation, and oligohydramnios --> presents at 1-6 MONTHS with head preference to one side, positional plagiocephaly + anterior displacement of ear and forehead on other side, limited neck motion, and SCM thickening or well-circumscribed mass on side of head flattening --> treatment: increased tummy time, passive stretching, and PT --> complications: craniofacial asymmetry --> associated conditions: DDH, metatarsus adductus, and clubfoot)

Newborn presents with cataracts, sensorineural deafness, and patent ductus arteriosus (PDA)

Congenital rubella syndrome (caused by transplacental transmission of maternal rubella --> presents with CLASSIC TRIAD of cataracts + sensorineural deafness + PDA)

Newborn boy born to mother without prenatal care via SVD presents to newborn nursery. PE shows <3rd %ile for weight, 50th %ile for head circumference, and hepatosplenomegaly. After 2 days, baby develops jaundice, clear rhinorrhea, and maculopapular rash on feet + buttocks that later desquamates.

Congenital syphilis (infection acquired via transplacental transmission of Treponema pallidum --> presents with "snuffles aka copious clear/purulent/serosanguinous rhinorrhea, diffuse maculopapular rash that involves palms + soles and may desquamate or become bullous, and abnormal long-bone radiographs with metaphyseal lucencies --> diagnosis: maternal positive VDRL/RPR tests --> treatment: penicillin --> late complications: frontal bossing, notched Hutchinson teeth, saddle nose, short maxilla, saber shins, CN8 deafness)

Newborn presents with chorioretinitis, hydrocephalus, and diffuse intracranial calcifications

Congenital toxoplasmosis (caused by transplacental transmission of maternal Toxoplasma gondii, obtained via cat feces or ingestion of undercooked meat --> presents with CLASSIC TRIAD of chorioretinitis + hydrocephalus + intracranial calcifications, sometimes with "blueberry muffin")

Causes of nephrogenic DI

Congenital, hypercalcemia, hypokalemia, lithium, amphotericin B, and demeclocycline

Key finding of putaminal stroke

Conjugate gaze deviation toward side of lesion (due to damage of frontal eye field efferents in ANTERIOR limb --> also associated with contralateral hemiparesis + hemisensory loss and homonymous hemianopia)

Child with delayed growth spurt/puberty Labs: normal IGF-1 and delayed bone age

Constitutional growth delay (presents with delayed puberty and DELAYED BONE AGE >2yrs from actual age --> no treatment)

60F with PMHx of HTN, T2DM, Hep C, and TB tx 10yrs ago presents with several months of LE swelling PE: symmetric pitting edema of LE, hepatosplenomegaly, ascites, and positive hepatojugular reflex

Constrictive pericarditis (chronic inflammation of pericardium resulting in right heart failure, usually caused by TB --> presents with peripheral edema, ascites, hepatomegaly/cardiac cirrhosis, elevated JVD with positive HJ reflex, Kussmaul's sign aka increased JVP on inspiration, and pericardial knock --> diagnosis: CXR and echo shows pericardial calcifications)

ECHO: pericardial thickening and calcifications, abnormal septal motion, and biatrial enlargement

Constrictive pericarditis (scarring and subsequent loss of normal elasticity of pericardial sac that prevents venous return to right heart during inspiration, leading to right heart failure --> causes: idiopathic or viral pericarditis, cardiac surgery, radiation therapy, and TB --> presents with fatigue, DOE, peripheral edema, elevated JVP, ascites with positive hepatojugular reflex, pericardial knock, pulsus paradoxus aka loss of radial pulse during inspiration, and Kussmaul sign --> ECG: nonspecific, AFib, or low-voltage QRS complexes --> diagnosis: JVP waveform shows prominent x and y descents, ECHO shows pericardial thickening + calcification + abnormal septal motion + biatrial enlargement --> treatment: diuretics and pericardiectomy)

Treatment of chemical burns of the eye

Continuous eye irrigation with normal saline (causes normalization of pH after 30mins - 2hrs --> can use IV tube or Morgan lens)

Which areas of the brain are affected by uncal (transtentorial) herniation?

Contralateral crus cerebri, ipsilateral CN3, ipsilateral PCA, and reticular formation (contralateral crus cerebri: causes IPSILATERAL hemiparesis --> ipsilateral CN3: causes IPSILATERAL fixed blown pupil and "down and out" gaze --> ipsilateral PCA: causes CONTRALATERAL homonymous hemianopia --> reticular formation: causes altered level of consciousness and coma)

Best next step in management for newborn with bilious vomiting and abdominal XR showing dilated loops of bowel

Contrast enema (if microcolon, dx with meconium ileus --> if rectosigmoid transition zone, order rectal suction biopsy and dx with Hirschsprung disease)

Management of cat bite

Copious irrigation and Augmentin (also give tetanus booster if last vaccine was >5yrs ago --> copious irrigation: routine wound care to clean out skin --> Augmentin: covers Pasteurella multicoda and oral anaerobes from oral cat flora)

ECG: right axis deviation, RBBB, RV hypertrophy, and RA enlargement

Cor pulmonale (right-sided heart failure caused by pulmonary HTN --> risk factors: COPD, ILD, OSA, PE, and chest wall disorders --> presents with fatigue, lethargy, DOE, exertional syncope/angina, peripheral edema, increased JVD, loud S2, RV heave, pulsatile liver, and tricuspid regurgitation murmur aka holosystolic murmur at left lower sternal border --> ECG: right axis deviation, RBBB, RV hypertrophy, and RA enlargement --> ECHO: pulmonary HTN, dilated RV, and tricuspid regurgitation --> diagnosis: right heart cath shows elevated CVP, RV EDP, and mean PA pressure >25 --> treatment: supplemental O2, diuretics, treat underlying cause, and IV inotropes for severe decompensation)

Risks of breech delivery

Cord prolapse, head entrapment, asphyxia, birth trauma, and obstetrical tears

Which glycogen storage disease is associated with ketotic hypoglycemia?

Cordi disease (type III glycogen storage disease: autosomal recessive deficiency in debranching enzymes resulting in accumulation of abnormal glycogen with very short outer chains --> MILDER form of von Gierke disease with NORMAL LACTATE levels --> presents at 3-6 MONTHS with hypotonia and weakness, hepatomegaly, and KETOTIC HYPOGLYCEMIA --> diagnosis: accumulation of limit dextrin-like structures in cytosol)

Which cranial nerve reflex indicates intact pons?

Corneal reflex (indicates intact CN5 + CN7)

30yo F presents with 1-day hx of foreign body sensation in left eye associated with blurry vision and photophobia PE: left eye erythema with ciliary injection, and purulent exudates on conjunctival sac

Corneal ulceration (ulceration of cornea cause by contact lens use, recent trauma, or ocular disease --> presents with foreign body sensation + eye pain, blurry vision, photophobia, erythematous eye with ciliary injection, and purulent exudates on conjunctival sac/ulcer surface)

1-hour-old newborn girl presents with facial deformities and cat-like cry PE: head circumference 3rd percentile, protruding metopic suture, wide-set eyes, flattened nasal bridge, and diffuse hypotonia

Cri-du-chat syndrome (congenital deletion on short arm of chromosome 5, aka 5p deletion --> presents with high-pitched crying/meowing, microcephaly, epicanthal folds, protruding metopic suture, hypertelorism, wide flat nasal bridge, diffuse hypotonia, and VSD)

Best next step in management for trauma patient with facial fractures and gurgling sounds

Cricothyrotomy (incision thru crciothyroid membrane to secure airway for patient in distress in which intubation is contraindicated or impossible --> indications include: oral or maxillofacial trauma, profuse oral hemorrhage, copious emesis, and anatomic abnormalities --> complications: no airway protection, CO2 retention, and no feedback about respiratory function)

Type of study used to examine associations between risk factors + disease at one particular time

Cross-sectional study (observational study design used to estimate PREVALENCE of disease, or measures BOTH prevalence of risk factor + disease simultaneously at one time as a "snapshot")

Diagnostic para: - Color: bloody - Normal amlyase - Low protein - High SAAG

HCC (similar to cirrhosis findings EXCEPT color is usually bloody due to malignancy)

Treatment of iron overload

Phlebotomy and deferoxamine

Definition of abdominal aortic aneurysm (AAA)

Enlargement of abdominal aorta >3cm (should only receive elective repair for asymptomatic AAA with size >5.5cm --> urgent repair for symptomatic and HD stable AAA --> emergent repair for symptomatic and HD unstable AAA)

1st line nutritional delivery mode for ICU patients

Enteral nutrition (EN: delivered via NG/OG tube to postpyloric duodenum --> helps maintain gut integrity and prevents atrophy of GALT and MALT)

Best next step in management for woman >30yo with palpable breast mass

Diagnostic MG (diagnostic mammogram: used to evaluate palpated mass or abnormal screening MG --> if small and solid/acellular, proceed to core biopsy --> if large or highly suspicious for malignancy, proceed to excisional biopsy)

Common cause of IE associated with UTIs

Enterococci (especially Enterococcus faecalis --> cause up to 30% of nosocomial-acquired IE)

Best next step in management for patient with blunt abdominal trauma, hemodynamic instability, and negative FAST

Diagnostic peritoneal lavage (indicated for patients who may deteriorate during CT)

Which sized nevi would be suspicious for melanoma?

Diameter >6mm (other signs of melanoma in ABCDE criteria with positive 1-2+ as suspicious for melanoma: asymmetry, border irregularities, color variegation, and evolution)

5yo M presents with new-onset clumsiness, drinking large amounts of water, and urinating "all the time" PE: afebrile, BP 96/65, HR 130 PE: dry mucous membranes and loss of peripheral visual fields Labs: hypernatremia and low urine specific gravity CT head: suprasellar mass with calcifications

Craniopharyngioma (benign slow-growing tumor derived from epithelial remnants of Rathke pouch within pituitary stalk, which is located in SUPRASELLAR region adjacent to optic chiasm --> presents BIMODALLY in children age 5-14yo and adults age 50-75yo --> presents with bitemporal hemianopia, growth failure, pubertal delay/sexual dysfunction, and diabetes inspidus --> diagnosis: CT/MRI shows suprasellar mass with cysts and/or calcifications --> treatment: surgical resection and/or radiation therapy)

MRI: suprasellar mass with calcifications

Craniopharyngioma (benign slow-growing tumor derived from remnants of Rathke pouch --> presents in CHILDREN AGE 5-14yo with growth failure, pubertal delay, central DI, and bitemporal hemianopia, worsening headache with papilledema --> diagnosis: CTI/MRI shows calcified and/or cystic suprasellar mass --> treatment: surgical resection +/- radiation)

Treatment of subdural hematoma

Craniotomy (need to drain hematoma to relieve ICP)

Which medications should be used with caution in patients with aortic stenosis?

Diuretics, beta-blockers, and vasodilators (should be used with caution or avoided in patients with severe aortic stenosis due to risk of hypotension)

38F with PMHx of HIV presents with 7-day hx of fatigue, worsening headache, and 1 episode of vomiting today Vitals: febrile 101F, HR 84 PE: oral thrush and bilateral papilledema

Cryptococcal meningitis (infection of leptomeninges caused by invasive fungus Crpytococcus neoformans, transmitted via inhalation of spores and causes CNS infection in immunocompromised patients --> presents with SUBACUTE 2wk hx of fevers, headaches, malaise, signs of elevated ICP including vomiting + papilledema, and NORMAL MRI --> CSF analysis: high opening pressure, monocytic pleocytosis, low glucose, and high protein --> diagnosis: positive cryptococcal antigen in CSF or positive India ink stain/culture on Sabouraud agar --> treatment: amphotericin B + flucytosine, with fluconazole for maintenance)

Most common causes of prolonged (>10 days) profuse watery diarrhea

Cryptosporidium, Cyclospora, and Giardia

Patient with HIV/AIDS (CD4 <100) presents with 2wk hx of low-grade fever, severe watery diarrhea, and weight loss

Cryptosporidoiosis (GI protozoa transmitted via drinking water/animal contact/human contact that causes severe watery diarrhea in patients with AIDS with CD4 <100 --> presents with low-grade fever and severe watery diarrhea --> diagnosis: stool exam with acid-fast stain shows oocysts --> treatment: antiretroviral therapy)

Two clinical signs of severe pancreatitis

Cullen sign and Grey-Turner sign (Cullen sign: periumbilical bluish coloration indicating hemoperitoneum --> Grey-Turner sign: reddish-brown coloration around flanks indicating retroperitoneal bleed)

Indications for PPSV23 vaccine alone

Current smokers, alcoholics, diabetes, CAD, lung disease, and cirrhosis (these patients should receive one-time PPSV23 alone <65 and then sequential PCV13 + PPSV23 at age 65)

Which paraneoplastic syndromes are associated with small cell lung cancer?

Cushing syndrome, SIADH, Lambert-Eaton syndrome, and paraneoplastic encephalitis

Skin exam: painless papule with small fluid-filled blisters on top that developed into an eschar-covered ulcer surrounded by non-pitting edema

Cutaneous anthrax (skin infection with Bacillus anthracis, a spore-forming gram-positive rod that releases edema toxin, resulting in black eschar with edematous borders and spreads to lymphatics --> risk factors: IVDU and exposure to unvaccinated animals/animal hides --> presents INITIALLY with painless pruritic papule with central vesicle/bullae that progresses to painless necrotic black eschar surrounded by edema, with eschar sloughing off at day 14 --> treatment: ciprofloxacin or doxycycline) cutaneous anthrax initial lesion is a painless and pruritic papule with central vesicle or bulla this progresses to painless and necrotic black eschar surrounded by edema eschar sloughs off at day 14

Skin exam: conical or elongated keratinaceous projection from skin

Cutaneous horn (skin lesion associated with seborrheic keratosis and SCC that does not rapidly progress)

34M with PMHx of smoking presents with intensely pruritic lesion on right foot PE: erythematous serpiginous rash on right foot

Cutaneous larva migrans (CLM: creeping cutaneous eruption caused by hookworm larvae from dogs--Ancylostoma canimum-- or cats--A brazilense transmitted by walking barefoot on contaminated sandy beaches or soil --> presents INITIALLY with pruritic erythematous papule at site of larvae penetration that develops within a few days into intensely pruritic, migrating, serpiginous, reddish-brown cutaneous tracks --> treatment: ivermectin)

35M with PMHx of HTN who stopped taking meds 3-4d ago presents with 2-day hx of SOB and dry cough Vitals: afebrile, BP 220/120, HR 105, RR 20, SaO2 96% on 2L NC PE: bibasilar crackles and S4 Fundoscopic exam: occasional cotton-wool spots Labs: elevated Cr Started on IV furosemide and nitroprusside with improvement, however next AM presents with confusion + agitation + generalized tonic-clonic seizure. BP 176/95 and HR 102 with normal PE.

Cyanide toxicity (caused by patients with underlying CKD who receive prolonged IV nitroprusside --> presents with acute onset headache, altered mental status, hyperreflexia, arrhythmias, tachypnea, vomiting, pink/cherry red skin, breath with bitter almond odor, and lactic acidosis with renal failure --> treatment: hydroxycobalamin or nitrites + sodium thiosulfate to induce methemoglobinemia --> complications: seizures and coma)

Treatment of anovulation in adolescent girls (immature HPA)

Cyclic progesterone (normally secreted by the corpus lute during ovulatory cycles to cause differentiation of proliferative endometrium into secretory endometrium --> withdrawal can cause menstruation)

Which chemotherapeutic agent is associated with hemorrhagic cystitis?

Cyclophosphamide (forms bladder-toxic metabolite acrolein, which can result in hemorrhagic cystitis and bladder cacner --> prevent with MENSA and adequate hydration)

Which etiology is associated with bronchiectasis of the upper lobes?

Cystic fibrosis

Management of IUFD at 20-23wks

D&E or vaginal delivery

Management of hypoglycemic episode in patient with diabetes

D50W (need to replenish glucose for hypoglycemia)

What are the 2 types of hypotonic IV fluids?

D5W and half-normal saline (D5W: used to treat free water deficit aka hypernatremia --> half-normal saline: used to treat hypernatremia and maintenance fluid for patients unable to maintain adequate oral hydration)

Guidelines for medication management s/p drug-eluting stent placement

DAPT for 12 months (DAPT: dual anti-platelet therapy combining aspirin + P2y12 receptor blockers such as clopidogrel, prasugrel, or ticagrelor)

Diagnosis of osteoporosis

DEXA T-score of <-2.5

Screening guidelines for osteoporosis

DEXA scan for women age >65

Which androgen is ONLY produced in the adrenal glands?

DHEAS (dehydroepiandrosterone sulfate --> elevated DHEAS indicates androgen-producing adrenal tumor)

Most common coagulopathy in patients with malignancy

DIC (disseminated intravascular coagulation: presents with MAHA + schistocytes, thrombocytopenia, low fibrinogen, and increased INR)

Causes of acquired antithrombin deficiency

DIC, cirrhosis, and nephrotic syndrome (leads to increased risk of DVT/PE)

Most common complications of placental abruption

DIC, hypovolemic shock, preterm delivery, and fetal hypoxia (DIC: due to tissue factor release by decidual bleeding --> hypovolemic shock: due to massive blood loss from bleeding placenta)

Clinical features of psoriatic arthritis

DIP deformities, dactylitis, and onycholysis (DIP deformities: includes morning stiffness and joint destructino --> dactylitis: "sausage digits" aka diffusely swollen fingers --> onycholysis: separation of nail bed and associated with nail pitting)

Manifestations of cholinergic toxicity

DUMBBELS (D: diarrhea/diaphoresis --> U: urination --> M: miosis/pupillary constriction --> B: bronchospasms --> B: bradycardia --> E: emesis --> L: lacrimation --> S: salivation)

65F presents with 2-day hx of pain and swelling over medial aspect of R eye PE: R eye tenderness, edema, and redness over medial canthus with purulent discharge with slight pressure

Dacrocystitis (infection of lacrimal sac caused by either Staph aureus, GAS, or GBS --> presents with acute onset pain and redness in MEDIAL CANTHAL region, sometimes with purulent discharge --> treatment: antibiotics)

Fundoscopic exam: tenderness, edema, and redness over the medial canthus with purulent drainage with slight pressure

Dacrocystitis (infection of lacrimal sac, usually due to Staph aureus or GAS/GBS --> presents with acute onset pain and redness in MEDIAL CANTHAL region, sometimes with purulent discharge --> treatment: antibiotics)

Treatment of neuroleptic malignant syndrome

Dantrolene and bromocriptine (dantrolene: RyR inhibitor that prevents release of Ca2+ from skeletal muscle SR --> bromocriptine: ergot dopamine agonist)

Treatment of dermatitis herpetiformis

Dapsone and gluten-free diet (dapsone: sulfa antibiotic --> gluten-free diet: long-term management of celiac disease)

2nd line Toxoplasmosis prophylaxis for HIV-positive patients with CD4 <100 and sulfa allergy

Dapsone or atovaquone, pyrimethamine, and leucovorin (need to combine ALL 3)

2nd line prophylaxis for PCP in HIV-positive patients with CD4 <200 and sulfa allergy

Dapsone, atovaquone, and pentamidine

Treatment of leprosy

Dapsone, rifampin, and clofazimine (note: clofazimine ONLY for multibacillary leprosy with extensive lesions and lion-like facies)

How long should lochia alba last postpartum?

Day 11-6wks postpartum (lochia alba: creamy, white/yellow, light vaginal discharge that should stop ~6wks postpartum)

How long should lochia rubra last postpartum?

Days 0-4 postpartum (lochia rubra: dark or bright red blood with occasional small clots with quantity decreasing every day)

How long should lochia serosa last postpartum?

Days 4-14 postpartum (lochia serosa: light serosanguinous bleeding with pink/brown color and decreasing quantity)

30F 6wks postpartum presents with lateral right wrist pain that worsens when lifting infant from crib PE: tenderness over radial side of wrist and 1st dorsal compartment

De Quervain tendinopathy (DQT: overuse syndrome caused by repetitive thumb abduction and extension causing damage to APL/EPB tendons where they pass under extensor retinaculum in 1st dorsal compartment --> presents in YOUNG WOMEN age 30-50yo postpatrum with tenderness at radial side of wrist/base of hand --> diagnosis: positive Finkelstein test, aka reproducible pain when adducting wrist with fingers closed over thumb in a fist --> treatment: NSAIDs and thumb spica splinting)

22F presents with 2-mo hx of pain in right wrist exacerbated by lifting her 3-mo-old son PE: ulnar deviation of right wrist with thumb in palm produces pain and tenderness over radial styloid

DeQuervain tenosynovitis (non-inflammatory thickening of APL and EPL tendons, which are both located within 1st dorsal extensor tendon compartment --> risk factors: new mothers, golfers, and racquet sports players --> presents with pain/tenderness at radial styloid and positive Finkelstein test aka pain at radial styloid with active/passive stretch of thumb tendons)

Management of "dirty" wounds (ex: bites)

Debridement, sterile dressing, and Augmentin (debridement and sterile dressing: used to clean open wound, should NOT CLOSE --> Augmentin: covers gram-positives and anaerobes)

47M with PMHx of HTN who recently went scuba diving for 6hrs presents with 2-hr hx of pins and needles sensation and weakness in right leg and 1-hr hx of confusion Vitals: BP 160/90, HR 110, RR 20, PE: somnolent, diffuse crackles, S4 gallop, grade 2/6 systolic ejection murmur over LUSB, and RLE strength 4/5

Decompression sickness (the bends: transfer of nitrogen gas from tissues into venous bloodstream when diver ascends too rapidly from high ambient pressure of deep water to lower ambient pressure at surface, resulting in vascular air emboli --> presents <12hrs from scuba diving with pruritus/mottling/cyanosis of extremities, respiratory distress with pulmonary edema and/or cardiogenic shock, confusion, gait ataxia, dysarthria, and localized stroke --> treatment; IV hydration, Trendelenburg positioning, 100% O2, and hyperbaric O2 therapy)

Spirometry findings of restrictive lung disease

Decreased FEV1 <80%, decreased FVC, decreased TLC, and normal FEV1/FVC ratio

Spirometry findings of COPD

Decreased FEV1, normal FVC, and FEV1/FVC ratio <70%

Cause of S4 heart sound

Decreased LV compliance (atrial gallop sound before S1: heard immediately after atrial contraction phase as high LA pressure pushes against stiff LV wall, causing S4 heart sound in late diastole best heard with patient in left lateral decubitus position --> associated with LV hypertrophy, aortic stenosis, HOCM, and acute phase of MI --> sounds like "TEN-NE-SEE")

Cause of pulsus paradoxus in cardiac tamponade

Decreased RV compliance (cardiac tamponade compresses RV free wall, decreasing RV compliance --> during inspiration, increased venous return causes SHIFT in IV septum toward LV cavity to further reduce LV filling)

Causes of age-related orthostatic hypotension

Decreased baroreceptor sensitivity, arterial stiffness, decreased NE content, and decreased sensitivity of myocardium to SNS

Cause of genitourinary syndrome of menopause

Decreased estrogen (results in atrophic vaginitis --> presents with nocturia, dysuria, frequent urination/urge incontinence, vaginal dryness, recurrent UTIs, and pelvic pressure)

Effect of alkalosis on Ca2+ levels

Decreased ionized Ca2+ (due to increased extracellular pH/alkalemia PROMOTING binding of Ca2+ to albumin --> resulting in DECREASED ionized Ca2+ but normal total Ca2+)

Effect of decreasing sample size in a study

Decreased power and increased type II error (power: 1-beta, therefore smaller sample size INCREASES beta error aka probability that type II error/false-negative exists --> in other words, a smaller sample size makes it more likely to state there is no difference when one actually exists)

33F G2P1 at 29wks presents with 1-day hx of severe right-sided abdominal pain, nausea/vomiting, and constipation. Having uterine contractions but no vaginal bleeding or LOF. Vitals: afebrile, BP 130/80, HR 118, FHR 160 with no decels PE: tender abdomen, uterine fundal tenderness and associated firm tender mass Labs: elevated WBC UA: normal

Degenerating uterine fibroid (can occur during pregnancy due to shifting of myometrial blood flow toward developing fetus, causing fibroid to outgrow blood supply leading to infarction and necrosis --> presents with uterine contractions, fundal tenderness, firm tender mass, and leukocytosis --> diagnosis: pelvic US --> treatment: acute pain control and indomethacin if pt <32wks)

Management of pre-eclampsia

Delivery at 37wks (or delivery at 34wks if PE with severe features)

Diagnosis of compartment syndrome

Delta pressure <30 (use needle manometry to calculate compartment pressure --> delta pressure = diastolic BP - compartment pressure)

Skin biopsy: microabscesses at tips of dermal papillae

Dermatitis herpetiformis (skin manifestation of celiac disease)

Presentation of glucagoma (pentad)

Dermatitis, diabetes, DVT, declining weight, and depression (dermatitis: p/w with necrolytic migratory erythema --> diabetes: p/w hyperglycemia --> DVT: p/w recurrent VTE --> declining wt: p/w weight loss --> depression: p/w neuropsychiatric sx such as ataxia + dementia + depression + proximal muscle weakness)

Skin exam: firm, hyperpigmented nodule on unilateral LE that dimples in center when pinched

Dermatofibroma (benign proliferation of fibroblasts on skin --> presents with "dimple" or "buttonhole" sign)

Where is the aortic dissection located in a patient with UE/LE pulse discrepancy?

Descending aorta (most common location: proximal descending aorta just distal to left subclavian artery, aka Stanford type B)

2nd line treatment for primary nocturnal enuresis refractory to lifestyle changes/enuresis alarms

Desmopressin (ADH analog that decreases urine production during sleep --> used for pts with no improvement to lifestyle changes/enuresis alarm OR want immediate improvement --> 3rd line/last resort tx is imipramine aka TCA)

65M with PMHx of T2DM and diabetic retinopathy presents with several month hx of nausea with occasional vomiting, abdominal bloating, early satiety, and several hypoglycemic episodes after meals despite decreasing premeal insulin

Diabetic gastroparesis (delayed gastric emptying caused by diabetic autonomic neuropathy that destroys enteric neurons, resulting in failure of fundus relaxation + uncoordinated and ineffective peristalsis --> risk factors: long-standing T1DM/T2DM, chronic poor control, and labile BG --> presents with nausea, early satiety, postprandial bloating + vomiting, impaired nutrition + wit loss, and labile BG/frequent hypoglycemia --> diagnosis: nuclear gastric emptying study shows delayed transit into duodenum --> treatment: optimizing diabetes control, smaller more frequent meals, and promotility drugs such as metoclopramide or erythromycin)

Fundoscopic exam: microaneurysms, dot and blot hemorrhages, hard exudates, and macular edema

Diabetic retinopathy (leading cause of blindness in USA --> presents with insidious worsening visual acuity bilaterally --> diagnosis: fundoscopic exam shows microaneurysms, hemorrhage, exudates, and retinal edema +/- cotton wool spots and newly formed vessels --> treatment: argon laser photocoagulation)

20yo M presents after falling off a trampoline doing a backflip and landing on his head with confusion, inability to move hands/legs, and increasing SOB in which respirations become faster/shallower with more use of accessory muscles

Diaphragmatic paralysis (occurs after high C-spine injury due to compression of cervical nerve roots C3-C5 which innervate diaphragm, resulting in hypercapnic respiratory failure --> presents with tachypnea, worsening SOB + use of accessory muscles, and increasing somnolence after cervical spine trauma --> treatment: orotracheal intubation with manual stabilization of C-spine)

4yo M presents with vague chest discomfort 2mo after high-speed MVA PE: decreased air entry in left lower lung base CXR: bowel loops within left chest cavity and mediastinal shift to the right

Diaphragmatic rupture (tear/avulsion of diaphragm caused by blunt thoracoabdominal trauma, resulting in sudden and unequal increase in thoracoabdominal pressure that results in diaphragmatic rupture --> usually seen in LEFT DIAPHRAGM due to congenital weakness of left posterolateral diaphragm and liver's protection on the right --> causes herniation of abdominal contents into thoracic cavity --> can present MONTHS-YEARS after thoracic trauma with chest discomfort and SOB due to lung compression --> CXR shows bowel loops within thoracic cavity and mediastinal shift to OPPOSITE side --> diagnosis: chest/abdominal CT --> treatment: surgical repair with thoracotomy vs. laparotomy --> complications: hernias and bowel strangulation)

Treatment of lactational mastitis

Dicloxacillin (covers MSSA, which is most common cause of lactational mastitis)

Treatment of loa loa and lymphatic filiarisis (elephantiasis)

Diethylcarbamazine

Which lung pathology is associated with INCREASED DLCO?

Diffuse alveolar hemorrhage (aka diffuse pulmonary hemorrhage/pulmonary vasculitis: causes abnormal increase in Hgb within alveolar space, thus increasing CO transfer --> causes: SLE --> PFTs: normal FEV1, normal TLC, and increased DLCO)

Paracentesis: straw-yellow ascitic fluid

Diffuse anasarca (severe generalized edema with SQ tissue swelling throughout body --> causes: liver/kidney failure, nephrotic syndrome, right-sided HF, protein-losing enteropathies, severe protein deficiency, and capillary leak syndrome)

65M with PMHx of non-ischemic cardiomyopathy tx with furosemide, carvedilol, lisinopril, and digoxin is recently diagnosed with AFib and started on rivaroxaban and amiodarone. Presents 2wks later with profound anorexia, nausea, and generalized weakness.

Digoxin toxicity (excess inhibition of Na+/K+ ATPase causing increased Ca2+ and positive inotropy + decreased HR due to vagus nerve stimulation --> causes: renal failure, hypokalemia, and drug-drug interactions with quinidine + propafenone + amiodarone + verapamil --> presents with anorexia, nausea/vomiting, abdominal pain, weakness, confusion, lethargy, blurry yellow vision/scotomas/blindness, arrhythmias, and AV block --> treatment: cardiac pacer, anti-digoxin Fab fragments, and magnesium --> prevention: decrease digoxin dose by 25-50% when starting certain meds)

ECHO: dilated ventricular chambers and diffuse hypokinesis

Dilated cardiomyopathy (caused by disruption of myocardial contractility and progressive biventricular contractile failure, causing ECCENTRIC hypertrophy)

Cause of S3 heart sound

Dilated ventricles (ventricular gallop sound after S2: heard during rapid ventricular filling phase in which increased volume causes turbulent blood flow to ventricles --> associated with mitral regurgitation, CHF, dilated CM, myocarditis, and high-output states such as pregnancy and anemia --> sounds like "KEN-TU-CKY")

Treatment of lead toxicity when venous lead >70 or acute encephalopathy

Dimercaprol and EDAT (administered on EMERGENCY BASIS for venous lead >70 or acute encephalopathy 2/2 lead poisoning --> dimercaprol: British anti-Lewisite --> EDTA: calcium disodium edetate)

Side effects of carbamazepine

Diplopia, ataxia, aplastic anemia, agranulocytosis, hepatotoxicity, SIADH, SJS, and CYP450 inducer

Presentation of CN3 palsy

Diplopia, ptosis, and mydriasis

Diagnosis of warm agglutinin AIHA

Direct Coombs positive with anti-IgG and anti-C3 (warm agglutinin AIHA: chronic anemia caused by autoimmune diseases such as SLE, viral infections such as CMV, immunodeficiency states, CLL, and drugs such as penicillin and alpha-methyldopa --> presents with AIHA --> treatment: steroids --> complications: VTE and lymphoproliferative disorders)

Diagnosis of cold agglutinin AIHA

Direct Coombs positive with anti-IgM and anti-C3 (cold agglutinin AIHA: acute anemia triggered by cold --> causes: Mycoplasma pneumonia, infectious mono, and CLL --> presents with anemia, livedo reticularis, and acral cyanosis with cold exposure --> treatment: avoidance of cold temps, rituximab, and/or fludarabine --> complications: ischemia and peripheral gangrene)

Which type of inguinal hernia is MEDIAL to inferior epigastrics?

Direct inguinal hernia

Most common sign of burn wound infection

Discoloration of burn eschar

Patient with AIDS (CD4 <50) presents with high fevers >102F, watery diarrhea, cough, and weight loss

Disseminated MAC (disseminated Mycobacterium avium complex infection: occurs in patients with AIDS with CD4 <50 --> presents with high-grade fevers >102F, weight loss, cough, abdominal pain, watery diarrhea, LAD, and hepatosplenomegaly --> labs: isolated high AlkPhos --> diagnosis: blood/LN culture shows non-TB myobacteria --> treatment: azithromycin + ethambutol --> prophylaxis: azithromycin or rifabutin)

36F with PMHx of IVDU who works as a commercial sex worker presents with 12hr hx of malaise, fever with chills, and pain in multiple joints Vitals: febrile 102.7F, BP 122/81, HR 104, RR 14 PE: several pustules on chest and extensor surfaces of forearms and tenderness of right wrist + ankle on palpation Labs: negative blood cultures x3

Disseminated gonococcal infection (DGI: bloodstream infection with Neisseria gonorrhoeae --> presents with either purulent monoarthritis or TRIAD of tenosynovitis, migratory polyarthralgia, and pustular dermatitis of extremities + torso --> diagnosis: NAAT testing of urine/cervix/urethra --> treatment: IV ceftriaxone and PO azithromycin)

Best next step in management for pancreatic cystadenoma >5cm

Distal pancreatectomy (due to risk of malignancy)

Treatment of transfusion-associated circulatory overload (TACO)

Diuretic therapy

56F with PMHx of HTN, T2DM, ovarian cyst presents with 2-day hx of progressively worsening dull LLQ pain, anorexia, nausea/vomiting, mild urinary urgency, and constipation but passing flatus Vitals: febrile 100.4, BP 134/82, HR 94 PE: LLQ tenderness UA: (+) leuk esterase

Diverticulitis (colonic wall inflammation caused by elevated luminal pressure/inspissated food particles eroding diverticular wall, usually seen in SIGMOID COLON --> risk factors: elderly, obesity, tobacco use, poor diet --> presents with LLQ pain, nausea/vomiting, UTI-like symptoms, sterile pyuria, and alteration in bowel habits --> diagnosis: abdominal CT --> treatment: antibiotics)

Location of Broca's area

Dominant frontal lobe (located in posterior inferior frontal gyrus --> damage to Broca's area via left MCA stroke causes expressive aphasia and sometimes extend to arcuate fasciculus to cause conduction aphasia)

Location of Wernicke's area

Dominant temporal lobe (located at posterior superior temporal gyrus --> damage to Wernicke's area via left MCA stroke causes receptive aphasia --> other associated features: anomic aphasia aka inability to speak nouns, conduction aphasia aka inability to repeat phrases, and contralateral superior homonymous quadrantanopsia aka right superior visual field defect)

1st line treatment of mild to moderate Alzheimer dementia

Donepezil, galantamine, and rivastigmine (cholinesterase inhibitors that improve cognitive function and may improve quality of life --> the NMDA receptor antagonist memantine is approved for moderate to severe dementia)

Best next step in management for patient with symptomatic prolactinoma

Dopamine antagonist (either bromocriptine or cabergoline --> if still symptomatic or prolactinoma >3cm, consider transphenoidal surgical resection)

Which CT finding is associated with cancer of the pancreatic head?

Double duct sign (dilation of BOTH common bile duct and pancreatic duct)

Which chemotherapeutic agents are associated with cardiotoxicity?

Doxorubicin and trastuzumab (doxorubicin: causes type 1 IRREVERSIBLE cardiotoxicity with myocyte necrosis + fibrosis --> trastuzumab: causes type II REVERSIBLE cardiotoxicity with myocardial stunning/hibernation without necrosis resulting in asymptomatic LV systolic dysfunction --> therefore before starting, pts should undergo baseline ECHO --> discontinue if pt develops decline in EF <16% from baseline)

Treatment of bacillary angiomtaosis

Doxycycline or erythromycin, and HAART initiation 2-4wks later

Treatment of hidradenitis suppurativa

Doxycycline, intralesional steroids, isotretinoin, and surgery

Treatment of lymphogranuloma venereum

Doxycyline (lymphogranuloma venereum: caused by Chlamydia trachomatis serovars L1-L3 --> presents with small 2-3mm painless genital ulcers that resolve, followed by painful suppurative inguinal nodes aka buboes)

Fundoscpic exam: small white/yellow deposits within macular region

Dry macular degeneration (non-exudative macular degeneration: occurs in 80% of patients with age-related macular degeneration --> presents with gradual decrease in vision, distorted vision, and central scotoma --> diagnosis: fundoscopic exam shows deposition of drusen/yellowish extracellular material between Bruch membrane and retinal pigment epithelium --> prevention: multivitamin and antioxidant supplements)

Characteristics of 1st degree burn

Dry painful burn without blisters

Characteristics of 3rd degree burn

Dry painless white burn

18-month-old boy presents with inability to walk and holds onto furniture while standing and steps sideways to move around PE: uses hands to push on legs while getting up and appears to be in pain when doing so, rest of milestones are normal

Duchenne muscular dystrophy (DMD: X-linked recessive disorder caused by frameshift deletion or nonsense mutation resulting in ABSENT DYSTROPHIN protein, leading to progressive myofiber damage and severe muscle weakness --> presents in YOUNG BOYS <5yo with gross motor delay, inability to walk until >18mo, Gower sign aka pt pushes hands on legs to assist in standing, diminished reflexes, and calf pseudohypetrophy --> diagnosis: elevated CK + aldolase, muscle biopsy shows fibrosis + fat + muscle degeneration, and genetic analysis showing dystrophin gene deletion --> treatment: steroids improve function and delay progression --> complications: cardiomyopathy, arrhythmias, and and respiratory insufficiency)

Tachycardia, diaphoresis, and flushing after meals

Dumping syndrome (complication of gastric bypass caused by high-carb foods rapidly emptying into small bowel, leading to osmotically driven fluid shifts from plasma to intestine --> fluid shift results in SNS activation, resulting in tachycardia + diaphoresis + flushing after meals)

Neonatal abdominal XR: air trapped in stomach + proximal duodenum with no distal intestinal gas

Duodenal atresia (failure of midgut to recanalize, associated with Down syndrome --> presents in NEONATES <2 days of life with bilious vomiting and abdominal distension --> diagnosis: abdominal XR shows "double bubble" sign and no distal intestinal gas --> treatment: enteral feeds, NG decompression, and surgical repair)

11yo F presents with 12-hour hx of persistent nausea/vomiting and epigastric discomfort after falling off balance beam and striking abdomen yesterday during practice PE: dry mucous membranes, scaphoid abdomen with linear bruising across epigastrium, and epigastric tenderness

Duodenal hematoma (caused by rapid compression of duodenum against vertebral column during blunt abdominal trauma, injuring blood vessels between submucosal and muscularis layers resulting in bleeding and hematoma formation --> continued hematoma expansion over 24-48hrs leads to progressive obstruction of duodenal lumen --> presents 1-2 days after BAT with epigastric discomfort, nausea, and worsening BILIOUS emesis with inability to tolerate liquids --> workup: abdominal XR shows gastric dilation with scant distal gas --> diagnosis: abdominal CT shows homogenous density within C-shaped duodenum --> treatment: bowel rest, NG decompression, and parenteral nutrition with serial CT scans)

Definition of Curling ulcer

Duodenal ulcer in severe burn patient

Indications for antibiotic therapy for Campylobacter gastroenteritis

Duration >7 days, bloody stools, high fevers, pregnancy, elderly, and immunocompromised

1st line treatment of vitiligo

Topical steroids (if extensive vitiligo or tx failure, give oral steroids + topical cyclosporine + PUVA)

43M presents with 1wk hx of severely pruritic blistering rash on hands, had similar rash 2x in previous 2mo that resolved with peeling of skin on hands PE: vesicular rash on dorsum + palms of hands and sides of digits

Dyshidrotic eczema (acute palmoplantar eczema: common skin disorder causing recurrent pruritic vesicular rashes on hands + feet --> risk factors: irritant or allergic contact dermatitis, UV radiation, and immune reactions to remote allergens or fungi --> presents with recurrent cute episodes of severely pruritic, deep-seated, vesicular/bullous rash on palms + soles + sides of digits --> diagnosis: usually clinical, but biopsy can show intraepidermal spongiosis and lymphocytic infiltrate --> treatment: topical emollients and topical high-potency steroids such as betamethasone dipropionate)

Complications of late- and post-term pregnancy (>41wks gestation)

Dysmaturity syndrome, macrosomia, oligohydramnios, and IUFD (these are complications for fetus --> complications for mother include severe OB laceration, PPH, and C-section)

Cause of muscular dystrophy

Dystrophin gene mutation (results in skeletal + cardiac muscle fiber degradation)

Treatment of low-risk BCC on trunk/extremities

ED&C (electrodessication and curettage: appropriate treatment for low-risk BCC on trunk/extremities --> side effects: scarring and hypopigmentation)

Best next step in management after diagnosis of pernicious anemia

EGD (esophagogastroduodenoscopy: required at initial diagnosis of pernicious anemia due to increased risk of gastric cancer --> also requires EGD if pt develops positive FOBT or mid-epigastric abdominal pain)

Treatment of acute cholangitis

ERCP (endoscopic retrograde cholangiopancreatography: indicated to relieve biliary obstruction during which sphincterotomy, stone extraction, and/or biliary stent can be performed)

Best next step in management for patient with suspected choledocolithiasis but negative RUQ US

ERCP (endoscopic retrograde cholangiopancreatography: uses fluoroscopy to visualize biliary tree for diagnostic and therapeutic purposes --> indicated for gallstones causing CBD dilation, which usually requires sphincterotomy)

Best next step in management for asymptomatic patient with elevated AlkPhos and RUQ US shows dilated bile ducts

ERCP (looking for PSC)

Best next step in management for patient with dilated intrahepatic ducts without pancreatic tumor on abdominal CT

ERCP (used to investigate PSC vs. cholangiocarcinoma)

Treatment of symptomatic pancreatic pseudocysts

ERCP-guided drainage

Which FHT indicates fetal head compression with contractions?

Early decelerations (basically mirrors mom's contraction with decel starting with contraction, nadir following contraction peak, and then returning to baseline after contraction)

CXR: prominent RA contour

Ebstein anomaly (apical displacement of tricuspid valve leaflets DOWNWARD into RV with atrialization of RV --> causes: lithium exposure in utero --> presents with tricuspid regurgitation aka holosystolic murmur that increases with inspiration, right-sided HF, and accessory conduction pathways --> CXR: prominent RA contour --> diagnosis: ECHO)

42yo M who recently immigrated to the US from Guatemala presents with progressive upper abdominal discomfort and nausea PE: hepatomegaly Liver US: 10cm smooth round cyst with daughter cysts inside

Echinococcosis (infection with Echinococcus granulosus, a dog tapeworm endemic to rural developing countries in areas with sheep farming --> acquired by ingestion of food/water contaminated with dog feces, allowing eggs to hatch in small intestine and travel to liver to form 1+ hydatid cysts --> presents YEARS LATER with RUQ pain, N/V, and hepatomegaly --> diagnosis: liver US shows large smooth round cyst with daughter cysts, CT scan shows well-defined hepatic cyst with eggshell calcification, and positive serology for E granulosus IgG --> treatment: albendazole for cysts <5cm, percutaneous therapy for cysts >5cm)

48F with PMHx of ovarian cancer on adjuvant chemo presents with 1-day hx of fever and skin rash Vitals: febrile 102F, BP 110/60, HR 114 PE: several indurated nontender macules and pustules with some developing into gangrenous ulcers on trunk Labs: pancytopenia

Ecthyma gangrenosum (cutaneous infection caused by Pseudomonas bacteremia, which invades vascular media + adventitia to cause ischemic necrosis --> risk factors: immunocompromise, especially on chemo --> presents with acute onset of painless red macules that become indurated pustules/bullae with "punched out" gangrenous ulcers --> diagnosis: blood and exudate cultures --> treatment: broad-spectrum IV fluoroquinolones)

32F presents with 2-day hx of vaginal bleeding and lower abdominal cramping PE: lower quadrant tenderness, moderate vaginal bleeding, and closed cervical os Labs: positive pregnancy test TVUS: fluid-filled endometrial cavity and no gestational sac Labs: serum b-HCG 2500, 2 days later now 2800

Ectopic pregnancy (lower than expected b-HCG rise accompanied by abdominal pain and vaginal bleeding --> 10% of cases show pseudo-gestational sac on TVUS)

16M presents with 1-wk hx of rash on forearms and back of legs PE: patches of erythema with mild lichenification over antecubital and popliteal fossae with clusters of painful umbilicated vesicles at sites of inflammation

Eczema herpeticum (complication of severe atopic dermatitis caused by superfinection of eczema with HSV, resulting in vesicular eruption on pre-existing inflamed skin --> presents with fever, PAINFUL skin rash with vesicles on erythematous base that evolve to "punched-out" erosions with hemorrhagic crusting --> treatment: acyclovir)

Which antiviral medication is associated with vivid dreams and CNS symptoms?

Efavirenz (NNRTI/non-nucleoside reverse transcriptase inhibitor: binds to and inhibits reverse transcriptase and does NOT require phosphorylation to be active --> side effects: rash, hepatotoxicity, vivid dreams, insomnia dizziness, depression, anxiety, confused thinking, and aggression)

Management of asymptomatic femoral hernias

Elective surgical repair (performed to prevent incarceration and strangulation of bowel contents)

Components of the Glasgow coma scale (GCS)

Eye opening, verbal response, and motor response (GCS: estimates severity of patient's neuro injury for triage and used to predict PROGNOSIS of coma and other medical conditions --> NOT used to diagnose coma)

Methods to reduce risk of VAP (ventilator-associated pneumonia)

Elevate HOB, suction of subglottic secretions, limited use of PPIs, and minimizing patient transport (elevating HOB: at 30-45° to reduce retrograde movement of gastric secretions --> suction of subglottic secretions: prevents pooling above endotracheal cuff --> limited use of PPIs: prevents elevation of gastric pH to reduces burden of microorganisms in gastric secretions --> minimizing patient transport: prevents movement of endotracheal tube)

Diagnosis of cor pulmonale

Elevated PA systolic pressure >25 (dx via right heart cath: shows RV dysfunction, pulmonary HTN, and no left heart disease)

Key characteristic of tuberculous pleural effusion

Elevated adenosine deaminase

Key characteristics of esophageal rupture pleural effusion

Elevated amylase and low pH <6

Key characteristics of pancreatic fistula pleural effusion

Elevated amylase and normal pH

Signs of impending respiratory failure

Elevated or normal PaCO2, decreased breath sounds, absent wheezing, AMS, and marked hypoxia with cyanosis

Treatment of acute mesenteric ischemia

Embolectomy or aortomesenteric bypass (embolectomy: performed if embolic mesenteric ischemia --> aortomesenteric bypass: performed if CHRONIC or acute thrombotic mesenteric ischemia)

59F with PMHx of HTN, CAD, T2DM presents with 1-day hx of fever, RUQ pain, and nausea/vomiting Vitals: febrile 102F, BP 112/76, HR 101, RR 18 PE: marked tenderness and voluntary guarding to palpation in RUQ Labs: elevated WBCs, elevated total bili, elevated AlkPhos CT abdomen: distended gallbladder with gas in gallbladder wall and lumen

Emphysematous cholecystitis (life-threatening type of cholecystitis caused by infection with gas-forming bacteria such as Clostridium/E. coli --> risk factors: age >50yo, T2DM, vascular disease, and immunocompromised --> presents with fever, RUQ pain, nausea/vomiting, and crepitus in abdominal wall adjacent to gallbladder --> labs: unconjugated hyperbilirubinemia and mildly elevated LFTs --> diagnosis: imaging shows air-fluid levels in gallbladder, gas in gallbladder wall, and occasionally pneumobilia --> treatment: IV zosyn and emergency cholecystectomy)

Which parameter can be used to determine correct ET placement or measure effectiveness of CP resuscitation?

End-tidal CO2 (capnography: indicates aerobic metaoblism)

Management of dysmenorrhea + menorrhagia in patient with no desire for more children

Endometrial ablation

Best next step in management for woman >45yo with endometrial cells on Pap test

Endometrial biopsy (due to risk of endometrial hyperplasia/cancer causing endometrial shedding --> risk factors: obesity, prior chronic anovulation, etc.)

Best next step in management for woman <45yo with persistent AUB despite COCP use

Endometrial biopsy (required for women >45yo with AUB or women <45yo with persistent AUB and failed COCP trial, increased estrogen exposure from PCOS/obesity, or Lynch syndrome)

Diagnosis of increased endometrial thickness

Endometrial stripe >4mm (visualized on pelvic US)

Pelvis US: right adnexal cyst with diffuse homogenous ground-glass echoes

Endometrioma (type of endometriosis with abnormal implantation of endometrial tissue within ovary, forming "chocolate cyst" --> presents with heavy bleeding + severe pelvic/adnexal pain during menses and adherent immobile uterus --> diagnosis: pelvic US shows "ground glass" adnexal mass, laparoscopy shows endometrial implants --> treatment: COCPs)

60yo F with PMH of successful cataract extraction on left eye 5 days ago presents with 12hr hx of decreasing vision and dull ache over left eye Vitals: febrile 100.6F, BP 140/90, HR 92, and RR 14 PE: left eye shows swollen eyelid + edematous conjunctiva + exudates in anterior chamber + decreased visual acuity

Endophthalmitis (bacterial or fungal infection within vitreous portion of eye, usually occurring within 6wks of eye surgery --> presents with eye pain and decreased visual acuity, swollen eyelids and conjunctiva, hypopyon aka cell layering within anterior chamber, and corneal edema --> diagnosis: vitreous Gram stain + culture --> treatment: intravitreal antibiotic injection or vitrectomy)

Management of common bile duct obstruction

Endoscopic stent placement (usually performed during ERCP --> recommended for patients with CBD strictures or pancreatic mass)

Best next step in management after diagnosis of esophageal stricture

Endoscopy and biopsy (required to rule out esophageal adenocarcinoma)

Winter's formula (used to determine appropriate respiratory compensation(

HCO3*1.5 + 8 (+/- 2 to create a range --> ex: if pt has HCO3- of 16, expected PaCO2 would be 30-34)

29yo M with PMH of seasonal allergies presents with 2-year hx of difficulty swallowing with pork/chicken/steak occasionally "getting stuck" in mid-chest seconds after swallowing. Drinking water alleviates symptoms. Occasionally induces vomiting to eject food.

Eosinophilic esophagitis (EoE: chronic, immune-mediate esophageal inflammation caused by extensive eosinophilic infiltration of esophageal mucosa --> occurs in YOUNGER MEN 20-30yo with asthma/eczema --> presents with intermittent solid food dysphagia with meat, chest/epigastric pain, and GERD --> workup: endoscopy shows furrowing + small whitish exudates + trachealization of esophagus aka multiple stacked ringlike esophageal indentations --> diagnosis: esophageal biopsy shows >15 eosinophils/hpf --> treatment: dietary therapy, PPIs, and topical glucocorticoids)

Endoscopy: circular rings and thickened, linear furrowing of esophagus

Eosinophilic esophagitis (chronic, immune-mediated esophageal inflammation associated with atopy aka asthma, rhinitis, and eczema --> presents with dysphagia, mid-chest and epigastric pain, reflux/vomiting, and food impaction --> diagnosis: failure of 2mo PPI trial, endoscopy shows esophageal furrowing + small whitish exudates + and trachealization of esophagus aka multiple stacked ring-like esophageal indentations), and esophageal biopsy shows >15 eosinophils/hpf --> treatment: dietary modification +/- swallowed fluticasone)

35yo M presents with recurrent skin bump on lower back that has previously resolved spontaneously PE: firm mobile nodule without drainage or tenderness, and does not change shape when pinched at edges

Epidermal inclusion cyst (discrete benign skin nodule lined with squamous epithelium containing semisolid core of keratin + lipid --> caused trauma/comedones/de novo resulting in epidermis lodging into dermis --> presents with dome-shaped, firm, freely movable cyst/nodule with central punctum that gradually increases in size and may produce cheesy white discharge --> management: self-resolving, excision for cosmetic purposes, and I&D for infected fluctuant cysts that are painful and erythematous)

Skin exam: dome-shaped, firm, freely movable cyst with central punctum

Epidermal inclusion cyst (gradually increases in size and sometimes produces cheesy white discharge)

21F with PMHx of FTT during infancy due to frequent oral ulcers + poor feeding presents with painful blisters on palms after starting golfing lessons. Also frequently develops foot blisters during hiking or competitive spots. PE: bullae and erosions on palms with moderately thickened skin of soles

Epidermolysis bullosa (EB: group of inherited disorders characterized by epithelial fragility triggered by minor trauma caused by mutations of proteins in intraepidermal and dermoepidermal adhesion complexes in BM zone --> presents in INFANTS with oral blisters 2/2 bottle feeding and CHILDREN/YOUNG ADULTS with friction-induced blisters at palms/soles + chronic thickening of soles --> diagnosis: biopsy for IF microscopy and genetic testing --> treatment: careful wound care and supportive measures)

Patient with traumatic head injury Head CT: hyperdense biconvex lesion that does not cross suture lines

Epidural hematoma (caused by fracture in pterion region, resulting in tearing of middle meningeal artery and accumulation of blood between dura matter and skull --> presents with LOC followed by lucid interval, then later signs of ICP such as headache + N/V + altered mental status --> diagnosis: CT scan shows hyperdense biconvex/lentiform lesion that does NOT cross suture lines)

75yo M with PMH of metastatic prostate cancer presents with 3wk hx of severe back pain, difficulty walking, and difficulty urinating PE: point tenderness over midline spine near T10/T11, decreased strength 3/5 in LE, 3+ DTRs bilaterally, and upgoing plantar reflexes bilaterally

Epidural spinal cord compression (ESCC: caused by spinal injury, epidural abscess/hematoma, or mets from lung + breast + prostate cancers or multiple myeloma --> presents with severe low back pain that is WORSE AT NIGHT, bilateral LE weakness and ataxia, increased DTRs, bilateral Babinski reflex, and bladder/bowel incontinence --> diagnosis: emergency MRI --> treatment: IV steroids to decrease vasogenic edema, alleviate pain, and restore neuro function --> workup: neurosurgery + radiation oncology consult)

65M with PMHx of ulcerative colitis presents with 1-day hx of right eye discomfort, photophobia, and watery discharge PE: R eye with localized bulbar conjunctival injection

Episcleritis (inflammation/infection of episcleral tissue between conjunctiva and sclera, associated with IBD --> presents with acute onset eye discomfort, photophobia, and watery discharge with diffuse/localized bulbar conjunctival injection)

Classic triad associated with Fabry disease

Episodic peripheral neuropathy, angiokeratomas, and hypohidrosis (Fabry disease: X-linked recessive disease caused by deficiency in alpha-galactosidase --> presents with TRIAD of episodic peripheral neuropathy + angiokeratomas + hypohidrosis --> complications: progressive renal failure and CV disease)

Which type of LAD is pathognomonic for secondary syphilis?

Epitrochlear LAD (lymphadenopathy found on MEDIAL forearm between biceps and triceps muscles)

Treatment of foodborne botulism

Equine-derived botulism antitoxin

1-hour-old boy born via SVD c/b shoulder dystocia presents with abnormal movements of right hand PE: right upper arm adducted and internally rotated, elbow extended, forearm pronated, and wrist + fingers flexed

Erb-Duchenne palsy ("waiter's tip": brachial plexus lesion usually caused by lateral traction on newborn neck during delivery, resulting in UPPER TRUNK C5-C6 damage with deficits in deltoid + supraspinatus + infraspinatus + biceps brachii --> presents with "waiter's tip" aka arm adducted, internally rotated, extended, and pronated)

Skin exam: crops of yellow-red papules on extensor surfaces of arms and shoulders

Eruptive xanthomas (plaques/nodules composed of lipid-laden histiocytes in skin caused by subcutaneous fat deposition due to marked hypertriglyceridemia >1000k --> causes: familial dyslipedemia, usually type IV causing high TGs --> presents yellowish nodules on eyelids, yellow-red papules on arms + shoulders + Achilles tendon --> diagnosis: triglycerides >1000k --> complications: pancreatitis)

Skin exam: anterior leg rash with raised, sharply demarcated borders and intense erythema

Erysipelas (skin infection of superficial dermis and lymphatics caused by group A strep aka Strep pyogenes --> presents with RAPID onset of fever and intense erythematous rash with raised, sharply demarcated borders --> treatment: penicillin)

25M who works as a construction worker presents with 2-day hx of fever and painful swollen right hand Vitals: febrile 102.2F PE: swollen erythematous tender dorsum of right hand, small traumatic laceration and beefy-red expanding margin and red streaks extending up arm, and palpable tender axillary LNs

Erysipelas (skin infection of superficial dermis and lymphatics caused by group A strep aka Strep pyogenes, often occurring on EXTERNAL EAR --> presents with RAPID onset of fever + chills, intense erythematous "beefy red" rash with raised sharply demarcated borders, and regional tender LAD --> treatment: oral penicillin, or IV ceftriaxone for severe cases)

Skin exam: "target lesions" on hands/feet with raised edematous papules with multiple rings and dusky center

Erythema multiforme (immune complex-mediated skin reaction caused by IgM deposition in microvasculature of skin --> causes: HSV, Mycoplasma, sulfa drugs, penicillin, and phenytoin --> presents with erythematous papules/plaques that develop into "target lesions" with multiple rings and dusky center showing epithelial disruption --> diagnosis: skin biopsy shows perivascular lymphocytic infiltrate and epidermal necrosis)

Skin exam: 2-3cm erythematous, tender, nonmobile nodules on anterior aspect of both shins

Erythema nodosum (EN: painful erythematous or violaceous nodules on shins around 2-3cm in diameter caused by delayed-type hypersensitivity reaction to antigen exposure --> causes: Crohn disease, sarcoidosis, Hodgkin lymphoma, mononucleosis, Behcet syndrome, strep infection, coccidiodomycosis, histoplasmosis, TB, and leprosy --> diagnosis: biopsy shows septal panniculitis without vasculitis)

Skin exam: multiple tender, erythematous SQ nodules on bilateral anterior LE

Erythema nodosum (inflammation of SQ tissues caused by delayed hypersensitivity reaction --> causes: Strep pharyngitis, TB, leprosy, cocciodiomycosis, histoplasmosis, sarcoidosis, Behcet syndrome, IBD, and medications such as penicillins + sulfonamides + OCPs --> presents with 2-3cm tender, erythematous or violacenous nodules usually located on anterior LE --> diagnosis: usually clinical, although biopsy can show septal panniculitis without vasculitis --> no treatment, resolves within a few week)

Sensation of food stuck in esophagus

Esophageal dysphagia

42yo M admitted after being pedestrian victim in MVC presents with turbid, green fluid in chest tube

Esophageal perforation (caused by blunt chest trauma, instrumentation such as endoscopy, esophagitis, or effort rupture in Boerhaave syndrome --> presents with chest/back/epigastric pain, SQ emphysema and crepitus, Hamman sign aka crunching sounds on cardiac auscultation, and pleural effusion with atypical green fluid --> workup: pleural fluid analysis shows low pH and high salivary amylase and CXR shows widened mediastinum, pneumomediastinum, PTX, and/or pleural effusion --> diagnosis: CT or esophagraphy with water-soluble contrast shows leak from perforation --> management: NPO, IV antibiotics, PPIs, and emergency exploratory thoracotomy)

60F with PMHx of GERD presents with 3-mo hx of dysphagia Barium swallow: 2cm tapered distal esophageal stricture with moderate dilation of proximal esophagus

Esophageal stricture (peptic structure: symmetric narrowing of esophagus usually caused by GERD, in which chronic gastric acid exposure leads to fibrosis and scarring of esophagus --> other causes: radiation, systemic sclerosis, and caustic ingestion --> presents with slowly progressive dysphagia to solid foods and improvement of heartburn sx --> diagnosis: barium swallow shows symmetric circumferential narrowing --> treatment: endoscopy with biopsy to rule out adenocarcinoma and perform dilation)

Indications for statin therapy in prevention of ASCVD

Established ASCVD, LDL >190, age >40 with T2DM, and 10yr risk >7.5% (established ASCVD: includes ACS, stable angina, arterial revascularization, stroke, TIA, or PAD)

Which medications increase TBG concentration, thus increasing required dose of levothryoxine?

Estrogen, tamoxifen, raloxifene, heroin, and methadone

Which medications are associated with the side effect optic neuritis?

Ethambutol and hydroxychloroquine (ethambutol: part of RIPE therapy for TB, associated with optic neuropathy and red-green color blindness --> hydroxychloroquine: immunosuppressant used to treat malaria, porphyria cutanea tarda, and autoimmune conditions)

Which alcohols caused anion gap metabolic acidosis?

Ethanol, methanol, and ethylene glycol (ethanol: causes alcohol ketoacidosis --> methanol: causes formic acidosis and visual blurring --> ethylene glycol: causes oxalic acidosis and ATN with calcium oxalate crystals)

Which anesthetic is associated with adrenal insufficiency?

Etomidate (inhibits 11-beta hydroxylase --> adrenal insufficiency usually seen in elderly and patients with critical illness)

Which 2 parameters determine postop pulmonary morbidity prior to lung resection?

FEV1 and DLCO (determine whether patient has enough pulmonary reserve to maintain adequate lung function following surgery --> FEV1 is MORE IMPORTANT than DLCO --> estimated postop FEV1 or DLCO <40% are at elevated risk of postop morbidity)

What changes in coagulation parameters are expected with DIC?

High PT and aPTT, low fibrinogen

9yo girl presents with 1wk hx of difficulty hearing soft sounds in right ear, ringing in right ear, and popping sensation when she swallows after flying home from Colorado a few days earlier PE: retracted right TM with surrounding dilated blood vessels and mild right-sided hearing loss

Eustachian tube dysfunction (inflammation from infection/allergies causes Eustachian tube obstruction, leading to middle ear pressure dysregulation and lack of middle ear ventilation --> presents with ear fullness/discomfort, tinnitus, conductive hearing loss, and "popping" sensation during yawning/swallowing --> diagnosis: otoscope shows retracted TM due to negative pressure within middle ear, with dilated blood vessels indicated inflammation --> treatment: abx for AOM, antihistamines for allergic rhinitis --> complications: AOM, permanent hearing loss, TM rupture, and cholesteatoma)

What is the best next step in management for a patient with conjugated hyperbilirubinemia?

Evaluate LFTs (normal AST/ALT/AlkPhos: indicates congenital bilirubin disorder such as Dubin-Johnson or Rotor syndrome --> elevated AST/ALT: indicates liver disease such as hepatitis, HCC, hemochromatosis, and sarcoidosis --> elevated AlkPhos: indicates intrahepatic cholestasis from PBC/PSC or biliary obstruction from choledocolithiasis or malignancy)

Treatment of non-extertional (classic) heat stroke

Evaporative cooling (aka spraying lukewarm water while fans blow air on patient's skin)

How often should newborns be breastfed?

Every 2-3hrs for 10-20mins

How often should cardiac enzymes (troponin and CKMB) be measured in patient with suspected MI?

Every 8h in first 24h (CKMB: peaks within 12-40h following MI and decreases after 2-3 days, but low specificity for MI --> troponin: peaks within 6h and gradually decreases over 7 days, highest sensitivity for MI)

Which bone pathologies are found in the diaphysis?

