PANCE Review 2
What is the classic CXR findings for tetrology of fallot?
"Boot shaped heart"
The terms "dermatitis" and "eczema" are frequently used interchangeably. When the term "eczema" is used alone, it usually refers to atopic dermatitis (atopic eczema).
"Eczematous" also connotes some crusting, serous oozing, or blister formation as opposed to mere erythema and scale.
withdrawl phase of psychostimulants
'crash' or severe somnolence for 1-2 days with cocaine or 3-4 days with meth.
Conditions associated with "low output heart failure"
((due to decreased ejection fraction)) - *ischemic heart disease* - long term HTN - dilated cardiomyopathy - valvular heart disease
Conditions associated with "high output heart failure"
((due to high metabolic state or shunting blood increasing myocardial demand)) -Hyperthyroid -Pregnancy -Anemia -Beriberi -AV fistula -Paget disease
Comparision of the *DISEASES OF THE VENOUS SYSTEM* (1) Superficial thrombophlebitis (2) Chronic venous insuff (3) DVT
(1) *SUPERFICIAL THROMBOPHLEBITIS* *Clinical features*: local tenderness, erythema along the course of a superficial vein *Diagnosis*: clinical *Tx*: Analgesics, monitor spread for cellulitis (2) *CHRONIC VENOUS INSUFF* *Clinical Features*: achings of LE worse at the end of the day; relieved by elevation of legs and worsened by recumbency; edema, pigmentation, ulcers *Diagnosis*: Clinical *Tx*: leg elevation, avoid long periods of standing, elastic stockings; if uclers develop unna-boots and wet-dry dressings (3) *DVT* *Clinical Features*: usually asx, calf pain may be present *Diagnosis*: Duplex u/s, D-dimer *Tx*: Anticoagulate
What treatment options are indicated for DVT?
(1) Anticoagulation - heparin bulus followed by warfarin x 3-6 months (2) Thrombotic therpay (-kinase) for pts w/ massive PT, hemodynamically unstable, right sided heart failure (3) Prophylactic IVC filter (greenfeild filter) - used in pts who are c/i for anticoag and thrombolytics - effective ONLY in preventing PE NOT DVT
Name the CHD associated w/ the following conditions: (1) Downs (2) FAS (3) Turners (4) Marfans (5) CHARGE
(1) Downs = VSD/ASD (2) FAS = VSD/ASD (Shot glass up side down and right side up) (3) Turners = COA, Bicupsid Aortic Valve (4) Marfan Syndrome: Mitral Valve Prolapse; Aortic Aneurysm; Aortic Root Dissection (5) CHARGE Association: Ventricular, Atrioventricular, and Atrial Septal Defects
In pts w/ chronic venous insuff, what is the management before a venous ulcer is present?
(1) Leg elevation *ABOVE* the heart during the day and night (2) Avoiding long periods of sitting/standing (3) Heavy-wt elastic stocking (knee-length) are worn during walking
What are the predisposing factors for aortic dissection?
(1) Longstanding systemic HTN (present in 70% of patients) (2) Trauma (3) Connective tissue diseases, such as Marfan's and Ehlers-Danlos syndrome (4) *Bicuspid aortic valve* (5) *Coarctation of the aorta* (6) Third trimester of pregnancy
What are the signs for AS?
(1) Murmur - Harsh crescendo-decrescendo systolic; Heard in second right intercostal space; Radiates to carotid arteries (2) S4 (3) *Parvus et tardus*-diminished and delayed carotid upstrokes (4) Sustained PMI (5) Precordial thrill
What are the target LDL levels for the following pt populations: (1) NO est CHD (2) Est. CHD/DM
(1) NO est CHD: LDL < 130 (2) CHD/DM: LDL <100
What are the complications that can occur due to a DVT?
(1) PE (2) Posthrombotic syndrome (chronic venous insuff) - occurs in 50% of pt and can lead to ambulatory HTN (3) Phlegmasia cerulea dolens - Occurs in extreme cases of DVT-indicates that major venous obstruction has occurrence. Severe leg edema compromises arterial supply to the limb, resulting in impaired sensory and motor function. - venous thrombectomy is indicated
What are the hemorrhagic and nonhemorrhagic causes of hypovolemic shock?
(1) hemorrhagic - trauma, GI bleed, retroperitoneal (2) nonhemorrhagic - voluminous vomiting, severe diarrhea, severe dehydration, burns, third-space losses in bowel obst
What are the clinical features of a MI?
(1) intense substernal CP - "crushing" or "elephant on chest" (2) Radiation to neck, jaw, arms, or back - *MOST COMMON* on *LEFT* side (3) Some experience epigastric discomfort (make sure to r/o w/ GERD sx) (4) Dyspnea (5)diaphoresis (6)weakness, fatigue (7) N/V, sense of impending doom (8) syncope
What patient population can have an asx or atypical MIs?
(1) post-op (2) DM (3) Elderly (4) Women
What is the management if ulcers develop in a pt w/ chronic venous insuff?
(1) wet-dry saline dressing 3x/day (2)Unna Venous boot (ext compression stocking) - changed every 7-10 days (3) For ulcers that do not heals w/ unna venous boot then apply *splint thickness skin graft* w/ or w/o ligation of adjacent perforator veins
diagnostic test for narcalepsy
(if unsure based on clinical history): Multiple Sleep Latency Test (MSLT) check orexin/hypocretin-1 levels (wake-producing hormones, usualy low in narcaleptics)
Allergic contact dermatitis occurs when contact with a particular substance elicits a delayed ________ hypersensitivity reaction.
(type IV)
What is the classical CXR findings for TAPVC?
*"Snowman"*, cardiomegaly, increased pulmonary vasculature
*CAP - signs/sx*
*1-10 day hx of cough, sputum, dyspnea, tachycardia, fever* - crackles on auscultation, inc breath sounds over areas of consolidation, dullness on percussion
If the aneurysm is > _____ in diameter or symptomatic, surgerical resection w/ synthetic graft placement is recommended (infrarenal aorta is replaced w/ fabric tube)
*> 5 cm* (normal renal aorta is 2 cm) <5 cm - tx is controversial but routine RAD is recommended
Acute bronchitis - cx (no chronic lung dz)
*>90% cxed by viruses - rhinovirus, coronavirus, RSV*
What HTN treatment is indicated for diabetics?
*ACE-I* (or possibly ARB), beta blocker with diuretic
What HTN treatment is indicated for a CHF pt?
*ACE-I*, diuretic, carvedilol, some beta blockers, ARB *NOT CCB*
What drugs are used post-MI for maintance therapy?
*ASA* - decreases mortality - prevents platelet aggregation to prevent thrombosis formation *BB* - decreases mortality - decreases HR/Contractility/afterload *ACEi* - initiate w/in hours of hospitalization if no c/i - been shown to decrease mortality - esp important in *DIABETICS* *Statins* - reduce risk of other coronary events
Solitary pulmonary nodule - sx
*ASYMPTOMATIC* - most are found unexpectedly during radiography
Name all the Acyanotic and Cyanotic CHD.
*Acyanotic:* Atrial septal defects Patent ductus arteriosus Ventricular septal defect Pulmonary stenosis Aortic stenosis Coarctation of aorta *Cyanotic* (Remember: Cyanotic 5Ts and H!!!!) TETRALOGY OF FALLOT TRICUSPID ATRESIA TRANSPOSITION OF THE GREAT ARTERIES TRUNCUS ARTERIOSUS TOTAL ANOMALOUS PULMONARY VENOUS CONNECTION HYPOPLASTIC LEFT HEART SYNDROME
2 Diastolic Murmurs
*Aortic Regurgitation* - Austin flint, blowing murmur *Mitral Stenosis* - opening snap
What is the management option for a non-hemodynamically stable sustained VT pt?
*BOX TRUMPS PILL* IMMEDIATE synchronous DC cardioversion Follow w/ Amiodarone to maintain sinus rhythm
Med that can cause Psoriasis:
*Beta blockers, NSAIDS, antimalarials (chloroquine), -statins, and Lithium.*
What are the EKG findings for V.Fib?
*COMPLETELY IRREGULAR* - No atrial P waves or QRS complexes can be IDed - in sum NO WAVES can be IDed
What is used for diagnosis of endocarditis?
*DUKE CRITIERIA* MUST HAVE: Two Major; One Major and Three Minor; OR Five Minor *Major* (1) 2 positive blood cultures (2) Evidence on echocardiogram of: Vegetation; Abscess, OR Dehiscence of a prosthetic valve *Minor* (1) Predisposing condition (2) Fever >38 degrees C (3) Immunologic signs (*glomerulonephritis, Osler's nodes, Roth spots, rheumotoid factor*) (4) 1 positive blood culture (5) Positive echo not meeting major criteria
What is the *classical* CXR finding for "TOGA"?
*EGG ON A STRING* Other: ↑ pulm vasculature; narrow mediastinum, cardiomegaly
What EKG findings are characteristic of cardiac tamponade?
*ELECTRICAL ALTERNANS* (alternate best variation in the direction of the EKG wave forms) - due to pendular swinging of the heart within the pericardial space, causing a motion artifact
What is the treatment for hemorrhagic tamponade secondary to trauma?
*EMERGENT SURGERY* is indicated to repair the injury Pericardiocentesis is only a temporarly solution, and surgery should *NOT* be delayed to perform pericardiocentesis.
What are the "Big 6" in regards to risk factors for CAD?
*FSH DAD* F - Family Hx of premature CAD/MI (M < 45; F < 55) S - Smoking (Cigarettes) H - HTN, Homocysteine levels elevated D - DM/Metabolic syndrome A - Age (M: > 45; F: > 55) D - Dyslipidemia - Elevated LDL; Low HDL
Most common cause of pericarditis?
*Idiopathic* 2nd most common cause = viral (coxackie)
What diagnostic test is as accurate as doppler but is less operator dependent?
*Impedance plethysmography* • A noninvasive alternative to Doppler ultrasound • Blood conducts electricity better than soft tissue, so electrical impedance decreases as blood volume increases. • High sensitivity for proximal DVT, but not for distal DVT (calf veins) • Poor specificity because there is a high rate of false positives
What is the effects of niacin?
*LOWER TGs*, lowers LDL, increases HDL 2nd line for lowering LDL
What is the *MOST COMMON* findings for cardiac tamponade?
*MC = Elevated JVP* - prominent x-descent w/ absent y descent
Where is the *MOST COMMON* location for acute arterial occlusion?
*MC* = femoral artery Less commonly = in situ thrombus
What is the *MOST COMMON* site for occulusion/stenosis in PVD?
*MC* = superficial femoral artery (in *hunter's canal*) Other locations: popliteal artery, aortoiliac occlusive disease
What is the *MOST COMMON CAUSE* of embolus from the heart?
*MCC* = AFib Other: post-MI, endocarditis, myxoma
What is the *MCC* of cardiogenic shock?
*MCC* = After acute M Other causes: cardiac tamponade, tension pneumo, arrhythmias, massive PE leading to RVF, CM, myocarditis
What is the *MOST COMMON CAUSE* for Acute Endocarditis?
*MCC* = Staph Aureus
Describe the "classical" murmur associated w/ MVP.
*MIDSYSTOLIC OR LATE SYSTOLIC CLICK* *MID - LATE SYSTOLIC MURMUR* Standings and Valsalva *increase* the murmur/click (b/c it reduces LV chamber size) Squatting *decreases* murmur and click (because it increases LV chamber size) Sustained handgrip *increases* MVP; in contast to the murmur of HCM with *decreases*
3 Holosystolic Murmurs
*MTV* *M*itral Regurgitation *T*ricuspid Regurgitation *VSD*
What is the *HALLMARK* of the PDA murmur?
*Machinary Type Murmur* S&S: Acyanotic, Early diastolic murmur + crescendo-decrescendo holosystolic/ pansystolic murmur, Sweating w/feeding, Bounding peripheral pulses, Wide pulse pressure
What is the medical and surgical management for MR?
*Medical* a. Afterload reduction with vasodilators; also salt reduction, diuretics, digoxin, and antiarrhythmics b. Chronic anticoagulation if patient has atrial fibrillation c. IABP as bridge to surgery for acute MR *Surgical* - Mitral valve repair or replacement (Must be performed before left ventricular function is too severely compromised)
Interpretation of Ankle/Brachial Index
*Normal: >1.0* Arterial Claudication: 0.5 - 0.9 *Severe Arterial Stenosis: <0.4*
Explain orthodromic and antidromic AVRT.
*Orthodromic AVRT (MORE COMMON):* Narrow Complex tachycardia in which the wave of depol travels down the aVnode and retrograde up the accessory pathway (narrow QRS - bypass going down normal conduction pathways) - Retrograde *Antidromic AVRT (LESS COMMON):* Wide Complex tachycardia in which wave of depol travels down the accessory pathway and retrograde up the AV node (The wider the QRS the farther the conduction is from the std conduction pathways and it is slower) - Anterograde
What are the 6Ps for acute arterial occlusion?
*P*ain (acute onset) *P*allor *P*olar (cold) *P*aralysis *P*aresthesis *P*ulselessness (use doppler)
Compare PVD and Acute Arterial Occlusion:
*PVD* Clinical features: intermittent claudication, rest pain, decreased pulses, ischemic ulcers Dx: Arteriogram Tx: Intermittent claud - conservative, Rest pain - surgery *Acute Arterial Occlusion* Clinical Features: 6Ps Dx: arteriogram Tx: Anticoagulate, emergent surgery
What is the EKG findings for A. Flutter?
*Pathogneumonic* - "saw-tooth" flutter waves best seen in II/III/avF Rate will be 250-350
What are the characteristic EKG findings for a MI?
*Peaked T waves* - occur EARLY and may be missed *ST Elevation (STEMI)* - TRANSMURAL MI - diagnostic of an acute infarct *Q Waves* - evidence of NECROSIS (SPECIFIC) - usually seen LATE, not acutely *T wave inversion* - sensitive NOT specific *ST Depression (NSTEMI)* - SUBENDOCARDIAL injury
DSM-IV-TR criteria for the diagnosis of sexual aversion disorder (SAD)
*Persistent or recurrent extreme aversion to, and avoidance of, all (or almost all) genital sexual contact with a sexual partner *causes marked distress or interpersonal difficulty. *not better accounted for by another Axis I disorder (except another sexual dysfunction)
dx criteria male erectile disorder
*Persistent or recurrent inability to attain, or to maintain until completion of sexual activity, an adequate erection *causes distress *not due to another axis I, drug, or medical condition
dx criteria female sexual arousal disorder
*Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement *causes distress *not due to another axis I, drug, or medical condition classify by subtypes: acquired vs lifelong, general vs situational, psych factors vs combined factors.
dx criteria for hypochondriasis
*Preoccupation with fears or idea that one has a serious disease based on misinterpretation of bodily symptoms *persists despite appropriate medical evaluation and reassurance. *belief is not of delusional intensity (as in delusional disorder, somatic type) and not restricted to a circumscribed concern about appearance (as in body dysmorphic disorder) *causes clinically significant distress or impairment in social, occupational, or other important areas of functioning *at least 6 months *not better accounted for by generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, a major depressive episode, separation anxiety, or another somatoform disorder
What is the characteristic CXR finding for COA?
*RIB NOTCHING* Others: Cardiomegaly; normal pulm vasculature; dilatation
What are the symptoms of AS?
*SAD* - Syncope, Angina, DOE
Influenza - sx
*SUDDEN/ABRUPT onset of sx* - severe dry cough first 3 days - high fever up to 104 - severe myalgias - HA - chills - conjunctivitis
What is the *TOC* for all valvular heart diseases?
*Surgery* - because these are "structural deformities" that cannot be fixed w/ drugs.
What is the *DEFINITIVE TREATMENT* for constrictive pericarditis?
*Surgical*: Complete resection of the pericardium is definitive therapy and is indicated in many patients. It has a significant mortality rate, however.
Explain the management of V.Fib.
*THIS IS A MEDICAL EMERGENCY! IMMEDIATE DEFIBRILLATION AND CPR ARE INDICATED* Give EPI (1 mg IV initially and then every 3-5 min) (increase Myocardial/cerebral blood flow and decreases the defibrillation threshold) then attempt to defibrillate 30-60 seconds both first epi dose.
CAP - tx (otherwise healthy pt)
*TX AS OUTPT! -- oral abx (doxy, zithromax, levaquin)*
What is the *SOC* to evaluate both the location and size of the AAA?
*ULTRASOUND*
Bronchiectasis - tx
*abx 10-14 days* - amoxicillin - augmentin - bactrim - tetracyclines *bronchodilators for acute exacerbations* *surgery for pts w/ disabling sx -- little long-term outcome, though*
Pertussis - tx
*azithromycin x5 days for pt and household contacts* - isolation until 5 days complete
Hospital-acquired pneumonia - dx
*clinical* - supported w/ cx of sputum & CXR
Pertussis - dx
*clinical* ---> inspiratory whoop & post-tussive emesis
Bronchogenic carcinoma - tx of choice of small cell
*combination chemo*
Bronchogenic carcinoma - definitive dx
*cytologic examination of sputum!* - bronchoscopy, exam of pleural fluid, & bx can also be more invasive modes of establishing dx
DSM-IV-TR criteria for the diagnosis of hypoactive sexual desire disordert0--thl 56\77kj
*deficient (or absent) sexual fantasies or desire for sexual activity *disturbance causes marked distress or interpersonal difficulty *not better accounted for by another Axis I disorder (except another sexual dysfunction) and is not due exclusively to the direct physiological effect of a substance (e.g., a drug of abuse, a medication) or a general medical condition no specific duration or severity criteria
Bronchiectasis - CT findings
*dilated, tortuous airways*
Erythema Multiforme can be induced by
*drug (sulfonamides, phenytoin, barbiturates, penicillin, allopurinol) and infections (herpes simplex virus, Mycoplasma sp.), or be idiopathic (50% of cases).*
Acute bronchitis - tx of acute exacerbation of chronic bronchitis
*first line = 2nd gen cephalosporins* - ceflacor - cefotetan - cefuroxime - cefprozil *second line = macrolide or Bactrim*
treatment of paraphilias
*no good data exists for tx and patients usually avoid unless forced by law tx should always include both pharm therapy and psychotherapy, beginning with modalities of lowest side effects such as CBT and relapse prevention and later antidepressants, to tx with a higher risk of severe complications such as antiandrogens and other hormones. meds: buspirone, SSRIs, lithium psychodynamic therapy, CBT, marital therapy
Solitary pulmonary nodule - most of them are what?
*old granulomas* from: - old/active TB - fungal infection - foreign body reaction
Acute bronchiolitis - dx
*overwhelmingly clinical* - viral detection from nasal culture - PCR or antigen deletion if cohorting with RSV-positive pt - CXR to r/o pneumonia (will see hyperinflation of lungs & inc AP diameter)
What is neurogenic shock characterized by?
*peripheral vasodilation and decreased SVR* Neurogenic shock results from a failure of the sympathetic nervous system to maintain adequate vascular tone (sympathetic denervation) . Causes include spinal cord injury, severe head injury, spinal anesthesia, pharmaco- logic sympathetic blockade
Solitary pulmonary nodule - mgmt if high prob of malignancy
*resect ASAP* -- no bx
clinical findings sexual aversion disorder
*severe anxiety and/or disgust associated with any attempt to have genital contact with a sexual partner *r/o panic disorder & aversion due to dyspareunia *psychotherapy, SSRIs, MAOIs may be effective
Hospital-acquired pneumonia - organisms
*staph aureus* *pseudomonas MC in ICU*
Atypical pneumonia - tx
*start empiric abx based on clinical features*
Influenza - tx (healthy)
*supportive*
Acute bronchitis - tx (healthy adults)
*supportive* - hydration - expectorants - analgesics - B2- agonists - cough suppressants
Bronchogenic carcinoma - tx of choice of non-small cell
*surgery!*
Carcinoid lung tumors - tx
*surgical excision -- good prognosis* - resistant to chemo/radiation
How can you diagnose multifocal atrial tachycardia?
*three different P-wave morphologies are required to make an accurate diagnosis* Rate is 100-200 Can also be diagnosed w/ vagal maneuvars or adenosine to slow AV block **Note that a wandering pacemaker is similiar but the rate is <100**
What is the pathophys for cardiac tamponade?
*ventricular filling is impaired during diastole* - decreases SV and CO Characterized by the elevation and equalization of intracardiac and intrapericardial pressure
What is the classifcal CXR finding for aortic dissection?
*widended mediastium* (>8 mm on AP view)
Sjogren's Syndrome Labs:
+Anti-R0
Ankylosing Spondylitis progressive fusion of the vertebrae
+Back pain Sacroiliitis
Bicep Tendonitis PE
+Speed's test +Yergason's
Cubital Tunnel Syndrome PE
+tinel on cubital tunnel
Acute bronchiolitis - RF
- *90% 1-9 mo* - winter & early spring - crowded conditions - formula fed - moms who smoke - prematurity
Bronchogenic carcinoma - metastasis pattern of small cell
- *AGGRESSIVE! spreads early* - starts in central bronchi and goes to regional lymph nodes
Epiglottitis - cx
- *H. flu type B* - incidence is lowering due to HiB vaccine - *LIFE THREATENING*
Acute bronchiolitis - cx
- *RSV = 50%* - inflammatory obstruction due to edema of bronchioles & mucous secondary to viral infection
Croup - dx
- *Steeple sign on CXR*
Croup - tx (moderate)
- *administer dexamethasone and nebulized racemic epi* - observe sx (may need to admit if little to no change) - humidified air - fever reduction (tylenol or motrin) - oral fluids
Croup - tx (severe)
- *administer dexamethasone and nebulized racemic epinephrine* - admit - may need supplemental O2, Heliox, or intubation as respiratory failure becomes more severe - humidifier, antipyretics, fluids
Bronchiectasis - sx
- *chronic foul smelling purulent sputum* - chronic cough - recurrent PNA
Pertussis - Paroxysmal stage
- *cough w/ whoop* --> chin fwd, tongue out, watery/bulging eyes, purple face - *post-tussive emesis* - exhuastion
Croup - tx (mild)
- *dexamethasone* - cool humidified air - fever reduction (tylenol or motrin) - oral fluids
Epiglottitis - sx
- *drooling, hot potato voice, tripod position* - sore throat - high fever - no cough
Pertussis - admit to hospital if
- *infant <3 mo* - apnea - cyanosis - resp distress
Croup - sx (mild)
- *no stridor at rest* - barking cough - hoarse cry
Asthma - dx
- *peak expiratory flow rate/spirometry* - can also be clinical
Croup - sx (general)
- *seal-like barking that is worse at night & inspiratory stridor* - can progress to respiratory distress
*CAP - dx*
- *sputum culture* - *CXR shows infiltrates*
*Pneumonia w/ HIV - definitive dx*
- *sputum staining* - broncheolar lavage
CAP - organisms
- *strep pneumo* - h. flu - m. cat - staph aureus - klebsiella
Croup - sx (severe)
- *stridor at rest and severe retractions (even withdrawal of the sternum* - anxious/agitated or pale and fatigued
Croup - sx (moderate)
- *stridor at rest* - at least mild retractions - little to no agitation
Asthma - sx
- *wheezing* - cough, dyspnea, inc resp. effort, dec. breath sounds
Pseudomonas pneumonia - MC in who
- CF
Haemophilus pneumonia - MC in who
- COPD - post splenectomy
Solitary pulmonary nodule - what imaging is best? why?
- CT - delineates mass & detects adenopathy or presence of multiple nodules
Carcinoid lung tumors - what imaging localizes the dz?
- CT - octreotide scintography
Paraneoplastic syndromes associated w/ small cell lung CA
- Cushing's - SIADH - Peripheral neuropathy - Myesthenia - Cerebellar degeneration
Acute bronchitis - cx (chronic lung dz)
- H. flu - Strep pneumo - M. cat
Criteria for discharging inpatient w/ croup:
- No stridor at rest - Normal pulse oximetry - Good air exchange - Normal color - Normal level of consciousness - Demonstrated ability to tolerate fluids by mouth - Caregivers understand the indications for return to care and would be able to return if necessary
Bronchiectasis - cx from recurrent infection
- TB - fungal - lung abscess
Acute bronchiolitis - sx
- begins as mild URI - escalates to inc resp distress, cough, wheeze, dyspnea, apnea episodes
Classic asthma trilogy
- bronchospasm - mucous production - chronic inflammation & edema of airway mucosa
Carcinoid lung tumors - AKA
- carcinoid adenomas - bronchial gland tumors
Hospital-acquired pneumonia - tx
- cefepime - ticarcillin/clavulanic acid - piperacillin/tazobactam
Epiglottitis - dx
- cherry red epiglottis - *thumb sign on lateral x-ray*
Pertussis - Catarrhal stage
- congestion - rhinorrhea
Acute bronchitis - sx
- cough - dyspnea - fever - sore throat - expiratory wheezes/rhonchi
Acute bronchitis - when are abx indicated in tx?
- elderly - underlying cardiopulm dz - cough > 7-10 days - immunocompromised - acute exacerbation of COPD
Bronchiectasis - bronchoscopy warranted to...
- evaluate hemoptysis - remove secretions - r/o obstructing lesions
Things to avoid when treating pt w/ epiglottitis
- examining throat - using narcotics, sedatives, or antihistamines - attempting venipuncture - placing pt supine
Indications for ventilation in acute asthma tx
- failure of max pharmacological tx - hypoxemia/hypercarbia - change in mental status - resp. fatigue or failure
Bronchogenic carcinoma - sx
- hemoptysis - cough - pain - anorexia/weight loss
Carcinoid lung tumors - sx
- hemoptysis - focal wheezing - recurrent pneumonia
Influenza - prophylaxis after vaccine in what population? Why?
- high-rish - Need prophylaxis for 6 wks because takes 6 wks for antibodies to build up
Acute bronchiolitis - tx (severe)
- hospitalization (if lethargic, hypoxemic, poor feeding, toxic looking) for *observation & supportive treatment* - aerosol Ribavirin (if <6 wks) & RSV-IVIG
Solitary pulmonary nodule - mgmt if low prob of malignancy
- if low probability of malignancy, CT q 3 mo for one year and then if no growth q 6 months for next 2 yrs
Influenza - who to NOT give live attenuated nasal vaccine to
- immunocompromised - those w/ reactive airway dz (asthma)
Atypical pneumonia - sx
- low-grade fever - nonproductive cough - myalgia, fever
*PJP - what lab findings?*
- lymphopenia - low CD4 count
Epiglottitis - tx
- nasotracheal airway indicated in ALL pts generally for 2-3 days - ceftriaxone 7-10 days - rifampin prophylaxis for close contacts
CAP - indication for hospitalization
- neutropenia - involvement >1 lobe - poor host resistance - >50 y/o w/ comorbidities - AMS - hemodynamic instability
Carcinoid lung tumors - bronchoscopy findings
- pink or purple central lesion that is well-vascularized - can be pedunculated or sessile
Status asthmaticus - signs
- pulsus paradoxus (heartbeat auscultated but not palpated) - Hypotension, tachycardia, retractions - cyanosis - silent chest - 1-2 word dyspnea - lethargy, agitation
Indications for admission in acute asthma exacerbation
- requires intubation - status asthmaticus - return ED visit in 24 hrs - complete lobular atelectasis - pneumothorax/pneumomediastinum - underlying cardiopulmonary dz
*Solitary pulmonary nodule - CXR findings*
- round or oval - sharply demarcated - not more than 5 cm - surrounded by nl lung tissue
Bronchogenic carcinoma - other tests
- sputum cytology - CXR/CT with abnormalities - PET scans
Criteria for admitting a pt with croup:
- stridor at rest/impending resp. failure - hypoxemia - cyanosis - pallor - decreased sensation - high fever - moderate croup not improved after dexamethasone and racemic epi treatment
Acute bronchiolitis - tx (non high risk)
- supportive tx as needed (fluids) - humidified O2 or other O2 therapy - trial of nebulized albuterol (d/c if doesn't work) - can d/c home if non-severe
Bronchiectasis - CXR hallmarks
- tram tracks - honeycombing - atelectasis
*Solitary pulmonary nodule - mgmt if intermediate prob of malignancy*
- transthoracic needle bx or bronchoscopy if lesion peripheral
**Tuberculosis here**
--
**metastatic tumors here**
--
Atopic dermatitis Treatment
-Avoid triggers -Moisturizing/non-allergen soap (eg; dove white) -Moisturizers, eg: petrolatum, Aquaphor ointment (not lotion) -Corticosteroid cream on/off with lesions, if above is ineffective Eg: Triamcinolone 0.1% cream; Sig: apply to affected area bid, PRN for exacerbations.
Treatment for Stevens-Johnson Syndrome
-Causative agent should be withdrawn immediately. -Dressings and topical antibiotics should be used to cover cleansed wounds to prevent infection. *bacitracin topical* - IV fluids should be started
Stevens-Johnson Syndrome Cutaneous lesions
-Ill-defined, coalescing erythematous macules with purpuric centers, although many cases of SJS/TEN may present with diffuse erythema. -Lesions start on the face and thorax before spreading to other areas and are symmetrically distributed. The scalp is typically spared, and palms and soles are rarely involved
Acne vulgaris exacerbating factors:
-Mechanical trauma, cosmetics, topical corticosteroids, and oral medications (corticosteroids, lithium, iodides, some antiepileptics). Endocrine disorders resulting in hyperandrogenism may also predispose patients to developing acne. -Menstruation -Oral contraceptives
Subtypes of psoriasis have a typical presentation:
-Plaque psoriasis -Guttate psoriasis. -Pustular psoriasis -Erythroderma (erythrodermic psoriasis)
Who needs endocarditis prophy prior to dental procedures?
-Prosthetic heart valves -Hx of infective endocarditis -unrepaired congenital heart disease -repaired congenital heart disease, if it was repaired with prosthesis and it is <6mos after procedure
Erythema Multiforme treatment:
-Removal of trigger -Topical or systemic corticosteroids -Oral antivirals (acyclovir)
Pityriasis Rosea Clinical features
-The eruption begins with a "herald" or "mother" patch, a single round or oval, sharply delimited, *pink or salmon-colored lesion on the chest*, neck, or back. -A few days or one to two weeks later, oval lesions similar in appearance to the herald patch, but smaller, appear in crops on the trunk and proximal areas of the extremities
Stasis Dermatitis Treatment
-Topical corticosteroids -Wet dressings *Stasis dermatitis should be treated with wet compresses and hydrocortisone cream; chronic dermatitis may require addition of zinc oxide with ichthammol and an antifungal cream.*
Seborrheic Dermatitis treatment face:
-Topical corticosteroids and/or antifungals. -Topical corticosteroids are often used in adults for SD affecting the face and body areas.
Rosacea is divided into four main subtypes:
-erythematotelangiectatic -papulopustular -phymatous -ocular rosacea. Granulomatous rosacea may be a variant of rosacea
Psoriasis
-is a common chronic skin disorder most commonly characterized by *well-demarcated erythematous plaques with silver scale.* -Locations: elbows, knees, extensor limbs, scalp, and, less commonly, nails, ears, and umbilical region
Treatment moderate-to-severe plaque psoriasis:
-phototherapy *Phototherapy includes narrow-band UVB*, [30] or PUVA, although data are limited.
Clinical Presentation of Erythema Multiforme
-target lesions of the extremities [lesions with 3 zones (red rim, clearance zone, and central blister or erosion)] -mucosal erosions -targetoid lesions [Erythematous papules without the clearance zone (2 zones) are more common centripetally]
what percentage of males and females have a bipolar disorder?
1% both male and female
If a patient presents with a severe HA and markedly elevated BP, what steps should you take in management?
1) Lower BP w/ Antihytensive Agent 2) order a CT of the head to r/o intracranial bleeding (SAH) 3)if CT is negative, one may proceed to a lumbar puncture
What three patient profiles can be diagnosed with unstable angina (USA)?
1) Pts with chronic angina with increasing freq, duration, and intensity of CP 2) Pts with new-onset angina that is severe or worsening 3) Patients w/ *ANGINA AT REST*
What TLC can be suggested for a HTN pts?
1) Reduce Salt Intake - recommended is a no added salt diet or DASH diet (<4g Na+/day) or a low sodium diet (<2g Na+/day) 2) Wt loss and exercise 3) AVOID alcohol consumption 4) Stop unncessary meds that can lead to HTN 5) Follow a low saturated fat diet rich in fruits, veggies, and low fat dairy
when is Apgar score assessed?
1, 5,10 minutes
What is the MC type of kidney stone? 2nd? 3rd?
1- calcium oxylate stones 2- uric acid stones 3- struvite stones (infection)
What are the risk factors for HTN?
1. Age-Both systolic and diastolic BP increase with age. 2. Gender-*more common* in men (gap narrows over age 60); men have higher complication rates 3. Race-It is *twice as common* in African-American patients as in Caucasian patients; African-American patients have* higher complication rates* (stroke, renal failure, heart disease). 4. Obesity, sedentary lifestyle 5. Family history 6. Increased sodium intake-This correlates with increased prevalence in large populations, although not in individuals; individual susceptibility to the effects of high salt intake varies. 7. Alcohol-Intake of more than 2 oz (8 oz of wine or 24 oz of beer) per day is associated with HTN.
Pertussis - 3 stages
1. Catarrhal 2. Paroxysmal 3. Convalescent
Contact Dermatitis: is an allergic or irritant skin reaction caused by an external agent.
1. Irritant contact dermatitis is caused by direct toxicity and can occur in any person without prior sensitization. 2. Allergic contact dermatitis is a *delayed hypersensitivity* reaction, which requires prior sensitization.
What is the main goal and treatment obtions for acute arterial occlusion?
1. Main goal: assess viability of tissues to salavage the limb a. Skeletal muscle can tolerate 6 hours of ischemia; perfusion should be reestab- lished within this time frame. b. If paralysis or paresthesias are present, amputation is probably necessary. 2. Immediately anticoagulate with IV heparin. 3. Emergent surgical embolectomy is indicated via cutdown and Fogarty balloon. Bypass is reserved for embolectomy failure. 4. Treat any complications such as compartment syndrome that may occur.
What are the S&S for aortic dissection?
1. Severe, tearing/ripping/stabbing pain, either in the anterior or back of the chest a. Anterior chest pain is *more common* with proximal dissection (type A). b. Interscapular back pain is *more common* with distal dissection (type B). 2. Diaphoresis 3. Most are hypertensive, but some may be hypotensive 4. Pulse or BP asymmetry between limbs 5. Aortic regurgitation (especially proximal dissections) 6. Neurologic manifestations (hemiplegia, hemianesthesia) due to obstruction of carotid artery
Explain the process of "Shock"
1. Shock is severe cardiovascular failure caused by poor blood flow or inadequate distribution of flow. 2. Inadequate oxygen delivery to body tissues results in shock, which may lead to organ failure and death. 3. The physical responses to shock are mediated by catecholamines, renin, antidiuretic hormone, glucagon, cortisol, and growth hormone
What are the S&S of a non-rupture AAA?
