UWorld Step 2

53 y.o. man to the ED complaining of sudden onset of intense epigastric pain with peritoneal signs. Abdominal US 2 wks ago (small stones and GB). Increased pain in upper abdomen when palpating after deep inspiration, no guarding or palpable mass. Dx?

Perforated peptic ulcer; free air is shown under right diaphragm (pneumoperitoneum). NSAID use and several day hx of epigastric pain followed by acute severe, constant pain (perf'd ulcer). Gastric secretion are released into peritoneal cavity -> peritonitis, rebound tenderness and guarding. - Murphy's sign

25 y.o. HIV pos male with AMS. Meds are antiretroviral, TMP-SMX, and azithro. CD4 is 40. MRI shows solitary, irregular, weakly ring-enhancing mass in periventricular area. Toxo positive!! PCR of CSF shows EBV DNA!!! Dx?

Primary CNS lymphoma!!! Weakly enhancing ring mass that is solitary or periventricular!!!!s EBV DNA in CSF is specific!!!!

70 y.o. right handed man at ED with right-sided weakness and urinary incontinence began 10 hrs ago. T2DM for last 20 yrs, HTN for last 28 yrs. 4/5 strength in RUE, 1/5 strength in RLE, Babinski on right side. Sensation decreased throughout right foot leg. Visual fields full.

Anterior cerebral artery stroke: CONTRALATERAL MOTOR and/or SENSORY DEFICITS, MORE PRONOUNCED IN *LOWER LIMB* Other features include urinary incontinence, gat probs, emotional disturbances. Anterior (internal carotid and its branches) Posterior circulation comprised of paired vertebral arteries (unite to form basilar artery, further divides into paired posterior cerebral arteries)

Pt with TSH 7.3 and normal free T4 recurrent pregnancy loss. Symmetrically enlarged, nontender, firm thyroid gland. Which antibodies does she have?

Anti-TPO; HASHIMOTOs. Subclinical hypothyroidism (symmetrically enlarged, nontender thyroid). High titers of TPO are also assoc'd with miscarrige in both euthyroid and hypothyroid women. Tx with levothyroxine is recommended in pts with subclinical hypothyroidism who have elevated anti-TPO antibodies.

54 y.o. with hx of T2DM treated with insulin and well controlled HTN. Feels well and plans to go to Hawaii in 1 week. Had flu shot 1 yr ago and Td booster 12 yrs ago. Which vaccines should he receive at this visit?

Tdap, flu, PPSV23 PCV13 + PPSV23 <65 y.o. in high risk pts (for everyone at age 65) PPSV23 alone in pts <65, then followd by sequential PCV13 and PPSV23 at 65. PPSV23 alone: chronic heart, lung, or liver dz, DM, current smoker, alcoholic

43 y.o. with acute right knee pain. No smoking or drinking. Recent dx of diabetes. Dad also has DM. Slightly swollen and tender rigth knee and mild hepatomegaly. Right knee X-ray reveals chondrocalcinosis and moderate effusion. Next step?

Serum iron studies; hereditary hemochromatosis. Arthritis with chondrocalcinosis (pseudogout; calcium pyrophosphate crystals). Elevated iron, ferritin, transferrin.

Acute pyelo in pregnancy

presents with fever and flank pain, can be complicated by ARDS and preterm labor Give abx and supportive therapy

Amphetamine abuse during pregnancy is assoc'd with

preterm delivery, preeclampsia, abruptio placenta, FGR, IU fetal demise - BTW: pts with long standing ankylosing spondylitis -> can develop bone loss due to osteoclast activity in the setting of chronic inflammation - BTW: stop paps at 65 or hysterectomy PLUS no hx of CIN2 or higher AND 3 CONSECUTIVE neg paps or 2 neg co-testing results

Systemic sclerosis cause of dyspnea

(anti-topo I, anti-pol III, and anti-centromere); due to intersitial lung dz! btw crest: calcinosis, raynaud, esophageal dysmotility, sclerodactyly, telangiectasia

narrow ocmplex tachycardia with hemodynamic instability. Tx?

(narrow complex tach) --> synchronized cardioversion!!! - Antiarrhythmics: stable recurrent or refractory wide complex tach - Unsynchronized cardioverzion (defib) -> rusrc effort in pts with pulseless cardiac arrest who have shockable rhythm like vfib, pulseless ventricular tach)

**Hyponatremia and polydypsia evaluation**

**serum osm >GGGG290: marked hypeglycemia or advanced renal failure** **urine osm <LLLL100: primary polydipsia, malnutrition** urine sodium <LLL25: SIADH, adrenal insufficiency, hypothyroidism urine sodium >GGG25: volume depletion, CHF, cirrhosis

31 y.o. G1P1 in hospital POD 2 due to lower abd pain, chills, pain with sitting. Pt initially planned to have a home delivery but came to the hospital when she had no contractions a day after SROM. After a 26 hr induction of labor, she had a primary c-section for arrest of descent. Pt has controlled asthma. Does not use tobacco, alcohol, or illicit drugs. T101, BP 100/60, P96. Cardiopulm eam normal. Pelvic exam shows small amounts of blood on perineal pad with mildly foul-smelling discharge. Bilateral LE are symmetric with minimal edema. Tx?

*Clindamycin + gentamicin* Postpartum endometritis. 24 hrs PP, purulen lochia and uterine tenderness. Risk factors: prolonged ROM, operative vaginal delivery, prolonged labor, c-section POLYMICROBIAL INFECTION! Tx: broad-spectrum abx esp (above) until pt is afebrile for 24 hrs. - Ceftriaxone: pyelonephritis - Ceftriaxone + azithro: acute cervicitis (gonorrhea, chlamydia)

20 y.o. man at the ED with one day hx of fever, HA, AMS, no hx of illness. CSF shows lymphocytic pleocytosis elevated protein level, normal glucose level. Pt started on high-dose IV acyclovir. 2 days later, pt complains of nausea and abd discomfort. PCR for HSV comes back positive. Afebrile, normotensive. Has AKI. Cause of AKI?

*Renal tubular obstruction* due to crystal induced AKI bc of IV acyclovir (low urine solubility, precips in tubules easily) - AIN: beta lactams and PPIs (7-10 days later); pts can have skin rash, eosinophilia, pyuria. - GLomerular injury: glomerulonephritis -_- RBC casts

Management of CIN3

If >25 and not pregnant --> do LEEP, conization or cryoablation!!! Follow up with pap test with HPV 1 and 2 yrs post procedure

PSGN

10-20 days after strep throat OR SKIN infections. Can have periorbital swelling, hematuria, oliguria. Pt may have HTN and UA shows RBC casts and proteinuria LOW C3 COMPLEMENT LEVELS - Drug induced intersitial nephritis: PCN, cephalosporins, sulfonamides (fever, rash, arthralgia) - IgA nephropathy: present with hematuria after URI - BTW: *molluscum pts should be tested for HIV, especially if widespr ead or involve the face!* - BTW: *bacillary angiomatosis* is due to Bartonella and is seen in IC pts - BTW: cryptococcus may look like MC skin lesions but would have involvement of lungs and CNS

Alcoholic hallucinosis happens within

12-48 hrs of last drink, resolves within 24-48 hrs

Anti-HTN in pregnancy

1st line: methyldopa, beta blockers (labetalol), hydralazine, CCBs (nifedipine) 2nd line: thiazides, clonidine CI: ACEi, ARB, aldosterone blocker, renin inhib, loop

Recurrent parotid tumor

2 lobes of parotid gland are separated by the FACIAL NERVE!!!!

When are pregnant women screened for GDM?

24-28 weeks! Earlier if high risk! Do 50 g 1 hr GTT - Initial prenatal visit: RhD screen, hb/hct, MCV, HIV, syph, hep B, rubella and vzv immunity, pap test, chlamydia, urine culture and protein - Inactivated FLU VACCINE IS SAFE DURING EVERY TRIMESTER and even during breastfeeding

absence seizure

3 hz generalized spike-wave activity - narcolepsy: decreased REM latency

Palpable breast mass

30+: mammogram +-/ US, if suspicious, do core biopsy <30: do US +-/ mammogram; simple cyst (needle aspiration if pt wants), if complex cyst (sold) then the image-guided core biopsy - remove catheter: 24-48 hrs postop!!!

AAA screening

65-75 y.o. men who have smoked. Surgery if 5.5 cm or greater. DO ULTRASOUND - BTW: "lone AF" in pts with paroxysmal, persistent, permanent AF. Pts with this are usually <60 and have CHADSVASC score of 0 (super low risk of embolization) -BTW: 68% of data within one SD, 95% within two SD, 99.7% within 3 SDs

Preterm labor managment

<32 wks: BETAMETHASONE, tocolytics, magnesium sulfate! 32-34: BETAMETHASONE, tocolytics, PCN for GBS 34-36: +/- BETAMETHASONE, PCN for GBS - BTW: placenta previa is painless, abruptio is painful

Septic hip joint in kids

>12,000 WBC, >38.5C, ESR >40, CRP >2

Lactose intolerance test

Hydrogen breath test!!! - diarrhea due to lactose deficiency has high osmotic gap.

Tx for organophosphate poisoning

ATROPINE (competes with ACh at muscarinic receptors; ALSO remove clothing and wash body). ACh-esterase stops working so you get bradycardia, miosis, bronchorrhea.

25 y.o. woman with occasional palpitations, better when she sticks face in cold water. Maneuver terminates palpitations by altering what?

AV node conductivity; She has paroxysmal supraventricular tachy. AV nodal reentrant tachycardia occurs in young normal pts. AVNRT due to presence of 2 conduction pathways (slow and fast) in the AV node. If atrial premature beat occurs at a critical time when fast pathway is refractory but slow isnt, it can initiate reentry mech Improved by vagal maneuvers that slow AV node conduction termporarily and increase AV node refractory period

69 y.o. man with 3 days of LLQ pain. Pain was intermittent, constant over past day. Nausea and fever past 2 days, urinary frequently. Hx of chronic constipation and right inguinal hernia repair 20 yrs ago. T 101.3, BP 122/80. Abdomen soft but tender to palpation in the LLQ. WBC 14,500. Bowel sounds present. DRE reveals normal prostate. No CVA tenderness. Normal UA. Next step?

Abdominal CT with contrast; ACUTE DIVERTICULITIS Chronic constipation and a low-fiber, hi-fat diet are risk factors. LLQ pain, fever, n/v, leukocytosis. Some have urgency/frequency due to bladder irritation from inflamed sigmoid colon. Dx: Abdominal CT with contrast

56 y.o. eval'd for fever on postop day 3. Had CABG for multivessel CAD requiring 4 grafts. Pt intubated and under mech ventilation. T 102, 130/80. BMI 28 kg/m^2. Coarse breath sounds bilaterally. Pt grimaces during palpation of RUQ. Bowel sounds decreased. TOtal bili 1, Alk phos 100, AST 32, ALT 34, amylase 110. CXR normal. Dx?

Acalculous cholecystitis (acute inflamamtion of GB in absence of stones); seen in hosp'd pts who are realy ill (after surgery, burns, sepsis, shock). Unexplained fever, diffuse or RUQ pain. Can have jaundice, RUQ mass, leukocytosis, maybe abnormal LFTs. Dx: ultrasound (acute chole without stones) Tx: abx coverage, cholecystostomy for drainage, cholecystectomy once stable

22 y.o. woman with headache for last 6 weeks. Pulsatile and assoc'd with nausea. Worse at night and awaken her from sleep. No photophobia, weakness, sensory changes, no meds. BMI 33. Normal neuro exam. Funduscopy shows papilledema. CT of the brain shows no abnormalities. LP shows elevated opening pressure with otherwise normal CSF analysis. Next step?

Acetazolamide; idiopathic intracranial hypertension (pseudotumor cerebri). Features of increased ICP in alert pt, absence of focal neuro signs (except 6th CN palsy), no evidence of other causes, and normal CSF except opening pressure. Avoid tetracyclines and isotretinoin!. Weight loss may help. Tx: ACETAZOLAMIDE (inhibits choroid plexus carbonic anhydrase)

y.o. male postal worker at ED, "crazed" past 4-5 days, has anxiety and sleeping less than usual. Moody with family. Frightened by large shadows at night that he thinks are from the other world and going to take him. Stopped going to work. Also has abdominal pain, constipation, and 'tingling' in fingertips. No other sx. Hx includes major depression and GERD. Fam hx of psychosis. 98.1F, 140/80. Bowel sounds decreased. Neuro exam is normal except for decreased sensation in fingertips and mild weakness in right arm. Dx?

Acute intermittent porphyria; hereditary prob with heme synthesis. -- intermittent neurovisceral symptoms. New onset of psych and neuro probs, with unexplained acute abdominal pain (it's neuropathic) and fam hx of similar sx. May also have vomiting, constipation, tachycardia. Age of onset is 30s or 40s. Sx last weeks. Dx: urinary porphobilinogen

65 y.o. woman tx'd for risperidone for psychosis. 2 wks later, better but husband says she has slowed down, maybe depressed. Mild tremor, does not swing arm when she walks. Lower dose of risperidone results in distressing return of hallucinations. Next step?

Add benztropine; antipsychotic-induced Parkinsonism! shuffling gait, rigidity, masklike facies. When reduction is not feasible, can be treated with antiparkinsonian med like benztropine (anticholinergic) or amantadine (dopaminergic med)

43 y.o. man with dull, non-radiating CP. Never had CP before but does have episodes of dyspnea and coughing. Hx of DM, allergic rhinitis, and childhood eczema. ECG shows ST depression in lateral leads but no evidence of MI with cardiac markers. Pt is admitted for further eval, tx'd with aspirin, clopidogrel, LMWH, metoprolol, and lisinopril. Day 2 has SOB and dry cough but no CP. Normal vitals. Exam shows prolonged expiration with bilateral wheezes. No crackles. Cause?

Adverse effect of medication. Pt initially admitted for CP (unstable angina), had bronchoconstriction (wheezing and prolonged expiration) probs bc of asthma now exacerbated by aspirin or beta blocker - BTW: urticaria - <6 wks is acute, >6 wks is chronic. Due to mast cell activation of superficial dermis, increasing histamine release causing localized swelling in upper layers of skin. Can be due to infx, NSAIDs, allergy, or direct mast cell activation, or idiopathic.

38 y.o. man with 2 days cough, chills, fever, night sweats. Right sided pleuritic CP on deep inspiration. Cough is productive of brownish sputum with occasional flecks of blood. Had asthma since childhood, poorly controlled over past year with 3 hospitalizations. Pneumonia 3 months ago. WBC 15,000, neutrophils 60%, Eos 12%. CT shows RLL infiltrate and bilateral central bronchiectasis. Dx?

Allergic bronchopulmonary aspergillosis; pt with asthma or CF with poor control, recurrent exacerbations, can have hemoptysis. Central bronchiectasis from recurrent cycle of inflammation. EOSINOPHILIA Tx: oral corticosteroids for months with itraconazole - btw: you want warfarin target to be like 2 or 3 to prevent coagulation (higher risk of prosthetic valve thrombosis with mitral valve)

27 y.o. complaining of joint pain. Sx began 10 days ago (bilateral pain in the MCP, PIP in joints, wrists, knees, ankles. Joint stiffness lasting 10-15 minutes on awakening in the morning. Pts had assoc'f fatigue and few episodes of loose BMs with mild skin itcing and patchy redness. No fever, WL, or LAD. Elementary school teacher. On exam, tenderness of involved joints without swelling or redness. What is elevated in pt?

Anti-parvo B19 IgM antibodies Polyarticular, symmetric arthritis in peripheral joints MCP, PIP, wrist, knees, ankles. No joint destruction. Also might have fever, fatigue, diarrhea. P8arvo IgM antibodies develop within 10-15 days and remain for 6 months. Sx resolve within 2-3 weeks

32 y.o AA with sudden left-sided weakness, thrombocytopenia, mitral regurg, pos ANA and RPR.

