STEP 3

Patient develops DVT during the first trimester of her pregnancy. How do you manage?

Anticoagulate with LMWH (enoxaparin) subQ or unfractionated heparin SbQ NEVER warfarin Stop anticoag when in labor or 24 hours prior if possible. Resme anticoag 12 hours post partm and continue for 6 weeks

62 year old woman presents with tearing chest pain and elevated BP. CXR shows a widened mediastinm, CT of the chest shows large aortic dissection extending from just proximal to the brachiocephalic artery to the celiac artery. How should this patient be manage?

Aortic dissection Standord type 1: involves the ascending aorta Stanford type 2: involves only the descending aorta Admit to ICU, *IV Beta Blocker*, emergent surgical repair

22 year old woman is broght to the ED with AMS. She is conscios but lethargic. Her friends report that she has been depressed and they are worrie dthat she may have tried to commit suicide by overdose. The pts admits to N/V/D. She also complains of vertigo and tinnitus. On examination she is breathing very qickly and deeply, and has a temperature of 101.8. What is the most appropriate treament for this patient?

Aspirin overdose -tinnitus, tachypnea, hyperpyrexia Mixed respiratory alkalosis + metabolic acidosis with elevated anion gap txt: activated charcoal within 1 hour of ingestion, IV NaHCO3 to alkalinize serum, hemodyalisis if needed

8 year old with asthma. Only uses albuterol. Rarely uses albuterol during the day but uses it at night 3-4 times a month. PE is normal. What is most appropriate next step.

Asthma is not under good control due to night time use of inhaler being >2 per month Pt has mild persistant asthma Add long acting inhaled steroid

What is the msot appropriate next step for ASCUS?

Atypical Squamos Cell of Unknown Significance Age 21-24 > repeat PAP in 1 year if positive colposcopy Age 25+ > HPV test > if positive then colposcopy

What should you counsel patients about when taking metronidazole?

Avoid EtOH for at least 3 days after finishing medication. Disulfram reaction

What meds cause hypokalemia?

B agonists, thiazide, loops, chloroquine, insulin

megaloblastic anemia with neuro symptoms

B12 def

What are the differences in presentation abetween a branchial cleft cyst and a thyroglossal duct cyst?

BCC: lateral neck TDC: midline neck, moves with swallowing, MC congenital cyst, ectopic thyroid tissue

What is the management of preeclampsia with severe features?

BP control with IV hydralazine, IV labetalol, oral nifedipine Seizure prophylaxis with IV MgSO4 Delivery

Gentle posterior pressure applied to the femur while ADDucting the flexed hip

Barlow's maneuver for developmental hip dysplasia femur head ends displaced

What are the treatment options for primary dysmenorrhea?

Basic period cramps Heat therapy, NSAIDS, combined OCP, GnRH agonist (leuprolide)-> medical menopause, surgery (laparoscopy for endometriosis or hysterectomy)

36 year old race car driver is brough tot he ED one day after crashing his car dring practice. His wife insisted he come to the hospital after she noticed bruising on his face. PE shows ecchymosis around both eyes and behind the ears. There is a continuous leakage of clear, watery fluid from his nose. What is the most likely diagnosis? What is the management?

Basilar skull fracture and CSF leak Admit for observation, CSF lead is self limiting Noncontrast CT of head if concern for hemorrhage. If (+) neurosurgery consult

What are the current guidelines for cervical cancer screening?

Begin PAP at 21 21-29 PAP every 3 years 30 + PAP every 3 years or PAP + HPV every 5 years stop screening at 65 if no + PAP hx

19 year old woman being treated for severe nodular acne that has not responded to topical or oral medications. You are considering starting oral isoretinoin. What should be done prior to initiating therapy?

BhCG and start on -women should have two neg pregnancy before starting, 2 forms of birth control labs: CBC, LFTs, lipids

6 week old with scleral icterus. Mom says he did not have jaundice at birth. Also has noticed a lightening of stool color and a darkening of the urine. Labs show elevations in serum conjugated bilirubin and liver aminotransferases. What is the most appropriate diagnostic imaging study for this condition?

Biliary atresia (it appears later in babys life, not at birth) Imaging gold standard is cholangiogram

What is the ddx for third trimester bleeding?

Bloody show- ok Placenta previa Vasa previa Placental abruption Uterine Rupture

7 month old girl has progressively worsening lethargy over several days. She is feeding less de to a weak suck and has decreased bowel movements. Her mother says she has been feeding he rmore table foods lately. She has ptosis of both eyelids and overall decreased muscle tone. What foods may have caused this? What is the most appropriate management?

Botulism honey-home canned foods Close monitoring for respiratory failure, botulinum immune globulin

Smoking cessation options in pregnancy

Buproprion, nicotine replacement

Criteria for prophylaxis and prophylactic agent used for the following HIV opportunistic infection: toxoplasma gondii

CD4< 100, TMP-SMX

Criteria for prophylaxis and prophylactic agent used for the following HIV opportunistic infection: histoplasma capsulatum

CD4< 150, itraconazole

Criteria for prophylaxis and prophylactic agent used for the following HIV opportunistic infection: pneumocystis jivroecii pneumonia

CD4< 200, TMP-SMX

Criteria for prophylaxis and prophylactic agent used for the following HIV opportunistic infection: mycobacterium avium complex

CD4< 50, azithromycin

Vasculitis in young asthmatic

CHurg Strauss/ eosinophilic granlomatosis with polyangitis

What is the first study of choice in a suspected esophageal perforation? What is the most common case of esophageal perforation?

CT or gastrografin-contrast eophagram **no barium due to inflammation risk Iatrogenic due to EGD, boerhaave syndrome, chest trauma Pt presens with pain in chest or upper abdomen, dysphagia, odynophagia, subctaneous emphysema

65 year old man with hx of ischemic cardiomyopathy due to chronic CAD is admitted with pneumonia. Abx are given. During the course of this hospital stay, he develops hypOtension and shock. A swan-ganz catheter is inserted and reveals the following: a decreased CO, increased SVR, increase PCWP. What is the most likely cause of this patients shock? What is the most appropriate treatment to raise his blood pressure acutely?

Cardiogenic shock, treat with inotropic cardiogenic meds like dobutamine or dopamine. Septic shock has decreased SVR and is massive vasodilation. Treat with lots of IV fluids and if you need a pressor give Norepi.

What is the nonsurgical management for Achilles tendon rupture?

Casting in equinus position (plantar flexion_

Overflow incontinence

Cause: bladder obstruction or neuropathy, unable to void normally--> over distention of bladder sxs: continuous leak of urine txt: treat underlying cause, intermittent caths

21 year old woman comes to the clinic with six months of chronic diarrhea. She complains of occasional nausea/vomiting and abdominal pain. Analysis of the stool shows steatorrhea. Serum anti-endomysial Ab and anti-tisse transglutaminase antibodies are positive. What test should be performed to confirm the dx? How should this condition be managed?

Celiac dz a. small bowel bx b. avoid gluten

7 day old newborn with purulent discharge from both eyes. Culture of exudate reveals chlamydia trachomatis. What is the most appropriate treatment?

Chlamydia conjunctivitis treat with ORAL erythromycin for 14 days. We put erythromycin ointment in the eyes of newborns to prevent gonococcal conjnctivitis--- does not prevent chlamydial.

What teratogenic agent is associated with gray baby syndrome?

Chloramphenicol

57 year old man has not seen a DR in 20 years. Admits to heavy alcohol use but denies tobacco. PE shows jandice, spider angiomata, gynecomastia, and abdominal distention with shifting dullness and fluid wave. What condition is most likely responsible for the PE findings? What lab test on the ascities fluid would help confirm the diagnosis?

Cirrhosis and portal hypertension Serum-ascites albumin gradient (SAAG>1.1)

What is the triple test for breast mass workup?

Clinical exam, imaging (diagnostic mammo or S dependent on age), needle biopsy If all negative, good to go If any one is positive, suspicious mass--> do excisional biopsy

36 year old auto mechanic is brought to ED follow injury in which his arm was pinned under a car for 30 min. He complains of continued pain in the arm. On physical examination, the arm is tight and tender to palpation. There is severe pain with passive extension. What is the first step in management?

Compartment syndrome Emergency fasciotomy

48 year old man with mole on his back that has grown larger over past 6 months. PE shows 0.7 cm asymmetric, brown lesion. Lesion contains areas of grey and black and has an irregular border. What is the most appropriate next step in managment?

Concern for melanoma think ABCDE A: asymmetry B: border irregularity C: color inconsistency D: diameter >6mm E: evolving (changed in shape size or color) Do an excisional biopsy. DO NOT do a shave becase it does not tell you how deep the melanoma goes

2 year old with low grade fever, runny nose, bark like cough x 3 days. Appears tired but still playing. Cough worsens at night. PE pt has coarse breath sounds, no wheezing or stridor, 02 sat is 99% on RA. What is the most appropriate next step at this time?

Croup -bark like cough that worsens at night No CXR because no hypoxia Give supportive care Can give single dose dexamethasone if patient worsens or develops stridor then give racemic epi and hospitalize

16 year old with nonproductive cough for two weeks. Has more severe episodes of cough that leads to vomiting. How do you diagnose? How do you treat?

Culture posterior nasopharynx which will reveal Bordetella pertusis (whooping cough) Treat with a macrolide like azithromycin or clarithromycin

thymic aplasia + T cell deficiency + hypocalcemia

DiGeorge syndrome

Trichomonas

Discharge: frothy, yellow-green, fishy Vaginal pH: >4.5 Wet mount: motile, pear shaped Treatment: metronidazole

Candida spp.

Discharge: thick, white, cottage cheese Vaginal pH: 4.4.5 Wet mount: yeast forms Treatment: oral fluconazole, topical clotrimazole, miconazole, nystatin

Gardnrella vaginalis

Discharge: thin, gray-white, fishy odor Vaginal pH: >4.5 Wet mount: clue cells (epithelial cells with bacteria coating them), + Whiff test (add KOH and its stinky) Treatment: metronidazole, clindamycin

Management for colles fracture

Distal radius fx with posterior and radial displacement of wrist and hand Closed reduction and casting

4 year old with difficulty climbing stairs and frequent falls when running. Pt did not have these difficulties in the past. When asked to stand up from the floor, he needs to use his hands to push himself up. ON PE, he has proximal muscle weakness in his LE and his calf muscles appear to be hypertrophied. What is the most appropriate medication used to treat this condition?

Duchenne muscular dystrophy SXS begin at 2-3 years old, starts with proximal muscle weakness in LE before UE Primary treatment is oral glucocorticoids like prednisone 0.75 mg/kg/day

Menstrual periods with urinary frequency, dysuria, painful defecation, pain upon deep penetration. PE with tenderness to palpation of the posterior wall of vagina. What is the most appropriate treatment for this patient?

Endometriosis NSAIDS, Combination OCPs GnRH agonist (leuprolide)> medically induced menopause Progestin Danazol Surgery

Patient with fever one day after emergent C/S, PE shows uterine tenderness and foul smelling lochia

Endometritis Treat with broad spectrm antibiotics like gent+clindamycin

21 year old with scrotal pain is seen in the emergency department. He complains of fever and chills for the last two days. He is sexually active and admits to a new sexual partner. The cremasteric reflex is present. The pain is relieved when the scrotal contents are manually elevated. US reveals normal blood flow. What other studies should be used to assist in diagnosis? What is the most appropriate treatment for this patient?