Ewing sarcoma, multiple myeloma, fibrosarcoma, fibroma, and bone cyst

Treatment of nodular BCC on trunk/extremities

Excisional biopsy with narrow margins (usually 3-5mm margins)

Diagnosis of angina (for patients with low-intermediate pretest probability of CAD)

Exercise ECG (initial stress test for diagnosis and risk stratification --> for patients with HIGH pretest probability of CAD--typical angina in men >40yo and women >60yo--diagnose with coronary angio)

77F with PMHx of HTN and GERD presents with 3-mo hx of SOB when climbing stairs that resolves with 5mins of rest Vitals: afebrile, BP 144/92, HR 72, RR 12, SaO2 98% on RA PE: JVP >3cm above sternal angle ECG: LBBB Best next step in management?

Exercise stress echo (normally would do an exercise ECG due to signs of angina, however pt has LBBB which is contraindication for exercise ECG)

24M with PMHx of allergic rhinitis on chlorpheniramine presents after suddenly collapsing during military drills at basic training camp in Texas Vitals: febrile 106F, BP 90/60, HR 130, RR 22 PE: restlessness, skin hot with diffuse sweating, and rales at both lung bases Labs: elevated Hgb + platelets + WBC, elevated BUN, and prolonged PT

Exertional heat stroke (EHS: caused by inadequate cooling of body in excessive ambient heat or >75% humidity, dehydration, poor acclimatization, obesity, and meds that impact heat dissipation such as anticholinergics, antihistamines, phenothiazines, and TCAs --> presents with temp >104F immediately after collapse with CNS dysfunction, renal/hepatic dysfunction, DIC, and ARDS --> treatment: ice-water immersion, fluid resuscitation, electrolyte correction, and management of end-organ complications)

53yo F presents in PACU following total thyroidectomy with neck tightness and 4cm ballotable swelling under incision that increases in size during exam

Expanding neck hematoma (enlarging fluid collection in neck after neck surgery with risk of airway obstruction from either DIRECT airway compression or INDIRECTLY from vascular compression causing venous congestion and laryngeal edema --> presents initially mild neck tightness and ballotable neck swelling, later upper airway obstruction presents with stridor + dysphagia + voice changes + "tripod" positioning --> management: evacuating hematoma by reopening incision and removing blood collection, wound exploration in OR, and airway eval for laryngeal edema and need for protective intubation)

Which physical exam finding is most commonly associated with tracheomalacia?

Expiratory stridor (due to more collapsible intrathoracic airway with expiration INCREASING intrathoracic airway causing EXPIRATORY stridor)

Indications for foot imaging of diabetic foot ulcer

Exposed bone, positive probe to bone testing, >14 days, >2cm, elevated ESR or CRP, and adjacent soft tissue infection

40yo M presents after MVC with fullness and tenderness in suprapubic region. Foley placed without resistance with immediate return of bloody urine. FAST: no intraperitoneal free fluid Pelvic XR: fracture of left pubic ramus

Extraperitoneal bladder injury (aka ANTERIOR bladder wall injury: caused by pubic ramus fracture, in which bony fragment can directly puncture and rupture bladder --> presents with gross hematuria, suprapubic pain/tenderness, difficulty voiding, and NEGATIVE FAST due to urine remaining in retropubic space --> diagnosis: retrograde cystography)

Labs: - High Ca2+ - Low phos - High PTH - Low 24hr urine Ca2+ excretion

Familial hypocalciuric hypercalcemia (FHH: congenital disease caused by defective GPCR Ca2+ sensing receptors in parathyroids/kidneys, requiring higher Ca2+ levels to suppress PTH --> presents with hypercalcemia and HYPOCALCIURIA with normal/high PTH levels --> treatment: bisphosphonates)

6-month-old girl presents with poor weight gain PE: wt <5th percentile Labs: low K+, low HCO3-, low phos UA: acidic urine with glucosuria and phosphaturia

Fanconi syndrome (example of type 2 RTA with generalized reabsorption defect in PCT causing excretion of HCO3-, phos, amino acids, and glucose into urine --> causes: hereditary defects including cystinosis + tyrosinemia + glycogen storage disease, Wilson disease, PCT ischemia, multiple myeloma, lead poisoning, and meds such as ifosfamide/cisplatin --> presents with growth failure, osteopenia, and metabolic acidosis --> labs: hypokalemia, low HCO3-, and low phos --> diagnosis: UA shows phosphaturia + glucosuria + aminoaciduria and acidic urine pH <5.5 --> complications: hypophosphatemic rickets)

Diagnosis of T2DM

Fasting glucose >126 and HbA1c >6.5%

Management of GDM postpartum

Fasting glucose at 24-72hrs, and 2hr 75g GTT at 6-12wks (2hr 75g glucose tolerance test: positive if fasting BG >95, 1hr BG >140, or 2hr BG >120 --> if screening is negative, repeat screening should occur at 3yr intervals)

Routine lipid screening in pediatric patients

Fasting lipid panel at age 9-11 and 17-21 (completed twice due to stable lipid levels just before and after puberty)

26yo M presents 1 day after generalized tonic-clonic seizure with displaced right femur fracture s/p intramedullary nailing with confusion, elevated BP 142/86, tachy to 102, tachypnea to 28, and decreased O2 sat to 90% Labs: low platelets, low PaO2 CTA: bilateral scattered ground-glass opacities but no filling defects

Fat embolism syndrome (occurs 24-74hrs after pancreatitis or fracture/surgery of marrow-containing bone such as femur + pelvis, resulting in embolization of fat/hematopoietic cells into venous circulation that physically obstruct pulmonary capillaries or cause microvascular occlusions in systemic circulation such as brain/dermal capillaries --> circulating fat globules lead to systemic inflammatory response and thrombocytopenia from platelet adherence/aggregation to circulating fat globules --> presents with TRIAD of respiratory distress, neurologic dysfunction, and petechial rash --> diagnosis: chest CT shows bilateral ground-glass opacities similar to ARDS --> treatment: supportive care --> prevention: early immobilization of fracture)

Complications of PBC (primary biliary cholangitis)

Fat malabsorption, HLD, deficiency of vitamins ADEK, osteomalacia, and HCC

35F with PMHx of bilateral reduction mammoplasty for mammary hyperplasia 2yrs ago presents with breast mass PE: fixed mass palpated in UOQ of R breast Mammogram: 3x3cm spiculated mass with coarse calcifications in R UOQ US: hyperechoic mass Core biopsy: foamy macrophages and fat globules

Fat necrosis of breast (benign condition caused by previous breast surgery or trauma --> presents as FIXED mass with skin/nipple retraction, calcifications on mammography, and hyperechoic mass on US --> diagnosis: biopsy shows fat globules and foamy histiocytes)

73yo M with PMH of stable angina, HTN, HLD, and COPD presents right anterior thigh pain that worsens while walking PE: small pulsatile mass in right groin area

Femoral artery aneurysm (2nd most common peripheral artery aneurysm after popliteal aneurysm --> causes compression of femoral nerve that runs LATERAL to artery --> presents with anterior thigh pain and pulsatile groin mass BELOW inguinal ligament)

Patient with recent cardiac catheterization presents with tender pulsatile mass and systolic bruit at femoral artery entry site

Femoral artery pseudoaneurysm (caused by inadequately sealed arterial puncture site, leading to hematoma contained within periarterial CT --> presents with tender pulsatile mass and audible SYSTOLIC bruit)

Which traumatic LE injury is associated with EXTERNALLY rotated hip?

Femoral neck fracture

Which type of hip fractures have a higher risk of avascular necrosis?

Femoral neck fracture (aka intracapsular hip fracture --> presents with shortened LE that is EXTERNALLY rotated)

Elderly woman presents with acutely shortened, externally rotated leg after following fall

Femoral neck fracture (caused by mechanical fall, resulting in lack of acetabular function and unopposed contraction of psoas + iliacus --> presents with ABDUCTED, EXTERNALLY ROTATED, and SHORTENED LEG compared to contralateral side --> treatment: arthroplasty or open reduction with internal fixation --> complication: avascular necrosis due to intracapsular fracture)

Decreased sensation over anterior thigh + medial leg and weakness of quadriceps muscle

Femoral nerve injury (compression of the femoral nerve L4-L2 under the inguinal ligament --> causes: pelvic fracture, prolonged pushing during labor, and extreme hip flexion during lithotomy position --> presents with decreased sensation in anterior thigh + medial leg, motor weakness of quadriceps, and decreased leg extension with diminished patellar reflex)

27F G1P1 presents with 3-day hx of numbness and tingling in anterior lower right leg and buckling of right knee when attempting to walk after moderately difficult forceps delivery 3 days ago PE: decreased sensation along anterior/anteromedial/medial aspect of right thigh + knee + + upper leg and weakness of quadriceps femoris muscle

Femoral nerve injury (compression of the femoral nerve L4-L2 under the inguinal ligament caused by prolonged pushing and extreme hip flexion in lithotomy position --> presents with decreased sensation in anterior thigh + medial leg, motor weakness of quadriceps, and decreased leg extension with diminished patellar reflex)

Best next step in management for fundal height > date discrepancy at >20wks gestation

Fetal dating US (fundal ht should correspond to gestation after 20wks, so discrepancy +/- 2cm needs to be evaluated for US)

Upper GI endoscopy: thickened gastric folds and multiple duodenal + jejunal uclers

Gastrinoma (Zollinger-Ellison syndrome/ZES: neuroendocrine tumor caused by excess gastrin production, with 20% associated with MEN1 --> presents in YOUNG ADULTS age 20-50yo with dyspepsia/reflux, abdominal pain, weight loss, diarrhea, and frank GI bleeding --> workup: upper GI endoscopy shows thickened prominent gastric folds and JEJUNAL ULCERS --> diagnosis: fasting serum gastrin >1000pg/mL, or positive secretin stimulation test/calcium infusion study if non-diagnostic gastrin level)

33F G3P0 at 28wks with PMHx of T2DM and increasing insulin requirements presents for routine prenatal visit PE: fundal height 24cm Fetal US: 4th percentile for gestational age and AFI 3cm

Fetal growth restriction (GFR: estimated fetal weight <10th percentile for gestational age, usually as a result of uteroplacental insufficiency from maternal vascular disease such as T1DM and chronic HTN --> worsening insufficiency causes decreased fetal O2 and nutrition, causing slowing of fetal growth and oligohydramnios --> presents with fetal wt <10th percentile for gestational age and AFI <5cm --> diagnosis: umbilical artery Doppler US to assess placental perfusion --> treatment: urgent delivery to minimize risk of fetal demise)

1-hour-old boy born via SVD to 29F without prenatal care presents in NICU with growth restriction PE: microcephaly, wide anterior fontanelle, cleft palate, and hypoplasia of distal phalanges

Fetal hydantoin syndrome (caused by in utero exposure to anti-epileptics phenytoin, carbamazepine, and valproate --> presents in NEONATES with cleft lip + palate, wide anterior fontanelle, distal phalange hypoplasia, cardiac anomalies such as AS/PS, and microcephaly --> prevention: lowering seizure med dose and 4mg folic acid)

Progression of typhoid fever

Fever, abdominal pain and salmon-colored rash, and hepatosplenomegaly (1st week: fever --> 2nd week: abdominal pain with constipation followed by diarrhea and salmon-colored abdominal rash --> 3rd week: hepatosplenomegaly with intestinal bleeding or perforation --> treat with ceftriaxone or ciprofloxacin)

Signs of complicated SBO

Fever, hypotension, tachycardia, guarding, leukocytosis, and metabolic acidosis (complicated SBO: requires urgent surgical exploration due to risk of impending ischemia, strangulation, and necrosis)

Treatment of hypertriglyceridemia

Fibrates (includes fenofibrate, gemfibrozil, and bezafibrate: upregulate LPL to increase TG clearance, and activates PPAR-alpha to induce HDL synthesis --> used to treat hypertriglyceridemia --> side effects: myopathy and cholesterol gallstones)

Cause of Marfan syndrome

Fibrillin-1 gene mutation (Marfan syndrome: autosomal dominant disease resulting in systemic weakening of CT --> presents with joint hypermobility, skin hyperelasticity, long fingers, pectus excavatum, scoliosis/kyphosis, and UPWARD lens dislocation with myopia --> complications: aortic root dilatation leading to AR, aneurysms, and aortic arch dissection)

Woman <30yo presents with solitary firm, smooth, mobile breast mass

Fibroadenoma

Woman >30yo presents with solitary, firm, smooth, mobile breast mass

Fibrocystic changes of breast

19F with PMHx of recurrent headaches presents with 6mo hx of elevated BP Vitals: BP 175/100, HR 80, RR 14 PE: systolic bruit heard under right ear

Fibromuscular dysplasia (FMD: systemic non-inflammatory disease affecting renal and internal carotid arteries, leading to arterial stenosis/aneurysm/dissection --> presents in YOUNG WOMEN with recurrent headaches 2/2 carotid artery stenosis/aneurysm, pulsatile tinnitus, TIA/stroke, secondary HTN, flank pain, and subauricular/abdominal BRUIT --> diagnosis: duplex US/CTA/MRA shows "string of beads" appearance of renal/internal carotid artery --> treatment: ACEIs/ARBs and percutaneous transluminal angioplasty/PTA)

25yo M with PMH of Crohn disease and smoking presents with 2mo hx of intermittent RLQ pain that has progressed to constant diffuse pain, nausea, and 2-day hx of bilious vomiting and constipation with flatus PE: dry oral mucosa and pale conjunctivae, distended tympanic tender abdomen, and decreased bowel sounds

Fibrotic intestinal stricture (cause of SBO in patients with poorly controlled Crohn disease --> presents with bilious vomiting, severe abdominal pain, partial/complete obstruction with some passage of flatus, distended tympanic tender abdomen, and either HIGH-PITCHED HYPERACTIVE or DECREASED/ABSENT BOWEL SOUNDS depending on stage of SBO --> treatment: surgical resection)

Best next step in management for child with isolated proteinuria

First morning urine protein/Cr ratio (if normal Pr/Cr ratio, obtain UA to dx orthostatic proteinuria vs. transient proteinuria --> if elevated Pr/Cr, evaluate for glomerular or parenchyma disease with BMP + complement levels + renal US + kidney biopsy)

Which physical exam signs are associated with acute angle-closure glaucoma?

Fixed dilated pupil and corneal cloudiness (acute angle-closure glaucoma: hypoxia from retinal disease that induces vasoproliferation in iris, causing iris to push against cornea and NARROW the angle to reduce flow thru trabecular network, resulting in increased IOP and complete angle closure abruptly --> occurs in ELDERLY patients --> presents with PAINFUL red eye, sudden vision loss, halos around lights, frontal headache, nausea/vomiting, fixed dilated pupil, and acute corneal opacification --> treatment: pilocarpine, an M3 agonist that opens meshwork into canal of Schlemm)

Signs of uncal herniation

Fixed dilated pupil and hemiparesis (fixed dilated pupil: caused by CN3 compression on IPSILATERAL side --> hemiparesis: caused by crus cerebri compression on CONTRALATERAL side)

Pulmonary flow-volume loop: flattening of both top + bottom of flow-volume curve

Fixed upper airway obstruction (limits airflow during BOTH inspiration and expiration --> ex: laryngeal edema)

25yo M presents after high-speed MVC with dyspnea to 34 RR, low SaO2 to 88%, and tachycardia to 120 PE: several chest wall and abdominal bruises, diminished breath sounds in anterior left lung, and portion of anterior left chest moving inward during inspiration

Flail chest (occurs when fracture of 3+ contiguous ribs in 2+ locations creates isolated chest wall segment/flail segment that moves PARADOXICALLY to rest of rib cage during inspiration --> caused by extreme trauma to chest wall, which also contuses underlying lung --> results in impaired generation of negative intrathoracic pressure during inspo and increased dead space during expo causing ineffective ventilation, pulmonary contusion of underlying lung which impedes O2 diffusion, and fracture-related pain causing respiratory splinting and atelectasis --> presents with tachypnea, hypoxia, and segment of chest wall that moves INWARD during inspiration --> management: mechanical PEEP to force flail segment to move outward during inspiration)

Indications for surgery in patient with rib fracture

Flail chest, failure to wean from respirator, and chest wall deformity

Which finding on JVP waveform is highly specific for cardiac tamponade?

Flattened y descent (due to restriction of passive RV filling from restricted venous return to heart)

Which class of medication is contraindicated in patients with aortic aneurysm?

Fluoroquinolones (includes levofloxacin, moxifloxacin, and ciprofloxacin: upregulate cell matrix metalloproteinases leading to increased collagen degradation, which can cause Achilles tendon rupture, retinal detachment, and aortic aneurysm rupture --> should be avoided in patients with aortic aneurysm or risk factors such as Marfan syndrome, Ehlers-Danlos, advanced atherosclerotic disease, and uncontrolled HTN --> other side effects: encephalopathy, peripheral neuropathy, tendonitis/tendon rupture, and QT prolongation)

Which antibiotics are contraindicated for patients with myasthenia gravis?

Fluoroquinolones, aminoglycosides, and macrolides (can trigger myasthenic crisis --> other meds contraindicated in MG: beta-blockers, CCBs, magnesium, and penicillamine)

Preferred medical treatment for pediatric OCD

Fluoxetine, fluvoxamine, and sertraline (preferred SSRIs for pediatric OCD)

1st line SSRIs for pediatric patients

Fluoxetine, sertaline, and fluvoxamine

Treatment of actinic keratosis

Focal cryotherapy and 5FU cream (aka topical fluorouracil)

Diagnosis of symptomatic ruptured AAA in hemodynamically UNSTABLE patient

Focused abdominal US (if AAA identified, need to do emergency surgical repair --> if AAA previously identified, can proceed straight to surgery)

Labs: - Macrocytic anemia - Increased homocysteine - Normal methylmalonic acid

Folate deficiency (vitamin B9 deficiency)

Treatment of hereditary spherocytosis

Folate, transfusions, and splenectomy (note: splenectomy ONLY for refractory anemia and/or splenomegaly)

62M with PMHx of HTN presents with incidental finding of enlarged mediastinal LN on recent CXR (unchanged from CXR 1yr ago) and several month hx of non-painful nodules in axillae PE: bilateral enlarged and tender axillary + inguinal LNs Labs: normal CBC and CMP

Follicular lymphoma (common form of non-Hodgkin lymphoma --> presents in ELDERLY with painless "waxing and waning" peripheral LAD in cervical/axillary/inguinal region, hilar and/or mediastinal LAD, and sometimes B symptoms --> diagnosis: excisional LN biopsy shows nodular growth of follicular lymphocytes, immunophenotype shows t14;18 and BCL2 overexpression)

55F with PMHx of HTN presents with 1-day hx of worsening dyspnea, blurry vision, dry mouth, and mild nausea Vitals: SaO2 93% PE: increased WOB, sluggishly reactive pupils, dry mucous membranes, weak neck muscles, and 4/5 strength in UE b/l ABG: respiratory acidosis and hypoxia

Foodborne botulism (ingestion of Clostridium botulinum toxin from improperly canned foods/moonshine/cured fish, which inhibits presynaptic ACh release at NMJ --> causes SYMMETRIC DESCENDING motor paresis starting with CN3, CN4, CN6, CN9, and CN10 eventually causing diaphragmatic paralysis and autonomic dysfunction --> presents within 36hrs of ingestion with ACUTE ONSET of blurry vision, diplopia, facial weakness, dysarthria, dysphagia, symmetric descending muscle weakness, and respiratory failure with hypoventilation --> diagnosis: elevated serum botulinum toxin --> treatment: equine serum heptavalent botulinum antitoxin)

3yo girl with PMHx of asthma recently dx from hospital after choking episode causing persistent cough and wheezing presents with persistent cough despite finishing course of oral steroids PE: diminished breath sounds and faint wheeze in RML CXR: unremarkable

Foreign body aspiration (occurs in YOUNG CHILDREN AGE 1-3yo after choking on food such as seeds/nuts or small toy --> presents with sudden-onset cough, SOB, focal wheezing/stridor, and focal area of diminished breath sounds +/- responsive to albuterol --> CXR: normal or hyperinflation of affected side with mediastinal shift toward unaffected side --> diagnosis + treatment: rigid bronchoscopy to identify and remove aspirated object)

47F with PMHx of T1DM presents with unresponsiveness after 24-hr hx of progressive vulvar redness, hardness, and swelling that spread to left upper thigh/lower abdomen Vitals: afebrile, BP 70/40, HR 130, RR 30 PE: erythema of lower abdomen to level of umbilicus and from left thigh to knee, purulent discharge from open laceration on left labium majus and marked edema of labia majora

Fournier gangrene (life-threatening necrotizing fasciitis caused by cutaneous breakdown in perianal/genital region, allowing portal of entry for GROUP A STREP anaerobic colonic/urogenital organisms into fascial planes + SQ fat, resulting in microthrombi of cutaneous vessels and gangrene of skin --> risk factors: diabetes and obesity --> presents with RAPID PROGRESSION of high fever, hypotension, and swelling + tenderness + crepitus in perinuem/lower abdomen --> labs: leukocytosis, acidosis, renal failure, and coagulopathy --> treatment: IV antibiotics + fluids and early surgical exploration + debridement --> complications: sepsis with >20% mortality)

Most common site of epidural hematoma

Fracture in pterion region (junction of frontal + parietal + temporal + sphenoid bones)

What is a Salter-Harris type III fracture?

Fracture of distal tibial epiphysis and growth plate (Salter-Harris type III/juvenile Tillaux fracture: distal tibial growth plate fracture that can cause growth arrest, limb-length discrepancy, physeal bars, premature OA, and decreased ROM if it occurs in boys <14 or girls <12)

Most common cause of ulnar nerve injury

Fracture of humeral median epicondyle (ulnar nerve in jury: presents with "ulnar claw" aka loss of flexion of wrist/medial fingers, radial deviation of wrist, loss of sensation over ring + pinky finger and hypothenar eminence, and DECREASED GRIP STRENGTH)

Most common cause of radial nerve injury

Fracture of humeral midshaft (radial nerve injury: presents with wrist drop aka loss of elbow/wrist/finger extension, decreased grip strength, and loss of sensation over posterior arm/forearm and dorsal hand)

Definition of type II odontoid fracture

Fracture through base of dens

Definition of type III odontoid fracture

Fracture through body of C2

Definition of type I odontoid fracture

Fracture through tip of dens

Paracentesis: repeat bloody ascitic fluid

HCC, ovarian cancer, or prostate cancer (diagnosis of bloody ascites: peritoneal RBC count >50,000 --> HCC: tumor growth disrupts and erodes nearby blood vessels --> ovarian and prostate cancer: peritoneal mets cause bloody ascites)

14yo F with PMHx of high plantar arches and mild scoliosis presents with 3wk hx of progressive lower limb weakness and clumsiness with difficulty walking PE: wide-based gait, difficulty maintaining balance, decreased strength 2/5 in LE b/l, and decreased vibratory and position sense in LE MRI: cervical spinal cord atrophy

Friedreich ataxia (autosomal recessive condition caused by GAA trinucleotide repeats in frataxin gene that is highly expressed in brain + heart + pancreas, resulting in progressive ataxia + cardiomyopathy + diabetes in adolescence --> presents in TEENAGERS with progressive gait and limb ataxia, dysarthria, limb weakness, loss of position/vibratory senses, loss of DTRs, and skeletal abnormalities such as scoliosis and high-arched feet/pes cavus --> imaging: cervical spinal cord atrophy --> diagnosis: genetic testing --> complications: HOCM and diabetes)

MRI: marked atrophy of medulla and dorsal columns of spinal cord

Friedreich ataxia (autosomal recessive defect in frataxin gene caused by trinucleotide GAA repeats, resulting in degeneration of spinal tracts --> presents in ADOLESCENTS/YOUNG ADULTS with progressive gait ataxia, dysarthria, loss of vibration/position sense, absent DTRs, scoliosis, diabetes mellitus, and HOCM --> complication: cardiac dysfunction leading to CHF/ arrhythmias/death)

Surgical management of severe GERD

Fundoplication (aka laparoscopic Nissen fundoplication: surgical method in which fundus is wrapped around backside of esophagus in order to anchor lower esophagus BELOW diaphragm --> used to treat severe refractory GERD and sliding hiatal hernia, and asymptomatic paraesophageal hiatal hernia)

CSF analysis: - WBC 10-500, lymphocyte/monocyte-predominant - Low glucose (<40) - High protein (>250) - High opening pressure

Fungal meningitis (inflammation of leptomeninges from fungal infection such as Cryptococcus in immunosuppressed patients --> CSF analysis: mild pleocytosis with LYMPHOCYTE or MONOCYTE predominance, elevated opening pressure, low glucose, and high protein)

Management of patient with acute STEMI and flash pulmonary edema

Furosemide (decreases cardiac preload to decrease pulmonary capillary pressure, thus relieving pulmonary edema --> also causes venodilation to further decrease preload)

Cause of anterior plagiocephaly

Fused coronal suture (infant will have unilateral fused coronal suture --> presents with unilateral bulging of forehead CONTRALATERAL to side of fusion)

Prenatal US: two intrauterine gestations with thick intertwin membrane and "lambda sign" of placenta

Fused di/di twins (fused dichorionic diamniotic pregnancies: occurs when di/di twins cause fetal overcrowding resulting in appearance of single fused placenta on US --> diagnosis: US shows 2 intrauterine gestations with THICK intertwin membrane and "LAMBDA sign" aka placental projection where intertwin membrane meets placentas)

Cause of posterior plagiocephaly

Fused lamboid suture (infant will have unilateral fused lamboid suture --> presents with unilateral bulging of skull base + mastoid CONTRALATERAL to side of fusion)

Which bacteria causes Lemierre syndrome?

Fusobacterium (Lemierre syndrome: life-threatening deep neck space infection that progresses to IJ thrombosis and infection --> caused by underlying bacterial tonsillitis that progresses to peritonsillar abscess --> presents with acute onset of painful pharyngitis and odynophagia, high fevers >102, rigors, and respiratory distress from associated septic PE)

Which hematologic disorder is associated with LOW MCHC?

G6PD deficiency (X-linked recessive disorder caused defect in G6PD leading to by inadequate NADPH neutralization of oxidant stresses such as sulfa drugs, antimalarials, infections, and fava beans --> presents with back pain, hemoglobinuria, jaundice, and splenomegaly after oxidant stress --> diagnosis: CBC shows LOW MCH, peripheral smear shows RBCs with Heinz bodies and bite cells/degmacytes --> treatment: avoidance of hemolytic triggers)

Two major organisms causing necrotizing fasciitis

GAS and Clostridium perfringens (GAS: classic causative agent --> Clostridium perfringens: causes gas gangrene in deep penetrating wounds or large bone fractures where it can thrive in anaerobic environment)

Head CT: butterfly lesion with central necrosis and heterogenous serpiginous contrast enhancement

GBM (glioblastoma multiforme, aka grade IV astrocytoma)

CSF analysis: - Normal WBC count - Normal glucose - High protein

GBS (Guillain-Barre syndrome: acute demyelinating polyneuropathy caused by recent respiratory or GI infection with Camylobacter jejuni, with molecular mimicry cross-reaction with peripheral nerve axons --> other causes: CMV, recent immunization, surgery, trauma --> presents with paresthesias in fingers/toes, symmetric ascending weakness and hyporeflexia originating in LE, decreased/absent DTRs, neuropathic back pain, autonomic dysfunction with bradycardia/ileus, and respiratory compromise --> diagnosis: abnormal EMG/nerve conduction and CSF shows albuminocytologic dissociation aka elevated protein with normal WBCs --> treatment: monitoring autonomic + respiratory function, IVIG, and plasmapheresis)

Neonatal CXR: diffuse hazy infiltrates bilaterally

GBS sepsis (group B strep sepsis: most common cause of sepsis in neonates, usually due to transmission of GBS from maternal genital tract to fetus during delivery, resulting in either bacteremia of unknown location + pneumonia + meningitis --> presents with high fever, respiratory distress, seizures, and leukocytosis with increased bands --> diagnosis: CXR shows diffuse hazy infiltrates b/l, blood culture positive for group B strep --> treatment: IV ampicillin and gentamicin)

Complications of excessive weight gain during pregnancy

GDM, fetal macrosomia, and C-section (GDM: dx at 24-28wks with 1hr 50g GCT and 3hr 100g GTT --> fetal macrosomia: dx by birth wt >8lbs, often requiring C-section due to risk of labor dystocia)

Triad of early satiety, intractable N/V, and weight loss PE: abdominal tenderness, distension, and succussion splash ("splash" heard on abdominal auscultation when rocking patient back/forth at the hips)

Gastric outlet obstruction (mechanical obstruction of stomach or duodenum caused by pancreatic adenocarcinoma with gastric/duodenal invasion, annular pancreas, PUD, gastric volvulus, gastric bezoar, or gastric polyps --> presents with early satiety, intractable N/V, weight loss, abdominal tenderness + distension, and succussion splash aka "splash" heard on abdominal auscultation when rocking patient back/forth at the hips that suggests retained food in stomach --> labs: hypokalemic hypochloremic metabolic alkalosis --> diagnosis: abdominal CT shows gastric distension and air-fluid levels, upper endoscopy shows obstruction)

45M with PMHx of smoking and joint/back pain presents with recurrent sinusitis and otitis refractory to antibiotics and intranasal steroids PE: erythema and small ulceration in right auditory canal Labs: low Hgb UA: 2+ protein and blood with 20-30 RBCs/hpf

GPA (granulomatosis with polyangitis: small and medium vessel necrotizing vasculitis caused by autoantibodies c-ANCA/PR3-ANCA, which primary affects nasopharynx + lungs + kidneys + skin --> presents in YOUNG ADULTS 30-50yo with recurrent sinusitis/otitis, oral or auditory canal ulcers, hearing loss, saddle-nose deformity, SOB, cough, hemoptysis, RPGN, livedo reticularis, non-healing skin ulcers, and pyoderma gangrenosum --> CXR: large nodular densities/cavitary lesions --> diagnosis: positive c/PR3-ANCA, skin biopsy shows leukocytoclastic vasculitis, lung biopsy shows granulomatous vasculitis, and kidney shows pauci-immune GN --> treatment: high-dose steroids and/or cyclophosphamide)

55yo F with PMH of ALL s/p allogeneic stem cell transplant 3wks ago presents with worsening crampy abdominal pain and watery diarrhea PE: generalized maculopapular rash Labs: negative C. diff and CMV

GVHD (graft vs. host disease: immune-mediated multisystem inflammatory condition caused by donor CD8+ T cells identifying antigens on host epithelial cells, creating a strong proinflammatory response --> occurs in 35-50% of patients who undergo allogeneic HSCT --> presents <100d after transplant with painful maculopapular rash, crampy abdominal pain and profuse watery diarrhea that mostly occurs at night, and liver inflammation with damage to biliary tract epithelium --> labs: elevated bilirubin, AlkPhos, and AST/ALT --> diagnosis: colonoscopy with biopsy --> treatment: steroids)

Treatment of post-herpetic neuralgia

Gabapentin (GABA analog that binds to high voltage-gated Ca2+ modulators to inhibit release of excitatory NTs --> SE: drowsiness, weight gain, ataxia, and fluid retention)

Treatment of postherpetic neuralgia

Gabapentin, pregabalin, and TCAs (for mild/moderate pain, can also try topical capsaicin and lidocaine)

Which cranial nerve reflex indicates intact upper medulla?

Gag reflex (indicates intact CN9 + CN10)

Triad of cervical myelopathy

Gait dysfunction, LMN signs in arms, and UMN signs in legs (cervical myelopathy: caused by spondylosis that narrows cervical spinal canal and compresses spinal cord, usually seen in MIDDLE-AGED/OLDER ADULTS --> presents with gait dysfunction, LMN signs in arms such as muscle atrophy/weakness and hyporeflexia, UMN signs in legs such as hyperreflexia and positive Babinski, and decreased propioception + vibration + pain sensation in all extremities --> diagnosis: C-spine MRI or CT myelogram --> treatment: immobilization and/or surgical decompression)

28F with PMHx of vaginal delivery 7mo who has been breastfeeding her baby for 6mo presents with right breast mass PE: soft, mobile, non-tender 4cm subareolar mass in right breast

Galactocele (benign milk retention cyst caused by dried deposited proteins in lactiferous duct, creating a blockage and milk accumulation behind the obstruction --> presents weeks-months after CESSATION OF BREASTFEEDING with soft, mobile, non-tender, subareolar mass <5cm --> diagnosis: US shows cystic mass, aspiration confirms dx --> treatment: ice packs + supportive well-fitting bra, needle aspiration if painful)

7-day-old boy exclusively breastfed presents with sepsis with blood cx positive for E. coli Vitals: febrile 100.8F, HR 158 PE: jaundice and hepatomegaly Labs: normocytic anemia, elevated WBC, elevated indirect bili, and elevated AST + ALT

Galactosemia (autosomal recessive disorder caused by GALT deficiency, resulting in inability to metabolize galactose to glucose, leading to galactose accumulation in tissues that causes oxidative destruction --> presents in NEONATES with vomiting, poor feeding/FTT, jaundice, hepatomegaly, cataracts, and E. coli sepsis --> labs: hypoglycemia, metabolic acidosis, elevated transaminases, and hyperbilirubinemia --> diagnosis: absent RBC GALT activity --> treatment: soy-based formula and galactose-free diet)

5-day-old girl born at home via SVD presents with fussiness and 1-day hx of non-bloody non-bilious vomiting after breastfeeding Vitals: afebrile, HR 180 PE: weight at 20th percentile, poor tone, jaundice, sunken anterior fontanelle with overriding sutures, bilateral cataracts, and hepatomegaly

Galactosemia (autosomal recessive inborn error of metabolism caused by GALT deficiency, resulting in inability to metabolize galactose with toxic galacticol accumulation in lens of eyes + retina + kidneys + Schwann cells --> presents in 1st week of life with poor feeding/vomiting after feeds, FTT, lethargy, hypotonia, dehydration, jaundice, hepatomegaly, CATARACTS, and E. coli sepsis --> labs: hyperbilirubinemia, transaminitis, hypoglycemia, metabolic acidosis --> diagnosis: positive urine reducing substance and absent RBC GALT activity --> treatment: galactose and lactose-free diet)

77F presents with 2-day hx of cramping abdominal pain + distension, nausea, and vomiting Vitals: afebrile, BP 110/86, HR 112, RR 24 PE: abdominal distension, mild diffuse tenderness, and high-pitched bowel sounds Abdominal XR: air-fluid levels throughout small bowel and air in liver

Gallstone ileus (obstruction of ileocecal valve via gallstone, which enters GI lumen via fistula between gallbladder and GI tract and causes intermittent "tumbling" obstruction with diffuse abdominal pain + vomiting until finally lodging in ileum--> risk factors: ELDERLY FEMALES and chronic gallstone disease causing pressure ulceration --> presents with cramping/colicky abdominal pain + distension, hyperactive bowel sounds, N/V, inability to pass flatus/stool, and hypovolemia --> diagnosis: abdominal XR shows air-fluid levels throughout small bowel and pneumobilia aka air in biliary tree, abdominal CT shows gallbladder wall thickening + pneumobilia + obstructing stone --> treatment: removal of stone and simultaneous/delayed cholecystectomy)

42F with PMH of HLD and RA presents with progressively enlarging right wrist mass PE: slight ulnar deviation at b/l wrists and 2cm firm, mobile, non-tender mass on extensor surface of R wrist that transilluminates with penlight

Ganglion cyst (mucinous-filled cyst usually occurring at the wrist seen in patients with underlying joint disorders/prior joint injury --> communicate with underlying joint via hollow pedicle, allowing fluid to flow from joint space to cyst --> presents with mobile, non-tender swelling at wrist that transilluminates --> resolves spontaneously)

Which disease is characterized by glucocerebrosidase (deficiency?

Gaucher disease (most common lysosomal storage disease caused by autosomal recessive deficiency in glucocerebrosidase aka beta-glucosidase --> presents with anemia, thrombocytopenia, hepatosplenomegaly, and OSTEOPOROSIS with avascular necrosis of femur + bone crisis --> diagnosis: presence of Gaucher cells in bone, aka lipid-laden macrophages resembling crumpled tissue paper --> treatment: recombinant glucocerebrosidase)

8yo boy presents after falling out of bed 10mins after sleeping, found by mom unconscious on floor with blue discoloration around lips that resolved after a few seconds. Regained consciousness after a few mins but seemed excessively sleepy.

Generalized tonic-clonic seizure (can present during sleep with muscle stiffening during initial tonic phase causing patient to fall, with contraction of chest wall muscles causing difficulity breathing --> presents with LOC and loss of postural tone, tonic-clonic convulsions, PERIORAL CYANOSIS, tongue biting, urinary incontinence, and post-ictal state --> workup: EEG --> treatment ONLY if EEG is abnormal)

Treatment of endometritis

Gentamicin and clindamycin (can sometimes add ampicillin)

Complications of maternal chronic hep C during pregnancy

Gestational diabetes, cholestasis, and preterm labor

Which bone pathologies are found in the epiphysis?

Giant cell tumor and chondroblastoma

Which primary bone tumor is only found in the epiphysis of long bones (usually knee)?

Giant cell tumor of bone ("osteoclastoma": benign locally aggressive tumor arising from neoplsatic mononuclear cells expressing RANKL surrounded by reactive multinucleated giant cells --> occurs in YOUNG ADULTS and ELDERLY w/ PAGET DISEASE --> presents with dull knee pain/swelling/stiffness and decreased ROM --> diagnosis: XR shows "soap bubble" eccentric lytic lesion in epiphysis, MRI shows adjacent soft tissues, biopsy shows MNG cells resembling osteoclasts interspersed with sheets of mononuclear stromal cells --> treatment: intralesional curettage/excision and denosumab)

Diagnosis of primary amenorrhea

Girls >13yo with absent menarche and pubic hair, or girls >15yo with absent menarche only

Patient appears hypovolemic Labs: low K+, low Mg2+, and metabolic alkalosis Urine lytes: low urine Cl- and low urine Ca2+

Gitelman syndrome (autosomal recessive reabsorption defect in DCT NaCl transporter --> presents with hypovolemia/euvolemia, hypokalemia, hypomagesemia, metabolic alkalosis, and HYPOCALCIURIA --> similar to lifelong thiazide diuretic use, less severe than Bartter syndrome)

Most commonly dislocated joint in human body

Glenohumeral joint (commonly dislocated due to shallow articulation between humeral head and glenoid fossa of scapula --> usually ANTERIOR dislocation caused from blow to EXTERNALLY ROTATED and ABDUCTED arm)

Which diabetes medication is contraindicated in patients with heart failure?

Glitazones (thiazolidinediones: PPAR-y activators that increase insulin sensitivity to regulate glucose metabolism + FA storage --> side effects: weight gain, osteoporosis, and WATER RETENTION/EDEMA thus increasing risk of CHF)

3-day-old girl presents with copious purulent eye drainage PE: bilateral eyelid edema, conjunctival ejection, and purulent discharge

Gonococcal conjunctivitis (most severe form of neonatal conjunctivitis caused by transmission of Neisseria gonorrhoeae via contact with infected maternal genital secretions during delivery --> presents at 2-5 DAYS of life with bilateral eyelid edema, conunctival injection/chemosis, and copious purulent exudate --> diagnosis: gram-stain with gram-negative intracellular diplococci OR positive Thayer-Martin culture --> treatment: single-dose IM ceftriaxone or cefotaxime --> prevention: ophthalmic erythromycin ointment after delivery --> complications: corneal ulceration, scarring, and blindness)

Renal biopsy: linear deposition of IgG on basement membrane

Goodpasture syndrome

Most common causes of VAP (ventilator-associated pneumonia)

Gram-negative bacilli and gram-positive cocci (GN bacilli: Pseudomonas, E. coli, and Klebsiella --> GP cocci: MRSA, Streptococcus)

62F with PMHx of HTN and T2DM presents with 3-wk hx of 2 episodes of vaginal bleeding PE: blood at cervical os and mass in left adnexa Pelvic US: 8x8cm left ovarian mass Endometrial biopsy: atypical complex hyperplasia

Granulosa cell tumor (malignant ovarian sex cord stromal tumor arising from granulosa cells, which converts testosterone to estrogen therefore causes hyperestrogenism --> presents in MIDDLE-AGED WOMAN >50yo with post-menopausal bleeding, endometrial hyperplasia, and breast tenderness --> labs: elevated estrogen and/or progesterone --> diagnosis: pelvic US shows mass, endometrial biopsy shows endometrial hyperplasia, and histology shows Call-Exner bodies aka granulosa cells arranged haphazardly around collections of eosinophilic fluid --> treatment: surgical resection)

Skin exam: widely scattered, erythematous, scaly papules and plaques following strep infection

Guttate psoriasis (cause: recent strep infection and RA on TNF-alpha inhibitors --> treatment: UV phototherapy, topical high-potency steroids, and vitamin D analogs such as calcipotriene)

Best pelvic shape for vaginal delivery

Gynecoid shape (has round to slightly oval pelvic inlet --> pelvic inlet diagonal conjugate >12.5cm --> distance between ischial spines >10cm --> pelvic outlet intertuberous diameter >8cm --> pubic arch >90°)

Which pathogens should a patient with recently dx HIV be screened for?

HAV, HBV, HCV, VZV, CMV, and Toxoplasma (those w/o immunity to HAV + HBV require vaccination --> if positive for Toxoplasma and CD4 <100, start patient on Bactrim)

Which type of conditions are associated with membranoproliferative glomerulonephritis (MPGN)?

HBC, HCV, lipodystrophy, and C3 nephritic factor (MPGN: nephritic + nephrotic syndrome in which mesangial growth causes GBM splitting and "tram-track" appearance on H&E and PAS stains --> HBV, HCV, and lipodystrophy: associated with type 1 MPGN with granular IF showing subendothelial IC deposits --> C3 nephritic factor: causes stabilization of C3 convertase and persistent complement activation, leading to "dense deposit disease" aka intramembranous deposits)

Management of needle-stick injury from HBV-positive patient in person without Hep B immunity

HBIG and HBV vaccine (should be administered within 12hrs of injury --> HBIG: provides passive immunization --> HBV vaccine: provides active immunization)

Tumor marker analysis: - Normal CEA - Normal CA 19-9 - Elevated AFP

HCC

Most common cause of persistently bloody ascites

HCC (hepatocellular carcinoma: liver tumor growth causes disruption and erosion of nearby bloody vessels causing bloody ascites --> other causes include ovarian/prostate cancer causing peritoneal mets --> workup; abdominal CT, AFP, and cytologic analysis of ascitic fluid)

Diagnosis of neonatal polycythemia

HCT >65% (neonatal polycythemia: caused by increased erythropoiesis 2/2 intrauterine hypoxia from pre-eclampsia/GDM/HTN/smoking/IUGR, erythrocyte transfusion from delayed cord clamping/twin-twin transfusion syndrome, or genetic/metabolic diseases such as hypo or hyperthyroidism and genetic trisomy --> presents with ruddy skin/plethora, lethargy, irritability, jitteriness, poor feeding, abdominal distension, tachypnea, cyanosis, and respiratory distress --> labs: HCT >65%, hypoglycemia, hypocalcemia, and hyperbilirubinemia --> treatment: IV fluids, glucose, and partial exchange transfusion)

Criteria for methotrexate management of ectopic pregnancy

HDS, unruptured adnexal mass <3.5cm, <8wks gestation, bhCG <5000, and no renal disease (if any of these criteria are not met, proceed to urgent laparotomy)

28F G1P0 at 35wks with PMHx of gestational HTN dx at 26wks presents with nausea, vomiting, and epigastric + RUQ pain Vitals: afebrile, BP 160/94, HR 80 PE: epigastric and RUQ tenderness, decreased bowel sounds, and 2+ edema of LE FHT: baseline 140s with moderate variability, no decels, and no accels UA: 3+ protein Labs: low plt <100k, high total bili + indirect bili, high AlkPhos, and high AST + ALT Peripheral smear: numerous RBC fragments

HELLP syndrome (hemolysis + elevated liver enzymes + low platelet syndrome: life-threatening pregnancy complication usually seen as a severe form of pre-eclampsia caused by abnormal placentation, triggering systemic inflammation and activation of coagulation system + complement cascade causing rapid platelet consumption and MAHA that causes hepatocellular necrosis and portal venous thrombi --> results in elevated liver enzymes, liver swelling, and distension of hepatic Glisson capsule --> presents with nausea/vomiting, RUQ pain, HTN + proteinuria, thrombocytopenia, elevated LFTs with indirect hyperbilirubinemia, and schistocytes on peripheral smear --> treatment: IV hydralazine + magnesium sulfate + immediate delivery --> complications: DIC and rupture of hepatic subscapular hematoma)

Best next step in management for patient with suspected cholecystitis but negative RUQ US

HIDA scan

62yo F POD#6 s/p elective coronary artery bypass grafting presents with worsening skin lesions PE: several large purple black patches in periumbilical area surrounded by erythema

HIT (heparin-induced thrombocytopenia: complication of SQ heparin in which heparin induces conformational change in platelet factor 4, causing formation of anti-PF4 antibodies that bind to surface of platelets and cause thrombocytopenia and prothrombotic state --> presents with necrotic skin lesions at heparin injection sites, arterial/venous thromboses, and thrombocytopenia --> diagnosis: serotonin release assay --> treatment: stop heparin and start argatroban or fondaparinux)

Which diseases are associated with severe seborrheic dermatitis?

HIV and Parkinson disease

Fundoscopic exam: cotton-wool retinal lesions in patient with HIV

HIV retinopathy (usually resolves over weeks-months)

Best next step in management for adult patient with new onset condylomata acuminata

HIV screening (since genital HPV associated with increased risk for other STIS)

Contraindications to amniotomy, fetal scalp electrode placement, and operative vaginal deilvery

HIV, HBV, and HCV

Most common malignancy to manifest in upper cervical lymph node

HNSCC (head and neck squamous cell carcinoma: type of SCC that usually originates from mucosal surfaces of head/neck such as nasopharynx, oral cavity, oropharynx, and larynx --> risk factors: history of alcohol/tobacco use --> presents with painless neck lump aka palpable cervical lymph node, and decreased appetite/weight loss --> diagnosis: FNA of lymph node shows SCC, laryngopharyngoscopy shows primary source)

Which murmurs DECREASE in intensity with increased venous return (squatting)?

HOCM and MVP (HOCM: S4 and systolic murmur best heard at left sternal border --> MVP: late systolic crescendo murmur with midsystolic click best heard over apex)

Which murmurs INCREASE in intensity with decreased preload (Valsava, standing)?

HOCM and MVP (HOCM: S4 and systolic murmur best heard at left sternal border --> MVP: late systolic cresvendo murmur with midsystolic click best heard over apex)

Best next step in management for patient with ASCUS/LSIL on Pap test

HPV co-testing (looking for high-risk HPV types such as 16/18 --> if high-risk HPV present, then proceed to colposcopy)

Indications for neonatal cardiac monitoring after birth

HR <100bpm, apnea, or gasping

Most sensitive predictor of postop anastomotic leak

HR >120

Skin biopsy: small vessel vasculitis with extensive IgA deposition

HSP (Henoch-Schonlein purpura: IgA-mediated vasculitis occurring in CHILDREN, usually triggered by URI --> presents with non-blanching palpable purpura on buttocks + LE, arthralgia/arthritis involving hips + knees + ankles, abdominal pain, and IgA nephropathy with hematuria + proteinuria + RBC casts --> diagnosis: clinical, and skin biopsy of purpura shows small vessel vasculitis with extensive IgA deposition --> treatment: hydration, pain control, and/or systemic steroids for severe symptoms)

CSF analysis: - WBC 10-500, lymphocyte-predominant - Normal glucose (40-70) - Normal/high protein (<150) - High RBCs

HSV encephalitis (caused by HSV-1 infection of brain tissue and is most common cause of fatal sporadic encephalitis in USA --> presents with ACUTE ONSET <1wk of fever, headaches, and focal neuro findings such as AMS/focal CN deficits/ataxia/hyperreflexia/seizures --> CSF analysis: lymphocytic pleocytosis and increased RBCs due to hemorrhagic destruction of temporal lobes --> MRI: bilateral temporal lobe lesions --> EEG: prominent intermittent high-amplitude slow waves --> diagnosis: HSV PCR analysis in CSF --> treatment: IV acyclovir)

Indications for IV acyclovir

HSV encephalitis, neonates with HSV, and pregnant women with HSV or VZV

35F with PMHx of HIV presents with 3-day hx of burning substernal chest pain and difficulty swallowing PE: vesicular rash around mouth and on lips

HSV esophagitis (cause of viral esophagitis especially in patients with HIV with CD4 <100 --> presents with DYSPHAGIA and VESICULAR orolabial lesions --> diagnosis: upper GI endoscopy shows circular/ovoid vesicular and ulcerated lesions that appear "volcano-like," biopsy shows multinucleated giant cells --> treatment: acyclovir)

Most common cause of Bell palsy

HSV reactivation (becomes latent in CN7 and then reactivated during times of stress, causing inflammation and edema of CN7/facial nerve resulting in nerve compression and degeneration of myelin sheath --> presents with acute-onset unilateral facial + mouth dropping, weakness in closing eye + raising eyebrow, decreased eye lacrimation, hyperacusis, loss of nasolabial fold, and decreased sensation of taste over anterior 2/3 of ipsilateral tongue --> treatment: steroids +/- valacyclovir)

Fundoscopic exam: widespread, pale, peripheral retinal lesions and central necrosis of retina

HSV retinitis (causes acute retinal necrosis syndrome in patients with HIV or immunocompromise --> presents with conjunctivitis + keratitis with eye pain followed by rapid progressive visual loss and keratitis --> diagnosis: fundoscopy shows widespread pale peripheral lesions and central necrosis of retina, indicating bilateral necrotizing retinitis --> treatment: IV valacyclovir)

Causes of erythema multiforme

HSV, Mycoplasma, sulfa drugs, penicillin, and phenytoin (erythema multiforme: presents with erythematous papules/plaques that develop into "target lesions" with multiple rings and dusky center showing epithelial disruption)

Strongest risk factor for CVA

HTN (increases risk of BOTH ischemic and hemorrhagic stroke by 4x due to elevated shearing force on intracerebral vascular endothelium, which accelerates atherosclerotic process and promotes thrombi formation)

Main side effect of EPO therapy for CKD

HTN (occurs 2-8wks after treatment initiation --> can be mild or severe leading to end-organ damage: enceophalopathy, stroke, retinal hemorrhages + exudates, papilledema, MI, HF, aortic dissection, and MAHA --> therefore pts started on EPO require close BP monitoring)

Sequelae of OSA

HTN, erectile dysfunction, and polycythemia (HTN: due to recurrent hypoxemia causing increased SNS activity --> ED: sleep fragmentation causes decrease testosterone, and hypoxemia leads to decreased protective nocturnal erections --> polycythemia: due to hypoxemia causing increased EPO and elevated HCT)

7yo boy with PMHx of bloody diarrhea 1wk ago after attending a family cookout presents with fatigue and no urine in 24hrs PE: scleral icterus and 2+ pedal edema

HUS (hemolytic uremic syndrome: immunologic disorder caused by infection with Shiga toxin-producing strain of E Coli serotype 0157:H7/Shigella in which toxin invades and destroys colonic epithelial lining, resulting in endothelial damage and microthrombi formation --> note: atypical form aHUS caused by complement gene mutations or autoimmune response --> presents 1-2wks after BLOODY DIARRHEA with fatigue, pallor, easy bruising, petechiae, jaundice, oliguria, and edema --> labs: triad of MAHA + thrombocytopenia + AKI --> treatment: IV fluids, electrolyte management, blood transfusions, and dialysis)

1st line treatment of Tourette syndrome

Habit reversal training (for intractable and distressing tics, 2nd line includes antipsychotics haloperidol or risperidone +/- tetrabenazine --> 3rd line includes alpha-2 agonists such as guanfacine or clonidine)

Which anesthetic is associated with liver toxicity?

Halothane

28F G2P0 presents for follow-up after 1st trimester miscarriage 9mo ago PE: symmetrically enlarged, non-tender, firm thyroid gland Labs: elevated TSH, normal free T4

Hashimoto thyroiditis (chronic lymphocytic thyroiditis: autoimmune disorder characterized by anti-TPO/anti-microsomal and anti-thyroglobulin antibodies that results in hypothyroidism --> presents with moderately enlarged NON-TENDER thyroid and subclinical/overt hypothyroidism --> diagnosis: elevated anti-TPO antibodies and thyroid biopsy showing Hurthle cells/lymphoid aggregates with germinal centers)

Type of bias in which study population affects outcome due to being aware that they are being studied

Hawthorne effect

Goals for diabetic health maintenance

HbA1c <7%, BP <130/80, and urine albumin/Cr ratio <30

Screening guidelines for neonatal intraventricular hemorrhage (IVH)

Head US at 1-2wks for all premature infants born <32wks (dx of neonatal IVH: head US shows hyperechoic blood within germinal matrix +/- extension to ventricles or parenchyma)

45M with PMHx of NASH dx by liver biopsy 5d ago presents with 24hr hx of colicky RUQ pain, vomiting, and melena Vitals: afebrile, BP 95/60, HR 110, RR 15 PE: scleral icterus and RUQ tenderness Labs: low Hgb, high WBCs, high total bili

Hemobilia (bleeding into biliary tract usually caused by hepatic/biliopancreatic interventions such as liver bx/chole/ERCP, but also caused by hepatobiliary tumors and blunt trauma --> presents with RUQ pain, jaundice, UGIB symptoms such as melena/hematemesis, anemia, and direct hyperbilirubinemia --> diagnosis: CT scan shows biliary hematoma/intraabdominal free fluid, ERCP shows oozing of blood from papilla --> management: IV fluids, blood transfusions, last resort angiography with embolization)

Treatment of lithium toxicity (symptomatic with Li >2.5, or asymptomatic with Li >4 and Cr >2)

Hemodialysis

Treatment of methanol/ethylene glycol ingestion

Hemodialysis and fomepizole

Causes of elevated UCB (unconjugated bilirubin)

Hemolysis, portosystemic shunt, drugs, Gilbert syndrome, and Crigler-Najar syndrome

Which conditions are associated with elevated LDH?

Hemolytic anemia, PCP, and germ cell tumors (hemolytic anemia: due to destruction of RBCs --> PCP: Pneumocystis pneumonia --> germ cell tumors: marker of tumor burden)

Causes of prolonged PTT

Hemophilia A/B, acquired hemophilia, VWD, SLE, APLS, heparin, liver disease, and vitamin K deficiency

Most common cause of shock in trauma setting

Hemorrhagic shock (remember "blood on floor and 4 more" aka causes of large blood loss: external bleeding can lose entire blood volume --> chest: lose up to 40% of blood volume/hemithorax --> abdomen/peritoneum can lose entire blood volume --> pelvis: can lose entire blood volume within retroperitoneum --> thigh: lose up to 1-2L)

CXR: effusion with partial opacification of hemithorax and blunting of costophrenic angle

Hemothorax

Why are thoracic vertebrae more stable than cervical vertebrae?

High facets and ribs that decrease motion

61M with PMHx of smoking and recently dx left-sided pleural effusion drained by thoracocentesis 2hrs ago now presents with dizziness and diaphoresis Vitals: SBP 70, HR 130, SaO2 91% on 40% FiO2 via face mask PE: dullness to percussion and absent breath sounds on left side of chest

Hemothorax (blood filling pleural space due to either trauma or THORACOCENTESIS that injures intercostal arteries along underside of ribs --> presents with hypovolemic shock and hypoxia --> treatment: tube thoracostomy and IV fluid resuscitation)

Abdominal US: solitary, well-demarcated, hyperechoic lesion Abdominal CT: early peripheral enhancement of hepatic lesion

Hepatic adenoma (benign epithelial tumors of liver caused by long-term OCP use, anabolic androgen use, and pregnancy --> usually asymptomatic or can present with RUQ pain and hepatomegaly --> diagnosis: US shows solitary hyperechoic lesion, abdominal CT shows early peripheral enhancement --> treatment: surgical excision --> complications: progressive growth, rupture with hemorrhage, or malignant transformation)

Triphasic abdominal CT: liver lesion with centripetal enhancement

Hepatic hemangioma (most common benign liver tumor --> diagnosis: triphasic CT shows liver lesion with centripetal enhancement, aka enhancement moving from periphery to center)

52F with PMHx of liver cirrhosis presents with 2-day hx of bright red blood per rectum + increasing abdominal distension and discomfort Vitals: afebrile, BP 91/55, HR 116, RR 18 PE: distended abdomen with positive shifting dullness and 2+ peripheral pitting edema Labs: low Hgb, low Na+, high K+, high BUN + Cr with BUN/Cr ratio of 38:1 Pt's furosemide + spironolactone held and receives blood transfusion, however UOP decreases despite adequate IV volume resuscitation UA: negative Urine lytes: urine Na+ of 5

Hepatorenal syndrome (renal hypoperfusion secondary to severe liver cirrhosis, which increases NO in splanchnic circulation 2/2 portal HTN causing systemic vasodilation and renal hypoperfusion, leading to activation of RAAS and worsening of volume overload --> precipitating factors that reduce GFR to cause hepatorenal syndrome: GI bleed, vomiting, sepsis, excessive diuretic use, SBP, and NSAID use --> presents similarly to pre-renal AKI with BUN/Cr >20:1, low urine Na+ <10, bland UA, however NO RESPONSE to IV fluids and withdrawal of diuretics --> management: treat hypovolemia/anemia/infx and give splanchnic vasoconstrictors such as midodrine, octreotide, or norepi)

Which hematologic disease is associated with high MCHC?

Hereditary spherocytosis (autosomal dominant defect in RBC membrane proteins spectrin/ankyrin resulting in sphere-shaped fragile RBCs that get trapped and destroyed in spleen --> presents with hemolytic anemia, jaundice, and splenomegaly after illness --> diagnosis: elevated MCHC, spherocytes on peripheral smear, elevated osmotic fragility on acidified glycerol lysis test, and abnormal eosin-5-maleimide binding test --> treatment: folic acid/blood transfusions and splenomegaly for severe hemolysis)

2yo boy presents with 2-day hx of sore throat and decreased appetite Vitals: febrile 100F PE: erythematous oropharynx with several small vesicles on uvula + soft palate + tonsillar pillars and slightly erythematous tonsils b/l

Herpangina (vesicular pharyngitis caused by Coxsackie A virus --> presents with viral pharyngitis and oral vesicles on uvula + soft palate + tonsillar pillars --> treatment: reassurance and supportive care)

74F presents with several day hx of right ear pain and 2 episodes of dizziness PE: several erythematous vesicles in right EAC and mild right-sided facial droop

Herpes zoster oticus (Ramsay-Hunt syndrome: reactivation of VZV in geniculate ganglion, which disrupts motor fibers of CN7 and CN8 --> presents with painful erythematous vesicular rash on auditory canal/auricle and ipsilateral facial paralysis --> associated with vertigo, nausea/vomiting, and hearing + taste disturbances --> treatment: valacyclovir)

Best method to diagnose infectious mono for patients >4yo

Heterophile antibody test (Monospot test: detects EBV antibodies that agglutinate to horse RBCs --> 25% false negative rate during 1st week of illness, so if negative need to repeat in 1 week --> for children <4yo, diagnose with serum anti-EBV antibody test)

CXR: retrocardiac air-fluid level

Hiatal hernia (protrusion of intraabdominal organs into thoracic cavity --> >90% are sliding hiatal hernias in which GE junction + proximal stomach slide into chest --> 10% are paraesophageal hiatal hernias/PEH in which gastric fundus migrates into thoracic cavity --> workup: CXR showing retrocardiac opacity with air/fluid level in thoracic cavity --> diagnosis: barium swallow or upper endoscopy)

Best next step in management for patient with elevated 24hr urine free cortisol and elevated ACTH

High-dose dexamethasone suppression test (NO cortisol suppression: dx with ectopic ACTH secretion and order CT CAP --> ADEQUATE cortisol suppression: dx with Cushing disease and order pituitary MRI)

Treatment of vulvar lichen sclerosus

High-dose topical steroid

According to NEXUS criteria, when is C-spine imaging necessary for patient with mild neck trauma?

High-energy injury and NSAID (N: neurologic deficit --> S: spinal tenderness --> A: altered mental status --> I: intoxication --> D: distracting injury)

Treatment of anal fissure

High-fiber diet, stool softeners, Sitz bath, and topical lidocaine, and topical vasodilators (high-fiber diet and stool softeners: to soften stool --> Sitz bath: increases blood flow to injured mucosa --> topical lidocaine: can enhance comfort --> topical vasodilators: nifedipine/nitroglycein used to reduce pressure and increase blood flow to anal sphincter --> fissures refractory to medical management tx with lateral sphincterotomy or fissure excision)

Which traumatic injury is associated with INTERNALLY rotated hip?

Hip dislocation

Patient with fever, groin pain, and abdominal pain with hip FLEXION

Hip septic arthritis

Neonatal abdominal XR: dilated loops of small and large bowel with no air in rectum and transition zone

Hirschsprung disease (congenital megacolon due to failure of neural crest migration resulting in lack of enteric nervous plexuses in distal segment of colon --> associated with Down syndrome --> presents in NEONATES with bilious emesis, abdominal distension, delayed passage of meconium >48hrs, and chronic constipation --> abdominal XR: dilated loops of small and large bowel with no air in rectum --> diagnosis: empty rectum on DRE, barium enema, and rectal suction biopsy --> treatment: colonic resection)

Common cause of chronic mediastinitis

Histoplasmosis (causes increased formation of connective tissue in mediastinum, resulting in fibrosing mediastinitis)

Fundoscopic exam: bright yellow plaque in retinal artery

Hollenhorst plaque (cholesterol emboli from internal carotid artery that lodges into retinal artery, usually a sign of severe atherosclerosis --> dx: fundoscopic exam shows bright yellow refractile plaques within retinal artery)

Patient with Marfanoid habitus and DOWNWARD lens dislocation

Homocystinuria (autosomal recessive disorder caused by cystathionine synthase deficiency --> presents with Marfanoid habitus, fair complexion, VTE, intellectual disability, and DOWNWARD lens dislocation)

5yo girl with PMHx of developmental delay and "eye problems" presents with sudden-onset left-sided weakness and slurred speech PE: weight <5th percentile and height 90th percentile, fair-skinned blue-eyed girl, long thin arms + legs and decreased upper-to-lower segment ratio, joint hyperlaxity and skin hyperelasticity, brisk LUE + LLE DTRs, and upgoing Babinski on left

Homocystinuria (autosomal recessive disorder caused by cystathionine synthase deficiency, resulting in errors in methionine metabolism --> presents with Marfaoid body habitus, fair hair and eyes, developmental delay, downward lens dislocation, megaloblastic anemia, and increased risk of VTE --> diagnosis: elevated homocysteine and methionine levels --> treatment: vitamin B6, folate, vitamin B12, and anticoagulation)

25M presents with painful mass on right eye PE: localized, red, tender swelling over upper eyelid of R eye

Hordeolum (abscess arising from eyelash follicle or from meibomian gland under eyelid located over upper/lower eyelid, usually caused by Staph aureus --> presents with localized, red, tender swelling over eyelid)

Peripheral smear: single, round, blue inclusions within RBCs

Howell-Jolly bodies (RBC nuclear remnants normally removed by spleen, so presence indicates asplenia or functiona hyposplenism from sickle cell disease, sarcoidosis, or thrombosis)

Treatment of infant botulism

Human-derived botulism IVIG

Abdominal US: smooth round cyst in liver

Hydatid cyst (caused by Echinococcus granulosis, a dog tapeworm)

Treatment of myoglobinuria

Hydration, alkalinization with IV bicarb, and mannitol diuresis (aka HAM)

Treatment of uric acid kidney stones

Hydration, low-purine diet, and alkalinization of urine (can use K+ citrate or K+ bicarb to dissolve stones --> target alkaline urine pH 6.0-6.5)

Which corticosteroid has both glucocorticoid and mild mineralocorticoid activity?