1. Usually asymptomatic and discovered on either abdominal examination or a radio- logic study done for another reason 2. Sense of "fullness" 3. Pain may or may not be present-if present, located in the hypogastrium and lower back and usually throbbing in character 4.Pulsatile mass on abdominal examination 5.Symptoms suggesting expansion and impending rupture include the following: a. Sudden onset of severe pain in the back or lower abdomen, radiating to the groin, buttocks, or legs b. Grey Turner's sign (ecchymoses on back and flanks) and Cullen's sign (ecchymoses around umbilicus)
DSM IV classifications of the stages of physiologic arousal and sexual response
1. appetite 2. arousal - plateau 3. orgasm 4. resolution
Drug exposure — Bullous Pemphigoid and Pemphigus vulgaris and pemphigus foliaceus may be precipitated by drugs.
1. captopril (ACE inhibitor group) 2. Furosemide (diuretic) 3. Penicillamine (used in the treatment of RA and Wilson's disease)
Bronchiectasis - 3 types of cx
1. congenital 2. recurrent infection 3. obstruction
describe 6 stimulus control measures (sleep hygeine measures)
1. go to bed only when sleepy 2. no non-sleep things in bed 3. if not asleep in 20 minutes, leave the bedroom 4. if awake at night for 20 minutes, leave bedroom 5. consistent wake up time 6. avoid naps
Bronchogenic carcinoma - two major categories
1. small cell 2. non small cell
Bronchogenic carcinoma - three types of non-small cell
1. squamous cell 2. adenocarcinoma 3. large cell carcinoma
Pts with MS are usually asx until the MV area is reduced to approximately __________ cm2.
1.5 cm2 Normal = 4-5 cm2
sleep requirements for 5-10 years old
10-11 hours
BP < _____ + HR > _____ = Dehydration.
100, 100
sleep requirements for 3-5 years old
11-13 hours
sleep requirements for 1-3 years old
12-14 hours
sleep requirements for 0-2 months old
12-18 hours
sleep requirements for 3-11 months old
14-15 hours
Bronchogenic carcinoma - 5 yr survival rate
15%
scribbles?
18-21 mths
What is the 1st and 2nd diagnostic test in pts with dysphagia?
1st = barrium swallow 2nd = endoscopy
DeQuervain's Tenosynovisits occurs on the
1st dorsal complartment
pharm therapy for schizophrenia
1st generation antipsychotics 2nd generation antipsychotics
Rheumatoid Arthritis Tx
1st line: NSAIDs New 1st line: Methotrexate (monitor Liver), if hepatotoxicity is present give *Leucovorin*
findings in Lewy Body Dementia
2 out of 3 required for Dx: fluctuations, visual hallucinations, parkinsonism. suggestive features: REM sleep d/o, severe neuroleptic sensitivity, low dopamine transporter uptake in basal ganglia on PET or SPECT.
at what age does baby lift head and smile responsively
2-3 mths
what percentage of males and females have a depressive disorder
20-25% of all females 10-15% of all males
Bronchogenic carcinoma - small cell accounts for what % of cases?
20-35%
throws ball over head and builds towers
24 mths
Bronchogenic carcinoma - squamous cell carcinoma what % of cases
25-35%
How long should an individual undergo treatment for an isolated PE with no other risk factors?
3 months
when is maintenance pharmacologic treatment of depression indicated
3 or more episodes of major depression or more than 2 episodes with a family history, a severe episode, or recurrence within one year of discontinuing meds.
indications for lifetime maintenance on an antidepressant
3 or more episodes of major depression. 2 episodes of major depression with either family history, age < 20 at first episode, any severe or sudden depressive episode, or recurrence within one year of discontinuing meds.
how long does it take for antidepressants to kick in?
3-6 weeks
What is the *MOST COMMON* age to find a venous hum?
3-6 y.o
findings in dementia with parkinson's
30% of all PD patients develop dementia insidious onset +/- hallucinations, delusions. may be exacerbated by PD treatment. risk factors: age > 70, depression, confusion/psychosis, facial masking on presentation
normal respiratory rate at birth; age 8-15 yrs
30-60; 15-25
Bronchogenic carcinoma - 5 yr survival rate after surgery of non-small cell
35-40%
Bronchogenic carcinoma - adenocarcinoma what % of cases
35-40%
uses pronouns
36 mths
testes usually descend by?
3mth; refer to urologist if not descended by 1yr
grasping reflex disappears by?
4 MTHS
strabismus is normal in newborn until when?
4 mths
SLE diagnosis criterion
4 or more of the criteria must be present serially or simultaneously to be considered to have SLE Malar rash- fixed erythema, non-scarring, nose and cheeks Discoid rash- erythematous, raised patches, frequent scarring Photosensitivity- rash with sun exposure Oral ulcers- painless Arthritis- nonerosive but true synovitis Serositis- pleuritis, pericarditis Renal disorder- proteinuria and/or casts Neurologic disorder- seizures or psychosis Hematologic disorder- hemolytic anemia, leukopenia, lymphopenia, thrombocytopenia Immunologic disorder- anti-dsDNA ab, anti- Sm Ab Antinuclear antibody
Solitary pulmonary nodule -approx what % are malignant
40%
stages of physiological sexual response in female
45 minutes excitement - clit enlarges, uterus elevates, secretions, vaginal entrance opens, labia majora swell in multip & flatten in nullip. increased respiration and muscle tension. (min to hours) plateau - uterus elevates further, vagina expands but entrance closes, bartholin's glands secrete, labia minora redden, sex flush (30 to 180 seconds) orgasm - contractions ~0.8 sec with full sex flush resolution. 3 to 15 seconds. resolution - 10-15 minutes. detumescence in 5 minutes, complete in 30 min. (longer if no orgasm)
Cubital Tunnel Syndrome occurs on the
4th ad 5th digits
Boxer's Fracture
4th and 5th Metacarpal Fracture
normal AHI (apnea-hypoxia index)
5
Signs/Symptoms of Arterial Embolism
5 Ps: *Pain*: constant, worse with movement *Pallor*: followed by cyanosis *Pulselessness*: associated with cold limb *Paresthesias*: damage to peripheral nerves *Paralysis*: nerve damage
How much induration would be considered a + test in an HIV pt & those in close contact w/ HIV pts? _____ mm is + in high risk populations (healthcare workers, homeless, foreign born). How much induration for all others would be +?
5 mm--> HIV 10mm--> high-risk 15 mm--> all others
define major depressive episode
5 or more symptoms lasting more than two weeks sufficient to cause impairment: Must include dysphoria/sadness or anhedonia &: Sleep disturbance Guilt Energy decrease Concentration difficulty Appetite increase or decrease Psychomotor retardation or agitation Suicidal thoughts
mild AHI (apnea-hypoxia index)
5-15 treat only if patient has symptoms: daytime sleepiness, mood d/o, insomnia, impaired cognition, cardiovascular d/o, etc.
A low flow rate is when _____% of urea is reabsorbed into the blood.
50
benifits of 2nd generation/atypical antipsychotics
5HT and DA antagonsim more effective for negative symptoms. lower risk of extrapyramidal symptoms and tardive dyskinesia.
If a pt has a + PPD & a negative CXR what should be done?
6 months of Tx with Isoniazide (INH)
diagnostic criteria for ADHD
6 or more symptoms present from either the Attention or the Hyperactive/Impulsive catagories for at least 6 months. Symptoms present in at least 2 environments. inattentive: frequent careless errors, short attention span, does not seem to listen, trouble finishing tasks, disorganized, avoids/dislikes work that requires sustained mental effort, loses things, forgetful, easily distracted. hyperactive/impulsive: fidgets, leaves seat in class, runs about, difficulty playing quietly, always on the go, talks too much, blurts out answers before questions completed, trouble waiting their turn, interrupts or intrudes on others.
Bronchogenic carcinoma - mean survival after discovery of small cell
6-18 weeks
at what age does a baby rollover and reach for objects?
6-8mths
The serum creatinine may still be normal with < _____% kidney damage.
60
In regards to A. Fib and rate control, what is the target rate? Perferred Tx?
60-100 bpm CCB - Perferred Tx (Alt: BB)
epidemiology of alzheimer's dementia
60-80% of dementia cases in older patients onset usually near age 65
ADHD sx must manifest before what age
7
sleep requirements for an adult
7-9 hours
sleep requirements for 10-17 years old
8.5 - 9.25 hours
Podagra
95% of patients with gout will have great toe involvement at some point during the course of illness. This is called Podagra
Pertussis - most cases occur in what age
<1 yr
LDL goal
<100
Fibromyalgia Dx
<11 0r 18 tender points or non-fibromyalgia
TG goal
<150
total cholesterol goal
<200
What is the sodium restriction amount given to patients with CHF
<2g per day
Normal protein (urine)
<300mg/24hours
Carcinoid lung tumors - typical pt age
<60 yrs
LDL goals for diabetics
<70
when should you hospitalize a patient with anorexia?
<75% ideal body weight or continued wt loss despite treatment. HR < 40, BP < 90/60, orthostatic changes in HR or BP, temp < 97. glucose < 60, K < 3, or other lyte imbalance. dehydration, hepatic or renal dz, CV compromise. poorly controlled diabetes. failure to respond to outpatient therapy. any psych disorder that requires hospitalization.
What is normal GFR?
> 60
Solitary pulmonary nodule -when does it become known as a "mass"
>3 cm
HDL goals for men
>40
When does a abdominal aortic aneurysm warrant surgical repair?
>5.5cm or increase in >5mm in 6 months
HDL goal for women
>50
What is the numerical value for TGs that designates pharmacological intervention?
>500 mg/dl
What are the risk factors for AAA?
>65 Male Smoker
Influenza - difference between A, B, & C
A & B - epidemic C - sporadic
Compartment syndrome
A condition in which increased pressure within a fixed anatomic compartment results in compromised blood flow and subsequent nerve injury and tissue death is _______________________
What is the definition of orthostatic hypotension?
A drop of 20 mmHG systolic or drop of 10 mmHG diastolic w/in 3 min of standing (HR increases > 20 bpm or dizziness)
Explain the pathophys of constrictive pericarditis and note the defining difference btween constrictive pericarditis and cardiac tamponade.
A fibrotic, rigid pericardium restricts the diastolic filling of the heart. Ventricular filling is *unimpeded* during early diastole because intracardiac volume has not yet reached the limit defined by the stiff pericardium. When intracardiac volume reaches the limit set by the noncompliant peri- cardium, ventricular filling is halted abruptly. (In contrast, ventricular filling is *impeded throughout diastole* in cardiac tamponade.)
How often should people be screened for dyslipidemia?
A lipid profile should be performed every 5 years starting at 20 y/o
Actinic Keratosis is the precursor of:
A precursor of squamous cell carcinoma in situ.
Describe the murmur of MR?
A. *Holosystolic* murmur at the *apex*, which radiates to the back or clavicular area, depending on which leaflet is involved B. AFib is common finding C. Other findings: *S3* gallop; laterally displaced PMI; loud, palpable P2
What EKG finding is defined as "irregularly irregular"?
A. Fib (Atrial rate is > 400 and vent rate is 75-175) *MOST COMMON ARRYTHMIA*
What is "holiday heart syndrome"?
A. Fib caused by excessive alcohol intake
If pt presnts with the classic symptoms of shock + trauma, GI bleed, vomiting, or diarrhea, what type of shock is most likely? A. Hypovolemic B. Septic C. Neurogenic D. Cardiogenic
A. Hypovolemic
Name the NYHA described..."symptoms occur w/ *vigorous activities*, such as playing a sport, pts are nearly *asymptomatic*? A. I B. II C. III D. IV
A. I
Which of the following abnormalities is NOT presents in tetrology of fallot? A. LVH B. Pulmonary Stenosis C. VSD D. RVH
A. LVH Remember...*"PROV"* *P*ulmonary Stenosis *R*VH *O*veriding Aorta *V*SD
diagnosis of dementia (major neurocognitive disorder)
A. Memory impairment B. At least 1 other cognitive domain:: aphasia, apraxia, agnosia, disturbance in executive functioning C. Affects social or occupational daily function D. Does not occur exclusively during delerium.
If a pt comes in with a BP of 110/70, what is their classification of HTN? A. Normal B. PreHTN C. Stage 1 HTN D. Stage 2 HTN
A. Normal (<120/80) Requires NO treatment
Septic shock is associated w/ severe peripheral vaso_______. Whereas hypovolemic shock is associated w/ peripheral vaso_______. A. vasodilation, vasoconstriction B. vasoconstriction, vasodilation
A. Septic shock causes severe peripheral vasodilation (flushing, warm skin) whereas hypovolemic shock is assocaited w/ peripheral vasoconstriction (cool skin)
Define the following arrhythmia description: "Absence of conduction of atrial impulses to the ventricles; no correspondence between P waves and QRS complexes. A ventricular pacemaker (escape rhythm) maintains a ventricular rate of 25 to 40 bpm" A. Third Degree (Complete) Heart Block B. Mobitz type II C. Winkebach D. First defree AV block
A. Third Degree (complete) heart block -Characterized by *AV DISSOCIATION* -Pacemaker impletation is necessary
diagnostic criteria for delerium
A. disturbance in attention and awareness B. Develops over short period of time. fluctuating severity during the course of the day. C. Disturbances in cognition. D. Not better explained by another pre-existing condition or coma. E. Evidence that disturbance is a direct consequence of a medical condition.
diagnostic criteria for binge eating disorder
A. recurrent episodes of binge eating (larger amount than reasonable in a discrete period of time and a sense of lack of control) B. binge episodes associated w/ 3 or more of the following: 1. eating more rapidly than normal 2. eating until uncomfortably full 3. eating a large amt of food when not physically hungry 4. eating alone out of embarrassment 5. feeling disgusted or guilty afterword C. marked distress regarding binge eating D: binge eating occurs at least 1 x months for 3 months. E. not associated with recurrent compensatory behaviors or in the course of AN or BN.
diagnostic criteria for bulemia nervosa
A. recurrent episodes of binge eating (larger amt of food than reasonable and a sense of loss of control over eating) B. recurrent inappropriate compensatory behavior to prevent wt gain (vomiting, laxatives, fasting exercise, etc.) C. binge eating and compensatory both behavior occur on average at least 1 x week for 3 months. D. self-evaluation is unduely influenced by body shape and weight. E. does not occur during an episode of AN.
Diagnostic criteria for anorexia nervosa
A. restriction of energy intake relative to requirements leading to low body weight. B. Intense fear of gaining wt or becoming fat. C. Disturbance in one's shape or body experience, undue influence of body weight or shape on self-evaluation.
What management should you take in a pt w/ hypovolemic shock?
ABCs Hemorrage --> direct pressure, IVF, PRBCs Nonhemorrhagic --> IVF (LR/NS)
What is the tx for cardiogenic shock?
ABCs Tx underlying cause Vasopressors - *DOPAMINE = TOC* -dobutamine w/ dopamine for futher increased in CO -NE/Phenyephrine for severe/resistance cases NTG is not generally indicated b/c of the hypotension (but give MOA) *IVF ARE LIKELY TO BE HARMFUL IF LV PRESSURE ARE ELEVATED*
Cross over test
AC joint spearation
Which 2 meds may cause pre-renal failure?
ACE-inhibitors NSAIDS
dx of primary vs secondary adrenal insufficiency
ACTH stimulation test monitor cortisol levels to distinguish 2ndary will cause increase in cortisol--> its pituitary related, not adrenal gland related
severe OSA
AHI > 30
moderate OSA
AHI of 15-30 treat regardless of whether patient has symptoms.
What is the management for HCM patients?
ALL patients *AVOID* strenuous exercise *FIRST LINE TX* = BB (2nd line = CCB) Diuretics if fluids retention Pacemaker Thromboembolism/endocarditis prophylaxis Surgery - Myomectomy has high success rate for relieving sx - excision of part of the myocardial septum (reserved for severe disease) AVOID Dig, B-Agonist, Nitrates
Auer rods
AML
Tests for SLE
ANA(antinuclear antibody) 95-98% of SLE Anti-dsDNA 70% of SLE Many other tests can be done but none are highly specific
Pt presents with a diastolic decresendo murmur best heard at the left sternal borders with a widened pulse pressure and a displaced PMI (down&left). What type of murmur is this?
AR
What are the diastolic murmurs?
AR, MS
What are the systolic murmurs?
AS, MR, VSD
Aortic stenosis presents with __________ pulse pressure. Aortic regurgitation presents with __________ pulse pressure.
AS--> narrow AR--> wide
What is the therapy for a pt post-MI?
ASA BB Clopidegril Statin
What cardiac abnormaliities that are associated w/ Eisenmengers?
ASD, VSD, TA, TOGA
What phenomenon is described as follows... ABERRANT VENTRICULAR CONDUCTION DUE TO A CHANGE IN QRS CYCLE LENGTH. Describes a particular type of wide complex tachycardia that is often seen in atrial fibrillation. It is more often misinterpreted as a premature ventricular complex.
ASHMAN'S PHENOMENON
What are the EKG findinds for HCM?
Abnml Q waves in inferior and apical leads, may have evidence of LVH
What are the clinical features of V. Fib?
Absent BP, Pulse, Heart Sounds No QRS complex IDed Untx --> Leads to "sudden cardiac death"
Explain WPW and the Tx?
Accessory pathways between the atrium and ventricle may occasionally be seen *MOST COMMON* is 'bundle of Kent' seen in Wolff-Parkinson-White syndrome *SHORTENED PR INTERVAL AND A "DELTA WAVE"* caused by early excitation of the ventricle via the accessory pathway. TX: Radiofreqency catheter abalation
When do people usually have Acne vulgaris?
Acne vulgaris classically begins as puberty commences, but the clinical course is highly variable. Women may note a fluctuating course centered on their menstrual cycle
What is Acne vulgaris?
Acne vulgaris is a skin disease affecting the pilosebaceous unit. It is characterized by comedones, papules, pustules, nodules, cysts, and/or scarring, primarily on the face and trunk
What are some of the causes of secondary HTN?
Acromegaly Inaccuracy Pheochromocytoma Cushing's Coarctation of the aorta Hyperaldosteronism
Which form of endocarditis is associated w/ a "normal heart valve"? A. Acute B. Subacute
Acute If untx, fatal in less than 6 weeks
What is the *MOST COMMON CAUSE* of a MI?
Acute Coronary Thrombosis Remember time is muscle w/ an MI o 20-40 min: irreversible cell damage o 3-6 hours: necrosis
Pustular psoriasis
Acute generalized pustular psoriasis (von Zumbusch): rare, severe, urgent. Palmoplantar pustulosis: chronic involvement of hands and feet.
Gout Treatment
Acute inflammation- NSAIDS (indomethacin), colchicine, corticosteroids, ACTH Uric acid lowering agents- allopurinol, probenecid, febuxostat, pegloticase ** Patients with more than 2-3 episodes a year or those who initially present with tophi or stones need life long treatment with uric acid lowering agents
What are 5 causes of an elevated troponin?
Acute intact Severe PE Heart failure Myocaditis Renal insufficiency
Gout Facts
Acute, EPISODIC, inflammatory arthritis M>F Uric acid crystals identified in joint fluid
What are the causes of ACUTE and CHRONIC MR?
Acute: (Higher Mortality) (1) Endocarditis (*MC* = Staph Aureus) (2) Papillary mm rupture (via MI) or dysfunction (form ischemia) Chronic: (1) Rheumatic Fever (2) Marfan Syndrome (3) CM
What are the S&S for AS in children?
Acyanotic, SEM thrill loudest at RUSB, Narrow pulse pressure *MCC* is Rheumatic fever, Congenital bicuspid valve
What is the initial LT treatment for moderate-severe CHF (III/IV)
Add Dig to loop and ACEi Can add Dig at anytime for *systolic dysfunction*
The medical significance of Barrett's esophagus is its strong association with esophageal ___________.
Adenocarcinoma
What management should be taken with USA?
Admit w/ IV access and O2 Medical Management: *"HANG"* Heparin (LMWH) Aspirin NTG - FIRST LINE THERAPY Glycoprotein IIb/IIa + BB - FIRST LINE THERAPY + Cardiac Cath
The childhood phase: Lasts from 2 years of age until puberty
Affected areas are typically less vesicular, with papules and plaques becoming more lichenified due to constant scratching Children typically have involvement of the flexural skin, with predominance in the antecubital and popliteal fossa, wrists, hands, ankles, and feet. image When facial involvement is present, it is typically confined to perioral and periorbital skin.
Affected skin is xerotic (dry) and pruritic. Symptoms start by 6 months of age in 45% of patients, and before the age of 5 in 85%. Patients may have a history of other atopic conditions such as:
Allergic rhinitis or asthma.
PMR epidemiology
Almost exclusively in caucasians >50 years old F:M 2:1 relatively common
What class of medications are indicated for patients with both HTN and BPH?
Alpha Blockers
CHF has which characteristics of CXR?
Alveolar edema (bat wings), kerley B lines (interstitial edema), cardiomegaly, cephalization (dilated prominent upper lobe vessels), pleural effusion
PMR and Giant Cell Arteritis
Always consider GCA in patients with PMR 5-15% of patients with PMR will also have GCA 50% of patients with GCA will have symptoms of PMR Look for: new and different headaches, scalp tenderness, jaw claudication, visual loss, diplopia, evidence of noncranial ischemia
Amyloid plaques & neurofibrillary tangles
Alzheimer's disease
Lyme disease Tx pregnant
Amoxicillin
What prophylaxis should you use for endocarditis in patients w/ *known valvular heart disease or prosthetic valves* who are about to undergo *oral surgery or GI/GU* procedures?
Amoxicillin
What are 8 common causes of chronic renal failure (CRF)?
Analgesic nephropathy (get serum ASA levels) Polycystic disease Interstitial nephritis Diabetes HTN Renal artery stenosis Kidney stones BPH
Drug classes for tx of RA
Analgesics for pain- topicals, acetaminophen, opioids NSAIDS for inflammation Glucocorticoids for inflammation- prednisone DMARDs to prevent erosions from occuring- Methotrexate and biologicals ( drugs in the form of protein created from live cells) **MTX is the mainstay of treatment
What are some of the causes of High Output Heart Failure?
Anemia, thyrotoxicosis, thiamine deficiency
What are the treatments for anemia, hypocalcemia, and hyperphosphatemia in the chronic renal failure pt?
Anemia--> EPO injections Hypocalcemia--> Ca & Vit D Hyperphophatemia--> Dialysis
staging for Hodgkin's disease
Ann Arbor criteria
What MI location is the MOST COMMON?
Anterior - LAD
If a pt is post MI w/ a second or third degree heart block, what is the appropriate treatment measures if it is an anterior MI? Inferior MI?
Anterior MI: pacemaker (temp then permanent) - worse prognosis Inferior MI: atropine IV, if not controlled then temporary pacement (better prognosis)
ACL
Anterior drawer test, Lachman test
Name the leads and corresponding artery for which ST-Elevation/Depression can be seen for the following infarctions: Anterior MI? Lateral MI? Inferior MI? Posterior MI?
Anterior: V1-V4 - LAD Lateral: I, avL, V5, V6 - Circumflex Inferior: II, III, avF - RCA Posterior Large R wave in V1/V2 - RCA
Polymyositis and Dermatomyositis Lab:
Anti-Jo-1
Scleroderma Labs:
Anti-centromere, Anti-Scl-70
What drugs are C/I to use with statins?
Antifungal (-azoles) and Abs (Erythromycin, Clarithromycin)...results in myosite and rhabdomyositis
In the CHD "transposition of the great arteries", what arteries are switched?
Aorta and Pulmonary Artery are switched
What does a bifid uvula suggest?
Aortic Aneurysm and Loeys-Dietz syndrome (is a newly recognised disorder of connective tissue which shares overlapping features with Marfan syndrome (MFS) and the vascular type of Ehlers-Danlos syndrome, including aortic root dilatation and skin abnormalities)
What is the *GOLD STD* for determining the extent of dissection for surgery?
Aortic Angiography
What is the common causes for AR?
Aortic Leaflet Abnormality: • *MC: Infective Endocarditis* • Bicuspid Aorta • Rheumatic heart Disease • Anorexigenic drugs Aortic Route Abnormality: • Marfaran Syn • HTN • Aortic Dissection • Syphillis • Ankylosing spondylitis • Psoratic arthritis • Lyme disease
Pt presents to the clinic with a *harsh cresendo-descendo systolic murmur* heard at the 2nd ICS RUSB that *radiates to the carotids*. What murmur is being described?
Aortic Stenosis
__________ has shearing pain often radiating to the back.
Aortic dissection
A high-pitched diastolic blowing murmur best heard at the 2nd ICS and is louder when leaning forward is ___________.
Aortic regurg
Syphilis can cause which type of heart murmur?
Aortic regurg
A mid-systolic ejection murmur best heard at the 2nd ICS with radiation to the carotid is __________.
Aortic stenosis
Valve replacement is required with __________.
Aortic stenosis
A murmur in an elderly pt with syncope, angina, and dyspnea is most likely to be ___________.
Aortic stenosis (SAD)
What is the *TOC* for AS?
Aortic valve replacemnt is the *TOC* - it is indicated in symptomatic patients
What artery is involved in peripheral arterial disease if a patient is complaining of claudication in butt and hip, and also complains of erectile dysfunction?
Aortoilliac Artery
Meniscus Injury
Apley's Knee Test
Rotator cuff Tear
Apley's Scratch test Drop arm Job's test (pain with extension of the arm and supination)
What is the *GOLD STD* for diagnosing and locating PVD?
Arteriography (contrast in vessels and RAD) - ONLY needed however, if surgery (revascularization) is being considered
Lyme disease 3º
Arthritis and encephalitis
__________ results in pleural plaques.
Asbestosis
whirlpool/intraluminal worms on KUB
Ascariasis
Cardiomegaly + straight moguls + prominent aortic knob + widened mediastinum = __________.
Ascending aortic aneurism
Charcho's triad (fever/chills, RUQ pain, jaundice)
Ascending cholangitis
After acute event, what tx are used for USA?
Aspirin, BB, nitrates
What are the 8 contraindications of beta-blocker therapy?
Asthma Heart block COPD DM Electrolyte imbalance Pregnancy Pheochromocytoma Cocaine user
What are the sx of MS?
Asx until MV reaches <1.5cm2 then the sx include DOE, orthopnea, PND, palpitations, CP, hemoptysis, Thromboembolism, if RVF occurs then ascities and edema may develop.
When diagnosing HTN in a patient, how many in office BP readings are required?
At least *2 readings over a span of 4+ weeks* The only exception is if the pt has severe HTN or the evidence of end-organ damage - then you diagnosis it on 1 BP reading
What is the MC cause of fever after surgery? What other population is prone to getting the same condition?
Atelectasis Newborns
Atopic Dermatitis
Atopic dermatitis is a chronic inflammatory skin condition that appears to involve a genetic defect in the proteins supporting the epidermal barrier.
What tachydysrhthmia is Sick Sinus Syndrome associated with?
Atrial Flutter
What is the *MOST COMMON* primary cardiac neoplasm?
Atrial Myxoma - benign gelatinous growth, usually pedunculated and usually arising from the interatrial septum of the heart in the region of the fossa ovalis. Most are sporaticaly inherited.
Fighet Bite (dog bite)
Augmentin
Sjogren's Syndrome
Autoimmune disorder with lymphocytic infiltration of exocrine glands
HCM is what type of genetic disorder?
Autosomal Dominant
Where 4 locations might breast CA spread to?
Axillary & supraclavicular nodes Spine Ribs Lungs
Shoulder Dislocation nerve risk
Axillary Nerve Injury (Brachial plexus Injury)
An elevation of serum creatinine & urea = __________.
Azotemia
Influenza - what type MC in schools and military camps
B
cooley anemia
B thalassemia major
How long before a BP reading does a pt need to stop smoking or using caffine? A. 15 min B. 30 min C. 1 hour D. 90 min
B. 30 min • Make sure the patient has not ingested caffeine or smoked cigarettes in the past 30 minutes (both elevate BP temporarily).
Name the NYHA described..."symptoms occur w/ *prolonged or moderate exertion*, such as climbing a flight of stairs or carrying heavy packages. *Slight limitation* in activity"? A. I B. II C. III D. IV
B. II
Define the following arrhythmia description: "P wave fails to conduct suddenly, without a preceding PR interval prolongation therefore, the QRS drops suddenly". A. Sinus brady B. Mobitz type II C. Winkebach D. First defree AV block
B. Mobitz Type II (second degree heart block) Often progress to complete heart block Site of block is within the *His-Purkinje System* Tx: Pacemaker implementation is generally indicated
It a pt comes in with a BP of 130/88, what is their classification of HTN? A. Normal B. PreHTN C. HTN Stage 1 D. HTN Stage 2
B. PreHTN (SBP: 120-139, DBP: 80-89) Tx: Lifestyle modification
What is the most likely murmur, based upon he sx listed below: Systolic Minor turbulence of right ventricular outflow and pulmonary artery Grade 1-3/6 in intensity Blowing in quality Loudest: LUSB Medium pitch Decreased with inspiration, sitting up, standing up A. Still's Murmur B. Pulmonary ejection murmur C. Pulmonary flow murmur D. Venous hum E. Carotid Bruit
B. Pulmonary Ejection murmur
If pt presents with the classic symptoms of shock + fever, possible site of infxn, what type of shock is most likely? A. Hypovolemic B. Septic C. Neurogenic D. Cardiogenic
B. Septic
What type of CAD is being described: CP that lasts < 10/15 min that is described as heaviness/pressure that is brought on by exertion, and relieved by rest or NTG? A. Unstable Angina B. Stable Angina C. Prinzmetal's Angina
B. Stable Angina
Which form of endocarditis is associated w/ a "damaged heart valve"? A. Acute B. Subacute
B. Subacute
The veins in the leg consits of superficial, deep, and perforating veins. The perforating veins connet the superficial and deep systems. Valves from from ____ to _____, and *not* visa versa. A. Deep, Superficial B. Superficial, Deep
B. Superficial to deep ALWAYS never the oppositie
Why might hemoptysis occur in mitral stenosis?
B/c the recurrent laryngeal nerve is impinged by the atrium
What dyslipidemia medications are indicated in children, pregnant, and breastfeeding pts?
BAS
how is the severity of anorexia determined
BMI. mild is > 17. moderate = 16-16.99. severe = 15. Extreme < 15
What is the definition for HTN emergency?
BP: >220/120, in addition to end-organ damage-immediate treatment is indicated
What is the characteristic findings on CXR for constrictive pericarditis?
BQ - CXR shows *calcification ring* ECHO can also show pericardial thickening - CT/MRI ae more accurate in diagnosis pericardial thickening
What is/are the DRUG OF CHOICE for prostatitis?
Bacertim or Cipro for 21 days
PJP - tx of choice?
Bactrim
What is the treatment for TOGA?
Balloon atrial septostomy, if inadequate shunting (emergency)
__________ is the Tx for mitral stenosis but not for aortic stenosis.
Balloon valvuloplasty
dislocate hip via posterior pressure ( adduct fully flexed hips; replace dislocated hip by abducting hips
Barlow/ Ortolani
What is the 1st line Tx for enuresis?
Behavioral Tx then Desmopressin (DDAVP)
etiology of Body dysmorphic disorder
Believed that BDD is a part of obsessive-compulsive spectrum of disorders but it is also closely related to social anxiety disorder and major depression. Cultural values that emphasize personal appearance may also contribute to the development of BDD
Are atrial myxoma malignant or benign?
Benign - however they can embolize, leading to metastic disease or cause relative valvular dysfunction
Ganglion Cyst
Benign, Firm, Fluid-filled lump
What HTN treatment is indicated for post-myocardial infarction?
Beta blocker, ACE-I
Bullous Pemphigoid Diagnosis
Biopsy and * direct immunofluorescence* will confirm the diagnosis.
Osteoporosis Tx
Biphosphonate, Weight bearing, supplement
What is the *MOST COMMON CAUSE* of secondary HTN in young women?
Birth Control Pills
What is the *MOST COMMON* age for a pulmonary flow murmur?
Birth to infancy: disappears early in infancy (3-6 mo) Common in pre-term neonate
How is a pneumothorax seen on CXR?
Black (full of air)
What is the treatment for tetrology of fallot?
Blalock-Taussig procedure
What is the tx for tricupsid atresia?
Blalock-Taussig shunt or Prostaglandin
Bullous Pemphigoid are commonly found in?
Blisters typically are found on the flexor surfaces of the arms and legs, axillae, groin, and abdomen.
Pertussis - organism
Bordatella pertussis
what are the personality disorder types under catagory B: Wild
Borderline Narcisistic Hystreonic Antisocial
Lyme Disease is causes by
Borrelia Burgdorferi Tick bite
OA in PIP
Bouchards
Humerous Fracture complication
Brachial artery compartment syndrome Look for fat and sail sign
Bronchogenic carcinoma - low grade type of adenocarcinoma
Bronchoalveolar cell carcinoma *slowest growing*
gray or pale yellow spots at periphery of iris which maybe associated with Down Syndrome
Brushfield's spots
Osteoarthritis common joints
C-spine L/S spine hands- most common sites PIP, DIP, and *base of thumb (CMC)* hips knees MTP #1 (base of big toes)
Femoral and popliteal PVD causes _____ claudication? A. buttox B. Thigh C. Calf D. Hip
C. Calf Claudication
If a pt comes in with a BP of 145/93, what is their classification of HTN? A. Normal B. PreHTN C. HTN Stage 1 D. HTN Stage 2
C. HTN Stage 1 (SBP: 140-159; DBP: 90-99) Tx: Lifestyle Modification + Drug therapy
Name the NYHA described...."symptoms occurs w/ *usual activities of daily living*, such as walking across the room or getting dressed. *Marketedly Limited*"? A. I B. II C. III D. IV
C. III
What is CAD risk primarily due to: A. VLDL B. HDL C. LDL D. Total Cholesterol
C. LDL (esp levels >160) Calculate LDL: Total Chol - HDL - TG/5
Define the following arrhythmia description: "progressive prolongation of the PR interval until a P-wave fails to conduct" A. Sinus brady B. Mobitz type II C. Winkebach D. First defree AV block
C. Mobitz I - Winkebach (second degree heart block) -Site of block usually @ AV node -Benign condition that does not require tx
If pt presents with the classic sx of shock + SC injury or neurologic deficits, what type of shock is most likely? A. Hypovolemic B. Septic C. Neurogenic D. Cardiogenic
C. Neurogenic
What form of angina is characterized by *"transient coronary vasospasm"*, the episodes occur at rest, and ass w/ ventricular dysfunction? A. Stable Angina B. Unstable Angina C. Prinzmetal's Angina
C. Prinzmetal's Angina
Flagellated, curved oxidase+, gram neg rods
C. jejuni
resist abduction of the arm, flexion of the biceps brachii
C5 myotome
Biceps reflex
C5-C6
Brachioradialis reflex
C5-C6
break the OK sign, resist wrist extension
C6 myotome
resist digit extension, forearm extension
C7 myotome
Triceps reflex:
C7-C8
break an interlocking grip of the fingers
C8 myotome
What is the TOC is severe CAD?