Epididymitis (+ Prens sign) UA + culture, discharge culture if present Abx that cover gonorrhea and chlamydia (ciprofloxacin and doxycycline)

An elderly man presents with HA following a fall in which he bumped his head on a table. CT scan shows lens shaped hematoma with midline deviation. What is the most appropriate management?

Epidural hematoma Emergent craniotomy Prognosis is good with treament

A 1 day old male neonate experiences choking episodes whenever feeding is attempted. Physical examination shows a healthy appearing neonate; however, he does appear to be drooling excessively. What is the most likely diagnosis?

Esophageal atresia Dx: place NGT and get CXR, see curled in chest Txt: surgical repair but if delayed do a gastrostomy to protect lungs from acid reflux

When evaluating a patient with a pleural effusion, what are the differences between exudate and transudate?

Exudate -spec. gravity: >1.020 -Protein count: high -cellularity: highly -Causes: infection, inflammation (due to presence of inflammatory mediators), cancer, lymphatic obstruction Transudate -spec. gravity: <1.020 Protein count: low -cellularity: low - causes: sodium retention, increased hydrostatic pressure, decrease oncotic pressure

69 year olf woman comes to clinic with epigastric abdominal pain that has been present over 4-6wks. Decreased appetite and 10 pound weight loss during this time. PE show sig. jaundice. CT scan shows 1.5 mass in head of pancreas. What options are available to biopsy this mass? If the bx shows pancreatic adenocarcinoma, what factors would determine if this lesion is surgically resectable?

FNA by endoscopic US, percutaneous bx guided by CT or US Sx with whipple: resectable if no mets to lymphnodes beyone peripancreatic region. No mets to liver, peritoneum, or extra abdominal site, no encasement of vasculature.

What are the characteristics of fetal alcohol syndrome?

Facial: short palpebral fissures, thin pper lip, smooth philtrum, flattened midface Deficient brain growth: structural brain abnormalities, <10th percentile head circumference, abnormal neuro exam, variable intellectual disabilities Growth retardation: <10th percentile for height and weight, FTT despite adequate intake, disproportionally low weight compared to height

What is the classic presentation of an infant with Hirschsprung disease?

Failure of NCC migration -aganglionic portion of colon that cannot relax, functional colonic obstruction You will see a delayed passage of meconium or chronic constipation, bilious vomiting, FTT PE: abdominal distention, explosive stool discharge following rectal exam

Management for femoral neck fracture

Femoral head replacement due to increased risk of avascular necrosis

Alcohol use in pregnancy

Fetal alcohol syndrome - CNS issues, growth retardation, facial abnormalities

What are the PE findings of bacterial endocarditis? What is the treatmetn?

Fever, new mrmur, osler nodes (painful nodles on fingertips or toe pads), janeway lesions (painless peripheral petichiae), splinter hemorrhages, roth spots (retinal hemorrhage) Empiric abx therapy with Vanc x4-6wks, valve replacement

anemia that develops after taking sulfa drug

G6PD def

A pt presents with profound fatige adter being treated for a UTI. The CBC shows normocytic anemia and examination of the peripheral blood smear demonstrates the presense of HEinz bodes and degmacytes What is the cause of her anemia? Whta drugs provoke this anemia?

G6PD def Sulfa drugs, nitrofurantoin, dapsone, isoniazid, antimalarials: primaqine and chloroquine Ibuprofen, high dose aspirin might be an issue fava beans

What are the indications for an emergent cholecystectomy?

Generalized peritonitis or emphysematous cholecystitis

38 year old with hemoptysis and recrrent sinusitis. His urine shows microscopic hematruia. what type of glomerlonephritis does he most likely have and what is the treatment?

Granulomatosis with polyangitis (Wegners) +cANCA, get biopsy txt: cyclophosphamide, glucocorticoids

2 year old boy with rash. Mom says rash appeared after an abrupt fever with temp of 103.7 but boy otherwise did not appear ill. After 3-4 days the fever suddenly improved and the pink rash started on the trunk and spead to his entire body. Today pt has no fever, and other than the rash a normal PE. What is the best treatment?

HH6- Roseola self limited, supportive care

How do you treat symptomatic menopaus?

HRT with estrogen + progesterone Never give estrogen alone in patients with a uterus due to cancer risk use lowest dose necessary to control sxs

21 year old man with genital herpes outbreak. One week later he develops painful oral erosions and a rash consisting of raised target lesions on his trunk and extremities. What is the most likely diagnosis?

HSV or mycoplasma pneumonia- erythema multiforme -occur after an infection -self limited, can give topical steroids, oral antihistamine, oral prednisone. DO NOT give acyclovir for acute. ONly for chronic suppression SJS/TEN is easy to confuse -medication related

What should you always check first in kids with suspected learning disabilities?

Hearing and vision

5 year old girl admitted to the hospital with 5 day history of worsening abdominal pain and bloody diarrhea. Labs show Hgb of 8.7, PLT of 90,000, and creatinine of 2.7 mg/dL. What is the most likely organism found on stool culture?

Hemolytic Uremic Syndrome hemolytic anemia, thrombocytopenia, kidney failure MCC in kids is enterohemorragic e.coli shiga toxin from contaminated meats

G2P2 woman did not receive prenatal care. 1 day old infant has severe anemia. Labs confirm anti-D Abs in mom. What could have prevented this?

Hemolytic disease of the newborn If mom is Rh (-) she can develop Ab if the fets is Rh (+). In future pregnancies, the Abs can attack fetal RBCs giving hemolytic disease of the newborn > severe anemia > death You can prevent this by giving Rh immune globulin (RhoGam, Rhophylac) at 28 weeks, after delivery, and any time there is risk of fetomaternal hemorrhage.

7 year old girl with dark urine and jandice. 1 wk hx of vague abdominal pain, occasional vomiting, and bloody diarrhea. PE shows no dehydration. Abd exam benign. Some petechiae on extremities. Labs show decrease hgb, low PLT, high creatinine, ++ blood and bilirubin on UA. Peripheral blood smear reveals schistocytes and thrombocytopenia Whta is the most likely diagnosis what organism is most likely implicated

Hemolytic uremic syndrome E coli 0157H7 Microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury Labs: increae LDH, increase indirect bili, decrease haptoglobin, negative COOMBS Txt: RBC transfusion, platelet transfusion, dialysis, plasma exchange, Eculizumab

Palpable purpura on the legs, associated with IgA nephropathy

Henoch-Scholein Purpura

66 year old man has total knee replacement for osteoarthritis. He is given sbQ enoxaparin to prevent DVT. POD#3 he is discharged to an inpatient rehab unit and on POD#6 the nurse notices some skin necrosis at the site of enoxaparin injection. On POD#7 the pt complains of pain and swelling in the left calf, dopper US shows DVT. Labs shows PLT # 70,000. Prior to admission to inpatient rehab th ePLT # was 210,000. What is the most appropriate management?

Heparin Induced thrombocytopenia Heparin indces formation of Ab against platelet factor 4 leading to plt activation, clotting, thrombocytopenia occurs due to increase consumption. Stop heparin and never give it again! test for antiplatelet factor 4 ab, if positive put on alternative anticoagulation like fondaparinx, argatroban, bilvalirudin Transition to warfarin when pt PLT # is normal

55 year old man being treated for chronic Hep B comes to clinic because of new onset jaundice and abdominal swelling. PE shows hepatosplenomegaly and ascites. An abdominal US shows a 2 cm mass in the liver. What is the diagnosis?

Hepatocellular carcinoma follow AFP all cirrhosis increases risk for hepatocellular carcinoma. Sometimes EPO is secreted so check for erythrocytosis.

Painful right sided rash with burning sensation

Herpes Zoster Reactivation characteristic dermatomal distribution post herpetic neuralgia: pain months after rash goes away Management: start antiviral within 72 hours of symptom onset, 7 day course, acyclovir/vacyclovir/famiciclovir Give analgesics Herpes zoster vaccine in pts older than 60

32 year old woman with fibroids, heavy bleeding, and HgB of 8. What medications can be used to terminate this episode of bleeding?

High dose estrogen (follow with course of progestin) Combined OCP taper High dose progestin Transxemic acid

Patient with leiomyomata uteri, increasingly heavy menstrual periods, and decreased Hgb management options

Hormonal contraceptives will decrease bleeding, may increase size of fibroids Endometrial ablation Myomectomy (surgical removal) uterine artery ablation (MUST be done with childbearing) Hysterectomy Iron for iron def. anemia

24 year old man discovered lump in his anterior neck while shaving. PE shows a solitary nontender thyroid nodule. What is the most appropriate management?

Hot nodules are never cancer

What patients should receive intrapartum prophylaxis against GBS?

IV PCN G patients with + GBS screen, + GBS bacteruria this pregnancy, previous infant with early onset GBS, anyone with unknown screening results, or 1. intrapartum fever or 2. prolonged rupture of membranes or 3. preterm labor

What is the treatment for chorioamnionitis?

IV broad spectrm abx usually ampicillin + gentamycin

What precautions should be taken prior to cardioversion to prevent an embolic even in a patient with stable a. fib?

If patient has been in a fib for >48 hours or unknown time do a transesophageal echo. If no thrombus is present then cardioversion followed by anticoagulation. If thrombs is present then anticoagulate for 3 weeks then repeat TEE. If it is definite that a fib has been present for less than 48 hours you can cardiovert without an echo for thrombus and then you can anticoagulate dependent upon risk.

Recurrent sinopulmonary infections + anaphylactic reaction to blood transfusions

IgA deficiency

21 year old woman comes to the clinic becase of recurrent gingival bleeding for the past three weeks. She has had two episodes of epistaxis during this time and has noticed a painless non puritic rash on her ankles and lower legs. She denied any heavy menstrual bleeding. She has no significant medical history and takes no medications. PE shows healthy appearing woman. No visible bleeding or absnormality of the oral cavity. There are numeros petechiae on her lower extremities. There is no hepatosplenomegaly. Labs show PLT # 40,000. PT and PTT are normal. What is diagnosis? What is treament?

Immune thrombocytopenia purpura No treament needed if asymptomatic If sxs: PLT transfusion, oral glucocorticoids, IVIG Splenectomy if not better

What is the treatment of mastitis is the postpartum period?

Inflammation of breast tissue most commonly caused by Staph aureus Continue breat feeding or pumping Antistaphylococcal PCN > dicloxacillin Vancomycin for MRSA U/S if abscess then I&D

38 year old man is being treated for a spontaneous DVT and PE. He had a previous DVT 2 years ago. Labs show guanine to adenine mtation in the gene for prothrombin. Other than routine treatment for this patients crrent thrombosis, what is the most appropriate long term management for this patient?

Inherited hypercoagulable states: Factor V Leiden, Protrombin G20210A, Protein C def, Protein S def, antithrombin def Acute txt: heparin, LMWN transitioning to long term therapy with warfarin Keep INR btw 2-3

What are the adverse effects of stimulant medication in the management of ADHD?