Hydrocortisone

What are the 2 major products of combustion in closed spaces (ex: house fire)?

Hydrogen cyanide and CO (HCN: produced from combustion of nitrogen-containing syntheic polymers such as foam/cotton/paint/silk, tx with hydroxycobalamin or sodium thiosulfate --> CO: odorless gas from fires/car exhaust/gas heaters, tx with 100% hyperbaric O2)

Treatment of milk protein allergy in infants

Hydrolyzed formula (milk protein allergy: presents with regurgitation after feeds, eczema, poor wt gain, and bloody stools)

Child with recurrent infections Labs: - Normal B cells - Low IgG and IgA - High IgM

Hyper-IgM syndrome (X-linked recessive disease characterized by defective CD40 on T cells, preventing class switching and leading to excess IgM and deficiency of all other Ig --> presents with recurrent sinupulmonary infections with encapsulated bacteria, opportunistic infections with PCP pneumonia/Cryptosporidium/CMV, frequent viral infections, and growth impairment --> treatment: antibiotic prophylaxis and interval IVIG)

Main side effects of thiazide diuretics

HyperGLUC (includes hyperGlycemia, hyperLipidemia, hyperUricemia, and hyperCalcemia)

Treatment of decompression sickness

Hyperbaric O2 and IV hydration

What is the key shock parameter associated with cardiogenic shock?

Increased PCWP (elevated pulmonary capillary wedge pressure due to increased LV pressure transmitted back to LA + lungs)

Labs: - High Ca2+ - Low phos - Low PTH - Low/normal vitamin D - High 24hr urine Ca2+ excretion

Hypercalcemia of malignancy (usually caused by SCC of lung/head/neck or renal/bladder/ovarian carcinomas due to secretion of PTH-related protein/PTHrP --> other causes: osteolytic mets, lymphoma causing increased Vit D, and multiple myeloma causing increased IL-6 --> presents with severe symptomatic hypercalcemia >14 and low PTH --> diagnosis: elevated PTHrP)

Most common causes of dural venous sinus thrombosis

Hypercoagulability, sinus infection, or head injury

Causes of hypertonic hyponatremia (serum osm >290)

Hyperglycemia, IV mannitol, IVIG, and iodinated contrast in CKD patient (hyperglycemia: causes dilutional hyponatremia due to high blood glucose pulling water out of cells and into ECF --> mannitol: osmotic diuretic --> IVIG and iodinated contrast: provide high levels of solute compared to free water --> other causes of hyper/isotonic hypernatremia: hypertriglyceridemia, cholestasis, and hyperproteinemia from multiple myeloma/MGUS)

Which electrolyte disturbance is associated with extensive skeletal muscle crush injury?

Hyperkalemia (caused by rhabdomyolysis and upregulation of postsynaptic ACh receptors, resulting in massive efflux of K+)

Which lab findings are associated with rhabdomyolysis?

Hyperkalemia, hyperphosphatemia, and hypocalcemia

Contraindications to succinylcholine use

Hyperkalemia, skeletal muscle injury, burns, disuse muscle atrophy, and denervation (ex of denervation: MS, GBS, PML, and critical illness polyneuropathy --> for these conditions, use non-depolarizing NMJ agents such as vecuronium or rocuronium)

Most common causes of pseudogout (CPPD)

Hyperparathyroidism, hypothyroidism, hemochromatosis, and joint trauma

36F G1P0 at 24wks with PMHx of T1DM, asthma, and UTI on macrobid 6d ago presents with 24hr hx of dry cough and SOB Vitals: febrile 100.8F, BP 137/92, HR 104, SaO2 92% on RA PE: b/l crackles at bases, 2/6 ejection-type murmur at LUSB, and 1+ edema of ankles b/l Labs: elevated WBC with increased eosinophils CXR: bilateral parenchymal opacities in mid and lower lung zones

Hypersensitivity pneumonitis (drug-induced pulmonary injury usually caused by medications such as nitrofurantoin, methotrexate, carmustine, bleomycin, busulfan, and amiodarone --> occurs 3-9 days from medication initiation --> presents with fevers, dry cough, SOB, wet basilar crackles, and erythematous maculopapular rash occurring 3-9 DAYS after medication initiation --> labs: leukocytosis with EOSINOPHILIA --> CXR: bilateral basilar reticular opacities --> treatment: cessation of drug)

27F who recently moved into new apt building and uses the communal pool + hot tub presents with 6-hr hx of SOB and nonproductive cough, and has had similar episodes lasting 18hrs 2-3x/week during last 3mo Vitals: febrile 100.2F, BP 110/60, HR 115, RR 26, SaO2 93% on RA PE: mild respiratory distress and diffuse fine crackles at lung bases

Hypersensitivity pneumonitis (mixed type 3/4 hypersensitivity reaction caused by repeated inhalation of inciting environmental antigen leading to alveolar inflammation --> causes: bird droppings in farmers, inhaled chlorine from hot tube/pool use --> presents with EPISODES of SOB + fever + cough + chest tightness + headache that occur a few hours after EXPOSURE TO ANTIGEN --> treatment: avoidance of antigen --> complication of chronic exposure: alveolar thickening + non-caseating granulomas + and upper lobe predominant pulmonary fibrosis with chronic HP on chest CT showing bilateral ground glass and reticular infiltrates with centrilobular nodules)

Which conditions increase the risk of osteoporosis?

Hyperthyroidism, hyperparathyroidism, hypercortisolism, hypogonadism, celiac disease, Crohn disease, liver disease, CKD, RTA, multiple myeloma, and alcoholism

Treatment of symptomatic hyponatremia with Na+ <130

Hypertonic 3% saline (goal is to raise Na+ levels by 4-6 mEq/L over period of hours --> max rate of correction is 8 mEq/L in 24hrs to prevent ODS)

67M presents with 3-wk hx of aching burning sensation in distal LE exacerbated by walking/relieved by elevation of foot PE: warm swollen tender MTP joints + ankles and clubbing of fingers + toes

Hypertrophic osteoarthropathy (abnormal proliferation of skin + bone at distal extremities, usually caused by BRONCHOGENIC ADENOCARCINOMA --> presents with arthralgias, joint effusions, clubbing, and periostosis of tubular bones)

Which laboratory abnormalities are associated with tumor lysis syndrome?

Hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia (hyperuricemia: due to release of nucleic acids and metabolization into uric acid --> hyperkalemia and hyperphosphatemia: due to liberation of intracellular ions --> hypocalcemia: due to precipitation of calcium and phosphate, reducing intravascular levels)

Which electrolyte abnormalities are seen in infants of diabetic mothers?

Hypoglycemia, hypocalcemia, and hypomagnesemia

Laboratory findings associated with laxative abuse

Hypokalemia and metabolic alkalosis (increased K+ loss in stool impairs Cl- reabsorption and affects Cl-HCO3 exchange, thus increasing HCO3 concentrations)

What is a common underlying cause of refractory hypocalcemia and hypokalemia?

Hypomagnesemia

Characteristic feature of refeeding syndrome

Hypophosphatemia (refeeding syndrome: failure of cellular energy metabolism and massive fluid/electrolyte shifts caused by reintroduction of carbs in patients with chronic malnourishment, which leads to increased insulin secretion and cellular uptake of K+/Mg2+/phospate and increased phosphate utilization during ATP formation, resulting in phosphate depletion --> presents with muscle weakness, arrhythmias, CHF, rhabdomyolysis, neuro dysfunction, seizures, and Wernicke encephalopathy --> labs: hypokalemia, hypophosphatemia, hypomagnesemia, low thiamine, and abnormal LFTs)

Which diseases are X-linked dominant?

Hypophosphatemic rickets, fragile X syndrome, and Alport syndrome

Which diabetes medications are associated with hypoglycemia?

Insulin and sulfonylureas

Which diseases are associated with multiple skin tags?

Insulin resistance, pregnancy, and Crohn disease

2-day-old boy born at term via SVD presents with 6-hr hx of SOB and blue lips + extremities Vitals: BP 60/30, HR 164, RR 68, SaO2 75% on RA and increases to 78% with 100% O2 via face mask PE: appears cyanotic, diffuse crackles in lung fields b/l, loud S2, and hepatomegaly CXR: cardiomegaly and moderate pulmonary congestion

Hypoplastic left heart syndrome (PDA-dependent congenital heart defect characterized by lack of left heart development, resulting in atretic mitral valve + underdeveloped LV + atretic aortic valve that cannot provide proper systemic circulation without PDA --> presents on DAY 2-3 OF LIFE with central cyanosis, heart failure, single loud S2, and NO MURMUR --> diagnosis: ECHO shows atretic mitral valve + underdeveloped LV --> treatment: PGE1 and then surgery)

1-hour-old newborn born at term via SVD presents with GU abnormality PE: curvature of underdeveloped penis, urethral meatus at ventral surface of base flanked by surrounding scrotal sac, and non-palpable gonads

Hypospadias (ventrally displaced urethral meatus caused by incomplete/partial fusion of urethral folds in utero --> causes: virilization of XX female or undervirilization of XY male --> presents with VENTRAL urethral meatus, dorsal hooded foreskin, underdeveloped penis/glans, and severe penile curvature aka chordee --> workup: karyotype analysis and pelvic US --> treatment: urology eval for surgical repair)

Contraindications to nitroglycerin during acute STEMI

Hypotension, RV infarct, and severe aortic stenosis

Definition of spinal shock

Hypotension, bradycardia, loss of all reflexes, and loss of motor function

Beck triad of cardiac tamponae

Hypotension, distended neck veins, and muffled heart sounds (cardiac tamponade: compression of heart due to fluid accumulation in pericardial cavity, which restricts venous return to heart resulting in decreased preload + decreased SV + decreased CO --> causes: acute aortic dissection or ventricular free wall rupture after MI --> presents with Beck triad + tachycardia + pulsus paradoxus aka decreased SBP by >10mmHg during inspo --> CXR: normal cardiac silhouette in ACUTE tamponade, enlarged globular cardiac silhouette in SUBACUTE tamponade, and ECHO shows equilibration of diastolic pressures in all 4 chambers --> diagnosis: ECG shows low-voltage QRS and electrical alterans)

Cause of J waves on ECG

Hypothermia (usually temp <90F)

45F with PMHx of HTN presents with 1-mo hx of progressive fatigue, myalgias, and muscle weakness in bilateral LE with difficulty getting up from chair + weakness and cramping in legs after walking short distances Vitals: BP 140/80, HR 64, RR 14 PE: mildly decreased strength in proximal muscles of LE and sluggish ankle reflex b/l Labs: normal ESR and elevated CK

Hypothyroid myopathy (caused by --> presents with proximal muscle weakness usually in LE, myalgias, fatigue, and delayed DTRs --> diagnosis: normal ESR, elevated CK, high TSH, and low free T4 --> treatment: levothyroxine --> complications: rhabdomyolysis)

Which condition is commonly associated with SCFE?

Hypothyroidism (lack of thyroid hormone prevents ossification of growth plate/physis --> presents more often with BILATERAL SCFE at YOUNGER AGE <10yo)

Causes of decreased CVP

Hypovolemic or distributive shock (hypovolemic shock: decreases CVP due to low intravascular volume --> distributive shock: decreases CVP due to low SVR)

Shock parameters: - Low CVP - Low PCWP - Low CI - High SVR - Low SvO2

Hypovolemic shock (loss of intravascular volume causes decreased preload, resulting in low CVP and PCWP, causing low CO and subsequent rise in SVR --> ECHO: small LV cavity volume with increased EF)

Causes of secondary polycythemia

Hypoxemia, ectopic EPO, renal transplant, and androgen abuse (hypoxemia: includes cardiopulmonary disease, OSA, or high altitude --> ectopic EPO: usually caused by EPO-producing tumors such as RCC or HCC --> androgen abuse: either through use of illegal steroids or exogenous EPO/"blood doping")

MRI: bilateral hyperintensity of globus pallidus

Hypoxic brain injury (due to high sensitivity of globus pallidus to hypoxic conditions)

Treatment of symptomatic Bartholin duct cyst

I&D with Word catheter

Best next step in management for patient with recent MI and persistent LV EF <30%

ICD placement (implanatable cardioverter-debrillator: detects dangerous rhythms and gives shock --> used to prevent sudden cardiac death from VFib)

What are the treatments for elevated ICP?

ICP HEAD (I: intubate --> C: calm aka sedate --> P: place drain aka ventriculostomy --> H: hyperventilate to PCO2 ~35 --> E: elevate HOB --> A: adequate BP so CCP >70 --> D: diuretic aka mannitol + lasix, plus osmotic therapy with hypertonic 3% saline)

Location of ST elevations for inferior STEMI (RCA occlusion)

II, III, aVF

Treatment of neonatal gonococcal conjunctivitis

IM ceftriaxone (only requires single dose --> can also do single dose of IM cefotaxime)

Outpatient treatment of PID

IM ceftriaxone and PO doxycycline

Treatment options for latent TB

INH and rifapentine for 3mo, rifampin for 4 months, and INH monotherapy for 6-9mo

Best next step in management if unable to obtain IV access in emergency

IO access (intraosseous access: usually inserted in proximal tibia --> contraindications: cellulitis over access site, fracture, previous IO attempt in chosen extremity, and bone fragility)

26yo F presents with sharp right knee pain most prominent at lateral aspect of knee that worsens when descending stairs PE: lateral knee pain with tenderness 2cm proximal to right lateral joint line

IT band syndrome (iliotibial band syndrome: common overuse syndrome arising where distal iliotibial band passes over lateral femoral condyle/LFE, due to inability of IT band to stabilize lateral thigh during flexion + extension of knee --> presents in INEXPERIENCED RUNNERS with poorly localized LATERAL knee pain and tenderness PROXIMAL TO LATERAL JOINT LINE near LFE --> diagnosis: Noble test, aka reproducible pain with pressure over IT band just proximal to LFE during flexion of knee --> treatment: activity modification and LE stretching/strengthening exercises)

Which diabetes medications are associated with weight gain?

Insulin, sulfonylureas, and glitazones

Differential diagnosis for lateral knee pain

IT band syndrome, LCL sprain, and lateral meniscal tear (IT band syndrome: presents in runners with lateral knee pain and tenderness proximal to lateral joint line during knee flexion --> LCL sprain: presents with abnormal passive adduction/varus laxity with lateral space widening of tibia --> lateral meniscal tear: presents with pain + popping on internal rotation of tibia/foot)

Best next step in management for patient with protracted active labor

IUPC (used to measure strength of contractions --> if <200MVUs over 10mins, give IV oxytocin)

Treatment of VTach in hemodynamically stable patients

IV amiodarone

Treatment of Histoplasmosis

IV amphotericin B, then oral itraconazole

Treatment of neonatal sepsis

IV ampicillin and gentamicin (can add cefotaxime if suspected meningitis --> alternative regimen: IV clindamycin and gentamicin)

Methods to decrease risk of pneumonia in patients with rib fractures

IV and regional anesthesia, pulmonary toilet, and IS (IV anesthesia: includes opioids and NSAIDs --> pulmonary toilet: clearing mucus/secretions out of airways)

Management of diverticular abscess with <3cm fluid

IV antibiotics and surgery

Management of contained appendiceal abscess

IV antibiotics, bowel rest, and percutaneous drainage (due to high risk of surgery in patients with contained abscess --> can return in 6-8wks for elective appendectomy)

Best next step in management for symptomatic sinus brady and 1+ alarm sign (hypotension, shock, lethargy, chest pain, or acute heart failure)

IV atropine (give 0.5mg bolus every 3-5mins for 3mg maximum --> if no response, try transcutaneous pacing OR IV dopamine OR IV epinephrine)

Best next step in management after diagnosis of DISTAL aortic dissection

IV beta-blocker, followed by vasodilator (usually IV labetalol: decreases LV contractility to reduce shear forces on aorta --> NOTE: patients with significant AR or tamponade should NOT receive beta-blockers as they worsen hypotension and precipitate cardiac arrest --> vasodilator: usually IV nitroprusside for pain control)

ICU inpatient treatment of CAP

IV beta-lactam and macrolide or IV beta-lactam and levofloxacin

Inpatient treatment of PID

IV cefoxitin and PO doxycyline

Treatment of Vibrio vulnificus infection

IV ceftriaxone and doxycycline

Best next step in management for postpartum patient with fever + abdominal pain

IV clindamycin and gentamicin (due to suspected endometritis --> can switch clindamycin to ampicillin if GBS-positive, clindamycin resistance, or persistent infection after abx)

Most common nephrotoxic medications

IV contrast, aminoglycosides, amphotericin, cisplatin, cyclosporine, and NSAIDs

Best next step in management for "cold septic shock" (septic shock converted to cardiogenic shock due to cytokine-induced myocardial dysfunction)

IV dopamine (requires pressor for treatment to increase inotropy/CO and renal blood flow to increase BP)

Which patient populations are at increased risk of vertebral osteomyelitis?

IV drug users, sickle cell anemia, and immunosuppression

Immediate management of abnormal uterine bleeding in HDS patients

IV estrogen or high-dose COCP (IV estrogen: conjugated equine estrogen --> high-dose COCP: high-dose estrogen stabilizes denuded endometrium to stop menstrual bleeding, while progestin stabilizes endometrial lining and prevents further proliferation)

Treatment of moderate hypothermia (temp 82-90F)

IV fluids and active external warming (includes warm blankets, heating pads, and warm baths)

Treatment of severe hypothermia (temp <82F)

IV fluids and active internal warming (includes warmed pleural/peritoneal irrigation and warmed humidified oxygen)

Treatment of mild hypothermia (temp 90-95F)

IV fluids and passive external warming (includes removing wet clothes and covering with blankets)

Management of acute decompensated HF with hypotension/shock

IV furosemide, IV vasopressor, and supplemental O2

Management of acute decompensated HF with normal/elevated BP

IV furosemide, nitroglycerin, and non-invasive ventilation

Best next step in management after diagnosis of epidural spinal cord compression (ESCC)

IV glucocorticoids (decrease vasogenic edema associated with obstructed epidural venous plexus, helps alleviate pain, and may restore neurologic function --> then obtain MRI to confirm ESCC, followed by neurosurgery +/- radiation oncology consult)

Best next step in management for patient with likely PE and no contraindications to anticoagulation

IV heparin (given to patients with moderate to severe respiratory distress and likely PE --> can do diagnostic eval AFTER heparin with CTA, TTE, or V/Q scan)

Best next step in management for patient with acute limb ischemia

IV heparin (should be given upon immediate clinical diagnosis BEFORE diagnostic imaging --> after receiving AC, pt should receive CTA of LE and surgical consult to assess need for percutaneous alteplase or surgical thrombectomy)

Treatment of TG-induced pancreatitis

IV hydration, pain control, insulin if glucose >500, and apharesis if glucose <500

Non-ICU inpatient treatment of CAP

IV levofloxacin or IV beta-lactam and macrolide

Treatment of methemoglobinemia

IV methylene blue (create mediators to reduce Fe3+ back to Fe2+)

Treatment of acute MS exacerbation

IV methylprednisone (IV steroids: hastens neurologic recovery --> 2nd line is plasmapharesis for pts refractory to steroids)

Which structures are involved in a 3rd-degree perineal laceration?

Internal and external anal sphincters

Treatment of AFib in hemodynamically stable patients with WPW

IV procainamide or ibutilide (procainamide: class 1A antiarrhythmic that blocks Na+ channel to increase AP duration and ERP, side effect includes reversible SLE-like syndrome --> ibutilide: class 3 antiarrhythmic that blocks K+ channel to increase AP duration and ERP, side effect includes torsades dep pointes)

Treatment of severe symptomatic hypercalcemia (Ca2+ >14)

IV saline and calcitonin (IV saline: restores intravascular volume and promotes urinary Ca2+ excretion --> calcitonin: inhibits osteoclast-mediated bone resorption to quickly reduce serum Ca2+)

64F with PMHx of T2DM, HTN, HLD, smoking, and anterior STEMI w/ placement of bare metal stent 4 days ago presents with acute-onset SOB and confusion Vitals: BP 72/40, HR 120 PE: cold clammy extremities and diaphoresis, JVD, bibasilar crackles, and harsh loud systolic murmur at left sternal border with palpable thrill ECG: sinus tachy with deep T wave inversion in leads V1-V5

IV septum rupture (mechanical complication of acute MI occurring 3-5 following LAD/RCA MI, leading to increased pressure + volume in RV resulting in acute right- and left-sided HF --> presents with acute cardiogenic shock, JVD, hepatomegaly, and harsh holosystolic murmur with palpable thrill at left sternal border --> diagnosis: pulmonary artery cath detecting left-to-right shunt or TTE visualizing septal defect)

Treatment of invasive aspergillosis

IV voriconazole and caspofungin (should be given for 1-2wks, then pt can transition to PO voriconazole)

Treatment of Guillain-Barre syndrome

IVIG or plasmapheresis

Treatment of exertional heat stroke

Ice-water immersion

66F presents with life history of mildly pruritic, rough, dry, scaly skin that worsens during winter months and has progressively worsened in last several years PE: bilateral LE skin appears rough and dry with horny plates resembling reptile scales

Ichthyosis vulgaris (chronic inherited skin disorder caused by mutations in filaggrin gene, resulting in diffuse dermal scaling --> presents with rough, dry, scaly skin resembling fish/reptile scales that worsens in winter + advanced age --> treatment: simple emollients, coal tar, salicylic acid, and topical retinoids)

Child with delayed growth spurt/puberty Labs: normal bone age

Idiopathic short stature (diagnosis of exclusion that occurs when child has delayed puberty but normal labs/bone age and NOT reaching mid-parental height --> familial short stature/FSS occurs when child is short with normal bone age, but mom is <5'1" or dad is <5'5" --> presents with delayed puberty and NORMAL bone age <1yr from actual age --> no treatment for FSS, treat ISS with growth hormone)

ICU patient presents with abdominal distension diminished bowel sounds Abdominal CT: gaseous distension of small and large bowels without air-fluid levels

Ileus (intestinal hypomotility WITHOUT obstruction commonly caused by abdominal surgeries, opiates, hypokalemia, and sepsis --> presents with constipation, decreased flatus, distended/tympanic abdomen, and DECREASED bowel sounds --> treatment: bowel rest, electrolyte corrections, and cholinergic drugs to stimulate intestinal motility)

Diagnosis of complex breast cyst/mass

Image-guided core biopsy

Treatment of non-invasive vulvar SCC (Bowen disease/SCC in situ)

Imiquimod or laser ablation

Management of knee dislocation

Immediate reduction, popliteal and distal pulse palpation, ABI, and duplex US (need to do meticulous vascular exam due to risk of popliteal artery injury after knee dislocation --> combo of normal pulses and ABI >0.9 excludes vascular injury)

Risk factors for fracture nonunion

Impaired blood flow, metabolic disorders, infection, and certain meds (impaired blood flow: smoking and arterial atherosclerosis --> metabolic disorders: T2DM, hypothyroidism --> infection: osteomyelitis --> certain meds: systemic steroids)

Two causes of diastolic heart failure (HFpEF)

Impaired myocardial relaxation and increased LV wall stiffness (both leads to increased LV-EDP which is transmitted to LA and pulmonary veins/capillaries causing pulmonary congestion and HF symptoms, causing include: --> 1. LV diastolic dysfunction from HTN, restrictive CM, or HOCM --> 2. valvular heart disease from aortic stenosis/regurgitation or mitral stenosis/regurgitation --> 3. pericardial disease from constrictive pericarditis or tamponade --> 4. systemic disorders causing high-output cardiac failure from morbid obesity, thyrotoxicosis, severe anemia, beriberi, Paget disease, or large AV fistula)

1st line preventative measure for postop pneumonia

Incentive spirometry (encourages high-TV respiration and help keep alveoli open --> other measures: CPAP, deep breathing exercises, intermittent positive pressure breathing, chest PT and suctioning, and sometimes bronchoscopic mucus plug removal)

5yo M presents with 1-day hx of left wrist pain PE: holding left arm against body with tenderness of left wrist and inability to move thumb Left forearm XR: cortical bulge at distal radius

Incomplete radial fracture (aka buckle fracture: occurs in YOUNG CHILDREN <10yo after FOOSH injury due to porous bone allowing for compression of distal metaphyseal cortex after injury, resulting in stable incomplete fracture involving only one side of bone --> presents with pain and tenderness over fracture site and limited ROM --> diagnosis: XR shows cortical bulge at distal radius/ulna --> treatment: pain control and splint placement)

What are the key shock parameters used to diagnose obstructive shock?

Increased CVP and decreased PCWP (increased CVP/right-sided preload: due to compensatory increased SVR --> decreased PCWP: due to inability for blood passing from right heart to left heart)

Cause of peripheral cyanosis (bluish discoloration and cool clammy distal extremities)

Increased O2 extraction (peripheral cyanosis: due to sluggish blood flow thru capillaries --> causes: peripheral vasoconstriction, high venous pressure, polycythemia, chronic bronchitis, and pulmonary HTN --> results in NORMAL PaO2 saturation but INCREASED O2 extraction)

Cause of right heart failure in Eisenmenger syndrome (when left-to-right shunt becomes right-to-left)

Increased PVR (increased pulmonary vascular resistance: uncorrected VSD/ASD/PDA results in left-to-right shunt and increased pulmonary blood flow, leading to increased PVR and pulmonary arterial HTN --> development of RV hypertrophy to compensate, creating right-to-left shunt and right heart failure --> presents with late cyanosis, clubbing, polycythemia, and right heart failure)

Effect of knee-chest positioning in patient with Tetralogy of Fallot

Increased SVR (knee-chest positioning kinks femoral arteries, causing INCREASED SVR/AFTERLOAD and increased pulmonary blood flow to reduce degree of right-to-left shunting and improve hypoxemia --> other options to treat ToF: inhaled O2 to stimulate pulmonary vasodilation and systemic vasoconstriction, and IV fluids to increase systemic venous return to improve RV filling + pulmonary flow)

Management of recurrent calcium kidney stones

Increased fluid intake, dietary Na+ and protein restriction, and thiazide diuretic

Effect of acidosis on Ca2+ levels

Increased ionized Ca2+ (decreased extracellular pH/acidemia causes DISSOCIATION of Ca2+ from albumin --> resulting in INCREASED ionized/free Ca2+ but normal total Ca2+)

What happens at birth when an infant takes first breath?

Increased lung volume and decreased PVR (decreased pulmonary vascular resistance: increased lung volumes leads to pulmonary vasodilation, which increases LA pressure > RA pressure, allowing foramen ovale to close --> then increased O2 from respiration + decreased PGs from placental separation allow closure of ductus arteriosus)

Why is TMP-SMX contraindicated in the 3rd trimester?

Increased risk of kernicterus (TMP-SMX/Bactrim: thought to unbind indirect bilirubin from albumin, causing increased levels of indirect bilirubin leading to kernicterus)

Risk factors of uric acid kidney stones

Increased uric acid, increased urine concentration, and low urine pH (increased uric acid: caused by gout and MPDs --> increased urine concentration: caused by dehydration and hot arid climates --> low urine pH, usually <5.5: caused by GI bicarb loss and compensatory acidification of urine from chronic diarrhea, diabetes, and metabolic syndrome)

Which type of inguinal hernia is LATERAL to inferior epigastrics?

Indirect inguinal hernia (herniation of bowel contents thru the DEEP inguinal ring LATERAL to inferior epigastrics + SUPERFICIAL inguinal ring and into scrotum, usually due to failure of process vaginalis to close --> covered by all 3 layers of spermatic fascia)

1st line tocolytic for patients <32wks

Indomethacin (NSAID that inhibits COX enzyme to decrease PG synthesis --> 1st line tocolytic for patients 24-32wks but CONTRAINDICATED after 32wks due to risk of premature PDA closure and oligohydramnios)

Which medications are recommended for pregnant patients <32wks in preterm labor?

Indomethacin, betamethasone, magnesium sulfate, and penicillin (indomethacin: NSAID used to inhibit contractions and delay delivery, risk of premature PDA closure causing decreased renal perfusion + oligohydramnios --> betamethasone: promotes fetal lung maturity --> magnesium sulfate: used for fetal neuroprotection --> penicillin: decreases risk of neonatal GBS infection)

3-month-old M presents with refusal to feed and floppy head PE: bilateral ptosis, sluggish pupillary reaction to light, copious drool, weak suck and gag reflexes, head lag, and flaccid extremities in extension

Infant botulism (caused by ingestion of Clostridium botulinum spores from raw honey OR environmental dust in California + Utah + Pennsylvania, resulting in release of botulinum toxin that blocks ACh receptors at NMJ --> presents in infants with bilateral ptosis, sluggish pupillary response to light, poor suck and gag reflexes followed by descending flaccid paralysis/hypotonia + constipation + drooling --> treatment: respiratory support, NGT feeds, and human-derived botulism IVIG)

Indications for RSV prophylaxis with palivizumab

Infants <2yo born premature <29wks, BPD, and HD significant congenital heart disease

Comlplications of nephrotic syndrome

Infection, thrombosis, and protein malnutrition (infection: due to loss of Ig --> thrombosis: due to loss of ATIII and plasminogen --> protein malnutrition: due to loss of protein)

32F with PMHx of HIV and IVDU presents with 3-day hx of fevers, chills, pleuritic chest pain, and SOB Vitals: febrile 102.7F, BP 120/68, HR 110, RR 22 PE: scattered crackles in both lung fields Labs: elevated WBC, low Hgb CT chest: multiple nodular lung lesions with small cavities

Infective endocarditis (IE: in HIV/IVDU patients, usually caused by Staph aureus and affects tricuspid valve, resulting in multiple septic pulmonary emboli and LACKING classic peripheral IE manifestations --> presents with high fevers, chills, pleuritic chest pain, SOB, and/or cough --> diagnosis: CT chest shows pulmonary septic emboli as pulmonary infiltrates, abscesses, infarction, pulmonary gangrene, or cavities within lung periphery)

Which infections require droplet precautions?

Influenza, adenovirus, Neisseria meningitidis, H flu type B, and Mycoplasma (require droplet precautions due to aerosolized particles >5 microns therefore transmitted within only 3-6ft of source)

When do you screen for pre-eclampsia in high-risk patients (T1DM, obesity, SLE, chronic hypertension, AMA)?

Initial prenatal visit (requires 24hr urine collection for total protein to establish baseline proteinuria --> started on daily ASA beginning at 12wks gestation)

Patient with penetrating injury to extremity presents with diminished pulses and hyporeflexia Best next step in management?

Injured extremity index (involves comparing systolic occlusion pressure DISTAL to injury site to occlusion pressure at proximal site in uninjured extremity --> abnormal IEI <0.9 requires CT scan or angiography)

Which physical exam finding is most commonly associated with laryngomalacia?

Inspiratory stridor (due to inspiratory collapse of supraglottic tissues such as epiglottis and arytenoids, which causes a more collapsible extrathoracic airway --> therefore, during inspiration or anything that decreases intrathoracic pressure beyond larynx, there is increased airway narrowing and turbulent airflow on INSPIRATION)

28F who fell while skiing yesterday presents with left-sided headache, neck pain, and transient leg weakness PE: mild ptosis and miosis of left eye

Internal carotid artery dissection (trauma/infection to internal carotid intima allows blood to flow into vessel wall creating a false lumen/aneurysm/intramural hematoma leading to arterial obstruction or thromboembolic events --> risk factors: HTN, smoking, OCPs, connective tissue disease --> presents with unilateral head/neck pain, transient vision loss, partial Horner syndrome with ptosis + miosis, tinnitus, carotid bruit, and signs of cerebral ischemia with stroke/TIA --> diagnosis: CTA --> treatment: thrombolysis if <4.5hrs after symptom onset, ASA, and anticoagulation)

Sites most often used for vascular grafts in CABG

Internal mammary artery, greater saphenous vein, radial artery, and gastroepiploic artery

47F G4P4 with PMHx of IBS and tubal ligation presents with 2-mo hx of lower abdominal pain relieved by urination and dyspareunia PE: tenderness to palpation over lower abdomen and anterior vaginal wall UA: trace blood Urine culture: negative

Interstitial cystitis (bladder pain syndrome: chronic painful bladder condition associated with psychiatric + pain disorders --> risk factors: fibromyalgia, endometriosis, IBS, sexual dysfunction, depression, and anxiety --> presents with bladder pain with filling + relief with voiding, urinary frequency/urgency, dyspareunia, and chronic pelvic pain --> treatment: bladder training, fluid management, behavior modification, analgesics, and TCA/pentosan polysulfate sodium for severe cases)

Which type of hip fracture has a greater need for implant devices?

Intertrochanteric fracture (aka extracapsular hip fracture --> presents with SHORTENED, ADDUCTED, and INTERNALLY rotated LE flexed at the hip)

Treatment of keloids

Intralesional steroids

Treatment of non-allergic rhinitis

Intranasal antihistamine and steroid (intranasal antihstamines: include azelastine and olopatadine --> intranasal steroids: include fluticasone and budesonide)

1st line treatment of allergic rhinitis

Intranasal corticosteroid (ex: fluticasone or mometasone --> can also add nonsedating oral antihistamine, cromolyn spray, and LT modifiers)

Management of HIV-positive pregnancy with viral load <1000 copies/mL

Intrapartum ART, vaginal delivery, and zidovudine for infant

Management of HIV-positive pregnancy with viral load >1000 copies/mL

Intrapartum zidovudine and ART, C-section, and multidrug ART for infant

40yo M presents after MVC with fullness and tenderness in abdominal and suprapubic region PE: abdominal distension with rebound + guarding FAST: positive for intraperitoneal free fluid

Intraperitoneal bladder injury (aka bladder dome injury: causes rupture of bladder dome, resulting in urine spilling into peritoneal space and resulting in urinary ascites and/or chemical peritonitis --> presents with gross hematuria, abdominal and suprapubic pain/tenderness with PERITONEAL SIGNS, and difficulty voiding/anuria --> diagnosis: retrograde cystography)

Best next step in management for patient with possible inhalation injury (facial burns, singed nasal hairs, carbonaceous sputum, low SaO2, carboxyHb >60%, etc.)

Intubation and administration of 100% O2

Treatment of epiglottitis

Intubation and ceftriaxone plus vancomycin (intubation: secures airway due to impending airway occlusion from swelling epiglottis --> ceftriaxone: covers H flu and Strep --> vancomycin: covers MRSA)

14-month-old girl presents with 14-hr hx of irritability, 2 episodes of non-bilious vomiting, 1 BM containing small amount of blood, and episodes of drawing knees toward chest. Recently had a URI 2wks ago. Vitals: febrile 100.4F PE: listless except for intermittent episodes fo discomfort, right-sided tenderness without guarding, and bright red blood/mucus on DRE Abdominal XR: normal

Intussusception (telescoping of proximal bowel segment into distal segment usually at ileocecal junction, causing compromised blood supply --> pathologic lead points: Meckel diverticulum in children, intraluminal mass/tumor in adults --> causes: IgA vasculitis or recent viral infection causing Peyer patch hypertrophy --> presents with intermittent severe abdominal pain, drawing legs to chest to ease pain, sausage-shaped mass on palpation, and "currant jelly" dark red stools --> diagnosis: CT/US shows "target sign" --> treatment: water-soluble or air contrast enema, or laprascopic reduction/resection if severe)

37F G8P8 presents with 5-hr hx of increasing vaginal bleeding PE: 8cm mass of upper cervix and right parametrium CT pelvis: right hydroureter above level of mass

Invasive SCC of cervix (advanced cervical carcinoma: invades thru anterior uterine wall into bladder, resulting in blockage of ureters and obstructive uropathy --> presents with vaginal bleeding, upper cervical mass, and hydroureter and/or hydronephrosis)

37M with PMHx of allogenic stem cell transplant 6wks ago for AML presents with 3-day hx of fever, pleuritic chest pain, and productive cough with thick brown sputum that persists despite starting oral antibiotics 2 days ago Vitals: febrile 102.2F, BP 102/66, HR 112 PE: right-sided crackles Labs: low Hgb and low WBC CXR: dense RUL infiltrate that has grown compared to CXR from 2 days ago Chest CT: several nodular lesions with surrounding ground-glass opacities in RUL Sputum gram stain: inflammatory cells but no organisms

Invasive aspergillosis (invasion of ubiquitous fungus Aspergillus fumgiatus in patients with severe immunocompromise --> risk factors: neutropenia, chronic steroid use, advanced HIV --> presents with TRIAD of fever + chest pain + hemoptysis --> chest CT: pulmonary nodules with surrounding ground-glass opacities aka "halo sign" --> diagnosis: positive sputum culture/BAL and positive fungal cell wall biomarkers such as galactomannan and beta-D-glucan --> treatment: 1-2wks of IV voriconazole + caspofungin, then oral voriconazole)

Key finding in midbrain stroke

Ipsilateral CN3 palsy, ataxia, and contralateral hemiparesis (ipsilateral CN3 palsy: due to compression of CN3 --> ataxia: due to damage to superior cerebellar peduncle --> contralateral hemiparesis: due to damage to cerebral peduncle)

Most common physical exam sign of epidural hematoma

Ipsilateral blown pupil

Labs: - Low H&H - Low serum iron - High TIBC - Low ferritin - Low transferrin saturation

Iron-deficiency anemia

62M with PMHx of allergies, HTN, BPH, and occasional oral herpes who works as a dentist presents with 4-wk hx of itchy, dry hands and scaly, cracking skin at dorsum of both hands extending to fingers unrelieved by moisturizing lotions PE: dry crusted irritated skin with erythema at fingers + finger webs + dorsum of hands and few vesicles at finger webs

Irritant contact dermatitis (ICD: localized non-immune inflammatory reaction triggered by a variety of chemicals, solvents, soaps/detergents, or acidic/alkaline solutions --> presents GRADUALLY with scaly pruritic rash with excoriations, hyperkeratosis, and fissuring + vesicles of involved skin --> treatment: avoidance of triggers and emollients/protective barriers)

Colonoscopy: sharply demarcated segments of cyanotic mucosa and hemorrhagic ulcerations

Ischemic colitis

Abdominal CT: colonic wall thickening, fat stranding, and air in bowel wall (pneumatosis) Colonoscopy: segments of cyanotic mucosa and hemorrhagic ulcerations

Ischemic colitis (type of "watershed" ischemia caused by hypovolemia from vascular surgeries, MI, underlying atherosclerotic disease, etc. --> presents with moderate abdominal pain and tenderness, bloody diarrhea, and low-grade fevers --> labs: elevated WBCs and lactic acidosis --> CT scan: shows colonic thickening, fat stranding, and edema + pneumatosis in bowel wall --> diagnosis: colonoscopy shows sharply demarcated segments of cyanotic mucosa and hemorrhagic ulcerations --> treatment: bowel rest, IV fluids, and antibiotics with enteric coverage)

Classic rash seen in dengue fever

Islands of white in sea of red (measles-like rash that blanches --> dengue fever also presents with high fever >104F, headache, severe myalgias + arthralgias, retro-orbital pain, and skin rash described above --> diagnosis: tourniquet test in which BP cuff is placed for several minutes, then count petechiae after)

Treatment of Strongyloidiasis and Onchocerciasis

Ivermectin

ECG: positive deflection at the junction between QRS complex and ST segment

J wave (Osborn wave: prominent upward deflection occurring immediately after QRS complex, usually seen in anterior leads --> caused by HYPOTHERMIA)

14yo F presents with 3mo hx of ankle achiness with pain spreading to knees/elbows/wrists that is worse in the morning and improves over the day. Also p/w fatigue. PE: mild swelling and tenderness of bilateral ankles, knees, elbows, and wrists

JIA (juvenile idiopathic arthritis: chronic autoimmune condition causing arthritis in children --> POLYARTICULAR JIA affects YOUNG GIRLS age 2-5yo and 10-14yo presenting with symmetric arthritis in 5+ joints, sometimes with uveitis --> treatment: NSAIDs and slit-lamp exam to evaluate for uveitis)

Diagnosis of jugular venous distension

JVP >3cm or CVP >8cm

Child with bilateral deafness and episodes of arrhythmia-induced syncope during periods of stress

Jervell and Lange-Nielsen syndrome (autosomal recessive congenital long QT syndrome also associated with sensorineural deafness due to associated mutations affecting endolymph production)

Skin exam: progressively enlarging, painless, purple-colored, ellipitical papules

Kaposi sarcoma (neoplasm of endothelial cells caused by HHV-8 that results in significant vascular proliferation on the skin, mouth, GI tract, and respiratory tract --> cause: states of severe immunosuppression such as HIV and transplant patients --> presents with dark violaceous plaques/nodules in localized cluster on skin --> diagnosis: biopsy shows lymphocytic infiltrate --> treatment: HAART therapy)

Young girl with primary amenorrhea and presence of uterus on pelvic US Labs: elevated FSH Best next step in management?

Karyotype analysis (if 45XO: dx with Turner syndrome --> if 46XX: dx with primary ovarian insufficiency)

Best next step in management for young girl with primary amenorrhea and absent uterus

Karyotype analysis (if 46XY: dx with complete androgen insensitivity syndrome aka CAIS --> if 46XX: dx with mullerian agenesis)

2-week-old girl born at term via SVD presents with 2-day hx of bruising on arms and legs PE: petechiae over face and trunk, scattered ecchymoses over extremities, erythematous fleshy irregular mass on thigh, and bruit over hepatic area Labs: low plts

Kasabach-Merrit syndrome (hemangioma with thrombocytopenia: rare newborn disease in which a giant hemangioma serves as a trap for platelets, leading to thrombocytopenia --> presents with large hemangioma and petechiae/bruising with thrombocytopenia --> treatment: platelet transfusions/FFP and surgical resection of hemangioma --> complications: hemolytic anemia and DIC)

Management of postpartum stress incontinence (<6wks postpartum)

Kegel exercises (used to strengthen pelvic floor muscles --> pts that develop chronic stress incontinence treated with continence pessary or midurethral sling)

CSF pathway

Lateral ventricle, foramen of Monro, 3rd ventricle, CA, 4th ventricle, foramen of Luschka and Magendie, and subarachnoid space

Skin exam: dome-shaped nodule with central keratinous plug

Keratoacanthoma (BENIGN cutaneous tumor often seen in middle-aged and elderly individuals --> presents as dome-shaped nodule with keratin-filled center that grows rapidly within 4-6wks, then spontaneously regresses --> resembles SCC, and some may transform)

Skin exam: small painless papules with roughened skin texture on posterior surface of bilateral UE

Keratosis pilaris (benign skin condition caused by retained keratin plugs in hair follicles with exacerbations occurring in cold, dry weather --> associated with atopic dermatitis and ichthyosis vulgaris --> presents on POSTERIOR SURFACE OF UPPER ARMS with small painless papules, roughened skin texture, and mottled perifollicular erythema --> treatment: topical emollients and keratolytics such as salicylic acid/urea)

1-hour-old boy born via SVD c/b shoulder dystocia presents with abnormal movements of right hand PE: right forearm supinated, wrist extended, hyperextension of MCP joints, and flexion of DIP/PIP joints

Klumpke palsy ("claw hand": brachial plexus lesion usually caused by upward force on newborn arm during delivery, resulting in LOWER TRUNK C8-T1 damage with deficits in intrinsic hand muscles such as lumbricals + interossei + thenar + hypothenar muscles --> presents with unilateral supinated forearm, wrist extension, and "claw hand" with MCP extension and DIP/PIP flexion)

Skin exam: reverse curvature of nails on both hands

Koilonychia (spoon nails: caused by iron-deficiency anemia)

Which disease is characterized by deficiency in galactocerebrosidase?

Krabbe disease (rare autosomal recessive lysosomal storage disease caused by galactocerebrosidase deficiency, resulting in destruction of oligodendrocytes --> presents with developmental regression, hypotonia, areflexia, and optic atrophy --> diagnosis: presence of globoid cells)

Which dermatome level supplies the inguinal ligament?

L1

Which nerve root is responsible for cremasteric reflex?

L1-L2 ("testicles move")

Patient presents with chronic worsening lower back pain that radiates to buttocks, groin, and thighs PE: loss of patellar reflex and weak knee extension

L3-L4 disc herniation (presents with loss of patellar reflex, radiculopathy in lower back/buttocks to hip/groin to lateral/anterior thigh to lateral leg to medial toes, and weak knee extension)

Which dermatome level supplies the knees?

L4 (remember "down on all 4s")

Which nerve root is responsible for knee jerk reflex?

L4 (remember "down on all 4s")

Patient presents with chronic worsening left leg weakness PE: decreased biceps femoris reflex on left leg and weak dorsiflexion of left foot

L4-L5 disc herniation (presents with decreased biceps femoris reflex, weak dorsiflexion, and difficulty in heel walking)

Most common sites of lumbar disc herniation

L5-S1 and L4-L5

Patient presents with chronic worsening lower back pain that radiates to buttocks and down left foot PE: decreased left ankle jerk reflex, weak plantar flexion in left foot, and positive straight leg raise for left leg

L5-S1 disc herniation (presents with ipsilateral radiculopathy that radiates down to posterior calf + lateral foot, loss of Achilles reflex, and weak plantar flexion aka difficulty in toe walking)

Contraindications to ECG exercise stress test

LBBB, pacemaker, and unable to exercise (for pts with LBBB or pacemaker: proceed to exercise echo --> for pts unable to exercise: proceed to pharmacologic echo)

Cholesterol goals for patients with T2DM

LDL <100, HDL >40, and TG <150 (if pt has cholesterol higher than this, add statin)

Which type of fluid should be used for burn patients?

LR (Lactated Ringer's --> avoid colloid solutions within first 24hrs due to pulmonary/respiratory complications --> avoid normal saline due to hyperchloremic metabolic acidosis)

Preferred fluid for fluid resuscitation of burn victims

LR (lactated ringers: BALANCED isotonic crystalloid solution --> contains physiologic levels of Cl-, K+, Ca2+ and includes sodium lactate, which metabolizes into HCO3- to correct acidosis and maintain normal blood pH)

60M with PMHx of anterior STEMI 2mo ago presents with 2wk hx of progressive DOE, orthopnea, and fatigue PE: bilateral crackles in lower lung fields, displaced apical impulse to left, and faint systolic murmur over apex ECG: deep Q waves and ST elevation in leads I, aVL, and V2-V5 (unchanged from ECG at discharge 2mo ago)

LV aneurysm (post-MI complication caused by thin and scarred fibrotic myocardium in remodeled areas affected by STEMI, leading to progressive LV enlargement --> presents 5 DAYS-3 MONTHS after MI with CHF, refractory angina, ventricular arrhythmias, mural thrombus with systemic arterial emboli, and mitral regurgitation --> ECG: persistent ST elevation and deep Q waves after recent MI --> diagnosis: echo shows thinned, dyskinetic LV portion in area of prior MI)

ECHO: thinned dyskinetic portion of LV in area of prior MI

LV aneurysm (post-MI complication occurring 5 DAYS-3 MONTHS after MI --> presents with decompensated CHF, angina, arrhythmias, septic emboli, and MR --> ECG: persistent ST elevation and deep Q waves in anterior leads)

ECG: persistent ST elevation and deep Q waves in leads from recent MI

LV aneurysm (post-MI complication occurring 5 days - 3 months after MI --> presents with CHF, angina, ventricular arrhythmias, mural thrombi w/ septic emboli, and MR --> diagnosis: echo shows thinned dyskinetic LV portion in area of prior MI)

Which post-MI complications occur 2wks - several months after MI?

LV aneurysm and Dressler syndrome (LV aneurysm: presents with decompensated HF, ventricular arrhythmias, mural thrombus w/ emboli, MR, and ECG showing persistent ST elevations + deep Q waves in MI leads --> Dressler syndrome: immune-mediated pericarditis presenting with fever, pleuritic chest pain, and pericardial friction rub)

Treatment of hepatitis C

Ledipasvir and sofosbuvir (aka Harvoni: combo of direct-acting antivirals --> ledipasvir: inhibits viral phosphoprotein NS5A that plays key role in RNA replication --> sofosbuvir: inhibits RNA-dependent RNA polymerase NS5B to prevent RNA replication --> side effects: fatigue, headache, diarrhea)

Which post-MI complications occur 3-14 days after MI?

LV free wall rupture, IV septum rupture, and papillary muscle rupture (LV free wall rupture: occurs hours-2wks after MI and presents with cardiac tamponade --> IV septum rupture: occurs hours-1wk after MI and presents with cardiogenic shock and harsh holosystolic murmur with palpable thrill at left sternal border --> papillary muscle rupture: occurs 2-7 days after inferior STEMI and presents with acute severe mitral regurgitation with hypotension + pulmonary edema + cardiogenic shock)

ECG: tall R wave in aVL and deep S wave in V3

LV hypertrophy (Cornell criteria: ECG shows tall R wave in aVL + deep S wave in V3 --> causes include chronic HTN, aortic stenosis, and HOCM)

ECG: increased QRS voltage and T wave inversions in leads V5 and V6

LV hypertrophy (usually caused by chronic HTN, but also associated with HOCM and aortic stenosis --> ECG shows tall R wave in aVL, deep S wave in V3, and increased QRS voltage in left-sided leads I, aVL, and V4-V6)

6yo M presents with 2wk hx of leg pain that is worse at night, nocturia, and urinary incontinence PE: tachycardia, soft non-fluctuant tender 5cm mass over R anterior distal thigh, and erythematous papular rash over chest/trunk/groin Labs: hypernatremia Skeletal survey: single small well-defined lytic distal femoral diaphyseal lesion

Langerhans cell histiocytosis (LCH: rare disorder in which histiocytes/macrophages within tissue proliferate and infiltrate 1+ organ systems --> presents with lytic bone lesions, eczematous/purplish papules, LAD, hepatosplenomegaly, pulmonary cysts/nodules, and central DI --> XR: "punched out" lytic lesions in skull, jaw, femur, vertebrae, etc. --> diagnosis: bone/skin biopsy shows Langerhans cells --> treatment: predinose + vinblastine and desmopressin for DI)

Patients presents with blunt abdominal trauma and peritonitis. HDS Best next step in management?

Laparotomy (can consider abdominal/pelvic CT en route to OR)

Characteristics of abnormal lymph node findings in children

Large >2cm, tender, firm, immobile LNs (usually located DIFFUSELY or supraclavicularly with associated fever/wt loss/night sweats)

Signs of delayed postpartum hemorrhage

Large blood clots, change 1+ pad/hr, symptomatic anemia, and soft boggy uterus

Which causes of hypoxemia are NOT able to be corrected with supplemental O2?

Large intrapulmonary shunt and dead-space ventilation (large intrapulmonary shunt aka airway obstruction: caused by diffuse pulmonary edema and atelectasis --> large dead-space ventilation aka blood flow obstruction: caused by massive PE or right-to-left cardiac shunt)

4 signs of high-risk pancreatic cyst

Large size >3cm, solid components or calcifications, main pancreatic duct involvement, and thickened irregular cyst wall (for high-risk pancreatic cysts, need to order EUS-guided biopsy to rule out malignancy)

62M with PMHx of COPD, GERD, smoking, and alcohol use presents with 4mo hx of hoarseness PE: dry nasal mucosa, poor dentition with mild thrush on lateral surfaces of tongue b/l, and fungating irregular mass on left vocal cord appearing white in some areas and red in others with some blood crusting

Laryngeal SCC (laryngeal squamous cell carcinoma: cause of >90% of lesions in adult larynx and caused by smoking + alcohol use --> presents with persistent hoarseness >30days, dysphagia, airway obstruction, hemoptysis, and referred otalgia via CN9/CN10 --> diagnosis: laryngoscopy shows fungating laryngeal mass)

40yo M presents with 4mo hx of hoarseness and raspy voice Flexible laryngoscopy: irregular, exophytic growths in clusters on surfaces of vocal cords

Laryngeal papillomatosis (recurrent respiratory papillomatosis/RRP: formation of papillomas on surface of vocal cords due to HPV6/11 --> presents with >1mo of progressive hoarseness --> diagnosis: flexible laryngoscopy shows irregular exophytic growths in clusters on vocal cords that appear warty/grape-like with dark-red punctate areas ---> treatment: surgical debridement --> complications: voice outcomes, airway obstruction, and lower respiratory tract involvement)

4-month-old M presents with inspiratory stridor that worsens with crying/lying down and improves with tummy time

Laryngomalacia ("floppy" supraglottis --> presents in INFANTS 4-8MO with inspiratory stridor that worsens when feeding/crying/supine and improves when prone)

Which FHT is associated with uteroplacental insufficiency?

Late decelerations (onset occurs AFTER start of contraction --> nadir occurs AFTER peak of contraction)

Management of uncomplicated PPROM <34wks

Latency antibiotics, betamethasone, fetal surveillance, and delivery at 34wks (latency antibiotics: ampicillin and azithromycin to prevent IAI --> betamethasone: promotes fetal lung maturity --> fetal surveillance: includes regular NSTs and fetal growth US)

Best next step in management for patient with positive PPD and negative CXR

Latent TB treatment (options: INH + rifapentine for 3mo --> INH monotherapy for 6-9mo --> rifampin for 4mo)

Best imaging modality to screen for cervical trauma

Lateral XR (aka C-spine XR)

Decreased sensation over anterior and lateral thigh

Lateral femoral cutaneous nerve injury (compression of lateral femoral cutaneous nerve arising from L2-L3 --> causes: tight clothing, obesity, pregnancy, and pelvic procedures --> presents with decreased sensation over anterior + lateral thigh)

Most specific finding associated with epileptic seizures

Lateral tongue biting (low sensitivity but high specificity for epileptic seizure --> frontal tongue biting sometimes associated with syncope)

70M with PMHx of T2DM and HTN presents with 10hr hx of sudden-onset right-sided weakness and urinary incontinence PE: 4/5 strength in RUE, 1/5 strength in RLE, (+) Babinski on right side, and decreased sensation throughout R foot and leg

Left ACA stroke (characterized by CONTRALATERAL motor/sensory deficits with LE > UE, urinary incontinence, gait dyspraxia, primitive reflexes, abulia, and emotional disturbances)

Patient with diplopia, dizziness, and unsteady gait PE: - Normal left lateral gaze - On attempted right gaze, right eye abducts with horizontal nystagmus while left eye stationary - Normal convergence

Left INO (left internuclear ophthalmoplegia: caused by defect in LEFT MLF in which right abducens nuclei fires but left MLF blocks signal, thus preventing activation of left eye MR and bursts of stimulation from PPRF to right abducens nuclei --> PRESERVES convergence)

75M with PMHx of T2DM and HTN presents with 10hr hx of sudden-onset right-sided facial droop and inability to speak, weakness, and loss of peripheral vision PE: homonymous hemianopia, aphasia, right-sided facial droop, 1/5 strength in RUE, 3/5 strength in LUE, decreased sensation throughout R face and arm

Left MCA stroke (characterized by CONTRALATERAL SENSORY + MOTOR deficits in face + UE > LE, conjugate eye deviation toward side of infarct, homonymous hemianopia or quadrantanopia, and aphasia if left MCA or hemineglect if right MCA)

75M with PMHx of T2DM and HTN presents with 10hr hx of sudden-onset right-sided vision loss and inability to read PE: "down and out" right eye, homonymous hemianopia, and alexia without agraphia

Left PCA stroke (characterized by homonymous hemianopia, alexia without agraphia, CN3 palsy with "down and out" eye, visual hallucinations due to calcarine cortex, sensory symptoms due to thalamus, and sometimes contralateral motor deficits if cerebral peduncle/midbrain is affected)

Which visual field defect would be expected in right optic tract/right optic radiation lesion?

Left homonymous hemianopia (lesion in optic tract: caused by occlusion of anterior choroidal artery --> lesion in optic radiation: occlusion of MCA branch or lesion involving posterior limb of internal capsule)

Which visual field defect would be expected in right occipital lobe lesion (lesion in right primary visual cortex)

Left homonymous hemianopia with macular sparing (right occipital lobe lesion: usually caused by PCA stroke --> macula spared due to collateral blood flow from MCA)

Which visual field defect would be expected in right parietal lobe lesion (dorsal optic radiation lesion)?

Left homonymous inferior quadrantonopia("pie on the floor" visual field defect --> caused by lesion in CONTRALATERAL parietal lobe aka location of dorsal optic radiation)

Which visual field defect would be expected in right temporal lobe lesion (Meyer's loop lesion)?

Left homonymous superior qudrantanopia ("pie in the sky" visual field defect --> caused by lesion in CONTRALATERAL temporal lobe aka location of Meyer's loop)

75M with PMHx of T2DM and HTN presents with 10hr hx of sudden-onset right-sided facial droop and weakness PE: loss of motor function diffusely in right face, UE, and LE

Left lacunar stroke (characterized by unilateral PURE MOTOR deficit in face + arm + leg --> NO sensory deficits, NO cortical deficits and NO visual field abnormalities)

Treatment of venous air embolism (VAE)

Left lateral decubitus positioning and high-flow/hyperbaric O2

Patient with diplopia, dizziness, and unsteady gait PE: - No eye movement during attempted left lateral gaze - Normal right lateral gaze - Normal convergence

Left lateral palsy (caused by defect in LEFT PPRF or CN6 nuclei --> prevents coordination of BOTH left eye LR and right eye MR, with preservation of right lateral gaze and convergence)

Which side of scrotum is most commonly affected by varicocele?

Left scrotum (due to left spermatic vein draining to left renal vein, which is vulnerable to compression where it passes between SMV and aorta --> increased pressure in left renal vein causes retrograde blood flow to testes and dilation of pampiniform plexus)

What is Virchow's node?

Left supraclavicular lymph node (location of lymphatic metastasis of abdominal cancers, usually gastric cancer --> travel via thoracic duct to left supraclavicular LN --> often ominous sign)

Which testis is more commonly affected by varicocele?

Left testis (due to left spermatic vein draining into left renal vein, which can be compressed by SMA and aorta)

6yo M presents with chronic left knee pain and abnormal gait PE: limited internal rotation and abduction of left hip, atrophy of left thigh muscles, and antalgic gait

Legg-Calve-Perthe disease (pediatric avascular necrosis of the hip caused by occlusion of end arteries supplying femoral head, leading to necrosis and collapse of periarticular bone + cartilage --> presents in YOUNG BOYS 4-8yo with insidious hip or referred knee pain, antalagic gait, and atrophy of thigh muscles on affected side --> diagnosis: XR shows avascular necrosis of hip aka flattened/fragmented femoral head --> treatment: cast)

23M with recently dx pharyngitis on azithromycin presents with severe sore throat, persistently elevated fevers, dysphagia and odynophagia, and SOB Vitals: febrile 104F, BP 90/58, HR 115, RR 24, SaO2 94% on RA PE: mild swelling and erythema of oropharynx and tonsils without exudate, swollen tender neck along left SCM, and basilar crackles b/l Labs: WBC 17.4K with 93% neutrophils Duplex US: left IJ thrombosis CXR: multiple peripheral lung nodules, some with cavitation

Lemierre syndrome (severe life-threatening infection caused by gram-negative anaerobic bacillus Fusobacterium necrophorum, which is normally part of oral flora, that invades lateral pharyngeal space via lymphatics and causes IJ thrombosis and infection --> infection of IJ causes septic thromboemboli to seed other organs, especially lungs --> causes: tonsillitis, mastoiditis, or recent dental work --> presents with weeklong duration of painful pharyngitis and odynophagia, high fevers >102F, rigors, neck pain/swelling along SCM, and respiratory distress --> diagnosis: duplex US shows IJ thrombosis, positive blood/pus culture --> treatment: IV antibiotics and possible I&D or vein excision)

Causes of methemoglobinemia

Local/topical anesthetics, dapsone, and nitrates (local/topical anesthetics include benzocaine and lidocaine)

Treatment of early localized Lyme disease

PO doxycyline or amoxicillin (use amoxicillin in pregnant patients --> give IV ceftriaxone for late disseminated Lyme disease with meningitis/carditis)

42M recently emigrated from Southeast Asia to Connecticut 1yr ago presents with 2mo hx of non-pruritic, non-painful skin lesion on left upper arm and numbness + tingling of left fingers PE: 4cm well-circumscribed hypopigmented patch on LUE with no sensation to pinprick, thickened tender ulnar nerve at left elbow, and absent touch + pain sensation in left ulnar nerve distribution

Leprosy (chronic granulomatous disease of skin and peripheral nerves caused by acid-fast bacillus Mycobacterium leprae endemic to Asia/Africa/South America and transmitted via respiratory droplets or nine-banded armadillo --> presents with 1+ chronic, ANESTHETIC, macular hypopigmented skin lesions with raised well-demarcated borders and nodular painful nearby nerves with loss of sensory/motor function --> diagnosis: full-thickness biopsy of skin lesion edge --> treatment: dapsone and rifampin +/- clofazimine)

Labs: - WBC >50,000 - Metamyelocytes > myelocytes - No basophils - HIGH leukocyte alkaline phosphatase

Leukemoid reaction (mobilization of mature + immature leukocytes from bone marrow during severe infections --> presents with WBC >50K with LATE NEUTROPHIL precursors, HIGH LAP, and no basophilia --> requires >24hrs of IV antibiotics)

Which anti-Parkinson medications are most strongly associated with psychosis?

Levodopa and pramipexole

Outpatient treatment of CAP in patient with many co-morbidities

Levofloxacin or beta-lactam and macrolide

What are the two types of testicular sex cord stromal tumors?

Leydig and Sertoli cell tumors (Leydig cell tumor: produces excess estrogen + testosterone and presents with gynecomastia, acne, precocious puberty, and low FSH + LH --> Sertoli cell tumor: very rare and occasionally associated with excessive estrogen secretion)

What are the 2 types of testicular sex cord stromal tumors?

