Step 3b
Pt with pancreatitis and elevated ALT >150, does not drink.
95% PPV for gallstone pancreatitis! do cholecystectomy if gallstones on imaging
Similar to asthma but really bad and some hemoptysis, improves with steroids, with transient lung infiltrates on CXR in diff parts of the lung (can be bilateral upper lobes, patchy)
ABPA allergic bronchopulmonary aspergillosis (eosinophilia, IgG, IgE) tx: PO steroids and *itraconazole*, not fluconazole
tympanostomy tube placement
chronic effusion for 6-12 months, hearing loss, failure of abx ppx
What finding is most consistent with severe aortic stenosis?
1. Single 2nd heart sounds during inspiration. 2. Soft 2nd single hear sounds, late-peaking systolic murmur 3. Delayed and diminished carotid pulse (parvus et tardus) 4. Loud but low intensity sounds during closure
When to ckmb and troponins rise?
3-6 hrs after MI myoglobin is 1-4 hrs after MI
When to screen for GBS in preg ppl
35-37 weeks!!! Give abx if UNKNOWN GBS STATUS AND: - <37 wks gestation - Intrapartum fever - ROM for 18+ hrs - Prior infant with GBS with COMPLICATIONS
56 y.o. eval'd for fever POD 3, underwent CABG with 4 grafts, still intub'd, has T2DM, HTN, is febrile, normal BP and HR. BMI 28.. Coarse breath sounds bilaterally. Heart sounds normal. Pt grimaces to palpation of RUQ. Bowel sounds decreased. Alk phos, LFTs, amylase normal. Hgb 10.8, WBC 17,000. CXR normal. Dx?
Acalculous cholecystitis; often in critically ill pts or pts that had recent surgery, also trauma, burns. --> Unexplained fever and RUQ pain, leukocytosis, possibly abnormal LFTs
5 y.o. with joint pain, last week pain in her knees, resolved, then pain in ankles and wrist. Now has a non-pruritic pink rash on her back. Had a sore throat recently which resolved on its own. Temp 101, multiple well demarcated red slightly raised outlines on trunk and proximal limbs. Elevated CRP and ESR, WBC 6500. Dx?
Acute rheumatic fever; prevent by treating strep pharyngitis with PCN - HSP: migratory arthritis and rash, but ITCHY purpuric rash, involves LE joints
VZV vaccine
Age 1 yr and age 4-6
Digitalis toxicity causes
Atrial tach with AV block
What type of intubation is contraindication if leaking CSF from nose and mouth!
Blind nasal!!!! the pt has a skull fracture, no blind attempts, esp nasal bc it will go straight to the brain!
65 y.o. with 4 weeks abd pain worse with eating, has had some weight loss bc eats less often. Several year history of heartburn, omeprazole last 4 weeks has not helped. BMI 34, 10 pack yr smoking hx, neg FOBT, nl labs; EGD showd mild esophagitis, no gastritis; abd US shows 2 large gallstones with no thickening or peri fluid, no ductal dilation, hard to see pancreas bc of gas. Next imaging step?
CT Abdomen; progressive 4 wks of epigastric pain worse with eating. Smoking or alcohol abuse can cause pancreatic cancer. Should do CT to see pancreas. Weight loss, jaundice, and nausea can also happens
65 y.o. with 4 wk hx of vague postprandial epigastric pain. 1 ppd smoker, FOBT positive, EGD shows antral ulcer, bx c/w adenocarcinoma. Next step?
CT Scan for mets duh; h pylori is associated with adenocarcinoma and malt (eradicate if resectable cancer, can cause remission in some MALT pts, but eradication can help prevent 2nd cancer of adeno if resectable)
40 y.o. man with worsening RLQ pain radiating to groin; past 7 days, worsening, also fever and anorexia, 2 wks ago tx for furunculosis of right thigh; hx of T1DM, has feber, tenderness to deep palpation of RLQ without rebound or guarding. Extension of right hip increases the pain. WBC 13.5k. Next step?