Insomnia- take early in day Appetite suppression - eat a big breakfast before taking and do weight checks in peds Decreased growth velocity - catch up in later life or take periods without medication Tics- avoid in tourettes Psychosis or mania - avoid use in psych patients

63 year old man with exertional dyspnea, denies chest pain or cough bt has epigastric abdominal pain. Labs show a crit of 31.2% and IDA. EGD shows clean based peptic lcer in the gastric antrum. Bx positive for h. pylori and neg for gastric adenocarcinoma. What is the most appropriate management?

Iron supplement and recheck CBC Get colonoscopy> cancer can cause IDA and he is over 50

Most likely cause of amenorrhea in patient with anosmia

Kallmann

7 year old with 10 day hx of fever, bilateral eye redness, cracked red lips, swollen hands, and cervical lymphadenopathy

Kawasaki disease (vasculitis) Treatment: IvIg, Aspirin Concerned for coronary artery aneurysm, heart failure, peripheral artery occlusion

Leiomyomata uteri

Leiomyomas, fibroids Benign smooth muscle tumors of uterus

woman with puritic rash on wrists and shins. Rash is composed of violaceos, polygonal papules. What is the most likely diagnosis

Lichen planus (4 Ps) associated with drugs and Hep C treat with topical corticosteroids

How to treat normal N/V in pregnancy?

Lifestyle: bland foods, small frequent meals, eat slowly, avoid triggers 1st line medical: Pyridoxine (Vit. B6) + doxylamine Then can add dyphenhydramine, meclizine, ondansetron

Stress incontinence

MC caused by weakening of pelvic floor sxs: occurs with increased abdominal pressre txt: wt loss, avoid caffeine and EtOH, do keigles, bladder training, use pessary, surgical txt

Full term newborn with strawberry hemangioma on left neck.What is the most appropriate management?

MC found on head and neck 60% gone in 2 years 90% gone by 9 years Txt: observation

Newborn born by C/S due to fetal distress. The 4 day old neonate develops fever of 101.2 and has a seizure that lasts less than 1 min. What abx therapy is most appropriate for this infant?

MCC bacterial meningitis in neonate is GBS and E. coli Less common: listeria, enterococcus, staph, gram neg, and HSV Treat with ampicillin + cefotaxime or Ampicillin + gentamycin If very ill, seizure, vesicles, or CSF pleocytosis we worry about viral and HSV and add acyclovir. THIS patient needs ampicillin+ cefotaxime/gentamycin AND acyclovir

What is the treatment of Graves dz during pregnancy?

MCC of hyperthyroidism autoAb that stimulate the TSH receptor and can cross the placenta and case fetal hyperthyroidism treatment in pregnancy: thionamides -Propylthiouracil (1st trimester only): can cause liver failure so dont want to use it long -Methimazole (2nd +3rd trimester): causes birth defects if used in 1st trimester - aplasia cutis PT and methimazole can both cause agranulocytosis If mom cant take these meds then thyroidectomy B blockers like atenolol and propanolol can be used to control symptoms but long term use can case fetal growth restrictions

56 year old smother with a history of HTN and HLD being evaluated for recurrent angina. What findinfs on cardiac cath would be indications for bypass grafting?

Major indications for CABG: 1. Left main coronary artery stenosis >50% 2. Severe 3 vessel coronary artery stenosis

5 year old with several episodes of painless GI bleeding. Hgb is normal and he is in no distress. How would yo diagnose a Meckle diverticulm in this patient?

Meckle's scan in hemodynamically stable patient -nuclear scan looking for gastric mucosa Meckle's diverticulum commonly has ectopic tisse like gastric or pancreatic IF pt is unstable might need to use arteriography to find and stop brisk bleeding

What is the MCC of interstitial nephritis?

Medications: beta lactams, sulfonamides, aminoglycosides, NSAIDs

Tibial joint line tenderness with clicking or locking and positive McMurray's test

Meniscal

72 year old man is diagnoses with type 2 diabetes. What medication is the most appropriate first line treatment?

Metformin

What are the causes of metabolic acidosis with an elevated anion gap?

Methanol Uremia (renal failure) Diabetic Ketoacidosis Propylene glycol Iron tablets or Isoniazid Lactic Acid Ethylene glycol Salicylates

What is the ddx of vaginal bleeding before 20 weeks gestation?

Miscarriage Cervical insufficiency cervical, vaginal, or uterine pathology ectopic pregnancy placental abruption

What should be performed at every prenatal visit?

Mom weight, blood pressure, assess gestational age, fetal heart tones, ask about fetal movements, check fetal presentation in 3rd trimester

2 month old brought in by aunt who is afraid he is being abused. Said when she changed his diaper she noticed a large bruise on his buttocks. Baby is WDWN NAD. PE shows 8x10 cm blur gray macule over the LS region. No edema or tenderness. What is most appropriate next step?

Mongolian spot congenital dermal melanocytosis present at birth and fade over first few years of life reassurance

66 year old woman fx her hip after falling from standing. Radiographs reveal pnched ot lesions in the vertebrae, hips, and femur. The pt says she has increasing back pain, weakness, and fatigue. Labs show amemia, hypercalcemia, increased BUN, and creatinine. What further studies would help to establish the diagnosis?

Multiple Myeloma SPEP: monoclonal Ab spike UPEP: Bence- jones protein BM bx: increase plasma cells

What are the components of BPP?

NST, fetal breathing, fetal movement, fetal tone, AFI

Increased AFP on second trimester maternal serum screening

NTD, abdominal wall defect, multiple gestation, incorrect dating (MCC)

32 year oolf man complains of swelling throughout his body which has been worsening over the past several weeks. He does not drink alcohol. He denies dysuria, hematuria, or any other symptoms. His blood pressure is 155/93/ Labs show hyperlipidemia, hypercoaglability, increased urine protein, decreased serum albumin. What is the most appropriate treatment?

Nephrotic syndrome, MCC in USA is FSGS txt: glucocorticoids, ACEi or ARB, statin nephrotic syndrome: proteinuria >3.5 g/day, hypoalbuminemia, peripheral edema, hyperlipidemia, hypercoaguability, increased risk of infection

What are the defining features of preeclampsia?

New onset HTN in 2nd half of pregnancy (BP > 140/90 after 20 weeks) Proteinuria End organ dysfunction: thrombocytopenia, renal insufficiency, impaired liver fxn, pulmonary edema, cerebral or visual sxs

51 year old man with no complaints or chronic health issues. What tests does USPSTF recommend for prostate cancer screening in this patient?

None by USPSTF American Cancer Society recommends PSA if pt desires

How do you treat a pregnant patient with syphilis?

ONLY IM benzathine PCN G If allergy, desensitize

What intervention should be performed for life threatening cases of acute cholangitis?

Obstruction of common bile duct, proximal infection Fever, RUQ pain, increase WBC, increase alk phos, increase bilirubin IV abx, ERCP to decompress CBD (piptazo or ceftriaxone + metronidazole) If pt is septic do emergent ERCP, eventual cholecystectomy

Patient's hip is flexed and ADDucted and moved into ABduction

Ortolani's manuever for developmental hip dysplasia femur head ends reduced

What malignancy is associated with the following tumor marker? CA-125

Ovarian CA, anything that irritates the peritoneum

What agents are used in the induction of labor?

Oxytocin--> IV short half life, give easy titration MIsoprostol --> prostaglandin E1 oral or vaginal Dinoprostone --> Prostaglandin E2 vaginal or cervical

Positive posterior drawer

PCL forced hyper flexion of knee

Most likely cause of amenorrhea in overweight female with acne and hirstutism

PCOS

52 year old man presents with progressibley worsening epigastric pain x 3 months. He describes the pain as brning in quality and it is worse when he eats. He has had a 6.6 lb wt loss. Stool examination is guaiac negative. Physical examination shows no abnormalities. What is the most appropriate initial step in management and why?

PUD vs Gastric Cancer Get EGD to rle out cancer with bx PUD txt: PPI, eradicate h. pylori, elimate NSAIDS tobacco and EtOH

60 year old man with left knee pain, thigh pain, and back pain. He also mentions that his favorite hat is too tight. PE normal. An Xray of the knee shows lytic lesions in the distal left femus. Lab shows normal serum calcium, phosphate, creatinine, and Hgb. The serum alk phos is elevated. What additional test would be most appropriate to confirm diagnosis? What is the most appropriate treatment?

Paget's disease of the bone -accelerated bone remodeling due to overactive osteoclasts> focal lytic lesions> eventual osteoblastic reaction causing focal bone sclerosis and hyperdensity a. Xrays to diagnose with radionuclide bone scan b. bisphosphonates, IV or oral (Zolendronic acid is the most effective)

57 year olf smoker with 3 day history of painless hematuria. PE shows no abd masses or tenderness. GU and prostate exams normal. Pt provides urine sample that is grossly bloody, UA shows no evidence of infection. No urinary casts are seen. What is the most appropriate next step to evaluate this patient?

Painless hematuria think bladder cancer especially transitional cell CA 1st get cystoscopy, urine cytology, CT abdomen and pelvis. Renal cell CA on ddx too but usually has flank pain.

2 day old infant delivered at 30 weeks has billious vomiting and lethargy. An abdominal Xray shows pneumatosis intestinalis. What is the most appropriate management?

Patient has necrotizing intercolitis Stabilize the patient, stop enteral feeding, start parenteral feeding Abx: ampicillin, cefotaxime, metronidazole Intestinal perforation> surgical

With what conditions wold you expect to see a positive Nikolsky sign?

Pemphigus vulgaris SJS/TEN staph scalded skin syndrome

34 year olf man is brought to the ED with sharp, left sided chest pain. The pain is relieved when sitting p and leaning forward. PE shows no chest wall tenderness. CTAB. Heart sounds normal. There is a pericardial friction rb. No murmur or gallops. What test would be most useful in confirming the diagnosis?

Pericarditis ECG> diffuse ST elevation, PR depression, diffuse T wave inversion (late) Echo/CXR: usually normal +/- pericardial effusion May or may not have elevated CPR, ESR, WBC

What is the treatment for infectious mononucleosis?

Pharyngitis + lymphadenopathy +significant fatigue Txt: supportive, NSAIDs, tylenol, rest Remember risk of splenic enlargement and rupture. Noncontact sports: wait 3 weeks after symptom onset Contact support: wait 4 weeks after symptom onset Give steroids if impending airway compromise

47 year old man in ED with HA, diaphoresis, tachycardia. BP 176/99. Labs markedly elevated Norepi, dopamine, and metanephrine in the urine. CT scan of abdomen shows 3 cm mass in right adrenal gland. a. what preoperative treament is necessary in this patient? b. what diagnosis should be considered if the CT scan showed bilateral adrenal masses? c. what other disorders of the adrenal glands can cause secondary HTN?

Pheochromocytoma a. alpha blocker: phenoxybenzamine, phentolamine OR labetalol (mixed alpha and beta blocker) Never give B blocker first, get uncontrolled alpha leading to vasoconstriction and increase in BP b. MEN2, von hipple lindau c. Cushing hyperaldosteronism> too much aldosterone gives HTN, hypokalemia, metabolic alkalosis

What is the difference between physiologic jaundice and breast milk jaundice?