Leydig and Sertoli cell tumors (Leydig cell tumors: most common type of sex cord stromal tumor and produces excess estrogen + testosterone causing gynecomastia, loss of libido, ED, acne, and precocious puberty --> Sertoli cell tumor: occasionally associated with excess estrogen)

37M presents with tender bilateral gynecomastia and small nodule on left testicle Labs: normal LFTs and serum b-hCG

Leydig cell tumor (most common type of sex cord stromal tumor and arises from Leydig cells, which primarily produce testosterone and some estrogen --> presents with bilateral gynecomastia, loss of libido, erectile dysfunction, acne, hirsutism, precocious puberty, and testicular mass --> labs: low FSH and LH --> diagnosis: scrotal US shows testicular mass --> treatment: radical inguinal orchiectomy)

Skin exam: nails in both hands show longitudinal ridges, fissuring, and thinning

Lichen planus of nails

Treatment of ocular rosacea (burning/foreign body sensations, blepharitis, keratitis, conjunctivitis, and corneal ulcers)

Lid scrubs, ocular lubricants, and topical metronidazole

Patient presents with HTN + hypokalemia Labs: low serum aldosterone

Liddle syndrome (autosomal dominant gain of function mutation causing INCREASED Na+ reabsorption in renal collecting tubules --> presents with HTN + hypokalemia, metabolic alkalosis, and LOW SERUM ALDOSTERONE --> treatment: amiloride)

1st line treatment of primary nocturnal enuresis

Lifestyle changes, enuresis alarm, and desmopressin (lifestyle changes: includes minimizing fluid intake before bedtime + avoid sugary/caffeine + voiding before bedtime + reward system --> 2nd line tx includes enuresis alarm --> desmopressin: ADH analog that decreases urine production during sleep and used for pts who desire immediate improvement --> 3rd line/last resort tx is imipramine)

Screening guidelines for HLD

Lipid profile every 5yrs for adults age 40-75 with ASCVD risk <7.5% (however according to USPSTF it should start at age 35 for men and 45 women)

Skin exam: soft, rubbery, irregular painless cyst with normal overlying epidermis

Lipoma (benign, painless SUBQ mass)

Which type of necrosis is caused by alkali burns?

Liquefactive necrosis (alkali burns cause liquefactive necrosis and cell membrane dissolution, leading to deeper penetration of tissues and more severe injuries)

Skin exam: reticular, purple discoloration on bilateral LE that blanches with pressure

Livedo reticularis (mottled reticulated vascular skin pattern caused by swelling of venules 2/2 small blood clots --> causes: polyarteritis nodosa, SLE, antiphospholipid syndrome, cholesterol emboli, homocystinuria, cryoglobulinemia, cold agglutinin AIHA, and amantadine toxicity --> presents with lace-like purple discoloration of skin, usually bilateral LE)

Classic skin findings associated with cholesterol embolization

Livedo reticularis, gangrene, and cyanosis (usually seen in LOWER extremities)

Which structure is at risk of injury with right-sided fracture of ribs 9-12?

Liver

Diagnosis of Reye syndrome

Liver biopsy (should show microvesicular steatosis in context of acute hepatic encephalopathy)

Diagnosis of hepatomegaly in neonates

Liver edge >3.5cm below costal margin (dx of hepatomegaly requires liver US)

Which tissues produce AST?

Liver, heart, skeletal muscle, and intestinal smooth muscle

28F G1P0 at 40wks presents for induction of labor, given intravaginal misoprostol and IV oxytocin, then patient-controlled bupivacaine via epidural catheter 20mins later pt complains of perioral numbness, metallic taste in mouth, tinnitus, anxiety, and palpitations Vitals: BP 150/86, HR 110

Local anesthetic toxicity (caused by accidental insertion of local anesthetic into vasculature rather than nerve, resulting in direct delivery of anesthetic into circulation and rapid systemic drug absorption --> blocks inhibitory neural pathways to cause CNS overactivity --> presents with perioral numbness, metallic taste, tinnitus, and seizures --> treatment: drug cessation, benzos, and supportive care)

Triggers for psoriasis flares

Local skin trauma, withdrawal from steroids, antimalarials, indomethacin, propranolol, HIV, and strep throat (note: HIV and strep throat more associated with guttate psoriasis)

Causes of recurrent pneumonia occurring in same anatomic location of lung

Localized airway obstruction (extrinsic bronchial compression: due to expanding neoplasm, LAD, or vascular anomaly --> intrinsic bronchial obstruction: due to foreign body, bronchiectasis, bronchial stenosis, or endobronchial carcinoid tumor)

Treatment of acute agitation in inpatient setting

Lorazepam and haloperidol (achieves rapid sedation in severely agitated combative patients)

Cause of central cyanosis (bluish discoloration around lips/tongue/nail beds)

Low PaO2 saturation (central cyanosis: usually caused by congenital heart disease)

Treatment of PAD

Low-dose ASA, statin, and exercise therapy

Management of renal osteodystrophy

Low-phosphate diet, phosphate binders, calcium, and vitamin D (ex of phosphate binders: calcium carbonate, calcium acetate, and sevelamer)

Ideal placement of central venous catheter (CVC) tip

Lower SVC (tip should be visualized on portable CXR just proximal to angle between trachea and right mainstem bronchus)

38yo M with PMH of right molar tooth extraction 2wks ago presents with fever, right-sided jaw pain and swelling, and difficulty swallowing Vitals: febrile 100.8F, BP 130/82, HR 112, RR 22 PE: patient appears ill and is drooling, elevated tongue that is displaced posteriorly, firmness of mouth floor, and erythematous warm neck that feels woody

Ludwig angina (rapidly progressive cellulitis of submandibular and sublingual spaces arising from CONTIGUOUS spread of polymicrobial dental infections in submandibular molars, resulting in bilateral edema of submandibular + sublingual spaces --> leads to elevation of mouth floor and posterior displacement of tongue, leading to acute airway obstruction --> presents with fever, unilateral jaw pain + swelling, posteriorly displaced tongue, elevated mouth floor, and warm erythematous "woody/brawny" neck --> complication: airway obstruction presenting with drooling, inability to lay flat, and tripod positioning)

Best next step in management for patient with suspected SAH but negative noncon head CT

Lumbar puncture (LP: required to EXCLUDE SAH in patients with negative head CT --> positive LP for SAH includes elevated opening pressure, xanthocromia aka yellow-pink discoloration due to Hgb breakdown, and high RBC count that does not decline with serial tubes)

66M with PMHx of knee OA presents with several month hx of LBP and difficulty walking that worsens with prolonged standing/walking downhill and is relieved by sitting/walking uphill

Lumbar spinal stenosis (narrowing of spinal canal and compression of nerve roots usually caused by degenerative joint disease in which IV disc herniation and facet osteophytes impinge on spinal cord --> presents in MIDDLE-AGED/ELDERLY patients with LBP on extension of spine--standing, downhill walking-- and relief of pain on flexion of spine--sitting/uphill walking, and some leg weakness/sensory loss/numbness --> diagnosis: MRI shows narrowing of spinal canal)

72M with PMHx of HTN and Parkinson disease presents with 4wk hx of worsening productive cough with persistent abundant yellow sputum, malaise, night sweats, and 6.6lb wt loss Vitals: febrile 100f, BP 126/88, HR 88, RR 14 PE: frail patient with resting tremor of b/l hands and scattered rhonchi Labs: low Hgb, high WBCs CXR: density with cavitation in RLL

Lung abscess (infection of oropharyngeal anaerobic bacteria into dependent portions of lung due to aspiration 2/2 swallowing dysfunction, especially if patient coughs during eating --> presents with indolent fever, night sweats, wt loss, and productive cough with foul-smelling sputum --> diagnosis: CXR shows cavitary infiltrate in dependent portion of lung with air-fluid levels --> treatment: clindamycin)

Most common causes of brain metastases

Lung cancer > breast cancer > melanoma > RCC

Which cancers usually caused multiple brain mets?

Lung cancer and malignant melanoma

Most common sites of hepatocellular carcinoma metastasis

Lungs, portal vein, and portal lymph nodes

Which diseases are transmitted via the deer tick (Ixodes scapularis)?

Lyme disease, anaplasmosis, and babesiosis (Lyme disease: requires 48-72h of tick feeding before salivary gland migration --> anaplasmosis and babesiosis: transmitted soon after attachment)

Which diseases are transmitted via Ixodes scapularis tick?

Lyme, babesiosis, and HGA (Lyme disease: skin/joint infection with Borrelia burgorferi --> babesiosis: RBC infection with Babesia microti --> human granulocytic anaplasmosis/HGA: granulocyte infection with Anaplasma phagocytophilum)

What is the key finding in pleural fluid analysis for patient with tuberculous effusion?

Lymphocytic leukocytosis, very high protein >4, and very high LDH >500

ECG: irregular narrow complex tachycardia with 3 different P-wave morphologies and variable PR interval

MAT (multifocal atrial tachycardia: type of SVT caused by atrial conduction abnormalities caused by COPD exacerbation, RA enlargement, hypokalemia, or sepsis --> usually asymptomatic with rapid irregular pulse --> diagnosis: ECG shows irregular narrow complex atrial tachy >100bpm with 3+ P-waves of diff morphologies and irregular PR intervals --> treatment: correct underlying disturbance, or verapamil for AV node blockage if persistent)

Treatment of recurrent variable decelerations

Maternal repositioning and amnioinfusion (maternal repositioning: moving mom to left lateral or all-fours to reduce cord compression and improve fetal-placental blood flow --> 2nd line is amnioinfusion to create more amniotic fluid to reduce umbilical cord compression)

2yo boy presents with generalized tonic-clonic seizure, has 2-day hx of sore throat + dry cough + low-grade fever PE: lethargic, dry mucous membranes, and hepatomegaly Labs: low glucose and elevated ammonia UA: normal

MCAD deficiency (congenital FA metabolic disorder caused by medium-chain acyl-CoA dehydrogenase deficiency, resulting in inability to break down FAs into acetyl-CoA and accumulation of fatty acyl carnitines in blood --> presents with vomiting, seizures, lethargy, hepatic dysfunction, and hyperammonemia --> diagnosis: HYPOKETOTIC HYPOGLYCEMIA --> treatment: avoiding fasting)

9yo boy recently adopted 3 days ago presents with painless tongue nodules PE: tall for age with long arms and fingers, and multiple discrete firm rubbery tongue nodules

MEN2B (multiple endocrine neoplasia type 2B caused by germline RET mutation --> presents with pheochromocytomas, medullary thyroid cancer, mucosal neuromas especially on tongue, and Marfanoid habitus --> management: prophylactic thyroidectomy at age <1yr and frequent monitoring of calcitonin + metanephrines)

What are the live attenuated vaccines?

MMR, varicella, Sabin polio, smallpox, yellow fever, and intranasal flu

Diagnosis of syringomyelia

MRI shows intramedullary cavity

Which infections require contact precautions?

MRSA, VRE, C diff, EHEC, scabies, and RSV

Screening guidelines for neural tube defects in pregnancy

MSAFP at 15-20wks (concern for NTD: MSAFP >2.5 multiples of median --> other causes of elevated MSAFP include incorrect gestational age dating, multiple gestation, and abdominal wall defects such as omphalocele or gastroschisis --> best next step in fetal US)

Causes of anion gap metabolic acidosis

MUDPILES (M: methanol --> U: uremia --> D: DKA --> P: propylene glycol and paraldehyde --> I: INH and iron --> L: lactic acidosis --> E: ethylene glycol aka antifreeze --> S: salicylates aka aspirin)

Most accurate test in measuring ejection fraction

MUGA scan (multi-gated acquisition scan: noninvasive nuclear test that uses Tech-99 to evaluate function of ventricles)

Postexposure prophylaxis for pertussis

Macrolide for all household contacts (should be given REGARDLESS of vaccination status)

Treatment of pertussis

Macrolides (age <1mo: give azithromycin --> age >1mo: give azithromycin, clarithromycin, or erythromycin)

34M recently returned from Kenya 2wks ago presents with intense chills/shivering followed by high-grade fevers and profuse sweating, with symptoms occurring every few days Vitals: febrile 102F, BP 100/60, HR 114, RR 18 PE: conjunctival pallor Labs: low Hgb

Malaria (protozoal disease caused by infection with Plasmodium, an RBC parasite transmitted via Anopheles mosquito --> presents with tertian/quotidian fevers with cold phase/hot phase/sweating stage, headache, malaise, mylagias, abdominal pain, vomiting, diarrhea, and hepatosplenomegaly --> labs: anemia and thrombocytopenia --> diagnosis: thick and thin peripheral blood smear shows trophozoite ring form within RBC or red granules/Schnuffner stippling within RBC cytoplasm --> treatment: chloroquine, mefloquine, atovaquone/proguanil, or primaquine for P vivax/ovale)

10yo boy 3hrs s/p uncomplicated tonsillectomy for OSA presents with high fever of 104.9F Vitals: BP 90/60, HR 130, RR 30 with deep breathing PE: mottled skin, bilateral basilar crackles, hyperdynamic precordium, cool extremities, and generalized muscle rigidity Labs: prolonged PT and PTT UA: 2+ blood and 2+ protein ECG: non-specific ST changes

Malignant hyperthermia (autosomal dominant or sporadic skeletal muscle receptor disorder caused by excessive Ca2+ release after exposure to anesthetics, resulting in high fever and sustained muscle contraction --> triggers: volatile anesthetics such as halothane, succinylcholine, and excessive heat --> presents with sudden-onset generalized muscle rigidity, high fever, tachycardia, and tachypnea --> labs: hypercarbia resistant to increased minute ventilation, hyperkalemia, and myoglobinuria --> treatment: respiratory support and dantrolene --> complication: rhabdomyolysis)

46M with PMHx of alcohol abuse, esophagitis, and gastritis presents with bloody emesis after eating fatty meal and having several alcoholic drinks Labs: low Hgb, elevated BUN and Cr, elevated AST NG suction: normal stomach contents mixed with bright red blood

Mallory-Weiss tear (MWT: longitudinal mucosal tear near GE junction causing submucosal arterial/venous plexus bleeding --> causes: sudden increase in abdominal pressure from forceful retching or BAT --> risk factors: alcoholism and hiatal hernia --> presents with hematemesis and epigastric pain after forceful vomiting/retching --> diagnosis: endoscopy shows longitudinal mucosal laceration --> treatment: spontaneous resolution in 90% of patients, or endoscopic electrocoagulation or EPI injection)

Indications for surgical repair for Stanford type B aortic dissections

Malperfusion syndrome, ongoing pain, and aortic diameter >6cm (malperfusion syndrome: limb ischemia, mesenteric ischemia, kidney failure, or spinal cord ischemia w/ paraplegia)

Thick, greenish discharge from breast in perimenopausal woman

Mammary duct ectasia

Management of fecal impaction

Manual disimpaction and enemas (afterwards, recommend bowel regimen with laxatives + increased intake of fluid and fiber)

Patient with Marfanoid habitus and UPWARD lens dislocation

Marfan syndrome

SCC (squamous cell carcinoma) arising in a wound or burn

Marjolin uler (increased risk of metastasis)

Indications for IVC filters

Massive GI bleed, hemorrhagic stroke, thrombocytopenia, liver failure, and INR >1.5

Absolute contraindications to breastfeeding

Maternal HIV, active untreated TB, herpetic breast lesions, VZV infection <5 days, chemo, radiation therapy, active drug/alcohol abuse, and infant galactosemia

Causes of fetal tachycardia

Maternal fever, terbutaline, fetal hyperthyroidism, and fetal tachyarrhythmia

Causes of fetal bradycardia

Maternal hypothermia, beta-blockers, fetal hypothyroidism, and fetal heart block

Knee XR: eggshell periosteal reaction around quadriceps

Myositis ossificans (formation of bone from soft tissue, usually as a result of injury --> most commonly seen in ARMS and quadriceps of THIGH)

Pelvic US: ovarian cyst with solid components, hyperechoic nodules, and calcifications

Mature cystic teratoma (dermoid cyst: type of benign germ cell tumor of ovary that contains elements from all 3 germ layers and can include teeth/hair/sebum --> presents in YOUNG FEMALES 10-30yo with unilateral pelvic pain or ovarian torsion --> diagnosis: pelvic US shows ovarian cyst with solid components, hyperechoic nodules, and calcifications --> treatment: surgical resection)

Which glycogen storage disease is associated with flat venous lactate curve with normal rise in ammonia during exercise?

McArdle disease (type V glycogen storage disease: autosomal recessive deficiency in skeletal muscle glycogen phosphorylase aka myophosphorylase, resulting in excess glycogen in muscle that is unable to be broken down --> presents in YOUNG ADULTS during strenuous exercise with painful muscle cramps, arrhythmias, myoglobinuria, and 2nd wind phenomenon --> diagnosis: flat venous lactate curve with normal ammonia rise during exercise)

What is the distribution of measures of central tendency in a positively skewed distribution (tail on right)?

Mean > median > mode

Best next step in management for patient with elevated 24hr urine free cortisol

Measure serum ACTH (if LOW ACTH, consider adrenal CT to look for adrenal adeoma --> if HIGH ACTH, do high-dose dexamethasone suppression test)

12yo boy presents with 5-day hx of weakness, pallor, and black shiny stools Labs: low HCT, low MCV, and low MCHC Abdominal scintigram using tech-99 pertechnetate: increased uptake in RLQ separate from activity in stomach/kidneys/bladder

Meckel diverticulum (true diverticulum caused by persistence of vitelline/omphalomesenteric duct that often contains ectopic acid-secreting gastric mucosa, which causes ulceration of surrounding small bowel and subsequent lower GI bleed --> most common congenital anomaly of GI tract associated with rule of 2s: 2x more likely in males, 2in long, 2ft from ileocecal valve, and found in 2% of population --> usually presents around AGE 2 with PAINLESS hematochezia/melena and signs of anemia --> diagnosis: tech-99 pertechnetate scan shows uptake at heterotopic gastric mucosa --> complications: intussusception, volvulus, and obstruction at terminal ileum)

Neonatal CXR: patchy infiltrates, coarse streaking of lung fields b/l, and flattening of diaphragm

Meconium aspiration (aspiration of meconium causing airway obstruction --> presents in TERM and POST-TERM NEONATES with delivery via meconium-stained fluid and respiratory distress --> diagnosis: CXR shows patchy infiltrates, coarse streaking of both lung fields, and flattening of diaphragm)

Neonatal abdominal XR with barium enema: microcolon

Meconium ileus (obstruction of neonatal intestine with meconium plug, preventing stool passage at birth --> presents with delayed meconium passage >48hrs after birth and bilious vomiting --> diagnosis: neonatal abdominal XR shows dilated loops of bowel, and contrast enema shows microcolon --> treatent: Gastrogaffin/hypertonic enema and genetic screening for cystic fibrosis)

Patient presents with stroke-like symptoms PE: right-sided tongue deviation, left-sided hemiparesis, and left-sided loss of position sense

Medial medullary syndrome (caused by branch occlusion of vertebral or anterior spinal artery, which damages hypoglossal nerve/CN12 + lateral corticospinal tract + DCML --> presents with tongue deviation TOWARD side of lesion, contralateral hemiparesis, and contralateral loss of position sense)

30yo F presents with 2-day hx of left knee pain after colliding with another hockey playing and hitting wall PE: small left knee effusion without erythema or warmth, tenderness at medial knee at joint line, and clicking + sharp pain with internal rotation of the knee while patient stands on left leg and knee bent slightly

Medial meniscal tear (caused by twisting force with foot in fixed position --> presents with popping sound followed by acute pain, knee effusion and sense of instability, reduced knee extension, tenderness of MEDIAL joint line, and pain when getting up from low position --> diagnosis: palpable locking/catching when joint is rotated or EXTENDED while under load, positive Thessaly test, and positive McMurray test --> diagnosis: MRI or arthroscopy)

Which structure is most commonly affected by Colles fracture (distal radius fracture)?

Median nerve (enters wrist thru carpal tunnel, but can be compressed due to DORSAL displacement of radius --> presents with impaired thumb abduction, paresthesia of first 3.5 digits, and decreased sensation over palmar aspect of hand)

Which structures are most commonly affected by supracondylar fractures of humerus?

Median nerve and brachial artery (supracondylar fracture of humerus: most common elbow fracture in children caused by FOOSH injury with hyperextended elbow, resulting in POSTERIOR displacement of distal humerus fragment --> anteriorly displaced PROXIMAL fragment then entraps median nerve + brachial artery, located ANTERIOR to humerus --> can present with diminished brachial/radial pulses, "ape hand" with inability to approximate tip of thumb + index finger, loss of wrist/lateral finger flexion, and loss of sensation over thenar eminence and palmar aspects of first 3.5 fingers --> diagnosis: elbow XR shows fracture line and posterior fat pad --> treatment: analgesia and immobilization)

6yo F presents with several month hx of multiple falls while running and 1mo hx of intermittent headaches worse in morning with occasional N/V PE: wide-based gait with difficulty tandem walking, bilateral CN6 palsies, and papilledema

Medulloblastoma (posterior fossa tumor originating in vermis of cerebellum that often compresses 4th ventricle, causing increased ICP --> most common malignant pediatric brain tumor --> presents with truncal/gait ataxia with wide-based gait and poor tandem walking, morning headaches, N/V, bilateral CN6 palsies, and papilledema --> treatment: resection, craniospinal radiation, and chemotherapy)

3 most common pediatric brain tumors

Medulloblastoma, astrocytoma, and ependymoma

Malaria prophylaxis for travelers to india

Mefloquine >2wks prior to travel and >4wks after returning (alternatives to mefloquine: atovaquone-proguanil or doxycycline)

Colonoscopy: dark brown mucosal pigmentation in proximal colon

Melanosis coli (sequelae of laxative abuse occurring within a few months of laxative onset --> presents with dark brown discoloration of colon with pale patches of lymph follicles that give appearance of alligator skin)

Characteristics of myotonic muscular dystrophy

Myotonia, cataracts, frontal balding, and testicular atrophy (remember myotonic MD caused by CTG trinucleotide repeat expansion --> CTG: cataracts, toupee, and gonadal atrophy)

Triad of sensorineural hearing loss, vertigo, and tinnitus

Meniere disease (caused by endolymphatic hydrops resulting in increased endolymph within inner ear --> presents with TRIAD of sensorineural hearing loss, vertigo, and tinnitus as well as aural fullness --> treatment: diet restriction of salt + caffeine + nicotine + alcohol, diuretics, and benzos/antihistamines/antiemetics for acute relief)

MRI: extra-axial, well-circumscribed, round homogenously enhancing dural-based mass in the frontal lobe

Meningioma (benign primary brain tumor arising from meningothelial cells found in MIDDLE-AGED + ELDERLY WOMEN --> present with neuro symptoms such as HA, seizure, focal weakness/numbness --> treatment: complete resection)

MRI: diffuse leptomeningeal enhancement

Meningitis (workup: CT/MRI shows diffuse leptomeningeal enhancement due to increased permeability of meninges)

Differential diagnosis for posterior mediastinal mass

Meningocele, enteric cyst, lymphoma, diaphragmatic hernia, esophageal tumor, and aortic aneurysm

Patient presents with burning pain and paresthesias at lateral thigh

Meralgia paresthetica (compression of lateral femoral cutaneous nerve at the waist as it passes under inguinal ligament)

Abdominal CT: focal bowel wall thickening, small-bowel distension, and mesenteric stranding

Mesenteric ischemia (intestinal angina: thrombosis/embolism of mesenteric arteries causing bowel ischemia and infarct --> causes: older age, atherosclerosis, CHF, AFib, infective endocarditis, CV aneurysms, and hypercoagulable disorders --> presents with sudden periumbilical abdominal pain out of proportion to exam findings, food aversion, and wt loss --> labs: leukocytosis, elevated H&H, elevated amylase + phosphate, and lactic acidosis --> abdominal CT: focal/segmental thickening of small bowel wall, small bowel dilation, and mesenteric stranding --> diagnosis: CTA/MRA show occlusion and calcification of mesenteric artery --> treatment: open embolectomy with vascular bypass or endovascular thrombolysis, IV antibiotics, and anticoagulation)

57M who works as industrial engineer presents with 1-mo hx of persistent increasingly severe left-sided chest pain PE: absent breath sounds and dullness to percussion over lower portion of left hemithorax CXR: left-sided pleural effusion with extensive peripheral soft-tissue density Thoracocentesis: bloody exudative effusion, negative cultures, and cytology showing malignant cells of uncertain type Open biopsy: dimorphic cell population with areas of spindle cells with numerous mitotic figures + areas of cuboidal epithelial cells

Mesothelioma (malignancy derived from mesothelial lining of pleura strongly linked to asbestosis --> presents with chronic cough, chest pain, and SOB --> CXR: pleural thickening with HEMORRHAGIC/BLOODY pleural effusion --> diagnosis: biopsy shows DIMORPHIC cellular population with spindle cells + cuboidal epithelial cells, Psammoma bodies, and POSITIVE CALRETININ --> poor prognosis)

Which two pathologic conditions exacerbate coagulopathy?

Metabolic acidosis and hypothermia

Causes of ring-enhancing brain lesion

Metastatic carcinoma, brain abscess, lymphoma, and GBM

Causes of osteoblastic lesions in axial skeleton

Metastatic prostate cancer and SCLC (commonly causes osteoBLASTIC bone mets)

Recommended T2DM management for patients with established cardiovascular disease

Metformin, GLP1 agonist, and SGLT2 inhibitor (metformin: inhibits glucagon to increase peripheral glucose uptake and results in weight loss --> GLP1 agonist such as exenatide and liraglutide: slows gastric emptying, suppresses glucagon secretion, and increases insulin release to cause wt loss + DECREASED MORALITY in patients wit CV disease --> SGLT2 inhibitors such as canagliflozin and empagliflozin: increase renal excretion of Na+ and glucose causing decreased BP and decreased risk of CHF)

Which diabetes medications are associated with weight loss?

Metformin, GLP1 agonists, and SGLT2 inhibitors (Metformin: inhibits glucagon to increase peripheral glucose uptake --> GLP1 agonists aka "tides": slow gastric emptying, suppress glucagon, and increase insulin release --> SGLT2 inhibitors aka gliflozins: increased renal excretion of Na+ and glucose)

Which anti-diabetic medications should be used with caution in patients with renal insufficiency?

Metformin, SGLT2 inhibitors, and acarbose (metformin: inhibits hepatic gluconeogenesis to increase glycolysis + peripheral glucose uptake, SE include lactic acidosis in pts with renal insufficiency + GI upset + B12 deficiency --> SGLT2 inhibitors/gliflozins: block reabsorption of glucose in PCT, SE include glucosuria causing UTIs/yeast infections + hyperkalemia + orthostatic hypotension --> acarbose: alpha-glucosidase inhibitor that inhibits intestinal brush border carbohydrate enzymes to decrease postprandial hyperglycemia, SE include GI upset)

Management of ectopic pregnancy in hemodynamically stable patient with <3.5cm adnexal mass

Methotrexate (folic acid analog that inhibits DHFR to reduce DNA synthesis used to treat uncomplicated ectopic pregnancies and medical abortions --> indications: HDS, unruptured <3.5cm tubal mass, <8wks gestation, b-hCG <5000, and no renal disease --> workup: repeat b-hCG in 1wk)

Treatment of diabetic gastroparesis

Metoclopramide and erythromycin (metoclopramide: D2 receptor antagonist that increases LES tone/GI motility to promote gastric emptying, SE includes Parkinsonism + tardive dyskinesia + hyperprolactinemia --> erythromycin: macrolide antibiotic with promotility side effect)

1st line treatment of HOCM

Metoprolol and atenolol (beta-blockers most commonly used as 1st line tx for HOCM as they prolong diastole and decrease myocardial contractility to decrease LVOT obstruction --> 2nd line includes non-DHP CCBs such as verapamil or diltiazem --> 3rd line includes class 1A anti-arrhythmic disopyramide used to treat HOCM + CHF)

Liver biopsy findings expected in Reye syndrome

Microvesicular steatosis

Neonatal abdominal XR with contrast: abnormally located Ligament of Treitz on right side of abdomen and "corkscrew" appearance of small bowel

Midgut volvulus (caused by midgut malrotation in neonates, resulting in clumping of small bowel on right side and Ladd bands --> presents at <1 MONTH with bilious emesis, abdominal distension, bloody stools, and bowel perforation with peritonitis --> diagnosis: abdominal XR shows gasless abdomen and NGT misplaced in duodenum, upper GI series shows Ligament of Treitz on right side of abdomen + "corkscrew" appearance of small bowel --> treatment: NPO, NG decompression, IV fluids, and Ladd surgical procedure)

15-day-old boy born at term via SVD presents with 1-day hx of 2 episodes of "green" vomit and little interest in feeding Vitals: afebrile, BP 85/50, HR 142, RR 46 PE: irritable boy with dry mucous membranes and mildly distended abdomen Abdominal XR: gasless abdomen

Midgut volvulus (twisting of bowel portion around its mesentery leading to obstruction and infarction, usually caused in NEONATES by midgut rotation anomaly during fetal development resulting in improper bowel positioning and small bowel clumped on right side --> presents at <1 MONTH with bilious vomiting, abdominal distension, bloody stools, and bowel perforation with peritonitis --> diagnosis: abdominal XR shows gasless abdomen + NG tube misplaced in duodenum, upper GI series shows Ligament of Treitz on right side of abdomen with "corkscrew" pattern --> treatment: NPO, NG tube decompression, IV fluids, and Ladd procedure to fix bowel in non-rotated position)

65F with PMHx of AFib, HTN, hypothyroidism, and osteoporosis presents with 2wk hx of constipation, abdominal pain, urinary frequency, and constant thirst Vitals: afebrile, BP 120/70, HR 90 and irregular, RR 12 PE: dry mucous membranes and decreased bowel sounds UA: normal

Milk-alkali syndrome (caused by excessive intake of calcium and absorbable alkali, causing hypercalcemia and renal vasoconstriction with decreased GFR + inhibition of Na/K/2Cl cotransporter + impaired ADH activity leading to renal loss of Na+ and water with increased reabsorption of bicarbonate --> risk factors: thiazide diuretics, ACEIs/ARBs, NSAIDs, and calcium carbonate --> presents with nausea/vomiting, constipation, polyuria, polydipsia, and neuropsych sx --> labs: hypercalcemia, hypophosphatemia, hypomagnesemia, low PTH, metabolic ALKALOSIS, and AKI --> treatment: isotonic saline followed by furosemide)

42F with PMHx of cramping abdominal pain + diarrhea 2wks after an outdoor picnic that resolved after 3 days presents with 4-day hx of worsening double vision and gait unsteadiness PE: mild ptosis of right eye with weakness of medial + upward gaze, bilateral LE weakness with loss of DTRs, and dysmetria on heel-to-shin testing

Miller-Fisher syndrome (MFS: variant of Guillain-Barre syndrome caused by recent URI/GI infection that creates anti-GQ1b antibodies directed against ganglioside found in peripheral nerves such as CN3/4/6 --> presents with rapid-onset ophthalmoplegia, cerebellar-like ataxia, and areflexia --> diagnosis: positive anti-GQ1b antibodies and CSF showing albuminocytologic dissociation --> treatment: plasmapheresis and IVIG)

1st line antidepressant for patient with poor sleep and appetite

Mirtazapine (alpha-2 antagonist + 5HT2/5HT3 antagonist + H1 antagonist: increases release of NE and serotonin from presynaptic junction --> 1st line tx of MDD with poor sleep and appetite --> side effects: appetite stimulation, weight gain, and somnolence)

CXR: straightening of left heart border, elevated left main bronchus, and pulmonary vascular congestion with cephalization of blood flow to upper lobes

Mitral stenosis

52F Mexican immigrant presents with several years of SOB and ankle edema Vitals: BP 131/78, HR 86 PE: early diastolic heart sound followed by diastolic rumble

Mitral stenosis (mitral valve narrowing usually caused by rheumatic heart disease, resulting in restricted LV diastolic filling causing increased LA pressure/dilation and increased PA pressures with normal/low LV diastolic pressure --> presents with exertional SOB and diastolic murmur with "opening snap" aka sharp sound after S2 with low-frequency diastolic rumble best heard at apex)

Most common cause of spontaneous mitral chord rupture

Mitral valve prolapse (causes myxomatous degeneration of mitral valve, which can lead to mitral chord rupture --> presents with holosystolic murmur best heard at cardiac APEX and prominent pulmonary edema)

45M presents with several months of progressive fatigue, weakness, and fleeting joint pains in knees + elbows as well as 2-mo hx of painless nonpruritic purple lesions on legs Vitals: afebrile, BP 147/91, HR 84 PE: multiple purpuric, palpable lesions on LE that do not blanch with pressure Labs: low Hgb, low WBC, high Cr, high AST + ALT, low C3 and C4 complement, and positive RF UA: 3+ blood, 3+ protein, and few dysmorphic RBCs

Mixed cryoglobulinemia (immune complex deposition in small- to medium-sized blood vessels leading to endothelial injury and end-organ damage --> causes: chronic hepatitis B/C, HIV, and SLE --> presents with fatigue, arthralgias, peripheral neuropathy, non-blanching palpable purpura, MPGN, HTN, SOB, and pleurisy --> diagnosis: low C4 and elevated serum cryoglobulins --> treatment: plasmapheresis, steroids, and/or rituximab)

Which findings on a transplanted liver biopsy indicate acute cellular rejection (ACR)?

Mixed portal tract inflammation with eosinophils, nonsuppurative cholangitis, and endotheliitis

ECG: progressive prolongation of PR interval leading to dropped QRS complex

Mobitz type I 2nd degree AV block (Wenckebach block: intermittent AV block due to impaired conduction within AV node --> presents ASYMPTOMATIC or with bradycardia, fatigue, lightheadedness, angina, syncope, HF in older patients with acute ischemia/other cardiac comorbidity --> diagnosis: ECG shows increasing PR interval and group beating followed by dropped QRS --> usually no tx required)

ECG: consistent prolonged PR interval with intermittent dropped QRS complex

Mobitz type II 2nd degree AV block (Hay block: intermittent AV block due to impaired conduction in His-Purkinje system --> diagnosis: ECG shows dropped QRS beats WITHOUT progressive PR lengthening --> treatment: pacemaker due to risk of complete heart block)

What is the distribution of measures of central tendency in a negatively skewed distribution (tail on left)?

Mode > median > mean

Treatment of BCC on face

Mohs surgery (micrographic surgery involving sequential removal of thin skin layers with microscopic inspection to confirm clear margins --> used to treat high-risk BCC or any BCC on face)

Management of spontaneous abortion in stable patient

Monitoring bhCG q1wk until 0, then q1mo for 6mo (monitoring b-hCG q1wk until 0: to ensure it is decreasing until fetus is completely aborted --> q1mo for 6mo: screening for gestational trophoblastic disease if it begins to rise)

Prenatal US: two intrauterine gestations with thin intertwin membrane and "T-sign" of placenta

Mono/di twins (monochorionic diamniotic twins: twins with 2 amniotic sacs and 1 placenta --> diagnosis: 2 intrauterine gestations with THIN intertwin membrane and "T-SIGN" aka placenta meeting membrane at 90° angle)

Prenatal US: two intrauterine gestations with normal heartbeats, single placenta, and no dividing intertwin membrane

Monochorionic monoamniotic twins (least common type of twin gestation --> diagnosis: US shows 2 intrauterine gestations with SINGLE placenta and SINGLE amniotic sac with no dividing membrane --> management: inpatient mgt at 28wks with frequent NSTs, steroids, and delivery at 32-34wks via C-section --> complications: preterm birth, twin-twin transfusion syndrome, umbilical cord entanglement, and IUFD)

Causes of high-output cardiac failure

Morbid obesity, thyrotoxicosis, severe anemia, beriberi, Paget disease, and large AV fistula

Classic finding associated with juvenile myoclonic epilepsy (JME)

Morning generalized tonic-clonic seizures triggered by sleep deprivation (JME: epilepsy syndrome affecting otherwise healthy adolescents --> presents with childhood abscence seizures and MORNING myoclonic and generalized tonic-clonic seizures triggered by sleep deprivation --> diagnosis: EEG shows bilateral polyspike and slow wave activity --> treatment: valproic acid)

1st line treatment of severe cancer pain

Morphine or hydromorphone (strong short-acting opioids --> if pt requires frequent or bedtime dosing, calculate TDD and convert to long-acting opioid such as SR morphine, oxycodone, and transdermal fentanyl patch)

25F presents with 5wk hx of right foot pain on plantar surface that worsens after standing for a long time PE: pain between 3rd and 4th toes on plantar surface of R foot, and clicking sensation when palpating this space while squeezing metatarsal joints

Morton neuroma (benign neuroma of intermetatarsal plantar nerve, sometimes caused by wearing high heels or shoes with high toeboxes --> presents with pain between 3rd and 4th toes on plantar surface and POSITIVE Mulder's sign --> treatment: orthotics and steroid injections)

Characteristics of superficial partial thickness 2nd degree burn

Mottled painful burn with blisters

Characteristics of deep partial thickness 2nd degree burn

Mottled painless burn with open weeping blisters

Indications for ITP treatment in adult patients

Mucosal bleeding or platelets <30k

Treatment of phantom limb pain (PLP)

Multimodal pain regimen (pharmacotherapy: includes TCAs, gabapentin, ketamine, and analgesics --> adjuvant therapies: includes biofeedback, CBT, and mirror therapy)

Causes of large gamma gap >4

Multiple myeloma, MGUS, Waldenstrom, hepatitis, HIV, and CT disease

Causes of osteolytic lesions in axial skeleton

Multiple myeloma, Paget disease of bone, thyroid cancer, RCC, and NSCLC

55M with PMHx of recent onset resting tremors and diabetes presents with several weeks of dizziness, falls, dry mouth, dry skin, and erectile dysfunction Vitals: BP 121/84 supine and 92/61 standing PE: rigidity and bradykinesia

Multiple system atrophy (MSA/Shy-Drager syndrome: rare degenerative disease caused by progressive degeneration of neurons in basal ganglia + inferior olivary nucleus + cerebellum characterized by Parkinsonism, autonomic dysfunction, and widespread neurological signs --> presents with Parkinsonism, orthostatic hypotension, impotence, incontinence, abnormal sweating, abnormal salivation or lacrimation, and gastroparesis --> treatment: fludrocortisone + salt supplementation + alpha-adrenergic agonists to increase intravascular volume)

Treatment of impetigo

Mupirocin cream

Cause of Angelman syndrome

Mutated maternal 15q11 allele (normally paternally derived UBE3A gene is silenced so you only have mom's gene --> however in Angelman syndrome, the mom's gene is mutated/deleted so you develop the disease)

Cause of Prader-Willi syndrome

Mutated paternal 15q11 allele (normally maternally derived gene is silenced so you only get dad's gene --> however, in PW dad's gene is mutated so you develop the disease)

Which conditions are commonly associated with SJS/TEN?

Mycoplasma infection, GVHD, and vaccination

21F presents with 8-day hx of fever, sore throat, non-productive cough, and hoarseness Vitals: febrile 100.9 PE: crackles over right posterior lower chest CXR: patchy lower right alveolar infiltrates with increased interstitial markings

Mycoplasma pneumonia (atypical/walking/interstitial pneumonia: infection with Mycoplasma, an atypical bacteria with no cell wall and not seen on Gram stain --> presents in YOUNG ADULTS <30yo with gradual onset of low-grade fever, non-productive cough, headache, sore throat, and erythema multiforme --> CXR: diffuse patchy inflammation localized to interstitial areas at alveolar walls, usually showing bilateral multifocal opacities --> treatment: azithromycin, doxycycline, or levofloxacin --> complication: cold agglutinin disease causing painful blue fingers/toes with cold exposure)

Peripheral smear: ovalomacrocytosis and neutrophils with reduced segmentation

Myelodysplastic syndrome (MDS: hematopoietic stem cell neoplasm that causes blood cell dysplasia and cytopenias --> risk factors: advanced age and previous chemo/radiation --> presents with anemia, infections 2/2 leukopenia, bruising/bleeding 2/2 thrombocytopenia, HSM, and LAD --> labs: pancytopenia with insufficient reticulocytes --> diagnosis: peripheral smear shows dysplastic RBCs aka ovalomacrocytosis and granulocytes aka hyposegmented neutrophils, bone marrow biopsy shows hypercellular marrow --> treatment: transfusions, chemo, and stem cell transplant)

40M presents 1hr after MVC with severe pain over sternum Vitals: SBP 80, HR 80, RR 10 ECG: multifocal PVCs ABG: PO2 is 100 After 1L LR, PO2 decreases to 60mmHg while breathing 4L O2 by nC. PCWP increased from 14 to 24.

Myocardial contusion (caused by blunt thoracic trauma with chest wall bruising, resulting in LV contractile dysfunction and cardiogenic shock --> presents with LV heart failure + pulmonary edema, hypotension, hypoxemia, PVCs on ECG, and WORSENING cardiac function with fluids)

EMG: short duration, low amplitude motor unit potentials

Myositis (either polymyositis or dermatomyositis)

28F presents with several month hx of stiffness/weakness of hands, decreased grip strength with inability to let go of objects, fatigue, excess sleepiness, mild slurring of speech and heaviness of tongue PE: flat affect and mild bilateral ptosis, weak hand grip b/l, mild atrophy of small muscles of hands, and noticeable lag when opening eyes after closing tightly

Myotonic dystrophy (MD: autosomal dominant disorder caused by expansion of CTG trinucleotides in DMPK gene --> presents in YOUNG ADULTS 12-30yo with MYOTONIA aka delayed muscle relaxation after contraction, progressive muscle atrophy and weakness, temporal wasting, bilateral ptosis, lid lag, dysarthria, dysphagia, grip myotonia, flat affect, cataracts, testicular atrophy, and sleep disturbances --> diagnosis: genetic testing --> no treatment, pts die from respiratory failure or cardiac arrhythmias at age 40-50)

14yo boy with PMHx of generalized tonic-clonic seizure at age 8 presents with 1-yr hx of learning disability and hyperactivity with short attention span PE: 9 lesions with coffee-stain-like appearance on chest + abdomen, small areas of increased pigmentation in axillae, and many small skin tags over chest + abdomen + back

NF1 (neurofibromatosis type 1: autosomal dominant disease with 100% penetrance caused by mutation in NF1 tumor suppressor gene on chromosome 17 --> presents with CICLOPS: Cafe-au-lait spots, Intellectual disability, Cutaneous neurofibromas, Lisch noduels aka pigmented iris hamartomas, Optic gliomas, Pheochromocytomas, Seizures --> other associations: meningioma causing focal neuro signs and bone lesions such as sphenoid dysplasia)

Which conditions are associated with increased risk of pheochromocytomas?

NF1, VHL disease, MEN2A, and MEN2B

Diagnosis of esophageal atresia with TE fistula in neonate

NG tube and CXR (shows presence of enteric tube in proximal esophagus with inability to pass feeding tube into stomach)

Skin exam: multifocal lesions with brownish hue, dilated blood vessels, and central epidermal atrophy located on pretibial areas bilaterally

NLD (necrobiosis lipoidica diabeticorum: skin condition that frequently precedes onset of diabetes --> presents on SHINS initially with bruised appearance, followed by raised hardened areas of skin with yellowish center and dark pink periphery that can ulcerate --> requires screening for diabetes with HbA1c or fasting blood glucose)

Which anesthetic is associated with peripheral neuropathy?

NO (nitrous oxide: inactivates vitamin B12 leading to inhibition of methionine synthase activity, resulting in peripheral neuropathy in patients with preexisting vitamin B12 deficiency)

What are the 3 causes of ascites in cirrhosis?

NO formation, splanchnic vasodilation, and RAAS activation (NO formation: caused by endotoxin accumulation from immune system impairment and increased portosystemic shunting --> splanchnic vasodilation: caused by increased NO and results in decreased SVR with increased HR + CO --> RAAS activation: due to splanchnic vasodilation and decreased SVR, leading to ADH release and Na+/H2O retention)

Best next steps in management for patient with bilious vomiting

NPO, NGT decompression, IV fluids, and abdominal XR (free air requires immediate ex-lap --> dilated loops of bowel requires contrast enema to dx meconium ileus vs. Hirschsprung disease --> NGT misplaced in duodenum requires upper GI series to dx malrotation --> double bubble sign requires dx of duodenal atresia and surgery)

Disqualifying criteria for C-spine XRs

NSAID (neurologic deficit: should proceed directly to MRI --> spinal tenderness --> altered mental status: should proceed to CT scan --> intoxication --> distracting injury)

Common causes of pill esophagitis (shallow ulcers in MID esophagus)

NSAIDs, bisphosphonates, tetracyclines, and potassium chloride

Abortive medications used for migraines

NSAIDs, triptans, ergotamines, promethazine, and prochlorperazine (NSAIDs: anti-inflammatory and analgesic --> triptans and ergotamines: serotonin receptor agonist that decreases neurogenic inflammation + CGRP release and induces vasoconstriction --> promethazine: 1st gen antihstamine that works as anti-emetic --> prochlorperazine: dopamine antagonist that also works as anti-emetic)

Scrotal US: testicular mass with cystic areas and calcifications

NSGCT (non-seminomatous germ cell tumor: includes yolk sac tumor, choriocarcinoma, teratomas, and embryonal carcinoma --> labs: elevated AFP with some elevated b-HCG)

Best next step in management for decreased fetal movement

NST (non-stress test: FHT for 20-40mins --> REACTIVE test is 2+ accelerations, baseline HR 110-160, and moderate variability --> non-reactive NSTs require BPP)

Which beta-blockers are recommended for variceal bleeding?

Nadolol, proranolol, and carvedilol (decrease hepatic venous pressure gradient to reduce portal HTN)

23F with PMHx of difficult rhinoplasty a few months ago presents with 2wk history of progressively worsening whistling noise during respiration

Nasal septal perforation (occurs due to to poor regenerating capacity of septal cartilage, as cartilage relies completely on overlying nasal sidewall mucosa for blood supply --> causes: post-op septal hematoma, self-inflicted trauma, syphilis, TB, intranasal cocaine use, sarcoidosis, and GPA)

Skin exam: erythematous vesicular papules/plaques with irregular borders and crusting/scaling on mouth, groin, and bilateral LE

Necrolytic migratory erythema (NME: skin condition associated with GLUCAGONOMA --> presents with acute onset of erythematous papules/plaques with irregular borders on face/perineum/LE that enlarge and coalesce over next 7-14 days with central clearing + blistering, crusting, and scaling at borders)

80yo M with PMH of T2DM, hypothyroidism, and HTN presents on POD3 s/p laparotomy for SBO with intense pain around laparotomy wound Vitals: febrile 101F, BP 121/76, HR 100, RR 16 PE: abundant cloudy-gray discharge and dusky friable SQ tissue + decreased sensation at wound edges Labs: BG 312

Necrotizing SSI (necrotizing surgical site infection: severe SSI caused by polymicrobial infection, usually seen in patients with diabetes --> presents with pain/edema/erythema beyond surgical site, fever + tachycardia, paresthesia or anesthesia at wound edges, purulent cloudy gray "dishwater" drainage, and SQ gas or crepitus --> treatment: urgent surgical exploration and IV antibiotics)

Patient bit by neighbors dog, tetanus vaccine UTD Best next step in management?

Observe pet for 10 days (if dog is healthy, NO RABIES PEP required --> if dog becomes symptomatic, give rabies PEP)

3wk-old boy born at 28wks via vaginal delivery c/b cervical incompetence presents in NICU with 6hr hx of bilious vomiting and no BM for past 24hrs (previously had small yellow seedy stools) Vitals: hypothermic at 96F, BP 75/45, HR 165, RR 70, SaO2 97% on 2L NC PE: lethargic neonate with tense distended abdomen and hypoactive bowel sounds Labs: leukocytosis and metabolic acidosis

Necrotizing enterocolitis (NEC: inflammation and necrosis of intestinal mucosa with invasion of gas-producing bacteria due to decreased bowel motility, increased intestinal permeability, and immature host defenses --> risk factors: prematurity, very low birth wt <3.3lb, and enteral feeds with formula --> presents with HYPOTHERMIA <97.7F, vital sign instability, lethargy, bilious emesis, bloody stools, and tense abdominal distension --> labs: leukocytosis and metabolic acidosis --> diagnosis: abdominal XR shows air in bowel wall + portal venous gas + pneumoperitoneum --> treatment: bowel rest, TPN, IV antibiotics, and surgery)

Neonatal abdominal XR: extravasation of bowel gas into damaged bowel wall and air in portal venous system

Necrotizing enterocolitis (poor intestinal perfusion in infants causing enterocyte dysfunction with impaired nutrient absorption, mucosal inflammation + necrosis, and translocation of gas-producing bacteria into bowel wall --> most common sites of necrosis at terminal ileum and proximal colon --> risk factors: prematurity, low birth wt <3.3lbs, enteral feeding, and reduced mesenteric O2 from cyanotic CHD/hypotension --> presents with PRODROME of non-specific lethargy and hypothermia followed by feeding intolerance, increasing abdominal distension, bloody stools, and bilious vomiting --> diagnosis: abdominal XR shows pneumatosis intestinalis, portal venous gas, and/or pneumoperitoneum --> treatment: bowel rest, parenteral nutrition, IV BSA, and surgery)

82F with PMHx of T2DM and Alzheimer dementia living in a nursing home presents with 2-wk hx of increased tearfulness especially at night, clutching of ear, new-onset drooling, and liquid dripping out of right side of mouth during feeding Vitals: febrile 100.4F, BP 140/90, HR 96, RR 18 PE: right ear canal with granulation tissue surrounding white drainage in floor of canal, and facial asymmetry with some downward deviation of right corner of mouth Labs: HbA1c 8.5%

Necrotizing otitis externa (NOE: osteomyelitis of skull base caused by Pseudomonas infection of external auditory canal, leading to granulation tissue formation with tissue-degrading proteases allowing spread of infection to damage CN7 + CN10 + CN11 --> risk factors: age >60yo, T2DM, and cerumen removal --> presents with severe deep-seated ear pain worse at night/with chewing, otorrhea, facial drooping, drooling, and granulation tissue on floor of EAC at border between bony-cartilaginous junction --> treatment: IV ciprofloxacin for 6-8wks +/- surgical debridement)

Diagnosis of simple breast cyst

Needle aspiration

Treatment of large pneumothorax >2cm in stable patients

Needle thoracostomy

Treatment of tension pneumothorax

Needle thoracostomy (most commonly inserted at the 5th ICS in midaxillary line --> can also insert at 2nd ICS in midclavicular line --> should always be followed by emergency tube thoracostomy for definitive PTX management)

Which neuropathy symptoms are associated with LARGE NERVE FIBER injury?

Negative symptoms (includes numbness/poor balance, loss of pressure + proprioception + vibration sensation, and diminished/absent ankle reflexes)

23F G1P0 at 38wks with limited prenatal care presents with decreased fetal movement for past few days, as well as 1-month hx of fatigue and joint stiffness PE: erythematous confluent facial rash FHT: fetal bradycardia at 80bpm

Neonatal lupus (caused by passive placental transfer of maternal anti-SSA/Ro and anti-SSB/La antibodies seen in patients with SLE and Sjogren, which bind to fetal cardiac cells causing irreversible injury to AV node --> presents with FETAL AV BLOCK causing fetal ventricular bradycardia at 50-80bpm --> complications: cardiomyopathy and hydrops fetalis --> management: BPP, fetal growth US, and possible delivery)

6-hour-old girl born via SVD after induction of labor for pre-eclampsia with severe features presents with respiratory distress and inability to feed due to tachypnea PE: birth weight <3rd %ile for gestational age, plethoric infant, sinus tachycardia, and tachypnea Labs: elevated HCT, low glucose

Neonatal polycythemia (neonatal hematocrit >65% in term infants caused by increased erythropoiesis from intrauterine hypoxia, erythrocyte transfusion from delayed cord clamping/twin-twin transfusion syndrome, genetic conditions such as trisomy 13/18/21, or metabolic disease such as hypo- or hyperthyroidism --> presents with ruddy/plethoric appearance, lethargy, irritability, respiratory distress, tachypnea, poor feeding, and cyanosis --> labs: hypoglycemia, hyperbilirubinemia, and hypocalcemia --> treatment: hydration via oral feeds or IV glucose)

Indications for VZIG post-exposure prophylaxis

Neonates, pregnant women, and immunocompromised patients (neonates: recommend giving VZIG if maternal infection developed 5 days before delivery or 2 days after --> pregnant women and immunocompromised: require VZIG if unimmunized and in contact with varicella)

Antidote to succinylcholine, vecuronium, rocuronium, etc.

Neostigmine and atropine (neostigmine: cholinesterase inhibitor that increases ACh in NMJ and has NO CNS penetration --> atropine: muscarinic antagonist used to prevent bradycardia and other muscarinic effects, can also use glycopyrrolate)

Labs: - Normal/high Na+ level - Low urine osmolality (<300) with overnight fasting - No response to desmopressin

Nephrogenic DI (abnormality in ADH receptors within renal collecting ducts, resulting in no response to ADH and excess fluid loss --> causes: chronic lithium use, hypercalcemia, and hereditary AVPR2/aquaporin 2 mutations --> presents with nocturia, dehydration, and hypernatremia --> diagnosis: low urine osmolality <300 after water deprivation and no response to desmopressin)

Cause of hypercalcemia on the kidney

Nephrogenic DI (systemic hypercalcemia results in nephrocalcinosis of renal CDs, resulting in resistance to ADH and sufficient aquaporin expression leading to increased urine volume with excess free water loss, aka nephrogenic DI --> presents with polyuria and volume depletion)

Diagnostic para: - Color: straw-colored - Low protein - Low SAAG

Nephrotic syndrome (causes BOTH low protein and low SAAG due proteinuria)

Side effects of calcineurin inhibitors (tacrolimus, cyclosporine)

Nephrotoxicity, HTN, tremor, hyperglycemia, HLD, gingival hypertrophy, hirsutism, and alopecia (note: tacrolimus does NOT cause gingival hyperplasia or hirsutism)

2yo girl presents with abdominal distension and blue skin lesions on trunk PE: rapid saccadic eye movements, abdominal distension with firm irregular abdominal mass in midline, and blue nodules on trunk

Neuroblastoma (tumor arising from neural crest cells that can occur anywhere along sympathetic chain but usually arises from adrenal medulla, associated with N-MYC oncogene --> presents in CHILDREN <4yo with abdominal distension, firm irregular abdominal mass that can cross midline, HTN, and opsoclonus-myoclonus syndrome --> diagnosis: elevated urine HVA and VMA, histology shows Homer-Wright rosettes positive for bombesin and NSE)

MRI: enhancing cystic lesions with calcifications throughout brain

Neurocysticercosis (infection of Taenia solium/pork tapework due to consumption of eggs in endemic areas such as Central/South America --> presents with SEIZURES --> diagnosis: MRI shows mix of enhancing and nonenhancing cystic lesions with calcifications --> treatment: albendazole)

Foot XR: bone loss, large osteophytes, several extraarticular bone fragments, and loss of joint space

Neurogenic arthropathy (Charcot joint)

70M with PMHx of Parkinson disease presents with dizziness and syncope when standing Vitals: seated BP 120/70 and HR 66 --> standing BP 89/60 and HR 68 PE: mild tremor and bradykinesia

Neurogenic orthostatic hypotension (NOH: common complication of neurodegenerative diseases caused by autonomic dysfunction 2/2 degenerative changes to autonomic ganglia and CNS nuclei, thereby impairing release of NE and resulting in failed vasoconstriction + increased HR --> presents with lightheadedness and syncope --> diagnosis: orthostatic measurement causes drop in SBP >20 but NO CHANGE IN HR)

56M with PMHx of smoking presents with 3mo hx of progressive difficulty walking due to imbalance, episodes of transient sharp stabbing pain in back + lower limbs, and involuntary dribbling of urine PE: 1+ knee + ankle reflexes b/l, impaired vibratory and position sensation in BLE, broad-based gait, and small irregular pupils b/l that constrict poorly to light but constrict normally when looking at finger placed near tip of nose

Neurosyphilis (form of 3° syphilis manifesting after years of untreated Treponema pallidum in which spirochetes directly damage dorsal sensory roots and dorsal spinal columns --> risk factors: MSM and HIV-positive patients --> presents with TABES DORSALIS with sensory ataxia + impaired vibration/proprioception + instability during Romberg, lancinating pains in face/back/extremities, neurogenic urinary incontinence, and Argyll Robertson pupils aka MIOTIC irregular pupils that constricts with ACCOMMODATION but not light --> treatment: IV penicillin for 10-14 days)

Newborn skin exam: blanchable red/purple patch on one side of face that does not cross midline

Nevus flammeus (port-wine stain: capillary malformation --> presents with blanchanble red/purple patches that does not cross midline and does not regress)

Newborn skin exam: blanching pink patch on forehead

Nevus simplex (macular stain/salmon patch/stork bite/angel kiss: presents with blanching pink patch located on eyelids/gabella/nape of neck --> no treatment: fades spontaneously by age 2)

Type of bias in which exposures that happen long before disease assessment can cause study to miss disease patients that die early/recover

Neyman bias (prevalence bias: type of selection bias --> ex: hospital-based study on snow shoveling and MI will miss patients who die in driveways before reaching hospital)

6-mo-old girl presents with irritability, listlessness, and inability of sitting/rolling even though she was able to do so several weeks before PE: hypotonic, hepatosplenomegaly, protuberant abdomen, cervical LAD, diminished DTRs, and bright red macula on fundoscopic exam

Niemann-Pick disease (NPD: autosomal recessive disease caused by sphingomyelinase deficiency, often seen in patients with Ashkenazi Jewish heritage --> presents at 2-6 MONTHS with loss of motor milestones, hypotonia, feeding difficulties, HEPATOSPLENOMEGALY, AREFLEXIA, and "cherry-red" macula --> diagnosis: biopsy shows foam cells aka lipid-laden macrophages in neurons --> poor prognosis, usually fatal by age 3)

1st line tocolytic for patients 32-34wks

Nifedipine (DHP CCB that inhibits Ca2+ entry into muscle cells leading to myometrial muscle relaxation --> 1st line tocolytic for patients 32-24wks --> side effects: peripheral vasodilation leading to flushing + headache, hypotension, tachycardia, and palpitations)

Which medications are recommended for pregnant patients 32-34wks in preterm labor?

Nifedipine, betamethasone, and penicillin (nifedipine: tocolytic that is preferred for pts at 32-34wks due to risk of premature closure of PDA with indomethacin --> betamethasone: promotes fetal lung maturity --> penicillin: give if GBS positive or unknown)

Child who completely wakes up with recurring nightmares, remembers the nightmares, and is able to be consoled

Nightmare disorder (occurs during REM sleep and more frequent in 2ND HALF of night)

Treatment of SCC of anus

Nigro chemoradiation protocol (involves chemo with 5-FU and mitomycin combined with radiation --> decreases need for surgery and improves quality of life)

Treatment for SAH-induced vasospasms

Nimodipine (CCB)

Diagnosis of arrest of active labor

No cervical change for >4hrs with adequate contractions or >6hrs with inadequate contractions (adequate contractions in >200 MVUs in 10-min interval --> causes of arrest of active labor: fetal malposition, macrosomia, pelvic deformity, or fracture --> treatment: C-section)

Diagnosis of complete SBO

No flatus and no air in rectum (complete SBO: high risk of bowel ischemia and perforation --> treatment: NG tube insertion for gastric decompression + emergent laparotomy to relieve obstruction and resolve underlying etiology)

Indications for IV neostigmine in Ogilvie syndrome

No improvement >48hrs and cecal diameter >12cm (neostigmine: cholinesterase inhibitor that does NOT penetrate CNS --> used to treat postop and neurogenic ileus, urinary retention, MG, and antidote to NMJ blockade)

Diagnosis of nocturnal enuresis

Nocturnal urinary incontinence in children age >5 (1st line treatment include enuresis alarm therapy and desmopressin)

1st line treatment of carpal tunnel syndrome during pregnancy

Nocturnal wrist splinting (holds wrist in neutral position and prevents excessive flexion during sleep to lower pressure --> 2nd line is steroid injections: safe during pregnancy but only for refractory cases --> 3rd line: surgery ONLY for severe sx such as motor weakness/thenar atrophy)

Skin exam: fleshed-colored pearly nodule with rolled border and central telangiectasias on back

Nodular BCC (causes up to 80% of BCC cases, the most common skin cancer in US --> risk factors: fair skin, heavy sun exposure, ionizing radiation, and chronic arsenic exposure --> presents as slow-growing pink/flesh-colored pearly or translucent nodule with elevated/rolled border and central telangiectasias --> dx/tx: surgical excisional biopsy with narrow margins, aka 3-5mm)

Skin exam: firm, nodular, darkly pigmented lesion elevated off of skin with uniform color and symmetric borders

Nodular malignant melanoma (type of melanoma that grows VERTICALLY and does not follow classic ABCDE criteria --> presents with 1+ of the following: "ugly duckling" sign, firmness, elevation from skin with nodular or pedunculated appearance, and continuous growth over a month --> diagnosis: full-thickness excisional biopsy)

Audiogram: bilateral drop in hearing around 4 KHz

Noise-induced hearing loss (caused by persistent loud noises damaging cochlea, especially at 4 KHz --> causes: loud headphone use, musicians, weapons manufacturers, etc.)

Management of acute decompensated HF (ADHF)

Noninvasive ventilation and IV furosemide (noninvasive ventilation: for pts with hypoxemia and respiratory distress to rapidly improve sx --> IV furosemide: aggressive diuresis to remove fluid overload --> for HTN patients: give IV nitroglycerin --> for hypotensive/shock pts: give IV norepi)

Patient appears hypovolemic Labs: - Hyponatremia - Low serum osmolality (<275) - High urine osmolality (>100) - Low urine Na+ (<40)

Nonrenal salt loss (hyponatremia due to total body volume depletion --> presents with dry mucous membranes, decreased skin turgor, and prerenal AKI with BUN/Cr ratio >20:1 --> causes: dehydration, vomiting, diarrhea, poor oral intake, etc.)

Which medications are associated with hyperkalemia as a side effect?

Nonselective beta agonists, ACEIs, ARBs, K-sparing diuretics, TMP, digoxin, NSAIDs, cyclosporine, heparin, and succinylcholine (nonselective beta agonists: propranolol, timolol, nadolol, and pindolol --> ACEIs + ARBs + K+ sparing diuretics + Bactrim: inhibits aldosterone or ENaC channel in renal CD to block K+ excretion --> ARBs: losartan, candesartan, and valsartan --> K-sparing diuretics: spirinolactone, eplerenone, triamterene, amiloride --> digoxin: cardiac glycoside --> NSAIDs: decreases renal perfusion leading to decreased K+ to CDs --> cyclosporine + heparin: blocks aldosterone activity and production --> succinylcholine: causes leakage of K+ from cells via ACh receptors)

Signs of early meningococcal infection

Nonsuppurative pharyngitis, severe myalgias, and cold pale mottled skin (caused by significant inflammatory response with IL-6 causing myocardial depression and poor perfusion --> treat with IV ceftriaxone)

Most common causes of bacterial rhinosinusitis

Nontypeable H flu > Strep pneumo > Moraxella

40F with PMHx of SAH from ruptured PComm aneurysm 3yrs ago presents with worsening gait disturbance and unsteadiness when walking PE: flat affect, psychomotor retardation, slow wide-based gait with small steps MRI: enlarged ventricles out of proportion to underlying brain atrophy

Normal pressure hydrocephalus (accumulation of CSF leading to ventriculomegaly with NORMAL opening pressure on LP --> causes: idiopathic in elderly, prior neuro insult such as SAH/meningitis/trauma in young people that causes scarring and destruction of arachnoid granulations --> presents with TRIAD of magnetic gait with slow wide-based steps, urinary urgency/incontinence, and cognitive impairment such as apathy/psychomotor retardation + UMN signs in LE --> diagnosis: MRI shows enlarged ventricles out of proportion to brain atrophy, or Miller Fischer test aka marked improvement with large-volume LP --> treatment: ventriculoperitoneal shunt)

What are the 3 isotonic IV fluids?