CT abd/pelvis; psoas abscess!!! hematologic seeding from distant infection, risk factors are HIV, IVDU, diabetes, Crohns - furunculosis with abscess: MRSA coverage even if healthy. Clinda, Bactrim, or doxy
22 y.o. with severe crush injuries of lower extremities, give morphine, temp 100.4, BP 190/90, Very large, peaked T waves on V1-V6 --> tx?
Calcium gluconate, pt has high potassium and CPK from massive necrosis and lysis, called rhabdo
55 y.o. with sudden palpits and chest tightness, has afib with RVR, then becomes unresponsive with no palpable pulse but cardiac monitor shows afib at the same high rate. Next step?
Chest compressions! Pt has PEA, do CPR, give epi every 3-5 mins until shockable rhythm, keep doing CPR in the meantime, after a couple rounds of epi can give amiodarone
67 y.o. admitted for aspiration pna, brief intubation. On day 8 hospitalization, now afebrile still on IV abx. No discomfort. Still can't ambulate tho working with PT. Had ischemic stroke 6 months ago with residual left sided weakness, walked with a cane before this admission. Vitals normal except mildly high BP and HR when stands. Rhonchi on RLL. On exam there is left sided weakness that is more prominent in the arm. Left knee can't be fully extended due to significant resistance at a certain point. What is the most likely cause of inability to ambulate?
Decondition. Old dude recovering from prolonged illness with bedrest. Spasticity is probably from prior stroke since he used a cane, not a new contracture. - Critical illness neuropathy is limb and resp muscle weakness in pts with multi organ system failure or severe sepsis. Has difficulty weaning off ventilator, have severe encephalopathy/coma. Pt is too stable for this dx.
32 y.o. with SOB and progressive weakness over weeks. No CP, palps, syncope., hx of migraines. Smokes dailys cis and uses meth. No hx of heart dz. BP 88/60, HR 105, RR 22. Pulse ox 91 on room air. Sitting upright and uncomfortable. Diffuse crackles through lung fields and dullness to percussion at right lung base. Extra sound in early diastole, best heard with bell at apex. Legs are cool and pulses diminished. Cr 1.9, other labs nl. Given meds and med that is beta1 agonist. How will this help?
Decreased LV ESV; increased HR (chronotropy) and contractility (inotropy)
1 hr old newborn with resp distress. Mom had uncomplicated preg. At 36 wks, mom had PROM with clear fluid. During inudciton, non-reassuring fetal heart abnorms. Pulm exam shows tachypnea, nasal flaring, intercostal retractions, clear breath sounds. Normal peripheral pulses. Nl CBC, blood ctx pending. CXR: increased lung volumes, fluid in interlobular fissures. Etiology?
Delayed resopriton and clearance of alveolar fluid; TRANSIENT TACHYPNEA OF NEWBORN -> caused by delayed resorption and clearance of alv fluid, often pts with c-section at increased risk. Tx: Self resolves (clear lungs the whole time on exam, fluid in alv fissures on CXR) in few hours to days.
12 y.o. boy in the ED with scrotal pain, 3 hrs ago cannonball dive into swiming poor, immediate sharp pain in scrotum; lay down, cool compress but still painful. Uncomf boy bent at the waist. Edema, faint ecchymosis, tenderness at right hemiscrotum. Next step?
Doppler US of scrotum! Torsion; doppler can eval contents and confirm torsion; would show reduced or absent blood flow or twisting of cord. - Localized blue small mass on upper testis can be torsion of of appendix testis, nl or increased blood flow on US; tx is supportive, pain managed, and scrotal elevation - Surgical evauation of hematoma: if rapidly expanding testicular hematoma from blunt force trauma!! This pt has mild ecchymosis after trauma, unlikely to be hematoma
Periodic breathing in premature baby but no other probs (random pauses of 5-10 sec, with tachypnea for a few seconds before and then normal)
Due to CNS immaturity and should resolve after 6 months (vs. apnea of prematurity which is 20+ sec and more serious)
Zenker's diverticulum
Dx: contrast esophagram!!! Tx is surgery
Homeless guy with anterior wall MI, no previous DM or HTN. Long term smoker. Echo shows nl LV size, LV anterior wall hypokinesis and EF 50%. 2 yrs later, pt found dead in the street. Autopsy shows dilated LV with a globular shape and thinned walls along with a scar on the anterior wall. Which med would have prevented this?