Physiologic: starts at day 2-3, peaks at day 3-5, billi <10mg/dL, due to inadequate UDPGT enzyme (that conjugates billirubin) Breast milk jaundice: starts btw days 3-5 and persistes for 3-12 weeks, bilirubin <10mg/dL, due to unknown substance in breast milk that increases intestinal absorption of bilirubin

36 year old woman with 1 month hx of sharp heel pain. Runner and has recently started running longer distances in prep for a marathon. Pain in worse when she first starts walking and then gradually improved as she continues to walk. PE of the foot shows decreased dorsiflexion and point tenderness near the medial process of the calcaneal tuberosity. What is the diagnosis? What is the appropriate management of this patients symptoms?

Plantar fascitits Heel pain worse when initiating walking, localized point tenderness, Stretching, NSAIDs, avoid flat shoes, do not walk barefoot, use shoe inserts If not working after 6 mo -1 year then try glucocorticoid injection or surgery to release fascia

Vasculitis of the kidney and GI tract but spares the lungs

Polyarteritis nodosa

62 year old with DVT in right thigh. No hx of recent travel, sx, or immobilization. Admits to intermittent stinging or brning in the hands associated with redness. Complains of intense pruritis when taking warm baths. Hg level is 18.1, EPO is slightly low. Labs for coagulation factor def and mutations are neg. What underlying disorder most likely predisposed to this patients DVT? Aside from treating her DVT how should her disorder be managed?

Polycythemia vera Txt with phlebotomy Myeloproliferative disorder of the RBCs, hight PLT treat with hydroxyurea if high risk for clots, low dose aspirin for hand pain, antihistamines for pruritis

Infants of mothers with pregestaional diabetes are at increased risk for what complications?

Polyhydramnios, congenital malformations (caudal regression syndrome aka sacral dysgenesis, situs inversus, NTD, transposition of great arteries), preterm birth, macrosomnia, still birth, hypoglycemia + hypocalcemia

6 day old infant develops fever, irritability, and an erythematous rash around the mouth. One day later the rash generalized and flaccid blisters appear. The upper layer of the skin begins the slough off, especially when gentle pressure is applied to the skin. a. what is the most likely causal organism? b. what is the treatment?

+nikolsky sign Staphylococcal scalded skin syndrome -caused by exotoxin produced by staphylococcal aureus txt: IV antistaphylococcal pcn, supportive care looks like SJS/TEN -in staph the mucous membranes are not involved

What are the recommendations for infective endocarditis antibiotic prophylaxis prior to dental procedures?

1. prosthetic cardiac valve 2. previous episode of infective endocarditis 3. congenital heart disease Give 2 gram amoxicillin 30-60 min prior to procedure

How do you manage post-menopausal vaginal bleeding?

10% have endometrial cancer, mst do bx to rule out endometrial hyperplasia and cancer Can do TVUS looking for abnormally thick endometrial layer

Appropriate weight gain during pregnancy for woman with BMI >30

11-20#

How old is a child that can stand unassisted, walk with assistance, say two words, stack two blocks?

12 months

Appropriate weight gain during pregnancy for woman with BMI 25-29-9

15-25#

When do you screen for HIV during pregnancy?

1st visit then 3rd trimester if high risk

When do you screen for gonorrhea and chlamydia in pregnancy?

1st visit then 3rd trimester if high risk

When do you screen for gestational diabetes?

24-28 weeks with 1 hour 50g GTT if abnormal, follow up with 3 hr 100g GTT

Appropriate weight gain during pregnancy for woman with BMI 18.5-24.9

25-35#

When do you administer Rh immune globlin (RhoGAM) if Rh negative?

28 weeks, after delivery, and any other time there is a risk of fetomaternal hemorrhage

Appropriate weight gain during pregnancy for woman with BMI <18.5

28-40#

When do you screen for group B streptococcs during pregnancy?

35-37 weeks If positive give IV PCN during labor

Complete mole

46 XX, no fetal tissue Vaginal bleeding, N/V, hyperemesis gravidarum uterus larger than given dates BhCG markedly increased snowstorm appearance Risk of malignant choriocarcinoma

Management of benign ovarian cyst

5-10 cm and asymptomatic, observation >10 cm needs surgical removal due to risk of ovarian torision

What bone or bones are of concern in boxer fx?

5th metacarpal

What bone or bones are of concern in jones fx?

5th metatarsal

A newborn has a right undescended testis. If this testis does not descend, when should surgical correction be performed?

6 months

What is the management of a pt with a 5 mm renal stone?

8mm or less can me managed medically Pain control with narcotics and NSAIDs alpha blocker like tamsulosin can relax smooth muscle in distal ureter

What is the initial treaments for 21-hydoxylase deficiency?

95% of congenital adrenal hyperplasia has ambiguous genetalia txt: glucocorticoids (hydrocortisone), mineralocorticoids (fludrocortisone)

67 year old former smoker that underdoes a screen abdominal ultrasound reveals a 5.2 cm abdominal aortic aneurysm located inferior to the renal arteries How should this be managed? What is the most important modifiable risk factor for the worsening of an existing AAA?

<5.5 cm and asymptomatic = observation >5.5 cm OR symptomatic = surgery Smoking is the #1 RF for getting AAA

At what BhCG level should you be able to visualize an IUP by TVUS?

>1500 if >1500 and nothing visible in uterus then suspect ectopic pregnancy

When do you do triple or quadruple screen?

@ 15-20 weeks for NTD and aneuploidy

What is the empiric antibiotic treament approach for an adlt patient with osteomyelitis? What other treatment options are importatnt in osteomyelitis besides antibiotics?

A. Vanc, cipro or levo, 3rd gen cephalo like ceftazidime, 4th gen cephalo like cefepime B. surg. debridement, hyperbaric O2, neg pressure wound therapy

57 year old man with DM has routine check up. PE normal. BP 129/76. Labs show mild proteinuria. What class of med should we begin?

ACEi or ARB to protect kidneys

What medications case hyperkalemia?

ACEi, ARBS, spironolactone, amiloride, B blockers, digoxin, NSAIDs, -azoles, trimethoprim

What medications are indicated to reduce mortality in patients with CHF?

ACEi, ARBS: counteract remodeling by RAAS B-blockers: conteract remodeling mediated by adenergic overstimulation aldosterone antagonists like spironolactone and eplerenone: conteract remodeling by RAAS Loops and digoxin help with symptoms but do NOT decrease mortality

Positive anterior drawer and positive lachman's test

ACL forced hyperextension of knee

Treatment for cushing syndrome caused by corticotroph pituitary adenoma

ACTH tumor, true cushing syndrome Sx to remove tumor (transsphenoidal resection +/- radiation)

7 year old with episodes of abrptly stops talking mid sentence, stares into space, and then resmes speaking without realizing what jst occured. What is the most appropriate treatment?

Absence seizures Ethosuximide, if fails then valproic acid

38 year old man comes to the clinic with progressive difficlty swallowing for the last 8 weeks. Both solids and liquids seem to get stck in his chest. He also has occasional heartbrn. A barium esophagram shows narrowing of the EG junction and "birds beak". What is the most appropriate study to confirm the diagnosis? How is this condition managed?

Achalasia a. esophageal manometry b. esophageal dilation with pnematic dilation, surgery for myotomy, botulinum injection Best initial test for dysphagia is a barim swallow before an EGD Medical therapy with nifedipine and nitrates if patient refuses above treatment

4 year old girl with 2 day history of right ear pain. Temp is 102.3. Patient has not taken any abx in the last year. PE shows opaque, erythematous, TM with mild bulging. What is the most appropriate treatment?

Acute Otitis Media Fever and pain give abx-- high dose amoxicillin (90mg/kg/day)

66 year old woman in ED with acute dyspnea. Hx of systolic heart failure. Pulse 106, RR 22, BP normal. Pulse Ox on RA 89%. PE with JVD, bilateral crackles, S3 gallop, 3+ pitting edema. No cardiac murmur. What is the most appropriate therapy at this time?

Acute exacerbation of CHF "NO LIP" Nitrates, Oxygen, Loop diuretics, Ionotropic drugs (dobutamine, milirinone, amrinone), Positioning (with legs down to pull fluid away from lungs)

49 year old man in ED with epigastric pain, NV x 2 days. Not eaten during this time. Hx of alcohol abuse. PE shows epigastric tenderness without guarding. Ecchymoses on flanks BL. What is the most appropriate initial lab test for this patient? What is the most appropriate inital management for his condition?

Acute pancreatitis most likely secondary to EtOH. a. serum lipase is most specific b. admit, monitor, aggressive hydration, NPO, pain control with morphine Flank bruising is Grey turners Periumbillical is Cullens If complications may need to get CT abdomen to rule out pseudocyst, etc. MCC pancreatitis is gallstone> consider US

76 year old woman brought to the ED due to 1 hr hx of nausea, vomiting, and severe periumbilical pain. She rates pain 10/10, has a 20 year hx of hyperlipidemia, and had a MI two years ago. Physical examination shows a slightly distended abdomen, normal bowel sounds, and mild tenderness to palpation. There is no rebound tenderness or guarding. What is the most likely diagnosis? What is the most appropriate next step?

Acute severe abdominal pain out of proportion to exam= Acute mesenteric ischemia Get a CT angiogram of the abdomen and consult surgery

34 year old man with hx of primary adrenal insufficieny is brough to the ED bc of AMS. His meds include usual doses of hydrocortisone and fludrocortisone. He is admitted to the hospital for treament of shock and pneumonia. VS are 101.5, HR 120, BP 80/50, RR 24. Labs show hyponatremia, hyperkalemia, and hypoglycemia. a. what is the most likely cause of this patients shock? What is the most appropriate managment of this patient's condition?

Addison's disease with adrenal crisis triggered by pneumonia ifxn mineralocorticoid def> hyponatremia, hyperkalemia cortisol def> hypoglycemia Adrenal crisis treatment: IV dexamethasone, IV hydration, IV glucose, correct electrolyte imbalance, hemodynamic monitoring, treat underlying cause (in this case abx for pneumonia)

How do you manage a patient with Preterm Premature Rupture of Membranes that is stable and the FHT are reassuring?

Admit, manage expectantly, give mom IM betamethasone Tocolysis: indomethacin, nifedipine, Atosiban Prophylactic Abx: apicillin or azithromycin Deliver at 34 weeks if possible to make it that long

You sspect that your patient is suffering from cladication due to peripheral vascular disease of the lower exteremities. What studies can be used to confirm the diagnosis? What medication can be used to relieve this patient's symptoms?