Normal saline, LR, and albumin (normal saline: unbalanced CRYSTALLOID solution --> LR: balanced CRYSTALLOID solution --> albumin: COLLOID solution used in patients with SBP, hepatorenal syndrome, large volume paracentesis, and hepatic encephalopathy)

Skin exam: pruritic, scaly, fissured, round plaque with intermittent clear yellow exudate

Nummular eczema (discoid eczema: idiopathic inflammatory disorder thought to be caused by decreased production of skin lipids --> presents with pruritic, erythematous, scaly/fissured plaques with intermittent clear yellow exudate on BACK + EXTREMITIES --> treatment: topical steroids and emollients)

57F presents with 3-mo hx of pain in left groin and distal anterior thigh with weight bearing PE: reproducible pain with internal rotation of left hip and mild limp favoring LLE

OA of hip (osteoarthritis of hip: most common joint disorder characterized by progressive destruction of articular cartilage, usually affecting DIP/PIP and large weight-bearing joints --> risk factors: age >40yo, obesity, and diabetes --> presents with groin/buttock/lateral hip that radiates down to lower thigh and worsens with activity + decreased rotational ROM WITHOUT synovitis --> diagnosis: XR of hip shows loss of joint space, osteophyte formation, and subchondral stenosis --> treatment: exercise + wt loss, NSAIDs, and local steroid injections)

Treatment of allergic conjunctivitis

OTC antihistamine and mast cell stabilizer drops (OTC antihistamine drops: for intermittent episodes --> mast cell stabilizer drops such as olopatadine and azelastine: for frequent episodes)

Treatment of small pneumothorax <2cm

Observation and supplemental O2

Treatment of ITP (immune thrombocytopenia)

Observation or steroids, IVIG, and anti-D IG (observation: for CHILDREN presenting exclusively with petechiae and ADULTS presenting with petechiae and plts >30k --> steroids + IVIG + anti-D IG: given if bleeding or plts <30k --> steroids/anti-D IG/IVIG: 1st line tx for CHILDREN with mucosal bleeding or ADULTS with mucosal bleeding or plts <30k --> splenectomy: last resort for chronic ITP refractory to IVIG/steroids or catastrophic bleeding)

Most common cause of vesicovaginal fistula

Obstructed labor (usually in the setting of YOUNG maternal age with small pelvis and limited/no prenatal care, leading to delayed diagnosis + labor intervention --> obstructed labor causes excessive fetal head compression and injury/necrosis of maternal vagina + rectum + blader, leading to erosion and fistula between proximal structures within first weeks postpartum)

Pulmonary flow-volume loop: "scooped-out" pattern on exhalation

Obstructive lung disease (intrapulmonary airway obstruction that decreases airflow during effort-INDEPENDENT phase of exhalation)

Shock parameters: - High CVP - Low/normal PCWP - Low CI - High SVR - Low SvO2

Obstructive shock (external compression of the heart preventing adequate pumping caused by cardiac tamponade, massive PE, or tension pneumothorax --> due to low CO, there is compensatory increase in SVR and thus increase in CVP/right-sided preload, but decreased PCWP/left-sided preload as blood cannot pass from right heart to left heart --> ECHO: diastolic collapse with elevated RV pressure in cardiac tamponade, RV dilation and hypokinesis in massive PE)

Alarm symptoms for patients with dysphagia

Odynophagia, weight loss, anemia, GIB, hematemesis, or recurrent vomiting (indications for upper endoscopy --> also should do upper GI endoscopy for men age >50 with >5yrs of sx and tobacco use)

67M with PMHx of HTN, CAD, and CHF presents with 5-day hx of large-volume watery stools 6-8x/day + mild abdominal cramps + nausea after eating at a restaurant, as well as 1-day hx of abrupt cessation of BMs + diffuse abdominal discomfort and distension Vitals: afebrile, BP 116/72, HR 102 PE: dry mucous membranes, distended tympanic abdomen with mild tenderness to palpation, hypoactive bowel sounds, and DRE showing empty rectal vault Abdominal CT: diffuse colonic dilation with non-dilated small bowels Labs: normal WBC and negative C diff testing

Ogilvie syndrome (acute colonic pseudoobstruction: acute megacolon caused by autonomic disruption of colon, resulting in cessation of intestinal motility and abnormal colonic dilatation --> causes: major surgery, severe trauma, sepsis, opioids, anticholinergics, dementia, stroke, MS, Parkinson disease, hypokalemia, hypomagnesemia, and hypocalcemia --> presents with severe abdominal distension + pain, N/V, obstipation, abdominal tympany, and hypoactive bowel sounds --> abdominal XR: colonic dilation with normal haustra and non-dilated small bowel --> diagnosis: abdominal CT shows colonic dilation with no anatomic obstruction --> treatment: NPO, NG/rectal tube decompression, and IV neostigmine if no improvement >48hrs or cecal diameter >12cm)

Which regions in the US are endemic for Histoplasma?

Ohio/Mississippi river valleys and Northeast (Histplasma usually found in soil contaminated with bat/bird droppings --> pts have history of interacting with chicken coops, farm buildings, bird roosts, or caves)

1st line treatment of chemotherapy-induced nausea

Ondansetron (serotonin receptor antagonist that blocks 5HT3 receptor --> used to manage acute emesis and useful for prophylaxis --> 2nd line meds include DA antagonists metoclopramide and prochlorperazine)

Screening guidelines for iron-defiency anemia in children

One-time CBC at age 1 (if positive for iron-deficiency anemia, recheck Hgb in 4wks and continue for 2-3mo until Hgb normalizes)

Screening guidelines for HIV

One-time HIV antibody for adults age 15-65

Screening guidelines for AAA

One-time abdominal US for male smokers age 65-75

Screening guidelines for HCV

One-time anti-HCV antibody for adults age 55-75, history of IVDU, HIV, or transfusions before 1992

Skin exam: extensive thickening and discoloration of multiple toenails in both feet

Onychomycosis (tinea unguium: chronic dermatophyte infection of nails caused by Trichophyton rubrum)

73F with PMHx of RA and HTN presents with 8mo hx of thickening and discoloration of multiple toenails in feet, and frequently snags stockings on nails

Onychomycosis (tinea unguium: chronic dermatophyte infection of nails commonly caused by Trichophyton rubrum --> risk factors: advanced age, tinea pedis, T2DM, and peripheral vascular disease --> presents with PAINLESS thick brittle discolored nails, fissuring of surrounding skin, and paronychia --> diagnosis: KOH microscopy of nail scrapings --> treatment: topical terbinafine or itraconazole, 2nd line includes PO griseofulvin + fluconazole + ciclopirox)

Pelvic XR: pelvic ring disruption and anterior widening

Open book pelvic fracture (severe pelvic fracture usually caused by trauma with high risk of life-threatening hemorrhage due to tearing of thin-walled presacral/lumbar venous plexus with bleeding filling up expanded pelvic pelvic and retroperitoneum --> presents with unstable pelvis on palpation and retroperitoneal hemorrhage such as hypovolemic shock/flank ecchymosis --> diagnosis: pelvic XR shows pelvic ring disruption with anterior widening of pubic symphysis --> treatment: pelvic binder to decrease pelvic volume and tamponade bleeding)

Indications for open reduction and surgical exploration for fractures

Open fractures, significant displacement, neurovascular compromise, polytrauma, and pathologic fractures (open fractures: part of bone sticking out of skin --> significant displacement: arm shortening, leg shortening, etc. --> neurovascular compromise: asymmetric pulses --> polytrauma: multiple fractures --> pathologic fractures: due to osteoporosis)

Coronal head CT: flattened appearance of globe

Open globe injury (OGI: caused by blunt force trauma to eye OR penetrating trauma at cornea from small high-velocity particles sent airborne by power tool, explosions, lawn mowers, or MVCs --> presents with fixed "teardrop" pupil, marked loss of visual acuity, extrusion of vitreous aka "gush" of fluid, absent afferent pupillary defect, decreased IOP, and increased/decreased anterior chamber depth --> workup: fluorescein eye exam shows puncture site --> treatment: eye shield, IV antibiotics, tetanus prophylaxis, and emergency ophtho consult --> diagnosis: CT scan of orbit shows flattened globe --> complications: endophthalmitis, post-traumatic cataract, and vision impairment)

16M presents with foreign body sensation, pain, excessive tearing, and decreased vision in left eye after helping father mow lawn and being hit by a flying object in left eye PE: obvious discomfort with left eye closed, and eccentric pupil of left eye

Open globe laceration (OGL: caused by penetrating trauma at cornea from small high-velocity particles sent airborne by power tools, explosions, lawn mowers, and MVCs --> presents with foreign body sensation, extrusion of vitreous aka "gush" of fluid, eccentric "teardrop" pupil, decreased visual acuity, absent afferent pupillary response, decreased IOP, and increased/decreased anterior chamber pressure --> diagnosis: fluorescein eye exam shows puncture site, CT scan of orbit shows lacerated globe --> treatment: eye shield, IV antibiotics, tetanus prophylaxis, and emergency ophtho consult)

Treatment of fracture of distal 1/3 of clavicle

Open reduction and internal fixation of clavicle (used to prevent nonunion)

24M with PMHx of ankylosing spondylitis and anterior uveitis on prednisolone eye drops presents with several day hx of blurry vision, needing more light to read, and glare while driving at night PE: normal eye appearance

Open-angle glaucoma (OAG: type of optic neuropathy characterized by increased intraocular pressure/IOP due to decreased outflow of aqueous humor in anterior chamber worsened by swelling of choroid/lens in posterior chamber, resulting in atrophy of optic head and enlargement of optic cup --> causes: systemic steroids, steroid eye drops, uveitis, vitreous hemorrhage, and retinal detachment --> presents with gradual PAINLESS loss of peripheral vision and consequent tunnel vision, central blurriness due to corneal edema, subscapular cataracts, and "cupping" of optic disc --> diagnosis: tonometry shows elevated IOP --> treatment: topical PG such as latanoprost, topical timolol, and/or laser trabeculoplasty)

Screening for children with oligoarticular/polyarticular JIA

Ophtho exams (need to be performed regularly due to risk of uveitis)

Best next step in management for patient with candidemia (bloodstream infection with Candida)

Optho evaluation (candidemia often causes endophthalmitis)

Treatment of post-nasal drip (upper airway cough syndrome)

Oral 1st gen antihistamine (ex: chlorpheniramine, diphenhydramine, doxylamine --> can also try combined antihistamine-decongestant)

Management of choanal atresia

Oral airway, OG tube feeding, and surgical repair

Treatment of neonatal chlamydial conjunctivitis

Oral azithromycin (requires tx with PO MACROLIDE --> monitor for pyloric stenosis due to increased risk with macrolide use in infants <1mo)

Treatment of trachoma

Oral azithromycin (should be given to everyone in entire region such as village/refugee camp)

Treatment of primary/secondary/latent syphilis in patient with anaphylactic penicillin allergy

Oral doxycycline (give for 14 days for primary + secondary syphilis, and 28 days for latent syphilis --> requires RPR at 6-12mo for test of cure)

Gold standard for diagnosis of T2DM in patients with PCOS

Oral glucose tolerance test (more sensitive in detecting glucose intolerance than fasting glucose/HbA1c)

Treatment of phymatous rosacea (irregular thickening of skin)

Oral isotretinoin

Which vaccine induces primarily mucosal IgA response?

Oral polio vaccine (OPV: promotes secretion of anti-poliovirus IgA antibodies in GI tract)

Treatment of C diff

Oral vancomycin, metronidazole, or fidaxomicin

6yo M presents with 1-day hx of fever and right eye pain + swelling PE: swollen erythematous eyelids of R eye, proptosis, and limited R eye adduction

Orbital cellulitis (infection POSTERIOR to orbital septum usually occurring in children --> risk factors: bacterial sinusitis, dental infection, preseptal infection, and orbital trauma --> presents with acute onset of fever, swollen red eyelids, proptosis, and painful restriction of EOMs with ophthalmoplegia and diplopia --> diagnosis: CT scan of orbits and sinuses to identify orbital abscess --> treatment: IV antibiotics +/- surgery --> complications: CN2 damage, cavernous sinus thrombosis, and brain abscess)

24yo M presents after a bar fight with eye pain + swelling and double vision when looking up PE: swollen + tender + ecchymotic left side fo face, inability to look up with left eye, and normal visual acuity Coronal CT: herniation of orbital fat into maxillary sinus, and entrapment of inferior rectus muscle

Orbital floor fracture (blowout fracture caused by blunt trauma to globe, which rapidly increases pressure that is transmitted posteriorly into orbit, causing fracture of weakest areas of bony orbit aka orbital floor + medial orbital wall in order to protect globe from rupture --> results in entrapment of IR muscle, which keeps affected globe in DOWNWARD position --> presents with unilateral eye pain + swelling and diplopia on UPWARD GAZE despite normal visual acuity --> diagnosis: coronal CT shows orbital floor fracture with herniation of orbital fat into maxillary sinus + entrapment of IR muscle --> complications: ischemia, fibrosis, and permanent dysfunction of IR muscle)

Coronal head CT: herniation of orbital fat into maxillary sinus and entrapment of inferior rectus muscle

Orbital floor fracture (presents with diplopia on UPWARD gaze and normal visual acuity)

Coronal head CT: presence of intraorbital fluid

Orbital hematoma (presents with diplopia and decreased visual acuity due to pressure-induced ischemia of optic nerve)

40yo F presents with 2mo hx of sore throat, dysphagia with solid foods, and worsening bad breath PE: enlarged firm right tonsil with 2cm ulceration and 2 enlarged firm fixed nontender LNs on right neck

Oropharyngeal HNSCC (oropharyngeal head and neck squamous cell carcinoma: malignancy of mucosal surfaces of oropharynx aka tonsil + base of tongue, which has higher lymphatic tissue and facilitates viral processing --> most commonly caused by HPV-16 --> other risk factors: younger age, multiple sexual partners, no tobacco exposure --> presents with persistently enlarged firm neck mass, ulcerated tonsillar lesion, pharyngitis, dysphagia, and halitosis --> diagnosis: biopsy of tonsil lesion with HPV testing, neck CT, and endoscopy to evaluate upper aerodigestive tract)

Difficulty initiating swallowing with coughing/choking after eating

Oropharyngeal dysphagia (characterized by difficulty initiating a swallow and then subsequent nasopharyngeal regurgitation/aspiration)

Athletic teen presents with chronic knee pain PE: swelling and tenderness over tibial tubercle

Osgood-Schlatter disease (osteochondritis of tibial tubercle --> presents in TEEN ATHLETES with painful knee with swelling over tibial tubercle and palpable nodule --> treatment: stop exercising or play through it)

Complication of rapid correction of hyponatremia

Osmotic demyelination (central pontine myelinolysis: massive axonal demyelination in pontine white matter due to rapid administration of 3% saline, which draws excess water from intracellular neurons/glia into ECF causing disruption of cellular metabolic activity and cell damage --> presents with acute paralysis, dysarthria, dysphagia, diplopia, LOC, and/or locked-in syndrome --> remember: "from low to high, your pons will die")

Hip XR: loss of joint space, osteophyte formation, and subchondral stenosis

Osteoarthritis of hip

Foot XR: bone necrosis with surrounding sclerosis and periosteal thickening

Osteomyelitis

Knee XR: bone necrosis with surrounding periosteal thickening

Osteomyelitis (presents with fever, swelling, and bony tenderness --> diagnosis: XR shows necrotic bone/sequestrum surrounded by periosteal thickening/involucrum)

68F with PMHx of osteoporosis on calcium + vit D + zoledronic acid presents with 3-day hx of mild pain in left lower jaw and gum swelling after loose molar extraction 3wks ago, with extraction site never healing PE: gingival edema and erythema surrounding area of exposed bone at left lower jaw

Osteonecrosis of jaw (ONJ: necrosis of jaw bone usually caused by high-dose IV bisphosphonates after dental procedures --> risk factors: concurrent cancer or steroid use --> presents following tooth extraction with localized swelling, mild pain, loosening of teeth, and area of exposed necrotic bone --> treatment: careful oral hygiene, antibacterial rinses, and oral abx + limited debridement for severe cases)

68yo F with PMH of osteoporosis and recent molar extraction 3wks ago presents with 3-day hx of mild pain in left lower jaw associated with gum swelling PE: gingival edema and erythema surrounding area of exposed bone at left lower jaw

Osteonecrosis of jaw (impaired bone remodeling causes exposed necrotic bone following dental procedures --> causes: extractions/implants while taking high-dose bisphosphonates, glucocorticoids, or cancer --> presents with mild pain and swelling of jaw, exposed necrotic bone, and loosening of teeth --> treatment: careful oral hygiene, antibacterial rinses, and if necessary can add oral antibiotics + debridement)

Knee XR: lytic lesion with ill-defined margins and surrounded by concentric layers of reactive bone

Osteosarcoma (malignant cancer of bone usually seen in CHILDREN or TEENS at long-bone metaphyses, aka site of greatest bone proliferation --> risk factors: retinoblastoma, Li Fraumeni syndrome, Paget disease, radiation, or benign bone tumors --> presents with unilateral bone pain and swelling --> diagnosis: knee XR shows lytic bone lesion, "sunburst" periosteal reaction aka concentric layers of reactive bone, and/or Codman triangle aka raised edge of ossified periosteum)

Diagnosis of chronic suppurative otitis media

Otorrhea and hearing loss for >6wks with TM perforation

34yo F presents with decreased hearing and ringing in left hear, however is better able to understand speech in noisy environments PE: slight reddish hue behind left TM

Otosclerosis (autosomal dominant with incomplete penetrance disease characterized by imbalance of bone resorption and deposition causing stiffening and fixation of ossicles, especially the stapes, resulting in conductive hearing loss/CHL --> presents in YOUNG CAUCASIAN WOMEN age 30-40yo with progressive CHL, paracusis of Willis aka improvement in speech discrimination in noisy environments, and reddish hue behind TM due to excess bony resorption exposing underlying blood vessels --> treatment: hearing aids for amplification or surgical stapes reconstruction)

COCPs reduce the risk of which cancers?

Ovarian and endometrial cancer (due to chronic ovulation suppression and progestin suppressing endometrial proliferation)

28F currently undergoing ovulation induction for fertility tx (last hCG 7d ago, LMP 3wks ago) presents with 2-day hx of increasing abdominal pain + distension, severe persistent nausea/vomiting, and one episode of watery diarrhea Vitals: BP 100/60, HR 104, RR 24 PE: sinus tachycardia, decreased breath sounds in b/l lung bases, and distended abdomen with tympany Labs: elevated HCT, elevated WBC, and b-hCG 1102 Pelvic US: small uterus with thin endometrium, bilateral enlarged ovaries with multiple cysts, and large amount of free fluid in abdomen

Ovarian hyperstimulation syndrome (OHSS: life-threatening complication of ovulation induction that occurs when hCG injections stimulate artificial maturation of multiple ovarian follicles causing exaggerated ovarian response and overexpression of VEGF leading to increased vascular permeability and capillary leakage --> results in third spacing and VEGF leakage into intraperitoneal cavity, leading to ascites and abdominal distension --> presents 1-2wks after ovulation induction with abdominal distension + ascites, N/V, pleural effusions, and intravascular volume depletion --> treatment: correct electrolyte imbalances, paracentesis and/or thoracocentesis, and VTE prophylaxis --> complications: VTE, DIC, renal failure, and death)

28F presents with 1-day hx of RLQ pain that began intermittent associated with increased activity, but pain continued to increase and 1hr ago became constant, severe, and associated with N/V Vitals: afebrile, BP 130/80, HR 98 PE: tenderness to palpation over RLQ Labs: negative b-hCG

Ovarian torsion (rotation of ovary around infundibulopelvic ligament causing ovarian vessel occlusion and eventual ovarian ischemia --> risk factors: ovarian cyst/mass, women of reproductive age, and infertility tx with ovulation induction --> presents initially with unilateral intermittent pelvic pain associated with activity that progresses to sudden-onset severe non-radiating pain + nausea/vomiting --> diagnosis: Dopper US shows adnexal mass with absent flow to ovary --> treatment: laparoscopy with detorsion, ovarian cystectomy, or oophorectomy if necrosis or malignancy)

36yo F presents with several month hx of fatigue, 22lb weight loss, anorexia, abdominal pain, and intermittent vomiting/diarrhea Vitals: BP 90/50, HR 108 PE: mild diffuse abdominal tenderness Labs: elevated eosinophils, low Na+, and low glucose

PAI (primary adrenal insufficiency: autoimmune destruction of all 3 layers of adrenal cortex, causing deficiency in aldosterone + glucocorticoids + androgens --> presents with TRIAD of hyponatremia, hypoglycemia, and peripheral eosinophilia --> treatment: hydrocortisone or dexamethasone + fludrocortisone --> complication: acute adrenal crisis presenting with severe hypotension + shock refractory to fluids and vasopressors)

Alveolar gas equation

PAO2 = 150 - (PaCO2 * 1.25)

How can you reverse warfarin anticoagulation for patients with INR >2?

PCC and IV vitamin K (PCC: prothrombin complex concentrate containing vitamin K-dependent cofactors 2, 7, 9, 10 with small amounts of protein C + S --> IV vitamin K: provide substrate for synthesis of new vitamin K-dependent clotting factors by liver)

Best next step in management for patient with diagnosed STEMI

PCI (percutaneous coronary intervention: cath lab clot removal and stenting with bare metal or drug-eluting stents, needs to occur within 90min of symptom onset --> if unavailable within 90mins, give IV tPA --> if adequate flow not established via PCI, refer for emergency CABG)

26F with PMHx of SLE on cyclophosphamide + prednisone 40 presents with 1wk hx of fever, chills, DOE, nonproductive cough, and fatigue Vitals: febrile 100.9F, BP 140/80, HR 112, RR 24, SaO2 86% on RA PE: use of accessory muscles to breathe, bilateral crackles, and trace peripheral edema in LE Labs: elevated WBC and elevated LDH CXR: bilateral interstitial infiltrates

PCP (Pneumocystis pneumonia: opportunistic infection of yeast-like fungus occurring in patients with untreated AIDS with CD4 <200 or chronic steroid therapy --> presents with fever/chills, dry cough, DOE, hypoxia with respiratory acidosis, and HIGH LDH --> CXR: diffuse bilateral reticulonodular infiltrates --> CT chest: diffuse bilateral ground-glass opacities with pneumatoceles --> diagnosis: induced sputum/BAL positive stained with methenamine silver shows disc-shaped yeast --> treatment: 21-day course of Bactrim, add steroids if pt has PaO2 <70 or A-a gradient >35 or SaO2 <92% on RA, and DELAY initiation of antiretrovirals by 1-2wks to prevent immune reconstitution syndrome --> prevention: TMP-SMX prophylaxis for pts on chronic steroid therapy or CD4 <200)

Which pneumococcal vaccine induces a T-cell dependent B-cell response?

PCV13 (pneumococcal CONJUGATE vaccine: consists of 13 capsular polysaccharides covalently ATTACHED to inactivated diphtheria toxin --> polysaccharide-protein conjugate then induces T-cell dependent B-cell response resulting in higher-affinity antibodies and memory cells leading to improved immunogenicity --> recommended for all infants and young children)

6-month-old girl presents with 2-mo hx of poor feeding, labored breathing, and recurrent respiratory tract infections PE: to-and-fro murmur in 2nd left intercostal space, loud S2, bounding peripheral pulses, and widended pulse pressure

PDA (patent ductus arteriosus: intact DA which connects pulmonary artery to descending aorta, becomes left-to-right shunt at birth due to decreased pulmonary vascular resistance, leading to progressive RV hypertophy and/or LVH and CHF --> causes: prematurity and congenital rubella --> presents with continuous "to and fro" machine-like murmur best heard at left infraclavicular area/pulmonic area, loud S2, bounding peripheral pulses, wide pulse pressure, and "differential cyanosis" in LE --> treatment: indomethacin to close PDA, or surgery)

Differential diagnosis for anterior knee pain

PFPS, Osgood-Schlatter disease, and prepatellar bursitis (PFPS: presents in young female athletes with anterior knee pain + quadriceps atrophy --> Osgood-Schlatter disease/traction apophysitis: presents in athletic teen boys with anterior knee pain + tender tibial tubercle --> prepatellar bursitis: presents in carpenters/plumbers with inferoanterior knee pain + tenderness + bogginess)

3 common causes of UE DVT

PICC line, thoracic outlet obstruction, and young athletic male

5-month-old boy born at 39wks via "natural home birth" presents with 2-day hx of projectile vomiting, diarrhea, and 1 seizure episode PE: wt/ht/head circumference at 10th percentile, fair hair and skin, blue eyes, eczematous rash, mild dehydration, and urine with musty odor

PKU (phenylketonuria: autosomal recessive disorder caused by mutation in phenylalanine hydroxylase, resulting in inability to convert phenylalanine into tyrosine leading to accumulation of phenylalanine and its neurotoxic byproducts --> presents in NEWBORNS <1yo with severe intellectual disability, seizures, musty body/urine odor, fair complexion, blue eyes, and hypopigmentatiof brain nuclei --> diagnosis: quantitative AA analysis shows elevated phenylalanine --> prevention: newborn screening test with tandem mass spec of dried blood spots --> treatment: low phenylalanine diet with avoidance of high-protein foods)

Screening tests for Cushing syndrome

PM cortisol, 24hr urine free cortisol, and low-dose dexamethasone suppression test (positive screening for Cushing syndrome: elevated urine cortisol, elevated PM salivary cortisol, and INADEQUATE suppression on low-dose dexamethasone suppression test --> after positive screening, need to measure ACTH level)

54yo M with PMH of alcoholism presents with 2wk hx of progressively labored breathing and epigastric pain Vitals: low SaO2 PE: decreased left-sided breath sounds with dullness to percussion and tender epigastrium CXR: large left-sided pleural effusion Thoracocentesis: exudative pleural fluid with elevated amlyase

PPF (pancreaticopleural fistula: disruption of pancreatic ducts resulting in leakage of pancreatic digestive enzymes into pleural/peritoneal cavities --> caused by chronic pancreatitis --> presents with dyspnea, cough, dysphagia, chest pain, and epigastric pain --> diagnosis: amylase-rich exudative pleural effusion --> treatment: bowel rest, and eventual ERCP with sphincterotomy and/or stent placement)

Neonatal CXR: clear lungs with decreased pulmonary vascularity

PPH (persistent pulmonary HTN: high pulmonary vascular resistance due to failure of pulmonary vasodilation, resulting in R-to-L shunting of deoxygenated blood thru foramen ovale and PDA, resulting in hypoxia --> presents in FULL-TERM NEONATES with tachypnea and severe cyanosis --> diagnosis: CXR shows clear lungs with decreased pulmonary vasculature, ECHO shows right-to-left shunt)

Complications of polyhydramnios (AFI >24cm)

PPROM, preterm labor, fetal malposition, and umbilical cord prolapse

Which pneumococcal vaccine induces a T-cell independent B-cell response?

PPSV23 (pneumococcal POLYSACCHARIDE vaccine: consists of 23 capsular polysaccharide that are UNATTACHED to toxins, therefore cannot be presented to T cells --> induces relatively T-cell independent B-cell response that is less effective in young children + elderly --> recommended in adults age <65yo with alcoholism, smoking, diabetes, CAD, lung disease, and cirrhosis)

Liver biopsy: fibrous obliteration of small bile ducts with concentric replacement by CT in onion-skin pattern

PSC (primary sclerosing cholangitis)

16yo M with recent hx of sore throat presents with right neck pain and earache Vitals: febrile 102F, tachy to 104 PE: enlarged tender cervical LAD, pooling of saliva in oral cavity, large right tonsil with swelling of right soft palate, and deviation of uvula to left

PTA (peritonsillar abscess/quinsy: acute group A strep bacterial infection of region between tonsil and pharyngeal muscles caused by persistent tonsillitis/pharyngitis progressing to cellulitis/phlegmon --> presents in TEENAGERS and YOUNG ADULTS with high fever, sore throat/dysphagia, earache, trismus, muffled "hot potato" voice, and swelling of peritonsillar tissues with purulent discharge and deviation of uvula to CONTRALATERAL side --> treatment: needle aspiration or I&D + IV antibiotics --> complications: airway compromise, aspiration pneumonitis, lung abscess, hemorrhage 2/2 septic necrosis into carotid sheath, posterior mediastinitis, and rheumatic fever/PSGN)

Causes of gastric outlet obstruction

PUD, cancer, Crohn disease, pyloric stricture, and gastric bezoars

50M with PMHx of mechanical AVR 5yrs ago (on warfarin) presents with new-onset 2/6 diastolic murmur at LUSB best appreciated by breath-hold at expiration Labs: INR 2.9

PVD (prosthetic valve dysfunction: 1st type of PVD is paravalvular leak aka regurgitation around valve resulting from dehiscence of valve from aortic/mitral annulus --> 2nd type of PVD is transvalvular regurgitation aka regurgitation thru valve resulting from cusp degeneration or valvular thrombus impairing valve closure --> presents with new-onset regurgitant murmur, MAHA, CHF symptoms, and VTE --> diagnosis: ECHO shows valve and surrounding anatomy)

Diagnosis of urinary retention

PVR >150ml in women and >50mL in men

Indications for addition of steroids to Bactrim for severe PCP pneumonia

PaO2 <70, A-a gradient >35, or SaO2 <92% on RA (indicates severe inflammatory response within lungs causing large right-to-left intrapulmonary shunting --> requires steroids and supplemental O2)

65M with PMHx of HTN presents with several months of constant left thigh pain PE: mildly antalgic gait Labs: elevated AlkPhos XR: cortical thickening in left femur Bone scintigraphy: increased radiotracer uptake in several spots, including left femur

Paget disease of bone (bone disorder caused by abnormal osteoclast activity, leading to increased bone turnover and disordered bone remodeling and resulting in focal enlargement + weakness + fracture of bone --> commonly involves skull, spine, and long bones --> presents in OLDER ADULTS with focal bone pain, bowing of long bones, pathologic fractures, arthritis of adjacent joints, frontal bossing, headaches, increased hat size, hearing loss, spinal stenosis, and radiculopathy --> labs: isolated elevated AlkPhos, elevated PINP/urine hydroxyproline, and NORMAL Ca2+ and phos --> diagnosis: XR shows osteolytic or mixed lytic/sclerotic lesions, bone scan shows focally increased radiotracer uptake --> treatment: bisphosphonates --> complications: osteosarcoma and giant cell tumor of bone)

70F presents with 2-mo hx of peeling, scaling, and cracking of right nipple PE: normal breast exam Mammogram: no masses or calcifications

Paget disease of breast (extension of underlying DCIS/invasive breast cancer up the lactiferous ducts and into contiguous skin of nipple --> presents with eczematous scaly red pruritic patches over nipple + areolar skin, nipple retraction, and sometimes ulceration --> diagnosis: clinical, biopsy shows Paget cells aka intraepithelial adenocarcinoma cells)

Indications for ankle XR

Pain at malleolar zone AND tender posterior margin/tip of medial or lateral malleolus OR unable to bear weight on 4 steps

Indications for foot XR

Pain at midfoot zone AND tender at navicular/5th metatarsal base OR unable to bear weight on 4 steps

What are two clinical signs of acute HIV infection?

Painful oral ulcerations and pink oval macular rash

Diagnosis of cervical insufficiency

Painless cervical dilation, cervix <2.5cm on US, and 2+ consecutive painless 2nd trimester losses (tx: placement of cervical cerclage at 12-14wks --> removed at 37wks or at delivery)

19M with PMHx of mountain bike fall 3 days ago with negative trauma workup presents now with persistent upper abdominal discomfort and nausea and 1 episode of non-bilious emesis Vitals: febrile 100.6F, BP 104/62, HR 108 PE: upper abdominal ecchymosis and tenderness with voluntary guarding, and decreased BS Bedside US: large amount of free fluid in upper abdomen

Pancreatic duct injury (occurs when blunt abdominal trauma rapidly compresses fixed retroperitoneal pancreas against vertebral column, resulting in leakage of inflammatory pancreatic juice and peripancreatic fluid accumulation --> presents with INITIAL NEGATIVE CT SCAN, low-grade fever, persistent abdominal discomfort, nausea/vomiting, increasing amylase over serial measurements, and peripancreatic fluid collection --> diagnosis: ERCP --> treatment: surgery)

Cause of normal D-xylose test (high urinary D-xylose)

Pancreatic insufficiency (due to normal small intestinal absorption)

CT abdomen: round, well-circumscribed, encapsulated fluid collection within pancreatic bed

Pancreatic pseudocyst (mature walled-off pancreatic fluid collection surrounded by thick fibrous capsule and contains enzyme-rich fluid/tissue/debris, which leaks amylase-rich fluid into circulation --> usually asymptomatic, but can present with abdominal pain/distension and nausea/vomiting --> diagnosis: abdominal CT --> treatment: ERCP drainage ONLY for symptomatic patients, infection, or evidence of pseudoaneurysm --> complications: spontaneous infection, duodenal or CBD obstruction, pseudoaneurysm, pancreatic ascites, and pleural effusion

Abdominal CT: parenchymal enhancement of pancreas, pseudocyst formation, or peripancreatic fluid collection

Pancreatitis

Side effects of mycopheonlate

Pancytopenia, HTN, hyperglycemia, and GI upset (less nephrotoxic and neurotoxic than tacrolimus/cyclosporine)

Screening guidelines for cervical cancer

Pap smear every 3yrs for women age 21-65 (alternative: pap smear + HPV cotesting every 5yrs for women age 30-65)

Screening guidelines for cervical cancer in patients with HIV

Pap smear yearly for CD4 >200 and every 6mo for CD4 <200

Management of CIN 2/3 s/p hysterectomy

Pap smears annually for 20 years (used to detect vaginal recurrence)

45M PPD#5 s/p cardiac catheterization for RCA STEMI presents with SOB and chest discomfort PE: crackles in all lung fields and new holosystolic murmur ECHO: severe MR with flail leaflet

Papillary muscle rupture (mechanical complication of RCA MI, usually affecting posteromedial papillary muscle of mitral valve supplied by RCA --> occurs acutely or within 3-5 days of MI --> presents with severe left-sided HF with pulmonary edema and new holosystolic murmur --> diagnosis: ECHO shows severe MR with flail leaflet)

Which conditions are associated with MEN2A disease?

Parathyroid adenoma, pheochromocytoma, and medullary thyroid carcinoma (MEN2A: associated with RET mutation)

Which type of PVD is more commonly seen in mechanical valves?

Paravalvular leak (regurgitation AROUND valve: caused by dehiscence of valve from aortic/mitral annulus, often due to annular degeneration or underlying IE --> presents with new-onset regurgitant murmur)

Management of menopausal symptoms for women with contraindication to estrogen (breast cancer, endometrial cancer, VTE, CAD, and liver disease)

Paroxetine (SSRI that is well-tolerated and used to treat vasomotor symptoms --> if pt fails paroxetine tx or on tamoxifen, 2nd line tx is clonidine or gabapentin)

62yo F with PMH of HTN, T2DM, ESRD on dialysis presents with right knee pain and swelling after falling on knee while walking up stairs, hearing a popping sound when she fell Vitals: BP 162/97, BMI 52 PE: right knee with large effusion and bruising over anterior aspect, midline patella, and limited ROM and straight leg raise Knee XR: high-riding patella

Patella tendon rupture (caused by sudden forceful contraction of quadriceps in deceleration from a fall, often seen in patients with tendinous fragility such as CKD/exposure to fluoroquinolone antibiotics --> presents with audible pop, rapid knee pain and swelling, midline or LATERAL patella, and inability to support weight/activity extend knee against gravity --> diagnosis: knee XR shows high-riding patella pulled proximal to femoral condyles --> treatment: surgery)

Knee XR: high-riding patella pulled proximally to femoral condyles

Patella tendon rupture (occurs DISTAL to patella --> patella rides HIGH with palpable defect BELOW patella)

14yo F presents with acute right knee pain after dismounting from balance beam, landing awkwardly on ground, hearing an audible pop, and being unable to straighten her knee since. PE: flexed right knee with decreased ROM and significant swelling/tenderness over medial side, large painful immobile deformity of lateral knee, palpable divot over trochlea, and minimal pain over tibial tuberosity

Patellar dislocation (caused by quick lateral movements on FLEXED knee and seen in young athletes, dances, and military trainees --> usually causes LATERAL displacement with associated tear of medial patellofemoral ligament --> presents with audible pop with knee giving away, FLEXED knee with reduced ROM, LATERAL displacement of patella out of trochlea, palpable depression at anterior knee, and hemarthrosis/tenderness along MEDIAL patella --> treatment: closed reduction, splinting, and rehab)

Differential diagnosis for inferior knee pain

Patellar tendinitis, prepatellar bursitis (patellar tendinitis: presents in basketball players/jumping sports with moderately localized pain at + below patella and tenderness at inferior margin of patella --> prepatellar bursitis: presents in carpenters/plumbers with inferoanterior knee pain + tenderness + bogginess)

17yo F presents with 3mo hx of poorly localized, achy pain at anterior right knee that worsens when she runs, sits for a long time, or goes up/down staircase. Also feels sensation that knee is "giving way" when running. PE: mild pain with flexion of right knee, and reproducible pain when knee extended and patella compressed into trochlear groove

Patellofemoral pain syndrome (PFPS: chronic overuse injury often causing chronic knee pain in YOUNG WOMEN --> presents with localized ANTERIOR KNEE PAIN that worsens when running/sitting/squatting/going up or down stairs, atrophy/weakness of quadriceps, and rotational or varus/valgus misalignment --> diagnosis: patellofemoral compression test aka reproducing pain when patella compressed into trochlear groove, OR reproducible pain during tonic contraction of quadriceps with knee flexed --> treatment: activity modification, NSAIDs, and quadriceps strengthening exercises)

Best next step in management after pregnant woman dx with high titers of anti-D, anti-Kell, or anti-Duffy antibodies

Paternal antigen testing (need to determine if father is positive for Kell to determine if fetus is at risk --> if father is positive, test fetal blood for Kell antibodies via cell-free DNA --> if fetus is positive, treat mother with IVIG or plasmapharesis)

Measure of resistance to air flow from ventilator

Peak pressure

ECG signs of hyperkalemia

Peaked T waves, short QT interval, QRS widening, and sine wave with VFib

5yo boy with PMHx of hereditary hemorrhagic telangiectasia presents with 2hr hx of confusion and weakness after developing a severe HA + vomiting during a shopping trip Vitals: afebrile, BP 140/90 PE: somnolent boy withdrawing from painful stimuli, left-sided weakness, and few telangiectasias along lips and tongue

Pediatric hemorrhagic stroke (usually caused by rupture of underlying vascular malformation such as AVM or aneurysm, but also related to hematologic abnormalities such as hemophilia/SCD --> risk factors: HHT/Osler-Weber-Rendu syndrome --> presents with sudden onset headache, vomiting, HTN, altered mental status, seizures, and focal neuro deficits --> diagnosis: head CT shows intraparenchymal bleed aka hyperdense fluid collection with irregular margins within cerebral cortex)

Best next step in management for primary amenorrhea (girl >13yo with absent menarche and no 2° sexual characteristics OR girl >15yo with 2° sexual characteristics but absent menarche)

Pelvic US (need to confirm presence of uterus --> if PRESENT UTERUS, proceed with FSH level --> if ABSENT UTERUS, proceed with karyotype analysis)

Strongest risk factor for uterine sarcoma

Pelvic radiation therapy

Skin biopsy: intraepidermal blisters with reticular IgG around epidermal cells

Pemphigus vulgaris

55M presents with 3wk hx of painful mouth ulcerations and diffuse onset of large, painful blisters on trunk + extremities PE: oral mucosa with several erosions/ulcerations, scattered large erosions a few flaccid bullae on trunk + extremities, and light rubbing of uninvolved skin causes easy sesparation of epidermis Punch biopsy: intercellular deposits of IgG

Pemphigus vulgaris (autoimmune disorder caused by anti-desmoglein 1/3 antibodies causing impaired adherence between epidermal keratinocytes --> presents with painful flaccid bullae/ulcers, mucosal erosions, and positive Nikolsky sign --> diagnosis: biopsy shows intraepithelial cleavage with acantholysis/detached keratinocytes, "tombstone cells" along basal layer, netlike "chicken wire" pattern of intercellular IgG and C3 deposits, and positive anti-desmoglein antibodies --> treatment: steroids and aggressive wound care)

Management of children with sickle cell disease

Penicillin until age 5 and folic acid

34yo M presents with 2hr hx of severe, sudden-onset penile pain after sexual intercourse in which he heard cracking sound, followed by pain + rapid loss of erection + inability to urinate PE: swollen and ecchymotic penis

Penile fracture (rupture of fibrous tunica albuginea caused by blunt trauma to erect penis --> presents with snapping sound and sudden-onset pain, rapid penile detumescence, and penile shaft hematoma --> treatment: surgical repair --> complication: urethral injury associated with blood at meatus, hematuria, dysuria, and urinary retention)

Indications for sigmoid resection with diverticulitis

Perforation with peritonitis, obstruction, fistula, or recurrent attacks

46yo M presents with 2-day hx of worsening anal pain and anal pruritus Vitals: febrile 100.4°F PE: erythematous and tender 1cm fluctuant mass near anal orifice with induration of overlaying skin

Perianal abscess (caused by occlusion of anal crypt gland, which allows high levels of bacteria to infect and form abscess --> risk factors: anoreceptive intercourse and constipation --> presents initially with pain on defecation and mild pruritus, and eventually progresses to constant pain with indurated erythematous fluctuant mass near anal orifice --> management: I&D --> complication: anorectal fistulae aka communication between abscess and perirectal skin/nearby organs)

ECG: sinus tachycardia with beat-to-beat variation in QRS axis and amplitude

Pericardial effusion (caused by pericardial inflammation leading to extra fluid in pericardial cavity, resulting in compression of cardiac chambers and limiting diastolic filling of right-sided chambers --> results in decreased preload and decreased CO --> presents with hypotension, tachycardia, syncope, distended neck veins, pulsus paradoxus aka loss of radial pulse on inspiration, and muffled heart sounds --> ECG: electrical alterans with sinus tachycardia or low-voltage QRS complexes --> diagnosis: echo --> treatment: emergency pericardiocentesis)

CXR: enlarged globular cardiac silhouette with "water bottle" heart shape

Pericardial effusion (fluid within pericardial space caused by recent viral illness, bacterial/fungal infection, neoplasms, post-MI, trauma, uremia, autoimmune disease, and hypothyroidism --> presents with SOB, clear lung fields, non-palpable point of maximal impulse, and possible development of early cardiac tamponade with Beck's triad of hypotension + elevated JVP + muffled heart sounds --> diagnosis: CXR shows "water bottle"-shaped heart with enlarged globular cardiac silhouette --> treatment: pericardiocentesis)

Chest auscultation: diastolic sound with squeaking quality best heard at left sternal border that persists during breath-holding

Pericardial friction rub (clinical sign of pericarditis)

ECHO: thickened pericardium with loculated pericardial effusion

Pericarditis (inflammation of pericardium caused by viral/bacterial infection such as coxsackievirus B, neoplasia, SLE, RA, uremia, acute STEMI/Dressler syndrome, or radiation therapy --> presents with sharp chest pain aggravated by inspiration + relieved by sitting up/leaning forward and friction rub --> ECG: widespread ST-elevation and/or PR depression --> diagnosis: echo shows pericardial thickening and loculated effusion --> treatment: NSAIDs, colchicine, and/or steroids)

Dilation of vasculature of junction of sclera and cornea

Perilimbal injection (ciliary flush: associated with inflammatory and infectious eye conditions such as anterior uveitis, endophthalmitis, and keratitis)

34M with PMHx of concussion after bike collision 4mo ago presents with 3mo hx of right-sided hearing loss and intermittent episodes of spinning sensation accompanied by nausea that resolve after 1 min, usually occurring while lifting weights/riding elevator/sneezing PE: nystagmus and symptom reproducibility during Valsava

Perilymphatic fistula (complication of head injury/barotrauma that causes leakage of endolymph from semicircular canals + cochlea into surrounding tissues --> presents with progressive sensorineural hearing loss and episodic vertigo with nystagmus during inner ear pressure changes such as Valsava, eleavtion changes, sneezing --> diagnosis: Tullio phenomenon, aka performing loud clap near patient's ear and observing for nystagmus --> treatment: ENT referral)

Triad of trichinellosis

Periorbital edema, myositis, and eosinophilia

Pregnant woman >36wks presents with acute onset dyspnea on exertion and orthopnea PE: positive JVP, bilateral crackles, and bilateral pitting edema in LE

Peripartum cardiomyopathy (PPCM: causes rapid-onset systolic CHF at >36wks gestation or early puerperium)

Diagnostic para: - Color: turbid - Normal amylase - High protein - Low SAAG - High PMNs (>250) and high LDH - Low glucose

Peritonitis (caused by intestinal perforation, iatrogenic, or SBP from liver disease --> high protein due to normal albumin synthesis, low SAAG due to lack of portal HTN --> presence of high PMNs and LDH + low glucose indicates bacterial infection)

28F with PMHx of IVDU presents with 2wk hx of weakness and anorexia and recent episode of syncope Vitals: febrile 100.8F, BP 112/58, HR 49 PE: dry oral mucosa with poor dentition, early diastolic murmur best heard at LUSB at full expiration, and needle track marks on right arm ECG: 2:1 2nd degree AV block Labs: elevated WBC, low Hgb

Perivalvular absces (occurs in 30-40% of patients with infective endocarditis and usually associated with AORTIC VALVE IE with periannular extension of infection into adjacent cardiac conduction pathways --> presents with fever, malaise, SYNCOPE, early diastolic murmur best heard at RUSB, and cardiac conduction abnormalities such as AV block --> treatment: surgical repair)

58M with PMHx of vitiligo presents with 2-mo hx of exertional SOB and easy fatigability PE: conjunctival pallor, areas of depigmentation on arms, and shiny tongue Labs: low Hgb and high MCV

Pernicious anemia (leading cause of vitamin B12 deficiency due to anti-IF antibodies, resulting in impaired vitamin B12 absorption --> risk factors: MIDDLE-AGED/ELDERLY adults with other autoimmune diseases such as vitiligo/thyroid disorder --> presents with macrocytic anemia and glossitis --> diagnosis: detection of anti-IF antibodies and EGD to rule out gastric cancer --> treatment: vitamin B12 supplementation)

Definition of prolonged postop ileus (PPI)

Persistent ileus >3-5 days postop

Diagnosis of pertussis

Pertussis culture, PCR, and lymphocyte-predominant leukocytosis

Differential diagnosis for medial knee pain

Pes anserine bursitis, MCL sprain, and medial meniscal tear (pes anserine bursitis: presents with medial pain + point tenderness at pes anserine bursa --> MCL sprain: presents with abnormal passive abduction/valgus laxity with medial space widening of tibia --> medial meniscal tear: presents with pain + "popping" on EXTERNAL rotation of tibia/foot)

34yo M presents with pain and penile curvature during erections PE: palpable plaque on dorsal side of penis halfway between glans and pubis

Peyronie disease (formation of fibrous plaques in tunica albuginea due to repetitive blunt trauma to penis during sexual intercourse, resulting in aberrant wound healing + upregulation of TGF-1 + reduction of tissue elasticity and expansion during erections --> presents with penile pain + curvature during erections and nodules/plaques on DORSAL side of penis --> treatment: NSAIDs, petoxifylline, and/or intralesional injections of collagenase)

Which drug overdoses are treated with sodium bicarbonate?

Phenobarbital, methotrexate, ASA, and TCA (weak acids include phenobarbital + MTX + ASA: in overdoses they become trapped in basic environments, therefore sodium bicarb used to alkalinize urine --> TCA: sodium bicarb used to overcome Na+-channel blocking activity, but need to use ammonium chloride to acidify urine)

Treatment of tyramine-associated hypertensive crisis

Phentolamine

74F with PMHx of HTN, T2DM, and seizures controlled with phenytoin presents with several days of worsening weakness + unsteadiness + 1 fall. Recently dx with UTI with sx improved after taking Bactrim. PE: bilateral nystagmus on lateral gaze, increased DTRs, dysmetria on finger-to-nose testing, and wide-based gait

Phenytoin toxicity (caused by dose adjustments, CKD, hepatic dysfunction, and medications inhibiting CYP450 system such as SICKFACES.COM: sodium valproate, INH, cimetidine, ketoconazole, fluconazole, alcohol abuse, chloramphenicol, erythromycin, sulfonamides, ciprofloxacin, omeprazole, metronidazole, amiodarone, grapefruit juice --> presents with cerebellar dysfunction including horizontal nystagmus, ataxia, dysmetria, slurred speech, N/V, and hyperreflexia --> treatment: supportive care with NG decontamination and possible HD)

Which medications are associated with megaloblastic anemia?

Phenytoin, MTX, TMP, pyrimethamine, and hydroxyurea (phenytoin: due to impaired absorption of folate from jejunum --> MTX, TMP, and pyrimethamine: inhibits DHFR to inhibit pyrimidine synthesis --> hydroxyurea: inhibits ribonucleotide reductase to inhibit DNA synthesis)

Which medications are most commonly associated with vitamin D deficiency?

Phenytoin, carbamazepine, and rifampin

Which conditions are associated with MEN2B disease?

Pheochromocytoma, medullary thyroid carcinoma, marfanoid habitus, and mucosal neuromas

Management of Sjogren syndrome

Pilocarpine, artificial tears, and NSAIDs (pilocarpine: cholinomimetic agent that is potent stimulator of sweat + tears + saliva --> artificial tears: keeps eyes moist --> NSAIDs: to treat arthralgias/arthritis, may need to add prednisone)

25M with PMHx of obesity presents with pain over intergluteal region and intermittent swelling with mucoid discharge that is sometimes blood-tinged PE: tender mass near tip of coccyx that drains mucoid fluid with pressure

Pilonidal disease (occlusion of edematous, infected hair follicle in intergluteal region with spreading of infection SQ, resulting in abscess and possible rupture creating pilonidal sinus tract --> hair/debris forced into sinus tract as patient sits/stands, resulting in recurrent infections and foreign-body reactions --> presents in YOUNG OBESE MALES with painful fluctuant mass above anus with associated mucoid/purulent/bloody discharge that worsens with intergluteal skin stretching --> treatment: abscess drain and excision of sinus tract)

10yo boy presents with 2wks hx of persistent headache, vomiting, and visual disturbances PE: bilateral retraction of upper eyelids, limited upward gaze with preference for downward gaze, and sluggishly reactive pupils to light

Pinealoma (germ cell tumor arising from pineal gland located in quadrigeminal cistern and causes mass effect on dorsal midbrain, resulting in pressure on pretectal region of midbrain near superior colliculus and CN3 aka Parinaud syndrome --> presents in CHILDREN age 1-12yo with limited upward gaze, light-near dissociation in which pupils react to accommodation but not light, and bilateral upper eyelid reaction aka Collier sign --> complication: obstructive hydrocephalus with headache + vomiting + papilledema + ataxia)

6yo F presents with several month hx of vision difficulties and morning headaches with occasional N/V PE: limited upward gaze, eyelid retraction, and papilledema

Pinealoma (tumor of pineal gland that compresses both tectum and cerebral aqueduct --> presents with Parinaud syndrome aka vertical gaze palsy, light-near dissociation, eyelid retraction, obstructive hydrocephalus, and precocious puberty in males due to hCG production)

Key finding in pontine stroke

Pinpoint reactive pupils (due to damage to descending SNS tract --> also associated with coma and total paralysis)

7yo M presents with 1-month hx of anal pruritus that worsens at night after a camping trip PE: mild perianal erythema with multiple excoriations

Pinworm infection (enterobiasis: common helminth infection caused by infection with nematode Enterobius vermicularis, transmitted via fecal-oral ingestion of eggs that mature to larvae in small intestine and then migrate thru rectum to deposit eggs in perianal region --> presents with NOCTURNAL perianal pruritus --> diagnosis: "scotch tape test" showing eggs on tape --> treatment: pyrantel pamoate or albendazole with tx for all household contacts)

Best next step in management for patient with: 1) Elevated 24hr urine free cortisol 2) Elevated ACTH 3) Adequate suppression with dexamethasone

Pituitary MRI (patient with high cortisol + ACTH and ADEQUATE suppression with dexamethasone indicates PITUITARY ADENOMA aka CUSHING DISEASE --> order pituitary MRI to evaluate tumor size)

Which conditions are associated with MEN1 disease?

Pituitary adenoma, pancreatic neuroendocrine tumors, and parathyroid adenomas (MEN1: associated with mutation in MEN1 gene --> can also see angiofibromas, collagenomas, and meningiomas)

36yo F with PMH of prolactinoma treated with cabergoline presents with acute onset of severe HA and vision disturbance, weakness, dizziness, and nausea Vitals: BP 80/50, HR 110 PE: mild ptosis and impaired adduction on right and bitemporal hemianopia

Pituitary apoplexy (sudden hemorrhage into enlarged pituitary adenoma caused by expanding mass outgrowing or compressing its blood supply, resulting in bleeding into sella turcica and compression of oculomotor nerves/optic chiasm --> presents with sudden onset severe HA, diplopia and/or bitemporal hemianopia, eye dysfunction, and adrenal crisis resulting in severe hypotension and hypoglycemia --> labs: hyponatremia, hyperkalemia, metabolic acidosis, low cortisol and aldosterone, and low ACTH --> treatment: rapid IV fluids and IV steroids)

Most important risk factor for placenta accreta

Placenta previa after prior C-section

54M with PMHx of T2DM presents with 1mo hx of progressively worsening pain and burning sensation on sole of left foot PE: tenderness to palpation between heel and forefoot when toes are dorsiflexed

Plantar fasciitis (overuse syndrome caused by inflammation and degeneration of plantar aponeurosis --> risk factors: pes planus, high-arched foot, obesity, working or exercising on hard surfaces --> presents in OBESE MIDDLE-AGED ADULTS with heel pain that worsens with long periods of standing/walking or during first steps of the day , and tenderness at bottom of heel when toes are dorsiflexed OR reproducible pain on palpation of medial plantar surface of heel --> workup: XR shows heel spurs, aka calcifications in proximal fascia --> treatment: activity modification, stretching, and padded heel inserts)

Heel pain on toe dorsiflexion

Plantar fasciitis (presents with heel pain when standing/walking and tenderness between heel + forefoot on dorsiflexion)

Measure of lung's ability to expand (compliance)

Plateau pressure

Signs of hepatopulmonary syndrome

Platypnea and orthodeoxia (platypnea: induced SOB in upright position --> orthodeoxia: hypoxia in upright position)

Which components are evaluated in FAST (Focused Assessment with Sonography for Trauma)?

Pleura, pericardium, flanks, and pelvis (pleura: look for PTX --> pericardium: look for hemopericardium and tamponade --> left/right flanks and pelvis: look for intraperitoneal free fluid)

Chest auscultation: squeaking sound best heard at lateral chest that disappears during breath-holding

Pleural friction rub (clinical sign of viral pleurisy: inflammation of parietal pleura due to viral infection from parainfluenza vivrus, RSV, adenovirus, and coxsackie --> presents following viral prodrome with pleuritic chest pain radiating to shoulder, shallow breathing + SOB, and pleural friction rub aka coarse grating sound that disappears during breath-holding --> treatment: supportive care and NSAIDs)

37M presents with 4-day hx of sore throat + headache + malaise and 2-day hx of fevers and sharp stabbing pain in right lateral chest that resolved after 1hr but has recurred 6x since Vitals: afebrile, BP 120/70, HR 80 PE: normal Labs: low WBC and elevated CK CXR and EKG: normal

Pleurodynia (viral inflammation of intercostal muscles usually caused by Coxsackie B, resulting in muscle necrosis --> presents with viral prodrome followed by sudden onset LANCINATING chest or abdominal pain --> diagnosis: elevated CK --> self-resolving after 1-2 days)

Mechanically ventilated patient presents with respiratory distress Mech vent: progressive hypoxemia, increased peak pressure, and increased plateau pressure

Pneumothorax (often occurs during mechanical ventilation due to PEEP causing pulmonary barotrauma, resulting in alveolar rupture and pneumothorax formation --> collapsed lung receives stable volume of air from ventilator, resulting in increased PEAK pressure and increased PLATEAU pressure)

Neonatal complications of maternal diabetes in 2nd and 3rd trimesters

Polycythemia, organomegaly, neonatal hypoglycemia, brachial plexopathy, clavicle fracture, perinatal asphyxia, and RDS (polycythemia: due to increased fetal metabolic demand leading to fetal hypoxemia and erythropoeisis --> organomegaly: due to excess insulin causing growth hormone effects --> neonatal hypoglycemia: due to sudden loss of hyperglycemic environment upon delivery --> brachial plexopathy + clavicle fracture + perinatal asphyxia: due to macrosomia leading to shoulder dystocia --> RDS: due to fetal hyperinsulinemia delaying cell maturation causing inability for fetal pneumocytes to produce surfactant)

Which glycogen storage disease is associated with severe cardiomegaly?

Pompe disease (type II glycogen storage disease: autosomal recessive deficiency in acid maltase/lysosomal acid alpha-1-4-glucosidase causing accumulation of glycogen in HEART, LIVER, and MUSCLE --> presents at 3-6 MONTHS with hypotonia, cardiomegaly, HOCM, and exercise intolerance)

Indications for intubation in hypercapnic patients

Poor mental status, hemodynamic instability, acidemia with pH <7.1, and failure of 2-hour NPPV trial

67M presents with 6-hr hx of severe pain in right foot PE: pale cool right foot with non-palpable pedal pulses and bilateral pulsatile masses in popliteal fossae

Popliteal artery aneurysm (most common peripheral artery aneurysm often associated with AAA, usually developing from disruption of atherosclerotic plaque in pts with pre-existing PAD and leads to acute limb ischemia --> presents with pulsatile mass in popliteal fossa and 6 Ps of acute limb ischemia: pain, pallor, paresthesia, pulselessness, poikilothermia aka cool extremity, and paralysis that occurs later --> diagnosis: arteriography with runoff --> treatment: heparin, thrombolysis, or surgery)

Which skin conditions are associated with hepatitis C?

Porphyria cutanea tarda, lichen planus, and cryoglobulinemic vasculitis (PCT: blistering cutaneous photosensitivity + hyperpigmentation and tea-colored urine --> lichen planus: presents with 5 Ps of pruritic purple polygonal papules/plaques --> cryoglobulinemic vasculitis: palpable purpura caused by cutaneous leukocytoclastic vasculitis)

What are the red flags associated with developmental dysplasia of hip (DDH)?

Positive Ortolani test, dislocated hip, and limited hip abduction (any of these red flags requires IMMEDIATE referral to orthopedic surgeon)

Which neuropathy symptoms are associated with SMALL NERVE FIBER injury?

Positive symptoms (includes burning + stabbing pain, allodynia, decreased pinprick sensation, and PRESERVED ankle reflexes)

46M with PMHx of left total nephrectomy after MVC 25yrs ago presents with generalized weakness and intermittent severe right flank pain and decreased urination, with occasional episodes of high UOP Vitals: BP 145/86, HR 86 Labs: low K+, high Cr UA: trace proteins

Post-obstructive diuresis (unilateral obstructive uropthy due to renal calculi causes mechanical obstruction to urine outflow, however obstruction is overcome by large volume of retained urine intermittently, leading to K+ wasting and dehydration --> presents with generalized weakness, unilateral flank pain, and poor urine output with intermittent episodes of high-volume urination --> diagnosis: hypokalemia and kidney US shows renal calculi/hydronephrosis)

Pain at distal amputation stump exacerbated by palpation or percussion

Post-traumatic neuroma (can occur after amputation due to regrowth of transected nerve fibers into tangled mass of unmyelinated nerve endings)

64yo M with PMH of BTK 3mo ago presents with intermittent burning pain with weight bearing on stump PE: slight bogginess over end of skin flap and reproducible pain that radiates up leg with gentle pressure over flap

Post-traumatic neuroma (transection of nerve fibers during amputation, which leads to inflammatory reaction and formation of tangled mass of unmyelinated nerve endings with decreased depolarization thresholds that cause pain signals spontaneously or in response to nonpainful stimuli --> presents WEEKS-MONTHS after amputation with focal burning pain/tenderness and altered local sensation that is worsened by focal pressure/palpation --> diagnosis: DECREASED pain with anesthetic injection --> treatment: excision of neuroma and TCAs)

Treatment of recurrent cystitis (>2 infections/6mo or >3 infections/1yr)

Postcoital antibiotics

Which test is used to diagnose PCL injury?

Posterior drawer test (patient supine with knee flexed 90°, should feel laxity when tibia pulled POSTERIORLY)

64M presents after high-speed MVC with severe pain and deformity of RLE PE: shortened and internally rotated right leg that is flexed and adducted, unable to dorsiflex or straight

Posterior hip dislocation (POSTERIOR displacement of femoral head with respect to acetabulum, usually caused by head-on MVCs in which knee strikes dashboard while hip is flexed and abducted --> often injures sciatic nerve, which branches into common fibular/peroneal and tibial nerves --> presents with SHORTENED INTERNALLY rotated leg, weak dorsiflexion, decreased ankle reflex, and decreased sensation)

Signs of child abuse on skeletal survey

Posterior rib fractures, skull fractures, metaphyseal corner fractures, and femur fractures in nonambulatory infant (also look for multiple fractures in various stages of healing)

Which structure is most commonly affected with midshaft fracture of humerus?

Radial nerve (C5-T1: radial nerve injury presents with wrist drop, decreased grip strength, and loss of sensation over posterior arm/forearm and dorsal hand)

45yo M presents after MVC with pain in lower abdomen and right groin and inability to move RLE PE: fullness in suprapubic region, adduction/flexion/internal rotation of RLE, bruising around scrotum and perineum, and blood at urethral meatus DRE: high-riding prostate

Posterior urethral injury (PUI: occurs in males with PELVIC FRACTURES due to abrupt upward shifting of bladder/prostate, leading to urethral tearing at bulbomembranous junction --> presents with pelvic fracture aka adducted and internally rotated RLE + perineal bruising, inability to void with suprapubic fullness, blood at urethral meatus, and high-riding prostate --> diagnosis: retrograde urethrography --> treatment: temporary suprapubic catheter and delayed urethral repair)

Fetal US: oligohydramnios, hypoplastic lungs, distended bladder, and enlarged fetal kidneys b/l with thin renal cortices

Posterior urethral valves (PUV: congenital disorder caused by abnormal persistent urethral folds resulting in bladder outlet obstruction in males --> diagnosis: fetal US shows bladder distension, hydronephrosis, and oligohydramnios --> complication: pulmonary hypoplasia, flat facies, limb deformities consistent with POTTER sequence)

When does postop atelectasis normally present?