CABG
What procedures can be used with "reversible" ischemia?
CABG and PTCA
What is the *MOST COMMON CAUSE* of V. Tach?
CAD w/ Prior MI = MCC OTher: active ichemia, hypotsn, CM, CHD, prolonged QT syndrome, drug toxicity
diagnostic tool for delerium
CAM: Confusion Assessment Method States that pt must have #1 and 2 and either 3 or 4: 1. Acute onset and fluctuating course 2. Inattention 3. Disorganized thinking 4. Altered level of consciousness
What is the *GOLD STANDARD* for MI diagnosis?
CARDIAC ENZYMES (<-- Per Stepup to Medicine) ANGIOGRAPHY (<-- Per Ovalle)
management of arousal disorders (female arousal d/o and male erectile d/o)
CBT for performance anxiety phosphodiesterase inhibitors urethral prostoglandins implants or suction
Bronchiectasis - congenital cx
CF
Bronchiectasis - what causes 1/2 of all cases?
CF
What is the MCC of heart failure due to fluid overload in infants and toddlers?
CHD such as PDA and VSD.
Kerley B lines
CHF
What are 2 causes of TRANSUDATIVE pleural effusions?
CHF Cirrhosis
__________ is elevated by electrical cardioversion or cardiac surgery, NOT by skeletal muscle.
CK-MB
What cardiac enzyme increases w/in 4-8 hour - peaks at 24 hours - and returns to nl at 48-72 hours?
CK-MB (best when measured 24-36 hours) Measure @ admission - every 8 hours for first 24 hours
Smudge cells
CLL
clonal malignancy of B lymphocytes
CLL (chronic lymphocytic leukemia)
Philadelphia chromosome
CML
A pt with N/V, headache, cherry face, confusion, and fatigue along with other family members with similar symptoms = __________.
CO poisoning
What is the MCC of multifocal atrial tachycardia?
COPD
What are 4 causes of secondary pulmonary HTN ?
COPD Cystic fibrosis Hypoxemia Obstructive sleep apnea (OSA)
What is the *MOST COMMON CAUSE* of A. Flutter?
COPD = MCC Other: rheumatic heart disease, CAD, CHF, ASD
What is the *DEFINITVE TEST* for prinzmetal's angina?
CORONARY ANGIOGRAPHY - displays coronary vasopasm when the pt is given "IV ERGONOVINE"
What are the indications for stents and thrombolytics?
CP 30-6 hours: ST elevation of 1mm or greater in 2 leads in STEMI --> use thrombolytics o CP < 30 min → STENT in STEMI/NSTEMI o CP > 6 hours - risk to benefit ratio in STEMI NEVER USE USE THROMBOLYTICS IN NSTEMI*** TPA - most expensive and most effective Streptokinase: least expensive an less effective
treatment of OSA
CPAP (continuous positive airway pressure) or BiPAP (biphasic). alternatives: trecheostomy, maxillomandibular advance, weight reduction, uvula...plasty (UPPP), oral appliance, or positional therapy.
What is the diagnostic TEST OF CHOICE for a pt with suspected nephrolithiasis?
CT
What test is 100% sensitive in dectecting AAA, but should only be used in hemodynamically stable pt?
CT (you *cannot* use plain radiography to r/o AAA)
What are the characteristic CXR findings for pericardial effusion?
CXR shows enlargement of cardiac silhouette when *>250 mL* of fluid has accumulated Cardiac silhouette may be have prototypical *"water bottle"* appearance. An enlarged heart w/o pulmonary vascular congestion suggests pericardial effusion
What are the CXR and EKG findings for hypoplastic left heart syndrome?
CXR: Enlarged heart with increased PVM and PV congestion ECG: RVH
What diagnostic tests can you order for AR?
CXR: LVH, dilated aorta ECG: LVH Echocardiogram-perform serially in chronic, stable patients to assess need for surgery to Assess LV size and function and Look for dilated aortic root and reversal of blood flow in aorta. Also in acute aortic regurgitation, look for early closure of mitral valve. Cardiac catheterization: to assesses severity of aortic regurgitation and degree of LV dysfunction
What are the CXR, EKG, and ECHO for AS?
CXR: calcific aortic valve, enlarged LV/LA (late) ECG: LVH, LA abnormality Echocardiogram-diagnostic in most cases. Findings include LVH; thickened, immobile aortic valve; and dilated aortic root
What findings can be seen for MR on CXR and ECHO?
CXR: dilated LV, pulmonary edema Echocardiogram: MR; dilated LA and LV; decreased LV function
What findings are seen on CXR and EKG for ASD?
CXR: large pulmonary arteries; increased pulmonary markings (vascularity) ECG: right bundle branch block and right axis deviation; atrial abnormalities can also be seen (e.g., fibrillation, flutter)
What diagnostic tests can be ordered and what are the results in MS?
CXR: left atrial enlargement (early) Echocardiogram-*most important test* in confirming diagnosis a. Left atrial enlargement b. Thick, calcified mitral valve c. Narrow, "fish-mouth"-shaped orifice d. Signs of RVF if advanced disease
What is the Tx (3 things) of severe hyperkalemia?
Ca gluconate Insulin Glucose
Ankylosing Spondylitis Finding
Calcification of the anterior and lateral
Scleroderma CREST
Calcinosis Cutis (deposition of calium in substance tissue) Raynaud's Phenomenon Esophageal Dysmotility Sclerodactyly Telangiectasis
Reactive Arthiritis organism involved
Campylobacter
Defined Cardiac Arrest and Sudden Cardiac Death.
Cardiac Arrest: sudden loss of CO; potentially reversible if circulation and O2 delivery are promptly restored Sudden Cardiac Death: unexpected death w/in 1 hour of sx onset secondary to a cardiac cause
What is the definitive diagnostic test for AS?
Cardiac Cath Can measure valve gradient and calculate valve area-< 0.8 cm2 indicates severe stenosis; normal aortic valve is 3 to 4 cm2 c. Useful in symptomatic patients before surgery
What diagnostic procedure is required for constrictive pericarditis?
Cardiac Cath - elevated and equal diastolic pressure in all chambers - ventricular pressure tracing shows a rapid "y" descent, which has been described as a dip, plateau, or a "square root sign"
NSTEM tends to be smaller than a STEMI and presents similar to USA, how can you differentiate the two?
Cardiac Enzymes
What are the complications of infective endocarditis?
Cardiac Failure Myocardial Abscess Various solid organ damage from showed emboli Glomerulonephritis
What complications account for the majority of deaths in hypertensive patients?
Cardiac complications - CAD, CHF w/ LVH, stroke, renal failure, PVD, and Aortic Dissection MOST deaths due to HTN are ultimately due to *MI/CHF*
Describe the changes in CO, SVR, and PCWP in patients with... (1) Cardiogenic shock (2) Hypovolemic Shock (3) Neurogenic Shock (4) Septic Shock
Cardiogenic: CO: decreased SVR: increased PCWP: *increased* <-- NOTE! Hypovolemic: CO: decreased SVR: increased PCWP: decreased Neurogenic: CO: decreased SVR: decreased PCWR: decreased Septic CO: *increased* <-- NOTE! SVR: decreased <-- Severely decreased PCWR: decreased
What are the CXR findings for CHF?
Cardiomegaly *KERLY B LINES* Prominent interstitial markings Pleural Effusion
What is seen on CXR in a pt with pulmonary edema?
Cardiomegaly Bat wing sign Enlarged pulmonary arteries B/L pleural effusion Fluid in fissures Cephalization Kerley B lines
What are the contents of the adrenal medulla?
Catecholamines (epi/norepi)
The coronary cath looks at what? Coronary angiography looks at what?
Cath --> determining a cardiac diagnosis Angiography --> presence and severity of CAD; looks at delineating coronary anatomy
What affect does ADH have on BP?
Causes water retention--> Elevated BP
DDX for somatoform disorders
Caution: Missed Diagnoses (5%) Disorders with vague/multi-system presentations: Lupus, MS, Lyme disease, Acute Intermittent Porphyria
What is it called when the pituitary gland does NOT release ADH?
Central Diabetes insipidus (DI)
What is the pathophysiology behind HCM?
Characterized by *thickened left ventricular walls* in the *absense* of valvular obstruction or systemic HTN, LV is decreased in size, Normal or increased systolic contraction 2 types: non-obstructive and obstructive
Rosacea Subtype 1: erythematotelangiectatic.
Characterized by prominent history of flushing and persistent central facial erythema and often roughness or scaling.
Subtype 3: phymatous.
Characterized by thickened skin, irregular surface nodularities, and enlargement. The most common presentation is rhinophyma, (image) but may occur in any other area of the face (including the ears and eyelids).
Subtype 4: ocular manifestations.
Characterized by watery or bloodshot appearance (interpalpebral conjunctival hyperemia), dryness, foreign body sensation, blurred vision, burning or stinging, light sensitivity, and telangiectases of the conjunctiva and lid margin, or lid and periocular erythema.
Juvenile Idiopathic Arthritis (JIA)
Childhood arthritis of unknown cause (6 weeks duration, under age of 16) Classification: systemic onset oligoarticular (1-4 joints, ANA+ 60%, uveitis 30%) polyarticular RFnegative (ANA+ 40%, uveitis 10%) polyarticular RF positive psoriatic arthritis (ANA+ 50%, uveitis 10%) enthesitis related arthritis (80% HLA B27+)
An S3 heart sound can be normal in which people?
Children, pregnant women
azithromycin (not pregnant), erythromycin (pregnant)
Chlamydia Tx
Acute __________ presents with sharp RUQ pain that comes & goes.
Cholecystitis
What syndrome is caused by "showers" of cholesterol crystals originating from a peripheral source (atherosclerotic plaque)?
Cholesterol Embolization Syndrome
skip lesions on Colonoscopy
Chron's
Pt presents to the clinic and describes the following S&S, what is the most likley dx? Sx: aching and tightness feeling of the R leg (involved); often worse at the end of the day and leg elevation *improves* sx.
Chronic Venous Insuff - classic presentation Contrast to Arterial insuff: leg elevation *does not* improve sx.
What is the MC cause of hemoptysis?
Chronic bronchitis
Fibromyalgia
Chronic pain in muscle and tension in absence of apparent inflammation
What is the pyelo DRUG OF CHOICE?
Cipro
What is the UTI DRUG OF CHOICE? What is it in pregnant women?
Cirpo Keflex
What are the symptoms of cardiogenic shock?
Classic symptoms: hypotension, oliguia, tachy, AMS PLUS enlarged neck veins and pulmonary congestion
What are the *CLASSIC* S&S for DVT? Are these typically seen in patients?
Classical symptoms: a. Lower-extremity pain and swelling (worse with dependency/walking, better with elevation/rest) b. Homans' sign (calf pain on ankle dorsiflexion) c. Palpable cord d. Fever These are not typically see in pts NOTE: Remember the *HOMANS SIGNS* can always be performed when looking for a DVT, however it is not a reliable test.
Diagnosis of Seborrheic Dermatitis
Clinical based Skin Biopsy
You think a patient is having a MI but has an allergy to Aspirin. What do you give them instead of ASA?
Clopidogrel
Wrist Fracture 2 types: Smith and Colles What is the Treatment?
Close Reduction long arm cast
A 5 mo pt presents the pediatric clinic, on exam you find the following results: Bounding radial pulses, Diminished femoral pulses, BP elevated in arms/decreased in legs. What is your *MOST LIKELY* diagnosis?
Coarc of the Aorta Sx: SEM loudest at ULSB, *Bounding radial pulses, Diminished femoral pulses, BP elevated in arms/decreased in leg*, Intermittent claudication, HA, epistaxis, paresthesias, CHF
Rib notching = __________.
Coarctation of the aorta
Dinner fork deformity of wrist
Colles fx
Distal radius w/ dorsal angulation
Colles fx
Patient has *strep bovis* endocarditis. What tests need to be ordered? Why?
Colonoscopy worry about CRC with Strep bovis
interventions for Conversion disorder
Communication "The good news is that it appears you don't have ____. However...." Multidisciplinary approach Physical medicine and rehabilitation Psychiatry/psychology
What are the EKG findings for RCM?
Conduction disturbancees and low voltage QRS complexes are common w/ amyloidosis and sarcoidosis - RBBB/LBBB may be present
What management should be taken for intermittent claudication?
Conservative *#1 = STOP SMOKING* 2) Graduated exercise program - walk to pt of claudication, rest, then cont walking 3) Foot care 4) Atherosclerotic risk factor reduction (hyperlipidemia, HTN, wt, DM...) 5) avoid extremes fo temp
What is the treatment for both stable&asx patients and symptomatic patients?
Conservative if stable and asymptomatic: salt restriction, diuretics, vasodilators, digoxin, afterload reduction (i.e. , ACE inhibitors or arterial dilators) , and restriction on strenuous activity *Definitive treatment* is surgery (aortic valve replacement). This should be considered in symptomatic patients, or in those with significant LV dysfunction on echocardiogram. Acute AR (e.g., post-MI): *Medical emergency-Perform emergent aortic valve replacement* Endocarditis prophylaxis before dental, GI, GU procedures
What are the 3 main functions of angiotensin?
Constrict arterioles Secrete ADH Secrete aldosterone
What condition is defined by *fibrous scarring ofthe pericardium* that leads to thickening of the pericardium. with obliteration of the pericardial cavity?
Constrictive Pericarditis
A rise in JVP on inspiration (Kussmaul's sign) may be seen in which 3 conditions?
Constrictive pericarditis Restrictive cardiomyopathy Cardiac tamponade
Contact Dermatitis vs Eczema
Contact: Borders are well defined to the area of contact with the offending agents. Eczema: Poorly defined borders.
What is the *GOLD STANDARD* diagnostic procedure for CAD?
Coronary Angiography
Bullous Pemphigoid Treatment
Corticosteroids, administered topically or systemically, are the cornerstone of therapy
Define the following terms in regards to PVCs: Couplet? Bigeminy? Trigeminy?
Couplet: two successive PVCs Bigeminy: Sinus beat followed by a PVC Trigeminy: sinus beat followed by two PVCs
What is/are the cause/s of myocarditis?
Coxsackie A or B virus, Chagas disease
Seborrheic Dermatitis treatment Cradle cap:
Cradle cap in infants can usually be managed using emollients such as topical olive oil applied once or twice a day as needed. -olive oil topical
Moon facies & buffalo hump
Cushing's syndrome
Pseudomonas is seen in kids with __________.
Cystic fibrosis (CF)
Which marker is elevated when coagulation has started?
D-dimer
If pt presents w/ the classic symtpoms of shock + history of MI, angina, or heart disease or if JVD is presents, what type of shock is most likely? A. Hypovolemic B. Septic C. Neurogenic D. Cardiogenic
D. Cardiogenic
Define the following arrhythmia description: (1) PR Interval is prolonged (>20 seconds) (2) A QRS follows each P waves A. Sinus brady B. Mobitz type II C. Winkebach D. First defree AV block
D. First degree AV block - Delay is usually @ the AV node -Benign condition that DOES NOT require tx
If a pt comes in witha BP of 172/110, what is the their classification of HTN? A. Normal B. PreHTN C. HTN Stage 1 D. HTN Stage 2
D. HTN Stage 2 Tx: lifestyle mod w/ 2 drug combination theapy
Name the NYHA described...."symptoms occur *at rest*. Incapacitating.? A. I B. II C. III D. IV
D. IV
What is the arrhythmia that is defined as *"rapid and repetitive firing of 3+ PVCs in a row, at a rate of 150 - 250 bpm? A. A. Fib B. V. Fib C. Trigeminy D. V. Tach
D. V. Tach
Based on the following description, what is the most likely murmur? Turbulence in Superior vena cava Continuous murmur Grade 1-3/6 in intensity Loudest: left infra-clavicular area, especially with sitting/standing disappears while lying supine Intensity changes with rotation of head and disappears with compression of the jugular vein A. Still's Murmur B. Pulmonary ejection murmur C. Pulmonary flow murmur D. Venous hum E. Carotid Bruit
D. Venous Hum
MOA of 1st generation antipsychotics
D2 antagonism. much more effective for positive symptoms than for negative symptoms.
Osteoporosis Gold standard
DEXA <2.5 (vertebral bodies, proximal femur, and distal radius
Herberden's nodes
DIP joint
What pt has the highest amputation risk?
DM
What are the risk factors for PVD?
DM, Smoking, CAD, hyperlipidemia, HTN, hyperhomocystinemia
dx criteria for pain disorder
DSM-IV-TR Diagnostic Criteria Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention. The pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain. The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering). The pain is not better accounted for by a mood, anxiety, or psychotic disorder and does not meet criteria for dyspareunia. Pain disorder associated with psychological factors Pain disorder associated with both psychological factors and a general medical condition Specify if: Acute: duration of less than 6 months., or Chronic: duration of 6 months or longer.
Homan's sign
DVT
What is the underlying cause for chronic venous insuff in many cases?
DVT Leads to ambulatory venous HTN, which result in edema, extravastion of plasma & RBCs into SQ resulting in brawing induration and brown-black color of skin. Eventually leads to reduced local capillary blood flow and hypoxia of tissues, mild trauma can precipitate tissue death.
Seborrheic Dermatitis Dandruff
Dandruff Also known as pityriasis capitis, white flaky deposits found on clothing and in hair are characteristic.
Tarsal Tunnel Syndrome
Decrease sensation in the plantar aspect of the foot Hx of tingling and burning discomfort.
Hyperventilation and __________ CO2 causes respiratory __________.
Decreased Alkalosis
Nerve that Dorisflex the foot
Deep peroneal Nerve (L4-S2)
What is definition of cardiogenic shock?
Defined as *SBP <90* w/ *urine output <20 ml/hr* and adequate LV filling Occurs when the heart is unable to generate a CO sufficient for tissue perfusion
In CHF there is systolic and diastolic dysfunction...what are they defined by and what is the *MOST COMMON CAUSE* of each?
Defined by *Ejection fraction* Systolic: <50% or decreased EF *MCC* - post MI Other: DCM/Myocarditis Diastolic: Nl/increased EF *MCC* = HTN leading to myocardial hypertrophy Other: AS, MS, AR, RCM/HCM
How does lobar pneumonia (PNA) present on CXR? What 3 things might cause it?
Dense lobar consolidation S. pneumonia H. flu Legionella
Fibromyalgia assoc with
Depression, anxiety, and irritable bowel disease
What fluids CANNOT be used in acute shock?
Dextrose (D5W) - the body cannot use it!
What condition causes a decrease in ADH, an increase in urine output, and an increase in serum osmolarity?
Diabetes insipidus (DI)
Fruity breath
Diabetic ketoacidosis
What pateints are niacin c/i in?
Diabetic patients (may worsen glycemic control)
Atopic dermatitis Dx
Diagnosis is made clinically Labs: eosinophilia, elevated IgE antibodies (hence atopy) R/o seborrheic dermatitis, contact dermatitis, drug sensitivity rxn
Diarrhea causes a __________ pH imbalance. Vomiting causes a __________ pH imbalance.
Diarrhea--> Metabolic acidosis Vomiting--> Metabolic alkalosis
HCM is which type of dysfunction: A. Systolic B. Diastolic
Diastolic (filling defect)
What is the #1 cause of heart failure?
Diastolic dysfunction
What are the common RF for dyslipidemia?
Diet - high in sat fat, choleserol, and calories, alcohol Age - increase until 65 y/o Inactive lifestyle, abdominal obesity Fmhx Male Meds (1) Thiazides - increases LDL, total, TG (2) BB - increase TG and lower HDL (3) Estrogen - TG increase w/ underlying dyslipidemia (4) Steroids and HIV drugs - increase serum lipids
Diffuse Scleroderma
Diffuse Cutaneous thickening (Heart, GI tract, lung, and kidneys may be involved) Renal Crisis Interstitial pulmonary fibrosis Anti-Scl 70 antibody ANA positive in 90%
Scleroderma AKA: Systemic Sclerosis
Diffuse or Limited Associated with Raynaud's Phenomenon and sophageal dysfunction 30-50 years old F>M 7-12:1 Presents affecting skin, joints, and esophagus
What is the *MOST COMMON* cardiomyopathy?
Dilated CM
What is the *ONLY* CXR finding for AS in children?
Dilation of AA is only radiographic sign in children
What are the signs of PVD?
Diminished or absent pulses, muscular atrophy, decreased hair growth, thick toenails, and decreased skin temperature Ischemic ulceration (usually on the toes) • Localized skin necrosis • Secondary to local trauma that does not heal (due to ischemic limb) • Tissue infarction/gangrene in end-stage disease Pallor of elevation and rubor of dependency (in advanced disease)
Osteoarthritis facts
Disease of cartilage Non-inflammatory M=F, up to 70% over 70 have radiographic evidence of OA, 10% symptomatic First line treatment should be acetaminophen and weight loss
What are the signs of left sided heart failure?
Dislaced PMI to the left Pathologic S3 (ventricular gallop) - S4 can be present Crackles/rales at lung bases (pulmonary edema, moderate severity of left ventricular HF) Dullness to percusssion and decreased tactile fremitus of lower lung feilds increased pulmonic component of heart sounds indicates pulmonary HTN
What is the tx for isolated systolic HTN?
Diuretic (preferred), calcium channel blocker (alternative therapy)
What is the initial test for DVT?
Doppler anlaysis and u/s -noninvasive but high operator dependent -high sensitive and specificity for proximal thrombi (popliteal and femoral), not so for distal (calf vein) thrombi
Colles 3Ds
Dorsal displacement distal fragment
trisomy 21 is what?
Down syndrome: poor Moro reflex, hypotonia, hypermobility of joints, flattened facies & occiput, excess skin on posterior neck, Brushfield's spots in eyes, mental retardation, hearing loss
what is the most common congenital and most common genetic cause of mental retardation?
Down's Fragile X
Brushfield spots on iris
Down's syndrome
Simean creases
Down's syndrome
Lyme disease Tx
Doxcycline
What are some drugs that can cause DCM?
Doxirubicin and Adriamycin
What are 5 common causes of pericarditis?
Dressler's syndrome SLE Infection Uremia Post-MI (24-48 hrs)
What is the name of the "postmyocardial infarction syndrome" that is immunologically based and consists of fever, malaise, pericarditis, leukocytosis, and pleuritis occuring weeks to months post-MI?
Dresslers Syndrome TOC = ASA
What is a major but rare side effect of procainamide?
Drug-induced lupus
What are the side effects of ACE- inhibitors?
Dry cough Facial edema HYPERKALEMIA
Fibromyalgia facts
Dysfunctional processing of pain in the CNS Etiology unknown F>M 7:1 Characterized by WIDESPREAD pain, non-restorative sleep, AM stiffness, fatigue often accompanied by irritable bowel, bladder, TMJ disorder *Psychiatric comorbidities- 40 to 70% *Must have >11/18 trigger points
Based on the folllowing description, what murmur is being described: Turbulence in carotid/subclavian artery Systolic ejection murmur Sometimes heard at base of neck Disappears with hyperextension of shoulders Grade 2-3/6 in intensity Occasional thrill over carotid A. Still's Murmur B. Pulmonary ejection murmur C. Pulmonary flow murmur D. Venous hum E. Carotid Bruit
E. Carotid Bruit
What are 4 of the MC organisms to cause UTIs?
E. coli Proteus Enterobacter Pseudomonas (in hospital)
What is the *SOC* for pericardial effusion?
ECHO -confirms the presence or absense of a significant effusion - can show as little as 20 ml of fluid
Wha studies can be ordered to evaluate for TR?
ECHO EKG (RVH, RAE)
What is the *SOC* for all valvular heart diseases?
ECHO (If you want to visualize the left side of the heart i.e. the mitral valve, you can get a *TEE*)
What is the *SOC* (both sensitive, specific, and diagnostic) for cardiac tamponade?
ECHO - *MUST* be performed if suspicion of tamponade exists
reserved for severely depressed pts or those unresponsive or intolerant of other meds, where rapid improvement is needed
ECT
What patients with CHF need ICD placement
EF < 35%
What diagnostic tests can be used in cardiogenic shock?
EKG - looks for STEMI, NSTEMI, Arrthythmias ECHO - dx mechanical complications Swan Gann Catheter (looks at PCWP - Normal LA Pressure -10 mmHg; Abnormal pressure = 15 mmHg)
What is the EKG and CXR findings for PDA?
EKG: LVH, LAE, LVH + RVH CXR: incraesed pulmonary artery vascularity, vein size
Explain the diagnostic findings of EKG, CXR, and ECHO for VSD.
EKG: LVH; LAE,+/-RVH CXR: Cardiomegaly; left atrial enlargement; incr. Pulmonary vasculature ECHO: Shows septal Defect
What is shown on an EKG for pericarditis?
EKG: ST SEGEMENT ELEVATION IN ALL LEADS EXCEPT AVR AND V1 - PR INTERVAL DEPRESSED BELOW BASELINE
What are the characteristic findings for PACs? What management would you recommend?
EKG: early p-waves that differ in morphology from the normal sinus P-wave - QRS is normal Management: can occur in healthy individuals and some patients can be asx so they *do not require treatement * If palpatations - prescribe *BB*
Lyme disease Lab
ELISA
Klebsiella pneumonia - MC in who
ETOH abuse
name 3 screening tests for anorexia
Eating Attitude Test (EAT): 26 questions. scores > 20 considered significant. Eating d/o examination (EDE): clinician-based test (training required) SCOFF: screening for Eating disorders in primary care: 5 yes or no questions.
If a pt show LVH on ECG what should be ordered next?
Echo
What is the *INITIAL TEST OF CHOICE*/*GOLD STD* for CHF?
Echo
What is the *SOC* for HCM?
Echo
What is the *SOC* for MVP?
Echo
What is the *SOC* to evaluate DCM?
Echo
What is the DIAGNOSTIC test of choice for atrial fibrillation?
Echo
What is the TEST OF CHOICE for pulmonary HTN?
Echo
Fibromyalgia treatment
Education Antidepressants- amitryptyline (good for sleep disturbance), cyclobenzaprine, fluoxetine, sertraline, venlafaxone, duloxetine, paroxetine Anticonvulsants- parababalin, gabapentin Analgesics- acetaminophen, tramadol Non-pharmacologic measures- CBT, AEROBIC EXERCISE, complementary therapies
interventions for Pain disorder
Education about mind-body duality Multidisciplinary team approach Focus on keeping pain manageable Focus on highest level of functioning Focus on psychological aspects of pain Non-invasive, non-narcotic treatment whenever possible Dual-action agents (5-HT and NE) Biofeedback and/or hypnosis
How does silicosis present on CXR?
Egg shell appearance
What ECG findings suggests a massive pericardial effusion and tamponade?
Electrial Alternans
Carpel Tunnel Syndrome Dx
Electromyogram
What lab is *pathognomic* for CHF?
Elevated *BNP*
What is the definition for HTN urgency?
Elevated BP levels along *w/o end organ damage* These rarely require emergency therapy and can be managed by attempts to lower BP over a periods of 24 hours.
If the TRIAD is met for a ruptured AAA, what is indicated *EMERGENTLY*?
Emergent Laparotomy
What is the treatment for endocarditis?
Empirical until blood culture are final → Nafcillin + PCN + Genta/ VANCO (MRSA/PCN allergy) Strep: PCN G/Cephtriaxone Staph: Nafcillin + PCN + gentamycine; oxacillin; Vanco (MRSA) Enterococci: PCN + streptomycin/gentamycin
what are the complications of VSD?
Endocarditis Progressive AR Heart Failure Pulmonary HTN and shunt reversal (*Eisenmenger's*)
What is the tx for VSD?
Endocarditis prophylaxis is important. Surgical repair is indicated if the pulmonary flow to systemic flow ratio is greater than 1.5:l or 2:l. For the asymptomatic patient with a small defect, surgery is not indicated.
What are the other causes of secondary HTN?
Endocrine causes-hyperaldosteronism, thyroid or parathyroid disease, Cushing's syndrome, pheochromocytoma, hyperthyroidism, acromegaly Medications-oral contraceptives, decongestants, estrogen, appetite suppressants, chronic steroids, tricyclic antidepressants (TCAs), nonsteroidal anti- inflammatory drugs (NSAlDs) Coarctation of the aorta Cocaine, other stimulants Sleep apnea
What diagnostic technique can be "diagnostic" in RCM?
Endomyocardial bx
Pea soup diarrhea
Enteric/Typhoid fever
small pearly nodules along midline of hard palate which are benign retention cysts
Epstein pearls
Lyme disease 1º
Erythema Migrans (bull-eye rash)
Erythema Multiforme
Erythema multiforme (EM) is an acute, immune-mediated condition characterized by the appearance of distinctive target-like lesions on the skin.
Which type of psoriasis is associated with worse arthralgia and severe pruritus?
Erythroderma (erythrodermic psoriasis)
What is the *MOST COMMON CAUSE* of HTN?
Essential/primary HTN (i.e. there is no identifiable cause)
Influenza - vaccine
Everyone >6 months; annually *mid sept-mid Nov* - can have IM or Intranasal if >5 yrs
Onion skin appearance of bone
Ewing sarcoma
Ankle sprain
Excessive inversion of the foot (Calcaneofibular or anterior talofibular)
What is the tx for AS in children?
Exercise restrictions (avoid contact sports), Surgery, Balloon Valvuloplasty in children, Valve replacement in adults
What diagnostic procedures can be used as a screening tool for CAD?
Exercise stress ECHO/EKG
Paget's Disease Radio finding:
Expanded bone that is denser than normal or has a "cotton wool" appearance
Intrinsic v. extrinsic asthma
Extrinsic = immunologically mediated, develops in childhood Intrinsic = worse w/ age, late onset
What systems should be assessed if a pt has a markedly elevated BP?
Eyes: papilledema CNS • Altered mental status or intracranial hemorrhage • Hypertensive encephalopathy may develop (suspect when BP is markedly ele- vated: 240/140 or higher, along with neurologic findings such as confusion). Kidneys: renal failure or hematuria Heart: unstable angina, MI, CHF with pulmonary edema, aortic dissection Lungs: pulmonary edema Kidneys: renal failure or hematuria
epidemiology of somatoform disorders
F >> M Male relatives: Substance use disorders and Antisocial personality disorder lower SES and educational level
patients most often affected by hypochondria
F=M
patients affected most often by pain disorder
F>M
What groups are most often affected by somatoform disorders?
F>M. Low SES and education level.
patients most often affected by body dysmorphic disorder
F>M. comorbid depression and/or anxiety common
what patients are most often affected by conversion disorder?
F>M. low SES and education.
small head, thin upper lip, microcephaly, small distal phalanges, developmental delay
FAS
Elbow fx
FAT PAD SIGN
Asthma dx by spirometry -
FEV1/FVC ration <75% with a >10% increase in FEV1 after bronchodilator therapy
Spondyloarthropathy
Family of disorders Progressive Spinal Inflammation- ultimate spinal fusion HLA B27 in >90% of cases of ankylosing spondylitis Isolated spinal disease- ankylosing spondylitis Associated with psoriasis- psoriatic arthritis Associated with inflammatory bowel disease- enteropathic arthritis Post infectious- reactive arthritis (after arthritis, conjunctivitis, urethritis, circinate ballanitis, keratoderma blennorhagica)
Compartment syndrome Tx
Fasciotomy
What are Kussmaul's respirations? Which 4 conditions may it be noted in?
Fast, deep breathing Metabolic acidosis DKA Kidney disease Liver disease
What are the clinical features of A. Fib?
Fatigue and Exertional Dyspnea Palpitations, dizziness, angina, or syncope Irregular, irregular pulse Blood stasis leads to formation of intramural thrombi, which can embolize to the brain Absense of an "*A Wave*" in JVP measurement.
What is the BEST marker for Iron Deficiency anemia?
Ferritin
What is the triad of pyelonephritis?
Fever Chills Flank tenderness
Pregnancy Treatment of Acne vulgaris
Few topicals are considered category B and safe to use in pregnancy, including clindamycin, erythromycin, and azelaic acid topical all of them.
Dupuytren's Contracture
Fibrous fascia causes contrature
Slapped cheek w/ lace-like rash
Fifth disease (Erythema infectiosum)
How might interstitial pneumonia (PNA) present on CXR? What 3 things might cause it?
Fine diffuse infiltrates Influenza CMV P. jirovecii
PR Interval >0.2 sec. All P waves have a corresponding QRS
First Degree Heart Block
The characteristic physical sign of a __________ may be seen in pts with CO2 retention (respiratory failure).
Flapping tremor
Lichen planus Location on body
Flexor Surface of wrists, lumbar region, shins, eyelids, scalp, buccal mucosa, tongue, lips, nails
DeQuervain's Tenosynovisits PE
Flinkstein
A pt experiencing a right ventricular MI needs __________ NOT nitro.
Fluid
Synovial analysis
Fluid must be cultured to differentiate between inflammatory disorder and septic joint. Volume will be high in all non-normal joint aspirations. Fluid is cloudy in inflammatory disorders and in septic joints. Viscosity is high in normal and non-inflammatory joints. Large white counts and percent of PMN's in both inflammatory and septic joints.
What is the major SE of niacin?
Flushing
Hutchinson's Fracture
Fracture of the radial styloid
Salter Harris Type 3
Fracture the growth plate and epiphysis
pale blue irides, long narrowed facies, large protruding ears and jaw, flat feet, hyperextensible fingers, autism
Fragile X syndrome
__________ after an anterior MI present with pericardial effusion and eventually tamponade.
Free wall rupture
What is the *MOST COMMON CAUSE* of endocarditis in IVDU?
Frequently presents with right-sided endocarditis S. aureus is the *most common cause* Other organisms include enterococci and streptococci. Fungi (mostly Candida) and gram-negative rods (mostly Pseudomonas) are less common causes.
Salter Harris Type 4
Fx through all three layers
Salter Harris Type 2
Fx through growth plate and the metaphysis
x linked recessive hemolytic disorder
G6PD def
neurotransmitters involved in schizophrenia
GABA, D, 5ht, NE
persistent excessive anxiety regarding general life events that lasts 6 or more months
GAD
treatment of narcalepsy with cataplexy
GHB, SSRIs, TCAs
What are the AE for BAS?
GI effects
complications of bulemia nervosa
GI: dental erosion, parotid gland swelling, esophageal rupture, gastroesophageal reflux, acute gastric dilation, constipation, cathartic colon. Pulm/Thoracic: aspiration pneumonitis, pneumomediastinum Cardiac: arrhythmia, diet pill toxicity = hypertension or palpitations, emitene cardiomyopahty (ipecac), mitral valve prolapse. Endocrine: irregular menses, mineralocorticoid excess. Metabolic: 'lyte imbalances, dehydration, nephropathy. HEENT: perimyolysis (anterior lingual surface), caries, pharyngeal soreness, cheilosis, epistais, parotiditis.
What is the *GOLD STD* for diagnosis of myocarditis? What is the tx?
GOLD STANDARD - BX OF MYOCARDIUM Tx: Supportive
What is the management for TR?