Ankle brachial index and doppler US ABI--- SBP ankle/SBP arm if </= 0.9 suggests peripheral vascular disease treat with exercise, angioplasty, surgical revascularization Medication: cilostazol

What diuretic or diuretic class would be most useful in each of the following situations? hyperaldosteronism

aldosterone antagonist: spironolactone, eplerenone

56 year old lifelong nonsmoker coems to the physician with intermittent SOB, wheezing, and cough. Xray shows hyperinflation of lungs and flattening of the diaphragm. Office spirometry shows FEV1/FVC ratio of 0.65 (normal >0.70) which is not reversible with inhaled albuterol. Las show elevated LFTs and a liver bx confirms presence of early cirrhosis. What disease specific therapy cold be used to treat his pulmonary disease? What treatment would potentially cure his condition?

alpha 1 antitrypsin deficiency a. alpha 1 antitrypsin infusion b. liver transplantation> new liver will make normal alpha 1 antitrypsin alpha 1 antitrypsin inhibits elastace, if deficient then elastase goes unchecked and get panacinar emphysema mtated form of a1at accumulates in liver leading to cirrhosis

Most likely cause of amenorrhea in elevated testosterone level and no axillary or pubic hair on exam

androgen insensitivity

anemia in a patient with rheumatoid arthritis

anemia of chronic disease

73 year old man with hx of stable angina presents with substernal chest pain that began at rest. Serum troponin is elevated. and an intitial ECG shows ST elevations in V2, V3, and V4 and V5. What is the most likely diagnosis? What artery is most likely involved?

anterior wall STEMI, LAD II, III, avf= inferior wall I, avL = lateral wall

pneumoconiosis associated with shipbuilding, roofing, plumbing, and break mechanics

asbestosis

Most likely cause of amenorrhea following dilation and curettage after spontaneous abortion

asherman

Define chronic kidney disease

at least one of the following for > 3 months eGFR <60 Urinary abnormalities: proteinuria, hematuria, WBC or RBC casts

Define Acute Kidney injury

at least one of the following: increase serum Cr of >0.3 mg/dL within 48 hours increase serum Cr >50% within 7 days urine output <0.5mL/Kg/hr for at least 6 hours

MCC of vaginal bleeding post-menopaus

atrophy of endometrium

Most likely cause of diarrhea in vomiting, diarrhea after eating reheated chinese fried rice

bacillus cereus

What are the treatments for obstructive sleep apnea?

behabioral modifications: weight loss, no EtOH before bed CPAP, oral devices Sx: uvulopharyngealpalateplasty

pneumoconiosis associated with exposure in the nuclear and aerospace industry

berylliosis

What malignancy is associated with the following tumor marker? alkaline phosphatase

bone mets, Paget's dz

Bullae appearance: tense, hard, difficult to rupture Presence of oral lesions: rare Treatment: topical coritcosteroids (clobetasol), (azathioprine, mycophenolate)

bullous pemphigoid

Most likely cause of diarrhea in pt recently treated for UTI

c. diff

67 year old man admitted for CAP. He is treated with levofloxacin and his symptoms improve. Six days after discharge he develops watery diarrhea and crampy lower abdominal pain with fever. What pathogen MCC? What is most appropriate inital therapy? WHat treatment should be considered if inital therapy fails or diarrhea recurs?

c. diff metronidazole oral vanc, fidaxomicin, rifaximin, fecal transplant

What is the management of shoulder distocia?

call for help suprapubic pressure McRoberts manuver: flex both mom legs agaisnt abdomen Try to deliver posterior shoulder Zavanelli manuver: push infant back in and do C/S

What management of PCOS?

can be oligo or amenorrhea, hyperandrogenism -> hirsituism, polycystic ovaried on US, infertility, obesity, insulin resistance, endometrial hyperplasia TXT: diet and exercise, OCP, metformin, spironolactone (hirsituism), clomiphene to help fertility

Urge incontinence

cause: overactive detrusor muscle sxs: preceded by sudden urge to void txt: life style, antimuscarinics (oxybutinin, darifenacin, tolterodine)

depth of infection: deeper dermis and sub q fat Causative organisms: s. aureus or s. pyogenes or others exam findings: edema, erythema, warmth, indistinct boarders treatment: oral dicloxacillin or cephalexin, IV cefazolin or clindamycin

cellulitis

pneumoconiosis associated with coal miners, large urban centers, and tobacco smoke

coal worker's

What malignancy is associated with the following tumor marker? carcinoembryonic antigen CEA

colon and pancreatic cancer

What is the msot appropriate next step for ASC-H?

colposcopy

passage of all POC + closed cervix

complete abortion

Most likely cause of diarrhea in HIV positive pt with <100 CD4 cells

cryptosporidium

What teratogenic agent is associated with clear cell adenocarcinoma of the vagina?

diesthystilbesterol

Decreased AFP, decreased estriol, increased hCG on second trimester maternal serum screening

downs syndrome

depth of infection: upper dermis Causative organisms: s. pyogenes exam findings: painfl raised red lesion swith clear demarcations treatment: oral pcn or amoxicillin, IV ceftriaxone or cefazolin

erysipelas

What are the treatment options for actinic keratosis?

erythematous scaly lesions on sun exposed areas can progress to SCC cryotherapy, currettage, topical 5-FU, topical imiqimod, topical ingenol mebutate, photodynamic therapy

What teratogenic agent is associated with microcephaly, intellectual disability, smooth philtrum?

fetal alcohol

What does late deceleration in fetal heart rate pattern indicate?

fetal hypoxia (uteroplacental insufficiency)

What is the management of a necrotizing soft tissue infection?

flesh eating bacteria organism MCC: group A strep fever, toxic, crepitus, pain out of proportion to exam findings Surgical debridement IV broad spectrum: meropenem+clinda+vanc or pip/tazo+clinda+vanc

Most likely cause of amenorrhea in ballet dancer with eating disorder?

functional hypothalamic amenorrhea

Describe the management of postpartum hemorrhage due to uterine atony

fundal or bimanual massage explore uterine cavity for clots/placenta give uterotonic agent: oxytocin, methylergonovine, carboprost, misoprostol Give IV fluids, possibly blood Suurgery --> artery ligation versus hysterectomy

What bone or bones are of concern in galezzi fracture?

fx radius wtih dislocation of the radial - ulnar joint

What are the treament options for condylomata acuminata?

genital warts caused by HPV many will resolve on own txt: topical chemical agents, podophyllin, trichoroacetic acid, 5-FU, imiqimod, IFN-alpha, cryosurgery, laser therapy, surgical excision

Fever without source in a 2 year old

get CXR and if patient looks very ill hospitalize

Most likely cause of diarrhea in diahhea began after backpacking in the mountains

giardia lamblia

vasculitis associated with perforation of the nasal septum

granulomatosis with polyangitis (wegner)

What are the risks of a congenital syphillis infection?

growth restrictions, prematurity, still birth, snuffles, hutchinson teeth, saber shins

What does early deceleration in fetal heart rate pattern indicate?

head compression

56 year old woman has routine labwork done to evaluate her chronic type 2 diabetes. Her AST and ALT are moderately elevated. Further studes show that she is negative for hep B and Hep C. Serum ferritin is 540 (elevated) and transferrin saturation is high. What further tests would help confirm the diagnosis of hereditary hemochromatosis? what is the most approptiate treatment?

hemochromatosis: AR disorder of increased iron absorption Labs: increase serum iron and ferritin, decreased TIBC, increased transferrin saturation a. liver bx used to be standard but now we test HFE gene b. phlebotomy

What malignancy is associated with the following tumor marker? alpha-fetoprotein

hepatocellular carcinoma, some testiculat, gastric cancer

What is the msot appropriate next step for HSIL?

high grade squamous intraepithelial lesion Age 21-24 > colposcopy Age 25+ colposcopy or LEEP

Most likely cause of amenorrhea in cyclic pelvic pain + blue bulge at introits on exam

imperforate hymen

depth of infection: superficial Causative organisms: s. aureus exam findings: papules-> vesicles-> pustules->honey colored crusts treatment: topical mupirocin or retapamulin, oral dicloxacillin or cephalexin

impetigo

13 year old with painful "boil" on back. PE shows 2 cm flunctuant, erythematous nodule that is tender to the touch. What is the management?

incise and drain warm compresses if big then abx: clindamycin or sulfamethoxazol

passage of some POC + open cervix

incomplete abortion

What bone or bones are of concern in greenstick fx?

incomplete long bone fractre from bending

Smoking in pregnancy risk

increase risk of placental abruption, preterm birth, low birth weight, and SIDS

bleeding before 20 weeks gestation + cramping + no passage of POC + ooen cervix

inevitable abortion

Management for femoral shaft fracture

intramedllary rod fixation

anemia in a patient who eats ice

iron

2 year old asian girl with strawberry tongue and desquamation of the hands and feet

kawasaki dz

Microcytic anemia wiht neuro symptoms

lead

How should like GERD be treated? If initial treament is ineffective what is nxt option?

lifestyle modifications H2 blocker or PPI

What teratogenic agent is associated with ebstein cardiac anomaly?

lithium

What diuretic or diuretic class would be most useful in each of the following situations? Acute pulmonary edema

loop

What diuretic or diuretic class would be most useful in each of the following situations? edema associated with nephrotic syndrome

loop diuretics

What diuretic or diuretic class would be most useful in each of the following situations? mild to moderate CHF and expanded extracelllar volume

loop diuretics and aldosterone antagonists to decrease mortality

What diuretic or diuretic class would be most useful in each of the following situations? hypercalcemia

loop diuretics increase urinary excretion of Ca

What is the msot appropriate next step for LSIL?

low grade squamous intraepithelial lesion Age 21-24 > repeat PAP in 1 year if positive colposcopy Age 25-29 > colposcopy Age 30+ > HPV test > if positive then colposcopy

What diuretic or diuretic class would be most useful in each of the following situations? increased intercranial pressure

mannitol

What malignancy is associated with the following tumor marker? S-100

melanoma, schwannoma, tumors of NCC origin

fetal death before 20 weeks gestation + no passage of POC + closed cervix

missed abortion

Criteria for prophylaxis and prophylactic agent used for the following HIV opportunistic infection: candida albicans

no prophylaxis, fluconazole or nystatin

Criteria for prophylaxis and prophylactic agent used for the following HIV opportunistic infection: Cryptococcus neoformans meningitis

no prophylaxis, treat with IV amphotericin +flucytosine

What are risk factors for obstructive sleep apnea?

obesity, male, advanced age, upper airway abnormality, smoking, nasal congestion

Management for intertrochenteric fracture

open reduction adn pinning

What is the treatment for: tinea capitis

oral antifungal: terbinafine or itraconazole -6weeks

What is the treatment for: tinea unguium

oral antifungal: terbinafine or itraconazole -6weeks hepatotoxic, monitor LFTs

What abx is used in the treatment of pelvic inflammatory disease?

outpatient: ceftriaxone + doxycycline, cefoxitin +probenacid + doxycycline inpatient: IV cefoxitin or cefotetan +doxycycline, IV clindamycin +IV gentamycin

What conditions area associated with erythema nodosm?

painful red violet nodules on skin due to hypersensitivity reaction confirmed with biopsy nonspecific finding associated with strep pharyngitis (MCC), sarcoidosis, TB, fungal infections, IBD, pregnancy, OCP use, idiopathic

What is cervical insufficiency?

painless dilation of the cervix during the 2nd trimester treat with placement of cerclage

What malignancy is associated with the following tumor marker? CA 19-9

pancreatic CA

What is the classic description of nodular basal cell carcinoma lesion?

papular, nodular, pearly, translucent, telangectasia inside the papules

What is the classic description of cutaneous squamous cell carcinoma lesion?

papule, plaque, nodule ulcerate or crust hyperkeratosis in well differentiated lesions nonhealing ulcer