Postop day 2-5

Urine labs: FENa >4% U-osm <50 UCr/PCr <20 UNa >40

Postrenal AKI

Treatment of tapeworms and flukes

Praziquantel (tapeworms/cestodes: Taenia solium causing cysticercosis and Diphyllobothrium latum causing vitamin B12 deficiency --> flukes/trematodes: Schistosoma causing liver inflammation + bladder SCC and Clonorchis sinesis causing gallstones)

Which medications are associated with priapism?

Prazosin, trazodone, sildenafil, methylphenidate, and cocaine (prazosin: alpha-1 antagonist --> trazodone: antidepressant that blocks serotonin, alpha-1, and histamine receptors --> sildenafil: PDE5 inhibitor --> stimulants: methylphenidate and cocaine --> treatment of priapism: corporal aspiration, intracavernosal phenylephrine, or surgical decompression)

Complications of maternal HTN during pregnancy

Pre-eclampsia, PPH, GDM, abruptio placentae, IUGR, preterm labor, and oligohydramnios

Best next step in management for patient with bilateral non-bloody nipple discharge

Pregnancy test, serum prolactin, and serum TSH (pregnancy test: rule out excess prolactin from pregnancy --> serum PRL: rule out prolactinoma --> serum TSH: rule out hypothyroidism)

5yo girl presents with dark hair under arms and in pubic area PE: wt at 97th percentile, mild facial acne, dark coarse hair across pubis and under axillae, and normal external genitalia Imaging: normal bone age

Premature adrenarche (early activation of adrenal androgens, usually due to obesity causing excess insulin production that stimulates adrenal glands to produce androgens --> presents in GIRLS <8yo and BOYS <9yo with body odor, oily skin + acne, pubic + axillary hair, and NORMAL BONE AGE --> no tx --> complications: PCOS, T2DM, and metabolic syndrome)

Indications for GBS prophylaxis in patient with unknown GBS status at onset of labor

Premature delivery <37wks, intrapartum fever, or PROM >18hrs

Risk factors for neonatal RDS

Prematurity <28wks, male sex, perinatal asphyxia, GDM, and C-section without labor

Patient who works as a house painter presents with inferior knee pain PE: bogginess and tenderness at inferoanterior aspect of knee

Prepatellar bursitis (housemaid's knee: inflammation of prepatellar bursa in front of knee cap caused by repeated trauma/pressure from excessive kneeling --> presents with INFERIOR knee pain, bogginess/tenderness at ANTERIOR aspect of knee, PAINFUL ACTIVE ROM but normal PASSIVE ROM --> diagnosis: knee XR shows swelling ANTERIOR to patella, and bursal fluid aspiration for cell count/gram stain/culture --> treatment: NSAIDs for non-infectious, drainage and systemic abx for infectious --> complication: 2° infection with Staph aureus)

Urine labs: FENa <1% U-osm >500 UCr/PCr >40 UNa <20

Prerenal AKI

6yo boy presents with 2-day hx of fevers and left lower eyelid redness + swelling with left eye swollen shut after mosquito bite Vitals: febrile 101F PE: erythematous edematous tender left lower eyelid, normal visual acuity, and normal EOMs Labs: leukocytosis

Preseptal cellulitis (mild infection of eyelid ANTERIOR to orbital septum caused by local trauma from insect bite/wound --> presents with fever, eyelid edema + erythema, chemosis, and NORMAL EOM --> treatment: oral doxycycline)

Complications of inadequate weight gain during pregnancy

Preterm delivery and low birth weight (preterm delivery: due to pts being unable to shunt enough nutrients to support fetus --> low birth weight: SGA infant <3rd percentile)

Complications of PPROM

Preterm labor, intraamniotic infection, placental abruption, and umbilical cord prolapse (due to these serious complications, PPROM requires inpatient management)

Complications of oligohydramnios (AFI <5cm)

Preterm labor, meconium aspiration, and umbilical cord compression

Where do venous stasis ulcers usually occur?

Pretibial area and above medial malleolus (caused by chronic LE edema and stasis dermatitis)

Most common cause of diuretic-induced hypokalemia

Primary hyperaldosteronism (presents with HTN, hypernatremia, hypokalemia, and metabolic alkalosis --> diagnosis: PAC/PRA >20 and aldosterone >15)

Labs: - High Ca2+ - Low phos - High PTH - High 24hr urine Ca2+ excretion

Primary hyperparathyroidism (PHPT: caused by parathyroid adenoma/hyperplasia with increased risk in MEN 1 + 2A --> usually asymptomatic or presents with abdominal pain/constipation, kidney stones, osteoporosis, neuropsych symptoms --> diagnosis: hypercalcemia with high PTH and high urine Ca2+ excretion --> treatment: parathyroidectomy for pts <50yo, symptomatic, osteoporosis, nephrolithiasis, CKD, Ca2+ >11.2, or urine Ca2+ excretion >400mg/day)

Causes of PTH-dependent hypercalcemia

Primary hyperparathyroidism, lithium, or familial hypocalciuric hypercalcemia

What are the indications for TB treatment for a patient with PPD induration size >5mm?

Recent TB exposure, CXR changes, and immunosuppression (recent TB exposure: recent contact of known TB case --> CXR changes: nodular of fibrotic changes --> immunosuppression: HIV, organ transplant, etc.)

Labs: - Hyponatremia - High urine osmolality (<400) after overnight fast - No response to desmopressin

Primary polydipsia (ADH-independent cause of polyuria + dilute urine due to excessive water intake --> causes: antipsychotics and psychiatric conditions --> presents with nocturia, dehydration, and HYPOnatremia --> diagnosis: HIGH urine osm >400 after water deprivation)

Indications for infective endocarditis prophylaxis

Prior IE, prosthetic heart valve, heart transplant with abnormal valve, and cyanotic CHD (before dental manipulation/respiratry tract incision: give amoxicillin for viridans strep coverage --> before GU/GI tract procedure in setting of ACTIVE infection: give ampicillin for Enterococcus coverage --> before surgery on infected skin/muscle AND before surgical placement of prosthetic cardiac material: give vancomycin for MRSA coverage)

Contraindications to oxytoxin use for labor

Prior classical C-section and fetal decelerations

Indications for low-dose aspirin at 12wks gestation for pre-eclampsia prevention

Prior pre-eclampsia, CKD, HTN, DM, multiple gestation, and autoimmune disease (considered high-risk for pre-eclampsia development --> prevention includes starting low-dose aspirin at 12wks gestation)

Management of patients with familial adenomatous polyposis (FAP)

Proctocolectomy with IPAA (proctocolectomy with ileal pouch anal anastomosis: surgical resection of colon with ileoanal reservoir)

Cause of increased basal body temperature after ovulation

Progesterone (increases after ovulation ~day 14 of menstrual cycle after LH surge --> predominant hormone in the luteal phase of the menstrual cycle)

Management of cancer-related anorexia/cachexia syndrome

Progesterone analogs (ex: megestrol acetate or medroxyprogesterone acetate --> used in palliation of anorexia and promoting weight gain --> 2nd line tx is steroids)

Diagnosis of prolactinoma

Prolactin >300

Anal exam: painless purplish mass protruding through anal verge

Prolapsed internal hemorrhoid (abnormal dilation of inferior hemorrhoidal plexus PROXIMAL to dentate line --> presents with itching, leakage of stool, and PAINLESS bleeding with purplish mass at anal verge --> diagnosis: DRE or anoscopy)

Which finding on JVP waveform is highly specific for tricuspid stenosis?

Prominent A wave (obstructed RV filling causes large atrial contraction --> results in flattened y descent and prominent A wave)

Which finding on JVP waveform is highly specific for tricuspid regurgitation?

Prominent V waves (due to incompetent tricuspid valve closure leading to sustained elevation in RA pressure during RV systole --> results in absent x descent and prominent V wave)

Which finding on JVP waveform is highly specific for constrictive pericarditis?

Prominent x and y descents (due to limited ability of RV to expand during ventricular systole, causing increased filling into RV)

Treatment of greenstick fracture

Prompt reduction and immobilization (aka cast placement --> need repeat XR prior to cast removal to confirm bony union --> NO long term complications)

Best next step in management for patient with recently dx non-bleeding esophageal varices

Propranolol (nonselective beta-blocker that reduces adrenergic tone in mesenteric arterioles, resulting in unopposed alpha vasoconstriction and decreased portal venous flow to reduce disease progression to large varices --> if contraindications to beta-blocker, treat with endoscopic variceal ligation)

Treatment of thyroid storm

Propranolol, PTU followed by SSKI, and hydrocortisone (propranolol: beta-blocker to block elevated SNS activity --> PTU followed by iodine solution SSKI: blocks T3/T4 hormone synthesis and release --> hydrocortisone: decreases peripheral T4 to T3 conversion and improves vasomotor stability)

Medications used for migraine prophylaxis

Propranolol, amitriptyline, topiramate, valproate, and verapamil (these meds should be used as PROPHYLAXIS for migraines --> indications for prophylaxis include 2+ uses of abortive meds/week or 2+ attacks per month that interfere with daily activities)

Which antivirals are associated with hyperglycemia and lipodystrophy?

Protease inhibitors (includes atazanavir, darunavir, indinavir, ritonavir, etc. --> prevent maturation of new HIV viruses --> side effects: hyperglycemia, lipodstrophy aka Cushing-like syndrome, and GI intolerance --> indinavir also associated with nephropathy, hematuria, and thrombocytopenia)

Cause of warfarin-induced skin necrosis

Protein C deficiency (also creates transient hypercoagulable state after initiation of warfarin --> treatment: cessation of warfarin and protein C concentrate)

Light criteria

Protein ratio >0.5, LDH ratio >0.6, and LDH >2/3 serum (causes of exudative pleural effusion: infection, cancer, CT disease, PE, pancreatitis, and post-CABG)

Colonoscopy: pale mucosa with ulcers, strictures, telangiectasias, and focal hemorrhage

Radiation proctitis (aka chronic radiation proctopathy: caused by radiation therapy within the first year --> presents with painful diarrhea, rectal bleeding, fecal incontinence, and excessive flatulence --> diagnosis: colonoscopy shows pale mucosa with TELANGIECTASIAS and ulcers/strictures)

Best next step in management for scrotal mass with scrotal US showing solid hypoechoic lesion

Radical inguinal orchiectomy (provides definitive treatment and confirms diagonsis)

74yo M with PMH of HTN and smoking presents with 1-day hx of acute onset constant, deep, dull back pain at L1-L4 levels Vitals: BP 140/90 PE: mild tenderness with deep palpation from epigastric to supraumbilical regions Spinal XR: prevertebral calcifications

Proximal AAA (proximal abdominal aortic aneurysm: proximal dilatation of aorta usually associated with atherosclerosis, which can markedly expand and rupture resulting in retroperitoneal hemorrhage --> risk factors: men age >60yo, smokers, and history of atherosclerosis or CT disease --> PROXIMAL anuerysms present with upper abdominal/flank/back pain --> DISTAL lesions present with lower abdominal/groin pain --> workup: XR shows prevertebral aortic calcifications --> diagnosis: abdominal CT if HDS, focused abdominal US if unstable)

Typical findings of Candida on wet mount with KOH prep

Pseudohyphae with budding yeast (aka blastoconidia --> Candida is characterized by PSEUDOHHYPHAE --> Aserpgillus + Mucor + dermatophytes have true hyphae)

32M with PMHx of obesity, chronic back pain, asthma, and GERD presents with acute onset of right eye pain + discharge this AM with difficulty removing contact lenses for last week PE: thick globular yellow discharge at medial eye corner, edematous hazy ulcerated cornea, and extensive scleral injection

Pseudomonal keratitis (contact lens-associated keratitis: caused by gram-negatives Pseudomonas and Serratia that form biofilm in contact lens solution --> presents with acute onset of painful red eye, corneal opacification + ulceration, and thick yellow globular discharge --> treatment: topical abx --> complications: corneal perforation, scarring, and permanent vision loss)

Most common pathogen causing CF-related pneumonia in adults

Pseudomonas (associated with precipitous decline in pulmonary function and increased risk of death)

Most common causes of infection in burn patients >5d since injury

Pseudomonas and Candida (after 5 days, consider GRAM-NEGATIVE SEPSIS in burn patients: CHANGE in wound appearance from partial-thickness to full-thickness injury, loss of viable skin graft, temp <97F or >102F, progressive tachycardia >90bpm, progressive tachypnea >30 RR, and refractory hypotension with SBP <90 --> other features: oliguria, unexplained hyperglycemia, thrombocytopenia, and mental status changes --> diagnosis: quantitative wound culture showing >10^5 bacteria and biopsy for histopathology --> treatment: Pip/Tazo or Carbapenem + vancomycin + aminoglycoside)

22yo M presents with several small pruritic skin pustules on LE after swimming in heated hotel pool 1wk ago

Pseudomonas folliculitis (hot tub folliculitis: skin infection with Pseudomonas caused by inadequately chlorinated swimming pool or hot tub --> presents within hours-few days after exposure with tender, pruritic papulopustular eruption and low-grade fever --> treatment: usually self-limited, but can prescripe oral cipro if lesions persist)

Patient with mild thrombocytopenia Peripheral smear: large clumps of platelets

Pseudothrombocytopenia (laboratory error caused by platelet aggregation in vitro due to incompletely mixed blood samples or presence of serum antibodies to EDTA --> presents with ASYMPTOMATIC mild thrombocytopenia --> diagnosis: peripheral smear shows large clumps of platelets --> treatment: drawing blood samples in tubes with non-EDTA anticoagulant such as heparin or sodium citrate)

40M with PMH of T1DM and recent tx for furunculosis of right thigh presents with 7-day hx of worsening RLQ pain that radiates to groin, fever, and decreased appetite Vitals: febrile 101.9F PE: tenderness to deep palpation on RLQ without rebound/guarding, and increased pain on right hip extension with decreased pain on flexion Labs: high WBCs

Psoas abscess (abscess formation in psoas muscle caused by hematologic seeding from distant skin infection or direct extension from intraabdominal infection such as diverticulitis or vertebral osteomyelitis --> risk factors: HIV, IV drug use, T1DM, and Crohn disease --> presents with subacute abdominal/flank pain that RADIATES TO GROIN, fever, anorexia, weight loss, and PSOAS SIGN aka abdominal pain with hip EXTENSION --> diagnosis: CT abdomen and pelvis --> treatment: drainage and broad-spectrum antibiotics)

Patient with fever, groin pain, and abdominal pain with hip EXTENSION

Psoas abscess (patient presents with positive psoas sign)

Which maneuvers help assess the deep abdominal spaces?

Psoas sign, obturator sign, and rectal exam (used to help diagnose appendicitis, especially in cases of contained appendiceal abscess)

Skin exam: nail pitting, oil spots, and separation of nail plate from nail bed of multiple nails in both hands

Psoriasis of nails (presents with nail pitting, oil spots, and onycholysis)

Patient appears euvolemic Labs: - Hyponatremia - Low serum osmolality (<275) - Low urine osmolality (<100)

Psychogenic polydipsia (excess free water intake causes dilutional hyponatremia with appropriately suppressed ADH secretion --> kidneys respond by excreting very dilute urine with urine osm <100)

Hyponatremia with urine osmolality <100

Psychogenic polydipsia (excessive thirst without underlying water deficit, resulting in excessive water intake that exceeds kidney's ability to excrete water --> presents with euvolemic hyponatremia and LOW URINE OSMOLALITY <100 --> treatment: fluid restriction)

Which eye condition is associated with chronic UV light exposure?

Pterygium (wedge-shaped proliferation of conjunctival tissue expanding from lateral aspects of eye toward cornea)

Diagnosis of precocious puberty

Puberty in girls <8 or boys <9 (pt with precocious puberty should then get bone age evaluation --> NORMAL bone age indicates premature puberty, either premature thelarche/adrenarche --> ADVANCED bone age with LOW LH/FSH indicates adrenal or GU tumor --> ADVANCED bone age with HIGH LH/FSH indicates CNS tumor)

Most common causes of isolated right-sided HF

Pulmonary HTN, RV infarct, tricuspid valve disease, Ebstein anomaly, constrictive pericarditis, and restrictive cardiomyopathy

Which anti-anginal medication is associated with reduced Ca2+ influx in ischemic cardiac myocytes?

Ranolazine (inhibits late phase of Na+ influx into ischemic cardiac myocytes, causing reduced Ca2+ influx leading to reduced ventricular wall stress and myocardial O2 demand --> used as "last resort" anginal therapy --> SE: constipation, dizziness, headache, nausea)

10yo M presents after MVC with bruising and severe pain over right chest, and progressive tachycardia and tachypnea over 6hrs Vitals: BP 110/66, HR 110, RR 24 PE: decreased breath sounds on right CXR: patchy, irregular alveolar infiltrates of peripheral RML and RLL

Pulmonary contusion (lung parenchymal bruising from transmitted kinetic energy that forms <24hrs after blunt thoracic trauma, causing pulmonary capillary damage and resulting in alveolar hemorrhage and airspace + interstitial edema --> presents with progressively worsening tachypnea, tachycardia, decreased breath sounds or rales, and hypoxia --> diagnosis: CXR shows unilateral diffuse interstitial infiltrates and/or patchy alveolar opacities NOT restricted by anatomical borders, chest CT shows NONLOBULAR patchy irregular alveolar infiltrates NOT restricted by anatomical borders and usually seen in ANTERIOR PERIPHERAL lung --> treatment: pain control, supplemental O2/ventilation, IS, and chest PT/pulmonary toilet)

CXR: patchy, irregular alveolar infiltrates located in anterior peripheral lung not restricted by anatomical borders

Pulmonary contusion (usually diagnosed by chest CT: ground-glass opacities in ANTERIOR PERIPHERAL lung)

Complications of mitral stenosis

Pulmonary edema, right heart failure, and AFib

Heart exam: diastolic murmur best heard along right sternal border accentuated with inspiration and leg raising in supine position

Pulmonary regurgitation (Graham-Steell murmur: usually caused by severe pulmonary HTN --> presents with loud P2 and diastolic "blowing" murmur best heard at RUSB accentuated with inspiration and leg raise)

Systolic murmur heard loudest along LUSB that does not radiate to neck, associated with RV heave on palpation Murmur increases with inspiration

Pulmonic stenosis

What are the components of tetralology of Fallot?

Pulmonic stenosis, RVH, overriding aorta, and VSD (remember "PROVe")

Key findings of thalamic stroke

Pure sensory loss, nonreactive miotic pupils, upward gaze palsy, and conjugate eye deviation away from side of lesion

Most common locations of hypertensive hemorrhages

Putamen > cerebellum > thalamus > pons > cerebral cortex (putamen inury: presents with contralateral hemiparesis and hemisensory loss, homonymous hemianopia, and conjugate gaze deviation TOWARD side of lesion --> thalamus: presents with contralateral hemiparesis + hemisensory loss, nonreactive miotic pupils, upgaze palsy, and eye deviation AWAY FROM side of lesion --> cerebellum injury: presents with IPSILATERAL hemiataxia --> pons injury: presents with coma, total paralysis, and pinpoint reactive pupils)

Major side effect of macrolide use in infants <1mo

Pyloric stenosis

28F with PMHx of Crohn's disease presents with 2mo hx of painful leg ulcer PE: painful ulcer with purulent base and violaceous border on left leg

Pyoderma gangrenosum (PG: skin lesion caused by systemic disorders such as IBD, RA, AML, etc. --> presents with initial inflammatory papule/pustule progresses to form expanding ulcer with purulent base and irregular violaceous border --> diagnosis: skin biopsy shows mixed neutrophilic infiltrate with dermal and epidermal necrosis --> treatment: local or systemic steroids)

Skin exam: painless ulcer with sharply defined edges and flat base containing purulent debris

Pyoderma gangrenosum (PG: skin lesion caused by systemic disorders such as IBD, RA, AML, etc. --> presents with initial painless inflammatory papule/pustule progresses to form expanding ulcer with sharply defined edges and purulent base --> diagnosis: skin biopsy shows mixed neutrophilic infiltrate with dermal and epidermal necrosis --> treatment: local or systemic steroids)

70M with PMHx of T2DM, HTN, and acute diverticulitis tx 4wks ago presents with 2-day hx of fever, worsening RUQ pain, and anorexia Vitals: febrile 102.7F, BP 130/80, HR 98, RR 18 PE: markedly tender RUQ with guarding Labs: low Hgb, high WBC, high total bili, high LFTs Abdominal CT: well-defined, hypoattenuating, rounded lesion

Pyogenic liver abscess (caused by direct extension from biliary tract infections/penetrating trauma OR hematogenous spread from systemic circulation--IE-- or portal circulation--intraabdominal infection --> presents with fever, severe RUQ pain, leukocytosis, and elevated LFTs --> diagnosis: CT scan shows well-defined hypoattenuating, rounded lesion with peripherally enhancing abscess membrane --> treatment: IV antibiotics and percutaneous aspiration + drainage)

Where is the lesion if a patient presents with pronator drict?

Pyramidal tract (aka lateral corticospinal tract: descending spinal tract involved in voluntary movement of contralateral limbs)

Treatment of myasthenia gravis

Pyridostigmine (AChE inhibitor that increases ACh availability at NMJ to provide rapid symptomatic relief --> can also add steroids/azathioprine that induce remission but take weeks to reach clinical efficacy --> eventually can receive thymectomy)

Diagnosis of urethrocele

Q-tip test shows >30° urethral movement during Valsalva

Knee XR: low-riding patella with intact connection to tibia

Quadriceps tendon tear (occurs PROXIMAL to patella in rectus femoris tendon --> patella rides LOW with palpable defect ABOVE patella)

Preferred antipsychotic meds for patients with Parkinson disease

Quetiapine and pimavanserin (low-potency 2nd gen antipsychotics --> quetiapine: associated with metabolic syndrome --> pimavanserin: NOT a dopamine antagonist)

Treatment of severe babesiosis

Quinine and clindamycin (treat for 7-10 days)

Best next step in management for patient with breast biopsy showing positive margins

Re-excision of biopsy site (need to remove entire cancer before proceeding to adjuvant therapy)

Contraindications to pharmacologic stress test (adenosine/dipyridamole)

Reactive airway disease, hypotension, and theophylline (for these pts, proceed to dobutamine stress echo)

Management of needle-stick injury from HBV-positive patient in person with adequate HBsAb levels

Reassurance (no treatment necessary if patient has adequate HbsAb quantities, indicating immunity)

Type of bias in which subjects with negative outcomes are more likely to report certain exposures compared to controls

Recall bias (type of observational bias --> common in RETROSPECTIVE studies)

68yo F with PMH of rheumatoid arthritis, hypothyroidism, right total knee replacement, and HTN recently d/c from ICU for pneumonia + septic shock requiring intubation presents with worsening LE weakness, frequent occipital headaches, and numbness + tingling in hands/feet PE: chronic joint deformities in both hands, decreased LE muscle strength, hyperactive knee reflexes, decreased proprioception in feet, and positive Hoffman sign

RA cervical myelopathy (caused by RA-related joint destruction of cervical spine, resulting in atlantoaxial joint instability and eventual subluxation --> risk factors: severe RA including elevated ESR/RF/CRP, rapidly progressive erosive disease, and hand deformities --> triggers of subluxation: forced neck extension during intubation --> presents with neck/cervical pain radiating to occiput, protruding anterior arch of atlas, scoliosis with loss of cervical lordosis, and slowly progressive UE + LE weakness, hyperreflexia, Babinski sign, and Hoffman sign aka flexion + abduction of thumb when flicking nail of middle finger --> diagnosis: urgent C-spine MRI showing separation of C1 and C2 --> treatment: stiff surgical collars and neurosurg cervical fixation)

Which vessel supplies the SA node?

RCA (right coronary artery: always supplies the SA node, therefore RCA infarct can cause sinus arrest --> RCA also supplies the PDA in 85% of people, which supplies the AV node, so RCA infarct can also cause complete heart block)

Neonatal CXR: diffuse, fine, reticular granularity and perihilar linear opacities bilaterally

RDS (respiratory distress syndrome: seen in premature newborns <28wks due to surfactant deficiency causing increased alveolar surface tension, leading to alveolar collapse and diffuse atelectasis --> presents mins-hrs after birth with severe respiratory distress and cyanosis --> diagnosis: CXR shows diffuse reticulogranular "ground glass" opacities, air bronchograms, and low lung volumes --> treatment: early CPAP and maternal antenatal steroids before birth)

Treatment of active TB

RIPE for 2 months, then INH and rifampin for 4 months (6mo total of treatment)

Skin exam: generalized maculopapular/petechial rash initially involving wrists + ankles that spreads to trunk + palms + soles

RMSF (Rocky Mountain Spotted Fever: infection with Rickettsia rickettsii bacteria due to bite from dog tick Dermacentor that is endemic to South Atlantic states such as Virginia and North Carolina --> presents with fever + headache + myalgia, followed by PETECHIAL or maculopapular rash that BEGINS ON WRISTS + ANKLES then spreads centrifugally and to palms + soles --> labs: thrombocytopenia, hyponatremia, and transaminitis --> diagnosis: Rickettsia serology or skin biopsy --> treatment: doxycyline --> complications: encephalitis, pulmonary edema, bleeding, and shock --> complication: Jarisch-Herxheimer reaction in which antibiotic directly injures bacteria and releases massive endotoxins causing sepsis)

18M who recently returned from camping presents with 4-day hx of fever + chills + headache and 1-day hx of rash and confusion Vitals: febrile 104.9F, BP 80/40, HR 130, RR 24 PE: multiple insect bites and diffuse maculopapular rash on trunk + extremities + palms + soles, multiple abrasions + petechiae + purpura over LE, basilar inspiratory crackles, and S3 gallop Labs: low plts

RMSF (Rocky Mountain Spotted Fever: infection with Rickettsia rickettsii bacteria due to bite from dog tick Dermacentor that is endemic to South Atlantic states such as Virginia and North Carolina --> presents with fever + headache + myalgia, followed by PETECHIAL or maculopapular rash that BEGINS ON WRISTS + ANKLES then spreads centrifugally and to palms + soles --> labs: thrombocytopenia, hyponatremia, and transaminitis --> diagnosis: Rickettsia serology or skin biopsy --> treatment: doxycyline --> complications: encephalitis, pulmonary edema, bleeding, and shock)

Diagnosis of prolonged rupture of membranes (PROM)

ROM >18hrs (increases risk of chorioamnionitis --> if pt has PROM and unknown GBS status, need to give IV penicillin G or ampicillin)

What are the non-treponemal tests for syphilis?

RPR and VDRL (non-treponemal tests: detects antibody to cardiolipin-cholesterol-lecitin antigen and provides QUANTITATIVE data with serum titers --> used for screening and test of cure after tx with 4-fold titer decrease at 6-12mo --> cons: low sensitivity with 20-30% FN rate, so possibly negative in early infection)

Criteria for successful extubation during SBT

RSBI <105 (RSBI: rapid shallow breathing index calculated by RR/TV --> pts with RSBI >105 are breathing fast and shallow and require continued ventilatory support --> pts with RSBI <105 are able to make proper breaths and have higher chance of successful extubation)

Best next step in management for asymptomatic patient with elevated AlkPhos and GGT

RUQ US and AMA (RUQ US: want to look for abnormal hepatic parenchyma or dilated bile ducts --> AMA: if positive, diagnose with PBC)

Where does a pacemaker end in the heart?

RV endocardium (transvenous implantable pacemaker aka cardioverter-defibrillator: passes thru SVC into RA into tricuspid valve and ends in RV endocardium --> complication: severe tricuspid regurgitation/TR in 10-20% of patients)

Mechanical complications of RCA MI

RV failure, papillary muscle rupture, and IV septum rupture (RV failure: occurs ACUTELY after MI and presents with hypotension + clear lungs + Kussmaul sign, ECHO shows hypokinetic RV --> papillary muscle rupture: occurs ACUTELY or within 3-5d of MI and presents with severe pulmonary edema + new holosystolic murmur, ECHO shows severe MR with flail leaflet and elevated PA pressure --> IV septum rupture: occurs acutely or within 3-5d of MI and presents with chest pain + new holosystolic murmur + cardiogenic shock, ECHO shows L-to-R ventricular shunt and increased O2 level from RA to RV

Most common causes of positive hepatojugular reflex

RV infarct, constrictive pericarditis, and restrictive cardiomyopathy

4 physical exam signs of basilar skull fracture

Raccoon eyes, Battle sign, hemotympanum, and CSF rhinorrhea/otorrhea (raccoon eyes: periorbital ecchymoses --> Battle sign: postauricular ecchymoses --> hemotympanum: blood within inner ear --> CSF rhinorrhea/otorrhea: leakage of CSF into sinuses and ears)

1-year-old girl presents with inability to move right arm PE: right arm held in pronation against chest with restricted movement

Radial head subluxation (nursemaid elbow: common injury in preschool children caused by axial traction on forearm with elbow extended from pulling/lifting/swinging child's arm --> presents with arm held extended and pronated --> treatment: hyperpronating forearm OR forearm supination with elbow fixation)

What are the indications for TB treatment for a patient with PPD induration size >10mm?

Recent immigrant, IVDU, high risk occupation, high risk TB reactivation, and children age <4 (recent immigrant: within 5yrs from TB-endemic areas --> IVDU: IV drug user --> high-risk occupation: prison, nursing home, hospital, homeless shelter, and Mycobacteriology lab personnel --> high risk TB reactivation: T2DM, leukemia, ESRD, and chronic malabsorption syndromes --> children age <4)

Which structure is involved in 4th-degree perineal laceration?

Rectal mucosa (high risk of anal/fecal incontinence)

72yo F presents with several months of intermittent lower abdominal discomfort, frequent urges for BM every day producing small-volume stools or just mucus, and sensation of incomplete evacuation PE: during Valsava, erythematous mass with concentric rings protruding thru the anus and spontaneously retracting

Rectal prolapse (mucosal or full-thickness layer of rectal tissue sliding thru anal orifice --> risk factors: women age >40yo with multiple births, prior pelvic surgery, pelvic floor dysfuction, chronic constipation/diarrhea/straining, stroke, and dementia --> presents with abdominal discomfort, constipation or stool incontinence with mucus, straining or incomplete bowel evacuation, and digital maneuvers required for defecation --> diagnosis: patulous anus and erythematous mass with concentric rings extending thru anus on Valsava --> treatment: increased fiber + fluid intake, pelvic floor muscle exercises, biofeedback, and surgery for full-thickness prolapse)

Screening for GBS in pregnant women

Rectovaginal culture at 36-38wks (identifies patients at risk for neonatal GBS transmission --> earlier testing indicated for patients with risk factors for early delivery)

69yo F with PMH of asthma, HTN, AFib on apixaban presents with 2-day hx of cough and wheezing and several hours of increasing abdominal pain PE: mild expiratory wheezing b/l, and localized fullness with tenderness and guarding just lateral to umbilicus on left side Labs: elevated WBC, low Hb

Rectus sheath hematoma (rupture of the inferior epigastric artery causing hematoma formation BELOW arcuate line, aka in lower aspect of rectus abdominus muscle --> risk factors: ELDERLY FEMALES on ANTICOAGULATION with abdominal trauma or forceful abdominal contractions/coughing --> presents with acute-onset abdominal pain with reboud/guarding that worsens with abdominal contraction aka Carnett sign, palpable abdominal wall mass --> labs: anemia and leukocytosis --> diagnosis: abdominal CT shows RSH --> treatment: serial monitoring or angiography with embolization/surgery for HDUS patients)

Indications for urate-lowering meds (allopurinol)

Recurrent gout attacks, tophi, uric acid kidney stones, renal insufficiency, and XR evidence of chronic gouty joint disease (should be started on either allopurinol, probenicid, pegloticase, or pegloticase)

Most common complication of anterior cervical spine surgery

Recurrent laryngeal nerve injury (results in vocal cord paralysis leading to hoarse voice and dyspnea)

3yo girl presents with 2mo hx of worsening hoarseness PE: normal Flexible laryngoscopy: several finger-shaped lesions on both vocal cords

Recurrent respiratory papillomatosis (RRP: presence of laryngeal papillomas due to vertical transmission of HPV6/11 from maternal genital warts to fetus --> presents with progressive hoarseness --> diagnosis: flexible laryngoscopy shows multiple finger-shaped lesions on true vocal cords --> treatment: surgical debridement --> complications: voice problems, airway obstruction, and repeated operative interventions)

Cause of phase 1a ventricular arrhythmias during MI

Reentrant ventricular arrhythmias (phase 1a/immediate ventricular arrhythmias: occurs within first 10mins of coronary occlusion during MI --> due to acute ischemia causing heterogeneity of conduction with areas of marked conduction slowing + delayed activation, predisposing to reentrant arrhythmias)

23F with PMHx of anorexia nervosa who was hospitalized and began receiving aggressive nutritional supplementation presents with SOB and orthopnea PE: bilateral crackles and 2+ pitting edema in LE b/l Labs: low phos

Refeeding syndrome (occurs when profoundly malnourished patients receive aggressive nutritional supplementation, resulting in shifting nutrients/fluids and causing hypophosphatemia and volume overload --> presents with CHF, edema, seizures --> diagnosis: hypophosphatemia --> treatment: IV phosphate)

Best next step in management for child with 1st febrile UTI

Renal US (can detect hydronephrosis suggestive of VUR --> if abnormal, proceed to voiding cystourethrogram/VCUG)

35yo F presents with recurrent headaches and epistaxis Vitals: BP 170/100 in right arm, 175/105 in left arm PE: LUQ abdominal bruit Abdominal CT: left kidney 8cm, right kidney 12cm

Renal artery stenosis (RAS: results in decreased renal perfusion and atrophy of affected kidney, leading to increased renin secretion and activation of RAAS and secondary hyperaldosteronism --> maladaptive complications include Na+ retention, vasoconstriction, and HTN --> causes: stenosis in proximal 1/3 due to atherosclerosis in older male smokers, stenosis in distal 2/3 due to fibromuscular dysplasia in young females or Williams syndrome --> presents with refractory HTN causing headaches/epistaxis, epigastric/flank/abdominal bruits, and asymmetric renal size)

65yo M with PMH of HTN, CAD s/p several PCIs for stable angina, TIA s/p right carotid endarterectomy, pulmonary edema, and smoking presents with sudden-onset SOB and orthopnea Vitals: BP 210/100, HR 104, RR 22, SaO2 86% on RA PE: distended neck veins and bilateral lung crackles Labs: low K+, high HCO3-, high BUN and Cr UA: trace proteinuria ECG: sinus tachy with LVH Echo: LVH with preserved EF

Renal artery stenosis (formation of plaque within renal artery causing renal ischemia, inducing activation of RAAS system resulting in Na+ and H2O retention, generalized vasoconstriction, and HTN --> causes: diffuse atherosclerosis, fibromuscular dysplasia, and Williams syndrome --> presents with resistant HTN with recurrent flash pulmonary edema, abdominal bruit, and secondary hyperaldosteronism with hypokalemia and elevated HCO3- --> diagnosis: >30% rise in Cr after starting ACEIs or ARBs, imaging showing atrophic kidney, and renal US with Dopper/CTA/MRA showing stenotic renal artery --> treatment: BP control, statins, ACEIs, and revascularization)

Most common complication of umbilical artery catheterization

Renal artery thrombosis (due to UA catheterization causing showering of emboli/thrombi that then lodge into small renal artery --> results in renal artery thrombosis, renin release, and HTN)

Patient appears hypovolemic Labs: - Hyponatremia - Low serum osmolality (<275) - High urine osmolality (>100) - High urine Na+ (>40)

Renal salt loss (hyponatremia due to salt-wasting nephropathy causing renal losses of salt and water --> presents with dry mucous membranes and skin turgor --> causes: diuretics such as thiazies and primary adrenal insufficiency/PAI)

Patient appears hypovolemic Labs: low K+ and metabolic alkalosis Urine lytes: high urine Cl-

Renal tubular defect (causes saline-UNRESPONSIVE metabolic alkalosis characterized by HIGH URINE Cl- >20 --> Bartter syndrome: autosomal recessive reabsorption defect in thick ascending LoH affecting Na+/K+/2Cl- cotransporter resulting in hypokalemia + metabolic alkalosis + hypercalciuria and presents similarly to chronic loop diuretic use --> Gitelman syndrome: autosomal recessive reabsorption defect in DCT NaCl transporter resulting in hypokalemia + hypomagnesemia + metabolic acidosis + hypocalciuria and presents similarly to lifelong thiazide diuretic use)

50yo F with PMH of pancreatic cancer tx with chemo presents with 3-day hx of constant dull flank pain, nausea, and hematuria PE: right flank and CVA tenderness UA: moderate blood with 20-30 RBCs/hpf Abdominal US: enlarged right kidney without hydronephrosis

Renal vein thrombosis (RVT: caused by hypercoagulability from membranous nephropathy/cancer/OCPs, volume depletion, or trauma --> results in markedly increased glomerular pressure, leading to renovascular congestion + capsular stretch + hematuria --> presents with fever, abdominal/flank pain, hematuria, and elevated LDH --> workup: renal US shows enlarged kidney without hydronephrosis --> diagnosis: CT/MRI/renal venography shows RVT --> management: anticoagulation or thrombolysis/thrombectomy if AKI present)

Best next step in management for patient >50yo with single pneumonia episode

Repeat CXR in 6-12wks (required to assess for malignancy)

Best next step in management for patient with HIV and CD4 <200 with negative PPD

Repeat PPD after HAART initiation (due to risk of false-negative PPD in patients with CD4 <200)

Type of bias in which subjects over- or under-report exposure due to perceived social stigma

Reporting bias (Hawthorne effect: type of observational bias in which study participants change their behavior when they know they are being studied)

Which acid-base findings are associated with salicylate toxicity?

Respiratory alkalosis and anion gap metabolic acidosis (since these compete with each other, there is usually normal pH)

Newborn born at 28wks via SVD c/b premature labor initially emerged vigorous with spontaneous respirations, but rapidly developed respiratory distress and central cyanosis Vitals: BP 65/35, HR 140, RR 70, SaO2 75% on RA and improves to 90% with CPAP PE: grunting, intercostal and subcostal retractions, nasal flaring, shallow respirations, and diminished breath sounds b/l CXR: diffuse, fine, reticular granulatiry and perihilar linear opacities b/l

Respiratory distress syndrome (RDS: surfactant deficiency in premature neonates <28wks with very low birth weight <3.3lb causes increased alveolar surface tension, resulting in alveolar collapse and diffuse atelectasis --> risk factors: prematurity <28wks, male sex, perinatal asphyxia, maternal DM, and C-section without labor --> presents within mins-hrs after birth with tachypnea >60, grunting, intercostal and subcostal retractions, nasal flaring, hypoxia, and cyanosis --> diagnosis: diffuse reticulogranular ground-glass opacities, air bronchograms, and low lung volumes --> treatment: early CPAP, with severe cases receiving intubation + exogenous surfactant therapy --> prevention: maternal antenatal steroids)

Criteria for initiating long-term supplemental O2 (LTOT) for patients with COPD

Resting PaO2 <55 or SaO2 <88% on RA, right HF, and HCT >55% (if pt has cor pulmonale or right HF, initiate O2 with PaO2 <59 or SaO2 <89% --> initiating LTOT has demonstrated prolonged survival and improved QOL for patients with COPD and significant chronic hypoxemia)

60F presents with progressively worsening fatigue, DOE, and LE swelling. Recently found to have significant proteinuria. PE: JVD and normal lung exam Echo: small pericardial effusion and concentric thickening of ventricular walls with diastolic dysfunction

Restrictive cardiomyopathy (intrinsic cardiac disease usually caused by systemic infiltrative conditions that cause extracellular deposition of material into heart --> causes incude PLEASH: post-radiation fibrosis, Loffler endocarditis, endocardial fibroelastosis, amyloidosis, sarcoidosis, and hemochromatosis --> presents with right-sided HF including fatigue, DOE, and LE swelling in absence of pulmonary edema --> ECG: normal or low-voltage QRS --> diagnosis: echo shows concentric thickening of ventricular walls and diastolic dysfunction)

Pulmonary flow-volume loop: decreased lung volumes with expiratory flow rate > inspiratory flow rate

Restrictive lung disease (decreased lung ventilation by either intrinsic lung disease such as pulmonary edema/fibrosis --> OR external condition preventing complete expansion of lung such as pneumothorax or obesity)

Fundoscopic exam: elevated retina with folds

Retinal detachment (separation of inner layers of retina caused by T2DM, recent ocular surgery, vascular disease, myopia, or degeneration --> presents with prodrome of photopsia with showers of flashes/floaters, followed by monocular vision loss like a "curtain drawn down" --> diagnosis: fundoscopic exam shows elevated retina with folds and/or tear, aka "crinkling" of retinal tissue and changes in vessel direction)

Fundoscopic exam: dark deposits surrounding macula, retinal vessel attenuation, and optic disc pallor

Retinitis pigmentosa (congenital disorder characterized by progressive retinal degeneration, associated with abetalipoproteinemia --> presents with painless progressive vision loss beginning with night blindness --> diagnosis: fundoscopic exam shows bone spicule-shaped deposits around macula, retinal vessel attentuation, and optic disc pallor)

Fundoscopic exam: nodular, cream-colored mass in center of retina

Retinoblastoma (intraocular malignancy caused by mutation in Rb gene --> presents with either LEUKOCORIA aka loss of red reflex or ESOTROPIA aka nasal deviation of gaze due to central vision loss --> diagnosis: dilated fundoscopic exam shows nodular cream-colored retinal mass, MRI shows retinal mass--> complication: osteosarcoma as a teenager)

Which imaging is used to evaluate for bladder or urethral injuries?

Retrograde cystourethrogram

Treatment of nodular/cystic acne

Topical retinoid, benzoyl peroxide, and topical macrolide (if severe, can add oral macrolide --> if unresponsive, start oral isotretinoin)

Best next step in management after diagnosis of penile fracture

Retrograde urethrography (performed BEFORE surgical repair of tunica albuginea due to 20% risk of concomitant urethral injury --> indicated if patient presents with penile fracture AND blood at meatus, hematuria, dysuria, and/or urinary retention)

Abdominal CT: large isodense collection anterior to psoas displacing kidney anteriorly

Retroperitoneal hematoma (internal hemorrhage in retroperitoneum caused by trauma or anticoagulation therapy --> risk factors: T2DM, age >60yo, HTN, and alcoholism --> presents with weakness, dizziness, back pain, tachycardia, and anemia --> diagnosis: abdominal CT shows large isodense collection in retroperitoneum aka ANTERIOR to psoas, causing displacement of kidney ANTERIORLY)

76yo M presents 5hrs after cardiac catheterization with hypotension, tachycardia, generalized weakness, and back pain PE: diaphoretic + clammy and mildly tender right groin arterial puncture site

Retroperitoneal hematoma (presents with sudden onset HD instability and ipsilateral flank/back pain, localized discomfort, and/or swelling of soft tissue --> diagnosis: non-contrast CT of abdomen and pelvis --> treatment: IV fluids/blood transfusion, bed rest, and intensive monitoring)

36yo F presents with 2-day hx of severe sore throat, worsening fever, difficulty swallowing, and neck pain/stiffness after swallowing fish bone that scratched her throat Vitals: febrile 102.2F, BP 126/80, HR 106 PE: pooling of saliva in hypopharynx, red bulging posterior pharyngeal wall, and stiff neck with reduced passive ROM Lateral neck XR: increased thickness of prevertebral soft tissues with air-fluid level

Retropharyngeal abscess (abscess of deep space of neck between buccopharyngeal fascia + constrictor pharyngeal muscles ANTERIORLY and alar fascia POSTERIORLY caused by penetrating trauma to posterior pharynx --> presents with neck pain, odynophagia, fever, nuchal rigidity, and bulging of pharyngeal wall --> complications: acute necrotizing mediastinitis, IJ vein thrombosis, and CN9-12 deficits)

Foot XR: periarticular osteoporosis, joint erosions, and joint space narrowing

Rheumatoid arthritis

57F presents with 2-mo hx of pain and swelling in knees with morning stiffness and 1-mo hx of progressive generalized fatigue PE: warm swollen tender knees with reproducible pain on passive movement Labs: low Hgb and high ESR XR of knees: osteopenia and subcartilaginous cysts around joints

Rheumatoid arthritis (chronic, systemic inflammatory disorder due to autoimmune inflammation and formation of pannus/proliferative granulation tissue erodes articular cartilage + bone, resulting in significant joint destruction + deformity --> risk factors: female, smokers, HLA-DR4 --> presents with fatigue, symmetric joint pain + swelling, morning stiffness, and involvement of MCP/PIP joints --> diagnosis: positive RF aka IgM against IgG Fc/anti-CCP and XR of joints show osteopenia + bony erosions + periarticular subcartilaginous cysts --> treatment: NSAIDs and MTX, screen for hepatitis B and C before starting --> for refractory cases: biologics such as etanercept or adalimumab --> complications: cervical atlantoaxial subluxation, ulnar finger deviation, swan neck and boutonniere deformities)

3yo boy recently moved to US from refugee camp presents with malnourishment PE: wt and length <5th percentile, scaling and fissures present at mouth corners with lips cracked and inflamed, swollen and hyperemic tongue and oropharyngeal membranes, erythematous scaly patches on eyebrows + cheeks + nose, rash on scrotal skin extending to medial aspect of both thighs, pale skin + conjunctivae, and brittle fingers + toenails Labs: low Hgb and low Cr

Riboflavin deficiency (vitamin B2 deficiency: lack of riboflavin ingestion from meat/eggs/yeast/dairy/veggies --> presents with angular cheilitis, glossitis, stomatitis, seborrheic dermatitis, and normocytic anemia)

Indications for exchange transfusion for newborns with jaundice

Rising bili despite phototherapy, total bili >25, and kernicterus

Which 2nd gen antipsychotic has the highest risk of tardive dyskinesia?

Risperidone (also associated with hyperprolactinemia --> if pt presents with EPS sx, discontinue risperidone and switch to clozapine or quetiapine OR tx with VMAT2 inhibitor such as valbenazine or deutetrabenazine)

Fetal US signs of trisomy 18 (Edward syndrome)

Rocker bottom feet, clenched hands with overlapping fingers, and diaphragmatic hernia

13-month-old boy presents with 3-day hx of fever that resolved on its own today, and now 3-hr hx of painless non-itchy rash PE: well-appearing infant with blanching pink macules on neck + back + abdomen + chest

Roseola infantum (exanthem subitum/6th disease: viral exanthem caused by HHV6 infection --> presents in BABIES <2yo with 3-5 days of high fever >104F that self-resolves, followed by blanching pink maculopapular rash that begins on neck + trunk and spreads to face and extremities --> treatment: supportive care)

62yo M with PMH of smoking, HTN, HLD, sigmoid diverticulosis, and IBS presents with 2-hour hx of sudden-onset severe abdominal pain Vitals: afebrile, BP 88/64, HR 117, RR 18 PE: pale and drowsy appearing patient, positive bowel sounds, and diffusely tender abdomen with flank ecchymoses without rigidity/guarding

Ruptured AAA (ruptured abdominal aortic aneurysm: rupture of localized aortic dilatation, usually located INFRARENALLY aka distal to renal artery origin --> results in peritoneal or retroperitoneal hemorrhage, which can quickly lead to hemodynamic instability and shock --> risk factors: males >60yo, smokers, HLD, and connective tissue disease such as Marfan/Ehlers-Danlos --> presents with sudden-onset severe abdominal/flank/groin pain, pulsatile abdominal mass, flank ecchymoses, and limb ischemia --> for hemodynamically STABLE patients, diagnose with abdominal CT and treat medically --> for hemodynamically UNSTABLE patients, diagnose with focused abdominal US and treat surgically)

32yo F presents with 1-hour hx of acute onset RUQ pain followed by syncope Vitals: febrile 100.6F, BP 80/50, HR 120, RR 20 PE: pt appears anxious and pale with abdominal distension, diffuse abdominal tenderness, tender hepatomegaly, cold extremities, and delayed cap refill Labs: low Hb, elevated WBCs Abdominal US: solid liver mass and free fluid in abdomen

Ruptured hepatic adenoma (benign epithelial liver tumor seen in YOUNG WOMEN on prolonged OCPs that usually remains asymptomatic, but can undergo malignant transformation in 10% of cases or rupture/hemorrhagic shock --> presents with acute onset severe RUQ pain with signs of hemorrhagic shock, low-grade fever, and mild leukocytosis --> diagnosis: abdominal US shows single solid liver lesion in right hepatic lobe and free fluid in abdomen --> treatment: symptomatic or >5cm needs surgical resection, asymptomatic and <5cm requires cessation of OCPs)

35F with PMHx of DVT on warfarin presents with 6-hr hx of acute onset of RLQ pain while playing tennis, now p/w diffuse abdominal pain and R shoulder pain Vitals: afebrile, BP 90/40, HR 118 PE: rigid abdomen with diffuse tenderness, rebound, and guarding Labs: low HCT

Ruptured ovarian cyst (rupture of corpus luteum cyst occurring in 2nd half of menstrual cycle AFTER ovulation --> usually does not cause hemoperitoneum UNLESS patient is on anticoagulation --> presents with sudden onset of severe unilateral lower abdominal pain during strenuous activity/sexual intercourse --> hemoperitoneum presents with diffuse severe abdominal pain, pleuritic chest pain, and shoulder pain --> diagnosis: pelvic US shows intraabdominal and pelvic free fluid with possible adnexal mass)

62yo F with PMH of T2DM, HTN, HLD presents with acute right knee and posterior calf pain after walking on treadmill Vitals: BP 166/88, BMI 41 PE: tenderness and induration at medial head of gastrocnemius, crescent-shaped patch of ecchymosis at medial malleolus, and moderate pitting edema at ankle

Ruptured popliteal cyst (ruptured Baker cyst: initially formed by excessive synovial fluid formation from OA/RA and positive pressure in knee during extension, resulting in passage of synovial fluid from knee joint into gastrocnemius or semimembranous bursa --> UNRUPTURED cyst presents as chronic painless bulge behind knee in median popliteal space most noticeable with knee extension --> RUPTURED cyst presents with posterior knee + calf pain, tenderness and swelling of calf, and arc of ecchymosis distal to medial malleolus aka crescent sign)

Which nerve root is responsible for ankle jerk reflex?

S1-S2

Which nerve roots supply sensation to buttocks and perineum?

S2-S4 (impingement of these nerve roots during cauda equina syndrome causes SADDLE ANESTHESIA)

Which nerve root is responsible for anal wink reflex?

S3-S4 ("winks galore")

Which dermatome level supplies the perianal region?

S4-S5

Stepwise treatment approach of severe asthma exacerbation

SABA, ipratropium nebulizer, systemic steroid, and IV magnesium (SABA + ipratropium: causes greater bronchodilation than either agent alone --> systemic steroid: increase rate of symptomatic improvement --> IV magniesum: give if no improvement after 1hr of therapy for additional bronchodilation)

Retroperitoneal abdominal organs

SAD PUCKER (S: suprarenal/adrenal glands --> A: aorta and IVC --> D: duodenum, except 1st part --> P: pancreas, head + body --> U: ureters --> C: colon, ascending + descending --> K: kidneys --> E: esophagus --> R: rectum, mid-distal)

ICU patient presents with abdominal distension and high-pitched hyperactive bowel sounds Abdominal CT: dilated loops of small bowel with air-fluid levels, and minimal air in colon + rectum

SBO (small-bowel obstruction: obstruction of small bowel caused by adhesions from previous abdominal/pelvic surgery, hernias, gallstone ileus, IBD, intussusception, volvulus, and neoplasms --> presents with acute onset of colicky abdominal pain, progressive N/V, obstipation, abdominal distension, and high-pitched hyperactive bowel sounds --> diagnosis: abdominal CT shows dilated loops of SMALL BOWEL ONLY with air-fluid levels --> management: aggressive fluid resuscitation, NG tube for gastric decompression, and potential surgery)

52M with PMHx of alcoholism and d/c from hospital 3wks ago for acute pancreatitis presents with 2-day hx of excessive sleepiness Vitals: febrile 101.F PE: lethargic, jaundiced, peripheral muscle wasting, spider angiomata across neck, and abdominal distension with fluid wave Labs: elevated WBC, prolonged PT + INR, elevated BUN and Cr, low albumin, high AlkPhos, and high AST + ALT

SBP (spontaneous bacterial peritonitis: common and potentially fatal bacterial infection of peritoneum caused by cirrhosis or ascites from anasarca --> organisms: aerobic gram-negatives such as E. coli or Klebsiella --> presents with fevers, chills, abdominal pain + distention with rebound and guarding, ileus, and worsening encephalopathy --> diagnosis: paracentesis analysis shows ANC >250, positive gram stain of paracentesis fluid --> treatment: 3rd gen cephalosporins such as cefotaxime)

Paracentesis: cloudy or turbid ascitic fluid

SBP (spontaneous bacterial peritonitis: common and potentially fatal bacterial infection of peritoneum caused by enteric bacteria translocating across intestinal wall and seeding ascitic fluid within peritoneal cavity --> causes: cirrhosis or ascites from anasarca --> organisms: aerobic gram-negatives such as E. coli or Klebsiella --> presents asymptomatically or with fevers, chills, abdominal pain + distention with rebound and guarding, ileus, and worsening encephalopathy --> diagnosis: ascitic fluid ANC >250, positive gram stain of paracentesis fluid --> treatment: 3rd gen cephalosporins such as cefotaxime --> prophylaxis: ciprofloxacin)

Goal BP for patients with acute aortic dissection

SBP 100-110 (control with IV beta-blockers that decrease change in pressure/change in time to decrease shear forces on aorta --> NOTE: patients with significant AR or tamponade should NOT receive beta-blockers as they worsen hypotension and precipitate cardiac arrest)

Indications for immediate ex lap in patients with penetrating abdominal trauma

SBP <90, frank blood in NGT or rectum, peritonitis, evisceration, and impalement

Diagnosis of pre-eclampsia

SBP >140, DBP >90, and proteinuria >300mg/24hr at >20wks

Diagnosis of pre-eclampsia with severe features

SBP >160 or DBP >110, plts <100k, Cr >1.1, elevated transaminases 2x ULN, pulmonary edema, and visual or cerebral symptoms

Indications for use of IV albumin

SBP, hepatorenal syndrome, hepatic encephalopathy, and large volume paracentesis

60y M presents with 3mo hx of enlarging lesion on lower lip associated with ulceration and slight pain PE: 3x7mm partially encrusted ulcer in vermillion zone of lower lip surrounded by 6x12mm area of induration

SCC (squamous cell carcinoma: 2nd most common cancer and most common cancer on the lip --> risk factors: excessive exposure to sunlight, fair skin tone, tobacco use, heavy alcohol use, chronic inflammation/scar formation, and immunosuppression --> presents with indurated ulcerating lesion on LOWER LIP, face, ears, hands --> diagnosis: biopsy shows invasive cords of squamous cells with KERATIN PEARLS --> treatment: curative resection)

Which type of esophageal cancer most commonly arises in proximal and mid esophagus?

SCC (usually caused by smoking, heavy alcohol use, N-nitroso containing food, hot liquids, and caustic strictures)

54M presents with coughing w/ bloody sputum, wt loss, anorexia, constipation, increased thirst, and fatigue PE: pt appears slim and pale Labs: hypercalcemia CXR: left-sided hilar mass

SCC of lung (squamous cell carcinoma of lung: type of lung cancer arising in CENTRAL portion of lung, aka HILAR MASS --> presents with cough, SOB, hemoptysis, and hypercalcemia of malignancy due to elevated PTHrP --> diagnosis: CXR shows hilar mass or cavitation, biopsy shows keratin pearls and intracellular bridges)

13yo M with PMH of obesity presents with 2mo hx of dull pain along anterior knee PE: limited hip ROM and knee points laterally during passive hip flexion

SCFE (slipped capital femoral epiphysis: anterosuperior displacement of proximal femur diaphysis due to weakening of growth plate 2/2 excessive shearing at proximal femoral growth plate, giving appearance of posteriorly displaced femoral head --> associated with hypothyroidism --> presents in OBESE TEENAGE BOYS with chronic dull hip pain >3wks, referred thigh/knee pain, altered gait, limited internal rotation of hip causing knee/foot to point LATERALLY, and thigh abduction + external rotation with passive hip flexion --> diagnosis: frog leg hip XR shows posteriorly displaced femoral head that looks like "ice cream falling off cone" --> treatment: non-weight bearing and surgical fixation --> complications: avascular necrosis of hip and early OA)

Causes of SIADH

SCLC, CNS disorders, head trauma, lung disease, cyclophosphamide, carbamazepine, SSRIs, and NSAIDs

Formula for standard error

SD/sqrt of N (basically divide standard deviation by square root of sample size --> can use SE to calculate 95% CI by 1.96*SE +/- mean)

Patient appears euvolemic Labs: - Hyponatremia - Low serum osmolality (<275) - High urine osmolality (>100) - High urine Na+ (>40)

SIADH (syndrome of inappropriate ADH: excess ADH secretion/ingestion due to CNS disturbance, pneumonia, small cell lung cancer, pain/nausea, or medications such as carbamazepine/SSRIs/NSAIDs/desmopressin --> presents with EUVOLEMIA and nausea, dizziness, headache, forgetfulness --> diagnosis: labs show hypotonic hyponatremia, high urine osmolality, and high urine Na+ --> treatment: fluid restriction + salt tablets)

66F with PMHx of degenerative disk disease, HTN, T2DM, and CKD presents with 6-mo hx of bloating, flatulence, 2-3 loose watery BMs daily, and mild intermittent crampy abdominal pain that is unrelated to eating/does not improve after defecation Vitals: afebrile, BP 142/87, HR 80, RR 13 PE: trace pitting edema of LE and mildly distended abdomen Labs: Cr 1.9, HbA1c 9.3%, and abnormal carbohydrate breath testing using glucose

SIBO (small intestinal bacterial overgrowth: caused by excess growth of colonic bacteria --> causes: altered small bowel motility from uncontrolled DM, chronic opiate use, chronic PPI use causing gastric hypochlorhydria, scleroderma, small intestinal diverticula, chronic pancreatitis, or surgery involving ileocecal valve --> presents with mild abdominal pain, bloating, flatulence, watery diarrhea, and vitamin B12 deficiency --> diagnosis: abnormal carbohydrate breath test with earlier peak in breath hydrogen/methane and jejunal aspiration showing high bacterial concentration --> treatment: oral rifaxamin/neomycin to reduce bacterial load)

38yo F with PMH of Roux-en-Y gastric bypass surgery 2yrs ago presents with 2mo hx of intermittent abdominal bloating and large-volume greasy diarrhea PE: mild diffuse abdominal tenderness without rebound, and hyperactive bowel sounds Stool testing: increased fecal fat Labs: macrocytic anemia and hypocalcemia

SIBO (small intestinal bacterial overgrowth: excessive bacterial growth in proximal small intestine caused by gastric bypass/small intestine surgery, strictures, motility disorders such as scleroderma/DM, or secretory disorders such as atrophic gastritis/chronic pancreatitis --> organisms causing SIBO include streptococci, Bacteroides, E. coli, and Lactobacillus --> presents with abdominal pain/bloating, steatorrhea + flatulence, weight loss, excess abdominal skin folds, and scaphoid abdomen --> labs: macrocytic anemia, deficiency of vitamin B12/ADEK, and increased fecal fat --> diagnosis: carbohydrate breath testing and endoscopy with jejunal aspirate + culture showing >10^5 organisms/mL --> treatment: rifaximin or augmentin, high-fat low-carb diet, metoclopramide, and avoiding antimotility agents)

Inhibitors of CYP450 system

SICKFACES.COM (S: sodium valproate --> I: isoniazid --> C: cimetidine --> K: ketoconazole --> F: fluconazole --> A: acute alcohol abuse --> C: chloramphenicol --> E: erythromycin --> S: sulfonamides --> C: ciprofloxacin --> O: omeprazole --> M: metronidazole --> others: amiodarone and grapefruit juice)

ECG: regular wide-complex tachycardia with 2 fusion beats

SMVT (sustained monomorphic ventricular tachycardia: ventricular arrhythmia associated with CAD and LV systolic dysfunction --> presents with palpitations and lightheadedness --> diagnosis: ECG shows wide-complex tachycardia with "fusion beats" aka hybrid of normal + wide QRS complex due to capture of electrical signal thru both atrium and ventricle briefly --> treatment: IV amiodarone for stable pts, synchronized cardioversion for unstable pts)

59yo M with PMH of COPD, smoking, HTN, GERD, and CKD presents with sudden-onset severe dyspnea and right-sided chest pain when driving to work Vitals: BP 130/80, HR 102, SaO2 89% PE: decreased tactile fremitus and breath sounds on right lung, scattered wheezes on left lung, and trace ankle edema

SSP (secondary spontaneous pneumothorax: caused by rupture of large alveolar bleb formed from chronic destruction of alveolar sacs, leading to air leakage into pleural space --> risk factors: known lung disease such as COPD/CF and cigarette smoking --> presents with acute-onset SOB/chest pain, hypoxia, unilaterally decreased breath sounds, and hyperresonance on percussion --> diagnosis: CXR shows visceral pleural line beyond which no pulmonary markings are seen --> treatment: observation with supplemental O2 to emergency tube thoracostomy)

1st line treatment of MDD with psychotic features

SSRI plus antipsychotic or ECT (ECT usually used in depressed elderly patients unable to eat/drink, psychotic, or actively suicidal due to rapid response)

56yo F with PMH breast cancer s/p right masectomy + radiation + chemo 7yrs ago presents with right arm swelling PE: non-pitting edema of right UE and 3 firm purple papules on inner surface of right arm

Secondary angiosarcoma (rare malignant tumors arising from internal lining of blood or lymphatic vessels --> risk factors: localized radiation therapy and chronic axillary lymphedema --> presents 4-8yrs after radiation therapy with multiple ecchymosis or purpuric masses on skin of breast/axilla/upper arm, lymphedema, and peau d'orange appearance of breast --> poor prognosis, although surgical resection is curative)

59M with PMHx of smoking and recently dx small cell lung cancer presents with diffuse headaches that get worse when leaning forward and chronic cough PE: increased JVP with prominent collateral veins,

SVC syndrome (superior vena cava syndrome: medical emergency characterized by obstruction of SVC impairing blood drainage from head + neck + UE, resulting in increased ICP --> causes: Pancoast tumor, mediastinal mass, fibrosing mediastinitis from TB/histoplasma, lymphoma, and thrombosis from indwelling catheters --> presents with facial plethora with blanching on fingertip pressure, conjunctival congestion, JVD and prominent neck veins, UE edema, headaches that are WORSE WHEN LEANING FORWARD, and dizziness --> treatment: endovenous stenting + radiation therapy --> complications: aneurysm/rupture of intracranial arteries)

Oxygenation goals in hypercapnic/hypoxemic patients

SaO2 88-82% and PaO2 60-70

Indications for supplemental O2 in newborns

SaO2 <87%, PaO2 <50, or respiratory distress (signs of respiratory distress include: RR >60/min, grunting, retractions, or cyanosis)

45F with PMHx of severe depression, migraine, and rheumatoid arthritis presents with nausea, fever, upper abdominal discomfort, and severe tinnitus + vertigo after overdosing on one of her meds several hours ago Vitals: febrile 100.5F, BP 120/76, HR 115, RR 26

Salicylate intoxication (caused by overdose of aspirin which initially stimulates respiratory center in medulla to cause tachypnea leading to respiratory alkalosis, then followed by uncoupling of OxPhos in mitochondria leading to anaerobic metabolic and anion gap metabolic acidosis --> treatment: alkalinization of urine with sodium bicarb or dialysis)

32F presents with weakness, tingling, and numbness of extremities Vitals: BP 110/70, HR 90, RR 14 Labs: low K+, low Cl-, metabolic alkalosis Urine lytes: low urine Cl- and low urine Na+

Saline-responsive metabolic alkalosis (due to loss of gastric secretions resulting in ECF loss, leading to increase aldosterone, increased renal Na+ and Cl- reabsorption, and increased urinary H+ and K+ excretion --> causes: vomiting, NG aspiration, antacids, and diuretic overuse --> presents with hypokalemia, metabolic alkalosis, and LOW URINE Cl- <20 --> treatment: isotonic saline infusion to restore both ECF volume and low serum Cl-)

Type of bias in which study population differs from target population due to nonrandom selection methods

Sampling bias (ascertainment bias: type of selection bias)

11yo boy presents with 2wk hx of intensely pruritic skin rash that started on hands and spread to trunk + LE. Cousin who recently visited and shared a room had similar sx. PE: numerous 2-3mm erythematous papules and vesicles with excoriations on neck/hands/feet/waistline

Scabies (skin infection with mite Sarcoptes scabiei transmitted via direct person-to-person contact --> presents with extremely pruritic rash of small erythematous papules/vesicles and pathognomonic burrows in axillae, periumbilical area, genitalia, and interdigital web spaces of hands + feet --> diagnosis: clinical or skin scraping microscopy showing mites/eggs --> treatment: topical 5% permethrin or oral ivermectin --> prevention: treating household contacts and decontamining linens)

Most common carpal bone fracture

Scaphoid fracture (caused by FOOSH injury that causes axial compression or wrist hyperextension, resulting in disrupted flow to proximal segment and avascular necrosis of scaphoid --> presents with tenderness in anatomic snuffbox aka radial wrist PROXIMAL to base of thumb, swelling at dorsum of wrist, and worsened pain with RADIAL deviation --> diagnosis: CT or MRI at time of injury, or thumb spica splint immobilization with repeat imaging in 7-10 days)

Most common sites of avascular necrosis

Scaphoid, femoral head, and 5th metatarsal

56F presents with 1wk hx of headaches and intermittent vision changes and 1-day hx of altered mental status Vitals: afebrile, BP 220/115, HR 90, SaO2 99% on RA PE: lethargic, shiny thickened skin on hands with multiple telangiectasias, and 1+ LE edema to shins Non-con head CT: unremarkable Labs: low HCO3- and high Cr UA: 1+ proteinuria

Scleroderma renal crisis (SRC: life-threatening complication of systemic sclerosis caused by collagen deposition within renal vasculature, leading to renal ischemia and activation of RAAS causing hypertensive emergency --> signs of systemic sclerosis: shiny thickened skin with multiple telangiectasias, swollen digits, ulcerations at digital tips, Raynaud syndrome, and esophageal dysmotility/dysphagia --> SRC presents with oliguria, altered mental status, and HTN EMERGENCY --> labs: MAHA, thrombocytopenia, intrinsic AKI, and mild proteinuria ---> treatment: IV captopril inhibitors to reduce RAAS and improve renal function + BP, possible HD for severe SRC)

42F presents with 2-hr hx of headache and lightheadedness that began 10mins after eating mahimahi PE: appears slightly flushed

Scombroid poisoning (histamine poisoning: caused by ingestion of accumulated histamine produced from bacteria within spoiled dark meat fish such as tuna/mahimahi/mackerel/bonito, triggering an anaphylactic-like reaction --> presents IMMEDIATELY after eating dark fish with flushing, burning sensation of mouth, urticaria, wheezing, itchiness, blurry vision, abdominal cramping, diarrhea, and headache --> treatment: antihistamines +/- albuterol plus EPI --> complications: bronchospasms, angioedema, and hypotension)

Recommended HCC surveillance for patients with cirrhosis

Screening abdominal US every 6 months

Skin exam: pigmented lesion with well-demarcated border and greasy "stuck on" appearance

Seborrheic keratosis (BENIGN epidermal skin lesion commonly seen in ELDERLY caused by squamous epithelial proliferation of immature keratinocytes with keratin-filled "horn" cysts --> presents with flat, greasy, pigmented lesion with "stuck on" appearance on head/trunk/extremities --> explosive onset of multiple SKs known as Leser-Trelat sign may indicate GI adenocarcinoma or other cancer --> biopsy: small cells resembling basal cells, hyperkeratosis, and keratin-containing cysts)

Management of caustic ingestion

Secure airway, decontamination, IV saline, CXR, and upper GI endoscopy (secure airway: if airway compromise, then intubate --> decontamination: remove contaminated clothing/visible chemicals and irrigate exposed skin --> IV saline: hydrate patient --> CXR: should perform serial CXR and abdominal XRs to identify signs of perforation --> upper GI endoscopy: performed <24hrs to assess severity of esophageal damage)

Patient with PMH of gastric bypass surgery presents with recurrent infections, new onset hypothyroidism, and cardiomyopathy

Selenium deficiency (presents with triad of immune dysfunction, thyroid dysfunction, and cardiomyopathy --> associated with MACROCYTIC anemia)

Scrotal US: solid hypoechoic testicular mass

Seminoma (type of germ cell tumor arising from seminiferous tubules and most common type of testicular tumor --> presents with painless homogenous testicular enlargement --> labs: elevated b-HCG and PALP, normal AFP --> diagnosis: scrotal US shows solid hypoechoic mass, histo shows large cells in lobules with watery cytoplasm and "fried egg" appearance)

What are two types of testicular germ cell tumors?