Geared more towards *MEDICAL MANAGEMENT* - tx the underlying cause (1) Tx LHF, endocarditis, or pulmonary HTN Severe regurg can be tx surgically is pulm HTN is NOT present - native valve repair surgery, valuloplasty of triscupsid ring, valve replacement surgery (Rare)
What is Rheumatic Fever?
General: Post infectious inflammatory dz Incidence: Common in age 5-15, Lower socioeconomic areas, 2-5 weeks latency Patho: Immune rxn to untreated group A β-hemolytic strep
Erythroderma (erythrodermic psoriasis)
Generalized erythema with fine scaling. It is often associated with pain, irritation, and sometimes severe itching.
Psoriasis Etiology:
Genetics: patients with psoriasis have a genetic predisposition for the disease.
What are the SE of fibrates?
Gl side effects (mild) Mild abnormalities in LFTs Gynecomastia, gallstones, weight gain, and myopathies are other side effects.
tx for CML
Gleevec
Duke's minor criteria mentions several immunological signs, differentiate the following: (1) Glomerulonephritis (2) Osler's Nodes (3) Janeway Lesions (4) Roth's Spots
Glomerulonephritis - post untx strep infxn - toxins attach the GBM and cause leakages (Sx: RBC Casts) Osler Nodes: small PAINFUL nodules on fingers/toes Janeway Lesions: small hemorrhages on palms and soles - NOT PAINFUL Roth Spots: fundus
Where is aldosterone secreted from?
Glomerulosa cells of the adrenal cortex in the adrenal gland
General Approach to a pt in shock...
Goal: stabalize pt and determine cause of shock *#1: ABC!!!!* a. Establish two large-bore venous catheters, a central line, and an arterial line. b. A fluid bolus (500 to 1,000 m l of normal saline or lactated Ringer's solution) should be given in most cases. c. Draw blood: CBC, electrolytes, renal function, PT/PTT d. ECG, CXR e. Continuous pulse oximetry f. Vasopressors (dopamine or norepinephrine) may be given if the patient remains hypotensive despite fluids. g. If the diagnosis is still in question after the above tests, a pulmonary artery cath/echo can aid in diagnosis
The End....
Good Luck
Granular/waxy casts are seen in __________. Broad casts are seen in __________.
Granular--> Acute renal failure (ARF) Broad--> Chronic renal failure (CRF)
What are 2 types of conditions that cause erythema nodosum on the legs?
Granulomatous conditions (TB, Sarcoidosis, Wegner's disease) Oral contraceptive pills (OCPs)
Interstitial lung disease has a ___________ appearance on CRX.
Ground glass
Which type of psoriasis has a strong association between recent streptococcal infection?
Guttate psoriasis
dx of DI
H20 deprivation test, if urine is still dilute, test is +
SIADH tx
H20 restriction
Which lipid has a protective effect by removing xs cholesterol from arterial walls and has at least as strong as the atherogenic effect of LDL?
HDL - every 10 mg/dl increase decreases CAD risk by 50% <30 - independent risk factor for CAD >60 - "negative risk factor" (counteracts)
red papules or vesicles on tongue, oral mucosa, hands, feet, buttocks, fever, sore throat
HFMD from Coxsackie
Ankylosing Spondylitis
HLA B27 is present in >90% of cases Primarily seen in males Chronic progessive inflammation of spine TX- NAIDs, sulfasalazine, MTX, TNF blockers
Ankylosing Spondylitis Lab
HLA-B27, increase ESR
Rheumatoid Arthritis Serotype
HLA-DR4
What is the *TOC* for lowering LDL levels?
HMG CoA reductase (Statins) Effects: *LOWER LDL*, min effect on HDL and TG Comment: have been shown to *reduce mortality from CV events significantly and reduce total mortality* SE: monitor LFTs (monthly for 3 mo, then every 3-6 mo); harmless elevation in CPK can occur
respiratory distress for a newborn
HR >60
Multinucleated giant cells on Tzanck smear
HSV
Primary aldosteronism causes secondary __________.
HTN
What is the #1 cause of diastolic dysfunction?
HTN
Cotton wool spots (ischemic exudates on Fund. Exam)
HTN retinopathy
What are the 2nd MC causes of CHF?
HTN, Valvular disease
Describe the CV exam findings for VSD.
Harsh, blowing *holosystolic* murmur with thrill At fourth left intercostal space (LLSB) Murmur *decreases* with Valsalva and handgrip The smaller the defect, the louder the holosystolic murmur Sternal lift (RV enlargement) As PVR increases, the pulmonary component of 52 increases in intensity Aortic regurgitation may be seen in some patients.
Osteoarthritis bony Protuberances
Heberden's node (DIP) Bouchard Nodes (PIP)
OA in DIP
Heberdens
Nephritic syndrome (inflammatory) is characterized by what 4 things?
Hematuria RBC casts HTN Oliguria
spontaneous hemarthrosis, increased PTT only
Hemophilia
excessively prolonged coag time
Hemophilia A
factor IX deficiency or Christmas disease
Hemophilia B
What is epiglottitis caused by and what are 2 major S & S?
Hemophilus influenza Drooling Tripod position
Janeway Lesions
Hemorrhagic, *nonpaiful* macules on palms and soles -Sign of *endocarditis*
Palpable papules
Henoch-Scholein purpura
What is a major side effect of Rifampin?
Hepatotoxicity
What are the 2 major side effects of Isoniazide (INH)
Hepatotoxicity Neurotoxicity (give B6)
Osmotic fragility test
Hereditary spherocytosis
microcytosis and increased mean corpuscular Hg concentration
Hereditary spherocytosis
What are 3 causes of elevated BUN?
High protein diet Hypovolemia/dehydration Upper GI bleed
What diagnostic procedures should be utilitzed for USA?
Higher risk for AE w/ Stress test sooo.... 1) Stablize w/ medical management before stress test or 2) undergo cardiac cath initially
Osteoarthritis common affect
Hip, knee, ankle, hand, shoulder, can cause spinal stenosis
What murmur *increases* in intensity with valsalva and standing, and decreases with handgrip and squatting?
HoCM (Hypertrophic Cardiomyopathy)
enlargement of lymphoid tissue, spleen, and liver, presence of Reed Sternberg cells
Hodgkin's disease
Reed - Sternberg cells
Hodgkin's lymphoma
What device can be used to detect silent ischemia and silent arrhythmias not assable by an in office EKG?
Holter Monitor
Unilateral ptosis, anhidrosis, miosis
Horner's syndrome
what kind of cells are seen with folic acid anemia?
Howell jolly bodies (DNA remnants), macroovalocytes, hypersegmented polymorphonuclear cells
__________ casts are common & can be normal due to intense exercise.
Hyaline
Athletic pseudo-nephritis will show which type of casts in the urine?
Hyaline & granular
What medicines do African Americans with CHF get that others do not
Hydralazine and Isosorbide Dinitrate
What 4 things might be seen on a CXR of a COPD pt?
Hyperinflation Flat diaphragm Tubular heart Increased retrosternal space
A renal failure pt with elevated phosphate & decreased calcium = Secondary __________.
Hyperparathyroidism
Osteoporosis Risk factor
Hyperparathyroidism, smoking, hyperthyroidism, age, cushing
What electrolyte abnormalities can cause prolonged QT interval?
Hypokalemia + Hypomagnesia
What is Beck's triad & in what conditions is it usually seen?
Hypotension Muffled heart sounds Increased JVP Seen in pericardial tamponade, RV infarct
What is *BECKS TRIAD*?
Hypotension, Muffled Heart Sounds, JVD **Caracteristic for Cardiac Tamponade**
Carpel Tunnel Syndrome RF
Hypothyroidism, Pregnancy, obesity, DM, RA
What are the grades for murmurs (I-VI)?
I = Very soft, *not immediately* apparent II = Soft, but *immediately audible* III =Loud, but *no palpable thrill* IV =Audible *with a palpable thrill* V =Can be heard with stethoscope *barely touching* the skin, with a thrill VI =Can be heard with stethoscope *not even touching* the skin, with a thrill
*Lateral Wall* EKG leads? Which artery supplies this area?
I, aVL, V5, V6 *Left* Coronary Artery (*Left Circumflex Artery*)
management of alcohol withdrawl with seizures or severe symptoms
I.V. benzos
4 type of acne severity:
I: comedonal: few lesions, no scarring II: Papular: Moderate number of lesions, little scarring III: Pustular: Lesions >25, moderate scarring IV: Nodulocystic: Severe scaring.
In regards to VT as a whole what is the *FIRST LINE THERAPY*?
ICD Amiodarone is considered the *BEST 2ND LINE TX*
As a general rule, what form of management should be given to all patient who are dx w/ sustained VT?
ICD Exception - EF is normal, then you can consider amiodarone
Hospital-acquired pneumonia - who is at highest risk
ICU pts on a ventilator
initial dx test for acromegaly/gigantism
IGF-1
*Inferior Wall* EKG leads? Which artery supplies this area?
II, III, aVF *Right* Coronary Artery
What are the vitamin K dependent factors?
II, VII, IX, X
mental retardation sx
IQ <70, abnormal muscle tone at 6mths
hypoparathyroid tx
IV Ca gluconate is severe Vit D, oral Ca, Mg+ if mild to moderate
What is the acute management for a RCA infarction?
IV NL Saline + MOA (Morphine, O2, ASA) *NITRO IS C/I IN A RIGHT SIDED MI*
What is the *TOC* for HTN Emergency in the setting of an MI?
IV NTG and BB (esmolol/labetalol)
What is the *TOC* for HTN emergency in the setting of aortic dissection?
IV Nitroprusside and BB (esmolol/labetalol)
What is the *TOC* for HTN emergency?
IV Nitropusside
In refractory V. Fib, what are the ACLS guidelines...
IV amiodarone followed by shock *sodium bicarb is NO longer recommended*
Osteomyelitis common in
IV drugs users
What is the tx for MVP?
If patient is asymptomatic: reassurance If patient has systolic murmur or thickened valve: antibiotic prophylaxis for dental procedures to prevent infective endocarditis For chest pain B-blockers have been useful, but they are unlikely to be required. Surgery rarely is required. The condition is generally benign.
Ganglion Cyst mass that occur from herniation at the joint and that transluinates
If rupture or needle aspiration increases of reoccurrence
In a hemodynamically *unstable* patient in A. Fib what manaement would you take?
Immediate electrical cardioversion to sinus rhythm
Which type of psoriasis is associated with 3rd trimester of pregnancy?
Impetigo herpetiformis / Pustular psoriasis
Seborrheic Dermatitis is a common inflammatory skin disorder that usually manifests as *erythema and scaling of the scalp, nasolabial folds.*
In adolescents and adults erythematous, circumscribed and scaly patches are commonly found on the scalp. Erythema accompanied by greasy scales in the nasolabial folds, postauricular area, forehead, and anterior chest are often present. In infants the characteristic distribution is extensive coverage of the scalp, hence the term "cradle cap."
Atopic dermatitis: Dry skin with erythema and scaling, and often with papules or vesicles, is noted in the acute flares. In infants, the extensor surfaces, cheeks, and forehead are preferentially affected. Unlike in seborrheic dermatitis, the groin and diaper area are usually spared. In older children and adults, atopic dermatitis most commonly affects skin flexures. Affected areas may be hyperpigmented or hypopigmented and excoriations from constant scratching are commonly seen.
In chronic atopic dermatitis, the skin appears thick and lichenified. Follicular hyperkeratotic papules known as keratosis pilaris (KP) are present on the extensor surfaces of the upper arms, buttocks, and anterior thighs, and are typically asymptomatic. KP are often seen in patients with atopic dermatitis, but may also be present in the absence of atopic dermatitis.
lab findings in HSDD (Hypo active sexual desire disorder)
In male hypogonadism, serum free testosterone will be low (do hormone therapy); No definitive laboratory testing for endocrinological causes of female HSDD (bupropion?) In both sexes may be a sign of hypothyroidism or hyperprolactinemia
Lichen planus Treatment
In mild cases, potent topical corticosteroids are used as first-line therapy
How might atelectasis be prevented after surgery?
Incentive spirometry
Osteoarthritis Labs
Increase AP, ESR, LDH
Septic Joint and Septic Arthritis Lab
Increase WBC, ESR, CR protein
Paget's Disease Labs:
Increase alkaline Phospahatase Increase urine hydroxyproline Normal Gamma-glutamyl Transpeptidase
Hypoventilation and __________ CO2 causes respiratory __________.
Increased Acidosis
What 2 things is aldosterone release dependent on?
Increased angiotensin II concentration Increased in plasma K
There are three age-group stages of atopic dermatitis:
Infantile (from infancy to two years old), childhood (from 2 years old to 12 years old), and the adult stage for those older than 12 years
Which type of MI may present with bradycardia & N/V? Why?
Inferior MI Due to vagal nerve compression
What is pericarditis and what is the MCC?
Inflammation of pericardium MCC: virus/ BQ: Dresslers syndrome
What is myocarditis and what is the etiology?
Inflammation of the myocardium Etiology: viral infection - coxsackieb, echovirus, and adenovirus Mechanism of injury: o INVASION OF MYOCARDIUM: VIRUS** o PRODUCTION OF TOXIN: DIPTHERIA** o AI: SLE/RHEUMATIC FEVER**
Most effective anti-inflammatories for mgmt of chronic asthma
Inhaled corticosteroids
What are the sx and signs for constrictive pericarditis?
Initial manifestations are secondary to systemic venous pressure elevation: edema, ascites, hepatic congestion. Later manifestations are due to elevation of left-sided intracardiac pressures: pulmonary congestion-cough, exertional dyspnea, and orthopnea. Signs include: a. Jugular venous distention (JVD)-*most prominent physical finding*; central venous pressure is elevated and displays prominent x and y descents b. *Kussmauls sign*-JVD (venous pressure) fails to decrease during inspiration c. *Pericardia! knock*-corresponding to the abrupt cessation of ventricular filling d. Ascites e. Dependent edema
What is the treatment for aortic dissection?
Initiate medical therapy immediately. a. lV ,B-blockers to lower heart rate and diminish the force of left ventricular ejection b. IV sodium nitroprusside to lower SBP below 120 mm Hg Type A dissections-surgical management Type B dissections-medical management
JIA Treatment
Injections, NSAIDS, MTX, TNF blockers, IL-6 or IL-1beta eye exams; all JIA patients need to be on a schedule for regular eye exams. *Oglioarticular JIA- ANA+ every 3 months until age 7; if ANA - and > age 7, every 6 months
Erb-Duchenne palsy ("Waiter's Tip" position)
Injury to nerve roots C5 & C6
Klumpke's palsy ("clawed hand")
Injury to nerve roots C8 & T1
How to interpret diagnostic tests in a DVT?
Intermediate-to-high pretest probability of DVT • If Doppler ultrasound is positive, begin anticoagulation. • If Doppler ultrasound is nondiagnostic, repeat ultrasound every 2 to 3 days for up to 2 weeks. Low to intermediate probability of DVT • If Doppler ultrasound is negative, there is no need for anticoagulation; obser- vation is sufficient. • Repeat ultrasound in 2 days.
Spirometry results intermittent, moderate, mild, severe asthma
Intermittent = >80% of expected Mild = 80% of expected Moderate = 50/60%-80% of expected Severe <50/60% of expected *sources vary on the 50 & 60%
*Pentoxifylline* is a medication indicated for ....
Intermittent Claudication
________ __________ = cramping leg pain that is reliably reproducable by the same walking distance (distance is very constant and reproducible) and pain is completely relieved by rest.
Intermittent Claudication
What is the HALLMARK of peripheral vascular disease (PVD)?
Intermittent claudication (pain in calves while walking)
Recent studies show that what device increases survival in pts w/ cardiogenic shock?
Intra-aortic balloon pump (IABP) - placed in descending thoracic aorta for mechanical support (1) decreases afterload (2) increases CO (3) Decreases Myocardial demand
What is the most important intracellular & extracellular buffer?
Intracellular--> Hgb Extracellular--> Bicarbonate
A fib is an irregularly __________ heart rhythm.
Irregular
What is the *MOST COMMON CAUSE* of V.Fib?
Ischemic Heart Disease = MCC Other: Prolonged QT (drugs or torsades de pointe) or A.Fib w/ rapid ventricular rate in pts w/ WPW.
In a male with prostatitis a direct rectal exam (DRE) should not be performed. Why?
It could cause bacteremia
Does Bullous Pemphigoid effect the eyes?
It is important to examine the oral mucosa, as oral lesions are present in up to 30% of patients. [4]
What is the often the trigger for cholesterol emboli syndrome and what is the S&S?
It is often triggered by a surgical or radiographic intervention (e.g., arteriogram), or by thrombolytic therapy. It presents with small, discrete areas of tissue ischemia, resulting in blue/black toes, renal insufficiency, ancl!or abdominal pain or bleeding (the latter is due to intestinal
What is very important about the ECHO and CHF?
It measures *EJECTION FRACTION* <40% = systolic dysfunction (*MOST COMMON*) >40% = diastolic dysfunction
Septic Joint and Septic Arthritis Dx
Joint Aspiration >50,000/mm3 WBC
Gout Joint Aspiration
Joint aspiration and analysis shows crystals that are: made from uric acid, needle shaped, and negatively birefringent
What is the diagnostic criteria for Rheumatic Fever?
Jones Criteria: 2 major OR 1 major + 1 minor ("Jonesin for the Fever") *Major Criteria: (J<3NES)* J - Joints (Migratory Polyarthritis), <3 - Cardiac involvement (pericarditis, CHF, MS) N - Nodules (subcutaneous) E - Erythema marginatum, S - Sydenham's chorea *Minor Criteria: (FEAR 1 P)* F - Fever, E - Elevate phase reactants (ESR, CRP), A - Arthralgia (poly) R - Rheumatic Heart Dz PmHx or prev strep infxn 1 - 1st degree heart block P - Prolonged PR interval
Where is renin produced? How does renin affect BP?
Juxtagloberular apparatus (JGA) of kidney Increases BP
when should you hospitalize a patient with bulemia?
K < 3, Cl < 88. esophageal tear, hematamesis, intractable vomiting, cardiac arrhythmia (long QT). suicide risk. failure to respond to outpatient treatment.
What is the screening test for nephrolithiasis?
KUB
fever >5 days + conjunctivitis, lip cracking and fissuring, strawberry tongue, inflammation of oral mucosa, cervical lymphadenopathy, exanthema, redness, swelling of hands & feet
Kawasaki; tx w/IV immunoglobulin
LVH may show __________ on CXR.
Kerley B lines
XXY
Klinefelter's syndrome
MCL tear
Knee valgus
LCL tear
Knee varus
__________ sign occurs when LV pressure drops on inspiration.
Kussmaul's
artery left lateral wall
L marginal artery
sensation anterior thigh, no reflexes
L2-3
Patellar deep tendon reflex
L2-L4
quadriceps strength
L3-4
sensation of lateral leg and dorsum of foot, great toe extension
L4-5
Achilles deep tendon reflex
L5-S1
sensation posterior calf, lateral foot, plantar flexion
L5-S1
What vessel corresponds to a poor prognosis in regards to CAD?
LAD - b/c it covers 2/3 of the heart
An anteroseptal MI is due to ischemia of which artery & changes will be seen in which ECG leads?
LAD, V1-V4
For patients that have CHD or CHD risk equivalents, what is the following: (1) LDL goal (2) Initial TLC (3) Consider Drug therapy
LDL goal: <100 Initiate TLC: 100 (*ALL* pts regardless of LDL) Consider drug therapy: >130
For patients that have NO CHD and >2 risk factors, what is the following: (1) LDL goal (2) Initial TLC (3) Consider drug therapy
LDL goal: <130 Initiate TLC: > 130 (*ALL* pt regardless of LDL) Consider Drug Therapy: >130
For patients that have No CHD but 2 risk factors, what is the following: (1) LDL goal (2) Initial TLC (3) Consider drug therapy
LDL goal: <130 Initiate TLC: >130 Consider drug therary: >160
For patients that have NO CHD and 0-1 risk factors, what is the following: (1) LDL goal (2) Initiate TLC (3) Consider Drug therapy
LDL goal: <160 Initiate TLC: >160 Consider drug therapy: >190
Before starting a patient on statins or fibrates, what lab must your order?
LFTs - can induce transient elevation in serum transaminases
What is the *acute tx* for CHF?
LMNOP L - Lasics M - Morphine N - Nitro O - O2 P - Position
What is initiated in all patients with an MI to prevent the progreessio of thrombus, however has NOT been shown to decrease mortality?
LMWH (enoxaparin)
What are the EKG findings for DCM?
LVH, LAE, Q waves, poor R wave progression, A.Fib LVH --> R in V5 (or V6) + S in V1 (or V2) > 35 mm LAE --> Lead II - M or noted appearance, V1 - biphasic
What organism should be ruled out with Perioral dermatitis?
Laboratory studies: Culture to rule out staphylococcal infection
What labs are appropriate to order for Rheumatic heart disease?
Labs: ASO and Anti-DNase B titers, Acute phase reactants
Ewing Sarcoma Clues
Lamellated or onion skin
Vasculitis
Large vessel- Giant Cell Arteritis Medium vessel- Polyarteritis Nodosa **Associated with Hepatitis B 30% of the time Small vessel- many disorders **Asscociated with ANCA (anti-neutrophil cytoplasmic antibodies) or Hepatitis C infection
Arterial Insufficiency:
Lateral Malleolus Painful
Dupuytren's Contracture of Feet is called
Ledderhose Disease
What are the clinical sx for MR?
Left Sided HF Sx Palpitations Pulmonary Edema
An anterolateral MI is due to ischemia of which artery & changes will be seen in which ECG leads?
Left circumflex, I, aVL, V4-V6
A large anterior MI is due to ischemia of which artery & changes will be seen in which ECG leads?
Left main, V1-V6
What are the sx of left-sided heart failure? What is the MCC of left-sided HF?
Left sided heart failure - dyspnea, orthopnea, paraxoysmal noctural dyspnea, nocturnal cought (nonproductive) Adv CHF - confusion and memory impairment NYHA Class IV - diaphoresis and cool extremeities at rest MCC = CAD/HTN
What is the MC cause of right-sided HF?
Left-sided HF
What is Leriche's syndrome?
Leriche's syndrome: atheromatous occlusian of distal aorta just above bifurcation causing bilateral claudication, impotence, and absent/ diminished femoral pulses
Lichen Planus
Lichen planus (LP) is a pruritic, chronic inflammatory dermatosis resulting from keratinocyte apoptosis that affects the skin, mucous membranes, genitalia, scalp (lichen planopilaris), and nails.
What are 2 conditions with high ammonia levels?
Liver-failure End-stage cirrhosis
Osteomyelitis in children affects
Long bones (tibial)
What are the long term and short term goals for treatment in dyslipidemia?
Long term: reduce coronary heart disease Short Term: reduce LDL levels
prescription treatment of delerium in a parkinson's patient
Lorazepam (avoid antipsychotics because they block dopamine).
What are the EKG findings for constrictive pericarditis?
Low QRS voltages, generalized T wave flattening or inversion, left atrial abnormalities Atrial fibrillation occurs in fewer than half of all patients.
How are uric acid stones treated?
Low purine diet, potassium citrate diet or allopurinol
What is the Tx (2 things) of minimal change disease?
Low salt diet Steroids
What is the MOA for fibrates (gemfibrozil)?
Lowers VLDL and TG, increses HDL Used if Statins, Niacin, and BAS dont work
Although Amiodarone is used to control numerous rhythms (A.Fib,V. Fib, V. Tach), why do most professionals call it "Ami-terrible"?
MAJOR AE = TORADES DE POINTE (B/C OF PROLONGED QT) Called "Amiterrible" b/c it has multiple AE that can affect multiple organs: Cardiac (bradycardia, prolonged QT, torsades); Heptatic toxicity, Thyroid (hyper and hypo); Pulmonary toxicity; Dermatolgic; Neuro; and Opthalmic (corneal deposits and optic neuritis); GI upset
which pharm treatment is more benificial for atypical depression (hypersomnia, hyperphagia, mood reactivity, long-standing interpersonal rejection sensitivity)
MAOIs (phenelzine, selegiline)
treatment for nightmare disorder that does not improve with age
MAOIs and other antidepressants, suppress REM
What is the MCC of Restrictive CM?
MCC = Amyloidosis Other common causes: Sarcoidosis, hemochromatosis, scleroderma, carcinoid syndrome, idiopathic Overall is caused by an infiltrating disease
What is the *MOST COMMON CAUSE* of DCM?
MCC = CAD w/ prior MI (from Stepup to Med) and Alcohol (from Ovalle)
What is the *MOST COMMON CAUSES* of MR?
MCC = MVP (according to ovalle)
What is the acute management for a NSTEMI/Non-Q wave MI?
MONA (THROMBOLYTICS ARE C/I) BB/CCB/STENT
What is the initial treatment of an MI upon admission?
MONA - Morphine, Oxygen, Nitro, Aspirin
What is the treatment of angina?
MONA--> Morphine Oxygen Nitro ASA
In a papillary muscle infact, what is the common resulting murmur and what is the management
MR ECHO - Emergeny MV replacement - afterload reduction w/ nitroprusside or intra-aortic balloon pump.
Name the holosystolic murmurs.
MR/TR/VSD
Osteomyelitis Dx
MRI
L'hermitte sign - electric feeling down back w/ neck flexion
MS
What is the pathophysiology behind MVP?
MVP is defined as the presence of excessive or redundant mitral leaflet tissue due to myxomatous degeneration of mitral valve leaflets and/or chordae tendineae. The redundant leaflet(s) prolapse toward the left atrium in systole, which results in the auscultated click and murmur.
If cardioverion is sucessful in V.Fib, what is your following management options for this patient.
Maintain continuous IV infusion of the effective antiarrhythmic agent. IV amiodarone has been shown to be the most effective. Implantable defibrillators have become the *MAINSTAY OF CHRONIC THERAPY* in patients at continued risk for VF. Long-term amiodarone therapy is an alternative.
clinical findings in male erectile disorder
Major depressive disorder, social anxiety, PTSD can be associated *MS, DM, hypogonadism may be organic causes *meds??? BP, antidepressants, antipsychotics? Standard labs: serum free testosterone and serum prolactin, especially if complaints of libido are also present Others: fasting glucose and lipids
Osteosarcoma most common bone tumor
Male> female Age 10 and 25
__________ is seen in nephritic syndrome.
Maltese cross
What patient population is is common to find MVP?
Marfan's syndrome, osteogenesis imperfecta, and Ehlers-Danlos syndrome. Presentation: "Tall, slender, young pt, most are ax but can have CP, angina, palpitations, syncope"
Compartment syndrome Dx
Measure compartment press +if >40
What methods are used for prophylaxis post-surgery?
Mechanical • Leg elevation, graduated compression stockings, early ambulation • Pneumatic compression boots-intermittently inflate and deflate, causing compression of the limb, usually the calves; very effective Pharmacologic • Heparin or LMWH: Unfractionated heparin or LMWH postoperatively until patient is ambulatory • Combination of pneumatic compression devices and pharmacologic prophylaxis may provide the greatest protection
Venous Stasis
Medial malleolus Painless
Venous ulcers are *MOST COMMONLY* located where?
Medially from the instep of the foot to above the ankle, overlying the incompetent perforator vein
Nerve involved with Smith and colles
Median Nerve injury common
What are the surgical and medical management options for MS?
Medical a. Diuretics-for pulmonary congestion and edema b. Infective endocarditis prophylaxis c. Chronic anticoagulation with warfarin is indicated (especially if patient has AFib) Surgical (for severe disease) a. *Percutaneous balloon valvuloplasty* usually produces excellent results. b. Open commissurotomy and mitral valve replacement are other options if valvotomy is contraindicated.
What is the tx for truncus arteriosus?
Medical: digitalis/diuretics; Surgical: Remove the PA from the TA, Replace truncal valve, Close VSD if was open
What is the causes of Stevens-Johnson Syndrome?
Medications are the leading trigger of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) in both adults and children
Treatment of Acne vulgaris
Medications that are effective for comedonal acne include *topical retinoids, benzoyl peroxide, azelaic acid, and salicylic acid. For patients with comedonal acne who desire treatment, we suggest topical retinoids as first-line therapy*
Barrett's esophagus refers to an abnormal change (__________) in the cells of the inferior portion of the esophagus.
Metaplasia
What is the *MCC* of neoplasms of the heart?
Mets from other primary tumors - lung, breast, skin, kidney, lymphoma, Karposi sarcoma (AIDS)
What is an important diabetic lab test that should be done every 6-12 months?
Microalbumin
If a patient presents superficial thrombophlebitis that occurs in different locations over a short periods of time, what condition should you be thinking of?
Migratory Superifical Thrombophlebitis - secondary to occult malignancy (*MC* the pancreas)
What is the initial LT treatment for mild CHF (I/II)?
Mild restriction of sodium intake (<4 g Na+) Physical activity Loop Diuretic ACEi Loop and ACEi are the *FIRST LINE TREATMENTS*
evaluation of dementia
Mini-cog (clock face and 3 words) - distinguishes from depression which affects longer term memory first. Mini Mental Status Exam (MMSE) Montreal Cognitive Assessment (MOCA) - better with educated or English-speaking patients FOTO test - better for ESL patient
what drug is serotonergic and andronergic (alpha 2)
Mirtazapine (Remeron)
Rheumatic heart disease MC affects which heart valve?
Mitral (M-A-T-P)
What is the *MOST COMMON* associated vavular abnormality associated w/ Rheumatic Fever?
Mitral Stenosis
A loud holosystolic murmur that radiates to the axilla is __________.
Mitral regurg
If a pt develops a new murmur it is most likely to be __________.
Mitral regurg
A 4th heart sound may be hear in pts with which conditions?
Mitral regurg, decreased ventricular compliance
A mid-diastolic murmur with an opening snap is __________.
Mitral stenosis
A young female with atypical chest pain and a murmur most likely has __________.
Mitral valve prolapse (MVP)
What two forms of heart block require a pacemaker?
Mobitz II (second degree heart block) 3rd degree heart block (complete)
Contact Dermatitis treatment: The treatment goals in patients with irritant contact dermatitis are to restore a normal epidermal barrier and then protect it from the irritating substance. Decreasing exposure to soap and water and increasing the use of emollients (and gloves in hand dermatitis) may control a chronic irritant contact dermatitis.
Moisturizers or topical corticosteroids + irritant avoidance In more severe cases, potent corticosteroid ointments under occlusion may be necessary to treat the acute phase; anything that prevents evaporation can be used for occlusion, including plastic wrap, Telfa gauze dressings, cotton gloves, or petroleum jelly. Systemic corticosteroids are not helpful in chronic cases unless corrective measures are taken to avoid the offending contactants.
Systemic Lupus Erythematosus presentation "MD SOAP Chair"
Molar Rash Discoid (Patchy) Rash Serositis (Pleuritis, pneumonitis, *pleural effusion* Oral Ulcer Arthriitis (Symmetric PIP, MCP, wrist, knee, feet) Photosensitivity CNS (Sz, stroke, psychosis, neuropathy Heart and hematologic (pericarditis, myocarditis ANA Immunolgic issues ( Anti-smith, Anti-dsDNA) Renal issue (increase BUN, serum creatinine, proteinuria
small to large blue to black macules on back & buttocks
Mongolian spots
Rheumatoid Arthritis H&P
Morning stiffness for 1 hour
allow infant's head to drop 1-2cm & watch infant abduct shoulders & elbows, and extending fingers, followed by flexing; disappears by 3-4mths
Moro/startle reflex
Describe the clinical features of MVP?
Most are *ASX* - palpitations and atypical CP can occur and TIAs from MV emboli (VERY RARE)
What are the sx of hyperlipidemia?
Most are Asx Severe: (1) Xanthelasma - yellow plaques on eyelids (2) Xanthoma - hard, yellowish masses found on tendons (finger extensors, achilles tendon, plantar tendon) (3) Pancreatitis w/ severe TG elevation
Dupuytren's Contracture (claw hand)
Most often the 4th and 5th finger
clinical findings & dx criteria for Conversion disorder
Motor and/or sensory symptoms suggestive of a neurologic disease (Paralysis, blindness, mutism, seizures, hemianesthesia, ataxia) Often after an acute stressor Typical reported emotional states: Overwhelmed by stressors (but not necessarily by neurologic symptoms) or "La belle indifference"/lack of stress in life
Shoulder fracture usually caused by
Motorcycle crash, MVA ejection
PANCE description of Actinic Keratosis
Multiple discrete, flat or elevated, keratotic lesions that have an erythematous base covered by scale. Firm, rough, indurated, white-topped, scaly, hyperkeratotic, "sandpaper" feel, erythematous papules, may be of varying colors
Describe the patho behind V. Fib?
Multiple foci in the ventricles fire rapidly, leading to chaotic quivering of the ventricles and NO CO. Reoccurance is high if *unrelate* to an MI and has a worse prognosis --> Pt will need a ICD/Amiodarone Fatal if untreated can result in "SUDDEN CARDIAC DEATH"
Systemic Lupus Erythematosus Facts
Multisystem autoimmune disorder 9:1 F:M Diagnosis is based on clinical and laboratory findings (fevers, arthritis, mucocutaneous, ANA) Spectrum disorder
factitious disorder w/primary physical complaints
Munchausen syndrome
Polymyositis and Dermatomyositis Dx
Muscle biopsy
Polmyalgia Rheumatica
Muscle pain and freq Associated with *Temporal Arteritis*
Polymyositis and Dermatomyositis H/P
Muscle weakness, Cutaneous manifestion: Red heliptropic rash on the face, violet discoloration of eyelid Gottron's papules
Fibromyalgia trigger points
Must have 11 or more of the 18trigger points for diagnosis
What is the MC cause of atypical pneumonia?
Mycoplasma
MC type of atypical CAP
Mycoplasma pneumoniae
Lyme disease 2º
Myocarditis, Heart Block, Meningitis, Bell Palsy Bell Palsy: Painless swelling, non-tendering swelling and erythema of the face.
Which cardiac marker is first to rise?
Myoglobin
Septic Joint and Septic Arthritis Tx
N. Go....Ceftriaxone Chlamydia...Doxycycline Staph...Vancomycin
Septic Joint and Septic Arthritis in active pt
N. Gonorrhea
What are the S&S of Dig toxicity?
N/V Anorexia Cardiac: ectopic ventricular beats, AV block, Afib CNS: green/yellow vision, disorientation
4 stages of normal sleep
N1 - light sleep (5% of sleep) N2 - moderate sleep (50%) N3 - deep sleep/slow wave (restorative) (20%) REM - dream sleep. active brain, inactive body. (25%)
MOA of Mamentine
NMDA receptor antagonist
What is the tx for superfiical thrombophlebitis?
NO anticoagulants needs Localized - Analgesic and activity Severe (w/ pain and cellultiis) - bed rest, elevation, hot compression. When sx resolve ambulation w/ elastic stockings. Abx are *NOT* neeed unless supporitive and I&D is needed.