Bullae appearance: flaccid, easy to rupture, +Nikolsky Presence of oral lesions: almost always Treatment: systemic glucocorticoids (prednisone, prednisolone), +/- immunomodulator (azathioprine, mycophenolate)

pemphigus vlgaris higher mortality rate than bullous pemphigoid

What teratogenic agent is associated with craniofacial anomalies, fingernail hyperplasia, and developmental delay?

phenytoin

vasculitis associated with hepatitis B

polyarteritis nodosa

What is the firstline diagnositic study for obstructive sleep apnea?

polysomnography

Most common cause of amenorrhea

pregnancy

What are the risk factors for chorioaminonitis?

prolonged rupture of membrances, prolonged labor, multiple cervical exams, meconim fluid, internal monitors

What malignancy is associated with the following tumor marker? Prostate-specific antigen

prostate pathology

What bone or bones are of concern in monteggia fx?

proximal ulna with dislocation of head of radius

What are the symptoms of intrahepatic cholestasis of pregnancy? Management?

pruritis especially on acral surfaces, worse at night Elevated total serum bile acid levels Txt: ursodeoxyxholix acid, hydroxizine, early delivery at 36 weeks Intrahepatic cholestasis has an increased risk of fetal demise so we deliver at 36 weeks

33 year old with rash that has developed over the past 2 years. Examination shows thick erythematous plaques with silver scales involving the scalp, elbows, and knees. What are the treatment options for the patient's condition?

psoriasis mild: emollient, topical corticosteroids, topical calcineurin inhibitors, topical retinoids, topical vit D severe: phototherapy, MTX, cyclosporin, retinoids, biologic agents

3 wk old infant delivered at 26 weeks develops tachypnea and tachycardia. Pt is dependent on mechanical ventilation. A continuos, machine like murmur is heard at mid left sternal boarder. What medication is most appropriate to give?

pt has a patent ductus arteriosus-- more common in premature infants Since patient is symptomatic we can give a cox inhibitor Most studied are indomethacin or ibuprofen

64 year old man with development of brown skin lesions on his face and trunk over the last 5 years. Exam shows multiple greasy appearing warty, hyperpigmented plaques with a stuck on appearance. What is the most appropriate management?

seborrheic keratosis benign curretage after cryosurgery for cosmetic reasons

spontaneous abortion complicated by uterine infection

septic abortion

What does sinusoidal waveforms in fetal heart rate pattern indicate?

severe fetal anemia

Fetal alcohol syndrome facies

short palpebral fisses, smooth philtrm, thin vermillion boarder

pneumoconiosis associated with foundries (casting metal), sandblasting, and mining

sillicosis

Management for clavicular fracture

sling or figure 8 bandage

What are clinical manifestations of obstructive sleep apnea?

snoring, daytime sleepiness, poor concentration, restless sleep, morning HA

What diuretic or diuretic class would be most useful in each of the following situations? diuretics used in conjunction with loop or thiazide diuretics to retain potassium

spironolactone, eplerenone

19 year old woman in ED with 1 day hx of fever, rash, and AMS. BF said over past day she devleoped a sunburn like rash withot being outdoors. LMP started 3 days ago. She appears lethargic. Temp is 39, Pulse 120, BP 85/50. PE shows erythematous macular rash involving the palms, soles, and mucous membranes. a. diagnosis b. managment

staph toxic shock syndrome -exotoxin remove source of infection supportive care, vasopressors for hypotension abx: clinda+vanco

Management for trigger finger and de Qervain tenosynovitis

steroid injection initially

Management of complete mole

suction curretage and serial BhCG to zero if not back to zero consider invasive/ malignant mole---gets chemotherapy

20 year old asian woman with weak pulses in the UE

takayasu arteritis

Treatment for cushing syndrome caused by exogenos glucocorticoid administration

taper off glcocorticoids> can get adrenal insufficiency if stop abruptly

If abnormalities on second trimester maternal serum screen what should you offer mom?

targeted sonogram or amniocentesis

Elderly woman with nilateral HA and jaw claudication

temporal arteritis (Giant cell)

associated with polymyalgia rheumatica

temporal arteritis (Giant cell)

What teratogenic agent is associated with phocomelia?

thalidomide

What diuretic or diuretic class would be most useful in each of the following situations? idiopathic hypercalciuria causing calcium stones

thiazide

Bleeding before 20 weeks gestation + no passage of production of conception +closed cervix

threatened abortion

Vasculitis in young male smoker

thromboangitis obliterans (Buerger)

Management for scaphoid fx

thumb spica cast

What is the treatment for: tinea corporis

topical antifungal

What is the treatment for: tinea pedis

topical antifungal: terbinafine, naftifine, clotimazole

5 year old girl with lice. Treatment?

topical permethrin, malathion, benzyl alcohol, spinosad, ivermectin lindane 2nd line - neurotoxicity

decreased AFP, decreased estriol, decreased hCG on second trimester maternal serum screening

trisomy 18 (edwards)

What does variable deceleration in fetal heart rate pattern indicate?

umbilical cord compression

What are the treatmetns for hypercalcemia?

usally mild and asymptomatic IV hydration, calcitonin (increase renal excretion, decrease bone absorption by osteoclasts) long term: bisphosphonates, glucocorticoids for sarcoidosis, lymphoma, granulomatosis

Most likely cause of diarrhea in vomiting and diarrhea after eating raw oysters

vibrio parahemolyticus

What is the ddx for first trimester bleeding?

Possible causes of bleeding include subchorionic hemorrhage, embryonic demise, anembryonic pregnancy, incomplete abortion, ectopic pregnancy, gestational trophoblastic disease.

8 year old boy with gross hematuria and generalized edema. Blood pressure is 150/88. UA shows RBS, RBC casts, and proteinuria. Pt had a significant throat infection three weeks ago. What is the treatment?

Post-streptococcal glomerulonephritis Hematuria+proteinuria+edema+HTN in pediatrics Check ASO titer to confirm Supportive care: avoid H2O overload with Na and water restriction, give loop diuretics for HTN

What is the recommended screening for ovarian cancer?

Pray like hell you dont get it aka none

In pediatric patients with gonadotropin-dependent precocious puberty, what is the primary goal with treament?

Precocious puberty is the development of secondary sex characteristics before age 8 in females and 9 in males. GDPP: early menarche of gonadal-hypothal-pit axis, main concern is early closure of epiphyseal plates and short stature. Treat these patients based on future predicted adult height

How do you manage asymptomatic bacteruria during pregnancy?

Pregnancy causes dilation of uterus which increases risk of pyelonephritis Treat with nitrofurantoin, amoxicillin, augmentin, cephalexin, or fosfomycin Repeat urine culture 1 week after abx

56 year old man with dizziness and fatigue. Ran his first marathon today. Has dry mouth, cracked lips. Creatinine is 1.5mg/dl and BUN is 50mg/dL. What would you expect his fractional excretion of sodium to be?

Prerenal azotemia= FeNA <1% FeNa> 2%= intrinsic kidney disease

What are the mjr categories of AKI?

Prerenal: due to underperfusion of kidneys Postrenal: due to urinary tract obstruction> prostatic dz MCC Intrinsic: pathology intrinsic to renal tissue

44 year odl woman with 3 month hx of generalized pruritis and fatigue. Hx of dry moth and dry eyes, previous exam for Sjorgen syndrome was inconclsive. PE shows mild hyperpigmentation of the skin but no jaundice or scleral icterus. Liver is moderatly enlarged but nontender. Lab testing shows minimally elevated AST and ALT, markedly elevated serum alk phos, and normal tot bili. ANA and antimitochondrial ab are positive. What test would confirm the diagnosis? What FDA approved drug may be used to treat this condition?

Primary biliary cirrhosis Liver biopsy Ursodeocycholic acid

Treatment for cushing syndrome caused by hyperfunctioning adrenal adenoma

Primary hypercortisolism unilateral adrenalectomy

Most likely cause of amenorrhea in patient with galactorrhea

Prolactinoma

31 year old woman comes to the clinic for amenorrhea for the last 6 months. She is not pregnant and does not desire pregnancy currently. Lab evaluation shows a serum prolactin level of 126. MRI shows 3mm mass in sella turcia. What is the most appropriate medical management of this patient? What are the indications for surgical treament of this condition?

Prolactinoma a. DOPA agonist like cabergoline or bromocroptine b. transphenoidal resection: indicated when medical management fails or in a woman with an adenoma >3cm who desires pregnancy Dopamine inhibits prolactin prodction

6 year old boy is brought to physician for 2 day history of erythematous maculopapular rash that started on the head and then spread down to his feet. Prior to that, the patient had two days of cough, congestion, and eye redness. On PE, the patient has multiple white-gray spots on his buccal mucosa. What is the most important treatment for this patient?

Pt has measles Prodrome: fever, cough, conjunctivits then Koplick spots and rash that starts on head and spreads to feet Treat: supportive care +/- oral Vit. A

How do you treat developmental hip dysplasia?

Pt in abduction splint like Pavlick Harness

32 year old woman with dysuria, fever, and suprapubic pain. On examination she has CVA tenderness. What is the most appropriate treament?

Pyelonephritis or complicated acute cystitis Ceftriaxone, cefepime, cipro, or levo

3 week old infant with projectile vomiting. Vomits immediately after feeding. Was at 50th percentile at 1 week now at 20th percentile for weight. Arterial blood gas and metabolic panel are ordered. What metabolic abnormalities would you expect in this patient?

Pyloric Stenosis Vomit= lose acid Hypochloremic, hypokalemic metabolic alkalosis K+ hides in cells in basic environments

When do yo screen for syphilis during pregnancy?

RPR or VDRL at 1st visit then 3rd trimester if high risk

What physical defects comprise the tetrology of fallot?

RV outflow tract obstrction, RV hypertrophy, VSD, overriding aorta (over VSD instead of LV)

How is genital herpes simplex virs infection managed during pregnancy?

Rare for HSV to cross placenta worry abot direct contact in birth canal pts with HSV are offered suppressive therapy with acyclovir @ 36 weeks If prodromal sxs or active outbreak then do C/S

What are the featres of WAGR syndrome

Rare genetic disorder Wilms tumor Aniridia Genitourinary anomalies: cryptorchidism, ambiguous genetalia Retardation (intellectual diability)

3 year old admitted for severe acute bronchitis 3rd hospitalization in 6 months. Has mild cough and congestions most of the time that worsens and becomes more productive. Mother says he has very foul smelling stools and at birth he was diagnosed with a meconium ileus. What test will most likely confirm the diagnosis in this patient?

Recurrent URI, steatorrhea, meconium ileus is cystic fibrosis CF is abnormal transport of chloride giving very thick secreations Order sweat chloride test and CFTR testing

man on IV vanc for suspected MRSA endocarditis. Five min later he develops a puritic erythematous rash involving his face, neck and pper body. What is next step in management?

Red man syndrome due to massive Mast cell mobilization Stop vanc, give benadryl and ranitidine resume vanc when sym

65 year olf man with hematuria nad vague back pain. PE is normal. leukocyte # is 5500 and Hbg is 21.8. What is the most likely diagnosis?

Renal cell carcinoma paraneoplastic syndrome - EPO prodction

Female infant born at 30 weeks has difficulty breathing. PE shows nasal flaring, grunting. RR is 62/min. CXR shows hazy interstitial infiltrates. What is most appropriate next step?