Anti-phospholipid syndrome (thrombotic event or pregnancy morbidity) anti-cardiolipin - *BTW: mesolimbic = antipsychotic efficacy, tuberinfundibular = hyperPRL, nigrostriatal: movement*

Scleroderma antibodies

Anti-topo I (anti-Scl70), anti-RNA polymerase III, anti-centromere antibodies Scleroderma: connective tissue thickening due to fibroblast dysfunction and increased collagen and ground substance production. Thickening of skin at hands and feet, then dermal, then hair follicles, sweat glands. Vascular dysfunction (Raynaud), esophageal dysmotility, ILD, HTN (renal involvement).

29 y.o. man with persistent vomiting and abd pain for last 24 hrs. Crampy, diffuse, progressive. BM 3 days ago. Green emesis. Not eaten bc of pain and nausea. T 98.2, BP 116/75, 94/55 standing. Abdomen distended with hyperactive bowel sounds. Percussion: tympany, diffuse tenderness. WBC 9,600, hct 45% Na 147, K 3.1, Cr 1 AST 20, ALT 12, bili 0.8 What historical finding would you expect in this pt?

Appendectomy 6 months ago; SBO -> vomiting and hypokalemia, decreased intake -> dehydration and orthostasis. Pts can have simple (obstruction) or strangulated (peritoneal signs, shock. Adhesions are most common cause of SBO

40 y.o. man with month of progressively worsening tingling in hands and feet. Restores antique furniture as a hobby. Skin over neck has patchy areas of hyperpigmentation and hypopigmentation. Hyperkeratoses on palms and soles. Increased sensitivity to pinprick and light touch over fingers and toes. Plantarflexion and dorsiflexion are weak at the ankle, weakness of interossei and wrist flexors and extensors. Hb 10.4. AST 50, ALT 62. Dx?

Aresenic poisoning!!! Exposure to antique wood, polyneuropathy, pancytopenia, mild transaminase elevation. STOCKING GLOVE NEUROPATHY, hyporeflexia, hypo/hyperpigmentation at area of exposure. Mees lines (fingernail striations) - AIP: partial deficiency of porphobilinogen deaminase (heme synth). patchy sensorimotor neuropathy and autonomic dysfunction. Not severe pain or skin involvement. - Lead poisoning: chronic can lead to stocking glove neuropathy with microcytic anemia; HAVE GI COMPLAINTS but NO SKIN FINDINGS

Acute cholangitis

Ascending infx due to biliary obstruction. Charcot triad: Fever, jaundice, RUQ pain (if hypotension and AMS, Reynolds pentad) Dx: cholestatic liver function abnormalities (hi direct bili, alk phos; mildly elevated AST, ALT), *biliary dilation on abdominal US or CT* Tx: abx coverage of enteric bacteria, biliary drainage by ERCP within 24-48 hrs

Best way to prolong survival in COPD pt with significant hypoxemia (PaO2 <55, SaO2 <88), or PaO2 <59 or SaO2 <89 with cor pulmonale, RHF, hct >55%

At home O2 therapy

Nephrotic syndrome increases the risk of

Atherosclerosis low plasma oncotic pressure -> increases hepatic lipoprotein synthesis!!! - monoclonal gammopathy can lead to amyloidosis -> nephrotic syndrome

65 y.o. woman with months of progressive cough and weakness. Limited mobility and SOB due to OA and COPD. Proximal myopathy sx, long smoking hx. Weakness in proximal muscles of upper and lower limbs, loss of DTRs. CT shown, something in lung. Cause of weakness?

Autoantibodies to VG calcium channels; Lambert Eaton!!! 50% malignancy (mostly SCLC) *absent DTRs!!!*, autonomic dysfunction like dry mouth and erectile dysfunction. - Polymyositis: reflexes preserved and CK elevated

53 y.o. man complains of occasional shaking in right hand for the last 3 months. Shaking while resting in an armchair watching TV. Stops when he reaches for the remote, more pronounced when focused. Coffee and alcohol have no effect. Left hand has no symptoms. Pt has no weakness, numbness, paresthesias, or gait dysfunction. Cause of condition?

Basal ganglia dysfunction PD: resting tremor (4-6 hz) that decreases with voluntary movement; involves legs and hands, less commonly face. *Tetrad: resting tremor, rigidity, postural instability, bradykinesia* - Essential: bilateral HANDS, possible isolated head tremor - Cerebellar: ataxia, dysmetria, gait disorder; increases and hand reaches its target - Physiologic: low amplitude (10-12 hz). Acute onset with increases SNS activity (drugs, anxiety, caffeine, hyperthyroidism). Worse with moevement & can involve face/extremities

37 y.o. man who is agitated, combative, psychotic. Urine tox pos for THC. Normal head imaging, in ED had seizure. Psychotic for another week, but sx subside and disappear with occasion use of benzo and supportive care. Cause?

Bath salts intoxication! PROLONGED duration of effect! Days to weeks - Schizophrenia: would have 6+ months of sx. Delirium, seizures, recovery in a week esp without antipsychs would not be typical - Ecstasy (MDMA) is amphetamine and causes increased feelings of euphoria and intimacy. - PCP: combative behavior but shorter duration, and detected on urine tox screen

3 week old boy with 1 wk hx of jaundice, pale colored stool. Breastfeeding and feeding well. T 99, nl cap refill. Jaundice and hepatomegaly. Labs show total bili 10.3, direct bili 8.1, hb 15. Mom's blood type O and him B+. Dx?

Biliary atresia; jaundice, light stool, hepatomegaly, direct hyperbili -- biliary atresia - Breast milk jaundice: starts in 2nd week of life!!! UNCONJ - Physiologic jaundice: after 24 hrs, gone after 1st wk. UNCONJ

74 y.o. woman with diarrhea, nausea, decreased appetite for 1 wk. Increasing fatigue and palpitations over past few days. Chronic afib and cardiomyopathy. EF 3 months ago was 40%. Meds include furosemide, metoprolol, digoxin, and warfarin. Long time smoker. Lungs have scattered wheezes. BP is 140/90, irregularly irregular. INR wks ago was 2.3. Next test?

Blood drug level; chronic afib with diarrhea, nausea, fatigue (DIGOXIN toxicity!); inciting even can be viral illness or excessive diuretic use. - AKI decreases renal acid excretion but does not raise blood ammonia level - renal tubular cl loss in loop or thiazide overuse (due to loss of extracell volume accompanying cl loss, stim'ing RAAS and excretion of H+) - BTW: dementia with lewy bodies cause visual hallucinations and parkinsonian motor sx!!!

4 day old boy lost 1 pound since birth, now 6 lb 15 oz. 10 minutes on each breast every 4 hours. Infant passed several dark-brown, sticky meconium stools first 2 days of life. Now only has smears of dark yellow; 3 wet diapers per day. Pic of diaper also shows brick-red urate crystals (4 day old infant should have 4+ wet diapers per day - rule of first week) Has scleral icterus and jaundice of face, chest, and abdomen. Total bili 15, direct bili 0.9. Cause of hyperbili?

Breastfeeding FAILURE jaundice (1ST WEEK OF LIFE) - Biliary atresia: conjugated in first 2 months (clay-colored stools, dark urine, enlarged liver) - Breast milk jaundice: no signs of dehyration or feeding probs - Galactosemia: CONJUGATED; G1UDP deficiency. Jaundice, vomiting, growth failure

23 y.o. primigravida at 38 wks admitted to hospital for SSROM and painful contractions. 8 cm dilated, 90% effaced with head at 0 station. IUPC shows contractions every 10 mins at 200 Montevideo units. 4 hrs later, cervix is unchanged. Normal FHR. Next step?

C-section: no cervical change for 4+ hrs with adequate contractions OR no cervical change 6+ with inadequate contractions. - Could have waited 2 hrs and redone cervical check if contractions were inadequate - Oxytocin: if cerical change is slower than expected or +/- inadequate contractions - Amnioinfusion: fluid into uterus to treat variable decels

Klumpe palsy in baby delivered with forcep assistance

C8 and T1!!! Claw hand; may cause Horners!!! - Erb-Duchenne: waiter's tip -- C5 and C6!!! - BTW: Hungtingon is atrophy of caudate!!!

Aphthous ulcers and perianal skin tags and fisturals in UC or CD?

CD!!! Focal ulcerations with transmural inflammation

Toxoplasmosis in HIV

CD4 <100: TMP-SMX prophylaxis! - Acyclovir: HSV - Albendazole: tx of neurocysticercosis - Azirthro: CD4 <50 (mycobacterium avum proph) - Fluconazole: coccidioidomycosis proph

Dysuria, pyuria, urinary frequency, urethral discharge in sexually active male. No culture growth on stain and urine culture

CHLAMYDIA! Dx: nucleic acid amplification - Gonorrhea: gram neg cocci!!! - Trichomonas: asymptomatic in men, uncommon cause of urethritis

35 y.o. man in office for LBP follow up. Aching pain left lumbar paraspinal area, worse at end of night and relieved with rest. Pain began 3 months, takes occasional acetaminophen and naproxen. No assoc'd fever, weight loss, radicular pain, LE weakness, urinary sx. Pt is factory worker and lifts heavy things. Flexion and extension of lumbar spine elicits pain. Mild tenderness in left lumbar paraspinal tissues but no midline tenderness. Everything else nl. Tx?

CHRONIC LBP: Exercise therapy, intermittent NSAIDs or acetaminophen, consider TCAs or duloxetine ACUTE LBP: moderate activity, NSAIDs/acetaminophen, consider: muscle relaxants, spinal manipulation, brief opioids

Secondary hyperPTH

CKD: low renal absorption of ca and elevation of pth - Tertiary: persistent secondary --> reactive hypercalcemia

65 y.o. man with 4 wk hx of weaknes and vague postprandial epigastric pain. FOBT positive, gastroduodenoscopy shows antral ulcer, bx shows adenocarcinoma. Next step?

CT scan for mets -H pylori is risk factor for MALToma and gastric adenocarcinoma, tx may cause remission of MALToma sometimes but not of adenocarcinoma

Multiple myeloma

Calcium (elevated), Renal insufficiency, Anemia, Bone lesions Hypercalcemia: fatigue, constipation, depression - Secondary spontaneous pneumothorax suspecte in pt with underlying lung dz; rupture of alveolar bleb is most common in pts with COPD - BTW: RA predisposes to amyloidosis

MAJORITY OF KIDNEY STONES ARE MADE OF

Calcium oxalate stones!!!!

Active 68 y.o. with 2 day hx of ankle pain, warm, inflamed, worse with any movement. X-ray reveals soft tissue swelling, small tibiotalar, joint effusion, chronic calcification of the articular cartilage. No fractures or dislocaiton. Dx?

Calcium pyrophosphate arthritis (pseudogout); *CHONDROCALCINOSIS (chronic calcificication of articular cartilage)* Tx: intra-articular glucocorticoids, NSAIDs, colchicine

PE tx

Cancer pt with good kidneys: LMWH VTE in pts with renal failure: unfractionated heparin therapy If you're super duper sure it's a PE and well's score is 6, just start the heparin drip before the CT angio - If pt is unstable and can't undergo angiography, do echo. If RV dysfunction, presume that it is PE and start tx. If stable and high well's score, start anticoag and then to CT angiography to confirm. If low, do D-dimer first

47 y.o. man with occasional daytime HA, dizziness, nausea; has restful sleep, is traffic controller in underground parking garge. Smoker. BMI 24, no JVD. 2-6 apical holosystolic murmur is present. Normal electrolytes, slightly elevated hct. Cause?

Carboxy-hb; exposed to automobile exhaust; polycythemia, intermittent HA, dizziness, nausea. Dx: ABG

37 y.o. man with sudden gait instability and right arm weakness this morning when smoking. Also had probs with balance and walking for past 2 days. No head trauma or LOC. Pt has mild HA, fatigue anorexia, night sweats, chills over last week. Hx of IVDU, yesterday was last injection. Febrile. Grade III holosystolic murmur heard loudest at cardiac apex. Neuro exam shows right lower facial droop and 2/5 strength in RUE. Wide based gait and difficulty with heel to shin. UA shows red cell casts and proteinuria. Cause?

Cerebral septic emboli; ischemic stroke due to septic emboli from infective endocarditis (valvular vegetations dislodge and travel to brain leading to infarction, abscess, and/or bacterial meningitis) Glomerulonephritis also suggests septic cardioembolism (immune complex mediated)....? idk why - drug-induced vascular spasm are attributable to cocaine/amphetamines and not heroin - BTW: SSRIs take 4-6 weeks to start working - BTW: dysthymia = 2+ yrs in adults, 1+ in peds

60 y.o. man with nausea and abd pain. Coronary angiogram and stent placement for CP 5 days ago, discharged next day. Painless, purple mottling of skin on both feet. Serum Cr 3.0, low C3 level. Normal UA. Cause?

Cholesterol emboli; systemic atheroembolism from disruption of atherosclerotic aortic plaque (cholesterol crystal embolism). Contrast induced nephropathy: muddy brown and epithelial cell casts, resolves after 3-5 days (atherosclerotic emboli takes longer).

39 y.o. G1P1 with 10 days of pelvic pressure and heavy vag bleeding, increasingly heavy (3 pads a day). Long hx of irregular menses and infertility. 6 months ago had pos preg test, had spontaneous abortion and did not seek medical care afterward. LMP was prior to spont abortion. At age 31 had LEEP for high grade CIN. Enlarged, mobile, non-tender uterus. Pelvic exam shows 2x2 red vascular nodule in posterior fornix that bleeds when touched with a cotton applicator. Dx?

Choriocarcinoma: enlarged uterus, abnormal bleeding, friable vaginal lesion. High levles of hCG after hydatidiform mole or after any pregnancy. Can have rapid mets to lungs and vagina.

53 y.o. man with 2 episodes of hemoptysis over past week. 2 yr hx of morning cough with 1 tbsp of white sputum. During last week, morning cough was accompanied by small amt of blood on 2 occasions. No dyspnea, fever, CP, or weight loss. Smoked for 30 yrs, works in construction. Takes ranitidine for heartburn. Cause of hemoptysis?

Chronic bronchitis; longstanding smoker with productive cough and recent hemoptysis (chronic bronchitis). Dx: 3+ months of chronic productive cough in 2 successive yrs!! - BTW: REMEMBER to treat pts with acute cervicitis (mucopurulent discharge, cervical friability) with azithro and ceftriaxone!!!

Cannabis intoxication vs cocaine intoxication

Cocaine doesn't cause conjunctival injection (causes pupillary dilation, anxiety, paranoia) Cannabis causes conj injection, dry mouth, tachycardia, increased appetite. CAN ALSO CAUSE psychomotor impairment, anxiety, and paranoia

Brain herniations

Cocaine use has risk of HTN vasculopathy -> intracranial hemorrhage -> basal ganglia hermorrhage is most common site!! Can cause: uncal herniation (part of temporal lobe against tentorium cerebelli): dilated, non-reactive ipsi pupil, further compression can cause CL extensor posturing - Cerebellum herniation: neck tilt, flaccid paralysis, coma, BP probs

65 y.o. with 2 month hx of fatigue and dyspnea on exertion. Afebrile, bp 162-83. Auscultation shows 2/6 mid-systolic murmur in 2nd left intercostal space with normal S2 splitting. No peripheral edema; guaiac neg stool. ECG: sinus tach and nonspecific ST-T changes Hb 8.6 MCV 74 Ferritin 8 Iron 26 IBC 474 (hi) Next step?

Colonoscopy and endoscopyo **She has iron def anemia!!! Low serum iron and ferritin with elevated IBC)** New IDA in elderly: GI blood loss (neg guaiac stool is not sufficient to exclude GI bleed) - BTW: herpetic whitlow of the hand is due to HSV, acquired from contact with genital herpetic lesion or infected orotracheal secretion (usual spontaneous resolution, but recur)

57 y.o. with breast tenderness over past 2 months. Pelvic exam shows lare, nontender left adnexal mass. US shows 10 cm solid left ovarian mass and thickened endometrial stripe. Next step?