SLE Treatment
NSAIDs Steroids Hydroxychloroquine (anti malarial drug, DMARD)- rare, dose dependent retinal toxicity, requires yearly eye exam Immunosuppressives- azathioprine, mycophenolate mofetil, clyclophosphamide
Psoriatic Arthritis Tx
NSAIDs, methotrexate
In cardiac tamponade, what findings can be found for their pulse?
Narrow pulse pressure (due to decrease SV) *PULSUS PARADOXUS (PATHOGNEUOMIC)* - exaggerated decrease in artierial pressure during inspiration (>10 mm Hg drop); can be detected by a decrease in the amplitude of the femoral/carotid pulse during inspiration - pulse gets strong during expiration and weak during inspiration
Shoulder impingement testing
Neer's impingement test
Legionella, E. coli, pseudomonas, klebsiella, Bordatella, & Hemophilis are examples of gram __________ rods.
Negative
Neisseria & meningitides are examples of gram __________ cocci.
Negative
Nikolsky's sign is __________ with Bullous Pemphigoid.
Negative
What is the condition called when collecting ducts of the kidneys are unable to respond to ADH?
Nephrogenic Diabetes insipidus (DI)
Café' au lait patches & rubbery skin nodules
Neurofibromatosis
What are 2 major side effects of Streptomycin?
Neurotoxicity Ototoxicity
What is the management option for hemodynamically stable sustained VT pts w/ SBP of > 90?
New ACLS says IV Amiodarone, IV procaimamide, or IV sotaolol
What is the *TOC* for the TG>500 mg/dl?
Niacin is the *first line* drug for hypertriglyceridemia 2nd line: Gemfibrozil
What management can be used for prinzmetal's angina?
Nitrates, CCB
What is the Tx of aortic dissection?
Nitride & BB
Tophi
Nodules that form from long standing high uric acid levels
what are the possible clinical findings for myocarditis?
Non-specific viral syndrome - pleuritic chest pain Dx: tachy, friction rub, S3 gallop, MR/TR, nonspecific T-wave changes, elevated troponin I and CK-MB w/ myocardial necrosis
What is the normal ejection fraction? What is the ejection fraction value that corresponds to increased mortality?
Normal = > 50% <50% is associated w/ mortality
What are the CXR findings for tricupsid atresia?
Normal size, "Boot-shaped", Concave ht border; ↓ pulm vasculature.
What type of anemia do renal failure pts get? Why?
Normocytic anemia EPO production slows & bone marrow becomes depressed
clinical findings & dx criteria for Somatization disorder
Numerous, multi-system complaints "+ ROS" Often poor historians with vague and/or contradictory information Onset before 30y/o Chronic Can be disabling Worse during times of stress
Coin-shaped/discoid plaques w/ vesicles & papules
Nummular eczema
Influenza - tx (at-risk child 1-5 yr with type A or B)
ONLY treatment: *Oseltamivir* (tamiflu)
Influenza - tx (at-risk child >5 yr with type A or B)
ONLY treatment: *Zanamavir*
pervasive orderliness, perfectionism, inflexibility, rigid, stubborn
Obsessive compulsive personality disorder (egosyntonic not distressing to patient) disorder (egodystonic distressing to pt)
What is the *MOST COMMON* age to see still's murmur?
Occurrence: 3-6 y.o.; occasionally in infancy
What is the *MOST COMMON* age to see a pulmonary ejection murmur?
Occurrence: 8-14 y.o. (school age) "Think - school aged kid getting "ejected" from school"
The infantile phase: Typically lasts from shortly after birth to 2 years of age
Often begins with dermatitis on the cheeks, forehead, and scalp with significant involvement of extensor surfaces of the limbs Commonly a prominent vesicular component with edema, weeping, and crusting Facial atopic dermatitis may be worse while infants are teething and with trials of new foods *Extensor surface involvement may be related to the onset of crawling*
Psoriatic Arthritis
Often begins years after onset of skin disease Sausage digit or dactylitis (arthritis of flexor tendon) Psoriatic arthritis and reactive arthritis are the most common causes
What is the 1st sign of acute renal failure (ARF)?
Oliguria
Oliguria is a urine output < _____ cc/24 hrs. Anuria is a urine output < _____ cc/24 hrs.
Oliguria--> 500 Anuria--> 50
What is a major side effect of Ethambutol?
Optic neuritis
Inflammatory disorders x-ray findings
Osteopenia erosions
Four characteristic x-ray findings of OA
Osteophytes Subchondral cysts Asymmetric joint space narrowing Sclerosis
Degenerative/mechanical arthritis x-ray findings
Osteophytes sclerosis joint space narrowing (asymmetric) subchondral cysts
What is the *MOST COMMON* type of ASD?
Ostium Secundum (*MC*) - occurs in the CENTRAL portion of the interarterial septum Osteum primum - occurs LOW in the septum Sinus venosus defects - occurs HIGH in the septum
Other triggers of contact dermatitis
Other common sensitizers in the US include *nickel (jewelry)*, formaldehyde and quaternium-15 (clothing, nail polish), fragrances (perfume, cosmetics), preservatives (topical medications, cosmetics), rubber, and chemicals in shoes (both leather and synthetic). Hypersensitivity to a number of medications may also occur, including topical hydrocortisone, topical antibiotics (eg, neomycin and bacitracin), benzocaine, and thimerosal. Allergens found in shoes include rubber chemicals, adhesives, and leather components. Although frequently considered, laundry detergents are a rare cause of allergic contact dermatitis.
QTc Prolongation: Women: > _____ Men: > ______
Overall think >0.48sec Women: *> 0.46 sec* Men: *> 0.44 sec*
__________ increases longevity in COPD pts.
Oxygen
String of pearls on ovarian US
PCOS
machine like murmur
PDA
Name the continuous murmurs.
PDA & Venous hum
Hampton's hump - peripheral wedge shape - pulmonary infarct
PE
Westmark sign - decreased pulm vascularity on CXR
PE
In a pt with Sarcoidosis what would PFTs and a CRX show?
PFT--> restrictive lung disease CXR--> B/L hilar adenopathy
Chandelier sign
PID
Bouchard's nodes
PIP joint
PT measures __________ factors. PTT measures __________ factors.
PT--> extrinsic (PeT) PTT--> intrinsic (PiTT)
tx of hyperthyroid is first trimester
PTU
thyroid storm tx
PTU and then iodine (iodine suppresses TSH release) Beta blocker dexamethasone
__________ typically presents with burning retrosternal chest pain.
PUD
Treatment for Sick Sinus Syndrome
Pacemaker and rate controlling meds
Polmyalgia Rheumatica H&P
Pain and stiffness of the shoulder and pelvis gridle
clinical findings for Pain disorder
Pain is the focus of clinical attention and not fully accounted for by a medical condition Psychological factors associated with initiation, exacerbation, and/or maintenance of pain F > M, Often chronic and disabling
Homan's Sign
Pain with dorsiflexion of the foot Sign of DVT
Compartment syndrome H&P
Pain with passive motion, pallor, pulselessness, paralysis, paresthesis, poikilothermia
What is the classic symtpoms for superficial thrombophlebitis?
Pain, tenderness, induration, and erythema along the course of the vein AND a *tender palapable cord*
Ransen Criteria: Leukocytosis, hyperglycemia, elevated LDH, elevated AST, falling hematocrit, rising BUN, falling calcium, arterial Po2 <60 mmHG
Pancreatitis
The pain of _________is relieved by leaning forward and pulling knees to chest. May radiate to the back and be associated with N/V.
Pancreatitis
In a pt with HTN emergency __________may be seen on ophthalmologic examination.
Papilledema
What is Croup caused by and what are 2 major S & S?
Parainfluenza Inspiratory stridor Barking cough
Croup - cx
Parainfluenza types 1 & 2
What are the signs of MS?
Parasternal life Murmor: • The *opening snap* is followed by a low-pitched diastolic rumble and presys- tolic accentuation. This murmur increases in length as the disease worsens. • Heard best with bell of stethoscope in left lateral decubitus position
Pill rolling tremor
Parkinson's disease
How might bronchopneumonia show on CXR? What might cause it?
Patchy infiltrates Mycoplasma Viral
What is the cause of *eisenmenger's syndrome* and what are the sx?
Patho: Complication of uncorrected congenital ht. anomalies produces L-to-R shunting, Increased pulm resist. over time reverses shunt to a R-to-L (causing Pulm HTN), Deoxygenated blood enters systemic circ → hypoxia S&S: Cyanosis, Clubbing, Polycythemia
What is the patho and S&S of hypoplastic left heart syndrome?
Patho: Hypoplasia and underdevelopment of LV S&S: MV/AV are hypoplastic, Discrete coarc or aorta present, Peripheral pulses weak/absent
What is the patho underlying VSD?
Patho: L-to-R shunt, 2x blood in LA/LV, RV hypertrophy due to ↑ pulm resist and ↓ blood flow in lungs
What is the pathophysiology behind PDA?
Patho: Pulm resistance ↓ → L-to-R shunt, ↑ pulm blood flow → ↑ workload on L side of ht and ↑ venous return to LA
Name the EKG findings that are characteristic of VT.
Pathogneuomic = *WIDE AND BIZARRE QRS COMPLEXES* QRS can be monomorphic or polymorphic *MONOMORPHIC* - all QRS complexes are *identical* *POLYMORPHIC* - the QRS complexes are *different* - beat to beat variation
Contact Dermatitis: History and examination
Patients generally report pruritus, burning, erythema, swelling, and blistering with acute contact dermatitis, and pruritus, burning, erythema or hyperpigmentation, fissuring, and scaling with chronic contact dermatitis.
Dyshidrotic dermatitis Treatment
Patients unresponsive to lifestyle measures alone should be started on topical corticosteroid therapy.
How pts monitor asthma at home
Peak expiratory flow
Psoriatic Arthritis Radio finding
Pencil in cup deformities, Sausage finger
Name the causes of cardiac tamponade.
Penetrating (less commonly blunt) trauma to the thorax, such as gunshot and stab wound Iatrogenic: central line placement, pacemaker insertion, pericardiocentesis, etc Pericarditis Post MI w/ free wall rupture
What is the STANDARD OF CARE for CAD?
Percutaneous coronary intervention (PCI)
________is defined as any cause of acute pericarditis that can lead to exudation of fluid into the pericardial space - can occur in associateon w/ ascites and pleural effusion in salt and water retention states such as CHF, cirrhosis, and nephrotic syndrome.
Pericardial effusion
Sharp, stabbing pain relieved by sitting up/leaning forward, & worse with movement.
Pericardial friction rub
A globular heart on CXR represents __________.
Pericardial tamponade
Persistent ST elevation in all leads alone with depressed PR intervals is likely to be __________.
Pericarditis
__________ is caused by coxsackie B virus and is typically seen post-MI.
Pericarditis
generalized ST segment elevations
Pericarditis
What are Cheyne-Stokes respirations?
Periodic breathing near death (i.e. HF, coma, neuro damage)
What lab is elevated with Atopic dermatitis?
Peripheral IgE levels may be elevated, but this is not a standard test for the diagnosis and Eosinophilia.
What are the S&S of right sided heart failure? What is the MCC?
Peripheral Pitting Edema (secondary to venous insuff) Nocturia (due to increased venous return from leg elevation) MCC = Left sided HF or Cor pulmonale (pure) JVD Hepatomegaly/Hepatojugular reflex Ascites Right ventricular heave
What are the S & S of right HF?
Peripheral edema, JVD, hepatojugular reflux (HJR), ascites
Characteristic of Rosacea
Persistent *facial redness, recurrent facial flushing, telangiectasias*, and skin dryness and sensitivity are common features of erythematotelangiectatic rosacea.
dx criteria & findings male orgasmic d/o
Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase during sexual activity that the clinician, taking into account the person's age, judges to be adequate in focus, intensity, and duration *typically reports unable to or takes forever to ejaculate *If neuro etiology is suspected, pudendal nerve conduction studies and evoked potential studies can be ordered (may be psychological or medication side effects)
dx criteria female orgasmic d/o
Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. Women exhibit wide variability in the type or the intensity of stimulation that triggers orgasm. Dx should be based on clinician's judgment that the woman's orgasmic capacity is less than what would be reasonable for her age, sexual experience, and adequacy of sexual stimulation she receives
Butterfly pattern on CXR
Pertussis
What is Bordatella usually a culprit of?
Pertussis (Whooping Cough)
Dupuytren's Contracture of Penis is called
Peyronie's Disesse
If a patient is unable to exercise, what procedure can you use as a screening test for CAD?
Pharmacological Stress Test w/ IV adenosine, dipyramidole, dobutamine
Pt presents with HTN that is not resolved by TLC or pharmacological therapy...what 2 conditions should ALWAYS be on your differential diagnosis?
Pheochomocytoma Renal Artery Stenosis
__________ may present with labile (borderline) HTN, tachycardia, sweating, tremors. What is it caused by?
Pheochromocytoma, excess epi/norepi
galactorrhea, bitemporal hemianopia, oligomenorrhea/amenorrhea
Pituitary tumor
Pityriasis Rosea
Pityriasis rosea (PR) is an acute, self-limited, exanthematous skin disease characterized by the appearance of slightly *inflammatory, oval, papulosquamous lesions on the trunk* and proximal areas of the extremities
Which type of psoriasis has multifactorial inheritance (30% with family history and HLA markers)?
Plaque psoriasis
What does Lights' criteria state about exudative pleural effusions?
Pleural fluid protein/serum protein ratio > 0.5 Pleural fluid LDH/serum LDH ratio > 0.6 Pleural fluid LDH > 2/3 upper limit of normal serum LDH
Sharp & severe pain, worse with deep inspiration & chest wall movement.
Pleuritic pain
Pneumonia w/ HIV - what organism
Pneumocystis jiroveci
What are 6 causes of EXUDATIVE pleural effusions?
Pneumonia (PNA) Cancer (CA) TB Collagen vascular disease Viruses CABG
Which 3 immunizations should be given to renal failure pts?
Pneumovax Prevnar Influenza
Broad casts seen in the urine of a renal failure pt = __________?
Poor prognosis (aka = renal failure casts)
Listeria, Clostridia, & Corynebacterium are examples of gram __________ rods.
Positive
Nikolsky sign is __________ with Stevens-Johnson Syndrome
Positive
Nikolsky's sign is __________ with Pemphigus Vulgaris.
Positive
Staph aureus, Staph epi, Step pyogenes, & Step pneumonia are examples of gram __________ cocci.
Positive
PCL
Posterior drawer test
Where is ADH secreted from?
Posterior pituitary gland
If a pt presents with cola-colored urine and HTN think of __________.
Poststreptococcal glomerulonephritis (PSGN)
__________ is a possible complication of strep pharyngitis that is NOT prevented by treatment.
Poststreptococcal glomerulonephritis (PSGN)
MI is associated with 30% mortality, 1/2 of the deaths are (pre/post) hospital?
Pre
FeNa < 1% = __________ FeNa > 2% = __________
Pre-renal failure (hypovolemia) Renal failure
PMR treatment
Prednisone 7.5-20mg/day Increase weekly until symptoms are controlled Maintain dose for 2-4 weeks Taper SLOWLY MTX may be steroid sparing
GCA treatment
Prednisone40-60mg/day Taper to 20mg after 2 months SLOW taper D/C after 1-2 years Low dose aspirin recommended
Before instituting drug therapy for HTN in a female what must you *ALWAYS* do?
Pregnancy Test Thiazides, ACEi, CCB, & ARBs are *CONTRAINDICATED* in pregnancy BB and hydralazine are safe!
clinical findings for Hypochondriasis
Preoccupation with (fear of having) a specific disease Misinterpretation of bodily symptoms M = F Episodes lasting months to years Stress-induced exacerbations
dx criteria body dysmorphic disorder
Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The preoccupation is not better accounted for by another mental disorder (e. g., dissatisfaction with body shape and size in anorexia nervosa).
clinical findings for Body dysmorphic disorder
Preoccupation with having a profound bodily deformity (not evident to others) Exception: Anorexia nervosa F > M Depression and anxiety common Need to be treated Insidious onset with gradual worsening Surgical intervention almost never successful but serotonergic agents may be helpful
Stevens-Johnson Syndrome Clinical Features:
Prodrome: Fever, Photophobia and conjunctival itching or burning, pain on swallowing may be early symptoms of mucosal involvement. Malaise, myalgia, and arthralgia are present in most patients.
Rheumatoid Arthritis Facts
Profound morning stiffness Chronic Inflammatory Symmetrical Typically involves PIP, MCP, Wrist, MTP (wrist 80%, PIP and MCP 90%) **Does not affect DIP joints and L/S spine is usually spared** F>M Muscle atrophy, weakness, weight loss, fever **exercise helps**
most common pituitary tumor
Prolactinoma
What is seen on CXR of pulmonary HTN?
Prominent pulmonary arteries
Influenza - tx (at-risk child 1-12 yr with type A)
Prophylaxis AND treatment: *Amantadine*
Influenza - tx (at-risk child >12 yr with type A)
Prophylaxis AND treatment: *Ramantadine*
What is the treatment for hypoplastic left heart syndrome?
Prostaglandin, Diuretics, Surgery, *Cardiac Transplantation*
What is the treatment for COA?
Prostaglandins → reverses closing of PDA temporarily, Surgery or cath techniques provide *definitive* repair
What is the HALLMARK of renal failure?
Proteinurea
What is the HALLMARK of renal disease?
Proteinuria
What is the triad of Nephrotic syndrome (leaky)?
Proteinuria Edema Hypoalbumineamia
Minimal change disease in children is classified by what 5 things?
Proteinuria Hematuria Fat Casts Crystals
Polymyalgia Rheumatica (PMR)
Proximal muscle aching and stiffness (neck, shoulders, hips, thighs) Systemic symptoms- fever, weight loss, malaise Morning stiffness- getting out of bed, combing hair, rising from chair
dx of sideroblastic
Prussian blue staining
Pseudogout
Pseudogout can be distinguished from gout by joint fluid analysis. It has positively birefringent crystals that are rhomboidal or square shaped and made from calcium pyrophosphate
etiology of Somatization disorder
Psychological distress manifest as physical symptoms: a defense mechanism Rewards of Somatization = Avoidance of inciting psychological conflict (kept unconscious) & attention is focused on physical symptoms
Describe the psychotherapeutic interventions used for factitious disorder and malingering
Psychotherapy needs to be supportive, empathic, and nonconfrontative - not candidates for confrontative insight-oriented psychotherapy and may decompensate in such treatment options: individual therapy, Family Therapy to address conflicted interpersonal relationships, face-saving opportunities, Therapeutic Double-Binds
What are the 3 parts of Horner's Syndrome?
Ptosis Miosis Anhydrosis
What clinical couse does ASD follow?
Pts are usually asx until middle age (~40 y/o) >40 - sx may include DOE, fatigue, and exercise intolerance Mild = normal lifespan
what is the pathphysiology underlying tetrology of fallot?
Pulm stenosis ↓ blood to lungs/amount of blood to L ht, R-to-L blood thru VSD allows deoxygenated blood to mix w/ oxygenated blood → hypoxemia, If ductus arteriosus remains open then pulm blood flow is adequate
If the diagnosis is unclear from the pts VS and clinical presentation, how can you diagnose hypovolemic shock?
Pulmonary Artery Cath
Based on the listed sx, what murmur is being described: Systolic Turbulence of left or right pulmonary artery branch Medium pitch Loudest: RUSB/LUSB Transmits well to left and right chest, axillae & back A. Still's Murmur B. Pulmonary ejection murmur C. Pulmonary flow murmur D. Venous hum E. Carotid Bruit
Pulmonary Flow murmur
What is the GOLD STANDARD for dx of a PE but is rarely done?
Pulmonary angiography
___________ is the term for when the heart beat is weaker during inspiration.
Pulsus paradoxus
What are the 5 most common S & S of pericarditis?
Pulsus paradoxus Friction rub JVP Pleuritic pain ECG changes
What is the *MOST COMMON CAUSE* of inpatient mortality post-MI?
Pump Failure (CHF) Mild: tx w/ ACEi and Diuretic Severe: can lead to cardiogenic shock - hemodynamic monitoring
artery posterior heart, AV node
R coronary artery
artery posterolateral surface of heart
R coronary artery
RBC casts are seen in __________. WBC casts are seen in __________.
RBC--> Glomerulonephritis (GN) WBC--> Pyelonephritis
An inferior MI is due to ischemia of which artery & changes will be seen in which ECG leads?
RCA, II, III, aVF
Radial Head Subluxation "Nursemaid's Elbow
Radial head released from Annular Ligament
What can be used to precisely measure the EF and left ventricular function?
Radionucleotide ventriculography using technetium-99m
Plaque psoriasis
Raised inflamed plaque lesions with a superficial silvery-white scaly eruption. The scale may be scraped away to reveal inflamed and sometimes friable skin beneath.
what are factitious disorders?
Rare psychological disorders Symptoms or evidence of disease are intentionally induced or produced goal is to "assume the sick role" Symptoms typically physical but can mimic psychiatric illness ex: "Münchausen Syndrome"
What is more important for cardiac tampondae - Rate or Amount?
Rate 200 mL of fluid that develops rapidly can cause cardiac tamponade 2L of fluid may accumulate slowly before cardiac tamponade occurs. When fluid accumulates slowly, the pericardium has the opportunity to stretch and adapt to the increased volume
In a hemodynamically stable patient, what management steps should you take?
Rate Control w/ CCB Duration of A.Fib <48 hours --> Cardioversion Duration of A.Fib > 48 hours --> Anticoagulate x 3 weeks w/ Warfarin (INR 2-3) then cardiovert or Duration of A.Fib > 48 hours --> get a TEE --> If thrombosis in left atrium then anticoagulate x 3 weeks and then cardiovert; If no thrombis in left atrium then cardiovert immediatly.
etiology of Conversion disorder
Reason/reward: Unconscious avoidance of psychological conflict Symbolic meaning in some F >> M Lower SES and educational level
On ophthalmological exam a pt with recent onset HTN will show __________. A pt with months/years of HTN may have __________. A pt with severe/ accelerated HTN may present with __________.
Recent--> copper wire Months/years--> A-V nicking Severe--> cotton wool spots, hard exudates
vaginismus
Recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse *hypothesized to be a conditioned anxiety reaction due to previous painful intercourse or sexual abuse *pt reports inability to achieve vaginal penetration *gynecologist may have observed pt unable to assume or maintain dorsal lithotomy position for pelvic
interventions for Somatization disorder
Regularly scheduled visits with one PCP (avoids need for pt to develop new symptoms & unnecessary work up) focused exams, ask about psychosocial factors & be empathetic pt education: goal is management of symptoms rather than cure Avoid premature psychiatric referral--Must happen after rapport and trust are established therapy may decrease somatization in some pts with time
Sausage digits
Reiter's syndrome
What is the *MOST COMMON* location for an abdominal aortic aneurysm (AAA)?
Renal Arteries and Iliac Bifucation
What is the *MOST COMMON CAUSE* of secondary HTN?
Renal Artery Stenosis
How does aldosterone affect BP?
Retains sodium--> Water retention--> Elevates BP
Roth Spots
Retinal hemorrhages with pale centers seen on fundoscopic exam - sign of *endocarditis*
vein dilation, hemorrhage, cotton-wool spots, acute vision loss
Retinal vein occlusion
decreased head circumference per ht and wt advances as well as loss of previously learned behaviors, social interactions,
Rett's disorder
What is the *MOST COMMON CAUSE* of MS?
Rheumatic Heart Disease Rheumatic heart disease causes an immune mediated damage to the MV which leads to scarring and narrowing of the MV orifice - additionally anything that increases flow across the MV exacerbates pulmonary venous HTN and ass sx
Lab Tests for RA
Rheumatoid Factor (RF)- 80-90% specific, 60-70% sensitive Anti-citrullinated protein antibodies (ACPA)- 98% specific, 68% sensitive Anti-CCP- clinical test is positive in about 70% of patients with RA **Diagnosis is made from H&P
an isolated node transforms into aggressive large cell lymphoma in CLL
Richter's syndrome
Describe the pathophys behind Restrictive CM.
Rigid and non-complient ventricular walls w/ normal systolic fnx, ventricle cavities are small, *diastolic dysfunction*, elevated ventricular filling pressure, LEAST COMMON
Rosacea
Rosacea is a common chronic disorder of the skin characterized by *redness, flushing, and other cutaneous findings that often include telangiectases*, roughened skin, rhinophyma, and general inflammation that can resemble acne
What are the EKG findings for "Torsades de Pointe"?
Rotation of the heart's electrical axis by at least 180° Prolonged QT interval (LQTS) Preceded by long and short RR-intervals Triggered by an early premature ventricular contraction (R-on-T PVC)
What are the S&S, EKG, CXR findings for pulmonary stenosis?
S&S: Asx, Acyantoic, SEM loudest on expiration at ULSB + ejection click, S2 split, Seen in *Noonan syndrome* EKG: RAD, RAH, RVH CXR: Normal heart size, Post-stenotic dilitation of pulmonary artery
"SPHERE" of lung CA complications
S- SVC syndrome (compression of SVC) P- Pancoast's tumor (lung apex) H- Horner's syndrome E- endocrine (Carcinoid syndrome: flushing, diarrhea, telangectasias) R- recurrent laryngeal nerve (hoarseness) E- exudative effusions
Osteomyelitis organisms
S. Aureus and Pseudomonas Shoe and sock involvement Pseudomonas
What is the *MOST COMMON CAUSE* of native valve endocarditis?
S. Viridians is the *MOST COMMON*organism in native endocarditis Other common organisms = S. Epidermidis, and enterococci *HACEK* group of organisms - Haemophillus, Actinobacillus, Cardiobacterim, Eikenella, Kingella
What is the typical pattern that may be seen on ECG in a pt with a PE?
S1Q3
nerves involved in parasympathetic sexual response
S2, 3, 4 pudendal nerve
Excessive secretion of AHD = __________.
SIADH
What condition causes excess ADH & in turn results in a decrease in serum osmolarity?
SIADH
Explain the systemic inflammatory response syndrome (SIRS) and its progression.
SIRS characterized by *two or more* of the following: • Fever(>38°C) or hypothermia(<36°C) •Hyperventilation (rate>20bpm) or Paco2 <32 mmHg • Tachycardia (> 90 bpm) • Increased WBC count (>12,000cell/hpf <4,000cells/hp for >10% band forms) Sepsis • When blood cultures are positive and SIRS is present • Blood cultures: Obtain two sets from two different sites (each set should have aerobic and anaerobic bottles). *Draw blood before antibiotic administration* Septic Shock • Hypotension induced by sepsis persisting despite adequate fluid resuscitation Multiple Organ Dysfunction Syndrome (MODS) • Altered organ function in an acutely ill patient usually leading to death
What are the S & S of left HF?
SOB, PND, orthopnea, rales, S3
1st line tx for depression
SSRI (fluoxetine, paroxetine, sertraline)
pharm treatment of obsessive compulsive disorder
SSRIs clomipramine (seratogenic TCA) (highly seretonin responsive)
(NSTEMI/STEMI) is larger and more devestating to the patient's health?
STEMI
What are the 3 contents of the adrenal medulla?
Salt Sugar Sex
Progressively lengthening PR interval until a QRS is dropped
Second Degree Heart Block, Type 1 (Weickenbach)
PR Interval >0.2 sec, but all the same. Some P waves do not have QRS
Second Degree Heart Block, Type 2
Pertussis - what is the cause of death?
Secondary infection with bacterial pneumonia
If lactates is present think __________.
Sepsis
Bursitis Aspirate to R/O
Septic Arthritis Gout/ Pseudogout
What is the *MOST COMMON CAUSE* of death in the ICU?
Septic Shock
Monoarticular inflammatory joint
Septic joint until proven otherwise. Arthocentesis is mandatory on initial presentation.
What are the S&S of HTN emergency?
Severe HA Visual Disturbances Alt Mentation
Hawkin's Impingment test
Shoulder impingement of the affected rotator cuff muscle
Heart rate varies from fast to slow and back again (Tachycardia - Bradycardia)
Sick Sinus Syndrome
Bone infarction is common with
Sickle Cell disease
What are the clinical features of TR?
Signs and symptoms of *RVF* (ascites, hepatomegaly, edema,JVD) *Pulsatile liver* Prominent *V waves* in jugular venous pulse with rapid y descent *Inspiratory S3* along LLSB may be present *Blowing holosystolic murmur at LLSB, Intensified with inspiration; reduced during expiration or the Valsalva maneuver* Right ventricular pulsation along LLSB AFib is usually present.
70 y/o pt presents with sx of dizziness, confusion, syncope, fatigue, and CHF. You order an EKG and it reveals sinus node dysfunction characterized by a persistant spontaneous sinus bradycardia. What is the most likely diagnosis? Management?
Sinus node dysfunction characterized by a persistent spontaneous sinus bradycardia Symptoms include dizziness, confusion, syncope, fatigue, and CHF. Tx: Pacemaker implantation may be required.
Define Sinus Bradycardia.
Sinus rate <60 bpm: clinically significant when rate is persistently <45 bpm Causes include ischemia, increased vagal tone, antiarrhythmic drugs; may be a normal finding in trained athletes. Can be asymptomatic; patients may complain of fatigue, inability to exercise, angina, or syncope Atropine can elevate the sinus rate by blocking vagal stimulation to the sinoatrial node. A cardiac pacemaker may be required if bradycardia persists.
Polymyositis and Dermatomyositis
Skeletal Muscle Inflammation
Describe the skin changes that are associated w/ chronic venous insuff.
Skin becomes thin, atrophic, shiny, and cyanotic Brawny induration develops w/ chronicity
Osler's Nodes
Small, *painful* nodules on the palmar surface of the fingers and toes -Sign of *endocarditis*
Distal radius w/ volar angulation
Smith's fx
Solitary pulmonary nodule - who is at inc risk for these being malignant?
Smokers, esp. those w/ inc pack yrs
Scaphoid (Fall on outstretched hard)
Snuff box tenderness
Malar rash
Spares nasolabial folds
Rheumatoid Arthritis Labs
Specific: Anti-Cyclic Citrullinated peptide Increase ESR, ANA
Systemic Lupus Erythematosus Lab
Specific: Anti-smith, Anti-dsDNA
What is the diagnostic TEST OF CHOICE for PE?
Spiral CT
__________ angina is typically brought on by exercise & relieved with rest & nitro.
Stable
What is the treatment for nonhemorrhagic tamponade?
Stable - monitor w/ EKG, ECHO, CXR Non-stable: *PERICARDIOCENTESIS* - if no improvement then can do fluid challenge
The pathophysiology of stable vs unstable angina?
Stable: due to increased demand Unstable: reduced resting coronary flow
Etiology of endocarditis for IV drug abuse or prosthetic valves
Staph
Septic Joint and Septic Arthritis most common causes is
Staph
Right sided endocarditis. Bugs and risk factors?
Staph aureus IVDA
What is the *MOST COMMON CAUSE* of prosthetic valve endocarditis?
Staphylococci are the *most common causes* of early-onset endocarditis; symptoms appear within 60 days of surgery (S. epidermidis *more commonly* than S. aureus). Streptococci are the *most common cause* of late-onset endocarditis; symptoms appear 60 days after surgery.
What is the initial LT treatment for mild-mod CHF (II/III)?
Start w/ a loop diuretic and ACEi Add a Beta Blocker if moderate disease is present.
Treatment for psoriasis
Start with topical corticosteroids. *Tar, topical retinoids (tazarotene), topical vitamin D, and anthralin*. For facial or intertriginous areas, topical tacrolimus or pimecrolimus may be used as alternatives or as corticosteroid sparing agents.
What are the 3 parts of Virchow's triad?
Stasis Hypercoagulable state Endothelial damage
What is the seen on the x-ray of a pt with Croup?
Steeple sign
Polymyositis and Dermatomyositis Tx
Steroid
Scleroderma Tx
Steroid
Stevens-Johnson Syndrome
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe mucocutaneous reactions, most commonly triggered by medications, characterized by extensive necrosis and detachment of the epidermis.
Pt presents with the following sx, what is the murmur? Systolic Low-frequency Twanging string Groaning, squeaking, or musical Vibratory/musical Loudest: LLSB and apex or MLSB
Still's Murmur Grade 2-3/6 in intensity No referral to cardiologist is needed
Name the innocent heart murmurs.
Still's Murmur Pulmonary ejection murmur Pulmonary flow murmur Venous hum Carotid Bruit
Shoulder Dislocation Tx technique
Stimson Technique, Traction Countertraction, scapular Manipulation, external rotation technique
What should be done with a pt on metformin that needs to undergo a CT scan with contrast? Why?
Stop metformin before systemic contrast Risk of lactic acidosis
Etiology of endocarditis for native valves
Strep
What is the *MOST COMMON CAUSE* for subacute endocarditis?
Strep Viridians (MCC) Other: Enterococci
What is the MC cause of community acquired pneumonia (CAP)?
Strep pneumonia
An aortic rupture near the carotids may be due to _________, and one near the heart is likely due to _________.
Stroke MI
Osteoarthritis Radiology
Subburst pattern and codman's triangle
Describe tardive dyskinesia
Sucking, smacking of lips Choreoathetoid movements of the tongue Facial grimacing Lateral jaw movements Choreiform or athetoid movements Occurs with long-term use of antipsychotic medications (monitor patients every 6 months)
Pts w/ repetitive PVCs are at increased risk for what?
Sudden Death by V. Fib (Esp when >10/hour)
If a pt has a Steven-Johnson reaction to a drug, DO NOT give them a __________ medication.
Sulfa
Avoid SLE
Sun exposure, NSAIDs, hydroxychloroquine
Radial Head Subluxation Tx
Supinator flexion or hyperpronation technique
What are the tx options fo eisenmengers?
Supportive, Heart/lung transplant, Endocarditis prophylaxis
Rotator Cuff muscle
Supraspinatous Infraspinatous Tere minor Subscapularis
Empty Can test
Supraspinatus muscle
What is the treatment for atrial myxoma?
Surgical Excision
Cauda Equina Syndrome tx
Surgical decompression
What is the tx for ASD?
Surgical repair when pulmonary-to-systemic blood flow ratio is greater than 1.5:1 or 2:1 or if patient is symptomatic.
Define *sustained V.Tach*. What are the associated risks?
Sustained VT lasts *longer than 30 secondas and is almost always symptomatic*! Ass w/ MI/Hypotsn Can be a life-treatening arrhythmia and can lead to V. Fib :0
Rheumatoid Arthritis findings
Swan neck/ Boutonniere, vasculitis
What is the DIAGNOSTIC test for the Dx of cystic fibrosis (CF)?
Sweat chloride test
What are the S&S of HCM?
Sx: DOE, CP, Syncope (post exertion/valsalva), palpitations, arrhythmias (AFib, ventricular), cardiac failure due to increased diastolic stiffness. *SUDDEN DEATH IN A YOUNG ATHLETE CAN BE THE FIRST SX OF THE DISEASE :(* Signs: Sustained PMI Loud S4 (corresponds to diastolic issue - remember diastole is 4 syllables) *Systolic Ejection Murmur - best heard at the left sternal border - increased w/ valsalva/standing/post-PVC and decreased w/ squatting/BB* Rapidly increasing carotid pulse w/ 2 upstrokes (*bisferious pulse*)
What are the S&S of RCM?