Respiratory Distress Syndrome CPAP if FiO2 is <0.4 Intbate and give exogenos surfactant if FiO2 is >0.4 Prior to delivery it would be nice to give mom IM betamethasone

47 year old man with abdominal pain x4 days. No BM x 5 days. Had a ventral hernia repair 8 years ago. PE shows abdominal distention and hyperactive bowel sounds with high pitched quality and rushing sounds. Xray of abdomen shows multiple air fluid levels in small bowel loops. What is the initial management? What wold be most appropriate next step if the patient develops sign of peritoneal inflammation?

SBO Initial: NPO, NGT, IV fluids Peritoneal signs: laparotomy to relieve obstruction

Severe recurrent infections by a variety of organisms (virus, bacteria, fungi, protozoa)

SCID

37 year old woman complains of fatigue, anorexia, and myalgias. Her sodim is 120 and uring osmolarity is 110mOsm/kg. What is the most appropriate treament for this patient?

SIADH: hyponatremia and concentrated urine treat nderlying problem, fluid restriction, sodium supplementation, loop diuretics, vasopressin receptor antagonists: conivaptan and tolvaptan

63 year old man with 2 week history of severe itching of whole body except head. Exam shows multiple small erythematos paples with occasional hemorrhagic crust. 1 cm, gray colored, raised track if found on the webbing between his fingers. What is the best treatment for this patient?

Scabies 1st line treatment: topical permethrin or oral ivermectin

12 year old boy with sore throat and fever. PE shows diffuse, erythematous rash on trunk and extremeties that spares the palms and soles. Rash blanches with pressure and is rough to touch but nontender. Pt also has red tongue. What is the most appropriate treatment?

Scarlet fever = GAS -strep pyogenes Red throat + sandpaper rash Concern for glomerulonephritis and rheumatic heart disease so we give PCN V or amoxicillin can also use 1st generation cephalosporin

How is HIV managed throughout pregnancy?

Screen at 1st and 3rd Antiretroviral therapy (HAART): continue current therapy if on. If not on, initiate regimine (avoid efavirenz if possible-- NTD) Monitor viral load periodically: if <1000 then SVD, if >1000 intrapartm IV Zidovdine and C/S Infant gets ZIdovudine for 6 weeks and do not breastfeed

How do you screen for syphillis? How do you confirm?

Screen with RPR or VDRL Confirm with treponemal antibody test

22 year old man comes to the physician because of a 1 year history of "dandruff". Examination of the skin shows crusting and scaling of the scalp. There are erythematous, greasy appearing, scaly plaques involving the eyebrows and the nasolabial folds. What is the appropriate management?

Seborrheic dermatitis -scalp and eyebrows malassezia antifungal shampoo: selenium sulfide, ketoconazole topical steroid, topical antifungal

35 year old woman with a hx of IV drg use comes to the physician becase of a 3 day history of left knee pain and fever. She is sexually active with multiple partners. Her temp is 102.5, plse 100, BP 140/90. She is alert to person, place, and time. The leftknee is tender and warm to touch. Labs show leukicytosis and elevated ESR. What is the most likely diagnosis in this patient? What is the most appropriate next step in management?

Septic arthirits Athrocentesis with joint fluid analysis wbc#, gramstain and cultre, histology

Most likely cause of amenorrhea in postpartum patient with inability to breastfeed

Sheehan

12 year old obese boy with left hip pain that causes him to limp. On PE pt has waddling gait and prefers to hold his hip FLEXED and EXTERNALLY ROTATED. He has restricted internal rotation of the hip. Most appropriate treatment for patient?

Slipped captital femoral epiphysis XR shows ice cream cone falling off Needs surgical pinning

Treatment for cushing syndrome caused by ectopic ACTH production from a non-pituitary site

Small cell lung CA: chemo and radiation Surgical resection of tumor, treat underlying tumor, BL adrenalectomy, Ketoconazole> suppresses adrenal steroid synthesis Mitotane> DDT that kills adrenal glands *might need cortisol replacement*

68 year old woman with a hx of varicose veins comes to the physician because of a rash on her lower legs that has developed over the past 3 years. PE shows edema and erythematous, hyperpigmented, scaling rash p to the mid-shins of the LE BL. What is the most appropriate managment?

Stasis dermatits -chronic venous insufficiency -red scaly changes with ulceration -treat with elevation, compression stockings, and treat varicose veins cause cellulitis is unilateral

56 yo woman with painful rash 2 weeks after starting sulfalazine for ulcerative colitis. Rash was preceded by fever, malasie, and arthralgias. Temp 102.2 and Plse 110. PE shows conjnctivitis, oral lcers, and erythematous target like lesions on her face, trunk and extremities. Over the next few days bullous lesions develop and the patients skin starts to slough off. a. What is the diagnosis B what is the managment

Steven Johnsons syndrome/ toxic epidermal necrolysis common triggers: medications (allopurinol, carbamazepine, lamotrigine, phenobarbital, phenytoin, sulfamethoxazole, sulfalazine), mycoplasma pneumonia, CMV Admit to ICU or burn unit Stop offending drug Wound care Supportive therapy : fluids, electrolytes, abx

68 year old man comes to physician becase of left arm pain and fatigue that are accompanied by dizziness, blurred vision, and unsteady gait. He recently bought a new house and has been painting the inferior walls. He finds that the symptoms occurs when he tries to paint using his left arm. Whats the diagnosis? What can aid the diagnosis? What is the treament?

Subclavian Steal Doppler US or MRA or CT angiography Bypass Surgery

What is the difference between Subclavian Steal and thoracic outlet syndrome?

Subclavian steal: narrowing of subclavian artery proximal to origin or vertebral artery (atherosclerosis)> arm claudication. HAS neuro symptoms due to brainstem ischemia thoracic outlet syndrome: compression of brachial plexus or subclavian vessels usually due to anatomic problem > arm claudication, NO NEURO symptoms

How should patients be counseled regarding nutrition during pregnancy?

Supplement folic acid and iron, need an additional 300-500 kcal/day Must fully cook meals, avoid unpastrurized dairy, avoid lunch meats, avoid fish high in mercury

What is the treatment for respiratory syncytial virus bronchilitis?

Supportive care (O2 and IV fluids) Steroids wont help bronchilitis Ribavirin is controversial and expensive

2 month old infant with left humerus fracture, parents say infant rolled off bed. Infant also has many bruises on legs. After stabilizing fracture what is the most appropriate management of this patient?

Suspicious injury, 2 month olds cant roll Evaluate for other injuries Order PT, PTT, CBC, metabolic panel for bruising Skeltal Survey CT head if indicated Call CPS if suspect abuse

60 year old caucasian woman undergoes screening for osteoporosis. DEXA scan shows T score of -2.7. In addition to starting treatment with bisphosphonates, what lifestyle counseling should she receive?

T score <-2.5 = osteoporosis, more commonin thin white postmenopausal women Bisphosphonates can cause GERD > take in morning wtih water on empty stomach and do not lie down or eat for 30 min. Lifestyle: take Ca and Vit D, do wt bearing exercise, avoid smoking, avoid heavy EtOH

48 year old presents with pallor and fatigue. No hx of bleeding. The CBC shows hypochromic, microcytic anemia. Hg is 9.4. Iron studies are normal. What is next step?

Thinking Iron def but iron studies normal so maybe thalassemias Get HgB electrophoresis

10 day old infant with white papular lesions in the mouth on the palate and tongue. The patient is eating well and has no other symptoms. What is the most appropriate treatment?

Thrush treat with nystatin oral suspension x 2 weeks if no response give fluconazole

16 year old boy in ED with sudden onset severe groin pain with radiation to the lower abdomen. On exam, the affected testicle is oriented transversely in the scrotum. The cremasteric reflex is absent. What is the diagnosis? What stdy can help confirm? What is the management?

Torison doppler US of scrotum Emergent surgery

What are the TORCH infections that can be acquired in pregnancy?

Toxoplasmosis Other (syphillis) Rubella Cytomegalovirus Herpes simplex

Most likely cause of amenorrhea in short stature, low set ears, webbed neck

Turners XO

What is the treatment for each type of renal tubular acidosis?

Type 1 and 2: oral bicarb, potassium, and diuretics Type 4: fludrocortisone, dietary potassium restriction Type 4 is hypoaldosteroneism

18 month female diagnosed with first febrile TI. What is the managment and follow up?

UTI with no known genitourinary tract abnormalities start with 3rd generation cephalosporin (cefixime, cefdinir, ceftibuten). Get renal and bladder US to rule out in: kids <2 with fever + UTI, recrrent UTI, and UTI + family history of genitourinary disease ( poor growth, HTN), or anyone not responding to antibiotics

Why is it important to surgically repair an ASD?

Unrepaired ASD can lead to RVF/CHF, arrythmias, Eisenmenger syndrome (R>L shunt), and paradoxical embolus/stroke

26 year olf brought to ED for prolonged bleeding from minor laceration on her arm. Cut her arm while doing some yard work and it has continued to ooze blood for hours. Has always brised easily. Occasional nosebleeds. Admits to heavy menstration. Labs show normal plt, PT, and increased PTT. Bleeding time is elevated. RIsocetin cofactor activity is markedly reduced. What normal substace is most likely deficient in this pt? What is the treatment for this disorder?

Von willenbrand disease- VWF DDAVP, give concentrated VWF if have to

Vasculitis of the kidney, upper airway, and lungs

Wegners Granulomatosis with polyangitis

28 year olf woman is referred for evaluation of mildly elevated AST and ALT which were discovered on an insurance physical. She does not drink alcohol. Total bilirbin and alkaline phosphatase were normal. Hepatitis B and C serologies are negative. Serum ferritin is 62 ng/dL. Serm ceruloplasmin is 12 (nml 15-60). What other tests could help comfirm the diagnosis? How are pts with this disease treated?

Wilson's disease a. low serum Copper, high 24 hr urinary copper, slit lamp exam of eyes show Keyser Fleischer rings, liver biopsy, genetic testing b. copper chelation therapy with penacillamine or trentine

thrombocytopenia +eczema + recurrent infections

Wiskott- Aldrich

A 44 year old man is brough to the emergency department after a MVA. He appears confused and disoriented. A CT scan shows a focal contusion with surronding cerebral edema. What is the most appropriate management?