Endometrial biopsy! Granulosa cell tumor occur in postmenopausal and more rarely prepubertal girls; SECRETE ESTROGEN and can cause endometrial hyperplasia or carcinoma

Pt with CHF; pathophys assoc'd with it?

Constriction of efferent renal arterioles! Decreased CO -> neurohormonal adaptations like increased SNS, activated RAAS, increased ADH secretion (all due to attempt to maintain CO and systemic pressure by increasing myocardial contractility, peripheral VC, expansion of ECF volume) Decreased renal perfusion in CHF and RAAS activation -> increased ag II --> **VC of AFF AND EFF GLOMERULAR ARTERIOLES** -> increase in renal vascular resistance and net decrease in renal blood flow, preferential VC of eff renal arterioles (increasing intraglom pressure to maintain GFR), aldost increases sodium resorption in PCT, meaning decreased sodium in DCT**

64 y.o. man with LE edema and increasing abdominal discomfort. T2DM and mitral valve repair surgery 12 yrs ago. Smoked a pack of cigarettes daily for the last 40 yrs. BP 142/80. JVP 16 cm. Middiastolic sound heard on auscultation. 4+ LE edema bilaterally. Serum albumin of 3.2. 24 hr urine protein excretion 1 g. CXR reveals normal heart size, clear lungs, spotty calcifications along left heart border. ECG shows enlarged atria, normal everything else, mild mitral regurg. Cause?

Constrictive pericarditis; peripheral edema, ascites, elevated JVP and clear lungs (Right heart failure due to CP). Limits diastolic filling. Pericarditis often from prior cardiac surgery, mediastinal irradiation, TB, malignancy, uremia. Pts present with right hart failure, hepatic congestion with hepatomegaly. Elevated JVP with hepatojugular reflux, Kussmaul's sign (increase or lack of decrease in JVP on inspiration), pericardial knock, and pericardial calcifications onf CXR. - Amyloidosis: increased ventricular wall thickness with normal nondilated LV cavity. Pts with amyloidosis may jave proteinuria, periorbital purpura, and hepatomegaly. - Cor pulmonale: RV failuree from pulmonary HTN due to severe lung dz --> ECHO: *pulm HTN, dilated RV, tricuspid regurg* - HTCM: asymmetric septal hypertrophy with increased LV wall thickness

28 y.o. kindergarten teacher compains of gritty sensation and discharge from right eye for 3 days. Also has rhinorrhea, mild sore throat, low grade fever. Sx began a wk after classes started in fall. PMH of genital herpes and endometriosis. Mild injection and granular appearance of tarsal conjunctive of right eye with profuse watery discharge. Pharynx has mild erythema without exudates. Next step in management?

Cool, moist compresses She has pink eye!! Viral conjunctivitis (self limited); if bacterial,, use arythro or polymixin-TMP drops - allergic conjunctivitis: olopatadine or azelastine drops

22 y.o. woman with recurrent syncope, first after roommate committed suicide. Now happens, provoked by strong emotion. Preceded by lightheadedness, weakness, blurred vision. Lasts about 3 mins, ends with rapid recovery. BP 110/70, 108/70 while standing. Normal ECG. Next step?

Counterpressure maneuver education; she has neurogenic (vasovagal) syncope. Tx: to avoid triggers, assume supine position with leg raising at onset of sx. Or leg crossing with tensing of muscles, handgrip; improves venous return, etc.

Cutaneous larva migrans:

Creeping eruption due to dog or cat hookworm larvae. Most infx from walking barefoot on contaminated soil or sand. Usually LE, super itchy with reddish-brown cutaneous tracks. Tx: ivermectin

35 y.o. man with SOB starting 2 days ago, worsened last night. Has also had dry cough. Hx of HTN, meds include chlorthalidone, amlodipine, labetalol. Meds ran out 4 days ago. Smoker and drinker, last drink 4 days ago. BP 220/120. Bibasilar crackles and 4th heart sound. Funduscopic exam shows normal optic discs and occasional cotton-wool spots. Potassium 5, creatinine 2.1. Admitted to ICU and started on IV furosemide and nitroprusside infusion. The next morning, confused/agitated, has a GTC seizure. BP 176/95. Exam shows normal breath sounds and no focal weakness. Dx?

Cyanide toxicity Pt had hypertensive emergency (renal failure and signs of CHF). Nitroprusside is quick onset and offset of action, breaks down into nitric oxide and cyanide ions. Prolonged cyanide can cause probs esp in pts with renal insufficiency. He had initial improvement of sx, followed by probs after nitro. - Alcohol withdrawal: peaks during SECOND DAY of cessation, seizures occurring at 12-48 hrs.

Fat embolism vs pulmonary contusion

Fat embolism: latent period of 12-72 hrs!!! Neuro probs and petechiae!!! Contusion: <24 hrs after blunt trauma, tachypnea, tachycardia, hypoxia --> intraalveolar hemorrhage and edema CT or CXR: patchy, alveolar infiltrate (not restricted by anatomical borders) Tx: supportive

Pt with signs of venous valve probs

Do US to confirm dx first, then give compression stockings. Might find fixable spot to do venous stenting

36 y.o. woman at 38 wks gestation with sudden bleeding and severe abd pain. Had GDM and fundal placenta. Smoker. Greatest risk for developing which complication?

DIC!! She had placental abruption (increased risk with smoking and cocaine)

Mechanism of relief responsible for rapid pain relief in stable angina pt improved with sublingual nitroglycerin?

Decreased LV wall stress; direct vascular SM relaxation causing systemic venodilation and increased peripheral venous capacitance. Primary anti-ischemic effects are mediated by *systemic vasodilation and decrease in cardiac preload.* --> reduced LV wall stress (reflecting afterload) and decrease in myocardial demand

20 y.o. with jaundice and dark urine. Immigrated to US under care of physician for some time. Takes acetaminophen for HA. No siblings. Dad died of DM and HF and liver probs due to alcohol. Scleral icterus and jaundice. Bili in urine, but not urobilinogen. Serum AST, ALT, alk phos are normal. What is most likely present in pt?

Defect in hepatic secretion of bilirubin; ROTOR SYNDROME After hb breakdown, 95% of bili is unconj, gets conj'd then goes to intestines where it gets deconj'd again and recycled to get reconj'd by liver. POS BILI URINE = CONJ BILI BUILDUP!!!!

64 y.o. man with increasing pain in right groin over past several months. Increases with activity, better with rest. Radiates to upper thigh. No hx of falls or trauma, fever, weight loss. Hx of lumbar disk herniation, but no current pain. BMI 34. Pain on passive internal rotation of hip. Direct pressure over groin does not increase the pain. Normal bulk, tone, reflexes, pulses. Cause?

Degenerative joint dz (OA!). Pain of hip OA is felt in groin, buttock, pelvis, can radiate to lower thigh or knee. Pts may have mild pain adn stiffness, worse with activity and weight bearing. - Trochanteric bursitis: friction of tendons and gluteus medius and tansor fascia lata over the greater trochanter of the femur (pain localized to lateral hip, worsened by direct pressure) - BTW: severe colitis - PO van with or without IV metronidazole; fidaxomicin for recurrent or severe who can't tolerate vanc

Borderline personality management

Dialectical behavioral therapy (psychotherapy)

42 y.o. foundwandering aimlessly at airport. Alert and answers questions but confused about identity and does not recognize name on his driver's license. Doesn't remember where he lives or how he got to airport or profession. Otherwise cognitively intact. Search or personal belongings reveal airline ticket from home town to airport town. Emergency contact on phone leads to his wife that said her husband just disappeared after she said she wanted a divorce that morning. All tests are normal. Most likely dx?

Dissociative amnesia: inability to recall important info after stressful or traumatic incident Depersonalization/derealization disorder: persistent or recurrent experiences of 1 or both (feeling or detachment from or being outside observer of self), derealization (experience surroundings as unreal); intact reality testing Dissociative identity disorder: marked discontinuity in identity & loss of personal agency with fragmentation into 2+ distinct personality states. Severe trauma/abuse

Distal vs midshaft humerus fractures

Distal: risk of brachial artery damage Midshaft: wrist drop (radial nerve palsy) - If someone has anterior shoulder dislocation, do test for axillary nerve palsy before doing closed reduction - Greater trochanteric pain syndrome: palpation of lateral thigh produces pain, pain while lying on that side. Standing on one leg also elicits hip pain - Iliotibial band syndrome hurts lateral knee - Osteonecrosis (do MRI to confirmm bc xrays might look normal)

Large volume rectal bleeding in old man

DiverticulosissSSSs!!!!! - Dx: confirmed by colonoscopy, - Tx: usually resolve spontaneously, some require surgery - Hemorrhoids don't cause large volume bleeding!

32 y.o. man with 2 day hx of fever, HA, malaise, myalgias. Slightly confused. Recalls getting tick bite 2 wks ago while walking through woods in Arkansas. Temp is 102F, BP 125/80, P100. No LAD, clear oropharynx. Abdomen is soft and nontender. No rash. No focal deficits. Plt 78,000, hb 14, alk phos 110, WBC 2500 (low) AST 98, ALT 105. Next step?

Doxy! Ehrlichiosis!!! Tick born (SE and South central US!!! Reservoir is white tail deer). Acute febrile illness with malaise and AMS!! !<30% have rash! Siilar to RMSF without the spots. Labs show leukopenia and/or thrombocytopenia along with elevated liver enzymes and LDH!!! Tx: doxy!!! Can give empirically

REM sleep behavior disorder

Dream enactment, usually in the latter part of the night. When awakened, can become fully alert. Usually in older adult men; prodromal sign of neurodenegeration for PD or dementeia with Lewy bodies - Nightmare disorder: vivid recall of disturbing dreams (not assoc'd with motor activity or sleep-related injury) - Sleep terrors and sleepwalking: younger ppl in deep non-REM sleep. Longer period of confusion, and *don't recall dreams*

65 y.o. woman with GCA, appropriate med therapy given, pt very med compliant, gets better. But 6 months later, slowly progressive muscle weakness. HA resolved but has myopathy. Normal CK and ESR. Cause?

Drug induced myopathy!!! Progressive proximal muscle WEAKNESS and atrophy *without pain*, LE > UE - Polymyalgia rheumatica: muscle *PAIN AND STIFFNESS* IN shoulder and pelvic girdle, TX IS GLUCOCORTICOIDS!!! - BTW: glucocorticoids cause leukocytosis through mobilization of marginated neutrophils and increased number of circulating neutrophils

58 y.o. with balance probs over last 2 wks. Muscle stiffness and 3 recent falls. Hx of bipolar and anxiety, started on valproate and risperidone for manic episode several months ago. Symmetric resting tremor of both hands. Finger tapping is slow and irregular bilaterally. Cause?

Drug-induced parkinsonism. Benztropine or amantidine can help - Akathisia: restlessness, can't sit still. (Pt who keeps leaving group home and walking around) *Tx: decraese antipsychotic dose and give beta blocker or lorazepam!!!* - Help for tardive dyskinesia: clozapine - BTW: adjustment disorder is within 3 months of stressor! - BTW: mirtazapine is good for low sleep; also causes increased appetite

FHR: nadir of decels corresponds with peak of contraction. Type and etiology?

EARLY, fetal head compression! Can be normal - LATE: uteroplacental insufficiency - Variable: cord compression, oligohydramnios, cord prolapse - BTW: first-line tx for smoking cessation - nicotine replacement therapy, bupropion, varenicline in combo with counseling and supportive therapy

Marfans pts most likely have what type of heart murmur

Early diastolic!!! Aortic dilation, regurg, dissection [early decrescendo diastolic murmur along left sternal border]; MVP [mid to late systolic murmur] - wide fixed split = ASD (Holt-Oram aka heart-hand sndrome assoc'd with radial and carpal bone deformities) - Opening snap with mid-diastolic murmur = mitral stenosis - BTW: solitary pulm nodule if within 2 yrs: do CT (benign? do serial CTs, suspicious? bx or PET. Highly suspicious? surgical exicion)

68 y.o. pt in ICU after CABG for CAD. On POD 1, nurse reports that pt is confused and has reduced UOP; afebrile, 80/50, p 118. No drainage from sternal wound. No drainage over past 4 hours, clear lungs, soft abdomen. ECG shows sinus tach and nonspecific T-wave changes. Pul artery cath: RA 20 mm Hg (nl 2-8), RV 35/20 (nl 15-30/2-8), PCWP 20 (nl 6-12). Next step?

Echo; *cardiac tamponade* is complication of CABG -> severe impairment of venous return -> cardiogenic shock (hypotension, elevated JVP, distant heart sounds = "Beck's triad"). There is elevation and equalization of intracardiac diastolic pressure (RA, RV, PCWP). *Urgent ECHO confirms dx* - coronary ang for dx or dobutamine infusion could be given if this were acute MI due to CABG, but unlikely bc of equalizatino of intracardiac diastolic pressures and insignificant ECG changes - CT pulm ang is for PE but would cause low or nl PCWP (impaired blood flow thru pulm circulation and return to LA)

33 y.o. woman with intermittent dizziness. Severe spinning sensation with 1-2 hrs of intense nausea. Lies down and closes eyes for relief, several similar episodes over past 2 yrs. Mechanical humming in right ear during these episodes, causing distortion of speech. Tuning fork on forehead, sound is more prominent in left ear. Cause?

Elevated endolymphatic pressure Meniere disease!! increased vol and pressure of endolymph (damages vestibular and cochlear components of the ear). *TRIAD: tinnitus/fullness, episodic vertigo assoc'd with nausea, sensorineural hearing loss* Tx: Sodium restriction, caffeine, nicotine, alcohol. Benzos, antihistamine, antiemetics for acute tx. Diuretics for long-term management - Vestibular schwannoma: would be progressive rather than episodic, and true vertigo is not typical - Otosclerosis: progressive conductive loss (not sensorineural); pts may have tinnitus but not vertigo

Male pt for infertility eval. Low LH and normal testosterone.

Exogenous androgen suppresses native testosterone but is detected as testosterone so normal serum test in test. Causes low GnRH, LH, FSH

19 y.o. with anxiety, insomnia fatigue: keeps checking if door is locked, stove is off. Checks homework a million times, knows it doesn't make sense. Management?

Exposure and response prevention (type of CBT) and/or SSRI - Dialectival behav therapy is for borderline personality disorder - BTW: test for preeclampsia with URINE PROT:CREAT RATIO or 24-HR URINE COLLECTION FOR PROTEIN

Factitious disorder vs malingering

Factitious: SICK ROLE, induction of symptoms Malingering: sneaky, secondary gain

Common cause of nonreactive nonstress test (no accels).

Fetal sleep (can last as long as 40 mins), so extend to 40-120 mins to ensure activity - reactive NST (2+ accels) has high NPV to rule out fetal acidemia - BTW: Follow up after removal of teratoma is observation - BTW: leuprolide is GnRH agonist that tx's endometriosis - BTW: can do CT during 2nd and 3rd TM if you have to but try not to

Pyloric stenosis

First born boy between 3-5 wks, formula feeding; projectile vomiting followed by hunger. Non-bilious Persistent vomiting: hypochloremic metabolic alkalosis; US shows thick pylorus. Do pyloromyotomy

Bipolar dz tx

First line: lithium (if healthy kidneys) and valproate. Also can use quetiapine and lamotrigine

42 y.o. man with recurrent palpitations; paroxysmal afib. echo shows normal LV function, no vlv dz. Started on a med. 2 wks later during stress test, HR increases from 75-165 and QRS length from 0.09 to 0.13 sec. Which med causes this?

Flecainide. Class I antiarrhythmics (tx of afib with structurally nl heart). Slowest rate of dissoc from na receptor; increases QRS at FASTER HR!!! less time for drug to dissociate from na channels.