Seminoma and non-seminoma (testicular germ cell tumors: make up 95% of all malignant testicular neoplasms --> seminoma: most common testicular tumor that presents with painless testicular enlargement and elevated placental ALP/PALP --> non-seminoma: includes yolk sac tumor that produces AFP, choriocarcinoma that produces b-HCG, embryonal carcinoma that presents with hemorrhagic mass + necrosis and elevated b-HCG, and teratoma that presents with calcifications/hair on scrotal US)

Ear PE: - Tuning fork lateralizes to unaffected ear - Air conduction > bone conduction b/l

Sensorineural hearing loss (causes: vestibular schwannoma, Meniere disease --> presents with Weber test lateralizing to UNAFFECTED ear --> Rinne test showing AC > BC b/l)

Patient with recent nasal trauma is unable to breathe through nose PE: soft, fluctuant swelling of septum bilaterally

Septal hematoma (accumulation of blood between perichondrium and septal cartilage that is rare complication of nasal trauma --> presents with nasal obstruction and soft flucuant swelling of nasal septum --> treatment: immediate incision and drainage, nasal packing, ice packs, NSAIDs, and antibiotics --> complications: septal abscess, avascular necrosis of septal cartilage, septal perforations, saddle nose deformity, and internal nasal valve collapse)

Treatment of polcythemia vera

Serial phlebotomy and hydroxyurea (NOTE: only add hydroxyurea if pt is elderly or has previous DVTs)

26F presents with several hours of severe, left-sided, throbbing headache + N/V that was not relieved by migraine med. Diagnosed with migraine w/ aura and received single dose of sumatriptan. 3 hours later, presents with disorientation and generalized tonic-clonic seizure. Vitals: BP 220/110, HR 120

Serotonin syndrome (overactivation of serotonin receptors resulting in severe prolonged vasoconstriction and autonomic instability --> causes: SSRIs/SNRIs, MAO inhibitors, TCAs, vilazodone, vortioxetine, tramadol, Zofran, triptans, ergotamine, linezolid, dextreomethorphan, meperidine, MDMA, and St. John's wort --> presents with hyperthermia, HTN, diaphoresis, diarrhea, hyperreflexia/clonus, hypertonia, tremors, seizures, and altered mental status --> treatment: cpyroheptadine)

Best next step in management for young girl with primary amenorrhea and presence of uterus

Serum FSH (if LOW FSH: central amenorrhea due to hypothalamic or pituitary pathology --> if HIGH FSH: peripheral amenorrhea due to lack of ovarian estrogen + inhibin production, proceed with karyotype analysis to dx with 45XO Turner syndrome or 46XX primary ovarian insufficiency --> if NORMAL: dx with imperforate hymen)

Best next step in management for child with precocious puberty and advanced bone age

Serum LH and FSH (need to determine basal LH --> if LOW BASAL LH, perform GnRH stimulation test to determine whether peripheral or central precocious puberty --> if HIGH BASAL LH, dx with central precocious puberty and order pituitary MRI)

Best next step in management after diagnosis of hyperlipidemia (HLD)

Serum TSH (need to screen for hypothyroidism after diagnosis of hypercholesterolemia and also before starting statins due to increased risk of statin-induced myopathy in hypothyroidism)

Young girl with primary amenorrhea and presence of uterus on pelvic US Labs: low FSH Best next step in management?

Serum TSH and prolactin (if HIGH TSH + PROLACTIN: dx with hypothyroidism --> if HIGH PROLACTIN with normal TSH: dx with prolactinoma --> if BOTH NORMAL: dx with functional hypothalamic amenorrhea aka low GnRH production/release)

Best method to diagnose infectious mono in patients <4yo

Serum anti-EBV antibody (due to less accurate monospot test for children <4yo)

Indication for IV bicarb

Serum pH <7.2 (aka severe acute acidosis)

9yo boy presents with 2-day hx of pruritic rash on trunk + arms, fever, and joint pain in wrists and ankles after starting oral penicillin for strep pharyngitis 9 days ago Vitals: febrile 101.8F PE: ill-appearing boy with diffuse urticarial rash on arms and back, palpable LNs in cervical + axillary + inguinal regions, and tender wrists + ankles

Serum sickness-like reaction (type 3 hypersensitivity reaction occurring 1-2wks after starting beta-lactam or Bactrim, resulting in immune complex formation --> presents 1WK AFTER STARTING ABX with fever, urticaria, and polyarthralgia --> diagnosis: low complement and elevated ESR/CRP --> treatment: remove offending agent, supportive care, and steroids/plasmapheresis if severe)

Cause of central cord syndrome

Severe extension injury (central cord syndrome: damage to CENTRAL portion of spinal cord --> often seen in ELDERLY patients with preexisting cervical stenosis --> presents with UE weakness/numbness, sensory loss, and reflex loss but PRESERVATION of DISTAL LE function)

Cause of anterior cord syndrome

Severe flexion injury (anterior cord syndrome: damage to anterior 2/3 of spinal cord, which receives blood supply from ANTERIOR spinal artery --> causes damage to corticospinal and lateral spinothalamic tracts bilaterally, however PRESERVES dorsal columns --> presents with paraplegia and loss of pain/temp sensation with PRESERVATION of deep touch/pressure + vibration + proprioception)

Treatment of comedonal acne

Topical retinoids (can also recommend topical salicylic, azelaic, or glycolic acid)

30-month-old girl presents with malaise, fever of 101F, abdominal pain, loose bloody stools, and 1 episode of generalized tonic-clonic seizure Vitals: febrile 103.5F PE: slightly decreased skin turgor

Shigellosis (infection with Shigella, a gram-negative non-lactose-fermenting bacilli that releases the enterotoxin Shiga toxin that damages GI mucosa, resulting in bacillary dysentery --> presents with high fevers >102.2, crampy abdominal pain, bloody mucoid diarrhea, tenesmus, and febrile seizures --> treatment: oral rehydration --> complication: hemolytic uremic syndrome)

Skin exam: initial itching/burning pain followed by eruption of small red papules

Shingles (herpes zoster: caused by reactivation of latent VZV virus due to age or immunocompromise --> presents with prodrome of ITCHING/BURNING PAIN and ALLODYNIA followed by small papules that become confluent and evolve into vesicles/bullae with subsequent crusting in 7-10 days --> treatment: acyclovir, famciclovir, or valacyclovir)

65yo M with recent MI and sustained Vtach treated with IV amiodarone s/p successful PCI presents on POD2 with full neuro recovery Labs: AST and ALT >1000

Shock liver (ischemic hepatitis: caused by global hypoperfusion and/or hypoxemia from all types of shock or respiratory failure, resulting in hepatocyte necrosis in zone 3 of liver lobule which surrounds central veins --> presents with AST/ALT >1000 and bilirubin rise several days later --> treatment: resolution within 7 days)

Causes of stress-induced ulcer

Shock, sepsis, coagulopathy, mechanical ventilation, TBI, burns, and high-dose steroids (usually associated with ICU-level care: involves splanchnic hypoperfusion, reflux of bile salts, and accumulation of ureimc toxins that impair formation of protective mucosal layer around stomach resulting in mucosal injury + occult GI bleeding)

Which functions are impaired by a rotator cuff impingement/tear?

Shoulder abduction and external rotation

ECG: sinus bradycardia with delayed and dropped P waves

Sick sinus syndrome

77F with PMHx of HTN and hypothyroidism presents with 3-wk hx of lightheadedness and presyncope when she gets out of bed Vitals: afebrile, BP 150/90, HR 64 and irregularly irregular, RR 16 PE: JVP 3cm above sternal angle, grade 1/6 systolic murmur best heard at LSB, and trace pitting edema of ankles Labs: normal TSH ECG: AFib with ventricular rate of 64bpm, unchanged from 1yr ago

Sick sinus syndrome (SSS: inability of SA node to generate adequate HR usually caused by age-related degeneration of cardiac conduction system resulting in fibrosis of sinus node and possible fibrosis of atria leading to paroxysmal atrial arrhythmias --> risk factors: ELDERLY, sarcoidosis, amyloidosis, hemochromatosis, Chagas disease, and cardiomyopathy --> presents with SYMPTOMATIC BRADYCARDIA leading to fatigue + DOE + lightheadedness + confusion + syncope/presyncope, AFib, and bradycardia-tachycardia syndrome characterized by brady alternating with SVT --> diagnosis: ambulatory ECG shows sinus bradycardia with sinus pauses/delayed P waves and SA nodal exit block/dropped P waves, exercise test shows chronotropic incompetence aka inadequate HR response to exercise --> treatment: pacemaker and rate-control meds for persistent paroxysmal tachyarrhythmias)

18M presents with several month hx of excessive urination and nocturia Labs: normal HCT and Na+ UA: low specific gravity

Sickle cell trait (SCT: caused by heterozygosity in Hgb beta-chain gene, usually asymptomatic with no change in overall life expectancy --> causes HYPOSTHENURIA aka inability of kidneys to concentrate urine due to RBCs sickling in vasa recta in response to hypoxic hyperosmolar conditions of renal medulla, resulting in impaired free water reabsorption and countercurrent exchange --> presents with polyuria + nocturia, hematuria, normal serum Na+, and LOW specific urine gravity --> diagnosis: Hgb electrophoresis shows HbA > HbS --> complications: papillary necrosis, UTIs during pregnancy, splenic infarct at high altitudes, VTE, priapism, and exertional rhabdomyolysis)

36M with PMHx of infiltrative pulmonary TB on RIPE therapy started 2mo ago presents with progressive fatigability Labs: low Hgb, low MCV, high ESR, high serum iron, and low TIBC Peripheral smear: hypochromic and normochromic RBCs

Sideroblastic anemia (caused by defective heme synthesis, usually due to pyridoxine-dependent impairment in early steps of protoporphyrin synthesis --> causes: X-linked defect in ALA, MDS, alcohol use, lead poisoning, vitamin B6 deficiency, copper deficiency, INH, and linezolid --> presents with microcytic hypochromic anemia --> labs: HIGH IRON, LOW TIBC, "dimorphic" RBC population with hypochromic + normochromic RBCs and basophilic stippling on peripheral smear, and ringed sideroblasts on bone marrow smear --> treatment: vitamin B6)

87F with PMHx of severe Alzheimer dementia presents with 12-hour hx of altered mental status and agitation Vitals: febrile 100.4F, BP 148/86, HR 92, RR 24 PE: distended abdomen with diffuse guarding and negative FOBT Labs: normal CBC Abdominal XR: "coffee bean" sign of sigmoid colon

Sigmoid volvulus (twisting of sigmoid colon around its mesentery, leading to bowel obstruction and infarct --> risk factors: chronic constipation, laxative use, hypothyroidism, anticholinergic drugs, MS, scleroderma, and Parkinson disease --> presents in ELDERLY with abdominal distention, constipation, vomiting, peritoneal signs, and "tire-like" feel of abdomen --> diagnosis: abdominal XR shows "coffee bean sign," barium enema shows "bird beak" sign --> treatment: sigmoidoscopy-guided placement of rectal tube to untwist volvulus and prevent acute recurrence)

Treatment of sigmoid volvulus

Sigmoidoscopy and rectal tube (sigmoidoscopy: used to derotate volvulus --> rectal tube: used to prevent acute recurrence)

Lyme disease prophylaxis after tick removal (ONLY if tick attached >36hrs)

Single-dose doxycyline

Diagnosis of mucormycosis

Sinus endoscopy with biopsy and culture (biopsy shows Mucor or Rhizopus species: irregular, broad nonseptate hyphae branching at wide angles)

ECG findings associated with massive PE

Sinus tachycardia, RBBB, and S1Q3R3 pattern

Liver biopsy findings in CHF/congestive hepatopathy

Sinusoidal congestion and hemorrhagic necrosis

Characteristics of category III FHT

Sinusoidal pattern or absent variability with bradycardia or recurrent late/variable decels (category III FHT: indication for immediate C-section)

Treatment of inflammatory acne

Topical retinoids and benzoyl peroxide (if moderate, can add topical macrolide --> if severe, can add oral macrolide)

Which radiographic factors increase malignant probability of solitary pulmonary nodule (SPN)?

Size >2cm, irregular borders, upper lobe location, and spiculation (other non-radiographic factors that increase malignant probability: advanced patient age, female sex, history of smoking, and family history of lung cancer --> nodules with intermediate/high probability of malignancy require biopsy or surgical excision --> if tissue diagnosis is unclear, require PET scan)

Which conditions cause upregulation of postsynaptic ACh receptors?

Skeletal muscle injury, burn injury, disuse muscle atrophy, and denervation (examples of denervation: stroke, Guillain-Barre syndrome, and critical illness polyneuropathy --> since all of these conditions are associated with hyperkalemia, need to use ONLY vecuronium and rocuronium since they do not affected postsynaptic ligand-gated channels)

Key signs of ACTH-dependent hypercortisolism (Cushing disease)

Skin hyperpigmentation and androgenic symptoms (skin hyperpigmentation: due to co-secretion of MSH and direct stimulation of MSH receptors by ACTH --> androgenic symptoms: due to ACTH stimulating androgen production from zona reticularis)

Child who has incomplete awakenings with marked autonomic arousal, no recall of dream content, and unresponsive to comfort

Sleep terror disorder (non-REM arousal disorder --> usually occurs in FIRST 1/3 of night)

Best next step in management after diagnosis of juvenile idiopathic arthritis (JIA)

Slit-lamp examination (due to high risk of uveitis in patients with JIA)

Characteristics of normal lymph node findings in children

Small <2cm, nontender, soft, mobile LNs (usually in LOCALIZED area with absent systemic symptoms)

Causes of positive D-xylose test (low urinary D-xylose)

Small intestine malabsorption, delayed gastric emptying, impaired GFR, and SIBO

Strongest modifiable risk factor for CAD

Smoking (#1 preventable risk factor for CAD --> diabetes is most important non-modifiable risk factor)

What is the risk factor most strongly associated with AAA progression?

Smoking (strongest modifiable risk factor for AAA development and progression --> other risk factors: advanced age >60yo, male sex, family history, HTN, atherosclerosis, and CT disease --> screening: one-time abdominal US for male smokers age 65-75yo)

Management of PAD (peripheral artery disease)

Smoking cessation and exercise (try conservative management first --> ASA can reduce CV mortality but does not improve symptoms)

6 risk factors for postop pulmonary complications (such as pneumonia)

Smoking, previous lung disease, age >50, thoracic or abdominal surgery, surgery >3hrs, and poor general health

What are 3 facial abnormalities characteristic of fetal alcohol syndrome?

Smooth philtrum, thin vermillion border, and small palpebral fissures

Where are diabetic foot ulcers most commonly seen?

Soles of feet and tops of toes (caused by peripheral neuropathy and microvascular insufficiency causing poor wound healing --> associated with Charcot deformity aka "rocker bottom" feet --> management: mechanical offloading, debridement, wound dressings, and antibiotics if infected)

1-hour-old boy born at term via SVD who did not move LE immediately after birth and did not cry on needlestick in heel presents with bilateral clubfoot deformity PE: cannot move LE and palpable full bladder

Spinal dysraphism (spectrum of neonatal disorders associated with incomplete closure of neural tube in utero --> includes spinda bifida, split cord malformation, spinal cord lipoma, dermal sinus tract, tight filum terminale, and tethered spinal cord --> presents at birth with BOTH motor + sensory loss of bilateral LE, bowel/bladder incontinence, and orthopedic deformities)

1yo boy presents with 2-mo hx of increasing weakness and difficulty feeding PE: tongue fasciculations, profound hypotonia, and absent DTRs

Spinal muscular atrophy (Werdnig-Hoffman syndrome: autosomal recessive disorder caused by genetic defect in SMN1 gene that results in progressive degeneration of anterior horn cells in spinal cord, leading to "floppy baby" syndrome --> presents with generalized symmetric proximal muscle weakness, hypotonia, areflexia, tongue fasciculations, and difficulty feeding/poor suck

Which structures are at risk of injury with left-sided fracture of ribs 9-12?

Spleen and kidney (spleen: located near ribs 9-10 --> kidney: located near ribs 11-12)

40M with PMHx of asymptomatic mitral valve prolapse and smoking presents with 2wk hx of fever, malaise, weakness, and unintentional 5lb wt loss with 4-day hx of left-sided chest and upper abdominal pain Vitals: febrile 103F, BP 120/70, HR 96, RR 16 PE: decreased breath sounds in LLL with dullness to percussion and 2/6 systolic murmur at apex Labs: elevated WBC with bandemia, low Hgb Abdominal CT: left-sided pleural effusion and splenomegaly with splenic fluid collection

Splenic abscess (infection and formation of splenic fluid collection usually caused by hematogenous seeding/septic emboli to spleen from Staph/Strep/Salmonella --> risk factors: infective endocarditis, sickle cell disease, HIV, IVDU, and trauma --> presents with TRIAD of fever + leukocytosis + LUQ pain, left-sided pleuritic chest pain w/ pleural effusion, and splenomegaly --> diagnosis: abdominal CT shows splenic fluid collection --> treatment: broad-spectrum abx and splenectomy, percutaneous drainage for poor surgical candidates)

"Watershed" areas of the colon most commonly affected by ischemic colitis

Splenic flexure and rectosigmoid junction (splenic flexure: at watershed line between superior and inferior mesenteric arteries --> rectosigmoid junction: at watershed between sigmoid and superior rectal arteries)

Best next step in management for patient with ITP and mucosal bleeding

Steroids, anti-D IG, and IVIG (ITP treatment ONLY if child presents with mucosal bleeding, or adult presents with mucosal bleeding or plts <30k)

Treatment of atlantoaxial joint subluxation

Stiff surgical collar and cervical fixation

25yo M presents to ED after falling 10ft from treehouse and landing on left side with left shoulder pain, left-sided chest pain, and abdominal pain Vitals: BP 114/72, HR 116 PE: bruising to left side of chest wall and abdomen, sharp left-sided chest pain with deep inspiration, and tenderness to palpation of left costal margin and LUQ

Splenic injury (common intraabdominal complication following blunt abdominal trauma that causes intraabdominal hemorrhage --> presents with LUQ pain, referred left shoulder pain, tachycardia, left costal margin tenderness from associated left lower rib fractures, and NEGATIVE FAST --> diagnosis: CT abdomen/pelvis with contrast --> treatment: splenic repair or removal)

Patient with sickle cell anemia presents with pallor Labs: - Normocytic anemia - INCREASED retic count - Normal WBCs - Thrombocytopenia

Splenic sequestration crisis (complication of sickle cell disease in YOUNG PATIENTS caused by RBC pooling in spoon, resulting in splenic vaso-occlusion and splenic engorgement --> presents with pallor, LUQ pain, splenomegaly, and hypovolemic shock --> diagnosis: normocytic anemia with RETICULOCYTOSIS and thrombocytopenia --> treatment: IV fluids, small-volume transfusions, and eventual splenectomy)

37M presents with 3-mo hx of low back pain moderately relieved by NSAIDs PE: palpable step-off in lumbosacral area and pain on hyperextension of spine

Spondylolisthesis (forward slip of vertebral body usually due to spondylosis, aka pars interarticularis defects/fractures caused by overuse injury --> most common site is L5/S1 slippage --> risk factors: adolescents age 10-19yo with growth spurts, athletes with repetitive back extension/rotation such as gymnasts + divers, and elderly >60yo with degenerative arthritis --> presents with pain on lumbar EXTENSION and palpable step-off in lumbosacral area --> diagnosis: lateral XR shows forward slippage of vertebra --> treatment: limited activity, PT, analgesics, and/or surgery)

Which types of lung cancer most commonly occur CENTRALLY in the lung?

Squamous cell carcinoma and small cell carcinoma (SCC: associated with 3 Cs of cigarettes, hyperCalcemia, and cavitation --> SCLC: associated with smoking, Cushing syndrome, SIADH, and Lambert-Eaton syndrome)

Which lung cancers are most commonly associated with smoking?

Squamous cell, small cell, and large cell carcinoma (association with smoking in order: SCC usually occurring centrally > SCLC also occurring centrally > LCLC that occurs peripherally)

Most common bacteria that causes postop meningitis

Staph aureus

Most common cause of bacterial conjunctivitis in adults

Staph aureus (bacterial conjunctivitis: presents with unilateral/bilateral conjunctival erythema, thick purulent yellow discharge that re-accumulates after wiping, and "stuck shut" eye when waking --> treat with topical antibiotics)

Most common pathogen causing CF-related pneumonia in children

Staph aureus (gram-positive cocci in clusters that colonizes the lungs in CHILDREN)

Most common cause of acute infection in burn patients (<5d since burn)

Staph aureus (gram-positive cocci: due to spread from hair follicles and sweat glands)

Most common cause of spinal epidural abscess

Staph aureus (tx of SEA: IV ceftriaxone and vancomycin + urgent decompression of epidural space with aspiration/surgery)

Most common organisms causing deep infections after puncture wounds

Staph aureus and Pseudomonas (Pseudomonas: most common infectious organism after puncture wounds thru sole of shoe)

Most common causes of vertebral osteomyelitis in IVDU

Staph aureus and Pseudomonas (vertebral osteomyelitis aka discitis osteomyelitis: infection of vertebral disc and adjacent vertebral bodies usually due to Staph aureus from continguous spread from adjacent soft tissue infection OR hematogenous spread from infective endocarditis --> presents with fever, localized spinal pain + tenderness, and possible focal neuro signs --> diagnosis: spinal XR shows destructive changes of vertebral bone and collapse of intervening disc space --> treatment: IV antibiotics)

Patient presents with sudden-onset nausea, abdominal cramps, and severe vomiting after eating at a picnic 2hrs ago

Staph aureus foodborne illness (transmitted via colonized food handlers during preparation --> usually caused by eating dairy items, meats, eggs, produce, and potato salads in summer months --> presents WITHIN 1-6HRS of ingestion with severe nausea/vomiting and abdominal cramps --> course: self-resolving within 24-48hrs)

Most common organisms causing septic arthritis in children <3mo

Staph aureus, GBS, E coli, and Klebsiella

Which bacteria are most commonly seen in prosthetic joint infections within first 3mo of surgery?

Staph aureus, Pseudomonas, and anaerobes (early-onset prosthetic joint infection/PJI: caused by perioperative contamination of joint or extension from overlying wound infection due to HIGHLY VIRULENT organisms such as Staph aureus, Pseudomonas, and anaerobes --> presents <3 MONTHS after knee surgery with acute knee pain, high fever, wound infection/breakdown, erythema, purulent drainage, and leukocytosis --> diagnosis: synovial fluid shows neutrophil-predominant WBCs >10k with positive Gram stain + culture --> treatment: IV antibiotics)

Most common organisms that cause CLABSI

Staph aureus, Staph epidermidis, and Candida

Which bacteria are commonly seen in prosthetic joint infections 3-12mo after surgery?

Staph epidermidis, Propionibacterium, and enterococci (delayed-onset prosthetic joint infection/PJI: caused by perioperative contamination of joint or extension from overlying wound infection with LESS VIRULENT organisms such as Staph epidermidis, Propionibacterium, and Enterococci --> present within 3-12 MONTHS after knee surgery with chronic joint pain, implant loosening, gait impairment, and/or sinus tract formation + ABSENT FEVER and LEUKOCYTOSIS --> diagnosis: synovial fluid shows neutrophil-predominant WBCs >10k with Gram stain + culture --> treatment: IV antibiotics)

Best next step in management for pregnant patient with suspected PPROM

Sterile speculum exam of vagina (decreases risk of chorioamnionitis as opposed to digital cervical exam)

Treatment of croup

Steroids and nebulized racemic epi (steroids: given if stridor with agitation --> nebulized racemic epi: given if stridor at rest --> pts also improve when breathing cold air due to vasoconstriction of subglottic vessels resulting in reduced subglottic edema)

Signs of child abuse for patient with scald injury

Stocking and glove burn with sharp demarcation, uniform depth, spared flexural creases, and absence of splash marks (child abuse scald injury: involves buttocks + back + legs if child id forced into bathtub with hot water)

Indications for hospitalization for patients with symptomatic kidney stone

Stone >10mm, anuria, urosepsis, AKI, complete obstruction, or refractory pain (require urgent urology consult for possible percutaneous nephrostomy or ureteral stent insertion)

Indications for urology consult for symptomatic ureteral stone

Stone >10mm, refractory pain, and no stone passage in 4-6wks (require more aggressive intervention such as lithotripsy or ureteroscopic intervention)

Best next step in management for patient with HIV with non-bloody diarrhea

Stool exam for culture, ova and parasites, C diff antigen, and acid-fast stain (culture/O&P: looking for microsporidia, Giardia, and Isospora belli --> C diff antigen: looking for C diff --> acid-fast stain: looking for Cryptosporidium and MAC)

Diagnosis of C diff

Stool toxin testing (includes stool PCR for C diff toxin genes or stool EIA for C diff toxins and glutamate dehydrogenase antigen)

Best next step in management with patient on PTU who presents with fever + sore throat

Stop PTU and obtain WBC (due to risk of agranulocytosis --> WBC <1000 requires permanent discontinuation of drug)

Patient with BPH presents with urinary frequency/urgency, nocturia, and some urinary incontinence

Storage LUTS (irritative/filling LUTS: symptoms of BPH caused by inability to STORE URINE in bladder, resulting in incomplete bladder emptying)

4yo boy presents with crossed eyes with left eye slightly deviated towards nose over last few months PE: 20/50 in L eye with temporal corneal light reflex, more intense red reflex in left eye, and left eye fixation from nasal to temporal when right eye is covered

Strabismus (ocular misalignment: characterized by nasal/esotropia or temporal/exotropia deviation of eye in children >4mo --> presents with intermittent eye deviation, asymmetric red reflex and corneal light reflex, and torticollis/head tilt --> diagnosis: positive cover test aka misaligned eye shifts to refixate on object when normal eye covered, and dilated fundoscopic exam to RULE OUT retinoblastoma --> treatment: correct refractive errors and PATCHING/BLURRING normal eye with atropine drops --> complications: amblyopia aka functional reduction in visual acuity and diplopia)

82M presents with 12-hour hx of left groin pain, nausea, and vomiting Vitals: febrile 102.2F, BP 90/60, HR 110 PE: 5cm firm tender inguinal mass Labs: high WBC with left shift

Strangulated inguinal hernia (protrusion of intraabdominal/pelvic contents thru abdominal wall, which can become trapped within hernia sac aka incarceration that leads to reduced venous outflow, resulting in ischemia and necrosis aka strangulation --> presents with PAINFUL inguinal mass that does not recede, fever, N/V, and leukocytosis --> treatment: urgent surgical repair)

Newborn skin exam: bright red raised plaque on cheek

Strawberry hemangioma (benign capillary tumor formed from abnormally proliferating endothelial cells --> presents as bright red, sharply demarcated, blanching nodule/plaque that rapidly enlarges during age 0-1 then slowly regresses by age 9 --> treatment: usually observation, can give topical propranolol for ulcerating or disabling lesions)

Common causes of IE associated with colon cancer

Strep bovis and Clostridium septicum (Strep bovis: aka Strep galolyticus or group D strep --> Clostridium septicum: gram-positive spore-forming colonic bacteria --> any IE caused by these 2 organisms should prompt screening colonoscopy to look for colon cancer)

Causes of erythema nodosum

Strep pharyngitis, TB, leprosy, coccidiomycosis, histoplasmosis, sarcoidosis, Behcet syndrome, and IBD (erythema nodosum: delayed hypersensitivity reaction resulting in SQ inflammation --> presents with erythematous SQ nodules on bilateral legs)

Most common cause of sepsis in patients with sickle cell disease

Strep pneumo (usually non-vaccine serotypes --> prevention: pneumococcal vaccine and prophylactic penicillin until age 5)

Most common cause of community-acquired bacterial meningitis

Strep pneumo (usually secondary to hematogenous spread from concurrent pneumococcal pneumonia, resulting in Strep pneumo bacteremia and meningitis --> diagnosis: CSF shows high OP >350, low glucose <40, high protein >200, and neutrophilic leukocytosis >1k --> treatment: IV ceftriaxone + vancomycin + dexamethasone, and add IV ampicillin if pt >50yo or immunocompromised)

Which conditions are associated with triggering guttate psoriasis?

Strep throat and HIV

44F G4P4 presents with 9-mo hx of progressive loss of small amounts of urine while running requiring an absorbent pad PE: 2nd degree cystourethrocele

Stress incontinence (type of incontinence due to pelvic floor muscle weakness from chronic pressure or injury, resulting in urethral hypermobility in which urethra moves improperly and is unable to fully compress against anterior vaginal wall during times of increased intraabdominal pressure --> risk factors: multiparity, obesity, and chronic high-impact exercise --> treatment: pelvic floor muscle exercises/Kegels, wt loss, continence pessary, and midurethral sling for severe cases)

65F with recently dx early-stage colon cancer presents with 12hr hx of intermittent, pressure-like, mid-sternal chest pain Vitals: BP 145/90, HR 101 and regular, SaO2 99% on RA PE: normal ECG: sinus tachycardia with deep symmetric T wave inversion in leads V2-V4 Cardiac cath and CTA: no obstructive CAD

Stress-induced cardiomyopathy (Takotsubo cardiomyopathy/broken heart syndrome: catecholamine surge from acute physical/emotional stress results in cardiac microvascular spasm with ischemia and myocardial stunning leading to impaired contraction and LV dysfunction, causing segmental mid + apical hypokinesis and basilar hyperkinesis --> presents with chest pain mimicking MI and decompensated HF --> workup: ECG shows ST elevation/T wave inversions in anterior precordial leads, moderate troponin elevation, and NO CAD on cardiac cath --> diagnosis: ECHO shows LV apical hypokinesis and basilar hyperkinesis --> treatment: resolves in several weeks with supportive care)

ECHO: LV apical hypokinesis and basilar hyperkinesis

Stress-induced cardiomyopathy (Takotsubo cardiomyopathy: ECHO shows "balloon-shaped" heart on LV contraction with LV mid + apical hypokinesis and basilar hyperkinesis)

Painless GI bleed in patient recently admitted to ICU

Stress-induced ulcer (gastric mucosal injury/bleeding caused by splanchnic hypoperfusion + reflux of bile salts + accumulation of uremic toxins that impair formation of protective mucosal layer around stomach, resulting in stress ulcer formation in proximal stomach + duodenum --> risk factors: shock sepsis, coagulopathy, mechanical ventilation, TBI/TSI, burns, and high-dose steroids --> presents HOURS-DAYS of severe physiologic stress with PAINLESS GI BLEEDING --> treatment: PPI and endoscopy --> prevention: prophylactic PPI for high-risk patients with bleeding diathesis, prolonged mechanical ventilation, and recent GI bleed)

Which conditions are treated with ivermectin?

Strongyloidiasis and Onchocerciasis (Strongyloidiasis: infection with threadworm Strongyloides stercoralis in which filariform larvae penetrate skin and migrate to lungs, presents with urticaria + abdominal pain + respiratory sx --> Onchocerciasis/river blindness: infection with roundworm Onchocerca volvulus that causes loss of elastic fibers in skin + eyes, presents with dermatitis + ocular lesions)

CXR: enlarged, globular cardiac silhouette

Subacute cardiac tamponade (caused by chronic processes that result in slow accumulation of pericardial fluid, allowing pericardium to progressively stretch and eventually accumulate 1-2L of fluid --> once >2L fluid enters pericardium, intrapericardial pressures rise and compromise cardiac function --> presents with Beck triad + tachycardia + pulsus paradoxus --> CXR: enlarged globular cardiac silhouette)

50M with PMHx of URI 1wk ago presents with 2-day hx of malaise, fever, fatigue, and pain in front of neck Vitals: febrile 101.3F, BP 150/70, HR 110 PE: thyroid gland diffusely enlarged and tender Labs: low TSH, high free T4, and high ESR

Subacute thyroiditis (de Quervain thyroiditis/granulomatous thyroiditis: self-limited post-viral inflammatory process caused by granulomatous inflammation of thyroid gland --> presents with fever, hyperthyroidism, and painful tender goiter --> labs: hyperthyroidism, high ESR, high CRP, and low radioiodine uptake --> treamtent: beta-blockers and NSAIDs, should resolve spontaneously within a few months)

67F with PMHx of HTN and smoking presents with 6-mo hx of moderate aching of left arm when carrying grocery bags, doing anything with arm raised above head, or lifts anything heavy. Last week, she felt dizzy and almost had LOC while cleaning a large mirror PE: BP 115/85, HR 72 PE: normal

Subclavian steal syndrome (significant atherosclerosis of left subclavian artery PROXIMAL to origin of vertebral artery, resulting in distal decreased pressure and "reversal" of blood flow in ipsilateral vertebral artery leading to ischemia in affected LUE and eventual vertebrobasilar ischemia --> presents with LUE pain/fatigue/paresthesias, absent LUE pulses and decreased BLE pulses, dizziness, ataxia, and dysequilibrium during exercise of LUE --> clinical diagnosis: lower brachial SBP in LUE/bilateral LE and systolic bruit in supraclavicular fossa --> diagnostic confirmation: doppler US or MRI --> treatment: statins, smoking cessation, and stent placement)

1-day-old girl born at 39wks via SVD presents with diffuse, fluctuant scalp swelling that continues to expand

Subgaleal hemorrhage (collection of blood between periosteum and gala aponeurotica, usually caused by vacuum-assisted delivery--> life-threatening hemorrhage due to potential massive blood loss, 25% mortality --> presents 12-72hrs after delivery with diffuse fluctuant scalp swelling especially over occiput, with superficial skin bruising --> management: serial Hgb monitoring)

1st line treatment for stable angina

Sublingual nitroglycerin and beta-blockers (sublingual nitroglycerin: dilates capacitance veins to decrease preload --> beta-blockers: reduces myocardial O2 demand by decreasing HR and myocardial contractility --> 2nd line for beta-blocker contraindication includes non-DHP CCBs such as verapamil/diltiazem which also decreases HR + myocardial contractility to reduce myocardial O2 demand)

Patient who recently underwent lap appendectomy 10 days ago now presenting with fever, RUQ pain, nausea, anorexia, SOB, and hiccups Vitals: febrile 102.8F PE: decreased breath sounds at right base, distended abdomen with pain on RUQ palpation, and decreased bowel sounds Labs: elevated WBCs CXR: right pleural effusion

Subphrenic abscess (complication of laparascopic abdominal surgery in which abscess forms below diaphragm --> presents with recurrent fever, abdominal pain, nausea/vomiting, and hiccups --> diagnosis: abdominal CT --> treatment: drainage and IV antibiotics)

22F G1P1 presents with sudden onset of heavy vaginal bleeding 30mins after uncomplicated SVD with spontaneously delivered placenta with nontapering vessel extending to margin of membranes PE: uterus with moderate tone c/w 24wk gestation

Succenturiate placental lobe (accessory lobe of placenta: causes retained products of conception during delivery resulting in postpartum hemorrhage --> presents with heavy vaginal bleeding after delivery, boggy uterus, placenta missing cotyledons, and retained placental fragments on US --> treatment: manual extraction)

Treatment of lead toxicity when venous lead 45-69

Succimer (dimercaptosuccinic acid: treatment of moderate lead toxicity with venous lead 45-69)

Which anesthetic is associated with severe hyperkalemia?

Succinylcholine (depolarizing NMJ blocker that binds to post-synaptic ACh receptors to trigger influx of Na+ and efflux of K+, resulting in depolarization and temporary paralysis --> used for rapid-sequence intubation --> side effects: severe hyperkalemia, hypercalcemia, and malignant hyperthemia --> CONTRAINDICATIONS: skeletal muscle injury, burn injury, disuse muscle atrophy, and denervation --> antidote: cholinesterase inhibitor)

Which medications are most commonly associated with SJS/TEN?

Sulfa drugs, anticonvulsants, NSAIDs, and allopurinol

Best method of sun protection in infants <6mo

Sun avoidance and protective clothing (avoid sunscreen in infants <6mo due to thin skin & high surface area to body ratio which increases exposure to sunscreen chemicals)

Best method of sunburn prevention

Sun avoidance and protective clothing (very important especially for infants <6mo due to thin skin, need to avoid sun from 10am-4pm --> for older children/adults, apply sunscreen with SPF >30 about 15-30mins before sun exposure and reapply every 2hrs)

57F with PMHx of smoking presents with localized tenderness and swelling of left calf with pain at rest that increases with weight bearing PE: superficial varicosities b/l and tender indurated erythematous thickening in linear distribution 1cm wide along medial aspect form just below left knee to ankle

Superficial thrombophlebitis (thrombosis of superficial veins usually occurring in UE around IV site, or LE secondary to VARICOSE VEINS --> risk factors: varicose veins and smoking --> presents with pain, erythema, tenderness, and swelling of distal extremity with palpable "cord-like" indurations with reddish discoloration --> treatment: NSAIDs, elevation, warm compress, and rule out migratory superficial thrombophlebitis that would require pancreatic cancer workup)

73M with PMHx of dementia, colon cancer, and recent laparotomy for intestinal obstruction 8d ago presents with severe left facial pain and inability to fully open mouth Vitals: febrile 102F, BP 150/80, HR 90, RR 16 PE: swelling, erythema, and severe tenderness in left preauricular area Labs: elevated WBC

Suppurative parotitis (bacterial infection of parotid gland due to salivary stasis causing retrograde seeding of bacteria from oral cavity thru Stenson's duct into parotid gland --> organisms: Staph aureus and oral flora --> risk factors: ELDERLY POSTOP pts with dementia who have inadequate fluid hydration, poor oral hygiene, and anticholinergics --> presents with fever, chills, rapid onset painful swelling of parotid gland aggravated by chewing, exquisitely tender erythematous pre/postauricular swelling, and trismus --> labs: elevated amylase without pancreatitis --> diagnosis: US/CT to rule out salivary stones/neoplasms --> treatment: IV antibiotics, hydration, massaging pus out of gland, and sialogogues such as pilocarpine/gum to increase salivary flow)

Which part of the oropharynx is involved in the respiratory compromise seen in inhalation injury?

Supraglottic airway (efficiently exchanges heat with inhaled air --> very susceptible to direct thermal injury and acute obstruction by edema and blistering)

Which muscle is most commonly injured in a rotator cuff tear?

Supraspinatus (most commonly injured due to degeneration of tendon with age + repeated ischemia from impingement between humerus and acromion during abduction)

Management of septic arthritis

Surgical I&D and IV antibiotics

Best next step in management for pressure ulcer with escar

Surgical debridement (due to presence of necrosis)

Treatment of mucormycosis

Surgical debridement and liposomal amphotericin B

Treatment of prepubescent child with scoliosis and Cobb angle >40°

Surgical fixation

Treatment of SCFE

Surgical pinning of femoral head (used to immediately stabilize physis and avoid avascular necrosis)

Best next steps in management of traumatic LE injury

Surgical repair and arteriography (surgical repair of bone occurs FIRST --> immediately after, should do arteriography/surgical exploration of femoral artery to assess for damage, especially if patient presents with absent distal pulses)

Treatment of single brain met in accessible location

Surgical resection followed by SRS or WBRT

Treatment of papillary thyroid cancer

Surgical resection, radioiodine ablation, and levothyroxine

Type of bias in which risk factor itself causes increased monitoring in exposed group relative to unexposed group

Surveillance bias (detection bias: type of observational bias)

Best next step in management for neonate with meconium ileus

Sweat testing (need to evaluate for cystic fibrosis)

Indications for aortic valve replacement (AVR) for patients with severe AS

Symptomatic, LVEF <50%, and upcoming cardiac surgery (symptomatic: pt presents with syncope/pre-syncope, angina, dyspnea 2/2 CHF, late-peaking crescendo-descrendo systolic murmur best heard at RUSB, and diminished delayed pulses aka pulsus parvus et tardus --> LVEF <50%: indicates excessive afterload created by stenotic valve --> upcoming cardiac surgery: valve can be repaired concomitantly)

Treatment of PSVT in hemodynamically unstable patient

Synchronized cardioversion

Treatment of persistent tachyarrhythmia with hemodynamic instability

Synchronized cardioversion (delivery of low-energy electric shock synchronized to QRS complex)

Most common symptom associated with massive PE

Syncope

4yo boy presents with 6wk hx of intermittent fevers that spike in evenings accompanied by pink nonpruritic rash and body aches, which usually resolve by morning Vitals: febrile 102.F PE: tahcycardiac, several pink macules at waist and bilateral axillae, splenomegaly, and swelling of both knees and tenderness with deep palpation Labs: anemia, thrombocytosis, and leukocytosis with neutrophil predominance

Systemic JIA (chronic autoinflammatory childhood disorder that occurs in CHILDREN <18yo --> presents with arthritis in 1+ joint for >6wks, daily fever >2wks that spikes in evenings associated with evanescent "salmon pink" rash, hepatosplenomegaly, and LAD --> labs: anemia, thrombocytosis, leukocytosis, elevated ESR/CRP, and elevated ferritin --> treatment: steroids or MTX)

Patient receives transfusion, then develops respiratory distress and HYPERTENSION PE: bilateral crackles, JVD, and pitting ankle edema CXR: bilateral pulmonary infiltrates

TACO (transfusion-associated circulatory overload: caused by rapid transfusion and/or large volume of blood --> risk factors: age <3yo or >60yo with chronic anemia, and underlying cardiac/renal disease --> presents WITHIN 6HRS of transfusion with respiratory distress, HTN, tachycardia, pulmonary edema, and signs of cor pulmonale with S3 gallop + JVD --> treatment: diuretics and supplemental O2)

Neonatal XR: pulmonary edema and enlarged supracardiac veins + SVC

TAPVR (total anomalous pulmonary venous return: pulmonary veins drain into right heart circulation, causing severely decreased CO and requiring PFO/PDA for survival --> presents immediately after birth with severe cyanosis and respiratory distress --> diagnosis: CXR shows pulmonary edema and "snowman sign" aka enlarged supracardiac veins + SVC --> treatment: PGE to maintain PDA and emergency atrial septostomy)

45F with PMHx of major depression and chronic back pain presents obtunded with tonic-clonic seizure after being found with empty pill bottle Vitals: febrile 100.9F, BP 90/70, HR 120, RR 16 PE: responds to painful stimuli, dilated pupils b/l, warm flushed skin, and decreased bowel sounds ECG: prolonged QRS interval

TCA overdose (overdose of tricyclic antidepressants which blocks cardiac fast Na+ channels and decreases myocardial conduction velocity, causing major cardiac toxicity --> presents with hyperthemia, anticholinergic effects such as dilated pupils + skin flushing + intestinal ileus, seizures, and QRS prolongation --> treatment: activated charcoal, IV sodium bicarb for cardioprotection, and dialysis)

1st line treatment of fibromyalgia

TCAs (ex: amitriptyline --> 2nd line treatment includes SSNRIs such as duloxetine/milnacipran or pregabalin)

Differential diagnosis for pediatric MIDLINE neck mass

TDC and dermoid cyst (TDC: thyroglossal duct cyst aka ANTERIOR MIDLINE neck mass that moves with swallowing or protrusion of tongue, usually presents after URI with erythema/tenderness/drainage --> dermoid cyst: cystic mass with trapped epithelial debris occurring along embryologic fusion planes)

Best next step in management for patient with suspected aortic dissection and renal insufficiency

TEE (transesophageal echo: has excellent sensitivity + specificity for aortic dissection --> 1st line method of diagnosis for patients with hemodynamic instability or renal insufficiency --> if pt is hemodynamically stable AND has normal renal function, can dx with CTA)

Diagnosis of triglyceride-induced pancreatitis

TG >1000 (treatment of TG-induced pancreatitis: IV hydration, pain control, and insulin if glucose >500 or apharesis if glucose <500)

Neonatal CXR: narrow mediastinum and egg-shaped heart

TGV (transposition of great vessels: abnormal rotation of great vessels causing aorta to come off of RV and PA to come off of LV --> presents with cyanosis <24hrs of life, SINGLE S2 heart sound, and possible VSD murmur --> diagnosis: CXR shows narrow mediastinum and "egg on a string" heart --> treatment: PGE to keep PDA intact and emergency atrial septostomy)

2-hour-old boy born via SVD presents with worsening cyanosis over past few mins not relieved by O2 PE: tachypnea, subcostal retractions, normal S1, single loud S2, and no murmur

TGV (transposition of great vessels: congenital cyanotic heart defect caused by abnormal rotation of great vessels during cardiac development, resulting in aorta arising from RV and pulmonary artery arising from LV and causing deoxygenated blood to circulate through body --> presents with cyanosis <24hrs of life, SINGLE S2, and +/- VSD murmur --> diagnosis: CXR shows narrow mediastinum aka "egg on a string" heart --> treatment: PGE to keep PDA intact and emergency atrial septostomy)

Which cytokines are responsible for cachexia in chronic disease/malignancy?

TNF, IFNy, IL1, and IL6

Pelvic US: large thick-walled multiloculated mass filled with debris obliterating right adnexa

TOA (tuboovarian abscess: complication of PID in which STD extends from lower genital tract to become polymicrobial infection of upper genital tract, resulting in inflammatory exudate + purulent fluid + wall thickening that conglomerates into complex mass to create pyosalpinx and TOA --> causes: chlamydia and gonorrhea --> presents with fever, abdominal pain with tenderness to RLQ/LLQ, and unilateral enlarged tender adnexal mass ---> labs: leukocytosis and elevated CRP + CA-125 --> diagnosis: pelvic US shows complex multiloculated adnexal mass with thick walls and internal debris --> treatment: ampicillin + gentamicin + clindamycin)

30yo M with PMH of smoking presents after MVC with low Hb levels. 1hr after transfusion, patient develops difficulty breathing. Vitals: BP 86/42, HR 110, RR 26, SaO2 88% on RA PE: bilateral crackles CXR: bilateral pulmonary infiltrates

TRALI (transfusion-related acute ling injury: rare transfusion reaction in which neutrophils activated by DONOR anti-leukocyte Abs cause damage to pulmonary capillary endothelium, resulting in inflammatory pulmonary edema --> risk factors: smoking, alcohol abuse, critical illness --> presents within 6hrs of transfusion with respiratory distress and noncardiogenic pulmonary edema --> CXR: bilateral pulmonary infiltrates --> treatment: transfusion cessation and respiratory supportive care, aka ventilation)

Patient receives transfusion, then develops respiratory distress and HYPOTENSION PE: bilateral crackles CXR: bilateral pulmonary infiltrates

TRALI (transfusion-related acute lung injury: caused by DONOR anti-leukocyte Abs attacking pulmonary capillary endothelium, resulting in inflammatory pulmonary edema --> presents with respiratory distress, HYPOTENSION, and noncardiogenic pulmonary edema --> treatment: respiratory support)

Most common cause of transfusion-related death

TRALI (transfusion-related acute lung injury: donor Abs attack recipient WBCs, causing Ab-WBC complexes to accumulate in lung vasculature and induce inflammation leading to non-cardiogenic pulmonary edema --> treatment: IV fluid resuscitation + vasopressors + respiratory support)

18yo F with anterior nasal packing for nasal bleeding 3 days ago presents with severe vomiting, diarrhea, and dizziness Vitals: febrile 102.2F, BP 90/60 supine and 66/45 standing, HR 120, RR 23 PE: diffuse confluent eryhematous macules on trunk + extremities and hyperemic oropharynx Labs: low platelets and elevated bands

TSS (toxic shock syndrome: caused by release of TSS toxin-1 from Staph aureus, which acts as superantigen and causes T-cell activation releasing a large amount of cytokines --> causes: tampon use, nasal packing, surgical wound infections, sinusitis, and septorhinoplasty --> presents with acute onset of fever >102F, hypotension with SBP <90, diffuse macular erythroderma, and skin desquamation over palms/soles --> includes 3+ multisystem involvement including vomiting/diarrhea, myalgias or elevated CK, mucous membrane hyperemia, AKI, thrombocytopenia, transaminitis, ARDS, and/or altered mental status without focal neuro signs --> labs: thrombocytopenia and increased bands --> treatment: IV fluids, removal of foreign materials, and broad-spectrum anti-staph antibiotics)

Neonatal CXR: bilateral perihilar linear streaking, fluid lines in fissures, and flat diaphragm

TTN (transient tachypnea of newborn: inadequate alveolar fluid clearance at birth results in mild pulmonary edema --> risk factors: C-section, prematurity, and maternal DM --> presents at birth with respiratory distress and CLEAR BREATH SOUNDS that resolves by day 2 of life --> diagnosis: CXR shows bilateral perihilar linear streaking/prominent pulmonary vascular markings indicating mild pulmonary edema, fluid lines in fissures, and flat diaphragm indicating hyperinflation --> treatment: supplemental O2 --> self-resolving within 28hrs)

35M with PMHx of untreated HIV and HCV presents with unusual behavior and decreased appetite Vitals: febrile 100.2F, BP 140/86, HR 96, RR 16 PE: mild scleral icterus Labs: anemia with high retic count, thrombocytopenia, high Cr, high UCB, high AST + ALT, high AlkPhos

TTP (thrombotic thrombocytopenic purpura: life-threatening microvascular disorder caused by acquired anti-ADAMTS13 antibody, causing accumulation of vWF multimers that accumulate on endothelial wall and trap platelets at small arterioles/capillaries leading to formation of small vessel thrombi --> presents with PENTAD: thrombocytopenia, MAHA, renal insufficiency, neuro changes, and fever --> labs: thrombocytopenia, anemia with retic count >2.5%, high LDH, low haptoglobin, high indirect bili + transaminases, and high BUN + Cr --> diagnosis: peripheral blood smear shows schistocytes, helmet cells, and triangle cells --> treatment: plasma exchange +/- steroids)

Indications for terbutaline during delivery

Tachysystole and tetanic contractions (tachysystole: >5 contractions in 10mins --> tetanic contractions: contraction lasting >2mins)

Treatment of tardive dyskinesia

Taper or change med, valbenazine, and deutetrabenazine (taper or change med: usually include 1st gen antipsychotics, risperidone, and metoclopramide --> valbenazine and detetrabenazine: VMAT2 inhibitors)

Best next step in management for woman <30yo with palpable breast mass

Targeted US (used to characterize mass and better for women <30 due to more dense breast tissue --> if US shows irregular or indistinct borders/complex cyst then proceed to MG and perform image-guided core biopsy)

Which disease is characterized by deficiency in beta-hexosaminidase A?

Tay-Sachs disease

6-month-old girl presents with irritability, listlessness, and inability to sit/roll even though she was able to do several weeks ago PE: hypotonic, cervical LAD, hyperreflexia, and "cherry-red" macula on fundoscopic exam

Tay-Sachs disease (autosomal recessive disease caused by beta-hexosaminidase A deficiency --> presents at 2-6 MONTHS with loss of motor milestones, hypotonia, feeding difficulties, HYPERREFLEXIA, and "cherry-red" macula --> differentiated from Niemann-Pick by LACK OF HSM)

Which physical exam signs indicate open globe laceration (OGL)?

Teardrop pupil, abnormal anterior chamber depth, and reduced IOP (teardrop pupil: peaked/eccentric pupil caused by iris stretching due to open globe laceration or presence of foreign object --> abnormal anterior chamber death: due to extrusion of vitreous fluid --> reduced IOP: due to extrusion of fluid --> other signs of OGL: loss of visual acuity and absent afferent pupillary response)

Diagnosis of hypothermia

Temp <96.8 (aka <36C)

41M with PMHx of IVDU presents with several month hx of multiple episodes of not answering when spoken to, staring into space with fumbling hand movements, and confusion afterwards

Temporal lobe epilepsy (most common type of recurrent seizure disorder characterized by epileptiform discharges originating from temporal lobe --> presents with preceding auras of fear/olfactory hallucinations followed by 30-90 second episodes of automatisms of hand/mouth such as repeating words or gesturing, "blank stares" aka inability to interact with environment, and postictal confusion --> diagnosis: EEG shows epileptiform discharges over temporal region --> treatment: anticonvulsant)

57F presents with SOB and restless during attempted insertion of subclavian venous cath Vitals: BP 100/70, HR 100, RR 24 PE: JVD and decreased left-sided breath sounds

Tension pneumothorax (common complication of central line placements caused by iatrogenic rupture of pleural, creating one-way entry point for air --> presents with respiratory distress, obstructive shock, and DECREASED UNILATERAL BREATH SOUNDS during/after central line placement --> diagnosis: clinical or via CXR --> treatment: urgent needle or tube thoracostomy)

28yo M presents with 2mo hx of enlarging left testicular mass PE: painless hard nodule in left testicle without inguinal LAD Scrotal US: solid, hypoechoic 5cm left testicular mass

Testicular cancer (malignancy usually arising from germ cells or possibly sex-cord stromal cells --> most common solid organ malignancy in YOUNG MEN AGE 15-35yo, other risk factors include FH and cryptorchidism --> presents with unilateral painless solid hard testicular nodule and dull ache in lower abdomen/perineum --> scrotal US: seminoma shows solid hypoechoic lesion, NSGCT shows lesion with cystic areas and calcifications --> diagnosis: elevated b-hCG + AFP + LDH and radical inguinal orchiectomy)

30yo M presents with acute onset of scrotal pain after lifting weights PE: marked swelling + induration + erythema of right hemiscrotum and absent cremasteric reflex US: enlarged right testicle with heterogenous echotexture and small hydrocele

Testicular torsion (insufficient fixation of testis to tunica vaginalis, leading to testicular hypermobility and twisting of the spermatic cord causing testicular ischemia/necrosis --> presents in ADOLESCENT BOYS with acute onset severe scrotal pain, N/V, profoundly tender enlarged high-riding testicle with marked scrotal swelling and erythema, and absent cremasteric reflex --> diagnosis: Dopper US shows twisting of spermatic cord, reduced blood flow, reactive hydrocele, and heterogenous echotexture --> management: surgical detorsion and fixation with exploration of contralateral side)

Neonatal XR: boot-shaped heart

Tetralogy of Fallot (anterosuperior displacement of infundibular septum characterized by PROVe: pulmonary stenosis + RV hypertrophy + overriding aorta + VSD --> most common cause of early childhood cyanosis and associated with DiGeorge syndrome --> presents with harsh pulmonic stenosis murmur with RV heave, VSD holosystolic murmur, single S2, "tet spells" aka SOB/syncope during crying + fever + exercise, and improvement with squatting --> treatment: early surgical correction)

67F with PMHx of HTN, HTN, smoking, and ischemic stroke 4wks causing right-sided numbness presents with transient burning pain in RUE and RLE induced by light touch PE: right-sided hemianesthesia, mild athetosis of right hand, and hyperesthesia on right side of body with exaggerated pain on light touch

Thalamic stroke (usually caused by lacunar stroke of small penetrating branches of PCA, which supplies VPL and VPM nucleus of thalamus that controls SENSORY INFO from contralateral side of body + face --> presents with sudden-onset contralateral PURE SENSORY loss, transient hemiparesis, athetosis, ballistic movements, and thalamic pain syndrome aka allodynia over area affected by stroke --> usually sensory deficits improve)

Labs: - Low H&H - High serum iron - Low TIBC - High ferritin - High transferrin saturation

Thalassemia and iron overload

CBC: - Low H&H - MCV <80 - Normal RDW - Normal/high RBC count

Thalassemia minor (congenital disease characterized by defects in 1 or 2 of alpha-globin or beta-globin chains --> Southeast Asian people are most likely to have ALPHA-thalassemia --> Mediterranean people are most likely to have BETA-thalassemia --> presents ASYMPTOMATICALLY with microcytic anemia, NORMAL/HIGH RBC count, and target cells on peripheral smear --> diagnosis: normal Hb electrophoresis OR elevated HbA2 for beta-thalassemia --> no treatment)

Treatment of tinea versicolor

Topical selenium sulfide, ketoconazole, or terbinafine

Treatment of erythematotelangiectatic rosacea (flushing, erythema, telangiectasias)

Topical brimonidine

Treatment of tinea corporis

Topical clotrimazole and terbinafine

1st line treatment of open-angle glaucoma (OAG)

Topical latanoprost (topical PG that increases drainage of aqueous humor via uveosclerar pathway --> 2nd line includes adding topical timolol --> 3rd line/"last resort: includes laser trabeculoplasty)

Which tests are used to diagnose a LATERAL meniscal tear?

Thessaly and McMurray tests (Thessaly test: patient stands on 1 leg and flexes knee 20°, should cause pain + clicking on EXTERNAL rotation of knee --> McMurray test: passively flex/extend patient's knee, should cause pain + clicking on INTERNAL rotation of tibia/foot)

Which tests are used to diagnose a MEDIAL meniscal tear?