Worry about increase ICP If severe increased ICP or herniation then drain CSF with ventriculostomy. Elevate head of bed to 30 degree, IV mannitol used cautiously. 2nd line: hyperventilation, sedation, hypothermia to reduce 02 demand

Recurrent bacterial infections after the age of six month

X-linked agammaglobulinemia (Brutons)

45 year old man with elevated LFTs, epigastric pain, RUQ pain that began 8 hours ago. He also has fever, N/V. What type of hepatitis would most likely cause AST to be twice as high as ALT? In a patient with acute hepatitis, what type of bilirubin would you expect to be elevateD?

a. Alcoholic b. hepatobiliary dz causes an increase in direct/conjgated bilirubin hemolysis causes indirect/unconjucated

72 year old with exertional dyspnea x 1 wk. Treated for infective endocarditis 6 weeks ago. VS 98.6, RR 16, HR 100, BP 148/62. Bounding pulses. Diastolic decresendo murmur at left sternal boarder. Echo shows early mitral valve closre and reverse blood flow across aortic valve. WBC # and ESR normal. What is the most likely diagnosis? What two classes of medications would be most likely to improve his symptoms?

a. Aortic regurgitation from previous infective endocarditis b. ACEi or CCB to decrease afterload and slow progression of regurgitation

65 year old woman with IBD x 5 years. Complains of colickly right lower quadrant pain and occasional low grade fevers. A colonoscopy shows cobblestoning and skip lesions. What would the colon biopsy most likely reveal? Under what conditions would you refer this person for a curative colectomy?

a. Crohn's disease, bx show transmural inflammation, noncaseating granulomas b. not curative in crohn's disease txt: 5-ASA, steroids, immunosppressants, anti-TNFa

23 year old woman with intermittent abd bloating and crampy lower abdominal pain x 6 weeks. There is no NV. She alternates between diarrhea and constipation, and defecation oftern relieved the abdominal pain. There is no blood or mucus in the stools. She has had no wt loss. She recently broke up with fiance and is staying with friends. The PE, labs, and imaging are all normal. a. what is the diagnosis? b. what initial management should be considered?

a. Irritable Bowel disease b. avoid gas producing foods, diet low in fermentable short chain saccarides, gluten free, high fiber, and exercise

39 year old man with prurits and RUQ pain x 2 weeks. 15 year hx of UC. PE shows mild jaundice but no other abnormalities. pANCA strongly positive. ERCP shows "beading" of the biliary system. a. what is the diagnosis b. what treatments options are available c. what malignancies is this patient at an increased risk of developing?

a. Primary Sclerosing Cholangitis b. No proven medical therapy but ERCP for dominant stricture dilation, liver transplant for advanced disease c. cholangiocarcinoma, gallbladder CA, hepatocelllar carcinoma usually yong men with IBD. Alk Phos, T bili, Direct bili are all elevated and will have a positive pANCA

What nonspecific lab studies are used in the screening of syphillis? What specific lab studies are used to confirm? What lab studies can be sed to identify the spirochetes in syphilis?

a. RPR, VDLR b. treponemal Ab (FTA-ABS or MHA-TP) c. darkfield microscopy of chancre

30 year old woman with neck pain. PE reveals tender thyroid thats diffusely enlarged. No nodules. Pt is started on naproxen for pain, thyroid blood tests are ordered. She returns to clinic in 2 weeks. Her pain has improved but now she is having palpitations and fine tremor in the hands. Results from the initial lab studies show a decreased serum thyroid stimulating hormone and increased free thyroxine (T4). A radioactive iodine uptake scan shows decreased uptake. What is the most likely diagnosis? What would be the most appropriate treament at this time? What would you expect the serum TSH to be at follow up in 6 months?

a. Subacute deQuervain thyroiditis b. beta blocker for palpitations c. TSH increased or normal Subacute thyroiditis is self limiting. Get hyperthyroid due to inflammation causing a massive dumping of thyroid hormones. Thyroid is not over active so do not get an increase uptake on radioactive thyroid scan. PTU and Methimazole block the production of thyroid hormones and does not work to treat this because this is a dumping of preformed hormones. Patients will cycle through hyperthyroid>hypothyroid>euthyroid depending on when in their disease you catch them.

43 eyar old man complaining of black stools. He denies abdominal pain. rectal examination reveals black stools that are strongly guaiac positive. a. Is this most likely an UGIB or LGIB? b. What anatomical structure makes the boundary btw the upper gi and lower gi tract? c. what is the most important aspect in management of an acute, large volume GI bleed?

a. UGIB b. ligament of treitz (btw duodenum and jejunum) c. Fluid restriction

45 year old man with heartburn. Treated for PUD in the proximal duodenum about 3 months ago. Now has recurrent epigastric abdominal pain, weight loss, and diarrhea. EGD reveals prominent gastric folds. There is a new peptic ulcer in the distal duodenum. Serum gastrin conc. is 560 (norm. <110). a. diagnosis b. with what endocrine tumors might this condition be associated? c. managment?

a. Zollinger Ellison Syndrome b. Gastrin secreting tumor -> MEN1 (hyperparathyroidism, pit. adenoma, pancreatic islet cell tumor) c. check gastrin levels, CT or MRI of abdomen, PPI to decrease gastric acid production, if PPI fails then octreotide, if Octreotide fails then sx resection

A 52 year old woman comes to the clinic for follow up of chronic hypothyroidism. She is asymptomatic on her current dose of levothyroxine but recent lab studies show a slightly suppressed TSH. a. What are the risks of giving a supratheraputic dose of levo? b. What is the most appropriate management of this patient?

a. accelerated bone loss and arrythmia> a. fib. b. redce levo dose, reevaluate in 6 wks MCC hypothyroidism is Hashimoto

2 year old boy is brought to the office by his mother because of a 1 year history of dry skin despite frequent application of moisturizing lotion. Says he constantly scratches his skin. PE shows erythematous patches and scaling on the face, neck, and antecubital and popliteal fossae. a. diagnosis b. patient is at increased risk for what condition later in life

a. atopic dermatitis (eczema) -family hx of allergies or asthma b. asthma later in life

What patient population is most susceptible to acquiring a neutropenic fever? What is the clinical definition of neutropenic fever?

a. cancer pts doing chemo b. fever: 101 on sincle reading or >100.4 for >1 hr neutropenia: absolute neutrophil # <500 Broad spectrum abx to treat

27 year old man complaining of watery diarrhea for last two weeks. Stools are not bloody. Occasional crampy abdominal pain. No fever or vomiting. Notes episodes of flushing of the cheeks, neck, and upper chest which are sometimes accompanied by a burning sensation. 24 hour urine sample shows elevated 5-hydroxyindoleacetic acid levels. Abdominal US shows numerous small, solid masses within the liver parenchyma. a. diagnosis b. most likely site of primary tumor c. first line medical therapy for this patient's symptoms

a. carcinoid syndrome b. primary tumor in lungs but if pt is symptomatic then mets to liver c. somatostatin analog (octreotide, lanreotide) Serotonin symptoms Be FDR B: bronchospasm F: flushing D: diarrhea R: right side heart murmur Primary mets that cause symtoms? small intestine and appendix

71 year old man with persistent cough. No fever or sputum production. Minimal SOB. Smoked 1 ppd x46 yr, but last 5 years only 2 cig per day. CXR shows 2 small nodules in the right upper lung. CT scan shows enlargement of several lymph nodes in the right lung and mediastinum. Needle biopsy confirms the diagnosis of small cell lung cancer. a. What treament modalities would be most appropriate for this patient? b. what paraneoplastic syndrome are associated with small cell lunch CA? c. what paraneoplastic syndromes are associated with squamous cell lung CA?

a. chemo, radiation b. ADH> SIADH, ACTH> Cushing sx, Lambert-Eaton Myasthenic Syndrome: tumor induces immune system to produce Ab against pre-synaptic Ca channels found at NMJ and gives muscle weakness that improves with use c. hypercalcemia> Humoral hypercalcemia of malignancy. PTHrP acts like parathyroid hormone Non-small cell lung Ca can present as pancoast tmor: superior sulcus of lungs and invades sympathetics and causes Horner's: ptosis, miosis, and anhydrosis

63 year old man in intubated and admitted to the IC for acute exacertaion of COPD. IN what situations is prophylaxis against stress ulcers in the ICU indicated? What stress ulcer prophylaxis treament or treaments are linked with an increased risk of c. diff infection?

a. coagulopathy, intubation/ventilation > 48 hrs, GI ulceration/ bleeding within past year, head trauma, spinal cord trauma, burn injury OR >/= 2 of the following: ICU >1 wk, sepsis, occult GI bleed for > 6 days, glucocorticoid therapy b. prophylaxis with PPIs, and H2 blockers

86 year old woman in Ed for AMS. Has sodim of 122. How rapidly can hyponatremia be safely corrected? What is the conseqence of correcting hyponatremia too rapidly?

a. do not correct faster than 12 mEq per 24 hr. b. risk of central pontine myelinolysis> severe damage of myelin sheeath of pons leading to paralysis, dysphagia, dysarthria

What antibiotic treatment of choice in RMSF? What is the abx treatment of choic in RMSF in pregnancy?

a. doxycycline b. chlorampenicol (gray baby syndrome though...)

What might chloroquine be avoided in a patient for malarial prophylaxis? In what pt should primaquine be avoided for malarial prophylaxis?

a. drug resistance is common in many parts of the world, check with CDC recommendations b. G6PD def

Classic presenting symptom in lyme dz? What abx are used in the txt of lyme dz?

a. erythema migrans (bulls eye) b. doxycycline, amoxicillin, ceftriaxone

32 year old woman complains of body stiffness and muscle spasms. She recently had a thyroidectomy for hyperthyroidism. The patient displays ipsilateral contraction of the facial muscles when tapping the cheek just anterior to the ear. What is the most likely case of these symptoms? What is the most appropriate treament?

a. hypocalcemia due to Sx removal of the parathyroid b. calcium IV or oral, Vit D, calcitriol, recombinant human PTH

22 year old woman comes to the clinic becase of intermittently bloody diarrhea that began one month ago. She also complains of colicky abdominal pain and fatigue. Colonoscopy reveals continous circmferential inflammation of the rectum and sigmoid colon. a. What serology would suggest a diagnosis of UC? b. what is the most appropriate initial therapy for MILD cases of C?

a. pANCA b. 5-ASA for mild, can also try steroids, immunosuppressants like cyclosporine, azathioprine, 6-mercaptopurine, and Anti-TNF alpha drgs like Infliximab

An 8 year olf bow develops 3 cm erythematous plaque on his chest. One week later he has the onset of multiple salmon colored, oval plaques in a christmas tree pattern over his chest and back a. diagnosis b treatment

a. pityriasis rosea infx of HHV-7 or HHV-8 b. reassurance. Itchy- topical corticosteroid

54 year old man with chronic hepatitis C virus infection develops skin blisters whenever he goes out in the sun a. what is the most likely diagnosis b. what is the management

a. porphyria cutanea tarda -defect in uroporphyrinogen decarboxylase-> elevated levels of uroporphyrinogen in blood and urine b. avoid triggers like EtOH, estrogens, polyhalogenated hydrocarbons Get phlebotomy to rid of iron Chloroquine Treat underlying cause (like Hep C)

18 yea old with scrotal mass. Painless lump on left testicle he discovered 2 days ago. PE confirms presence of non-tender nodule on the inferior pole of the testicle. a. what is the most appropriate next step in management? b. what further testing should be performed before beginning treatment?

a. ultrasound to r/o hydrocele etc b. If US reveals a solid mass> orichiectomy via inguinal approach. Increase risk of recurrence with scrotal incisions, no needle bx. B4 orchiectomy test> BhCG, AFP, LDH. Imaging for mets and lymphnode, CXR, CT of abdomen and pelvis. Sperm banking to preserve fertility. After surgery then chemo "Eradicate Ball Cancer": Etoposide, Bleomycin, Cisplatin

What diuretic or diuretic class would be most useful in each of the following situations? altitude sickness

acetazolamide

What diuretic or diuretic class would be most useful in each of the following situations? glaucoma

acetazolamide or mannitol