45 y.o. man with progressive SOB and fatigue for past several weeks. 2 yrs ago, alcoholic cirrhosis and esoph varices had banding. Months ago had massive ascites and therapeutic paracentesis. On furosemide, spironolactone, nadolol. No alcohol for past 2 yrs. BP 114/72, no change in dyspnea with lying down. Flat neck veins and heart exam nl. Decreased breath sounds on right. Left sided breath sounds are normal. 1+ bilateral LE pitting edema. Cause of sx?

Fluid passage thru diaphragmatic defects. pt with cirrhosis and portal HTN have peripheral edema and abnormal ECF volume regulation. Can develop HEPATIC HYDROTHORAX (pleural effusion not due to heart or lungs). Transudative, due to small defects in diaphragm (permit peritoneal fluid into pleural space (mosty right side bc less muscular diaphargm). Tx: salt restriction and diuretics. Therapeutic thoracentesis.

OCPs and liver lesion

Focal nodular hyperplasia (benign) nonvascular lesion. Asymptomatic, found incidentally when workup for gallstone disease, dyspepsia. Arterial enhancement and a central stellate scar. No further testing necessary - bacterial meningitis (neutrophilic pleocytosis): 50+ or IC - listeria! - Pulmonary cachexia (20-40% of COPD pts) bc of energy imbalance bc of increased work of breathing and low dietary intake

Lead poisoning

GI manifestations, neuropsych (forgetfulness), neuropathies, microcytic anemia --> batteries, plumbing, home restoration, distillation of alcohol with lead parts) - caustic: endoscopy within 24 hrs!

Which DM drug helps promote weight loss

GLP1 agonists (exanatide, liraglutide) - Pioglitazone: option in metformin-failure pts unable to take sulfonylureas (cause weight gian and can induce CHF in pt with heart dz) - DPP4 inhibitors: low risk of hypoglycemia and can be used in pts with CKD but don't affect weight - BTW: measure PTH in hypercalcemia, even if you suspect malignancy bc then next step is to investigage with CXR, PTH-rp, bone scan, electrophoresis for MM if PTH is normal and calcium is high - BTW: hereditary pattern of HCM is AUTOSOMAL DOMINANT

Pt with achalasia like sx and LES failing to relax. Weight loss and smoking hx. Next step?

Gastroesoph endoscopy to rule esoph cancer causing pseudoachalasia. Do LES myotomy or pneumatic dilation, or botox if they are poor candidates

58 y.o. man brought to ED after suicide attempt. 100F, BP 76/40. Bilateral wheezing. Cold and clammy extremities. ECG shows profound sinus bradycardia and first-degree AV block. Pt is given IV fluids and atropine, but brady and hypoTN don't improve. Next step?

Glucagon; BETA BLOCKER OVERDOSE - bradycardia, AV block, hypotension -> shock; and diffuse **wheezing**. Tx:IV fluids and atropine; if refractory hypotension, IV glucagon - CCBs, digoxin, and cholinergic drugs can do the same but NOT WHEEZING.

Gonorrhea vs chlamydia knee arthritis

Gonorrhea: monoarthritis! Septic arthritis!!!! Can also have migratory asymmetric arthritis with vesicular, pustular, or maculopapular lesions of the trunk and extremities! Reactive would have urethritis, conjunctivitis, and knee pain in young men

Which HPV causes condyloma acuminata? Tx?

HPV 6 and 11!! Tx: trichloaracetic acid or podophyllin resin (iquimod is immunologic tx); Excisional therapy for larger lesions (high recurrence rate)

Coarctation of aorta

Happens as ductus begins to close (~3 days of life) -> HF, tachypnea, poor feedig, shock (prolonged refill), metabolic acidosis, decreased renal perfusion

Transient synovitis

Healthy young kid with recent URI (abducted and externally rotated). No inflammation. US shows joint effusion, acute and transient (NOT legg-calve-perthes, which would have sx for more than a few weeks! Marked reduction in internal rotation and abduction <- widening of joint space but minimal damage to femoral head on imaging. Osteonecrosis of the femoral head: tx is conservative management, if worsens do casting and bracing)

Cardiac catheterization complications

Hematoma: might have mass, no bruit Pseudoaneurysm: bulging, pulsatile mass, systolic bruit (contained hematoma within periarterial connective tissue) AV fistula: no mass but continuous bruit Don't assume these are the case if pt is hemodynamically stable; do CT!!! If unstable, go to cath lab

63 y.o. man with 2 wk hx of ulcer on sole of foot just below head of first metatarsal bone. Nontender ulcer with a thick surrounding callous. Feet are warm and dry. Walks several miles a day, BP 156/98, BMI 32. What test would diagnose underlying cause of pt's foot ulcer?

Hemoglobin A1c. Peripheral neuropathy is most common cause of foot ulcers in pts with diabetes (*sole of foot*, other weight-bearing sites) - AbI to dx PAD

Post-exposure prophylaxis to HIV

High risk (open skin or mucous membrane exposure to their fluids): prophylaxis recommended Timing: URGENTLY for 28 days - (2 NRTIs + integrase inhibitor, protease inhibitor or NNRTI) Low risk: no prophyalxis

What can cause substance/medication-induced psychotic disorder?

High-dose glucocorticoids

58 y.o. woman with headache after gourmet meal with heavy sauces and wine. Pt is anxious and tremulous. Hx includes major depression with psychotic features, GAD, OA. After multiple med trials, stabilized on phenelzine and risperidone. Depression has been in remission for past 5 years. Meds are ibuprofen. What other finding?

Hypertension. Phenelzine is a MAOi!! Have drug-drug interaction with foods that have tyramine (cheese, aged meat, soy, overripe fruits, some alcohol). Tyramine metabolism is inhib'd by MAOi's which cause sympathomimetic effect --> *Hypertensive Crisis!* - Hyperreflexia and myoclonus (serotonin syndrome) - give cyproheptadine - Muscle rigidity (NMS) can happen within 2 wksof antipsychotic. Elevated CPK, WBC. Thabdo can happen -> myoglobinuria and ARF. Give amantadine or bromocriptine

46 y.o. man with weakness and chest tightness on and off over past 24 hrs, no PMH. ECG shows afib. Dad had MI at 68, mom has MG. Should be eval'd for what?

Hyperthyroidism (causes can be cardiac [CAD, HTN, valve dz, CHF, HTCM], pulmonary [OSA, PE, COPD, acute hypoxia], obesity, endocrine, drugs/alcohol) - All pts with new onset AF should have TSH and free T4 levels measured! - BTW: ADPKD is assoc'd with valvular dz but is less common

First line imaging for suspected PID hx causing infertility

Hysterosalpingogram

Mastoiditis tx

IV ABXAND DRAINAGE OF PURULENT MATERIAL!! cAN CAUSE ORBITAL CELLULITIS. - Can do CT or MRI to confirm, not x ray

Tx for symptomatic sinus bradycardia

IV atropine!!! If inadequate response, then give IV epinephrine or dopamine or tranQ pacing - Adenosine: causes block of impulse conduction at AV node (identify or terminate SVT) - Amiodarone: SVT and ventricular tachyarrhythmias - NE for hypotension and shock (not for tx of bradyarrhythmias) - IV glucagon: increases cAMP to treat beta block/CCB toxicity

Pt with acute aortic dissection. Tx?

IV beta blockers!!! Surgical emergency

45 y.o. with months of fatigue and exertional dyspnea after gastrectomy 5 yrs ago. Shiny tongue and pale palmar crease. No LAD, hepatomegaly, or splenomegaly. Hb 7.8 WBC 3800 Bili total 2.3, direct 0.4. normal liver enzymes, LDH 190 Mech?

Impaired DNA synthesis~ B12 deficiency!! Loss of IF after gastrectomy. B12 needed for thymidylate nad purine molecules for DNA synth!!! -> ineffective EPO, delayed nuclear maturation -> decreased transition to mature RBC -> increased hemolysis -> hyperbili (jaundice) - Glossitis: riboflavin, niacin, folic acid, iron!

66 y.o. woman with 2 days increasing cough and fever. CAP 4 months ago and sinusitis 2 months ago. Fatigue, weakness, right sided CP. Never smoker and rare drinker. Appears well, has mucosal pallor. No lymphadenopathy. Crackles in LLL. Point tenderness over right 7th and 8th ribs. No HSM. WBC 13,000 and Hb 9.4. CXR shows LLL consolidation and right sided osteolytic lesions with fractures at 7th and 8th ribs. Increased risk of infx bc of what?

Impaired effective antibody production; she has multiple myeloma!!! --> osteolytic lesions, fractures, hypercalcemia from bone destruction, and anemia. Pts with MM are prone to infx. Neoplastic infiltration of bone marrow alters and impairs normal lymphocyte population -> ineffective antibody production and hypogammaglobulinemia. Respiratory and UTIs are common.

Mitral stenosis causes

Increased pulmonary vascular resistance -_- Pulm HTN bc increased LA pressures bc of stenotic valve and thus dilation of LA --> afib.

Strongest predictor of stent thrombosis after intracoronary stent implantation?

Premature discontinuation of antiplatelet therapy! Less likely to be atherosclerotic plaque rupture at the same exact site that stent was placed.

Most common cause of unilateral bloody nipple discharge without coexisting breast mass or lymphadenopathy

Intraductal papilloma

37 y.o. man coughed up small amt of bright red blood. 3 days of fever, pleuritic CP, cough with borwn sputum. Oral abx 2 days ago with no improvement. Received ASCT for AML 6 wks ago complicated by GVHD and prolonged neutropenia. 102.2F, right sided crackles. CXR shows dense RUL infiltrate and CT shows severeal nodular lesions with surrounding ground-glass opacities in RUL. Sputum gram stain shows inflammatory cells with no organisms. Dx?

Invasive aspergillosis; classic triad of fever, plueritic CP, and hemoptysis. CT reveals nodules with ground glass opacities (halo sign). Tx: IV voriconazole plue caspofungin. - TB has same sx but not thick sputum with ground glass opacities - PCP has not hemoptysis - BTW: bupropion is assoc;ed with increased seizure risk so CI in bulimia, anorexia bc electrolyte abnormalities

80 y.o. woman with fatigue. Lives alone with bilateral knee OA. On lisinopril, chlorthaldine, naproxen, low dose aspirin for heart. Has conjunctival pallor, both knees deformed due to bony overgrowth. Normal renal fx. Cause of pallor?

Iron deficiency anemia (most likely due to concurrent NSAID and aspirin use -> both cause gastric ulcers/gastritis causing chronic GI blood loss and depletion of iron stores)

Tx of latent tb

Isoniazid and B6 only (pos IFG, neg CXR)

Single lytic bone lesion in kid with mild hypercalcemia

Langerhans histiocytosis - hyperPTH osteitis fibrosis cystica: in older ppl

19 y.o. girls with lower abd pain that started 10 hrs ago in yoga class, vomited 3 time and intensified since then. Never been sexually active, LMP was 1 wk ago. US shows complex left adnexal mass without doppler flow. Small amount of free fluid. Next step?

Laparoscopy. OVARIAN TORSION - BTW: do blood cultures before starting abx therapy in pt with IE!!!

Long acting oral contraceptive in woman with hypermenorrhea?

Levonorgestrel-containing IUD - Copper IUD can cause heavy bleeding!!! CI if Wilson dz, heavy bleeding -Medroxyprogesterone injections: cause weight gain!!!

Pt with lung adenocarcinoma of LLL, FEV1 of 1.6 L nad DLCO 66%. Management?

Lobectomy. Localized adenocarcinoma or NSCLC. Do PFTs first to make sure that FEV1 is >1.5 L and DLCO is >60% - Cisplatin for SCC of the lung!!! (no resection)

Adrenal mass producing cortisol

Low ACTH, low DHEAS (bc it is dependent on ACTH) - Aldos producing adenoma: hypernatremia, hypokalemia (elevated aldost to renin ratio)

18 y.o. with HA over last 3 months; daily, holocranial, pulsatile. Bothersome at night. Double visions,has papilledema nad left lateral rectus palsy. BMI 34. CT without contrast normal. MRI shows empty sella; post contrast MRI venography is normal. Next step?

Lumbar puncture with opening pressure. IIH!!! Can also have pulsatile tinnitus. Empty sella is in 70% of these pts!! But not diagnositc; LP indicated to document elevated opening pressure. Papilledema is not CI to LP unless there is evidence of obstructive hydrocephalus or space occupying lesion. Pseudotumor causes communicating hydrocephalus.

65 y.o. with 4 month hx of periodic back pain radiating to puttocks and thighs. Pain exacerbated by walking or prolonged standing, but can tolerate biking without significant discomfort. Assoc'd sx include occasional tingling and numbness in both LE. Med hx notable for BPH, HTN, hypercholesterolemia, treated appropriately. Neuro exam shows normal motor strength, DTRs, plantar reflexes. Dx?

Lumbar spinal stenosis; most common cause of back pain in pts age 60+. Due to narrowing of spinal canal, seen in degenerative arthritis. Sx are posture-dependent. Standing and walking upright worsens sx, *lumbar flexion relieves pain* - Lumbar disc herniation: acute back pain with unilateral radiation down sciatic nerve to the foot; follows inciting event, *lumbar flexion makes pain worse*

Most common valvular abnormality in pts with infective endocarditis

MVP with coexisting mitral regurgitation! IE: pt with 2 wk history of low grade fever and progressive weakness. *Has long hx of heart murmur (clue).* Does not use drugs. Has splinter hemorrhages, small petechiae on palate, and audible murmur, elevated ESR. US shows hematuria and 1+ proteinuria. Tx: empiric vanc, then others based on culture results.

72 y.o. man with overnight hernia repair. No immediate postop complications, next morning has severe right knee pain. Hx of HTN, COPD, mild aortic stenosis. Smoke. Fever, redness and swelling of right knee and limitied ROM due to pain. Synovial fluid analysis: WBCs 30,000, 90% neutrophils, *few rhomboid-shaped crystals*, no organisms on gram stain. What is most likely assoc'd with pt's current condition?

Meniscal calcification!!! PSEUDOGOUT (release of CPPD crystals from sites of chondrocalcinosis into joint space; POSITIVELY birefringent crystals. - Heberden nodes: enlarged bony spurs at DIP joints in OA

Thyroglossal duct cyst

Midline neck mass, do US first to make sure it's not just thyroid. Then do excision of the cyst, track, and hyoid bone - Thyrotoxicosis in a baby who's mom had Grave's

1 month old boy with blood streaked stool, breastfed since birth, 3-5 yellow seedy stools daily, bloody over the past 24 hrs. Nurses every 2-3 hrs, regurgitates large amount. 40th percentile H, W, L. Appears will, has diffuse eczema. FOBT pos. Cause?

Milk protein-induced enterocolitis. Eczema, regurg or vomiting, painless/bloody stools. *Soy and dairy should be avoided IN MOM'S DIET*. Formula-fed babies should be on hydrolyzed formula; should resolve over days. Better and can tolerate soy and milk by one year.

32 y.o. woman with nagging dry cough over last 8 weeks, present during day and awakens her at night. No SOB, CP, wheezing. Hx of chronic rhinorrhea and occasional itching skin rash. Normal CXR. One wk of chlorpheniramine improves sx. Decrease in which is most likely responsible for sx relief?

Nasal secretions! WAT. 3 most common causes of chronic cough are upper-airway cough syndrome, asthma, GERD. She probably has postnasal drip assoc'd with allergic rhinitis, improved with first generation antihistamines (H1 blocker)

IVDU with IE tx

Most common cause is S. aureus, give IV vanc bc it covers MRSA - btw: hypotonia, HF, macroglossia, NORMAL GLUCOSE = pompe dz = lysosomal acid maltase or alpha glucosidase deficiency - S. epidermidis is coagulase negative loser. It can cause IE due to infected peripheral venous cath

Survival in pts with witnessed sudden cardiac arrest

Most critical factor: elapsed time to effective resuscitation! (effective bystander CPR, prompt rhythm analysis, early defib)

CYP 450 inhibitors

NSAIDs, acetaminophen, metronidazole, amiodarone, cimetidine, indinavir, grapefruit juice, azoles, acute alcohol use Inducers: Carbamazepine, ginseng, St. John's wort, phenobarbitol, *OCPs*, rifampin

Pt motivated to reduce alcohol intake but unable to maintain abstinence. First line drug?