Enalapril!!!! ACEi's limit ventricular remodeling (LV thinning) and should be started within 1 day after MI
Follicular thyroid cancer
Firm nodule that is cold on thyroid scintigraphy. Characterized by invasion of the tumor capsule Spreads hematogenously - Calcitonin: parafollicular (MEN2) - Papillary (psammoma) thyroid cancer: spreads to local tissue and lymph nodes - Hurthle cells are nonspecfic, Hashimoto/benign adenomas/follicular cancer
3 y.o. brought to ED after she told mom she swallowed a coin. Mom is unsure when she swallowed it. She is asx. Afeb, satting well, no drooling or coughing. CXR shows the class coid in the neck area. Next step?
Flex endoscopy. If <24 hrs and asx, observe and repeat CXR in 12-24 hrs. If ingestion time is 24+ hrs OR UNKNOWN, endoscopic coin removal
59 y.o. with 3 mo hx of persistent ear pain, not improved with OTC meds. He is a welder and 40 year smoker, normal ear on exam. no tenderness or crepitus on palpation of the temporomandibular joint. Poor dentition. Normal tonsils and no erythema on posterior pharynx. Nontender 2 cm lymph node on right side of his neck. Next step?
Flex laryngopharyngoscopy! Pt has referred otalgia often from dental and temproromandibular diseases, also HEAD AND NECK SCC esp with hx of smoking, welding fumes, and cervical LAD
What seizure may be missed by EEG?
Focal seizure!!!! Also these are not provoked by hyperventilation
72 y.o. man with AMS, had abd discomfort earlier in the day, had vomiting, is insulin dependent diabetic. Feber 101F, moaning in pain and flexing his hips; dry mucous membranes, chest auscultation reveals coarse crepitations. Distended, tender abdomen with guarding and hyperactive bowel sounds. Warm extremities with distal pulses. On exam what should you spend special attention to?
Groin for incarceration; dehydration, AMS, may even have coarse crepitations of lungs bc of aspiration 2/2 n/v
aflatoxin is associated with what
HCC!!!
29 y.o. with fever, hx of IVDU, and IE. 3/6 holosystolic murmur heard at the apex that radiates to the axilla. Has splinter hemorrhages. 3/3 cultures grew GPC in clusters. Next step?
IV Vanc immediately (most important step, can get echo later)
57 y.o. with days of very red and warm super tender face only on one side. Tx?
IV cefazolin = erysipelas GAS, deeper and can cause bacteremia and be fatal!!! (Tx for impetigo are topical mupirocin and retapamulin)
Tx for lyme meningitis/heart block
IV ceftriaxone!
Angiography vs CT in mesenteric ischemia
If suspect thrombosis, do CT angio; if suspect acute ischemia due to narrowing
82 y.o. with heart murmur, no CP, dyspnea, or LE edema. Has HTN tx with amlodipine, lifetime non-smoker, BP 145/60 and HR 72, lungs clear, echo shows calcific aortic valve without stenosis but with severe aortic regurg. LV is dilated with EF 63%. Which compensatory mech best explains why this pt is asx with the existing pathology?
Increased LV compliance; so EF is normal looking but up to half is regurgitant flow, so chronic volume overload causes increased SV to help increase CO, causing eccentric hypertrophy and increased LV compliance to accommodate additional LV volume and increased LV contractility.
32 y.o. man with 6 mo progressive weakness and exertional dyspnea. PMH of knife injury and stab in right thigh 10 months ago. Doctor sutured it. Arrested several times for robbery. Drinks alcohol and occasionally crack. Right leg feels warmer and more flushed compared to left. Carotid upstroke is brisk. PMI displaced to the left, systolic murmur heard over cardiac apex does not change with valvalva. Cause of sx?