Sx: Fatigue, dyspnea, *RIGHT SIDED HEART FAILURE* sx - leg edema/hepatomegaly, ascites, distended neck veins Signs: S3/S4 and A.Fib
What are the pathognomic S&S for pericarditis?
Sx: PLEURITIC CP THAT IS RELIEVED BY SITTING UP AND LEARNING FORWARD - "POSITIONAL" PE: PATHONGMONIC - FRICTION RUN - SCRATCHY, CREAKY LEATHER (Although not always present)
What are the S&S of AR?
Symptoms a. Dyspnea on exertion, PND, orthopnea b. Palpitations c. Angina d. Cyanosis and shock in acute aortic regurgitation (medical emergency) Physical examination a. *WIDENED PULSE PRESSURE*-markedly increased systolic BP, with decreased diastolic BP b. Diastolic decrescendo murmur best heard at left sternal border c. *Corrigan's pulse* (water-hammer pulse)-rapidly increasing pulse that collapses suddenly as arterial pressure decreases rapidly in late systole and diastole; can be palpated at wrist or femoral arteries d. *Austin-Flint murmur*-low-pitched diastolic rumble due to narrowing of mitral valve orifice by aortic regurgitation, resulting in relative mitral stenosis e. Displaced PMI (down and to the left) and S3 may also be present.
In pts with chronic venous insuff, symptoms of leg swelling are worsened by periods of (rest/inactivity)?
Symptoms are worsened by periods of sitting or inactive standing
A drug reaction rash will be __________.
Systemic (NOT on just one arm)
What are the clinical features of DCM?
Systolic Heart Failure Left Sided Heart Failure sx S3 Gallop (Sytolic Dysfunction <-- 3 syllables in systole) MR/TR
Murmur of Hypertrophic Cardiomyopathy
Systolic Murmur Increase with valsalva (decreased preload) Decrease with squat (increased preload)
What are the characteristic of hypertrophic obstructive cardiomyopathy (HOCM)? (i.e. type of murmur, what echo shows, and which drugs to avoid)
Systolic ejection murmur DECREASES with squatting INCREASES with vasalva Echo: septal hypertrophy & LVH Avoid: strenuous activity, digitoxin & ntiro
resist digit abduction (spreading fingers apart) or digit adduction (hold piece of paper between adjacent fingers
T1 myotome
What are 3 granulomatous conditions?
TB Sarcoidosis Wegner's disease
What are 6 causes of cavitary lesions in the lung?
TB Squamous cell carcinoma (SCC) Autoimmune Vascular Lung abscess Congenital
Fibromyalgia Tx
TCA: Amitriptyline FDA approved Pregabalin
What is the *SOC* for endocarditis?
TEE - Tranesophageal (NOT transthoracic) ECHO!
What are the perferred tests for aortic dissection?
TEE and CT Transesophageal echocardiogram (TEE) has a very high sensitivity and specificity; ~ it is noninvasive and *can be performed at the bedside* (good in the unstable pt) CT scan and MRI are both highly accurate (MRI more so); MRI takes longer to perform, making it less ideal in the acute setting.
What is the *SOC* for diagnosis of ASD?
TEE is Diagnostic!
SJS <10% total body surface area (TBSA) involvement. Causes include Mycoplasma pneumoniae, viral infections, and vaccines, or drug-related.
TEN >30% TBSA involvement. Drug-related.
What is the *INITIAL TOC* for dyslipidemia?
TLC (1) Diet - high in omega-3s; <30% of total calories from dat, <10% from sat fat, <300 mg/dl of chol (2) Exercise: increase HDL and decraese CHD risk
What is a nonpharmacological treatment that can be used for the tx of CAD?
TLC - EXERCISE is crucial and DIET modification (decrease fat, cholesterol)
What pharmacological therapies are first line for all CAD patients?
TLC, Aspirin, BB, Nitrates (2nd line: add CCB)
What is the *TOC* and second line tx for rheumatic heart disease? What is the prophylaxis?
TOC = PCN (If allergic Azithro/Erythromycin) ARF requires NSAIDS and C-reactive protein monitoring Always prophylax for dental/GI/GU procedures w/ Amoxicillin or erythromycin Tx valvular pathology if present.
What is the *INITIAL TOC* for HTN?
TOC = Thiazides (HCTZ) 2nd line diuretic = Loop
What are the causes for TR?
TR is usually secondary to RV dilatation. Any cause of RV dilatation can result in enlargement of the tricuspid orifice. • Left ventricular failure is the *MOST COMMON CAUSE* (according to *STEP UP*). • Right ventricular infarction • Inferior wall MI • Cor pulmonale, secondary to pulmonary HTN b. Tricuspid endocarditis-seen in IV drug users (staph aureus) (*MOST COMMON CAUSE* according to Ovalle) c. May be secondary to rheumatic heart disease; usually accompanied by mitral and aortic valve disease d. Epstein's anomaly-congenital malformation of tricuspid valve in which there is downward displacement of the valve into the RV e. Other causes include carcinoid syndrome, SLE, and myxomatous valve degeneration.
What is the treatment for pulmonary stenosis?
TX: Mild=no tx, Mod-severe=balloon dilation via cardiac cath
What is the tx for pericarditis?
TX: SUPPORTIVE - AVOID ANTICOAGS NSAIDS are the *MAINSTAY* to treatment (Glucocorticoids if non-responsive to NSAIDS)
What is the HALLMARK of pericardial tamponade?
Tachycardia
name 4 cholinesterase inhibitors
Tacrine, Donepezil, Galantamine, Rivastigmine
Pt with tetrology of fallot will have classically turn cyanotic when crying, what is the phenomenon referred to as?
Tet spells (hypoxic episodes)
What may you find on H&P with psoriasis?
The *Auspitz sign*, which refers to the visualization of pinpoint bleeding after removal of scale overlying a psoriatic plaque. The *Koebner phenomenon*, which describes the development of skin disease in sites of skin trauma, may occur in patients with chronic plaque psoriasis.
What determines the mortality and morbitdity rate in hypovolemic shock?
The *rate of volume loss* - the slower the volume loss the better the prognosis b/c the compensatory mechanisms can respond.
Describe the Blisters found in Bullous Pemphigoid:
The blisters may be several centimeters in diameter and contain a clear serous fluid that may become bloody after several days. If the blisters burst, eroded, crusty areas slowly heal to leave postinflammatory hyperpigmentation with occasional milia.
Diagnosis of Actinic Keratosis
The diagnosis of AK is often made based on visual and tactile clinical inspection. Biopsy is indicated if the diagnosis is uncertain; a common indication for biopsy is distinguishing AK from SCC.
Stasis Dermatitis DIAGNOSIS
The diagnosis of stasis dermatitis is usually clinical, based upon the clinical appearance of the skin lesions, ranging from erythema, scaling, and *hyperpigmentation* to *pitting edema*, erosions, and crusts ; history of *venous insufficiency*; and other clinical signs of chronic venous insufficiency, including varicosities.
Seborrheic Dermatitis treatment Scalp:
The first-line therapy for scalp SD is a shampoo or scalp preparation containing one of the following compounds: salicylic acid, ketoconazole, Evidence selenium sulfide, Evidence crude coal tar, Evidence or pyrithione zinc. *Antifungal shampoos include selenium sulfide 2.5%, ketoconazole 2%, or ciclopirox 1% shampoo. *
Stasis dermatitis typically presents with erythematous, scaling, and eczematous patches or plaques on chronically edematous legs.
The medial ankle is most frequently and severely involved, although the skin changes may extend up to the knee and down to the foot. Pruritus is variable but, when present, results in lichenification from chronic scratching or rubbing. Acute forms may present with severely inflamed weeping plaques, vesiculation, and crusting
What can worsen psoriasis?
The most common offenders are beta blockers, lithium, and antimalarial drugs.
common psychiatric comorbidities of factitious disorders
The overwhelming majority of patients have severe underlying personality disorders
Pityriasis Rosea Diagnosis
The presence of a herald patch by history or on examination, the characteristic morphology and distribution of the lesions, and the *absence of symptoms other than pruritus* combine to make PR an easy diagnosis in most instance.
Atopic dermatitis Pearl:
The term atopy refers to the *genetic predisposition* for the pt to make IgE antibodies in response to allergen exposure
Seborrheic Dermatitis
The term is derived from the distribution of this disorder, in which erythematous, scaly patches *develop in areas that are rich in sebaceous glands, such as the scalp, face, and upper trunk.* The term "seborrhea" refers to excess oil secretion, although this finding is not uniformly present in patients with seborrheic dermatitis It tends to worsen with stress. In *infants*, SD may manifest as scaling of the scalp and is termed *cradle cap.*
Lichen simplex chronicus treatment
The treatment of lichen simplex chronicus centers of the discontinuation of the itch-scratch cycle. Commonly used therapies include topical corticosteroids under occlusion and intralesional corticosteroids
Dyshidrotic dermatitis Clinical manifestations
The typical physical finding is the presence of multiple small vesicles on the palmar or plantar skin, especially along the lateral aspects of the fingers and toes. Erythema, desquamation, cracking, and fissuring may be seen in older lesions.
Carpel Tunnel Syndrome H&P
Thenar muscle atropy/worsen at night *+Tinel's & Phalen's*
What will an ECHO show for RCM?
Thickened myocardium Increased LA/RA size with normal LV/RV size *Amylodosis - myocardium will be brighter and have a sparkling appearance*
The adult phase: Extends from puberty through adulthood
Thickened, dry skin and lichenified plaques are typical. In addition to the *flexural skin, the upper back and arms as well as the dorsal surfaces of the hands and feet are often affected.* image Dyshidrotic changes may be present on the palms and soles.
Limited Scleroderma
Thickening distal to elbows but can involve the face Pulmonary hypertension with right heart failure Anti-centromere *CREST- Calcinosis, Raynaud's, Esophageal dysmotlity, Sclerodactyly, Telangiectasia*
Subtype 2: papulopustular.
This is considered the classic presentation of rosacea. image Characterized by persistent central facial erythema, telangiectases, transient papules, and/or pustules in the central facial distribution.
Pityriasis Rosea
This morphologic pattern has been referred to as a "fir tree" or "Christmas tree" distribution.
What is the Tx for a pneumothorax (PTX)?
Thoracocentesis in 5th ICS
Gamekeeper's Thumb Tx
Thumb Spica Splint
Epiglottitis will show __________ sign on x-ray.
Thumbprint
What is the GOLD STANDARD for diagnosis of Sarcoidosis? Who is it more common in?
Tissue bx AA females
Before taking a pt to surgery what must you have?
Tissue bx!
How do you diagnosis Bullous Pemphigoid?
To diagnose bullous pemphigoid, a *skin biopsy* should be performed, preferably excising an entire blister with some adjacent unaffected tissue.
What cyanotic CHD is associated w/ the following pathophys and sx Patho: Common pulm veins don't form into post. wall of LA but in other places, PV most commonly arises from SVC, Oxygenated blood mixes w/ deoxygenated blood in R side of ht S&S: Cyanosis, SEM at LLSB, Diastolic murmur, split S2?
Total Anomalous Pulmonary Venous Connection (TAPVC) (cyanotic)
__________ is elevated by skeletal muscle trauma & IM injections and returns to normal in 48-72 hours.
Total CK
Salter Harris Type 1
Transverse fx through the growth plate
Name the components of *VIRCHOW'S TRIAD*:
Trauma (endothelial injury) Stasis (venous) hypercoagulability
Cubital Tunnel Syndrome
Trauma or stretching the ulnar nerve
What is the Tx for secondary HTN?
Treat underlying condition O2
Scleroderma treatment
Treat what is treatable PPI for reflux disease Vasodialators for Raynaud's phenomenon ACE I for renal crisis Pulmonary hypertension medications- spoprostenol, ilaprost, sildenafil, tadalafil, bosentan Immunosuppressants for interstitial lung disease
Treatment for Perioral dermatitis
Treatment (1) *Avoid topical steroids because they will aggravate the lesions. (2) Use topical metronidazole or erythromycin* or oral minocycline, doxycycline, or tetracycline. (3) Untreated lesions will fluctuate over time, similar to rosacea.
Treatment for Rosacea
Treatment a. Reduce triggers such as alcohol or hot beverages. b. *Topical metronidazole* (most effective), sodium sulfacetamide, or erythromycin often is sufficient. c. *If topical treatment fails, systemic antibiotics, such as tetracycline, minocycline, or doxycycline*, are tried until remission and then continued at lower doses for maintenance. d. Very severe cases may need oral isotretinoin under the care of a dermatologic specialist.
What is the management for cholesterol embolization syndrome?
Treatment is supportive. *Do not anticoagulate*. Control BP. Amputation or surgical resection is only needed in extreme cases
Pityriasis Rosea Treatment
Treatment: No treatment required; rash usually disappears spontaneously in 3-4 wks
What is the *TRIAD* associated w/ AAA rupture?
Triad of *abdominal pain, hypotension, and pulsatile abdominal mass*
What is the*MOST COMMON* age to find a carotid bruit?
Trick question - it can occur at any age
pharm treatment of major depressive disorder
Tricyclics (amitriptiline) MAOIs (phenelzine, selegiline) SSRIs SNRIs (venlafaxine, duloxetine) other: Buprenorphine (NE &DA reuptake inhib), mirtazapine (alpha 2 and 5HT2 agonist)
Triggers for Contact Dermatitis
Triggers — The most common sensitizer in North America is the plant oleoresin urushiol found in poison ivy, poison oak, and poison sumac . Ginkgo fruit and the skin of mangoes also contain urushiol and can produce allergic contact dermatitis.
Atopic dermatitis: Pruritis ----> lichenification
Triggers: climate, food, contact w/ allergens, mechanical or chemical irritants, emotions- stress
What CHD is assocaiated w/ following clinical signs: Cyanosis, Systolic murmur, Absent tricuspid valve, ASD/PDA/VSD?
Triscupsid Atresia
__________ is the last marker to fall.
Troponin
What is the *MOST IMPORTANT* cardiac enzyme?
Troponin (I&T) <-- greater sensitivity and specificity than CK-MB Increase w/in 3-5 hours - peak at 24-48 hours - return to nl at 5-14 days Obtain levels on admission - every 8 hours for 24 hours
What cardiac enzyme stays elevated longest?
Troponin 1
Troponin (I/T) is falsely elevated in patients w/ renal failure?
Troponin I
__________ markers rise in 3-13 hrs, return to normal in 7-10 days, & are not normally detected.
Troponin T & I
What cyanotic CHD is described as follows: Single arterial trunk arises from normal ventricles, Pulm arteries originate from common arterial trunk, CHF develops due to pulm overload. S&S: Cyanosis, Pansystolic murmur at LLSB?
Truncus Arteriosus
short stature, webbed neck, prominent ears, low posterior hairline, broad chest w/ widely spaced nipples, hearing impairment, absence of secondary sex characteistics
Turner syndrome (monosmy X)
webbed or redundant skin of neck is significant of?
Turner's syndrome
What is the Tx (3 things) for Poststreptococcal glomerulonephritis (PSGN)?
Tx HTN agressively AVOID steroids Decrease protein & Na in diet
What is the management for DCM?
Tx acutely like CHF --> LMNOP - lasics, morphine, nitro, O2, position LT: ACEi, BB, Diuretics, Chronic Anticoag (increased risk for emboli), AVOID alcohol, transplant (last resort)
What is the management for RCM?
Tx the underlying disorder, prevent arrhythmia, control HR, tx sx of HF Hemochromatosis - phlebotomy/deferoxamine Sarcodosis - glucocorticoids Amyloidosis - no tx (avoid dig b/c increased dig toxicity)
Calvicular Fracture
Tx: Figure eight Sling
What is the treatment for PDA?
Tx: Indomethacin/Ibuprofen, Ligation
The daily sanford classification has type A and type B - explain each.
Type A: *proximal* - involves the *ascending aorta* (includes retrograde extension from descending aorta) - *MOST COMMON* Type B: *distal* - limited to the descending aorta
what labs do you need to order in a pt with a potential dx of HTN?
UA, Chem Panel (K+, BUN/Cr), Fasting glucose, lipid panal, ECG
In superficial thromboplebitits, what is the *MOST COMMON* location in the UE and LE?
UE: *MC* in the site of IV infusion LE: *MC* in varicose veins (great *saphenous* system) secondary to static blood flow NOTE: Virchow Triad applies to thrombophlebitis!
Gamekeeper's Thumb What ligament is injury with this?
Ulnar Collateral Ligament
How can you differentiate VT from PVST?
Unlike PVST, VT *DOES NOT* respond to vagal maneuvars or adenosine
__________ angina typically has pain at rest, increased frequency, & change from previous angina.
Unstable
__________ is azotemia that leads to confusion & drowsiness.
Uremia
The inability of the kidney to concentrate urine is called __________.
Uremic syndrome
Cauda Equina Syndrome H&P
Urinary overflow incontinenece; change in bowel habits
For acute renal failure due to interstitial nephritis from abc, what should be ordered?
Urine eosinophils
Explain the CHADS score for A. Fib?
Used to assess patients risk and when to anticoagulate w/ "Warfarin" verus "electric shock" DO NOT ANTIVERT PATIENTS WITH HIGH RISK! (CHAD SCORE >/= 2+ ALWAYS ANTICOAGULATE CHADS 2+ PATIENT Criteria for CHADS Score - BQ *C*ongestive Heart Failure (1 point) *H*ypertension (1 point) *A*ge over 75 years (1 point) *D*iabetes Mellitus (1 point) *S*troke or TIA history (2 points) Mitral Stenosis or prosthetic heart valve carry similar risk and also indicate Warfarin Interpretation CHADS Score >2 (CVA risk >5% per year): Warfarin with goal INR 2.0 to 3.0 CHADS Score 1 (CVA risk >4% per year): Warfarin or Aspirin CHADS Score 0: Aspirin 81 to 325 mg daily **NEW ONSET A.FIB W/ NO PRIOR DOCUMENTATION - CARDIOVERT***
Reactive Arthiritis
Uveitis, Balanitis, conjunctivitis, Asymmetric oligoarthritis
In the case of a MI w/ sudden cardiac death, what is the *MOST COMMON CAUSE*?
V. Fib
*Posterior Wall* EKG leads? Which artery supplies this area?
V1, V2 *Right* Coronary Artery
*Anterior Wall* EKG leads? Which artery supplies this area?
V1, V2, V3, V4 *Left* Coronary Artery
What is the *MOST COMMON* CHD?
VSD
What is the MC pediatric heart problem?
VSD
Define *non-sustained VT*.
VT that lasts *less than 30 seconds* - brief, asx Worse prognosis when CAD/LV dysfunction are present.
What is the treatment for AVRT?
Vagal Maneuvars IV Adenosine = TOC Prevention: DIG = TOC Recurrent/Symptomatic = radiofreqencu catheter abalation of either the AV node or accessory tract
What is the *MOST ACCURATE* diagnosis of DVT for the calf veins?
Venography • Invasive and infrequently used • Allows visualization of the deep and superficial venous systems, and allows assessment of patency and valvular competence
Virhcow's Triad
Venous Stasis Hypercoaguability Vascular Damage
__________ is the screening TEST OF CHOICE for a suspected DVT.
Venous U/S
Pt presents with an ulcer that is *NOT* very painful (3/10) and located just above the medial malleolus and has rapidly recurred for the 3rd time in 6 mo. Is this ulcer, most likely venous or arterial?
Venous ulcer Classic presentation (1) less pain than arterial (2) located over medial malleolus (3) rapidly recur *Ulcer formation is directly proportional to the amount of swelling present*
Abdominal cancer mets is typically seen in the left supraclavicular node (called __________) via the thoracic duct.
Virchow's node
What is the treatment for coumadin overdose?
Vit K or fresh frozen plasma (FFP)
Bitot spots (white patches on sclera)
Vitamin A deficiency
pupura, corkscrew hairs, gingival bleeding
Vitamin C deficiency
Smith Fracture
Volar angulation Blow to back of wrist or fall w/ palm closed
reduced levels of clotting factor 8
Von Willebrand disease
Desmopressin
Von Willebrands
Atypical pneumonia - CBC results
WBCs only SLIGHTLY elevated, possibly normal
Delta wave
WPW
If a person has recurrent sinus infections think of __________ disease.
Wegner's
What 2 signs may be seen on CXR of a pt with a PE?
Westermark sign Hamptom's Hump
What are 3 signs of pleural effusions on CXR?
White Meniscus sign Blunting of costophrenic angles
How is atelectasis seen on CRX?
White (airless)
Oral lichen planus - Lichen planus of the mucous membranes can occur in conjunction with cutaneous disease or independently. Mucous membrane disease may consist solely of lacelike Wickham's striae that are particularly evident on the buccal mucosa or can include papular, atrophic, or erosive lesions
Wickham's striae
What are the EKG findings for PVCs? Tx?
Wide, Bizzare QRS complexes followed by compensatory pause are seen; a P-wave is not usually seen because it is buried within the wide QRS complex. Increased Incidence w/ Age >10 PVC/hour --> Pathologic Exercise should improve PVCs, if not then pathologic Tx: Symptomatic - BB
What 2 signs may be seen on the CXR of a pt with an aortic dissection?
Widened mediastinum Prominent aortic knob
Guttate psoriasis
Widespread, erythematous, fine, scaly papules (water drop appearance) on trunk, arms, and legs. The lesions often erupt after an upper respiratory infection.
Azure lunate on nails
Wilson's disease
Kayser - Fleischer rings - brown ring bet. Iris & cornea
Wilson's disease
Silent ischemia/atypical symptoms are seen in which populations?
Women, elderly, diabetics
radial nerve palsy
Wrist drop
Carpel Tunnel Syndrome Tx
Wrist splints, NSAIDs, Steroid injection Surgery: Transverse carpal ligament
What are the MCC for AS?
Young Pt: Bicuspid instead of tricuspid Aortic Valve Elderly pt: calcifications of the aortic valve
Who is Primary pulmonary HTN most common in? What is the Tx?
Young females with RHF O2 & transplant
What are 2 Tx options for influenza?
Zanamivir (Relenza) Oseltamivir (Tamiflu)
What are the risk factors for a DVT?
a. Age>60 b. Malignancy c.Prior history of DVT, PE, or varicose veins d. Hereditary hypercoagulable states (factor V Leiden, protein C and S deficiency, antithrombin III deficiency) e. Prolonged immobilization or bed rest f. Cardiac disease, especially CHF g. Obesity h. Major surgery, especially surgery of the pelvis (orthopedic procedures) i. Major trauma j. Pregnancy, estrogen use
What can pulse volume recordings be used to look at in PVD?
a. Excellent assessment of segmental limb perfusion b. Pulse wave forms represent the volume of blood per heart beat at sequential sites down the leg. c. A large wave form indicates good collateral blood flow. d. Noninvasive using pressure cuffs
What is the *MOST COMMON* location for cholesterol emboli to come from?
abdominal aorta, iliac, and femoral arteries
Bell clapper deformity
abnormal attachment of testis in scrotum
How are struvite kidney stones treated?
abx
Bird's Beak on Barium swallow
achalasia
management of narcististic personality disorder
acknowledge their fear/trigger to defuse behavior. do not respond with hostility.
GH secreting pituitary adenoma
acromegaly or gigantism
What is the MC serious respiratory infection in infants?
acute bronchiolitis
self limited autoimmune IgG disorder which presents as abrupt onset of peptechiae, purpura, hemorrhagic bullae on skin and mucosal membranes
acute immune idiopathic thrombocytic purpura (ITP)
2 types of acute leukemias
acute lymphocytic leukemia: kids acute myelogenous leukemia: adults
w/I 1 month of trauma and last 2 weeks-mth
acute stress disorder
Muddy brown casts
acute tubular necrosis
treatment of bipolar with psychotic symptoms
add antipsychotics
treatment of bipolar with dangerous behavior/agitation
add benzodiazepine, antipsychotic, or electroconvulsive therapy
Bronchogenic carcinoma - MC type
adenocarcinoma (type of non-small cell)
Boggy uterus
adenomyosis
maladaptive behavioral or emotional sx developing after stressful event and ending w/I 6 mths
adjustment disorder
advantages and disadvantages of antidepressants for ADHD
adv: not a controlled substance, less possibility of abuse by others, tx of comorbid depression, no rebound effect, limited growth effects. disadv: less effective for inattention. titration/time to efficacy. Strattera/atomoxetine has a black box warning for liver function.
advantages/disadvantages of alpha 2 agonists for treatment of ADHD
advantages: no effect on growth or appetite, may aid in sleep disadvantage: not as effective for attention symptoms. effective for hyperactivity and impulsivity only. side effects: hypotension, sedation, dizziness, weakness, slow heart rate.
presentation of subcortical dementia
affects fundamental function first: motivation, mood, timing, arousal.
physiologic jaundice appears when; breast feeding jaundice appears when?
after 24 hrs, peaks 3-5 days; 2nd to 3rd day of life
presentation of acute stress disorders
after exposure to traumatic event, patient experiences: re-experiencing, avoidance, increased arousal, or dissociation symptoms (amnesia, reduced awareness) duration = maximum of four weeks usually self-resolves, or may go on to become PTSD
presentation of PTSD
after traumatic event, patient experiences: re-experiencing in dreams, thoughts, flashbacks avoidance or numbing (detachment/alexathymia) or increased arousal (hypervigilance, irritability) symptoms last at least on month beginning immediately after initial trauma
presentation of frontotemporal dementia
age 45-65. progressive personality/social behavioral changes / disinhibition which may show up as massive wt gain or innappropriate behavior. prominant impairment of executive function: language loss more than memory.
presentation of attention deficit hyperactivity disorder
age inappropriate problems with attention, learning, impulse control, and hyperactivity. hyperactive symptoms usually outgrown by adolescence, but inattention often remains.
opioid withdrawl treatment
agonist substitution (buprenorphine, methadone), alpha adrenergics (clonidine, lofexidine) for autonomic arousal, loperimide for diarrhea, benzos for anxiety, NSAIDS for pain, Bentyl for GI spasm
fear of being stuck in place without escape route
agoraphobia
Pertussis - how is it contracted
air droplets
management for patients with schezoid personality disorder
allow private room & limit # on the treatment team don't be overly freindly/familiar. maintain professional distance.
what ethnicities are alpha and beta thalassemia common in?
alpha- Asian; beta- Mediterranean
Perioral (periorificial) dermatitis
also known as periorificial dermatitis, is a skin disorder that typically presents with multiple *small inflammatory papules around the mouth, nose, or eyes.*
Catatonic Schizophrenic
alternating stupor and excitement. very rare.
prevention of adrenal crisis
always give "stress doses" of cortisol for surgeries or illness never stop steroids abruptly
name 6 types of dementia
alzheimer's vascular dementia dementia with parkinson's dementia with huntington's lewy body dementia frontotemporal dementia
tx for nephrogenic DI
amiloride HCTZ NA+ restrictive diet
name a TCA
amitriptyline
increased energy, mydriasis (pupil dilation), bruxism, tachycardia/arrhythmia/SCD, bronchodilation, appetite suppression euphoria, grandiosity, fascination with repetition depression or suicidality, formication (sense of bugs on the skin), psychosis, hallucinations, paranoia aggression/violence
amphetamine / cocaine intoxication
cause of alzheimer's dementia
amyloid-beta protein deposits intracellular neurofiber tangles loss of neurons
Paraneoplastic syndromes associated w/ all lung cancers
anemia DIC eosinophilia thrombocytosis acanthosis nigricans
Hazy/steamy cornea w/ fixed dilated pupil
angle closure glaucoma
Bamboo spine
ankylosing spondylitis
etiology/risk factors for delerium
another medical condition or illness: impaired vision severe illness dehydration baseline impaired cognition physical restraints malnutrition >3 meds added on admision bladder foley cath other iatrogenic events (HAP, lack of sleep, etc)
What is "postphbleitic syndrome"?
another name for *chronic venous insuff* - venous stasis disease
2nd generation antipsychotics
antagonize DA (selectively mesolimbic tract) and 5HT clozapine, olanzapine, quetiapine, rispiradone, aripzole, ziprasidone
LAD
anterior wall of LV, anterior 2/3 of IV septum
when do fontanelles typically close?
anterior: 4-26mths posterior: 1-3mths
medical treatment of bulemia
antidepressants baclofen
pharm treatment of PTSD
antidepressants - especially sertraline
medications that cause hyperprolactinemia
antipsychotics (phenothiazines) cimetidine (H2 blockers) metoclopromide estrogen verapamil (Ca channel blockers)
inability to conform to social norms, disregard, violation, lack empathy
antisocial
personality disorder with a strong genetic component
antisocial
history of conduct disorder is a prerequisite to what personality disorder?
antisocial personality disorder
pharm treatment of generalized anxiety disorder (GAD)
anxiolytic antidepressants benzodiazepines buspirone (GAD is the only indication for buspirone, but it is not first line for GAD.)
pharm treatment phobias other than public speaking
anxiolytic antidepressats benzodiazepines
Tearing chest pain to shoulder blades
aortic dissection
Hill sign (leg systolic >20 mmHg than arm systolic)
aortic insufficiency
Bicuspid valve is susceptible to calcification and _________ later.
aortic stenosis
Actinic Keratosis
are common cutaneous lesions that result from the proliferation of atypical epidermal keratinocytes. Major risk factors for the development of AKs include chronic sun exposure, fair skin, advancing age, and male sex.
name 4 'atypical' or second generation antipsychotic drugs
ariprazole (Abilify) clozapine (Clozaril) olanzapine (zyprexa) risperidone (Risperdol) ziprasadone (Geodon) quetiapine (Seroquel)
start to walk?
around 1 year
interventions for Hypochondriasis
as PCP, see pts regularly & reassure SSRIs effective tx comorbid illness: often depression, anxiety, or OCD CBT with exercises intended to modulate sensations of benign bodily discomfort due to normal physiology & help patients reattribute these sensations to their appropriate cause rather than to fears of serious illness
Right Ventricular failure
ascites, anorexia, edema
most common causes of infant respiratory distress are?
aspiration, congenital pneumonia, transient tachypnea
etiology of adjustment disorder
associated with a major stressor such as divorce, job loss, financial problems, physical illness, etc.
define bipolar 2
at least 1 depressive episode and at least one hypomanic episode
dx for schizophrenia
at least 2 sx must be present during 1 month period & continuous signs must persist for at least 6 months: delusion, hallucinations, disorganized speech, grossly disorganized behavior, negative sx SOCIAL FX, OCCUPATIONAL FX, or both must be affected
Strongest predisposing factor to asthma -
atopy! - asthma - allergic rhinitis - atopic dermatitis
overeating, weight gain, oversleeping, reactive mood, leaden paralysis, oversensitivity to interpersonal rejection
atypical depression
what kind of structures signify myeloid leukemia
auer rods
Crescent sign on hip xray
avascular necrosis
extreme sensitivity to rejection, intense social anxiety
avoidant
What are the personality types under category C: Worried
avoidant Dependant Obsessive/Compulsive
which access is the global assessment of function (GAS)?
axis 5
CAP - inpatient tx
azithromycin + ceftriaxone
Rodent ulcer
basal cell cancer
For any level of BP elevation, the descision to start medical therpay is dependent on what?
based on the pts total cardiovascular risk and not just the elevation of BP - estimation of the overall risk depends on CV and clinical risk factors, AKA "*The BIG 6 - FSH DAD*"
Battle sign
basilar skull fx
Raccoon eyes
basilar skull fx
describe a panic attack
begin abruptly, have multiple symptoms, last a few minutes
define regression
behavior adjustment under stress or severe sickness to a more irritable, childlike manner. this is when personality disorders often manifest
psychosocial therapy for schizophrenia
behavioral therapy for social abilities, communication. group therapy. case management. family therapy for loved ones.
treatment of amphetamine intoxication
benzodiazepine, haldol, restraints, calm environment
treatment for marijuana intoxication
benzos, antipsychotics for psychosis
meds required for alcohol withdrawal
benzos, diazepam (valium), Librium, thiamine, folic acid, multivitamins
treatment of PCP intoxication
benzos, haldol, acidification of urine, restraints, decreased sensory stimuli
management of alcohol withdrawl with DTs
benzos, haldol, admit to ICU
Atrial septal defect
best diagnosed via cath
pharm treatment of social phobia with performance anxiety
beta blocker before public speaking
which thalassemia results from point deletion and which from gene mutation?
beta; alpha
age groups most affected by narcalepsy
bimodal distribution: age 15 and 36.
at least one MDD episode w/ at least one hypomanic episode (never experienced manic episode)
bipolar II
average HR until 6yrs
birth 90-190 2-6 yrs: 68-138
non surgical treatment for hyperparathyroidism
bisphosphonates cinicalcet surgery is best treatment
peripheral smear of G6PD shows
bite cells and Heinz bodies
Residual schizophrenic
blunted affect, social withdrawl, disorganized thoughts, odd behavior.
preoccupation w/ imagined defect in physical appearance
body dysmorphic disorder
unstable and unpredictable mood, impulsive
borderline personality
Floppy baby syndrome
botulism
air fluid level on KUB
bowel obstruction
possible etiology of ADHD
brain is chronically under-stimulated and underdevelops.
what is Plummer Vinson syndrome?
brittle nails, cheilosis, smooth tongue, formation of esophageal webs from iron deficiency
Triple layer sputum
bronchiectasis
Leading cx of cancer deaths in men & women?
bronchogenic carcinoma
binge eating as well as vomiting, laxatives, excessive exercise
bulimia nervosa
what drug inhibits the reuptake of Norepi and dopamine
buproprion (Wellbutrin)
Aortoilliac occlusive disease cuases _____ and _____ claudication (in addition to the calves)
buttox and hip
Beefy red plaques w/ satellite lesions
candidiasis
prolactinoma tx
capergaline (dopamine agonist) bromocriptine
fluid accumulation under scalp due to birth trauma
caput succedaneum
hypoparathyroid sx
cardiac arrhythmias ricketts and osteomalacia numbness/tingling
Electrical alterans on EKG
cardiac effusion
Beck's triad - distend neck veins, fall BP, muffled heart sounds
cardiac tamponade
complications of anorexia nervosa
cardio: bradycardia, hypotension mitral valve prolapse, SCD, peripherla edema, refeeding syndrome (Mg and PhO4 decrease) Derm: dry skin, lanugo hair, carotenodermia GI: constipation, refeeding pancreatitis, acute gastric dilation. endocrine/metabolism: amenorrhea, infertility, osteoporosis, thyroid abnormalities, hypoglycemia, hypercortisolemia, neurogenic diabetic insipidues, impaired temp regulation Neuro: cerebral atrophy Heme: pancytopenia, decreased ESR Mortality!!! (highest of any psych disorder)
What are the CXR for truncus arteriosus?
cardiomegaly and increased pulm vasculature
treatment of conversion disorder
careful wording/communication. physical medicine +/- rehab for symptoms. refer to psychology or psychiatry. rule out difs: MS, brain tumor, frontal lobe epilepsy, movement disorders, lupus, porphyria.