Naltrexone: reduces craving and heavy drinking days (5+ drinks for men, 4+ women), and increase days of abstinence - Acamprosate (glutamate modulator) used once abstinence is achieved!! - Disulfiram is aldehyde dehydrogenase that give bad rxn to alcohol; pts must be abstinent and highly motivated - BTW: kleptomania - loving to steal for no reason, therapy is CBT. Maybe SSRI, opioid antags, lithium, anticonvulsants

51 y.o. with mild right sided for pain for past several weeks. Hx of T1DM, HTN, hypercholesterolemia. Exam shows significantly deformed right food and mildly deformed left foot. X-ray of right foot suggests effusions in several of the tarsometatarsal joints, large osteophytes, several extra-articular bone fragments. Cause of complaints?

Nerve damage; CHARCOT JOINT (neurogenic arthropathy) Assoc'd with: *vit B12 deficiency, diabetes,* peripheral nerve damage, spinal cord injury, tabes dorsalis, syringomyelia Sx: deformed joints, loss of neuro input, decreased sensation, mild pain, fractures unsuspected, degenerative joint dz and loose bodies on joint imaging Tx: treat underlying condition, mechanical devices to assist in weight bearing to decrease further trauma, x-rays

56 y.o. man with progressive urinary frequency, urgency, hesitancy for past several months. New LBP and perineal pain during ejaculation. No dysuria or hematuria. Long term smoker. No suprapubic or CVA tenderness. Rectal exam shows increased anal sphincter tone and smooth, slightly enlarged prostate. DTRs normal Urine culture is neg PSA WNL. Cause of condition?

Non-infectious chronic prostate inflammation; chornic prostatitis/pelvic pain syndrome = 3+ months without identifiable cause, can present as voiding probs, irritative voiding sx, pain with ejaculation or blood in semen. Pts are afebrile and have little or no prostate tenderness, cultures are neg and UA are nl. CP/CPPS is dx of exclusion, categorized as inflam or noninflam based on presence of WBC in urine and prostate secretions. Etiology unclear. Tx: abx, tamsulosin (alpha blocker), finasteride (5alpha reductase inhib) - Epididymitis: irritative voiding sx but scrotal pain and swelling and purulent urethral discharge - Chronic bacterial prostatisis: dysuria and requency but pts have UTI, prostatic tenderness, pos urine culture

COPD exacerbation, given tx but still dyspneic, follows commands though; a little acidotic. Next step?

Non-invasive positive pressure ventilation

Antepartum surveillance evaluates for fetal hypoxia. Performed in pregnancies with a high risk of fetal demise due to maternal or fetal conditions. Most common modality is biophysical profile (BPP): *non-stress test, US of amniotic fluid, fetal tone, movement, breathing movement*

Normal aka reactive NST has 2+ accels that are 15+ bpm above basline and 15 seconds long within a 20 minute period. BPP <4 = urgent delivery BPP 6 is unsure unsure BPP 8+ is great, rules out hypoxia Pt has gestational HTN and needs weekly BPPs starting at 32 wks. - Contraction stress test: external fetal HR monitoring during spontaneous or induced uterine contractions - Doppler of umb artery: eval of umbilical artery flow in fetal IUGR only

Rett syndrome

Normal initially, but then decel in head growth, loss of communication skills, *stereotypical hand movements* like clicking or hand clapping, autistic features, sleep disturbance like waking up screaming, gait disturbance. - Tay Sachs: normal until 6 months also, mental deterioration, *macrocephaly*, cherry red spot in macula - Angelman: happy angels, MR, hand flapping

Old man with increasing confusion the past 2 days. Also had n/v, back and abd pain. At baseline is interactive and pleasant. Med hx of T2DM with metformin and HTN with amlodipine. Pt appears disheveled and confused. Normal lung and heart sounds. No neck masses or enlarged lymph nodes. Normal labs except WBC 3,200, platelets 87,000 and calcium 14.1. Next step in management?

Normal saline infusion. Pt has severe, symptomatic hypercalcemia (likely due to malignancy); can cause weakness, GI distress, neuropsych probs. Typically are volume depleted due to polyuria and decreased oral intake. Give aggressive saline hydration and calcitionin!!! Also give bisphosphs but this takes a couple days - BTW: glucocorticoids inhibit activation of vit D, treats hypercalcemia due to excessive vit D intake, granulomatous diseases, and certain lymphomas (can take 2-5 days) - BTW: less than 4 hrs since tylenol overdose? give activated charcoal, then check levels, give N-acetylcysteine if needed (if levels above tx line in nomogram, if >10 ug/mL if timing of ingestion unclear, or any evidence of liver injury

52 y.o. man with right knee pain. Past 2 yrs after weight bearing activity, better with rest and knee extension. Stiff after prolonged periods of sitting. Had ACL surgery in high school. No other med hx except for acid reflux (omeprazole prn). Antalgic gait favoring right knee *and valgus deformity of both knee joints*. No focal tenderness of effusion, but crepitus felt when right knee is flexed and extended. ACL stable. Xray shows medial joint space narrowing. Tx?

OA (better rest, crepitus, joint space narrowing). Tx: weight loss, activity, simple analgesics, *physical therapy like quadriceps stengthening*

OBSTRUCTIVE VS RESTRICTIVE FEV1:FVC RATIO

OBSTRUCTIVE <70% RESTRICTIVE >70% FEV1: OBSTRUCTIVE <80% FEV1: RESTRICTIVE <80% FVC: NORMAL OR DECREASED FVC: <80%

Oppositional defiant disorder vs conduct

ODD does not include stealing or aggression (just angry and argumentative toward authority) - cyclothymia is like less severe bipolar, around for at least 2 yrs

Pt with painless jaundice and distended gallbladder at right costal margin (Courvoisier sign).

Pancreatic cancer!!! --> mostly at head, can compress pancreatic duct and common bile duct, seen as "double duct sign" --> intra and extrahepatic biliary duct dilationand distended GB. Might also have pruritus, pale stools, dark urine

Cerebellar hemorrhage presentation

Occipital HA, neck stiffness, n/v, nystagmus, ipsilateral hemiataxia.

62 y.o. man with fall 2 days ago, did not see a step and tripped. Wife says he keeps bumping into things. No HA, weakness, ocular pain. Has HTN and T2DM. BP 140/80. Loss of peripheral vision in both eyes. Normal reflexes, strength, gain. Funduscopy shows?

Optic disc cupping; open-angle glaucoma -> peripheral vision loss, enlargement of the optic cup (increased cup:disc ratio) - AV nicking or cotton wool spots: HTN retinopathy

Sunburn tx -_-

Oral NSAIDs, topical application of cool compresses, aloe vera, etc. - PO or topical steroids don't help - Mupirocin and silver diazine is for blistering burns

60 y.o. man with 6 mo hx of constant back and thigh pain, headache. Moderate, deep, achy pain in mid lumbar area that does not radiate and is worse ith changes in position. No hx of trauma. No other sx. Recent hearing aid for hearing loss. Mild thoracic dextroscoliosis and decrease in normal lumbar lordosis. LE show mild anterolateral femoral bowing. Cause?

Osteoclast dysfunction!!! Paget dz of bone!!! Bone bain, HA, unilateral hearing loss, femoral bowing!!! Increase in bone turnover due to OC dysfunction and compensatory increase in bone formation!! Disorganized bone remodeling due to osteoclast dysfunction. Give bisphosphs Dx: amnormal appearing OCs, disorganized "mosaic" pattern of lamellar bone. Elevated alk phos May get enlarging cranial bones -> hearing loss, HA, increasing hat size. Complications: benign giant cell tumor and osteosarcoma!!! - Osteomalacia due to malabsorption of calcium and vit D: muscle weakness, bone pain, deformity but NOT unilateral hearing loss, and no reason for malabsorption like Celiac dz

43 y.o. with generalized pruritus for past 4 months with skin excoriations and mild hepatomegaly. Eye exam shows xanthelasmasq. Anti-mitochondrial antibody is positive. Pt at greatest risk for what?

Osteomalacia; pt has PBC Assoc'd with increase in HDL compared to LDL. Complications: malabsorption assoc'd with nutrient deficiencies and HCC. Pts may develop metabolic bone dz (osteoporosis or osteomalacia); etiology unclear. Tx: ursodeoxycholic acid, liver transplant

Cervical mucus in healthy pt

Ovulation!!! Corresponds with LH surge. Cervical mucus plug is barrier to ascending infection DURING pregnancy (brown, red, yellow thick mucus shed during of before labor)

Assessment for PE (Modified Wells)

PE unlikely -> D-dimer -> low = excluded PE likely -> CT -> confirmed/not - BTW: Panic disorder 1+ month of worry about future attacks or change in behavior to avoid attacks - BTW: CA-125 has low specificity in premenopausal women - BTW: pts should wear supportive bra, void nipple stimulation, use ice packs and NSAIDs (don't pump!)

Hi pleural fluid amylase vs serum amylase

PLEURAL FLUID AMYLASE: esophageal rupture (amylase from spit); dx - water soluble esophagogram SERUM: pancreatitis

Acute traumatic coagulopathy. Next step?

Packed RBC, FFP, plateletin 1:1:1 ratio. Even if plts are normal

Acute aortic dissection treatment!

Pain control Reduction of SBP (100-120) Decrease in LV contractility (reduce aortic wall stress)

35 y.o. man has been acting weird for past 2 days. Untreated HIV and hep C. Fever, mild scleral icterus. Platelets 45,000. Elevated indirect bili and creatinine. Oropharynx is normal and no nuchal rigidity. Normal CT. Next step?

Peripheral blood smear!! Pt has thrombotic thromboytopenic purpura (TTP); life threatening disorder of the microvasculature characterized by formation of small vessel thrombi that consume platelets, shear RBCs, often cause end organ damage (renal and CNS). PENTAD: thrombocytopenia, MAHA, renal insufficiency, neuro changes and fever Acquired ADAMTS13 autoantibody which prevents cleavage of vWF, multimers accumulate and shear platelets, form thrombi Dx: Smear shows hemolytic anemia (hi LDH, low haptoglobin) with SCHISTOCYTES, helmet cells, triangle cells Tx: Plasma exchange

28 y.o. man with chronic cough, last yr had severe pneumonia with 4 days in the ICU. Intermittent cough and episodes of thick, yellow sputum with sometimes blood. SOB and fatigue, abx for resp infx twice over last yr. Pt has lost 6 kg over past yr. Never smoker. Crackles of RLL and scattered wheezing. Cause of chronic cough?

Permanent destruction and dilation of airways (bronchiectasis) - could consider ILD/fibrosis bc of collagen deposition due to tissue damage (enlargement of airspaces) but would not have recurrent resp infxs.

68 y.o. man with LLL pneumonia Long hx of DM, hypothyroidism, hypercholesterolemia,HTN, diabetic retinopathy, peripheral neuropathy, nerphropathy. AV fistula placed for possible dialysis. Meds are insulin, furosemide, atorvastatin, levothyroxine. Bleeds persistently during blood draw. Las: Hb 11.5, platelets 160,000, BG 178, BUN 56, Cr 3.5. Baseline cr 3.2-3.5. Cause of bleeding?

Platelet dysfunction: uremic coagulopathy common in CRF. Ecchymoses, epistaxis, GI bleeding, subdural hematoma. Platelet-vessel wall and platelet-platelet dysfunction. Normal aPTT, PT, thrombin time. *BT = PLATELET FUNCTIONS (prolonged)* Normal platelet count here but they just don't work right. Tx: DDAVP, cryoprecipitate, conjugated estrogens. DDAVP increases factor VIII:vWF multimers from storage sites.

18 y.o. African American man with 3 day progressive fatigue and exertional dyspnea. 2 wks ago, dx'd with URI tx'd with amoxicillin. Spleen enlarged, mild scleral icterus. Hb 7.8 and retic 10% (anemia with reticulocytosis). What finding most likely seen?

Positive direct Coombs test (Autoimmune hemolytic anemia!!) ; hi LDH and low haptoglobin Direct Coombs shows anti IgG or anti-C3 bound to RBCs. Wram AIHA Tx: high dose glucocorticoids!! Cold AIHA = mono or Mycoplasma (IgM)

LOC in pt during nocturnal bathroom break. Pathophys?

Post-micturition syncope: reflex (neurally mediated); increased PSNS can lead to bradycardia, asystole, AV block. Decreased SNS: VD, hypotension, syncope - BTW: fam hx of sudden death can be congenital long QT syndrome (also causes syncope with triggers like exercise, startle, sleeping)

Recurrent URIC ACID STONE tx

Potassium citrate (URINE ALKALINIZATION) Thiazides are good for calcium stone prevention

Young immigrant pt with left sided hemiparesis with afib

Probably has mitral stenosis; progressive dyspnea, nocturnal cough, and hemoptysis suggests rheumatic mitral stenosis!

42 y.o. man with periodic difficultry breathing and wheezing, visited ENT 2 weeks ago for persistent nasal blockage. Dx'd with stable angina 6 months ago. Current meds are aspirin, diltiazem, atorvastatin, and albuterol. Normal vitals. Cause of respiratory sx?

Pseudoallergic drug reaction. Pt has aspirin-exacerbated respiratory disease (reaction to NSAIDs)... not IgE-mediated but occur in pts with comorbid asthma, chronic rhinosinusitis with nasal polyps, and chronic urticaria. 10-20% of pts with asthma develop AERD (cough, wheezing, chest tightness, nasal and ocular sx, facial flushing within 30 mins to 3 hrs of HSAID ingestion Zileuton and motelukast may improve respiratory and nasal sx

35 y.o. G1P0A1, trying to conceive for the 3 yrs. Past few weeks, morning sickness, abdominal distension, breast fullness. LMP was 2 months ago and home urine preg test was positive. Takes daily prenatal vitamin. PE shows soft, nontender, tympanic abdomen with no masses. Bedside US reveals thin endometrial stripe. 2 office urine pregnancy tests are negative. Dx?

Pseudocyesis; symptoms of early pregnancy, believes she is pregnant but office exam (thin endometrial stripe, neg urine preg tests) excludes pregnancy. Somatization of stress affects HPA axis causes early preg sx or when bodily changes are misinterpreted. Belief is strong enough that she misinterprets negative home preg test as being positive. --> it is a form of somatization so requires psych eval and tx - Missed abortion: cessation of early preg sx, preg test is pos and US reveals nonviable IUG

Pt with pacemaker and new LE swelling, pulsation in neck when lying down. Liver mildly enlarged

Pt has severe tricuspid regurgitation due to adverse effect of pacemaker (RV lead of implantable pacemeker or ICD passes thru SVC into RA then thru tricuspid valve to terminate in the endocardium of the RV) Damage to tricuspid valve leaflets or inadequate leaflet coaptation can occur --> severe TR in 10-20% of pt!

45 y.o. with HIV with increasing SOB, left sided CP, chills, productive cough. Sx began 7 days ago. At first thought he had the flu but after 3 days began coughing up green phlegm and left sided CP. Pain worse with deep breaths or cough. His CD4 is unknown. Cigarettes and drinks alcohol regularly. 102F, BP 110/70. Poor dentition and decreased breath left lung base.

Pt has sx of URI that progressed to pleuritic CP, productive cough, fever, CXR showing large pleural effusion. Pts who are IC are at increased risk for complications of pneumonia like empyema. - Bronchopleural fistula: similar sx but CXR evidence of air in pleural space - PJP: CD4 <200. CXR can be normal. or bilateral diffuse infiltrates

34 y.o. with fever, dry cough, fatigue for 2 wks. Park ranger in Arizona and recently returned trip to a state park in New England. Spelunker and spends a lot of time in caves. No smoking or drinking, has 2 cats. 100F 128/72. Bilateral crackles. CXR shows bilateral alveolar opacities and hilar lymphadenopathy. Bronchoscopic biopsy reveals granulomas with yeast forms. Risk factor for this condition?