Thessaly and McMurray tests (Thessaly test: patient stands on 1 leg with knee flexed 20°, should cause clicking + pain with INTERNAL rotation of knee --> McMurray test: passively flex/extend knee, should cause clicking + pain with EXTERNAL rotation of tibia/foot)

Most common causes of drug-induced pancreatitis (DIP)

Thiazide and loop diuretics (aka HCTZ and furosemide, which cause hypersensitivity to sulfonamide molecule + pancreatic ischemia due to reduced blood volume + increased viscosity of pancreatic secretions --> other antihypertensive causes of DIP: ACE inhibitors and statins --> analgesic causes: NSAIDs, opiates, mesalamine, and sulfasalazine --> antibiotic causes: INH, tetracyclines, metronidazole, and Bactrim --> antiepileptic causes: valproate and carbamazepine --> antiviral causes: lamivudine and didanosine --> immunosuppressant causes: azathioprine, mercaptopurine, and steroids --> other causes: asparaginase and estrogens)

Fetal US signs of Down syndrome

Thickened nuchal fold, esophageal atresia, duodenal atresia, VSD, and complete AVSD

Treatment of papulopustular rosacea (small papules/pustules)

Topical metronidazole, azelaic acid, or ivermectin (papulopustular rosacea: overgrowth of sebaceous glands on central face --> topical metronidazole: antibiotic that kills skin anaerobes--> azelaic acid: dicarboxylic acid that kills acne bacteria --> ivermectin: antihelminthic agent that kills facial mites --> NOTE: 2nd line tx for refractory cases includes oral doxycycline)

1st line treatment of female pattern hair loss (seen in vertex/center of scalp with sparing of hairline)

Topical minoxidil (direct vasodilator that increases blood flow to scalp)

Most common locations for spinal epidural abscess

Thoracic > lumbar > cervical

Treatment of prepubescent child with scoliosis and Cobb angle 30-40°

Thoracolumbosacral spinal brace

Diagnosis of blunt thoracic aortic injury in hemodynamically unstable patients

Thoracotomy and intraoperative TEE (pts that are HDUS and high probability of BTAI should proceed directly to OR)

Skin biopsy: segmental thrombosing vasculitis with vein and nerve involvement

Thromboangiitis obliterans (Buerger disease: smoking-related medium vessel vasculitis seen in MALE HEAVY SMOKERS >40yo --> presents with intermittent claudication, superficial nodular phlebitis, Raynaud phenomenon, and gangrene/autoamputation of digits --> diagnosis: clinical, skin biopsy shows segmental thrombosing vasculitis with vein + nerve involvement --> treatment: smoking cessation)

Laboratory findings associated with DIC

Thrombocytopenia, prolonged PT and PTT, low fibrinogen, high D-dimer, and schistocytes on smear

Anal exam: 1.5cm purplish, tense, tender mass at anal verge with severe tenderness on palpation

Thrombosed external hemorrhoid (abnormal dilation of inferior hemorrhoidal plexus DISTAL to dentate line --> presents with fullness in perirectal area, acute pain/tendernes, and purplish mass at anal verge --> diagnosis: DRE or anoscopy --> treatment: sitz baths, stool softeners, and topical lidocaine)

Differential diagnosis for anterior mediastinal mass

Thymoma, teratoma, thyroid neoplasm, or terrible lymphoma (remember the 4 Ts of anterior mediastinal mass)

Best next step in management for patient with hyperthyroidism and low TSH

Thyroid radioiodine scintigraphy (DIFFUSELY increased RAI uptake: Graves disease --> FOCAL increased RAI uptake: toxic adenoma or toxic multinodular goiter --> LOW RAI uptake: thyroiditis)

9yo girl presents with worsening bowing of right leg since she was able to walk at 10mo PE: 95th percentile for weight and right knee bowed out during walking XR of RLE: collapse of medial aspect of metaphysis of proximal tibia

Tibia vara (Blount disease: pathologic cause of bowlegs due to abnormal cartilage growth --> risk factors: obesity and early walking --> presents in CHILDREN >2yo with asymmetrical bowing, lateral thrust with ambulation, and leg length discrepancy --> treatment: surgical correction)

24yo F dancer with PMH of irregular light menstrual periods presents with 2wk hx of dull aching pain at anterior aspect of lower leg Vitals: BMI 16 PE: point tenderness over anterior aspect of right shin

Tibial stress fracture (caused by repeated tension/compression of bone without adequate rest, usually seen in athletes or other individuals who increase activity level --> risk factors: female athletic triad with low caloric intake, low bone density, and hypomenorrhea/amenorrhea --> presents with gradual onset of localized activity-related pain, swelling, and point tenderness on palpation --> treatment: reduce weight-bearing for 4-6wks, only refer to ortho for fracture at high risk of malunion aka anterior tibial cortex or 5th metatarsal)

Indications for Lyme disease prophylaxis after tick removal

Tick attached >36hrs, prophylaxis started within 72hrs of removal, and local infection rate >20%

Skin exam: pruritic annular plaques with scaly border and central clearing

Tinea corporis (ringworm: dermatophyte infection with Microsporum, Trichophyton, or Epidermophyton ocurring on body --> cause: contact with infected pets or farm animals --> presents with enlarging erythematous scaly rings with central clearing --> diagnosis: KOH prep with blue fungal stain shows branching septate hyphae --> treatment: topical clotrimazole or terbinafine)

Treatment of Giardia

Tinidazole (recommended for symptomatic pts or asymptomatic pts with high risk of disease spread)

Where are arterial ulcers most commonly found?

Tips of digits (arterial ulcers caused by PAD: present with location at tips of digits, diminished pulses, skin pallor, loss of hair, and intermittent claudication)

Most common causes of congenital newborn infections

ToRCHeS (T: Toxoplasma gondii presenting with classic triad of chorioretinitis + hydrocephalus + intracranial calcifications --> R: Rubella presents with classic triad of cataracts + sensorineural deafness + PDA --> C: CMV presents with periventricular calcifications and later sensorineural hearing loss --> H: HSV-2 presents with meningitis and herpetic lesions, HIV presents with recurrent infections and chronic diarrhea --> S: syphilis presents with classic triad of snuffles + desquamative maculopapular rash + abnormal long-bone XRs)

Treatment of anogenital warts (condylomata acuminata)

Topical TCA or podohyllin, imiquimod, cryosurgery, or laser treatment

Treatment of tinea corporis/pedis

Topical azoles, terbinafine, and tolnaftate

Treatment of oral lichen planus

Topical betamethasone and tacrolimus

Treatment of angle-closure glaucoma (ACG)

Topical timolol, apraclonidine, pilocarpine and IV acetazolamide (topical timolol: decreases aqueous humor production --> apraclonidine: decreases aqueous production and increases outflow --> pilocarpine --> causes ciliary muscle contraction to open trabecular meshwork --> IV acetazolamide: inhibits CA to rapidly reduces further production of aqueous humor)

1st line treatment of condyloma acuminata (genital warts)

Topical trichloroacetic acid, topical podophyllin, and 5-FU cream (chemical tx: repeated weekly until lesions are gone --> for motivated pts with uncomplicated condyloma, can give topical imiquimod 3x/wk and podofilox 2x/day for 3 days --> large excisions require cryotherapy, laser therapy, or excision)

59M with PMHx of coronary artery disease s/p stenting and paroxysmal AFib on sotalol presents with 2 episodes of syncope at rest, mild generalized weakness, and few recent bouts of diarrhea 2/2 food poisoning Vitals: BP 130/90, HR 60

Torsades de pointes (type of polymorphic ventricular tachycardia --> causes: hypokalemia, hypomagnesemia, hypocalcemia, QT prolongation from quinidine + procainamide + sotalol + ibutilide + macrolide + haloperidol + TCAs + Zofran, and congenital long QT syndrome --> presents with sudden-onset syncope and weakness that can progress to VFib --> diagnosis: ECG shows shifting sinusoidal waveforms --> treatment: magnesium sulfate, refractory cases can tx with IV isoproterenol or temporary pacemaker)

9yo boy presents with 24-hr hx of moderate grain pain since hockey game, now p/w decreased appetite PE: edema of left aspect of scrotum, marked tenderness to palpation of superior aspect of left testicle that does not improve with elevation, and 3mm area of bluish discoloration overlying point of maximal tenderness

Torsion of testicular appendange (LESS INTENSE type of testicular torsion characterized by twisting of a small piece of tissue above testicle --> presents in PREPUBERTAL BOYS with acute onset moderate scrotal pain for >12hrs duration, scrotal edema, tenderness to palpation of ONLY SUPERIOR aspect of testicle, PRESENT cremasteric reflex, and "blue dot" sign at top of scrotum aka area of bluish discoloration over point of maximal tenderness --> diagnosis: usually clinical, Dopper US can show increased flow --> management: rest, raising area to prevent swelling, and analgesia)

Indication for phototherapy for newborns with jaundice

Total bili >12 at 24hrs (also if >15 at 2 days or >18 at 3 days --> if bilirubin continues to increase on phototherapy, requires immediate exchange transfusion)

Diagnosis of pathologic jaundice in a neonate

Total bili >12, direct bili >2, or rate of rise >5/day (pathologic jaundice of newborn: requires immediate Coombs test --> if positive, indicates Rh or ABO incompatibility --> if negative, indicates twin/twin or mom/fetus transfusion, infant of diabetic mother, hereditary spherocytosis, G6PD deficiency, etc. --> treat with phototherapy and/or double volume exchange transfusion)

26yo M presents with 4wk hx of intermittent lower abdominal pain/cramps with rectal urgency, bloody diarrhea, nausea, and decreased appetite Vitals: febrile 101.3F, BP 90/50, HR 130, RR 15 PE: abdominal distension, diffuse tenderness to palpation, hypoactive breath sounds, and DRE shows marked tenderness and mucus mixed with blood Labs: low Hb, high WBCs, and high ESR

Toxic megacolon (transmural inflammation of a markedly dilated colon caused by IBD, C diff colitis, or Chagas disease --> presents with bloody diarrhea, abdominal distension and tenderness, fever, tachycardia, and hypotension --> labs: elevated WBCs and ESR --> diagnosis: abdominal XR shows colonic distension with >6cm dilation of right colon and loss of haustral markings --> treatment: bowel rest, NG suction, and steroids with broad-spectrum antibiotics)

MRI: multiple ring-enhancing lesions at gray-white matter junction and basal ganglia

Toxoplasma encephalitis (reactivation of Toxoplasma gondii in patients with advanced AIDS with CD4 <100 --> presents with fever, headaches, altered mental status, and focal neuro deficits --> diagnosis: MRI shows multiple ring-enhancing lesions in basal ganglia and positive T gondii IgG serology --> treatment: sulfadiazine + pyrimethamine + leucovorin and initiating HAART therapy within 2wks --> prevention: Bactrim for CD4 <100)

22yo M with blunt thoracic trauma presents with respiratory distress. Intubated and right chest tube placed. CXR shows multiple rib fractures, right PTX, pneumomediastinum, and SQ emphysema. 2hrs later chest tube drainage system has persistent large air leak despite adequate chest wall seal. Diagnosis?

Tracheobronchial injury (injury to tracheobronchial airway caused by thoracic trauma, resulting in continuous extensive extrapulmonary air accumulation with each breath due to large diameter of proximal airway --> presents after blunt thoracic trauma with tension PTX, SQ emphysema/crepitus, and persistent air leak from chest tube --> diagnosis: bronchoscopy shows damage to tracheobronchial lumen --> treatment: operative repair)

Severe pneumothorax, palpable crepitus in neck region/chest wall, and audible crunch on cardiac auscultation

Tracheobronchial injury (rapid leakage of air from tracheobronchial tree into pleural space and surrounding tissues, resulting in pneumomediastinum --> causes: spontaneous rupture of pulmonary bleb, trauma, iatrogenic, and Boerhaave syndrome aka esophageal perforation --> presents with chest pain, dyspnea, voice changes, SQ emphysema causing crepitus in neck region/chest wall, and Hamman sign aka audible crunch on cardiac auscultation --> diagnosis: bronchoscopy which visualizes lumen of tracheobronchial tree --> treatment: surgery)

42F with PMHx of smoking and respiratory failure 2/2 GBS tx in ICU 9mo ago presents with 3-mo hx of progressive SOB, intermittent wheezing, and cough that is usually nonproductive but occasionally has produced white sputum PE: high-pitched, end-expiratory wheezes heard in anterior aspect of lungs

Tracheomalacia (softening and deterioration of tracheal cartilage caused by atrophy and/or reduction of tracheal elastic fibers and decreased integrity of tracheal cartilage, leading to excessive end-expiratory collapse --> causes: prolonged intubation with endotracheal tube that damages tracheal cartilage directly --> presents with SOB, non-productive cough, and high-pitched end-expiratory stridor in ANTERIOR aspect of lungs)

Best next step in management for patient with recently dx laryngeal cancer

Tracheostomy (due to risk of life-threatening airway compromise with laryngeal SCC and inability to provide endotracheal intubation)

Normal growth for a 12-month-old infant

Triple birth weight and 50% height increase

4yo boy living in large refugee camp in Egypt presents with 10-day hx of mild rhinorrhea + cough, and 2-day hx of mild eye redness with scant watery discharge PE: several pale follicles and inflammatory changes in tarsal conjunctivae b/l and mildly thickened conjunctivae

Trachoma (conjunctival + tarsal infection caused by Chlamydia trachomatis serotypes A/B/C that spreads in crowded/unsanitary conditions and is leading cause of blindness worldwide --> ACTIVE phase presents with follicular conjunctivitis + pannus/neovascularization in cornea with concomitant nasopharyngeal infection --> CHRONIC phase presents with eyelid scarring, inversion of eyelashes/trichiasis, corneal ulcerations, and blindness/cicatricial trachoma --> diagnosis: inflammation and pale follicles within tarsal conjunctiva --> treatment: oral azithromycin)

Diagnosis of placenta previa

Transabdominal US, then transvaginal US >20wks (transabdominal US: high false-positive rate for detecting placenta previa so need to confirm with transvaginal US)

Management of menopausal symptoms for women without uterus

Transdermal estrogen patch (estrogen-only MHT preferred due to avoiding risk of breast cancer with long-term postmenopausal COCP use)

56M with PMHx of kidney transplant for FSGS 1yr ago presents with 8wk hx of uncontrolled HTN Vitals: BP 160/90, HR 78, RR 16 Labs: Cr 2.4 (up from 1.5 two weeks ago)

Transplant RAS (transplant renal artery stenosis: occurs within first 2yrs of transplant due to operative issues such as trauma during organ procurement/abnormal suture placement, infection with CMV/BK virus, or atherosclerosis of donor artery --> presents with resistant HTN, worsening renal function after starting ACEIs/ARBs, lateralizing abdominal bruit, and recurrent flash pulmonary edema --> diagnosis: renal vascular imaging with Doppler US --> treatment: angioplasty with stent placement)

Which type of PVD is more commonly seen in bioprosthetic valves?

Transvalvular regurgitation (regurgitation THROUGH valve: caused by cusp degeneration or valvular thrombus impairing valve closure --> presents with CHF symptoms)

Pathophysiology of digital clubbing

Trapping of unfragmented megakaryocytes (normally, pulmonary circulation causes fragmentation of megakaryocytes --> however in states of chronic lung inflammation, this does not occur and unfragmented megakaryocytes enter systemic circulation and become trapped in distal fingertips --> release PDGR and VEGF that promote connective tissue hypertrophy and capillary permeability + vascularity, leading to digital clubbing --> causes of clubbing: lung cancer, mediastinal lymphoma, lung abscess, empyema, bronchiectasis, CF, chronic cavitary infection from aspergillosis/TB, pulmonary fibrosis, asbestosis, pulmonary AVMs, and cyanotic congenital heart disease with right-to-left shunts)

Causes of tension pneumothorax

Trauma, central venous catheter insertion, PEEP, and chest tube clamping

Diagnosis of Felty syndrome

Triad of RA, splenomegaly, and neutropenia

Diagnosis of disseminated gonococcal infection (DGI)

Triad of tenosynovitis, dermatitis, and polyarthralgia (DGI: caused by disseminated Neisseria gonorrhea that presents either as MONOARTICULAR purulent arthritis of knee or TRIAD of tenosynovitis of hand + dermatitis with 2-10 pustules on LE + migrating polyarthralgia)

22M with PMHx of IVDU who returned from Mexico 2wks ago presents with 1-wk hx of abdominal pain + nausea/vomiting + and diarrhea that spontaneously resolved, followed by 4-day hx of fever + double vision, painful swelling around eyes + significant muscle pain in neck and jaw muscles Vitals: febrile 101F, BP 110/70, HR 92, RR 14 PE: subungual splinter hemorrhages, periorbital edema, and chemosis Labs: low Hgb, high eosinophils, and high creatine kinase

Trichinellosis (parasitic infection caused by roundworm Trichinella spiralis endemic to Mexico/Argentina/China/Thailand/central Europe and transmitted via ingestion of undercooked pork containing encysted Trichinella larvae, which are released by gastric acid within 1st week and invade small intestine to develop into worms, then 4wks later worms release new larvae that migrate and encyst into striated muscle --> presents with prodrome of abdominal pain + nausea/vomiting + diarrhea, followed 3wks later by TRIAD of periorbital edema + UE myositis + eosinophilia --> other symptoms include fever, subungual splinter hemorrhages, conjunctival and retinal hemorrhages, and chemosis --> treatment: albendazole + steroids --> complications: heart/lung/CNS involvement)

Most common cause of tinea capitis in USA

Trichophyton tonsurans (causes black dot TC that presents with initially scaly erythematous plaque on scalp --> progresses to patchy alopecia with residual black dot of "broken hair" --> treatment: oral griseofulvin or terbinafine)

Most common complication of transvenous implantable pacemaker/ICD

Tricuspid regurgitation (TR: presents with right-sided heart failure, RV heave, and holosystolic murmur best heard at left sternal border that intensifies with deep inspiration/leg raise)

Most common complication of pacemaker implantation

Tricuspid regurgitation (seen in 10-20% of patients --> due to damage to RV endocardium, resulting in damage to tricuspid valve leaflets --> presents with RV heave, holosystolic murmur best heard at LLSB that intensifies with inspiration/leg raise, and right-sided HF aka distended jugular veins + pulsatile tender hepatomegaly + abdominal distention with ascites + LE edema --> diagnosis: echo)

What is the key finding in pleural fluid analysis for a patient with chylothorax?

Triglycerides >110 (indicates lymphatic fluid)

1st line treatment for Parkinson disease with only tremor

Trihexyphenidyl (antimuscarinic agent: used for treatment of Parkinsonian tremor and acute dystonia --> improves tremor and rigidity but has little effect on bradykinesia)

1-hour-old boy born via SVD to 37F with no prenatal care presents for evaluation PE: 5lb3oz boy with prominnet occiput, narrow palpebral fissures, small recessed mandible, short sternum, hands clenched with index finger folded over middle finger and small finger folded over right finger, grade 2/6 holosystolic murmur best heard at LLSB, prominent abdomen, and generalized hypertonia

Trisomy 18 (Edward syndrome: 2nd most common trisomy after Down syndrome --> presents with PRINCE Edward: Prominent occiput, Rocker-bottom feet, Intellectual disability, Nondisjunction, Clenched fists with overlapping fingers, and Ears that are low-set --> other signs: micrognathia, congenital heart disease, and omphalocele --> screening: 1st trimester screen shows low b-HCG and low PAPP-A, fetal US usually shows rocker-bottom feet + clenched hands + diaphragmatic hernia --> death usually occurs by age 1)

2nd trimester quad screen: - Low AFP - Very low estriol - Very low b-HCG - Normal inhibin A

Trisomy 18 (Edward syndrome: caused by meiotic nondisjunction of chromosome 18)

Which patient population is at high risk for atlanto-occipital dislocation?

Trisomy 21

2nd trimester quad screen: - Low AFP - Low estriol - High b-HCG - High inhibin A

Trisomy 21 (Down syndrome: caused by meiotic nondisjunction or Robertsonian translocation of chromosome 21)

45yo F with PMH of obesity and plantar fasciitis presents with 2mo hx of constant, burning right lateral hip pain after a long hike in the mountains. Worsens when patient rises from chair or climbs stairs Vitals: BMI 39 PE: point tenderness over lateral hip and worsening pain with passive leg abduction

Trochanteric bursitis (greater trochanteric pain syndrome/GTPS: overuse syndrome involving friction of tendons of gluteus medius/minimus + tensor fascia lata where they run over greater trochanter --> risk factors: elderly women >50yo, obesity, history of low back/LE disorders such as scoliosis, osteoarthritis, plantar fasciitis --> presents with chronic lateral hip pain worsened with repetitive hip flexion such as climbing stairs/walking uphill or lying on affected side and focal tenderness over greater trochanter/lateral hip during FLEXION --> diagnosis: US shows degeneration of tendons/tendinosis, XR to rule out concurrent hip joint disorders --> treatment: exercise, PT, activity modification, local heat, NSAIDs, and local steroid injections)

CSF analysis: - WBCs 5-1000, lymphocyte-predominant - Very low glucose (<10) - High protein (>250)

Tuberculous meningitis (inflammation of leptomeninges from TB --> CSF analysis: mild pleocytosis with lymphocyte predominance, EXTREMELY LOW GLUCOSE, and high protein)

MRI: subependymal nodules in lateral ventricles

Tuberous sclerosis (autosomal dominant condition caused by mutation in TSC1/TSC2 --> presents with HAMARMASS: Hamartomas in CNS + skin, angiofibromas, mitral regurgitation, ash-leaf spots, rhabdomyoma of heart, mental retardation, angiomyolipoma of kidneys, seizures, and shagreen patches --> complications: subependymal giant cell astrocytomas and ungual fibromas)

Skin exam: malar rash with raised flesh-colored fibrous papules

Tuberous sclerosis (neurocutaneous disorder in which autosomal dominant or de novo mutation in TSC1/TSC2 genes results in CNS hamartomas in CNS + skin and other benign tumors in heart + kidney --> presents with epilepsy/infantile spasms, intellectual disability, autism/ADHD, cardiac rhabdomyoma, mitral regurgitation, and renal angiomyolipoma --> SKIN FINDINGS include malar rash containing facial angiofibromas, ellipitical ash-leaf spots aka hypopigmented macules, and shagreen patches aka thickened leathery skin --> --> diagnosis: genetic testing --> complications: subependymal giant cell astrocytomas and ungual fibromas --> surveillance: baseline echo and EEG, neuropsychiatric screening, regular skin/eye exams, serial MRI of brain + kidney, and serial ECG)

Strongest predictor of prognosis for gliomas

Tumor grade (aka degree of anaplasia: grade IV astrocytoma aka GBM has neovascularity and necrosis --> worst prognosis with mortality <1yr)

Causes of primary ovarian insufficiency (POI)

Turner syndrome, fragile X carriers, autoimmune oophoritis, chemo, radiation, and galactosemia (note: women <40yo with ovarian failure should be tested for FMR1 gene mutations)

Cause of medial meniscal tear

Twisting force on a fixed foot (medial meniscal tear: presents with popping sound followed by acute pain, small effusion/crepitus, locking or catching with ROM, tenderness along medial joint line, and pain when getting up from low position)

Cause of MCL tear

Twisting injury or blow to lateral knee (MCL tear: presents with tenderness at medial joint line and valgus laxity)

Which statistical test is used to compare two means?

Two-sample t test

5-month-old girl presents with poor wt gain PE: wt <5th percentile Labs: low K+, high Cl-, low HCO3-, normal anion gap ABG: metabolic acidosis UA: alkalotic urine

Type 1 RTA (DISTAL renal tubular acidosis: kidney disorder characterized by inability of PCT to excrete H+ into urine, resulting in impaired urine acidification --> causes: analgesic nephropathy, congenital urinary tract anomalies, amphotericin B toxicity, and autoimmune disorders causing hypergammaglobulinemia such as Sjogren/RA --> presents with growth failure and normal gap metabolic acidosis --> diagnosis: HYPOKALEMIA, HYPERCHLOREMIA, LOW HCO3-, and alkalotic urine with pH >5.5 --> treatment: oral sodium bicarb --> complications: increased risk for calcium phosphate kidney stones)

Cause of osteogenesis imperfecta

Type 1 collagen mutation (osteogenesis imperfecta: autosomal dominant disorder characterized by mutation in type 1 collagen gene COL1A1, resulting in defect in type 1 collagen found in bone + skin + tendon + sclera + dentin + fascia --> presents with frequent fractures from minor trauma, conductive hearing loss, speech delay, short to normal stature, joint hypermobility, blue sclera, and dentinogenesis imperfecta --> treatment: bisphosphonates to reduce fracture risk)

Stillborn male fetus born at 36wks to 26F G5P1A3 without prenatal care presents for autopsy eval PE: wt 4.9lb, short bent extremities, multiple limb fractures, and hypoplastic thoracic cavity

Type 2 osteogenesis imperfecta (type 2 OI: autosomal dominant disorder caused by defective type 1 collagen synthesis, resulting in decreased bone density and increased skeletal fragility --> presents on ANTENATAL US with multiple fractures, shortened femur, hypoplastic thoracic cage, growth restriction, and IUFD --> prognosis: usually lethal in utero, infants who survive given supportive care)

Diagnosis of IUFD

US >20wks shows absence of fetal cardiac activity (IUFD: intrauterine fetal demise aka fetal death >20wks prior to expulsion from mother --> risk factors: nulliparity, obesity, HTN, and DM --> presents with decreased/absent fetal movement, no fetal HR, and no fetal cardiac activity on US --> management: 20-23wks can do D&E or vaginal delivery, >24wks vaginal delivery ONLY)

3mo-old F presents with 2-day hx of fever, fussiness, and not wanting to feed with inability to finish bottles Vitals: febrile 102.9F, HR 160 PE: tired-appearing girl with crying on palpation of lower abdomen

UTI (most common bacterial infection in febrile infants --> presents in GIRLS and UNCIRCUMCISED BOYS with fever, fussiness, poor feeding, abdominal discomfort, and decreased UOP --> diagnosis: UA and urine culture via straight cath --> treatment: antibiotics, then later abdominal US for children age <2 with 1st febrile UTI)

Colonoscopy: mild erythema and small shallow ulcers in rectum and sigmoid colon

Ulcerative colitis (colonoscopy shows inflammation and superficial ulcerations extending from anorectum CONTINOUSLY to more proximal regions of colon)

Which structure is most commonly affected by medial epicondyle fracture of humerus?

Ulnar nerve (C8-T1: presents with radial deviation of wrist upon flexion, loss of sensation over hypothenar eminence + ring/pinky fingers, and DECREASED GRIP STRENGTH)

Patient with slowly progressive right-handed clumsiness for several months PE: decreased sensation at 4th and 5th digits + decreased grip strength of R hand

Ulnar nerve injury at elbow (caused by compression of ulnar nerve as it passes behind medial epicondyle at elbow into forearm, therefore unable to innervate FCU and medial portion of FDP --> causes: prolonged leaning on elbow, sleeping with elbow in extreme flexion, hitting funny bone, and ESRD with HD due to positioning + chronic uremia --> presents with unilateral hand "clumsiness," numbness and paresthesia of 4th and 5th digits, and DECREASED GRIP STRENGTH)

Patient with right-hand clumsiness for several months PE: decreased sensation over 4th and 5th fingers of R hand

Ulnar nerve injury at wrist (causes: hamate fracture or compression from bicycle handlebar --> presents with intrinsic hand weakness/"clumsiness" and numbness/paresthesias at 4th and 5th digits)

32F G3P2 at term is in labor with contractions every 3mins for last 8hrs, 100% efface, 4cm dilated, -2 station Vitals: afebrile, BP 120/80, HR 80, RR 20 Membranes suddenly rupture yielding a large amount of clear fluid, and FHR decreases to 90bpm

Umbilical cord prolapse (caused by SROM when baby is at fetal station <0 due to space for cord to fall out that is not occupied by baby's head --> presents immediately after SROM with rapid-onset fetal prolonged deceleration or bradycardia --> diagnosis: pelvic exam shows palpable umbilical cord between fetus and cervical os--> treatment: emergency C-section)

Indication for orchiopexy

Undescended testis by age 1

Knee XR: full-thickness lytic bone lesion with well-defined borders and surrounding reactive sclerosis

Unicameral bone cyst (simple bone cysts usually occurring in proximal humerus or proximal femur --> seen in CHILDREN age 5-15yo)

Indications for emergent surgery with spinal cord injury

Unstable vertebral fracture, non-reducible spinal cord compression, and ligamentous injury with facet instability

Treatment of pulseless VTach and VFib

Unsynchronized cardioversion

Diagnosis of Mallory-Weiss syndrome

Upper GI endoscopy (confirms dx and can treat persistent bleeding)

Best next step in management for newborn with bilious vomiting and abdominal XR shows gasless abdomen

Upper GI series (need to rule out midgut malrotation/volvulus --> upper GI series would show Ligament of Treitz on right side of abdomen + "corkscrew" appearance of small bowel --> treat with Ladd procedure)

3 components of inhalation injury

Upper airway edema, acute respiratory failure, and CO poisoning

30yo M who plays as an MLB pitcher presents with 2-day hx of right arm pain, swelling, and heaviness that worsens with arm elevation above head and improves with rest PE: swelling and redness of right arm from elbow to shoulder

Upper extremity DVT (caused by thoracic outlet abnormalities that compress or injure axillosubclavian vein --> risk factors: ventral venous catheter, cancer, congenital cervical rib, or YOUNG ATHLETIC MEN who weight lift/baseball pitching/rowing --> presents with acute right arm pain/swelling/heaviness that WORSENS with arm elevation above head, and dilated SQ collateral veins in chest/UE --> diagnosis: Doppler or duplex US --> treatment: thrombolysis or 3mo of anticoagulation)

Management of autonomic dysreflexia

Upright position, removal of tight-fitting clothes, eval for urinary retention/fecal impaction/pressure sores, and BP control with nitrates or hydralazine

Best next step in patient with genital burns

Urethral catheterization (needs to be done ASAP to prevent edema that can obstruct visualization and catheterization of urethra)

42F presents with 3-wk hx of intermittent loss of small amounts of urine only after voiding PE: 3cm midline cystic tender mass in mid-third of vagina and PVR 50mL

Urethral diverticulum (urethral mucosa herniation into surrounding tissue due to recurrent periurethral gland infection along anterior vaginal wall, which creates inflammation and an abnormal out-pouching that can collect and store urine --> presents with post-void dribbling, dysuria, urinary frequency, dyspareunia, and tender cystic anterior vaginal mass with expression of urine or pus --> diagnosis: pelvic MRI --> treatment: surgical excision of diverticulum)

Causes of initial hematuria

Urethritis or urethral trauma

Patient with penetrating injury to extremity presents with hematoma at entry site, cool to touch extremity, and absent pulses Best next step in management?

Urgent surgical exploration (patient presenting with extremity vascular injury and HARD SIGNS of injury need urgent surgical repair)

Which kidney stones are radiolucent on XR?

Uric acid and xanthine stones

Major cause of recurrent UTIs during pregnancy

Urinary stasis (due to high levels of progesterone causing relaxation of ureters + bladder)

32F G2P2 POD#0 s/p repeat cesarean delivery at 39wks presents with nausea and lightheadedness after walking to bathroom Vitals: BP 80/50, HR 124, RR 18 PE: pale and cold skin, firm uterine fundus at umbilicus, tender abdomen but no bleeding from incision site

Uterine artery injury (rare but life-threatening complication of C-section that causes rapid and massive blood loss postpartum, resulting in retroperitoneal hemorrhage --> presents with hypovolemic shock, no incisional bleeding, and minimal abdominal/back pain --> treatment: emergency laparotomy)

32F G3P2 s/p delivery of 9lb newborn at term following 2hr 2nd stage of labor assisted by medial episiotomy presents with firm pale mass in lower vagina, moderate vaginal bleeding, and SOB Vitals: BP 60/40, HR 60 PE: unable to palpate uterus

Uterine inversion (prolapse of uterine fundus thru cervix/vagina due to excessive fundal pressure, forceful traction on umbilical cord, and/or abnormally adherent placenta --> risk factors: nulliparity, fetal macrosomia, placenta accreta, and rapid L&D --> presents with severe abdominal pain, postpartum hemorrhage, and smooth round mass protruding thru vagina with non-palpable abdominal uterus --> treatment: IV fluids, manual replacement of uterus, and then uterotonic drugs after replacement to prevent uterine atony/recurrence of prolapse)

30yo F presents with moderate left eye pain and blurry vision PE: left eye conjunctival injection with accumulation of pus in anterior chamber

Uveitis (inflammation of uvea from virus/parasite associated with sarcoidosis, RA, juvenile idiopathic arthritis, and HLA-B27 conditions --> presents with moderate pain and blurry vision, constricted pupils, conjunctival injection, hypopyon aka pus in anterior chamber, and mutton fat keratitic precipitates/nodules on iris)

Causes of elevated A-a gradient >15

V/Q mismatch, diffusion limitation, and right-to-left shunt (V/Q mismatch: caused by pneumonia, ARDS, atelectasis, CHF, and diffuse pulmonary edema causing right-to-left intrapulmonary shunt --> diffusion limitation: caused by ILD, emphysema, pulmonary fibrosis, etc. --> right-to-left shunt aka dead-space ventilation: caused by massive PE, PFO, ASD, and pulmonary AVMs)

Location of ST elevations for anterior STEMI (LAD occlusion)

V2-V4

28M with PMHx of MVC s/p laparotomy and daily surgeries for extremity fractures presents on POD#9 with increasing respiratory secretions, worsening oxygenation, and new-onset tachycardia Vitals: febrile 102.6F, BP 125/80, HR 125, RR 22 CXR: new RLL and LLL infiltrates with left-sided pleural effusion

VAP (ventilator-associated pneumonia: type of HAP occurring >48hrs after intubation, usually caused by aspiration of oropharyngeal or gastric secretions --> presents >2 DAYS AFTER INTUBATION with fever, tachycardia, leukocytosis, increased respiratory secretions, worsening oxygenation, lower TVs, increased inspiratory pressure, and new pulmonary infiltrates on CXR --> diagnosis: endotracheal aspiration or BAL sampling of lower respiratory tract)

Which cardiac arrhythmia is associated with AC electrocution (ex: wall socket)?

VFib

Triad of hemangioblastomas, pheochromocytomas, and renal cell carcinomas

VHL disease (von Hippel-Lindau disease: autosomal dominant disease caused by deletion of VHL gene on chromosome 3p, resulting in lack of ubiquination of HIF-1a --> presents with HARP: hemangioblastomas in retina + brainstem + cerebellum + spine, angiomatosis, RCC with clear cell subtype, and pheochromocytomas --> also associated with paragangliomas, hearing loss from endolymphatic sac tumors in middle ear, and pancreatic neuroendocrine tumors)

Neonatal MRI: layered hyperdense fluid collection within enlarged ventricles

VKDB (vitamin K deficiency bleeding: causes intracranial hemorrhage with obstructive hydrocephalus --> classic VDKB presents in 1st week of life with easy bruising, mucosal bleeding, and GI hemorrhage --> late-onset VDKB presents between age 2 WEEKS TO 6 MONTHS with vomiting when supine, bulging anterior fontanelle, persistent downward gaze, and intermittent bradycardia + HTN --> diagnosis: MRI shows layered hyperdense fluid collection within enlarged ventricles --> prevention: IM vitamin K at birth)

Risks associated with COCP use

VTE, stroke, MI, HTN, hepatic adenoma, cervical and breast cancer (VTE + stroke + MI + HTN: due to estrogen effects and increased risk with women age >35yo using tobacco --> hepatic adenoma: risk of rupture and HCC transformation --> cervical cancer: --> breast cancer: due to progestin component)

Treatment of PSVTs in hemodynamically stable patient (ex: AVNRT, WPW, ATach, etc.)

Vagal maneuver or IV adenosine (vagal maneuvers: include carotid sinus massage, cold water immersion, Valsava, and eyeball pressure that stimulates vagus nerve to slow AV nodal conduction --> IV adenosine: pushes K+ out of cardiac myocytes to hyperpolarize cells and decrease AV node conduction)

Treatment of persistent tachyarrhythmia with hemodynamic stability

Vagal maneuvers and adenosine (vagal maneuvers: bearing down, squatting, breath holding --> adenosine: decreases AV node conduction by pushing K+ out of cells cause hyperpolarization)

Management of IUFD >24wks

Vaginal delivery

Management of pregnant patients with corpus luteum removal <10wks gestation

Vaginal progesterone (due to loss of corpus luteum which produces high levels of progesterone to maintain pregnancy --> pts require progesterone supplementation to prevent pregnancy loss until 10wks)

Which test is used to diagnose MCL injury?

Valgus stress test (abnormal passive ABDUCTION: knee either extended or flexed at 30° angle --> should see LAXITY aka medial space widening of tibia when ABDUCTING lower leg, aka lateral/valgus force applied)

1st line treatment of juvenile myoclonic epilepsy (JME)

Valproic acid

Treatment of pregnant women with PMHx of myasthenia gravis who present with pre-eclampsia with severe features

Valproic acid (cannot give magnesium sulfate due to risk of myasthenic crisis --> give seizure prophylaxis with valproic acid)

Intrapartum antibiotic prophylaxis for patient with anaphylactic penicillin allergy and GBS resistant to erythromycin

Vancomycin (last-resort intrapartum GBS prophylaxis --> however do not reach high concentrations in amniotic fluid so requires neonatal observation and eval)

Preop prophylactic antibiotic for patient with anaphylactic penicillin allergy

Vancomycin or clindamycin (provide good coverage against gram-positive skin flora and are not structurally related to penicillin)

Which medications are associated with ototoxicity?

Vancomycin, aminoglycosides, amphotericin B, loop diuretics, and cisplatin (associated with bilateral symmetric SNHL as well as NEPHROTOXICITY)

Which FHT indicates cord compression?

Variable decelerations (decrease in FHR >15bpm below baseline with onset to nadir <30s, entire episode lasting <60s --> mild variables indicative of transient cord compression --> severe variables with brady <70bpm and duration >1min indicative of uteroplacental insufficiency)

Diagnosis of recurrent variable decelerations

Variable decels with >50% of contractions (indicates persistent umbilical cord compression with lack of fetal-placental blood flow in which fetus cannot tolerate, causing hypoxemia and acidosis --> treatment: maternal repositioning and amnioinfusion)

22M presents with left scrotal mass that increases in size after prolonged standing, as well as scrotal heaviness that improves with lying down PE: irregular soft mass in left scrotum above and separate from left testis that increases in size with Valsava

Varicocele (tortuous dilation of pampiniform plexus surrounding spermatic cord and testis, usually occurring in LEFT SIDE due to drainage into left renal vein --> presents in YOUNG MEN with dull scrotal pain/heaviness after prolonged standing that improves with lying down, subfertility, testicular atrophy, and palpation of soft irregular mass/"bag of worms" above testis that increases with Valsava --> diagnosis: scrotal US shows retrograde venous flow, tortuous anechoic tubules adjacent to testis, and dilation of pampiniform plexus veins --> treatment: gonadal vein ligation)

36F G3P2 at 35wks with PMHx of 2 C-sections presents with ROM 30mins ago and painless vaginal bleeding Vitals: afebrile, BP 140/96, HR 92 PE: cervical os 1cm dilated with minimal vaginal bleeding Doppler US: unable to detect FHTs

Vasa previa (aberrant condition in which fetal vessels overlie cervix surrounded by only thin fetal membranes, instead of traveling in umbilical cord surrounded by Wharton jelly , making these vessels prone to tear with ROM + contractions --> risk factors: placenta previa, multiple gestations, IVF, and succenturiate placental lobe --> presents with PAINLESS MINIMAL vaginal bleeding with ROM or contractions, FHT abnormalities such as bradycardia/sinusoidal pattern, and rapid fetal exsanguination and demise --> diagnosis: fetal anatomy US at 18-20wks --> management: emergency C-section)

4-month-old M presents with chronic biphasic stridor that worsens when crying/feeding and improves with neck extension

Vascular ring (congenital malformation of aortic arch system causing compression on trachea and/or esophagus --> presents with biphasic stridor that worsens with crying/feeding and improves with neck extension, vomiting, and solid food dysphagia --> diagnosis: CT scan, direct laryngoscopy, bronchoscopy, and echo --> treatment: surgical division of structures creating ring)

45F presents with occasional episodes of nocturnal substernal chest pain lasting 10-15mins that wake her from sleep, then resolve spontaneously Resting ECG: normal Extended ambulatory ECG: transient ST elevation in leads V4-V6 during pain episode

Vasospastic angina (varient/Prinzmetal angina: spontaneous non-exertional angina caused by vascular smooth muscle hyperreactivity causing focal/diffuse coronary artery spasms, transient myocardial ischemia, and angina --> presents in YOUNG ADULT SMOKERS <50yo with recurrent episodes of chest discomfort at rest/during sleep with spontaneous resolution <15mins --> diagnosis: ambulatory ECG shows contiguous ST elevation during episodes --> treatment: CCB and sublingual nitroglycerin)

Which antidepressant is associated with dose-dependent HTN?

Venlafaxine (SNRI that inhibits both serotonin + NE reuptake, resulting in increased SBP and DBP --> requires regular BP monitoring)

85F presents with restlessness and SOB during attempted placement of IJ venous catheter Vitals: BP 80/50, HR 112, RR 30, SaO2 85% on RA PE: breath sounds equal and normal While being evaluated, patient develops PEA

Venous air embolism (VAE: introduction of air into venous circulation caused by trauma, neurosurgery, central venous catheter manipulation, barotrauma, and scuba diving/decompression sickness --> if >50mL, VAE can lodge into RV to cause RV outflow tract obstruction or lodge within pulmonary arterioles to obstruct pulmonary flow --> presents with sudden-onset dyspnea + respiratory distress, obstructive shock, and cardiac arrest --> treatment: left lateral decubitus/left lateral Trendelenburg positioning to trap VAE on lateral wall of RV + high-flow/hyperbaric O2 to encourage absorption of nitrogen gas into blood and shrink air embolus)

Diagnosis of lead toxicity

Venous lead level >5 (screening: capillary/fingerstick lead level --> diagnosis: venous lead level)

Prophylaxis for cluster headaches

Verapamil (non-DHP CCB that reduce vascular smooth muscle contractility --> used for cluster headache prophylaxis, PSVT prophylaxis, rate control in AFib, HOCM, and angina --> SE: gingival hyperplasia, cardiac depression, AV block, hyperprolactinemia, and constipation --> 2nd line cluster headache prophylaxis is lithium)

52F with PMHx of HTN, HLD, and smoking presents with severe dizziness, unsteadiness, and nausea after hairdresser tilted patient's head back and to the left PE: pt appears uncomfortable and keeps eyes closed, nystagmus, impaired pinprick sensation of left side of face and right UE/LE

Vertebral artery dissection (type of posterior circulation stroke caused by minor trauma such as sports injuries/neck manipulation that involves neck EXTENSION + TORSION, causing damage to ipsilateral spinal trigeminal tract + spinothalamic tract, inferior cerebellar peduncle, vestibular nucleus, nucleus ambiguus, and sympathetic tract --> presents with LATERAL MEDULLARY aka WALLENBURG syndrome: vertigo, dipoplia, nystagmus, ataxia, diminished gag reflex, dysphagia, and loss of pain/temp sensation in IPSILATERAL FACE + CONTRALATERAL UE and LE)

Which physical exam sign is indicative of CN4 palsy (trochlear nerve palsy)?

Vertical diplopia on downward gaze (due to loss of innervation to SO muscle --> other signs of CN4 palsy include hypertropia and extorsion of affected eye resulting in "chin tuck and head tilt" appearance to compensate)

Which physical exam sign is indicative of orbital floor fracture?

Vertical diplopia on upward gaze (due to entrapment of IR muscle from herniation of orbital flat into maxillary sinus)

36F with PMHx of childhood asthma and URI 2wks ago presents with 2-day hx of persistent spinning sensation associated with nausea and vomiting

Vestibular neuritis (self-limited infection of CN8 that follows viral URI --> presents with ACUTE PERSISTENT VERTIGO following viral URI, nausea/vomiting, and impaired gait with patient falling toward affected side --> diagnosis: abnormal head thrust test in which pt looks at fixed target with head rapidly rotated, then eyes abnormally move away and return to target with horizontal saccade --> treatment: meclizine, steroids, and vestibular rehab --> NOTE: vestibular neuritis + hearing loss = labyrinthitis)

MRI: enhancing cerebellopontine angle mass extending into internal auditory canal

Vestibular schwannoma (acoustic neuroma: benign tumor of CN8 arising from Schwann cells --> presents with unilateral sensorineural hearing loss, imbalance at night, and facial numbness/weakness)

52M presents with several month hx of left-sided hearing loss and feeling off-balance at night PE: Weber test localizes to right ear, air conduction > bone condunction b/l, and decreased sensation to touch on left side of face

Vestibular schwannoma (acoustic neuroma: benign tumor of CV8 Schwann cells that forms in internal auditory canal, causing cochlear nerve compression + gradual loss of input to vestibular nerve + eventual compression of CN5 and CN7 in cerebellopontine angle --> associated with NF2 if b/l vestibular schwannomas --> presents with UNILATERAL sensorineural hearing loss, imbalance at night, and facial numbness/paralysis --> diagnosis: audiogram and MRI w/ contrast of internal auditory canal --> treatment: surgical resection or stereotactic radiosurgery)

Which types of colonic polyps require more intensive follow-up colonoscopic surveillance?

Villous adenoma, sessile serrated polyps, high-grade dysplasia, large size >1cm, and 3+ concurrent adenomas

Which chemotherapeutic agent is associated with peripheral neuropathy?

Vincristine (causes neurotoxicity with areflexia and peripheral neuritis)

CSF analysis: - WBCs 10-500, lymphocyte-predominance - Normal glucose (40-70) - Normal/high protein (<150)

Viral meningitis (inflammation of leptomeninges from viral infection, usually caused by enteroviruses such as group B coxsackievirus --> CSF analysis: mild pleocytosis with lymphocytic predominance, normal glucose, and slightly elevated protein <150 --> diagnosis: viral PCR --> treatment: supportive, usually resolves within 1-2wks)

32F with PMHx of a recent cold 2wks ago presents with 5-day hx of fatigue, feet swelling, and progressively worsening SOB Vitals: afebrile, BP 110/65, HR 90, RR 20 PE: bilateral basilar crackles, elevated JVD, and 2+ bilateral pitting edema above ankles

Viral myocarditis (inflammation of myocardium causing disruption of myocardial contractility, resulting n compensatory ECCENTRIC hypertrophy and development of dilated cardiomyopathy --> major cause of sudden cardiac death in adults <40yo --> causes: viral infections, Trypanosoma sleeping sickness, Toxoplasma gondii, Lyme disease, Mycoplasma, CO toxicity, black widow venom, rheumatic fever, doxorubicin, cocaine, Kawasaki disease, sarcoidosis, SLE, polymyositis, and dermatomyositis --> presents in YOUNG ADULTS <55yo with chest pain, decompensated HF with SOB + orthopnea + edema + hepatomegaly, and dilated cardiomyopathy with MR with S3 gallop + holosystolic murmur --> ECG: sinus tachycardia --> CXR: cardiomegaly and pulmonary edema --> diagnosis: echo shows dilated ventricular chambers + global hypokinesis + decreased EF, cardiac MRI shows late enhancement of epicardium, and cardiac biopsy shows lymphocytic infiltrate with focal necrosis --> treatment: diuretics, milrinone, ACE inhibitor, IVIG, and pacemaker --> complications: sudden cardiac death, arrhythmias, heart block, and mural thrombus with systemic emboli)

Which medications are associated with idiopathic intracranial HTN (IIH)?

Vitamin A, isotretinoin, tetracyclines, danazol, and growth hormone

Labs: - Macrocytic anemia - Increased homocysteine - Increased methylmalonic acid

Vitamin B12 deficiency

Which supplementation should be added to the diet of an exclusively breastfed infant?

Vitamin D and iron (vitamin D: should be given to ALL exclusively breastfed infants --> iron: should be given to PREMATURE babies, maternal iron deficiency, and babies introduced to cow's milk <12mo)

Management of women with hx of preterm labor for subsequent pregnancies

Weekly IM progesterone in 2nd and 3rd trimester (start at 16-20wks and continue until 36wks --> should also perform serial cervical length measurements by TVUS in 2nd trimester and place cerclage if cervical length <2.5cm)

Causes of thoracic outlet syndrome

Weight lifting, baseball, rowing, cervical rib, and Pancoast tumor (weight lifting: causes hypertrophy of scalene + subclavius muscles --> baseball/rowing: repetitive overhead arm motions causes damage to axillosubclavian vein --> cervical rib: congenital abnormality of thorax --> Pancoast tumor: upper lung tumor that compresses lower trunk of brachial plexus)

Labs: - Normal Ca2+ - Low phos - High PTH - High AlkPhos - Low 24hr urine Ca2+ excretion

Vitamin D deficiency (most common cause of osteomalacia aka defective mineralization of organic bone matrix due to decreased intestinal Ca2+ and phosphate absorption, leading to secondary hyperparathyroidism that normalizes Ca2+ but results in severe hypophosphatemia --> causes: malabsorption, intestinal bypass surgery, celiac sprue, chronic liver disease, or CKD --> presents with fatigue, diffuse bone pain and muscle weakness, muscle cramps, difficulty walking, waddling gait, and pathologic fractures in weight-bearing bones of LE --> labs: low/normal Ca2+, SEVERELY LOW PHOS, low urine Ca2+, elevated PTH and AlkPhos --> diagnosis: low 25 OH-D levels + XR shows decreased bone density with thinning of cortex, eventual codfish vertebral bodies with concave shape, and bilateral symmetric pseudofractures aka Looser zones)

Fundoscopic exam: loss of fundus details, floating debris, and dark red glow

Vitreous hemorrhage (bleeding into vitreous humor usually caused by proliferative diabetic retinopathy --> presents with PAINLESS sudden loss of vision and onset of floaters --> diagnosis: difficulty visualizing fundus, floating debris, and dark red glow --> treatment: upright position during sleep)

Patient with BPH presents with weak urinary stream, split stream, hesitancy, and straining during urination

Voiding LUTS (obstructive LUTS: symptoms caused by BPH in which patient has trouble voiding)

Strongest predictor of severity of aspiration pneumonia

Volume of aspirated fluid (other risk factors increasing severity: aspiration of stomach acid, caustic ingestion, and solid material)

70F with PMHx of HLD and T2DM presents with 4-mo hx of increasing vulvar pruritus that has not improved with topical emollients PE: firm white plaque with overlying excoriations on left labium majus, mild atrophy of labia minora b/l, and vagina with minimal rugation but no lesions

Vulvar SCC (vulvar squamous cell carcinoma: malignancy caused by continuous inflammation + hyperplasia of vulvar epithelium, resulting in malignant transformation and development of neoplastic lesion --> risk factors: persistent HPV infection, lichen sclerosus, tobacco use, immunodeficiency, prior cervical cancer, and VIN/CIN --> presents with vulvar pruritus and unifocal firm white vulvar plaque OR friable ulceration vulvar lesion --> diagnosis: vulvar biopsy --> treatment: non-invasive disease tx with imiquimod or laser ablation, invasive disease tx with wide local excision and LN dissection +/- chemoradiation)

Newborn boy born at term to 34F G1P0 via SVD presents for newborn nursery eval. PE: absence of iris in both eyes, urethral opening at ventral side of penile shaft, and unpalpable left testis

WAGR syndrome (11p deletion syndrome: de novo gene deletion on chromosome 11p13 --> presents with WAGR: Wilms tumor, aniridia, GU abnormalities, and mental retardation --> note: Wilms tumor in WAGR patients presents EARLIER between age 1-3 and often bilateral)

Which congenital syndromes have increased risk of Wilms tumor?

WAGR syndrome, Denys-Drash syndrome, and Beckwith-Wiedmann syndrome (WAGR syndrome: Wilms tumor, aniridia, GU malformations, and mental retardation --> Denys-Drash syndrome: Wilms tumor, diffuse mesangial sclerosis w/ early-onset nephrotic syndrome, and dysgenesis of gonads --> Beckwith-Wiedemann syndrome: Wilms tumor, macroglossia, organomegaly, and hemihyerplasia)

Treatment of multiple brain mets (or single brain met with poor performance status)

WBRT (whole brain radiation therapy)

Characteristics of VIPoma

WDHA syndrome (presents with Watery Diarrhea, Hypokalemia, and Achlorhydria --> secretory diarrhea usually occurs during periods of fasting/dehydration and presents w/ odorless tea-colored stools)

64F with PMHx of HTN presents with 1-week hx of bitemporal headache, dizziness, blurry vision, and tingling + numbness of feet Vitals: afebrile, BP 140/90, HR 70, RR 16 PE: decreased pinprick sensation and loss of ankle reflexes b/l, decreased visual acuity b/l, and fundoscopic exam shows dilated segmented and tortuous retinal veins Labs: low Hgb, elevated gamma gap, and elevated ESR

Waldenstrom macroglobulinemia (B-cell malignancy caused by excess production of monoclonal IgM, a large Ig that can clog microvasculature and cause hyperviscosity syndrome --> presents with vision changes, headaches, vertigo, dizziness, ataxia, peripheral neuropathy, cryoglobulinemia, bleeding, hepatosplenomegaly, LAD, renal insufficiency, and fundoscopic exam shows "sausage-link" dilated segmented tortuous retinal veins --> labs: anemia, large gamma gap, and elevated ESR --> diagnosis: Ig assay shows very high IgM levels >1000, SPEP shows monoclonal IgM spike, bone marrow biopsy shows lymphocytic infiltration with >10% clonal B cells --> treatment: urgent plasmapharesis)

Fundoscopic exam: dilated segmented tortuous retinal veins bilaterally

Waldenstrom macroglobulinemia (excess monoclonal IgM resulting in hyperviscosity syndrome --> presents with headaches, vision changes, vertigo, dizziness, ataxia, peripheral neuropathy, bleeding, HSM, LAD, renal insufficiency, and fundoscopic exam showing "SAUSAGE-LINK" retinal veins --> labs: anemia, large gamma gap, and elevated ESR --> diagnosis: SPEP shows monoclonal IgM spike, bone marrow biopsy shows >10% clonal B cells --> treatment: urgent plasmapharesis)

Which medications are metabolized by the CYP450 system?

Warfarin, anticonvulsants, theophylline, and OCPs (therefore CYP450 inducers will DECREASE drug levels --> CYP450 inhibitors aka SICKFACES.COM will INCREASE drug levels)

Treatment of intussusception

Water-soluble or air contrast enema (leads to non-operative reduction of intussusception)

1-year-old girl presents with 1-day hx of fever and drowsiness PE: appears septic, hypothermia, lethargy, nuchal rigidity, positive Brudzinki's sign, and large petechial and purpuric lesions all over body In ED, pt becomes hypotension and dies despite aggressive IV fluids and antibiotics

Waterhouse-Friderichsen syndrome (adrenal hemorrhage caused by meningococemiaka bloodstream infection with Neisseria meningitidis --> presents with large petechiae purpuric lesions and sudden vasomotor collapse --> can attempt treatment with IV ceftriaxone or penicillin G but usually has 100% mortality --> prophylaxis for close contacts: rifampin, ciprofloxacin, or ceftriaxone)

What are the 5 signs of renal cell carcinoma?

Weight loss, flank mass, hematuria, intermittent fever, and paraneoplastic syndrome (polycythemia: caused by ectopic EPO production --> hypercalcemia: caused by ectopic PTHrP production)

Initial management of knee OA

Weight loss, regular moderate activity, quadriceps exercises, and NSAIDs (2nd line management: injectable steroids or hyaluronic acid --> 3rd line: total knee arthroplasty, an elective surgery consisting of replacement of articular surface of knee with prosthetic components)

Indication for D-dimer assay

Wells score <4 (indicates diagnosis less likely PE and lack of surgery/cancer/immobilization --> D-dimer <500 excludes PE)

23F with PMHx of anorexia nervosa presents with confusion and unsteadiness when walking PE: not oriented x3, restricted lateral gaze on both sides and evokes horizontal nystagmus, diminished ankle reflexes b/l, and slow wide-based gait

Wernicke encephalopathy (caused by long-term thiamine/vitamin B1 deficiency due to poor dietary intake, impaired metabolism, or poor absorption --> causes: chronic alcoholism, malnutrition from anorexia, hyperemesis gravidarum --> presents with TRIAD of confusion, gait ataxia, and oculomotor dysfunction including bilateral CN6 palsy and horizontal nystagmus --> treatment: IV thiamine followed by glucose)

Fundoscopic exam: new blood vessels within macular region with leakage/bleeding

Wet macular degeneration (exudative macular degeneration: occurs in 10-15% of age-related macular degeneration --> presents with distorted vision and central scotoma, with sudden onset rapid loss of vision --> diagnosis: fundoscopic exam shows choroidal neovascularization under retina + macula --> treatment: injections of VEGF inhibitors such as bevacizumab or ranibizumab)

Diagnosis of BV and Trichomonas

Wet mount prep (used to differentiate BV vs. Trichomonas --> both present with foul-smelling, watery, vaginal discharge and vulvar pruritus --> BV: wet mount shows clue cells --> Trichomonas: wet mount shows motile -pear-shaped trichomonads)

Colonoscopy: villous atrophy with numerous PAS-positive materials in lamina propria

Whipple disease (rare multi-systemic illness caused by intracellular gram-positive bacillus Tropheryma whippelii --> presents in WHITE MEN AGE 40-60yo with weight loss, steatorrhea, arthralgias, chronic cough, CHF, aortic regurgitation, skin hyperpigmentation, generalized LAD and/or mesenteric LAD, dementia, supranuclear ophthalmoplegia, and myoclonus --> diagnosis: small intestinal biopsy shows PAS-positive material in lamina propria --> treatment: penicillin for 1 year)

Treatment of invasive vulvar SCC

Wide local excision and LN dissection (may possibly require chemoradiation depending on extent of disease)

Causes of post-op fever

Wind, water, wound, walking, and wonder drugs (wind: post-op pneumonia or atelectasis occurring on POD1-2 --> water: post-op UTI occurring on POD3-5 --> wound: SSI or abscess occurring on POD5-7 --> walking: DVT/PE occurring on post-op POD5+ --> wonder drugs: drug fever/reaction to blood products can occur anytime)

18-month-old boy with PMHx of recurrent AOM, herpes labialis, and pneumonia presents with bloody stools PE: fair complexion, eczema on cheeks + trunk + extremities, and scattered petechiae on LE Labs: low plts Peripheral smear: low plt count with small plts

Wiskott-Aldrich syndrome (X-linked recessive disease caused by defect in WAS protein gene, resulting in impaired actin cytoskeleton and abnormal cellular migration + immune synapse formation in WBCs and platelets --> presents with TRIAD of thrombocytopenia, eczema, and recurrent pyogenic infections --> labs: thrombocytopenia with smaller platelets and elevated IgE + IgA --> treatment: hematopoietic stem cell transplant --> complication: increased risk of autoimmune disorders)

35M with PMHx of IVDU presents BIBA with weakness, lethargy, and inability to hold head up Vitals: febrile 100.6F, BP 110/66, HR 104, RR 19 PE: ptosis b/l, dilated pupils with sluggish reaction, shallow respirations, and 2 abscesses present on L thigh ABG: hypoxia and acute respiratory acidosis

Wound botulism (contamination of puncture wound with Clostridium botulinum spores, which germinate in anaerobic environment and generate botulinum toxin in vivo --> impairs presynaptic release of ACh at NMJ resulting in descending motor paresis beginning with CNs, diaphragmatic paralysis, and autonomic dysfunction --> presents ~10d in IVDU patients with cutaneous abscesses with fever, diplopia/ptosis/mydriasis, dysphagia/suppressed gag, respiratory failure, ileus, orthostatic hypotension, and urinary retention --> diagnosis: positive C botulinum culture or toxin ID --> treatment: equine botulinum antitoxin, respiratory support, and wound debridement)

Management of superficial wound dehiscence

Wound packing with wet-to-dry dressing

Best way to transport an amputated digit

Wrapped in saline-moistened gauze in plastic bag immersed in ice water

6-month-old with recurrent infections Labs: - Absent B cells - Low IgA, IgG, and IgM

X-linked agammaglobulinemia (X-linked recessive condition caused by defective BTK gene, resulting in no B-cell maturation --> presents at AGE 6MO with recurrent bacterial and enteroviral infections, absent/scanty lymph nodes, and absent tonsils --> diagnosis: absent B cells and low Ig of all classes)

Best next step in management for paraplegic patient with unilateral, non-erythematous, LE swelling

XR of LE (looking for fractures, compartment syndrome from hip fracture, etc.)

65M with PMHx of HTN, GERD, OA presents with difficulty swallowing, frequent coughing during meals, some food/medication regurgitation, "gurgling" sound in voice, and change in breath odor

Zenker diverticulum (pharyngoesophageal diverticulum: pseudodiverticulum occurring thru zone of muscle weakness between inferior pharyngeal constrictor fibers and cricopharyngeus muscle, aka Killian triangle --> caused by cricopharyngeal motor dysfunction resulting in abnormal spasm/diminished relaxation of CP muscles during swallowing, resulting in increased intraluminal pressure above muscle and eventual herniation of mucosa, creating a pouch for retained food --> presents with dysphagia, halitosis, "gurgling" sound in voice, and regurgitation of undigested food/meds --> diagnosis: contrast swallow study --> treatment: cricopharyngeal myotomy, diverticuloectomy or otomy)

52M with PMH of alcoholism presents with recurrent skin infections and diffuse skin rash around mouth and extremities PE: multiple unhealed skin infections, pustular skin rash around perioral region and extremities, decreased axillary/facial/pubic hair, and hypogonadism

Zinc deficiency (loss of trace mineral obtained from meat/nuts/fortified cereal and mostly absorbed in duodenum and jejunum, causing decreased gene transcription and cell division --> causes: malabsorption from Crohns/celiac disease, bowel resection, gastric bypass, poor PO intake, or TPN dependence --> presents with alopecia around axillary/facial/pubic region, pustular skin rash around perioral region + extremities, hypogonadism, impaired wound healing, impaired taste/smell, and immune dysfunction --> associated with acrodermatitis enteropathica aka defect in intestinal zinc absorption --> can predispose to alcoholic cirrhosis)

Which trace mineral deficiencies are seen in patients with TPN dependence?

Zinc, selenium, copper, and chromium (zinc deficiency: presents with alopecia + pustular skin rash + impaired taste/wound healing --> selenium deficiency: presents with thyroid dysfunction + cardiomyopathy + immune dysfunction --> copper: presents with coiled brittle hair with perifoillicular hemorrhages + skin depigmentation + peripheral neuropathy --> chromium deficiency: presents with impaired glucose control in diabetics)

45yo M presents with 6-mo hx of recurrent burning epigastric pain, weight loss, and frothy foul-smelling floating stools/diarrhea PE: midepigastric tenderness to deep palpation Labs: positive occult blood in stool and positive fecal fat GI endoscopy: 2 duodenal ulcers and jejunal ulcer

Zollinger-Ellison syndrome (ZES/gastrinoma: gastrin-producing tumor found in pancreas or duodenum that causes uncontrolled gastrin secretion, leading to parietal cell hyperplasia and excess gastric acid causing multiple ulcers, as well as inactivation of pancreatic enzymes and injury to mucosal brush border --> causes: 80% sporadic, 20% associated with MEN1 --> presents in YOUNG ADULTS AGE 20-50yo with multiple refractory duodenal + jejunal ulcers and steatorrhea --> diagnosis: elevated serum gastrin >1000 in presence of normal gastric acid pH <4, and CT/MRI/somatostatin receptor scintigraphy for tumor localization --> need to be screened for MEN1 with assays for PTH, ionized Ca+, and prolactin)

Location of ST elevations for lateral STEMI (left circumflex occlusion)

aVL, V5, V6

Indications for IV bicarb for acute metabolic acidosis