Phalen's
carpal tunnel
Tinel's
carpal tunnel
sudden drop of muscle tone triggered by emotional factors
cataplexy - finding is specific to narcalepsy
motor immobility, excessive purposeless activity, bizarre postures, grimacing, echolalia, echopraxia (echo movement)
catatonia
Cherry red spot on ophthal exam
central occlusion of retinal artery
sudden, painless unilateral vision loss
central occlusion of retinal artery
Complications of increasing Na+ too quickly
central pontine myelinolysis
Blood & thunder retina
central retinal vein occlusion
area of the brain primarily affected by alzheimer's
cerebral cortex
complications of decreasing Na+ too quickly
cerebral edema
chronic impairment of muscle tone, strength, coordination, movements, mental retardation
cerebral palsy
Seborrheic Dermatitis Presentation
characterized by *well-demarcated erythematous plaques with greasy-looking, yellowish scales distributed on areas rich in sebaceous glands such as the scalp, the external ear, the center of the face, the upper part of the trunk, and the intertriginous areas*
treatment for orgasmic disorders
check meds psychotherapy
anaplastic thyroid cancer tx
chemo and radiation
Dew drops on rose petal
chicken pox
name 2 low potency first generation antipsychotics
chlorpromazine thioridazine
1st generation antipsychotics
chlorpromazine, fluphenazine, haldol all antagonize D2
Rice water diarrhea
cholera
organic causes of decreased sex drive
chronic illness, pain, atherosclerosis, prolactin, microvascular and nerve damage, neuro disorder, chromosomal disorder
Asthma - patho
chronic inflammation and edema of airway muscles, acute bronchospasm & mucous production
describe dementia
chronic onset of months to years; steady progression of symptoms; depressed or disinterested mood; alertness relatively normal
presentation of generalized anxiety disorder (GAD)
chronic, excessive anxiety/worry > 6 months. restlessness, irritability, muscle tension, fatigue, decreased concentration, insomnia, or restless sleep.
Ortolani test/sign
click of hips - congenital hip dysplasia
Influenza - dx
clinical, but can also do nasal swab or washing
define dependance
clinically significant impairment or distress manifest by 3 or more of the following in a 12 month period: tolerance withdrawl taking larger amount or for longer period of time than intended persistant desire or unsuccessful efforts to cut down use. great deal of time spent acquiring or recovering from substance reduction in social or occupational activities continued use despite knowledge of harm
open comedo (a blackhead)
closed comedo (a whitehead)
which antipsychotic is best for refractory schizophrenia and may treat tardive dyskinesia
clozapine (Clozaril)
what cluster is schizoid, schizotypal, paranoid?
cluster A (mad)
what cluster is antisocial, borderline, histrionic, narcissistic?
cluster B (bad)
what cluster is avoidant, dependent, obsessive compulsive?
cluster C (sad)
Figure 3 sign on chest xray
coarctation of aorta
what are the non-pharm treatments of depression
cognitive behavioral interpersonal therapy supportive insight-oriented
therapeutic treatment of phobic disorders
cognitive behavioral therapy (CBT) behavioral therapy with exposure
therapy for panic disorder
cognitive therapy: educate patient about bodily senses, panic attacks. behavioral therapy: relaxation and deep breathing
therapeutic treatment of generalized anxiety disorder
cognitive, behavioral, supportive
Solitary pulmonary nodule - AKA
coin lesions
apple core lesion on Barium enema
colon cancer
undifferentiated schizophrenic
combination of delusions and hallucinations with disorganized behavior.
Salter Harris Type 5
compression fx
violation of basic rights of others or social norms, aggression toward people & animals, destruction of property, deceitfulness, serious violation of rules
conduct disorder
presentation of borderline personality disorder
confluence of anxiety, depression, and psychotic symptoms. very intense mood lability, abrupt shifts "splitting" = shifts from all good to all bad self-harm behavior (cutting) common but not as a suicidal attempt. may be attention-getting. however, suicidal attempts also common. feeling 'empty' may come across as needy or hostile
presentation of generalized anxiety disorder in a child
constant worry or tension with no stressor. leads to difficulty concentrating, fatigue, irritability, sleep disturbance, restlessness. often comorbid with major depressive disorder. genes and stress both related to onset and etiology.
one or more neuro sx that cannot be explained clinically, shifting paralysis, blindness, mutism
conversion disorder
S1Q3, inverted T3 on EKG
cor pulmonale from PE
sympathetic control of sexual response in the male
corpus spongiosum engorgement ejaculation (contracts seminal vesicles, prostate, vas deferens and bladder neck) corus cavernosum detumescence
what is the evidence for a genetic component to substance abuse/dependance
correlates at same percentage as DM, HTN, or asthma
premature fusion of one or more sutures
craniosynostosis
Degenerative/mechanical arthritis physical exam
crepitus bony enlargement reduced ROM
define partial remission from anorexia nervosa
criteria for AN previously met. Criteria A (low body weight) has not been met for a sustained period but fear of gaining and disturbance of self-image are still present.
define full remission from anorexia nervosa
criteria for AN previously met. Now no criteria have been met for a sustained period of time.
Steeple sign
croup
Klebsiella pneumoniae hallmark
currant jelly sputum in pt w/ chronic illness (includes ETOH abuse)
moody, erratic, impulsive, somewhat volatile
cyclothymic
central DI
decreased ADH production
hypoparathyroid labs and EKG
decreased PTH decreased Ca increased phosphorus prolonged QT
Septic shock is defined by what?
defined as hypotension induced by sepsis that persists despite adequate fluid resuscitation. This results in hypoperfusion and can ultimately lead to multiple organ system failure and death.
erroneous beliefs based on misinterpretation of reality, paranoia, idea of reference,
delusions
presentation of delusional disorder
delusions for at least 1 month - usually jealousy, persecutory, grandiose, erotomanic (love from afar), somatic, or Capra's syndrome (delusion that a someone around them has been replaced by an imposter). Does not involve hallucinations or obviously odd behavior. May or may not respond to treatment.
clinging, submissive, lack self confidence, dislike being alone
dependent
dysthymia
depressed mood for over 2 years with over 2 symptoms: decreased sleep decreased energy decreased appetite decreased concentration low self esteem hopelessness no history of major depressive episodes during first 2 years. significant to cause impairment. no manic, mixed, or hypomanic episodes. not substance induced or due to other medical conditions.
what is electroconvulsive therapy used for
depression mania catatonia NOT for psychosis.
what other disorders might conduct disorder indicate later in life?
depression or bipolar.
what are the common comorbid findings for AN
depression, anxiety, OCD
gloomy, pessimistic, low self esteem, overly critical
depressive
diagnostic criteria of adjustment disorder
depressive symptoms. reaction is in exess of what is normally expected. usually time-limited
Gotton's sign - scale/papules on dorsal hand
dermatomyositis
Describe serotonin syndrome.
described as the triad of mental status changes, autonomic hyperactivity, and neuromuscular abnormalities, but other symptoms may be present: ●Hyperthermia ●Agitation ●Slow, continuous, horizontal eye movements (referred to as ocular clonus) ●Dilated pupils ●Tremor ●Akathisia ●Deep tendon hyperreflexia (common) ●Inducible or spontaneous muscle clonus (common) ●Muscle rigidity ●Bilateral Babinski signs ●Dry mucus membranes ●Flushed skin and diaphoresis ●Increased bowel sounds May occur at therapeutic doses of meds, but risk increases with interactions.
tx for central DI
desmopressin
describe delirium
develops over a short period of time (hours to days), direct physiologic consequence of another medical condition. rapid mood swings and diurnal effect
distinguishing between pituitary adenoma and small cell lung cancer in cushings
dexamethasone test: if administration of dexamethasone leads to a decrease of cortisol production then it is a pituitary adenoma
Mitral stenosis
diastolic murmur with opening snap at the apex
Atypical pneumonia - CXR results
diffuse infiltrates or unilateral lower lobe infiltrates
Gray colored pseudomembrane
diphtheria
clinical findings in EtOH intoxication (CNS depressants in general)
disinhibition, impaired judgement, aggression, slurred speech, ataxia, nystagmus, attention/memory impairment, delirium, stupor, coma, death
Disorganized/Hebephrenic Schizophrenic
disorganized speech/behavior and inappropriate affect. Typically early onset, poor prognosis.
exhibitionism
displaying genitals in public
long term pharm therapy for alcoholics
disulfuram (antabuse), naltrexone, acamprosate. ondansetron and topiramate in trials.
presentation of schezoid personality disorder
don't interact with people but don't miss it (rare). may have blunted affect No delusions or hallucinations (separates from schezophrenia)
hormone involved in attraction, love, psychosis, amphetamines
dopamine
4 factors hypothesized to contribute to schizophrenia
downward drift stress-diathesis (predisposition + major stressor) genetics (12% correlation w/ 1 parent, 40% w/ 2 parents, 47% w/ twins) Dopamine or other neurotransmitters
common side effects of TCAs
drowsiness dry mouth dizziness tachycardia disorientation urinary retention weight gain incoordination
side effects of wellbutrin
dry mouth HA agitation nausea dizziness insomnia anxiety
side effects of TCAs
dry mouth, blurred vision, urinary retention, constipation, tachycardia, orthostatic hypotension, sedations, weight gain, sexual dysfunction, decreased seizure threshold. Lethal cardiac toxicity.
KUB (abd XR) - double bubble
duodenal atresia in an infant
what does NOS mean?
dx for pts with atypical sx; mixed presentation, sx < dx threshold, or presentation that does not meet criteria for specific disorder
Tapioca vesicles on hands
dyshidrosis
chronic, persistent mild depression manifested by pessimism, brooding, loss of interest, decreased productivity
dysthymic disorder
when do we get more N3 sleep
earlier in the night
Ring of fire sign on US
ectopic pregnancy
nonpharm treatment of bipolar to be used alongside pharm treatment
educate patient and family psychotherapy group therapy family therapy
diagnosis of thalassemia
electrophoresis
hallmark seen on CBC of hemolytic anemia
elevated retic count in presence of falling or stable hmt
treatment of binge eating disorder
emphasize reduction in caloric intake and increase physical activity. identify psych issues such as depression & treat with atypicals +/- obesity treatment drugs or bariatric surgery topiramate (averse effect - word finding difficulties)
Parenchymal bullae or subpleural blebs
emphysema
Pt presents with a new heart mumur and an unexplained fever, what should ALWAYS be in your ddx?
endocarditis
What is seen on a CXR for cardiac tamponade?
enlargement of cardiac silhouette when > 250 mL has accumulated - clear lung feilds
treatment of alcohol intoxication
environmental control (emphasize safety and calm reassurance.) If severe, add haldol for agitation/psychosis. Restraints. Monitor vitals and fluids.
treatment of sleep walking disorder
environmental safety sleep hygeine +/- low dose benzos
Phren's sign - pain relieved w/ elevation of scrotum
epididymitis
LOC then period of lucency, then neurologic deterioration
epidural hematoma
Thumbprint sign on lat. Neck xray
epiglottitis
parasympathetic control of sexual response in the female
erection of clitoris, vaginal transudate secretion from bartholin's glands secretion from skene's glands (peri-urethral)
parasympathetic control of sexual response in the male
erection of the penis from corp cavernosum secretion from Cowper's and Littre's secretion from prostate and periurethral glands
red faced, "slapped cheek", lacy, pink macular rash on torso
erythema infectiosum (fifth disease)
small pustules on erythematous bases appearing 3-5 days after birth, that normally resolve w/I week or 2
erythema toxicum
Atypical pneumonia - tx Mycoplasma
erythromycin
Atypical pneumonia - tx legionella
erythromycin
Cork Screw Esophagus on Barium swallow
esophageal spasm
opioid intoxication
euphoria, apathy, dysphoria, psychomotor retardation or agitation impaired judgement constipation meosis respiratory depression coma, death
Koebner's phenomenon
evening, maculopapule rash from scratching - JRA
PMR exam and labs
exam is unremarkable except muscle tenderness Synovitis variable in knees, wrists, MCPs (12-77%) ESR >50 (Normal 0-22 in males 0-29 in females) Anemia and elevated LFTs may be seen **History and elevated ESR are key**
Paget's Disease
excessive resorption and excessive formation
presentation of separation anxiety disorder in a child
excessive worry about separation from home or caregivers. may be assoc with tantrums at separation, fear of caregiver saftey, school refusal, clinginess. may have nightmares with themes of separation. somatic complaints. often progresses to Panic Disorder in adolescence or adulthood. not related to normative separation anxiety of infancy.
stages of physiological sexual response in male
excitement (minutes to hours) - corpus cavernosum engorges, testes lift, incr respiration, incr muscle tension. plateau (30-180 seconds) - sympathetic control: corp spongiosum engorges, cowper's gland secretion, glans darkens, testes fully elevate, 'sex flush' orgasm - emission (sperm & seminal fluid collect in urethra) ~0.8 sec, ejaculation ~0.8 sec resolution - scrotum descends within 30 sec, testicular "congestion". partial detumescence in 5 minutes, complete in 30 minutes. +/- perspiration on palms and soles.
Left ventricular failure
exertional dyspnea
Psoriasis located on
extensor surface
side effect of antipsychotic meds
extrapyramidal sx, dyskinesias
intentionally fake mental or psych sx to assume sick role
factitious disorder
Most important RF for morbidity in asthma
failure to dx from recurrent wheezing
<2 yrs w/ weight <5th percentile on more than 1 occasion
failure to thrive
what type of therapy should be included in any treatment of an adolescent?
family therapy
masochism
fantasy, urge or behavior involving the act of being humiliated, beaten, bound or otherwise made to suffer
What is the phenotypic presentation of a pt w/ atrial myxoma?
fatigue, fever, syncope, palpitations, malaise, and a *low- pitched diastolic murmur that changes character with changing body positions (diastolic plop)*
presentation of Paranoid personality disorder
feeling that people will hurt them (not a delusion) manifests as an obsession with justice/equity especially sensitive to power differentials tendancy to over-interpret based on minutea react with explosions of hostility/anger to inequity
etiology of eating disorders
females ages 14-21 most common. bimodal peak at age 13 and 18. F:M ratio is 10:1. bulemia affects 1.5-2% of young females, anorexia affects 0.4%. certain professions: actors, dancers, wrestlers, models, gymnasts.
tx for iron def anemia
ferrous sulfate 325mg TID that should be continued for up to 6 mths
negative symptoms of schizophrenia
flat affect alogia (poverty of speech) apathy anhedonia, impaired attention
what are negative sx of schizophrenia?
flat affect, apathy, poor grooming, social withdrawal, anhedonia, poor eye contact, poverty of speech
Swan neck deformity
flexed DIP & MCP, extended PIP - RA
tx of addisons
fludrocortisone
general management of alcohol withdrawl
fluids, electrolytes, thiamine CIWA (Clincal Institute Withdrawl Assessment) to document the severity of symptoms if early or uncomplicated: long-acting oral benzos, carbamazepine, alpha or beta blockers
name the SSRIs
fluoxetine (Prozac) sertraline (Zoloft) Escitalopram (celexa) Citalopram (lexapro)
medical treatment for anorexia nervosa
fluoxetine may prevent relapse
treatment of patients with suicidal risk
focus on therapeutic alliance communicate with patient's significant others determine level of care necessary document thoroughlly collaborate with other health care providers monitor counter-transference consider consultation
Tea & toast diet
folate deficiency
macrocytic anemias
folic acid, vit B 12, hemolytic, sickle cell,
Damage to common fibular nerve or paralysis of muscles in anterior of leg
foot drop
steppage gait
foot drop
new term for conversion disorder
functional neurologic symptom disorder
specific tx of secondary hypothyroid (pituitary adenoma)
give with cortisol to prevent adrenal crisis
RBC casts
glomerulonephritis
Negative bifringement needle crystals, parallel & yellow
gout
Degenerative/mechanical arthritis (OA) History
gradual onset, chronic aggravated by use improves with rest grinding, popping, locking, buckling hx of prior trauma or surgery
therapy for PTSD
group therapy most helpful
Paraneoplastic syndromes associated w/ large cell lung CA
gynecomastia
Hair-like cytoplasmic projections on lymphocytes
hairy cell leukemia
false sensory perceptions
hallucinations
positive symptoms of schizophrenia
hallucinations delusions bizarre behavior disordered thought process (incoherent, tangential)
what are positive sx of schizophrenia?
hallucinations, bizarre behavior, delusions
name a high potency first gen antipsychotic
haloperidol (Haldol)
name 2 high potency first generation antipsychotics
haloperidol (Haldol) fluphenazine
Aortic stenosis
harsh systolic murmur at Right 2nd intercostal space
increased risk of thyroid carcinoma and thyroid lymphoma
hashimotos
causes of hypoparathyroidism
head or neck surgery decreased serum Mg
central DI causes
head trauma head surgery idiopathic tumors sarcoidosis TB syphillis
What is the *MOST COMMON* source of emboli that cause acute arterial occlusion?
heart Other locations: Aneurysms and atheromatous plaque
S3
heart failure
Anterior fat pad
hemarthrosis - radial head fx
Heinz bodies
hemolytic anemia
RBC destruction
hemolytic anemia
Spontaneous hemarthrosis
hemophilia
Bronchogenic carcinoma - hallmark of squamous cell
hemoptysis *dx w/ sputum*
drug which often causes ITP
heparin
Studies have suggested an association of lichen planus with which Hepatitis?
hepatitis C virus (HCV)
Isoniazid SE
hepatitis, peripheral neuropathy
What is a major side effect of Pyrazinamide?
hepatotoxicity
acute onset fever, posterior pharyngeal vesicles which are grayish white and quickly form ulcers w/ erythematous halos, dysphagia, fever, vomiting
herpangina from Coxsackievirus
transvestic fetishism
heterosexual male excited by cross-dressing
Pulmonary stenosis
high-pitched systolic ejection murmur at Left 2nd intercostal space
Bronchiectasis - dx of choice
high-resolution chest CT
what role does genetics play in mood disorders
higher risk with a first degree relative, but not 100% even in twins
Ewing Sarcoma
highly malignant cartilage tumor occuring in diaphysis of the long bone in children 5-15 yrs.
Hyperthyroidism is associated with what type of heart failure?
highoutput heart failure
How to dx asthma when spirometry not helpful
histamine or methacholine challenge test
attention seeking, exaggerate thoughts & feelings
histrionic
A significant literature supports the hypothesis that PR is a manifestation of: human herpesvirus 7
human herpesvirus 7
Ground glass appearance on CXR
hyaline membrane dz or pneumocystis carnii
collection of fluid in scrotum due to patency of process vaginalis
hydrocele
all 4 alpha globulin chains are deleted in still borns
hydrops fetalis
Paraneoplastic syndromes associated w/ squamous cell lung CA
hypercalcemia
What are the components of metabolic syndrome?
hypercholesterolemia hypertriglyceridemia impaired glucose tolerance diabetes hyperuricemia HTN
What is the most important and modifiable risk factors for CAD?
hyperlipidemia
Asthma - cx
hyperresponse to respiratory infection, air pollutants, allergens, food, exercise, or emotion
acromegaly less obvious symptoms
hypertropic cardiomegaly (killer) hypertension colonic polyps
Chvostek's sign twitch facial nerve on tap
hypocalcemia
Trousseau's sign - carpal spasm w/ inflate BP cuff
hypocalcemia
preoccupation of contracting serious illness
hypochondriasis
less severe than manic & does not cause social impairment
hypomanic
at least 4 days of abnormally & persistently elevated, expansive, irritable mood
hypoomanic
diagnostics for OSA
hypopnea, apnea index (AHI) = number of apneas and hypopneas per hour. also monitor O2 sat.
abnormal placement of urethra where meatus is proximal & ventral to it normal or anterior location
hypospadias
What are the classical symtoms for all patients in shock?
hypotension oliguria tachycardia alt mental status
risks of rispiradone or quetiapine for delerium patients
hypotension. (less risk of EPS than haldol)
adrenal insufficiency (addisons)
hypotensive hyponatremic hyperkalemic hypoglycemic hyperpgimentation not enough cortisol
Osborn wave/Jwave (upward deflect of S)
hypothermia
treatment of opioid intoxication
if uncomplicated: supportive therapy and observe if severe: naloxone and CV support
new term for hypochondriasis
illness anxiety disorder
Honey colored crusts
impetigo
What is the hallmark of personality disorders
inability to be flexible or adapt. "doing the same thing over and over again despite the situation changing"
presentation of depressive disorders in a child/adolescent
inability to feel pleasure, feelings of hopelessness, low self esteem or feelings of worthlessness. can manifest as irritability, decline in school, social relationships, activities, suicidal ideation.
IPV?
inactivated polio vaccine
labs for primary hyperparathyroid
increased PTH increased Ca decreased phosphate
Pyrazinamide SE
increased uric acid, hepatitis
sulfonylurea MOA
increases insulin release causes more absorption of glucose--> wt gain and hypoglycemia
metformin MOA
increases insulin sensitivity blocks gluconeogenesis
Janeway lesion
infective endocarditis
Pneumonia - def
inflammation in the alveoli or interstitium of the lung fed by microorganisms
Acute bronchitis - def
inflammation of the airways characterized by cough
presentation of narcisistic personality disorder
inflated sense of self-esteem, entitled, arrogant, condescending, scornful, etc. most often a defense of true insecurity Use people as a mirror of their own grandeur easily offended. become hostile quickly. outburst as a result of feeling threatened. usually do not present for medical care because they don't like to acknowledge people have more knowledge than they do tend to treat med professionals by either idealizing or putting-down diagnosed more in men
Biphosphonate MOA
inhibits osteoclast activity
findings in dementia with huntington's
insidious and gradual onset clinically established Huntington's or risk based on family history or genetic testing.
side effects of stimulant drugs for ADHD
insomnia nervousness decreased appetite dysphoria sedation growth retardation psychosis (in higher doses)
define MR
intellectual functioning significantly below average based on IQ and adaptive functioning which causes lifelong impairment. must be < 18 y.o. often seen with deficient adaptive functioning (social skills, hygeine, work, health, safety, etc.)
pedophilia
interest is in children of a certain age and sex. not incest.
WBC casts
interstitial kidney disease
Currant jelly stool
intussusception
most common cause of anemia world wide
iron deficiency
name 3 conditions and 1 medication class associated with restless leg syndrome and periodic limb movement disorder
iron deficiency pregnancy renal failure antidepressants can worsen symptoms.
microcytic anemias (<80)
iron deficiency, thalassemia, sickle cell, chronic disease
treatment of restless leg and periodic limb movement
iron supplementation dopamine agonists (pramipexole, ropinirole, levodopa) gabapentin last line: opioids or benzos.
presentation of phobic disorder
irrational fear, producing avoidance, recognized by the patient as excessive
withdrawl from cannibis symptoms
irritability insomnia appetite suppression anxiousness nausea long term = asthma/COPD
Bullous Pemphigoid
is a *chronic*, acquired autoimmune blistering disease characterized by *autoantibodies against hemidesmosomal antigens*, resulting in the formation of a subepidermal blister.
Stasis Dermatitis
is a common inflammatory dermatosis of the lower extremities occurring in patients with chronic venous insufficiency, often in association with *varicose veins*, dependent chronic edema, hyperpigmentation, lipodermatosclerosis, and ulcerations.
Shoulder fracture complication
is adhensive capsulitis or rotator cuff tear
Dyshidrotic dermatitis
is an intensely pruritic, chronic and recurrent, vesicular dermatitis of unknown etiology that typically involves the palms and soles and lateral aspects of the fingers. Although the term "dyshidrotic" implies eccrine sweating, the vesicles seen in dyshidrotic dermatitis are from cytokine-induced intercellular fluid accumulation and have nothing to do with abnormal sweating.
describe periodic limb movement disorder
kicking during sleep. significant enough to disrupt sleep, but may or may not affect quality of life.
nephrogenic DI
kidney does not respond to ADH
Current jelly sputum
klebsiella, PNA
What diagnostic techniques can be used for acute arterial occlusion?
l. Arteriogram to define site of occlusion 2. ECG to look for MI, AFib 3. Echocardiogram for evaluation of valves, clot, MI
What is the treatment for septic shock?
l. IV antibiotics (broad-spectrum) at maximum dosages 2. Surgical drainage if necessary 3. Fluid administration to increase mean BP 4. Vasopressors may be used if hypotension persists despite aggressive IV fluid resus- citation . a. Dopamine is typically the *INITAL TOC* b. If dopamine does not increase the BP, norepinephrine may be given.
What is the diagnostic procedure for hyperlipidemia?
l. Lipid screening -Measure total cholesterol and HDL levels (nonfasting is acceptable). If either is abnormal, then order a full fasting lipid profile. 2. A full fasting lipid profile includes TG levels and calculation of LDL levels. 3. Consider checking laboratory tests to exclude secondary causes of hyperlipidemia. a. TSH (hypothyroidism) b. LFTs (chronic liver disease) c. BUN and Cr, urinary proteins (nephrotic syndrome) d. Glucose levels (diabetes)
Describe the findings on CV exam for ASD.
l. Mild systolic ejection murmur at pulmonary area secondary (ULSB) to increased pulmonary blood flow 2. Wide, fixed splitting of S2 3. Diastolic flow "rumble" murmur across tricuspid valve area (LLSB) secondary to increased blood flow 4. In advanced disease, signs of RVF may be seen.
What are the causes for HTN Emergency?
l. Noncompliance with antihypertensive therapy 2. Cushing's syndrome 3. Drugs such as cocaine, LSD, methamphetamines 4. Hyperaldosteronism 5. Eclampsia 6. Vasculitis 7. Alcohol withdrawal 8. Pheochromocytoma 9. Noncompliance with dialysis
What are the clinical features of VT?
l. Palpitations, dyspnea, lightheadedness, angina, impaired consciousness (syncope or near-syncope) 2. May present with sudden cardiac death 3. Signs of cardiogenic shock may be present. 4. May be asymptomatic if rate is slow 5. Physical findings include *cannon a waves* in the neck (secondary to AV dissociation, which results in atrial contraction during ventricular contraction) and an Sl that varies in intensity.
What are the complications of ASD?
l. Pulmonary HTN-does not occur before 20 years of age, but is a common finding in patients over 40 2. *Eisenmenger's disease* is a late complication seen in a minority of patients, in which irreversible pulmonary HTN leads to reversal of shunt, heart failure, and cyanosis . 3. Right heart failure 4. Atrial arrhythmias, especially *AFib* 5. Stroke can result from paradoxical emboli or AFib.
What are the clinical features of neurogenic shock?
l. Warm, well-perfused skin 2. Urine output low or normal 3. Bradycardia and hypotension (but tachycardia can occur) 4. Cardiac output normal, SVR low, PCWP low to normal
What is the treatment for neurogenic shock?
l. judicious use of IV fluids as the *MAINSTAY* 2. Vasoconstrictors to restore venous tone, but cautiously 3. Supine or Trendelenburg position 4. Maintain body temperature.
difference between autism and asperger's
language and cognitive abilities are preserved in aspergers
fine hairs
lanugo
ACTH secreting pituitary adenoma
leads to cushings
unrestrained growth of leukocytes and leukocyte precursers
leukemia
fungal pneumonia - MC in who
leukemia, lymphoma
Purple, papule, polygonal, pruritis, planar
lichen planus
Wickham's striae
lichen planus
etiology of Hypochondriasis
likely a multidetermined disorder *turning inward of unacceptable feelings of anger *learned behavior from childhood *form of depression or OCD with a symptomatic focus on bodily function
possible etiologies of borderline personality disorder
likely genetic, present since birth, chemical imbalance history of trauma or abuse arrested development in the 'separation-individuation' phase at 18-36 months where a child explores on their own and returns to parents to recharge. they can't recall the sensation of their soothing person. diagnosed more often in women
meds for bipolar depression
lithium lamotrigine quetiapine or ariprazole ECT
name two mood stabilizers
lithium valproate (anticonvulsant)
treatment of bipolar mania and maintenance:
lithium anticonvulsants (valproate, carbamazepine, lamictil) atypical antipsychotics (olanzepine, clonazepine, ariprazole, quetiapine, risperidone, ziprasidone)
major causes of nephrogenic DI
lithium use high blood calcium
treatment of bipolar with severe depression
lithium, lamotrigine, quetiapine, ariprazole, eletroconvulsive therapy. (mood stabilizer first, then antidepressant)
tx for bipolar
lithium, valproic acid, carbamazepine Lithium has a narrow therapeutic index; weight gain, tremor, thirst
Terry's nails - white nail bed
liver disease/cirrhosis
Rifampin SE
liver dysfunction, rash, flu
thyroid papillary tx
lobectomy if < 3 cm total thyroidectomy if >3
Bronchiectasis - PE findings
localized chest crackles clubbing
sedative withdrawl treatment
long acting benzos. reduce as tolerated.
Carcinoid lung tumors - def
low-grade malignant neoplasms that grow slowly and rarely metastasize
Do you want your total cholesterol:HDL ratio to be higher or lower?
lower Ratio of 5.0 is avg (<4.5 is ideal) Ratio of 10.0 is double the risk Ratio of 20.0 is triple the risk
What is the MOA for BAS?
lowers LDL; *INCREASES* TG!!! Effective when used in combination w/ statins or niacin to tx severe disease in high risk pts - third line agent for lowering LDL
why can't bupriopion be used with anorexia nervosa?
lowers seizure threshold
name 2 medium potency first generation antipsychotic drugs
loxapine droperidol
hallmark of CLL
lymphocytosis w/leukocytosis
Drusden spot
macular degeneration
Metamorphosia - wavy or distorted vision (measure with Amsler grid)
macular degeneration
psychogenic causes of sexual dysfunction
major depression w/ anhedonia or failure to socialize anorexia nervosa - low estrogen, amenorrhea, sexual avoidance substance abuse - initially increased sex, then dysfunction
depressive sx must be present for 2 week period, no manic sx, must include depressed mood or anhedonia, not result of bereavement
major depressive disorder
management of obsessive compulsive personality disorder
make them partners in their own care disrupting their schedule will only make them defiant give tons of information (over-educate) and let them make their own decisions.
diagnostic criteria for substance abuse
maladaptive pattern with 1 or more in a 12 month period of the four: failure to fulfill obligations hazardous situation (drunk driving) legal problems social or interpersonal problems
faking sickness to get benefits
malingering
Compare and contrast the etiology, diagnostic criteria, clinical findings for factitious disorder and malingering
malingering: goal=external incentives NOT a psych disorder vs. factitious disorder: goal=sick role (no external incentives) for both: dx by 1:1 sitter or video monitoring, patient will flee or argue rather than "confess" if confronted
abnormally persistant elevated, expansive, irritable mood that lasts for 1 week
mania
occurrence of one or more manic or mixed episodes which often cycle w/depressive episodes (not needed)
manic depression/bipolar I
vaginal leucoohea and bloody discharge are due to what and resolve when?
maternal estrogen/ usually 7-10days
presentation of oppositional defiant disorder
may be present in one environment or another. negative, hostile, and defiant pattern of behavior: loses temper, argues, refuses to follow adult requests, deliberately annoys people, blames other for mistakes, touchy or annoyed easily, angry and resentful, spiteful or vindictive. usually presents by age 8. can start as early as preschool years. may be caused by biological, psych, or social factors.
Koplik's spots in mouth, fever, cough, coryza
measles (rubeola)
MEN II
meduallary carcinoma hyperparathyroid pheochromocytoma
macrocytic anemia (>100)
megaloblastic, sideroblastic
presentation of alzheimer's dementia
memory loss (usually short term first) visual spatial disturbance (early finding) apraxia language disturbance personality changes (insidious onset and gradual progression) depression in 1/3 of patients delusions/hallucinations later in 1/3 of patients
Brudzinski's sign - neck flexion causes hip flexion
meningitis
area of the brain most affected by substance use
mesolimbic dopamine system in the amygdala - stimulated by all abused substances
tx of hyperthyroid in 2nd and 3rd trimester
methamazole
cyclothymia
mild depressive and hypomanic periods lasting over 2 years
very small white papule son nose, cheeks, forehead, chin resolving on own in month or 2
milia
blockage of eccrine sweat glands in flushed macular appearance on neck, face, scalp, diaper
miliaria
Opening snap murmur
mitral stenosis
Crescendo murmur at apex
mitral valve prolapse
Increases with standing
mitral valve prolapse
Mid-systolic click
mitral valve prolapse
treatment for narcalepsy
modafinil is first line methylphenidate/Ritalin dextroamphetamine/Adderall
when is non-pharm treatment used for depressive disorders?
moderate depression/dysthymia
management of avoidant personality disorder
monitor for depressive episodes and treat with meds if necessary
treatment of sleep terror disorder
monitor, usually decreases with age. consider low dose benzos or TCAs if severe.
hallmark of multiple myeloma
monoclonal spike on serum protein electrophoresis
meds for bipolar with agitation/dangerous behavior
mood stabilizer first then add benzodiazepine, antipsychotics, or ECT
meds for bipolar with psychotic symptoms
mood stabilizer then add antipsychotic
Unilateral conjunctivitis
more common with bacterial conjunctivitis
when do we get more REM sleep?
morning hours
pharm treatment of panic disorder
most antidepressents but NOT bupropion potent benzodiazepines (alprozalam, clonazepam) 2nd line because highly addictive and high street value
clinical findings female sexual arousal disorder
most women with this disorder complain of decreased or absent subjective sexual arousal and many are not aware of the degree of their genital response
Bronchogenic carcinoma - adenocarcinoma arises from where
mucus glands
What are the clinical featues of pericardial effusion?
muffled heart sounds soft PMI Dullness at left lung base +/- pericardial friction rub
treatment for anorexia nervosa or bulemia nervosa
multidisciplinary team: PCP, subspecialists, psych, dietition, dentist. weight restoration and symptom control. CBT or interpersonal therapy (focuses on either grief, role transitions, role disputes, or interpersonal deficits.)
Keratitis
multiple diffuse punctuate lesions
Rouleou formation on peripheral smear
multiple myeloma
malignancy of plasma cells
multiple myeloma
opioid withdrawal
naloxone, methadone, clonidine tapering
inflated self image, grandiosity, need for admiration, lack of empathy, difficulty aging, fantasies of unlimited success, beauty, brilliance
narcissism
common side effects of SSRIs
nausea, headache insomnia anxiety decreased appetite sexual dysfunction
What are the indication for surgical treatment and what are the surgical options?
ndications: rest pain, ischemic ulcerations (tissue necrosis), severe symptoms refractory to conservative treatment that affects quality of life or work Options Surgical bypass grafting-this is the *most common procedure* and has a 5-year patency rate of 70% (immediate success rate is 80% to 90%). Angioplasty-balloon dilatation
secondary to areas of surface capillary dilation
nevus simplex (stork bite)
Pellagra (diarrhea, dermatitis, dementia)
niacin deficiency
name 3 parasomnias (unpleasant or undesirable behaviors that occur during sleep)
nightmare disorder sleep terror disorder sleepwalking disorder
hormones involved in erection and vaginal lubrication
nitric oxide, VIP (vasoactive intestinal peptide)
are memory and consciousness impaired in schizophrenia?
no
management of antisocial personality disorder
no treatment shown to be helpful anecdotal cases of spiritual conversion as a provider, beware of their influence
during what phase of sleep does somnambulism (sleep walking) occur?
non REM
during what phase of sleep does sleep terror disorder occur
non REM.
neurotransmitter associated with increased sexual activity
norepinephrine - alpha 1 and 2 and beta agonists
etiology of malingering disorder
not a true psych disorder or illness symptoms are intentionally produced for secondary gain: external incentives such as disability $, avoiding jail, etc.