Recreastional activity: Histoplasma in Midwest, lesser extent in the NE. Granulomas with narrow based budding yeast. - Coccidioidomycosis: Arizona; CP, cough, fatigue, fever. - BTW: give RhoGam at 28 wks and after delivery is baby is Rh pos and mom is Rh neg

50 y.o. with sudden RUE and RLE weakness, worsened over hour with severe HA, N/V. Chronic untreated HTN. BP 174/102. Neuro exam shows right hemiplegia, right hemisensory loss, leftward deviation of the eyes. Dx?

Putaminal hemorrhage (basal ganglia)!! Common site of hypertensive intraparenchymal brain hemorrhage. Internal capsule is adjacent to putamen, almost always involved -> CL hemiparesis, CL sensory loss, conjugate gaze deviation toward lesion side. - Lobar hemorrhage usually occipital lobe (homonymous hemianopsia) and parietal lobe (CL hemisensory loss) - Medial medullary syndrome (ASA): CL arm and leg hemiparesis, CL loss of position, TONGUE DEVIATION toward lesion - Pontine hemorrhage: coma, total paralysis, pinpoint pupils

Tx of hyperkalemia with significant ECG changes.

Rapid tx with calcium gluconate!!! Stabilizes cardiac myocyte ECG: peaked T waves, bradycardia, arrhythmias Temporary (insulin) and definitive (cation exchange, dialysis) can happen after calcium

41 y.o. woman at 35 weeks gestation with uterine contractions 6 hrs ago, feels 3-5 contractions every hour. 2 days ago, pos GBS. Cervix is closed, vertex presentation. FHR is normal and tocometry shows irregular uterine contractions. Next step?

Reassure and discharge home! Braxton Hicks contractions False labor: mild, irregular contractions with NO CERVICAL CHANGE

Hepatorenal syndrome characteristics

Renal dysfunction, minimal hematuria (<50 RBC/hpf), lack of improvement with volume resuscitation Common inciting factors are SBP and GI bleeding in someone with ESLD!

29 y.o. nulligravid with lump in left breast, painful. Pt has no hx of medical probs or surgeries. Exam reveals 4x5x6 cm mobile mass, well circumscribed with posterior acoustic enhancement. Aspiration yields clear fluid with resolution of mass. Managment?

Repeat breast exam in 2 months; simple breast cyst, might reaccumulate

Chronic LBP in young healthy man, worse at night, improvement with activity, elevated ESR. Reasons for reduced VC, TLC, and normal FEV/FVC?

Restrictive pattern due to diminished chest wall and spinal mobility!

Kid with painful swallowing, neck spasm shortly after waking up. Sore throat over the last week. 101.2F, RR 33. Drooling, stiff neck. Bulge in posterior pharyngeal wall. Trouble breathing. Dx and next step?

Retropharyngeal abscess and intubation - BTW: neuroblastoma, mets to the eyes! FTT, n/v. Arises from posterior mediastinum, can cause Horner, raccoon eyes - Ruptured chordae tendinae: mitral regurg (acute, causes severe sx)

Retrospective vs case control

Retrospective: first ascertain risk factor exposure and outcome both in the past (exposure is determined before the outcome in known) Case control: outcome selected first and controls without those outcomes. Then risk factors are looked at

RBCs in urine sed of pt who had seizures, dx?

Rhabdo (urine sed can't tell between myoglobin and hb!!!)

44 y.o. Asian immigrant with persistent cough and dyspnea on exertion for 3 months. No fevers, chills, runny nose, sputum. Over past yr, progressively worsening SOB and can't sleep lying flat. No CP but has had palpitations in past. Not a smoker or drinker, moved to US 10 yrs ago. In mild distress. 98F, BP 110/70, BMI 34. Heart sounds distant due to body habitus. Lung: crackles. CXR reveals enlarged cardiac silhouette with vasular congestion. Left main stem bronchus appears to be elevated. No lung pathology. ECG shows irregularly irregular rhythm. Pathophys of condition?

Rheumatic heart disease; presentation is mitral stenosis!!! Loud first heart sound, opening snap after S2, diastolic rumble at apex. MS causes eventual backflow of blood into LA, elevated LA and pulmonary vasular pressures -> LA enlargement nad can compress recurrent laryngeal nerve to cause persistent cough or hoarse voice. Enlargement can displace left main stem bronchus. 70% of pts develop afib (irreg irreg)

64 y.o. with palpitations aned lightheadedness past several days. Has had palps previously but recently have seemed sustained and uncomfortable. No CP or SOB. Hx of CAD and prior PCI. Echo shows mild LV dilation, LVEF of 30%, no valve probs. Potassium 4.2, mg 1.9. On day 2 hospitalization. Day 2: sudden-onset palpitations that felt like fluttering in her chest. Alert and in no distress. Lungs clear. ECG shows Tx?

Rhythm strip shows wide-complex tachycardia with 2 fusion beats --> sustained monomorphic ventricular tachycardia If hemodynamically stable, IV amiodarone (give procainamide, sotalol, etc if unresponsive. - Carotid sinus massage: terminates PSVT (regular, narrow-complex tach; fusion beats not seen) - Digoxin: supraventricular arrthmias (afib, aflutter, atrial tach)

Management of pt with mono EBV?

Risk of splenic rupture. Avoid contact sports; difficult to palpate splenomegaly in muscularpts. US may confirm complete resolution

45 y.o. woman with progressive proximal myopathy. Normal ESR, elevated CK. Normal electrolytes and creatinine. Sluggish DTRs. Next step?

Serum TSH and free T4; she is healthy with fatigue and delayed DTRs! If normal, then do ANA, anti-Jo, muscle biopsy

62 y.o. woman at the ED due to acute leg pain, fell off treadmill after pain at right knee and posterior calk with subsequent swelling at the calf and right ankle. Hx of T2DM, HTN, hypercholesterolemia. Exam shows tenderness and induration at medial head of gastrocnemius. Moderate pitting edema at ankle and crescent-shaped patch of ecchymosis at medial malleolus. Cause of sx?

Rupture popliteal cyst

19 y.o. pt with viral URI treated with antiviral, after several days of symptomatic improvement, now has high fever, dyspnea, cough. Crackles in bilateral lung midfields. 2/6 systolic ejection murmur. Extremities are warm with bounding pulses. CXR revelas alveolar infiltrates in midlung fields with several thin-walled cavities. Bug?

S. aureus (secondary bacterial pneumonia!) usually in 65+ pts but this is MRSA!!! Necrotizing pneumonia that is rapidly progressing and often fatal; fever, productive cough with hemoptysis, leukopenia, and *multilobar cavitary infiltrates* - Aspergillus (IC pts -- fever, pleuritic CP, hemoptysis) - Histoplasma (mild, subacute sx, fever, myalgias, cough, CP) - Peptostreptococcus (rare, putrid sputum with abscess/empyema) - BTW: cervical conization complications include cervical stenosis, incompetence, and preterm delivery

All pts with cirrhosis should undergo

SCREENING ENDOSCOPY for potential varices, determine risk of hemorrhage, etc.

17 y.o. G1P0 with preeclampsia. Increased ankle clonus. Hb 8.2, platelets 56,000, LDH 1648. Admitted to maternity ward for induction of labor, delivers boy. Most likely complications in the neonate?

SGA; pts have preeclampsia with severe features (HA with visual sx, increased ankle clonus, thrombocytopenia). ELevated LDH and anemia are consistent with microangiopathic hemolysis (known feature of preeclampsia). Preeclampsia: increased risk of uteroplacental insufficiency -> SGA Maternal complications: abruptio placentae, DIC, eclampsia

S4 MEANS

STIFF VENTRICLE - tamponade has hypotension, not borderline HTN -_-

32 y.o. woman at ED with eakness, tingling, numbness of extremities. K of 2.9, cl 88, bicarb 37, serum pH 7.56. Urine cl: 7 (nl >20), na: 16 (nl >40). Cause of condition?

Self-induced vomiting; Based on urinary ch levels and ECF volume, metabolic alkalosis can be classified as saline responsive or unresponsive. If responsive, has low urinary cl excretion, corrects with saline. Due to loss of gastric secretions!!!

28 y.o. woman follow up visit on psych meds. Says "I am not feeling depressed for 1st time in yrs, but voices just won't go away." She hears voices several times a weeks saying she's stupid and ugly. 2 months ago, hospitalized for increasing auditory hallucinations and fears that boss and coworkers replaced by imposters. Also had major depressive sx at that time. Tx with fluoxetine and aripiprazole and discharged. During the past month, continued hearing voices. Usually drinks 1 to 2 glasses of wine, increased to 4 per day. Dx?

Shizoaffective disorder; hx of major depressive episode with concurrent sx of schizophrenia. Dx: delusions or hallucinations for 2+ wks in absence of major mood episode (depressive or manic) - Bipolar I: at least 1 manic episode, if psychotic sx present, only during mood episodes. - BTW: most ppl with MG have thymic abnormalities (thymoma, thymic hyperplasia)

Study evaluating association between alcohol consumption and cancer of the oral cavity. If smoking is considered as potential confounder, what properties must smoking have to be considered confounder?

Should be related to alcohol consumption. extraneous factor with properties linking it with exposure and outcome of interest

42 y.o. man with nonpruritic, nonpainful skin lesions of LUE began 2 months ago. Tingling and numbness of left fingers. Emigrated from SE Asia to Connecticut a year ago. 4 cm, well circumscribed, hypopigmented patch on left upper arm with no sensation to pinprick. Ulnar nerve thickened at left elbow (wth) with touch and pain absent in left ulnar nerve distribution. Next step to confirm dx?

Skin bx from edge of the lesion. LEPROSY!!! Chronic granulomatous dz of skin and peripheral nerves caused by acid-fast bacillus *mycobacterium leprae* transmitted through air droplets (armadillo wth). Manifestations: 1+ chronic, anesthetic macular (often hypopigmented) skin lesions with raised, demarcated borders. Nerves nearby become nodular and tender, loss of sensation (segmental demyelination). Dx: Full thickness bx of skin lesion!!! Tx: Dapsone and rifampin!!! Add clofazimine if severe (multibacillary)

CLL blood smear finding

Smudge cells

45 y.o. obtunded woman with empty bottle of meds next to her. On the way to ER had seizure. PMH: major depression and chronic back pain. Temp 100.9, BP 90/70. Pupils 8 mm, skin warm and flushed. Lungs are clear. Bowel sounds decreased. EKG shows QRS of 130 msec, change from previous EKG. Next step?

Sodium bicarbonate; TCA overdose (hyperthermia and anticholindergic effects including dilated pupils and intestinal ileus); QRS prolongation (decreases conduction velocity). First secure their airway! In cases of hypotension, QRS prolongation, and vent arrhythmia, give sodium bicarb! - Calcium gluconate is for hyperkalemia cardio-protection!!! - Mg sulfate: tx for torsades de points (QT prolongation) - BTW: Major depression = 5+ SIGECAPS sx

Pt has GBS, is stable. Next step?

Spirometry! Respiratory failure is life-threatening complication found in up to 30% of pts.

40 y.o. man with 2 wks of fever, malaise, weakness, 5 lb weight loss. During the last 4 days, left sided CP and upper abd pain. Has asymptomatic MVP. His wife was treated for URI 3 wks ago. Travels to mexico often, long tiem smoker. 103F. Decreased breath sounds in LLL with dullness to percussion. 2/6 systolic murmur at apex. WBC 27,000, 60% neutrophils. Imaging: left sided pleural effusion with splenomegaly and splenic fluid collection. Underlying dx?

Splenic abscess!!! Fever, leukocytosis, LUQ abd pain, possibly left CP, pleural effusion, splenomegaly. Risk fator for splenic abscess: infection (IE!!!) with hematogenous spread, IS, IVDU, trauma, hb-opathy. 10-20% incidence of splenic abscess or infarction with left sided endocarditis. Tx: splenectomy! - BTW: vascular ring - uncommon congenital anomalies where aortic arch vessels encircle trachea or esophagus

Pt with known cirrhosis with AMS, fever. Asterixis, ascites and increased AST:ALT. Dx and next step?

Spontaneous bacterial peritonitis; paracentesis should be done to look for pos ascites fluid culture. - If inconclusive, can do lapaoscopy to look for other causes of peritonitis like intestinal perforation or abscess Tx: 3rd gen cephalosporine, fluoroquinolones for SBP prophylaxis

Tx of HIT!!!

Stop heparin and start argatroban (stop all heparin products!) thrombin inhib like argatroban or fondaparinux

Most beneficial therapy to reduce progression of diabetic nephropathy

Strict BP control!!! Toward 130/80

BTW

Studies have shown that risk for sepsis is present up to 30 yrs after splenectomy (Haemophilus, meningococcal vaccines weeks before operation, and daily oral PCN for 3-5 yrs after splenectomy)!

Severe pain with flexed elbow and internally rotating arm. Painful abduction of arm above the shoulder. Painter (overhead work). Elevation of internally rotated and outstretched arm shows pain over anterior lateral aspect of shoulder. Next step?

Subacromial lidocaine bc it's probably impingement syndrome (rotator cuff tendinopathy), if it doesn't get better then might be rotator cuff tear.

39 y.o. woman with 2 days of fever, heavy vag bleeding and lower abd pain; 6 days ago had elective abortion at 8 wks gestation. Since then she had bleeding increasingly heavy and malodorous soaking thru pad every 2-3 hrs. Fever, bp 100/65. Exam reveals lower abd tenderness but no rigidity or guarding. Pelvic exam: foul-smelling, purulent, bloody discharge from cervical os. Bimanual exam shows tender, anteverted, soft uterus 12 wks in size. Transvaginal US shows 12 cm uterus with irregularly thickened echogenic endometrial stripe with active blood flow. *Small amount of free fluid in pelvis.* Next step after abx?

Suction curettage; SEPTIC ABORTION. Fever, lower abd pain, heavy bleeding, *malodorous, purulent discharge.* Can occur with any abortion esp if dirty. Enlarged, boggy, tender uterus; intrauterine echogenic material with blood flow (inflammation and infx from retained products of conception). Risk of peritonitis: medical emergency (TREATMENT: BROAD-SPECTRUM ABX, SUCTION CURETTAGE) - BTW: when tardive dyskinesia occurs and can't stop med, switch to clozapine

Infx or med that increase oxidative stress

Sulfa drug (bactrim), antimalarial, nitrofurantoin. Pos Prussian blue stain (hemosiderin, found in urine during hemolytic episodes). Oxidative stress --> hemolysis (G6PD deficiency) G6PD catalyzes reduction of NDP to NADPH in HMP shunt. Without G6PD in presence of oxidizing agents, hb becomes oxidized to met0hb, denatured globin, sulfhb --> Heinz bodies formes that attach to RBC membrane, decrease membrane pliability, promote RBC removal in spleen's reticuloendothelial system

28 y.o. at 35 w gestation with n/v, epigastric and RUQ pain with preeclampsia. FHR normal. Hb low, low platelets, hi bili, high liver enzymes. Peripheral smear shows numerous RBC fragments. Cause of dx?

Systemic inflammation and platelet consumption (HELLP syndrome) resolt of abnormal placenta triggering systemic inflammation and activation coagulation system and complement. Platelets are consumed, microangiopathic hemolytic anemia (MAHA) occurs. HCC necrosis and thrombi in portal system -> elevated liver enzymes. *Abd pain due to swelling with distention of hepatic (Glisson's) capsule!* Can get pulmonary edema due to generalized arterial vasospasm --> increased SVR and high afterload (also bc of increased capillary permeability). Mg sulfate can cause resp and neuro probs but both would happen together (DTR decreased) Tx: delivery if 34+ weeks or any age if abnormal FHR or worsening mental status!! Mg for seizure prophylaxis, antiHTN drugs

Which med helps facilitate passage of ureteral stone?

TAMSULOSIN - Alpha1 receptor blockers lower muscle and reducing reflex ureteral spasm secondary to stone impaction - Finasteride: loops promotes calciuria -Phenazopyridine: is analgesic for urinary tract mucosa treats dysuria of cystitis

45 y.o. man recently immigrated from China with dyspnea, fatigue, abd distension. No medical probs, farmer entire life. BP 110/60. Pedal edema, increased abd girth with free fluid, elevated JVP. Decreased heart sounds and S3. CXR shows ring of calcification around heart, JVP tracings show prominent x and y descents. Cause of sx?

TB! Constrictive pericarditis impairs ventricular filling during diastole (sings of overload with ascites, JVP, pedal edema. Sharp x and y descents, pericardial calcifications can help confirm constrictive pericarditis. TB in developing countries are common cause of const. pericarditis. In US, it is idiopathic/viral (40%), radiation therapy (30%), cardiac surg, and CT disorders. - COPD and pulm emboli cause cor pulmonale (pulm HTN: widely split S2, increased intensity of pulmonic component of S2), but pericardial calcifications = constrictive pericarditis - pneumonioses: asbestosis and silicosis; get DOE, pulm HTN, cor pulmonale yrs after exposure. CXR showhs parenchymal nodules (silicosis) and leural plaques (asbestosis) - Psittacosis: birds and hhumans: fever, dry cough, HA, pulm findings (not heart)

45 y.o. immigrant from china has dyspnea, fatigue, abdominal distension for past 2 months. 98F. Pedal edema, increased abdominal girth, elevated JVP without inspiratory decline. Decreased heart sounds and accentuated sound after S2 in early diastole. CXR demonstrates ring of calcification around heart, JVP tracings shows prominent x and y descents. Cause of sx?

TB!!! Constrictive pericarditis (pericardial fibrosis and obliteration of pericardial space); impairs ventricular filling, causing signs of venous overload. Kussmaul's sign (lack of typical decline in CVP and presence of pericardial knock (early heart sound after S1). Sharp x and y descents, and pericardial calcification on CXR. TB is the most common cause of constrictive pericarditis in Africa, India, and China!!! - T. cruzii (Chagas) causes megacolon, megaesophagus, cardiac dz!!! Causes both systolic and diastolic HF. Causes arrhythmia and mitral/tricuspid regurg, and cardiomegaly

Tx of PJP

TMP-SMX!!! PLUS CORTICOSTEROIDS!!! (possibly reduces inflammation due to dying organisms); use if PaO2 <70 or Aa gradient 35+ Alternate regimen: pentamidine, atovaquone, TMP + dapsone, clinda + primaquine

G6PD triggers

TMP-SMX, dapsone, primaquine, infx, metabolic abnormalities, fava beans --> pallor, jaundice/dark urine, abd/back pain LOW HB, INCREASED IND BILI, *INCREASED LDH, DECREASED HAPTOGLOBIN*

First step in eval of hyperthyroidism:

TSH and free T4 (if both high, MRI pituitary gland; if TSH low, consider graves) If no goiter and opthalmopathy, do radioactive iodine uptake scan. If high (diffuse = GRAVES; nodular = TOXIC ADENOMA, MULTINODULAR GOITER) low (measure SERUM THYROGLOBULIN; hi = thyroiditis or iodide exposure, LOW = EXOGENOUS HORMONE) - BTW: during pregnancy, increased HR and blood volume precipitates sx of RF mitral stenosis

Pulsus paradoxus is found in?

Tamponade but also in SEVERE ASTHMA AND COPD!

Pneumothorax tx

Tension: needle decompression (would have cyanosis, CL tracheal deviation, JVD, hemodynamic instability). Do CHEST TUBE OVER NEEDLE THORACOSTOMY THOUGH Pneumothorax: insertion of chest tube (high PEEP -> lung tissue damage and leak, air entering pleural space coming from the lung and not the exterior means it's a closed pneumothorax)

67 y.o. woman with sudden right side numbness, eval shows ischemic stroke 4 wks ago. Returning sensation but allodynia on that side. Long term smoker. Most likely location of stroke 4 wks ago?

Thalamus; lacunar stroke!! Penetrating branches of posterior cerebral artery. Sudden CL sensory loss. *Weeks or months later, gets Dejerine-Roussy syndrome (thalamic pain syndrome): allodynia over affected area.*

32 y.o. at 18 wks gestation with increasing confusion. Seen in ED previously for N/V was treated with IV fluids and antiemetics. Was unbalanced and fell recently. Persistent vomiting and lost 7 kg. BP 110/60. K+ 3.2, Glucose of 70. Has nystagmus but no scleral icterus. Pupils are equal and reactive to light and accomodations. Has epigastric pain and bilateral absent ankle reflexes. AST 110, ALT 114, lipase 32. Dx?

Thiamine deficiency; WERNICKE assoc'd with hyperemesis gravidarum. AMS, oculomotor dysfunction, gait ataxia Pts with HG have hypochloremic metabolic alkalosis, hypokalemia, hypoglycemia, and elevated serum aminotransferases. Give thiamine before glucose tho. - Acute fatty liver dz of pregnancy is present with n/v, elevated AST and ALT, hypoglycemia IN THIRD TRIMESTER

First TM bleeding with closed cervix and normal HR

Threatened abortion (outpatient observation), usually end up fine

Scaphoid fracture management

Thumb spica cast and repeat x ray in 2 weeks - S. epidermidis infx joint: if <3 mo or >24 months after knee surg, then S. aureus. If 5 months or something, S. epidermidids

Tx for lichen sclerosus?

Topical cortisteroid! White vulvar plaques/loss of minora, intense pruritus, periana figure 8, spares vagina. - Atrophic vaginitis: vulvovag dryness, loss of vaginal elasticity, thinning vulvar skin, decreased vaginal diameter -- low dose topical estrogen

42 y.o. man with fatigue nad dark urine. Used IVDU in past, long smoking hx. Icteric. alk phos 822, AST 55, ALT 44. Prothrombin 11. Total bili 11, direct 8. Next step?

US of abdomen; elevated conj bili with elevated alk phos (cholestasis). Next step is abd US for hepatic parenchyma assessment and biliary ducts. Biliary dilatation : EXTRA HEPATIC No dilataion: INTRA HEPATIC

Acute appendicitis in pregnancy (n/v, RLQ, fever, leukocytosis)

US with graded graded compression (noncompression and dilation of appendix are diangostic)

1 day old boy with macrocephaly and jaundice. Mom had consisten prenatal care but traveled to Zambia. She had fever for 2 wks, swollen glands, muscle aches that resolved spontaneously. Hepatomegaly, CT shows hydrocephalus and diffuse intracranial calcifications. Maternal exposure to what caused infant's condition?

Undercooked meat --> TOXO (also cat feces, unwashed fruits/veggies) - CMV: periventricular calcifications, head circumference is small or normal -> SALIVA - RUBELLA: cataracts, hearing loss, heart disease, congenital parvo (hydrops) -> RESPIRATORY

Hepatorenal syndrome

indicates ESLD. Progressive renal failure in liver dz (secondary to renal hypoperfusion bc of VC of renal vessels). Precip'd by diuretic and infx. You get splanchnic arterial dilation (and overall decrease in vascular resistance) -> local renal VC and decreased perfusion/GFR. - Fever and leukocytosis can occur with bowel ischemia

45 y.o. woman with severe abd pain, nausea, 2 bilious vomiting over past 4 hrs. Last several weeks had episodic epigastric and RUQ abd pain with nausea. Has MVP and migraine headaches relieved by NSAIDs. Drinks wine every night, T 101, BP 140/95. Ha tenderness, guarding, rigidity over upper adbomen, rebound tenderness and reduced bowel sounds. Stool guaiac positive. Next step?

Upright xray of chest and abdomen: signs of peritonitis - PERFORATED VISCUS. Preceding epigastric pain, nausea, hx of NSAIDs and alcohol use. Pos stool guaiac: PUD. Do xray to see free intraperitoneal air under diaphragm PERF VISCUS: abd pain, fever, tachycardia, signs of peritonitis

Hyperandrogenism during pregnancy

Usually due to ovarian masses; "luteomas." 30% of them ccuase hirsutism and acne. Dx: US (6-10 cm and bilateral in half of pts). They usually regress spontaneously after delivery. But female is now at hi risk of virilization. - Krukenberg tumors: solid on US and can cause new hirsutism, but are mets from GI cancer (would have weight loss, abd pain, etc). - Theca lutein cysts: multi-septated cystic mass that is asymptomatic or cause new onset hyperandrogenism, arise from high beta-hCG (molar preg or multiple gestation); suction curettage indicated when complete mole is seen, but the assoc'd theca lutein cyst regresses spontaneously

55 y.o. man with severe retrosternal pain starting a few hours ago. Had burning epigastric pain and CP for the past few days. Med hx includes non-ischemic cardiomyopathy. T 102F, bp 110/65, pulse 110. In sever pain. ECG within normal limits. CXR shows widened mediastinum and some mediastinal air. Next step?

Water-soluble contrast esophagrogaphy (no pneumomediastinum in aortic dissection)

VIPoma

Watery diarrhea, hypokalemia, *hypercalcemia, hyperglycemia* Mostly are at the pancreatic tail.

Ppl with calcaneal fractures should have what checked???

X-ray of the spine bc of high energy axial loading injuries (compression fracture of neck or femur or lumbar verts!!) - Polyarthritis of 3 y.o. girl with pos ANA. At risk of which complication? Dx? Juvenile idiopathic arthritis. Risk of chronic anterior uveitis and blindness! - Stack splint for Mallet finger (flexed DIP and can't extend distal phalanx) = extensor tendon injury

Heat stroke management

Young dude: ice water immersion Old ppl who have low tolerance of heat: evaporative cooling

New onset hypoxia by pulse ox 85% during endoscopy

acuired met-hb -> altered state of hb! Topical anesthetics, dapsone, nitrates in infants --> iron component of hb gets oxidized -> met-hb which can't bind oxygen (shows faslely normal O2 sat)

Fever and sore throat in pt taking antithyroid durgs

agranulocytosis! Stop the drug and check WBC only if symptomatic, then can treat with culture, oral PCN, and acetaminophen - Methimazole also: 1st TM teratogen, cholestasis - Propylthiouracil: hepatic failure - BTW: give statins to all ppl with significant CAD - BTW: magnesium is excreted renally so becareful if pt has high cr - BTW: pts with 21-hydroxylase deficency have elevated 17-hydroxyprogesterone - BTW: postmeno bleeding - do pelvic US, if endometrial stripe is >4 mm, do biopsy; if cancer, do hysterectomy

Causes of acute pancreatitis

alcohol, gallstone, HYPERTRIGLYCERIDEMIA, meds, infx, recent ERCP, trauma. Serum TG 1,000+. Eruptive xanthomas are due to hyperTG. Do fasting lipid prolife to determine if hyperTG is cause of xanthomas and pancreatitis. Clx: n/v, constant epigastric pain better partially by leaning forward. Do aggressive volume resuscitation. Isotonic crystalloids wtfh

Pericardial calcification (other findings?)

elevated RV diastolic pressure with "dip-and-plateau" waveform. JVP rises with inspiration (Kussmaul's sign), and there is a pericardial knock - Palivizumab PREVENTS bronchiltis caused by RSV - Hypoxia -> lactic acidosis (gap acidosis)

Exogenous steroid use

elevated hct, hepatotoxicity, elevated LDL (androgens are anabolic)

Chronic gout tx

allopurinol, febuxostat (inhibit uric acid production), probenecid promores excretion. Indomethacin (NSAIDs) are also for chronic tx

Human bite abx prophylaxis

amoxicillin-clav!!! Aerobic and anaerobic oral organisms

First line treatment for acute mania

antipsychotics, lithium and valproate. If mania + acute behavioral agitation (psychosis, shouting, banging on door), give antipsychotics - Avoid valproate in liver disease

Tx for acute mania

antipsyhotics, lithium, mood stabilizers like valproate lithium, valp, and carbamazepine take longer to work and require gradual titration

Compications ofGCA

aortic aneurysm, follow pt with serial CXRs - BTW: MPGN causes - hep B and C, syphilis, gold, penicillamine, SLE, RA

Acute limb ischemia

arterial occlusion (typically caused by cardiac emboli, thrombosis, or trauma) Pts with large anterior STEMI are at high risk of LV thrombus (hi risk for systemic embolization) Tx: Require immediate anticoag and TTE (ECHO)!!! - BTW: tx for performance only social anxiety - beta blockers or benzo in pts without substance abuse hx; if chronic, can give SSRI, CBT - BTW: herniated risk pain radiates to thighs and below knee; pos straight leg test -*BTW: digoxin toxicity - increased ectopy and vagal tone; ATRIAL TACH WITH AV BLOCK*

Atypical pneumonia tx

azithromycin: indolent HA, malaise, fever, persistent dry cough, pharyngitis (nonexudative); normal WBC, CXR: diffuse reticulodular opacities

Uncomplicated cystitis in women first line tx

bactrim, nitrofurantoin, fosfomycin (don't need culture unless failed tx) - BTW: pleural effusions DECREASE tactile fremitus!!! Lobar consolidation is the only thing that increases it

SAH:

berry aneurysm rupture CT angiography vasospasm (use nimodipine) trauma xanthochromia

anti-TPO Ab

both in hashimoto's and Grave's. Thyroglobulin is Hashimoto's anti-TSH receptor ab Grave's - Diffuse, markedly decreased uptake on scan: subacute thyroiditis (painful hyperthyroidism)

Neuro review

brainstem lesion: cranial nerve dyspfunction ipsilateral to the lesion with CL motor weakness and sensory changes. Cerebellum lesion: dysdiadochokinesia (difficulty with rapidly alternating movements), dysmetira (finger to nose probs), limb ataxia, intention tremor. Vermis: ataxic gain adn trunk, saccadic movements of eye, horizontal nystagmus supratentorial white matter lesion: partial or complete hemiparesis with possible sensation changes CL to lesion

Hashimoto's

can happen in kids. 6 y.o. in vignette; would see lymphocytic infiltration on FNA (next to germinal centers which are sites of antibody-secreting plasma cells), Hurthle cells, fibrotic tissue

Causes of clubbing

cancer, empyema, CF, bronchiectasis, ILD, CV disease

Vagal maneuvers are what and do what

carotid sinus massage, cold water immersion, valsalva, eyeball pressure -> increase PSNS tone and decrease conduction speed in the AV node, increase AV node refractory period.

Biliary cyst

congenital dilation of biliary tree; most common is single, extrahepatic cyst. abd pain, jaundice, palpable mass. Older kids might have pancreatitis. US, might need ERCP, and surgery

Copper vs progesterone iud

copper does not cause amenorrhea

Polycythemia vera causes

elevation of RBC, WBC, and plt, low EPO tho - btw do gonorrhea and chlamydia test for WOMEN under 25 or at risk, not men tho bc they would be symptomatic. - everyone needs HIV screening once in their life from 15-65 y.o. *24 and HIV antibodies*

Opioid intox

decreased RR and decreased bowel sounds (not necessarily miosis); give naloxone

Cirrhosis findings

decreased total T3 and T4, normal free levels. Normal TSH.