Solitary pulmonary nodule - likely benign when
not enlarged in >2 yrs
Pertussis - Convalescent stage
number and severity of paroxysms worsens
how is the severity of bulemia determined?
number of episodes per week: mild = 1-3 moderate = 4-7 severe = 8-13 extreme > 14
presentation of somatoform disorders
numerous, multi-system complaints, described as a "positive ROS". Onset < 30 y.o. Chronic symptoms may be disabling, worse during periods of stress.
Explain the presentation for a cocaine induced MI? What is the *MOST COMMON CAUSE* of death?
o Tachycardia, HTN, vascular constriction o Sudden death due to *V.Fib*
BMI >30
obesity
risk factors for obstructive sleep apnea
obesity is #1. age, male gender, post-menopausal women, craniofacial anatomy (retrognathia in Down's), EtOH or nicotine, genetics. Mallampati score = looking at posterior structures through pt's open mouth.
infants are what kind of breathers?
obligate nose
presentation of obsessive compulsive disorder
obsessions increase anxiety. compulsions lower anxiety. recognized by patient as excessive/unreasonable. causes impairment (time-consuming) and marked distress
etiology of PTSD
occurs after exposure to a traumatic event with a real or threatened injury or illiciting intense fear/horror.
describe nightmare disorder (phase of sleep, motor or no motor, arousal or no arousal?)
occurs during REM sleep. No motor activity. Autonomic arousal secondary to fear. Usually improves with age.
acromegaly non surgical tx
octreotide surgery is best
correct administration of levothyroxine
on empty stomach do not take vitamins within 4 hour
SIADH dx
one of exclusion
diagnostic criteria for a major depressive disorder
one or more major depressive episodes / no history of mania, mixed, or hypomanic episodes
define bipolar 1
one or more manic or mixed episodes (history of depressive episodes not required)
presentation of conversion disorder
onset after an acute stressor. Motor and/or sensory symptoms suggest a neurologic disease (paralysis, blindness, mutism, seizures, ataxia, etc.). Most resolve in days to weeks but may recur again with stress. Pt may be acutely overwhelmed or "la belle indifference"
findings in vascular dementia
onset of cognitive defects with stroke or TIA. evidence for decline is prominent in complex attention and frontal executive function. + findings on neuro exam or imaging. fast step-down progression.
6 mths of negative, hostile, defiant behavior, loss of temper, arguments with adults, annoying others, anger, resentment, blaming others
oppositional defiant disorder
what disorder frequently transitions to conduct disorder
oppositional defiant disorder
Ethambutol SE
optic neuritis
treatment of dementia
optimize nutrition, ensure safety, treat behavior disturbance (aggression, insomnia, delusions) Meds: cholineterase inhibitors for mild to moderate. Mamentine for moderate to severe.
What agents can be used in less severe emergencies?
oral agents - clonidine, captopril, and nifedipine.
specific testing for GH secreting pituitary adenoma/ acromegaly
oral glucose suppression test: if oral glucose suppresses GH, normal response no suppression --> MRI for tumor
causes of normocytic anemias
organ failure, impaired marrow functioning
defect in type 1 collagen resulting in bone fragility & pathological fx
osteogenesis imperfecti
Gibbus - angular convex of spine 2nd to vertebral collapse
osteoporosis or mets
Sunburst on bone xray
osteosarcoma
orgasm hormone
oxytocin
hormones involved in attachment
oxytocin, vasopressin
hallucinogen intoxication: PCP
pain insensitivity, nystagmus, hyperacusis, ataxia, HTN, tachycardia rigidity seizures, coma or death
presentation of pain disorder
pain is the focus of clinical attention, not fully accounted for by a medical condition. psychological factors associated with initiation, exacerbation, and/or maintenance of pain. often chronic and disabling.
Acute bronchiolitis/RSV prophylaxis in high risk pts <2 yrs
palivizumab
Cullen sign
pancreatitis
Grey-Turners sign
pancreatitis
hallmark of acute leukemia
pancytopenia w/ circulating blasts
period of extreme anxiety that peaks within 10 minutes, declines w/I 30, and rarely lasts for more than an hr
panic attack
intense fear of impending harm or death, going crazy
panic disorder
What are the three personality disorder types under catagory "A": "weird"
paranoid schezoid schezotypical
pervasive distrust & suspicion
paranoid personality
psychotherapy techniques for conduct disorder
parent management training multisystemic therapy functional family therapy CBT marital therapy NOT group therapy or individual relationship-based.
Adenosine
paroxysmal supraventricular tachycardia
Scotty Dog spine XR
pars articularis fx
what causes fifth disease
parvovirus B19
negativity, stubborn, irritability, procrastination, argumentive, resentful to those seeming more fortunate
passive aggressive
define tolerance
pateint needs and increased amount to produce same effect
Machinery-like murmur
patent ductus arteriosus
management of schezotypical personality disorders
patience when taking history. they tend to tell their stories differently.
presentation of avoidant personality disorder
patient desires social interaction but is afraid of it. 3 common comorbidities: depression, anxiety, substance abuse down-trodden appearance, unsure of self
management for paranoid personality disorder
patient education: give a lot of information so there is no room for interpretation. don't approach the patient from a position of power
Sulfas, macrobid, and antimilarials
patients with G6PD deficiency
voyeurism
peeping tom, bathroom camera
Nikolsky's sign - pressure separates epidermis from dermis
pemphigus vulgaris
Hot potato voice
peritonsillar abscess
egosyntic, lack insight regarding problems, inflexible patterns of relating to others
personality disorder
common comorbidities for BN
personality disorder, substance abuse, bipolar
name two MAOIs
phelezine selegiline (transdermal)
moderate to severe mental retardation, hyperactivity, seizures, autism, hypopigmentation
phenylketonuria
tx for polycythemia
phlebotomy
Scotch tape test
pin worms
Christmas tree pattern on trunk - herald patch
pityriasis rosacea
Heavy painful vaginal bleed in 2nd or 3rd trimester
placenta abruptia
Heavy painless vaginal bleed in 2nd or 3rd trimester
placenta previa
2nd MC cx of hospital-acquired infection
pneumonia
Primary cx of mortality from infectious dz
pneumonia
What are the common cuases of septic shock?
pneumonia, pyelonephritis, meningitis, abscess formation, cholangitis, cellulitis, and peritonitis (however it is not limited to the ones listed)
inc RBCs & inc total blood volume dx by presence of JAK2 mutation
polycythemia vera
diagnostic study to evaluate sleep disorders
polysomnogram ("sleep study") includes an EEG, EKG, EMG of chin and legs, EOG (eye movements), pulse ox, nasal airflow, and respiratory effort.
chvostecks sign
positive if tapping on cheek produces muscle contraction, present in hypoparathyroidism, due to decreased Ca in blood
tx of schizo
positive sx: haloperidol negative sx: risperidone Clozapine is 2nd line
Osteoporosis often in
post menopausal women
define withdrawl
predictable constellation of signs and symptoms after abrupt discontinuation or rapid decrease
Chadwick's sign (blue cervix)
pregnancy
avoid live vaccines (MMR & varicella)
pregnancy, immunocompromised
presentation of hypochondria
preoccupation w/ a specific disease. misinterpretation of bodily symptoms. episodes last months to years +/- stress exacerbation.
presentation of body dysmorphic disorder
preoccupation with profound bodily deformity (exception: anorexia nervosa). insidious onset with gradual worsening.
treatment of delerium
prevent by minimizing risk factors. treat underlyng cause. avoid benedryl, benzos and other drugs (H2 blockers, TCAs, steroids, etc.) involve family members or a 'sitter' antipsychotics: Haldol, risperadone, quetiapine
What is 'secondary gain' in somatoform disorders?
privileges of the sick or external incentives
Status asthmaticus
progressively worse asthma attack that is unresponsive to usual therapy
Inflammatory (RA) History
prolonged morning stiffness swelling redness systemic features: fever, weight loss, fatigue, fluctuating symptoms
Paranoid schizophrenic
prominent delusions and auditory hallucinations. usually older onset, better prognosis.
Beefy red tongue
pronounced anemia
Milkman lines or looser zones
pseudofractures - osteomalacia
Positive bifringement needle crystals, perpendicular & blue
pseudogout
Hot tub folliculitis
pseudomonas aureginosa
Auspitz sign - small speck of blood when pick a scale
psoriasis
Cup & saucer appearance proximal phalynx on xray
psoriatic arthritis
suicide risk factors
psych illness (MDD, substance abuse, bipolar, anxiety, etc) - 90% of suicide completions. availability of means hx of attempts family history of suicide medical illness (new or worsening condition) social factors (military, divorce, financial stress, unemployment, legal problems, hx of abuse) Demographics: male, native american/alaskan native, white. Homosexual
common comorbidity of MR patients
psychiatric disorders (4-6 x's that of normal population)
etiology of somatoform disorders
psychological distress manifests as physical symptoms as a defense mechanism.
sexual sadism
psychological or physical suffering/humiliation of a victim for excitement
pharm therapy for conduct disorder
psychostimulants (possibly comorbid ADHD) anticonvulsants (depakote, Tegretol/carbamazepine) atypical antipsychotics (risperidone, seroquel) antidepressants (buproprion, fluoxetine) *but psychosocial interventions are the primary treatment
management of desire disorders (hypoactive desire and sexual aversion)
psychotherapy behavior or exposure therapy precoital benzodiazapines
treatment of dysthymia
psychotherapy only
treatment of childhood depression
psychotherapy, psychosocial intervention first line antidepressant efficacy questionable, few meds are approved. first line: SSRIs (prozac/fluoxetine , lexapro/escitalopram are FDA approved) wellbutrin for comorbid substance abuse, antipsychotics as adjunct, TCAs, and SNRIs (Remeron approved) less effective in kids.
What is 'primary gain' in somatoform disorders?
pt can avoid psychological conflict and focus attentio on physical symptoms instead
treatment of pain disorder
pt education regarding mid-body duality. multidiscipline approach for pain mgmt, focus on level of functioning. non-invasive, non-narcotic treatment. 5HT and NE meds (tricyclics or SNRIs) biofeedback or hypnosis helpful.
dyspareunia
pt may describe superficial or deep pain upon penetration, which may persist only during sexual activity or she may describe a chronic throbbing pain, which lasts hours after sexual contact *work up prior to mental health referral: Yeast cultures, STIs, and eval for endometriosis. Hormonal assays and cytological examination may also be performed
treatment of factitious disorder
pt will flee or argue rather than confess. approach patient carefully from a place of concern.
difference between anorexia nervosa and bulimia nervosa?
pts w/bulimia nervosa maintain normal body weight or are overweight
Long standing MS can result in what complications?
pulmonary HTN, RVH, and A.Fib
2 types of bulimia
purging- vomiting, laxatives nonpurging- excessive exercise, fasting
Olive shaped mass on palpation
pyloric stenosis
2 types of delerium
quiet type (more common from renal and hepatic encephalopathy) excited type (common from benzo withdrawl)
Negri bodies on brain tissue
rabies
PVD can be diagnosed by the *Ankle-to-Brachial Index (ABI)*....what does the ABI measure?
ratio of SBP at the ankle to the SBP in the arm Normal ABI: =/> 1 Claudication ABI: <0.7 Rest pain ABI: <0.4 False ABI can be seen in DM
fetishism
recurrent intense sexually arousing fantasies, urges or behavior involving nonliving objects
presentation of panic disorder with or without agoraphobia
recurrent, unexplained panic attacks If agorophobia also present: distress in public or avoidance of public situations without a 'safe person'
management of borderline personality disorder
refer for psychotherapy. good long-term outcomes. learn to internalize the presence of the therapist. mood stabilizers, antidepressants may help.
treatment of somatoform disorders
regularly schedules visits w/ on PCP, empathy and support. careful wording when giving dx. caution against missing a diagnosis. brief, focused exam at each visit. manage symptoms. don't focus on cure. possible psych referral after rapport established.
presentation of dependant personality disorder
rely on others to make decisions for them they enjoy being ill, given a serious diagnosis because others will take care of them. may seem as though they don't want to get better. may recurrently present for medical care may make requests of providers that are not clinical
causes of secondary hyperparathyroidism
renal Vit D deficiency
How can a physician know if a patient is having a recurrent infaraction?
repeat *ST-Elevation* on EKG post 24 hours of the MI
most common cause of death in opioid intoxication
respiratry depression
2 types of anorexia nervosa
restrictive & binge eating and purging
2 types of anorexia nervosa
restrictive type: during the last 3 months, the patient has not engaged in recurrent episodes of binge eating or purging. wt loss is primarily accomplished w/ dieting, fasting, or exercise. Binge-eating/purging type: during last 3 months, pt has engaged in recurrent episodes of binge-eating or purging behavior (vomiting, lexatives, enemas, or diuretics.)
Curtain coming down
retinal detachment
floaters or flashers at onset of symptoms
retinal detachment
Asthma - definition
reversible airway obstruction caused by airway narrowing
fever resolves before pink macular rash
roseola
frotteurism
rubbing against someone
maculopapular from head to toe (teratogenic)
rubella (German measles)
Grains of sand on erythematous base - Koplik spots
rubeola (measles)
acute phase of psychostimulants
rush: cocaine seconds to 3 minutes. Meth 5-30 minutes. high: cocaine lasts 1 to 4 hours. meth lasts 4 to 16.
Strep pneumo hallmark
rust-colored sputum
desire to cause pain sexually, physically, mentally; seeking humiliation rather than physical inflicted pain
sadism; masochism sadomasochism
demeaning, humiliating, cruel towards others
sadistic
sedative/anxiolytic intoxication (benzos, barbituates)
same as alcohol
treatment of sedative intoxication
same as alcohol - can use IV flumazenil to antagonize and reverse benzo toxicity
S-shaped burrows on skin
scabies
Anatomical snuff box tenderness
scaphoid fx
Sandpaper rash
scarlet fever
management of patients with dependent personality disorder
schedule frequent visits that are not crisis-driven (follow-ups every 6 weeks). be very clear about professional boundaries. try to 'spread dependency around'
which personality disorder is related to psychosis or schezophrenia
schezotypical. NOT schezoid.
delusions or hallucinations lasting for 2 weeks w/o mood disorder sx
schizoaffective disorder
lifelong voluntary social withdrawal, eccentric
schizoid personality
illusions, hallucinations, delusions, impaired reality orientation; problems in affect, motivation, perception, communication, disorganized speech
schizophrenia
strange, eccentric, peculiar throughts
schizotypal personality
presentation of sleep terror disorder
screaming and motor agitation. occurs during first 1/3 of the night (non REM) confused on waking.
mood disorder due to less daylight hours
seasonal affective
Stuck on waxy plaques
seborrheic keratosis
intoxication of cannibis
sedation, drowsiness, euphoria, enhanced sensory awareness, altered time perception, altered motor function, red conjunctiva, salt-craving, increased appetite, dry mouth tachycardia, anxiety, panic rarely psychosis
adverse effects of 1st generation antipsychotics
sedation, orthostasis, anticholinergic effects (dry mouth, urinary retention, constipation), weight gain, hyperprolactinemia, QT prolongation. Extrapyramidal symptoms: acute dyskinesias such as dystonia, parkinsonism, akathesia. tardive diskinesia. Neuroleptic malignant syndrome: fever, rigidity, delirium, lab abnormalities, potentially fatal.
what are some folic acid metabolism antagonists?
seizure meds, trimethoprim
treatment for sexual pain disorders (dyspareunia and vaginismus)
sensate focus. gradual desensitization.
Bence proteins
serum protein in multiple myeloma
retinal hemorrhages & hyphema should be suspicious for
shaken baby syndrome
signs of alcohol withdrawl
shakes (fine tremor or tongue tremor) irritability, insomnia, agitation, nausea, vomiting, autonomic hyperactivity (tachycardia, diaphoresis), seizures (tonic-clonic, may be lethal), Delerium Tremors (DTs) (visual or sensory hallucinations)
Cardiac cath will show what in cardiac tamponade?
show equalization of pressures in all chambers of the heart shows elevated right atrial pressure w/ loss of y descent
autosomal recessive hemolytic anemia
sickle cell
side effects and benifits of Mirtazapine
side effects: increased appetite, dry mouth, drowsiness. rare agranulocytosis benifits: sedating, weight gain, minimal drug interactions, few sexual side effects.
major side effect of bupropion and benifits
side effects: insomnia, weight loss, headache, agitation, nausea. lowers seizure threshold. benifits: activating! minimal drug interactions, few sexal side effects
side effects and benifits of MAOIs
side effects: orthostatic hypotension, weight gain, sexual dysfunction, insomnia, edema. Hypertensive crisis with tyramine-containing foods or sympathomimetics. Serotonin syndrome with serotonergic agents. benifits: more effective for atypical depression.
acquired disorders with reduced hemoglobin synthesis causing iron accumulation
sideroblastic anemia
hallucinogen: dextromethorphan and Ketamie toxicity
similar to PCP, but generally less severe. more pronounced dissociative effects.
sedative/anxiolytic withdrawl symptoms
similar to alcohol but no DT's. increased risk of seizure with short-acting benzos.
hallucinogen GHB (gamma hydroxybutyrate/Xyrem) intoxication
similar to alochol but more rapid progression to toxicity
What is management based on for AAA?
size
Bronchogenic carcinoma - is non-small cell slow or aggressive?
slow
Bronchogenic carcinoma - #1 RF
smoking
positive/protective factors against suicide
social support spirituality sense of family children or pregnancy life satisfaction coping strategies problem-solving skills
vague complaints involving many organ sx not explained by any medical condition or substance use (usually GI, repro, neuro)
somatization
withdrawl from amphetamine or cocaine
somnolence
common side effects of Remeron/mirtazapine (SNRI)
somnolence dry mouth increased appetite abnormal dreams constipation
side effects of SNRIs
somnolence or insomnia, anxiety, headache, nausea, sexual dysfunction. also dry mouth, decreased appetite, and sweating with duloxetine (Cymbalta). benifits: minimal drug interactions. helps neuropathic pain.
side effects of SSRIs
somnolence, nausea, sexual dysfunction. less common: dry mouth, insomnia, headache
cautions for electroconvulsive therapy
space-occupying CNS lesion MI in the last 6 months history of malignant arrhythmia.
Most important study in asthma pts
spirometry
In patient with Class IV sx who are still symptomatic despite the previously mentioned treatment, what can you add?
spironolactone
Describe neuroleptic malignant syndrome.
ssociated with the use of neuroleptic agents and characterized by a distinctive clinical syndrome of mental status change, rigidity, fever, and dysautonomia. Autonomic dysfunction may result in death. Most often seen with the "typical" high potency neuroleptic agents (eg, haloperidol, fluphenazine) Symptoms may begin with first dose. Most often develop within two weeks of starting therapy, but may appear after years. Treatment is stopping the offending agent and supportive care.
breast feeding up to what age
start weaning off my 2 years; primary up to 4 mths, cereal can be added at 4 mths, fruit @ 5, veggies @ 6
treatment for premature ejaculation
start-stop method, pinch base of penis, SSRIs.
pharm treatment of ADHD
stimulants: amphetamine derivatives (dextroamphetamine, lisdexamfetamine) or methylphenidate derivatives (dexmethylphenidate/Focalin, or Ritalin). alpha 2 agonists (Guanfacine or Clonidine) antidepressants (NE and DA drugs: Atomexetine/Strattera or buproprion/Wellbutrin. TCAs used in the past.)
first line treatment for insomnia
stimulus control therapy, relaxation/biofeedback, CBT sleep restriction paradoxical intention, sleep hygeine education
sx of primary hyperparathyroidism
stones (most common), stomach moans, bones, and psychic groans
possible etiologies of antisocial personality disorder
strong genetic component. no fMRI response in the amygdala to seeing emotion in other people (crying)
Worst headache of life
subarachnoid hemorrhage
PTSD has high comorbidities with?
substance abuse & depression
presentation of antisocial personality disorder
substance abuse common often associated with a history of childhood misconduct unable to acknowledge others' feelings. common triad: fire-setting, cruelty to animals, eneurisis. criminal conduct common: lying, stealing, forcing sexual acts (even as children) will take advantage of others, manipulate
tolerance and withdrawal are a part of
substance dependence
differential for schizophrenia
substance intoxication (meth/coke, hallucinogen) medical condition (encephalitis, temp lobe epilepsy, Huntington's, syphilis, CNS lupus) schizoaffective disorder delusional disorder major depression with psychotic features bipolar, mania with psychotic features paranoid, schizoid, schizotypical personality d/o OCD factitious/malingering
What medication can lead to Stevens-Johnson Syndrome in children?
sulfonamide antimicrobials, phenobarbital, carbamazepine, and lamotrigine. An association with acetaminophen/paracetamol has also been reported.
treatment of adjustment disorder
supportive therapy (friends, counselor, etc.) time-limited pharm treatment for target symptoms: sedatives for insomnia anxiolytics for anxiety *NOT antidepressants
Viral pneumonia - tx
supportive! - analgesics - fluids - cough suppressants
If a pt has a rupture AAA what treatment is indicated?
surgery - all of these pts are unstable
opioid withdrawl symptoms
sweating, piloerection, diarrhea, yawning, mild fever, insomnia, craving, distress/irritability, dysphoria, nausea, vomiting, myalgia, spasm, lacrimation, rhinorrhea, mydriasis
Inflammatory disorders physical exam
swelling warmth
dx of ADD
sx <age 7 for at least 6 mths AND occur in at least 2 settings
nerves involved in sympathetic sexual response
sympathetic chain from T11 to L2 (pelvic plexus)
presentation of factitious disorder
symptoms are physical but can mimic psych illness. ex: Munchausen syndrome
hallmark of somatoform disorders
symptoms are real, not intentionally produced, not medically explained
diagnostic criteria for autism
symptoms before age 3 at least 6 deficits total with: 2 from social interaction category (lack of emotional reciprocity, lack of nonverbals, lack of joint attention and lack of peer relationships), 1 from communication category (stereotyped or delayed speech, etc), and 1 from behaviors (restrictive, compulsions, fixations).
presentation of schizophreniform disorder
symptoms of schizophrenia for more than one month but less than 6 months
presentation of brief psychotic disorder
symptoms of schizophrenia lasting no longer than 1 month. Usually in response to a stressful event.
Presentation of schizoaffective disorder
symptoms of schizophrenia with superimposed symptoms of major depression and/or mania. Must have 2 weeks of psychotic symptoms without mood symptoms. Better prognosis than schizophrenia, worse than mood disorders.
etiology of factitious disorder
symptoms or evidence of disease are intentionally produced. goal is to assume the 'sick role' (secondary gain)
Which murmurs are most commonly benign...sytolic/diastolic?
systolic
how are meds started for patients with schizophrenia or psychotic disorder
target symptoms push dose to max for 4 to 6 weeks. switch, don't add maintain on lowest effective dose
JVD w/ trach deviation
tension pneumothorax
Blue dot sign
testicular appendix torsion
Bag of worms
testicular varicocele
sex drive hormone
testosterone (and estrogen in female)
Atypical pneumonia - tx chlamydia
tetracycline
Boot shaped heart
tetralogy of Fallot
hereditary anemias in which synthesis of aplpha/beta globin chains is reduced resulting in defective hemoglobinization
thalassemia
Most clavicular Fracture involves
the central 1/3
Lichen simplex chronicus (LSC) is a common cutaneous disorder characterized by well-circumscribed erythematous, often *hyperpigmented, patches and plaques of thickened lichenified skin* most commonly occurring on:
the neck, ankles, scalp, pubis, vulva, scrotum, and extensor forearms, as a result of chronic rubbing and scratching.
pretibial myxedema
think hyperthyroidism
how do you assess for suicide risk
thoughts/intent/plan "Have you ever felt life is not worth living" "Have you had thoughts of taking your life" "Do you have plans to take your life" "Have you had an attempt"
platelet consumption treatments
thrombocytic purpura (TTP) hemolytic uremia syndrome (HUS) disseminated intravascular coagulopathy (DIC)
most common cause of abnormal bleeding
thrombocytopenia- decrease of platelets in bloods
Pts with A. Fib are at increased risk for what?
thromboembolism and hemodynamic compromise
Paraneoplastic syndromes associated w/ adenocarcinoma of the lung
thrombophlebitis
Spaghetti & meatballs on KOH
tinea versicolor
diagnostic criteria for schizophrenia
total duration of symptoms, including prodromal and residual, is at least 6 months. social and occupational dysfunction present. one month of at least two of the following symptoms: delusions hallucinations disorganized speech disorganized/catatonic behavior negative symptoms (flat affect, alogia, apathy)
follicular and medullary thyroid cancer tx
total thyroidectomy
pull infant by arms to sitting position & watch head lag behind
traction response
What is the *HALLMARK* of prinzmetal's angina?
transient *S-T ELEVATION* on ECG during chest pain, which respresents transmural ischemia
pituitary adenoma treatment
transphenoidal surgery for all types but prolactinoma
Egg on a string
transposition of the great vessels
treatment of body dysmorphic disorder
treat anxiety and depression if present. surgical interventions not helpful. serotonergic agents may help (SSRIs or clomipromine)
describe the treatment schedule for depression
treat to remission the maintain for 6 months to one year before trying to taper off medication.
side effects of lithium
tremor, GI upset, polyuria/dipsia, psychomotor slowing, weight gain, psoriasis, hypothyroid and goiter, increased WBCs, teratogenic - causes Ebstein's anomaly, cardiac symptoms with T-wave flattening and SA ode dysfunction
Strawberry cervix
trichomoniasis
large tongues that seem larger than mouth may be significant of?
trisomy 21
presentation of schezotypical personality disorder
trouble with interpersonal relationships unable to carry out plans may have strange communication or some psychotic symptoms may present similar to drug use or psychosis magical thinking very different metaphysical veiw point (superstitions) singularly odd- tend to do unusual things but not following a society trend frequently have schizophrenic family members
management of hystrionic personality disorder
try not to respond to flirtatious behavior. patience to get a clear history.
Bronchiectasis - cx from obstruction
tumor
dx of cushings
two of the following must be positive: 24 hour urine cortisol late night salivary test dexamethasone test
clinical features female orgasmic disorder
typical patient will complain of normal libido and sexual excitement without the capacity to reach orgasm *Substance induced orgasmic disorder may be caused by TCAs, SSRIs, alpha-blockers, D-2 blockers and benzodiazepines
lead pipe appearance (loss of haustral markings) on Barium enema
ulcerative colitis
Gamekeeper's thumb
ulnar collateral ligament sprain
etiology of Pain disorder
unconsciously determined punishment to expiate guilt or for aggressive feelings or an effort to maintain a relationship with a lost object somatic expression of depression?
presentation of obsessive compulsive personality disorder
unlike OC anxiety disorder, they are unaware of their behavior. not recognized as silly. may over-plan, try too hard, 'work-a-holic' very orderly like things to be predictable poor spontaneity, don't display much 'feeling', they prefer 'thinking social defenses - tendancy to over-analytize prefer to dissociate to talk about their feelings often don't present for help because it will disrupt their schedule may become problematic if leads to depression or problems with relationships
normal Babinski up to 2 yrs
upgoing plantar
describe restless leg syndrome
urge to move limbs due to discomfort, NOT pain. worse with rest, gets better with movement. affects quality of life.
What can you monitor for the successfulness of tx in cardiogenic shock?
urine output
pharmacotherapy for insomnia
use only after non-pharm treatments have failed: Benzos - good for coexisting anxiety, but high side effects. Nonbenzo/benzo receptor agonists (Ambien, Lunesta) - act on GABA receptor omega 1 only. less side effects and less dependence than benzos. Melatonin Trazadone (off label) Benedryl (diphenhydramine) - Histamine is a wake-promoting hormone.
describe the typical course of schizophrenia
usually prodromal period in adolescence. acute psychotic break age 15-25 for males, 25-35 for females with or without a major stressor. often deteriorates with each episode. first 5 years are most prognostic. 20-30% maintain somewhat normal lives. 40-60% are severely impaired.
treatment of childhood anxiety
usually psychotherapy alone (CBT) or in combo with meds: antidepressants (SSRIs, TCAs, SNRIs) adjunctive anxiolytics/benzodiazepines if severe (in older adolescents)
sympathetic control of sexual response in the female
vaginal vestibule engorgement contract genital smooth muscle clitoral detumescence
prodromal period of fever, resp; itchy rash is vesicular erythematous torso & face to extremities (dew drop on rose petal)
varicella (chicken pox)
What is the most common cause of stasis dermatitis?
varicose veins
name three SNRIs
venlafaxine (Effexor) duloxetine (cymbalta) desvenlafaxine (Prestiq)
greasy covering more often found on preterm infants
vernix caseosa
presentation of hystrionic personality disorder
very dramatic, emotional vs rational, overly-familiar. tend to respond to a sexual component, come across as flirtatious. often relay their medical histories in a vague way ("it hurts everywhere... for forever") some correlation with borderline or narcisistic diagnosed more often in women
In what patient population is hypothermia seen in septic shock?
very young, elderly, debilitated, and immunocompromised
diagnosis of factitious disorder
video monitoring or 1:1 sitter
diagnosis of malingering disorder
video monitoring or sitter
presentation of conduct disorder
violates rules and rights of others. aggression to people or animals. destruction of property. deceit, theft, serious rule violation. assoc w/ abuse, parental substance use, family conflict, poverty. more common in males. often assoc w/ ADHD and learning disorders.
pernicious anemia
vit B 12 def
What is the *TOC* for TG < 500 mg/dl?
weight loss, diet, exercise (wt loss is the *primary goal*)
detumescence
when blood flows out of organ
hyperparathyroid EKG
will show short QT syndrome
Influenza - common in what season?
winter
Mycoplasma pneumonia - MC in who
young adults/college students
HCM is *MOST COMMON* in what patient population?
young atheletes
meds associated with ↓ sexual activity or sexual dysfunction
β-blockers SSRIs - low libido and delayed orgasm (increased seretonin = inhibit NO, incr PRL, decr endorphins from mu interaction) serotonergic migraine meds prostaglandin inhibitors like Ibuprofen, Naproxen anticholinergics antihistamines TCAs and atypical antidepressants (least effect w/ desipramine or bupropion)
What effect does HTN have on the kidney?
• Arteriosclerosis of afferent and efferent arterioles and glomerulus-called *nephrosclerosis* • Decreased GFR and dysfunction of tubules-with eventual *renal failure*
Explain *"Nonbacterial Thromboltic Endocarditis (Marantic Endocarditis).
• Associated with debilitating illnesses such as metastatic cancer (found in up to 20% of cancer patients) • Sterile deposits of fibrin and platelets form along the closure line of cardiac valve leaflets. • Vegetations can embolize to the brain or periphery. • Although the use of heparin may be appropriate, no studies have confirmed its efficacy.
What effect does HTN have on the eyes?
• Early changes-*Arteriovenous nicking* (discontinuity in the retinal vein secondary to thickened arterial walls) and *cotton wool spots* (infarction of the nerve fiber layer in the retina) can cause visual disturbances and scotomata • More serious disease-hemorrhages and exudates • Papilledema-an ominous finding seen with severely elevated BP (indicated HTN Emergency)
Explain the D-dimer in DVT.
• Has a very high sensitivity (95%), but low specificity (50%); can be used to rule out DVT when combined with Doppler and clinical suspicion According to ULM: D-Dimer less than 500 - strong evidence against thromboembolism. But if >500 you MUST w/u patient!!!!!
What effect does HTN have on the CNS?
• Increased incidence of *intracerebral hemorrhage* • Increased incidence of other stroke subtypes as well (transient ischemic attacks [TIAs] , ischemic stroke, and lacunar stroke) • Hypertensive encephalopathy when BP is severely elevated (uncommon)
Explain Leutic Heart:
• Luetic heart is a complication of *syphilitic aortitis*, usually affecting men in their fourth to fifth decade of life. Aneurysm of the aortic arch with retrograde extension extends backward to cause aortic regurgitation and stenosis of aortic branches, most commonly the coronary arteries. • Treatment: IV penicillin and surgical repair
What is the correct procedure for blood presssure readings?
• The arm should be at heart level, and the patient should be seated comfortably. • Have the patient sit quietly for at least 5 minutes before measuring BP • Use a cuff of adequate size (a cuff that is too small can falsely elevate BP readings). The bladder within the cuff should encircle at least 80% of the arm.
Explain *Nonbacterial Verrucous Endocarditis (Libman-Sacks Endocarditis)*
• Typically involves the *aortic valves* in individuals with *SLE* • Characterized by the formation of small warty vegetations on *both sides* of valve leaflets and may present with regurgitant murmurs • Rarely gives rise to infective endocarditis, but can be a source of systematic embolization • Treat underlying SLE and anticoagulate.
What is the symptoms for "rest/continuous pain"in PVD?
• Usually felt over the distal metatarsals • Often *prominent at night-awakens patient from sleep* • Hanging the foot over side of bed or standing relieves pain-extra perfusion to ischemic areas due to gravity • Rest pain is always worrisome-suggests severe ischemia such that frank gangrene of involved limb may occur in the absence of intervention
What medication can lead to Stevens-Johnson Syndrome?
●Allopurinol ●Aromatic anticonvulsants ●Antibacterial sulfonamides ●Lamotrigine ●Nevirapine ●Oxicam NSAIDs
Classic presentation of cutaneous lichen planus is a papulosquamous eruption characterized by the development of flat-topped, violaceous papules on the skin (picture 1A-D). Often, the clinical manifestations are described as the four "P's:"
●Pruritic ●Purple (actually a slight violaceous hue) ●Polygonal ●Papules or plaques
Patients with stasis dermatitis may present with other signs of chronic venous insufficiency and related comorbidities, including:
●Varicosities ●Secondary lymphedema ●Atrophie blanche (stellate, porcelain-white scarring areas resulting from microthromboses) ●Secondary cellulitis ●Ulceration
Describe extrapyramidal symptoms (EPS).
●akathisia = motor restlessness. most common symptom. ●parkinsonism = masking face, resting tremor, cogwheel rigidity, shuffling gait ●dystonias = involuntary contraction such as sphincter tightness, torticollis. Very rarely, may cause laryngospasm. More common with high potency first generation antipsychotics. Treatment is cogentin/benztropine