Urge incontinence

detrusor overactivity: risks are 40+, woman, pelvic surgery (tx is kegel exercises and bladder training, also antimuscarinics like oxybutynin) HAVE NORMAL PVR (*<150 mL in women, <50 in men*); tx after Kegel exercise is antimuscarinics!! - BTW: spillage of dermoid cyst (teratoma) contest can lead chemical peritonitis - BTW: tx for PID - IV cefoxitin/cefotetan PLUS PO doxy or IV clina + gentamycin

RIPE tx for TB

do RI for 6 months and PE for 2 months Do all of them for 2 months and continue RI for 4 more months to prevent relapse

Pseudoachalasia

due to esoph cancer (smoker, weight loss, onset <6 months, age 60+) Endoscopic eval to differentiate between achalasia and pseudoachalasia!!! - BTW: UC has bimodal distribution!! 15-40, 50-80

Interstitial lung disease

due to known causes or idiopathic; collagen deposition in ECM around alveoli --> scariing (increased recoil, decreased TLC, FRC, RV) Fibrosis: decreased diffusion capacity

Placenta previa

dx at 18-20 wks; schedule c-section at 36-37 wks. Avoid DCE and intercourse! - Doppler can eval from vasa previa - *BTW: RECESSION (means baby goes from 0 to negative station) with sudden abd pain = UTERINE RUPTURE!*

Atypical glandular cells of pap

either cervical or endometrial adenocarcinoma; should be investigated with colposcopy, endocervical curettage, and endometrial biopsy to eval ectocervix, endocervic, and endometrium. - LEEP is cone bx that removes cervical transformation zone (not the endometrium!)

Shoulder dystocia risk factors

fetal macrosomia, maternal obesity, excessive pregnancy weight gain, GDM, post-term pregnancy

19 y.o. woman with recurrent HA, worse recently (last hrs and remit spontaneously or after acetaminophen). No hx of N/V, abd pain, sweating, fever. 6 months ago, BP was hi, now 175/100 on right, 170/102 on left. Uncomfortable and cooperative. Systolic bruit heart under right ear. Cause of htn?

fibromuscular dysplasia typically affects renal and ICA -> stenosis, aneurysm, dissection. Recurrent HA caused by carotid artery stenosis or aneurysm (pulsatile tinnitus, neck pain, flank pain, TIA). HTN from RAS -> seconary hyperaldosteronism. Abdominal bruit (neck if ICA); *subauricular systolic bruit* highly suggestive of FMD as carotid atherosclerosis should not be present in young ppl (also suggests FMD in old ppl bc subauricular bruit is not expected in atherosclerosis) Do vascular imaging (US, CO, MR ang); give ACEi, cure with PTC or surgery.

58 y.o. man after suicide attempt, lethargic. T 100,BP 76/40, pulse 40/min. Diffuse bilateral wheezing. Extremities are cold and clammy. Pt is given IVF and atropine, but bradycardia and hypoTN don't improve. Antidote?

glucagon (beta bloker OD: bradycardia, AV block, hypoTN, *WHEEZING*)

Most common side effects of levodopa/carbidopa

hallucinations, dizziness, HA, agitation After yrs: involuntary movements more likely - BTW: primary hyperPTH would have high higher urine calciu/cr clearance ratio (>0.02); <0.01 in familial hypocalciuric hypercalcemia

Gestational HTN

happens AFTER 20 WEEKS GESTATION (Greater than 140/90) - *PRETERM LABOR is risk with HTN. Also, superimposed preeclampsia, placental abruption, FGR, stillbirth* - COPD DOES NOT CAUSE CLUBBING!! Look for occult malignancy

Overflow incontinence

has markedly increased PVR STRESS HAS NORMAL PVR -BTW: In pts with recent menarche, immature HPO axis -> anovulation and abnormal uterine bleeding -BTW: opioid withdrawal - dilated pupils, piloerection, dysphoria, myalgias, abdominal pain

Management of DKA

hydration with normal saline (add dextrose 5% if glucose <200), IV insulin, potassium monitoring and repletion (hold insulin if K+ <3.3)

OCPs can cause

hypertension!!! After switching off OCPs, try lifestyle change, then diuretic, then look for FMD

MAOI and tyramine result

hypertensive crisis - Serotonin syndrome: hyperreflexia and myoclonus - Reaction formation: pt feared dying but behaved opposite, like pretending to be fearless about new dx - Rationalization: justify behavior like a doc saying he was unable to transfer pts to someone else when this wasn't true - Intellectualization - avoid anxiety by focusing on intellectual aspects of dx

Thiazide metabolic effects

impair insulin release from pancreas and glucose utilization in peripheral tissues --> 'HYPERGLYCEMIA' esp in pts with DM, HTN, dyslipidemia, abdominal obesity - Other things it causes are incrased LDL, TG, and hyperuricemia - hyponatremia, hypokalemia, hypomagnesemia, hypercalcemia

Asymptomatic bacteriuria

in preg: increased progesterone -> ureteral dilation -> pt with untreated ASB during preg have risk of ascending infx (pyelo). Also increased risk of preterm labor and low birth weight

SIBO

increased bacteria load altering normal flora (proximal SI normally contains minimal bacterial colonization due to acidity and peristalsis. If you lose anatomic (GI surgery, fistulas) or functional (motility disorder, acid suppression) protective mechs, can get SIBO. Pts get bloating, discomfort, malabsorption, weight loss, and macrocytic anemia. - Dumping syndrome: late complication of gastric bypass; rapid onset osmotic diarrhea after ingestion of hi carb meals. Crampy abd pain, diarrhea, nausea, hypoglycemia

Fetal hyperglycemia and hyperinsulin in 2nd and 3rd TM

increased metabolic demand -> fetal hypoxemia -> EPO increased (polycythemia), organomegaly, neonatal hypoglycemia - Increased sugar in 1st TM: congenital heart dz, NTD, small left colon, spontaneous abortion

Asymptomatic bacteriuria increases the risk for what during pregnancy

increased risk for acute pyelonephritis and other ascending infx. Also assoc'd with increased risk of preterm labor and low birth weight. Risk factors: pre-gestasional DM, hx of UTI, multiparity Tx: cephalexin, amox-clav, nitro; DO TEST OF CURE AFTERWARDS Progesterone cause smooth muscle relaxation and ureteral dilation

Toxic adenoma

increased uptake in one spot of the thyroid (gain of function mutation in TSH receptor)

Myelodysplastic syndrome

increased with age and hx of chemo or radiation. Can manifest and anemia, granulocytopenia, thrombocytopenia. Will have normo or macrocytic anemia with insufficient reticulocytosis. Have dysplastic RBCs and granulocytes (reduced segmentation). Do BMT for dx.

Dacryocistitis

infection of lacrimal sac (infancts and 40+); sudden onset of pain and redness in medial canthal region, maybe purulence from punctum. S. aureus or beta hemolytic strep - episcleritis: infx of episcleral tissue between conjunctiva and sclera (acute mild-mod discomfort, photophobia, watery discharge); diffuse or localized bulbar conjunctival injection - hordeolum: abscess over upper or lower eyelid (S. aureus); painful! - chalazion: blockage of meibomian gland -> inflammation (not painful) - orbital cellulitis: infx posterior to orbital septum

If the confidence interval crosses the null value,

it is NOT STATISTICALLY SIGNIFICANT

ARDS management

keep low tidal volume (decrease likelihood of overdistending the alveoli). Increase FiO2 but <0.6. Increase PEEP to improve oxygenation by preventing alveolar collapse at the end of expiration. Prevent SpO2 <88%

HSV encephalitis CSF findings

lymphocytic pleocytosis, increased RBCs, elevated protein, low CSF glucose Dx: PCR analysis of HSV DNA; do MRI to see temporal lobe lesions, not CT

What is Ebstein's anomaly

malformed and inferiorly attached tricuspid valve -> cause RV to bevome functionally part of RA -> "atrialization" or the RV - Tricuspid valve atresia: cyanotic infant with left axis deviation and small or absent R waves in precordial leads (V1-V3) --> hypoplastic LV, underdevelopment of pulmonary valve/artery -> decreased pulmonary markings (need ASK and VSD for survival) ECG of TVA is Minimal R waves in v1-v3, tall peaked P waves

Normal distribution

mean, median, mode are equal - Neg skewed: mean is less than median is less than mode - Pos skewed: mean is greater than median is greater than mode

Confounding defined as

mixing up of effect of exposure with effect of extraneous factor. Must have some properties linking it with the exposure and outcome of interest (people who drink alcohol are more likely to smoke, which increases cancers of the oral cavity

Placenta previa risk factors

multiparity, smoking, previoius uterine surgery

What gifts can be accepted from pharm companies?

nonmonetary gifts of minimal value AND directly benefit the pt (unbiased educational material or drug samples)...wat.

Ugh. Somatic sx disorder

obsession with 1 unexplained health prob factitious and malingering: intentional Illness anxiety disorder: super scared of illness but no actual sx

Livedo reticularis causes

obstruction, vasospasm sluggish flow in superficial venules. Can be seen in healthy ppl OR sign of polyarteritis nodosa, SLE, or vasoocclusive prob (antiphospholipid, cryoglobulinemia) antiphosph syndrome is assoc'd with prolongation of PTT!!!!!!!#@@$@$#% - HIV pt with LBP, lower uterine segment mass, and hydronephrosis: Cervical cancer (irregular vag bleeding and postcoital spotting) - HypoPTH: can cause soft tissue calcification, calcium deposits in the basal ganglia - If pt has signs of glomerulonephritis: BIOPSY THAT stuff

Pressure ulcers

occur over bony prominences (sacrum, ischial tuberosities, heels, 1st or 5th metatarsal head - Arterial ulcers: tips of toes - Venous stasis ulcers: chronic LE edema and dermatitis (*pretibial area or above medial malleolus*)

Opioid induced constipation

opioid induced constipation: asymmetric colonic dilation or empty rectal vault - Ogilvie: colonic dilation without anatomic obstruction

Pulseless electrical activity

organized rhythm on cardiac monitoring without a measurable or palpable pulse in a cardiac arrest pt; DO CPR AND EPINEPHRINE for adequate perfusion CPR until can figure out reversible causes of PEA (5 H's and T's: hypovolemia, hypoxia, hydrogen ions, hypokalemia, hypothermia. Toxins, tension pneumothorax, tamponade, thrombosis, trauma) No role for cardioversion or defib in PEA and/or asystole. Pulseless vtach is different!!! Would use defib

Beckwith-Wiedmann syndrome

overgrowth, predisp to neoplasms. Macrosomia, macroglossia, hemihyperplasia, abd wall defects (umbilical hernia, omphalocele) -> hyperinsulin and hypoglycemia. Increased risk of Wilms tumor!!! Dx: abd US and AFP every 3 months until 4 yrs, then a3m age 4-8 yrs.

Tx of choice for ppl with mitral stenosis

perutaneous mitral balloon commissurotomy. If tooo much calcification on the valve, do valve replacement

Exudative effusion

pleural protein/serum protein >0.5 pleural LDH/serum LDH >0.6 or pleural LDH >2/3 upper limit nl ETIOLOGIES: empyema, chylothorax (super high TG, milky white fluid), malignancy, TB

How to decrease postop pulmonary complications in pt with COPD

preoperative physical therapy (aerobic exercise, inspiratory muscle training)

Mississippi AA man with cough, hilar adenopathy, erythema nodosum, non-caseating granulomas, ruled out sarcoid

rapid decomp with tx of steroids sounds like infx like TB, ruled out; TB mimicking dz: histoplasmosis! or blastomycosis!!! HILAR LAD more indicative of histo!! (MI and OH river basins!) Can be disseminated in IC pts (LAD, pancytopenia, HSM, can have reticulonodular infiltrates on CXR) May have caseating or non-caseating granulomas! Dx: histoplasma urinary or serum antigen testing Tx: amph B or itraconazole - Blastomyces: contact with soild, rotting wood (presents in dissemination in IC pts with skin lesions, osteolytic bone lesions, or prostate involvement) - Coccidioides: SW US - Hypersensitivity pneumonitis: non-caseating granulomas, but should improve with steroids

HSV retinitis

rapidly progressive (CMV retinitis is less acute)

Ocular rosacea

red pustular rash affecting central face (cheeks and nose). Rosacea: erythematotelangiectatic, papulopustular, phymatous (irregular thickening of skin and nose), ocular (involvement of *cornea, conjunctiva, lids*, gritty sensation, ulcers, chalazia)

Caustic injury

remove contaminated clothing and do upper GI endoscopy within 24 hrs After 2-3 wks, do barium swallow to look for strictures or pyloric stenosis Don't do lavage, charcoal or anything that can cause vomiting

Syringomyelia pathophys

represents dilation of central canal or separate cavity within spinal parenchyma (cervical and thoracic spine, also can involve brainstem). Most commonly assoc'd with Arnold Chiari malformation type 1. Loss of spiothalamic tracts!!! pain/temp --> eventual areflexic weakness of upper limbs - Anterior spinal cord syndrome: sudden loss of pain and temp below level of injury

Aspirin toxicity metabolic probs

respiratory alkalosis with mixed metabolic acidosis - Allergic reaction: impaired ventilation, respiratory acidosis - Persistent vomiting/excessive diuresis: increased serum HCO3 and metabolic alkalosis

Amiodarone toxicity

restrictive pattern with reduced diffusion capacity of CO (progressive dyspnea, nonproductive cough, bilateral crackles, CXR findings)

Eval of ascites

serum to ascites albumin gradients 1.1+ indicates = portal HTN (cardiac ascites, cirrhosis), while <1.1 means malignancy, pancreatitis, nephrotic syndrome, TB) Subtract serum minus ascites albumin (pt in question had serum alb of 3.8, ascites alb of 2.5 --> 1.3 gradient, consistent with cirrhosis with increased hydrostatic pressure in hepatic capillary beds - BTW: tardive dyskinesia is due to D2 receptor upregulation and supersensitivity

57 y.o. man with right arm and leg weakness, first noticed 2 hrs ago when he could not grip a pen. Now unable to shake hands and walks with mild limp. Mild, constant headache for past several days. Hx of HTN and hyperlipidemia. Does not smoke or drink. BP 180/100. Mild asymmetry of lower face, decreased muscle strength in right arm, post Babinski sign on the right side. Blood glucose 210. Normal CT. Cause of sx?

small-vessel lipohyalinosis; lacunar stroke!! in the internal capsule (occlusion of deep penetrating arteries of the brain). Combo of microatheroma formation and lipohyalinosis --> thrombotic small-vessel occlusion. PURE MOTOR HEMIPARESIS - Borderline personality disorder: persistent pattern of unstable relationships, mood lability, impulsivity, recurrent suicidal behavior. Tx: psychotherapy with behavioral focus

Osteoclastoma

soap bubble appearance (giant cell bone tumor) - serosanguineous drainage and incisional pain = incisional hematoma

Pts with COPD; risk of AKI

they often have CO2 retention, so have respiratory acidosis and compensatory metabolic alkalosis. Diuretics help treat cor pulmonale but might cause reduction in cardiac output and subsequent prerenal AKI.

Intrauterine fetal demise (>20 wks)

vaginal delivery preferred at >24 wks even if breech. Can be done immediately, but wait til whenever pt is ready (waiting more than 2-3 wks after dx can lead to coagulopathy)

Week 15 gestation; 13 week ultrasound showed increased nuchal thickness, and elevated beta-hCG. Next step?

week 10-13: CVS week 15-20: amniocentesis week 15-22: quadruple screen, NOT DIAGNOSTIC - pts with hx of sexual assault have increased lifetime risk of depression and suicide - **BTW: PTSD sx have to be 1+ month!!! Acute stress disorder is 3+ days, less than a month** - BTW: generalized anxiety disorder- worry about multiple things SIX+ MONTHS, may have fatigue, conc probs, irritability, sleep probs, muscle tension

PP depression

within 4 wks of birth - BTW: Chi square test compares categorized outcome (2x2 box_ - BTW: two sample z and t test compare 2 MEANS - BTW: ANOVA compares 3 or more variables - BTW: meta-analysis is a bunch of studies - BTW: Dressler's sydrome - 2 wks after MI, pericarditis; give NSAIDs and corticosteroids if refractory!

Lichen sclerosus

wrinkles thin vulvar skin, does not affect vaginal tissue - *atrophic vaginitis can cause dyspareunia, seen in estrogen deficient pts in setting of radiation and chemo induced menopause*