Increased cardiac preload; high output heart failure after traumatic injury to the right thigh causes shunting of large amount of blood thru it and decreases SVR and increases preload and CO. Widened pulse pressure, strong peripheral arterial pulsation (brisk carotid upstroke), systolic flow murmur, tachycardia, flushed extremity, may LVH from hi flow
25 y.o. g1p1 with amenorrhea after 12 wk ago had vaginal delivery. Complicated by retained placenta and postpartum hemorrhage requiring manual extraction of the placenta and a blood transfusion. No menstrual period since then. Has been breastfeeding exclusively with no sexual intercourse. BP 100/70, HR 60. Normal pelvic exam. Cause of amenorrhea?
Lactational amenorrhea, resulting in high levels of prolactin, inhibiting GnRH and can occur for 6 months!! - Sheehan syndrome is absent TSH, LH and FSH and low PRL; would have inability to lactate, amenorrhea, hypotension - Asherman syndrome: Intaruterine adhesions -> secondary amenorrhea -- no withdrawal bleeding (34 y.o. had baby 4 months ago, no menstsruation. Had postpartum hemorrhage with transfusion and emergency, previously normal periods. Normal FSH and TSH, normal exam, neg upreg test)
Old man with bowel resection after strangulated hernia, falls on POD 3 while getting OOB, after fall responsive but confused and slurred speech, BP 89/50, pulse 122, decreased bibasilar lung sounds and distended neck veings, enw RBBB and non-spec ST and T wave changes. Unsuccessful improvement with IV resuscitation, then pt pupils dilate, pulse drops to 45//min, unresponsive, dies. D?
Massive PE; hypotension, right heart strain, cardiogenic shock. JVD, RBBB,
Which meds are the best at increasing HDL levels
Niacin > gemfibrozil > statin
62 y.o. with progressive SOB and nonproductive cough. Now worse PND and orthopnea. Using accessory muscles, HR 130 and irregular, neck veins are disetnded, bilateral crackles on auscultation. Pt is most likely to benefit from which intervention?
Non-invasive ventilation; give her frickin O2 - milrinone and dobutamine are for severe acute decomp HF but with hypoperfusion, hypotension, end organ dysfunction
Baby with cyanosis, pulse ox 85% on room air, doesn't go up despite 100% O2. Mom used topical anesthetic on him. PaO2 high or low? pCO2?
Normal PaO2, and pulse ox reads at 85%. Tx is methylene blue for methemoglobinemia!!! Also caused by dapsone, nitriles, and local anesthetics
Sickle Cell with left thigh pain for over a year, hx of sickle cell crises 3 wks ago had URI which resolved spontaneously. Height and weight 10th percentile, Pain on movement of leg with restricted ROM. Limping, has normocytic anemia and normal WBCs. Cause of sx?
Osteonecrosis of femoral head
Retinoblastoma gene associated with what other cancer
Osteosarcoma - also assoc'd with Paget dz!!!
What post op day to pelvic abscesses present?
POD 7; Febrile, loose stools and emesis with meals, tachy, abd exam distended, decreased bowel sounds, fluctuant mass on left side of rectum, WBC 17, free air below diaphragm , dx? p.a. - Lots of free air (vs. a little which is normal after abd surgery) can mean perf'd viscus, pt would have severe diffuse abd pain, sepsis, n/v, ileus, peritonitis
40 y.o. with long hx of alcohol admitted for fever, jaundice, abd pain. PMH significant for lap app 3 yrs ago, has hi white counts, etc, had ERCP and stone extracted. Today, has 3 episodes of vomiting and deep gastric pain, worse by lying flat and better with leaning forward. Cool and clammy, abd distended and tender. WBC 21k, amylase and lipase 400s. What happened?
Pancreatic inflammation by the ERCP. ERCP can cause acute inflammation!!! Gallstone in the ampulla of vater can also cause pancreatitis but in this pt ERCP showed stone removed and visualized biliary tree
61 y.o. with lightheaded, dizziness with bright red BMs 2 over the past hour, but no stool! Has had some crampy abd pain after eating the past several days. Hx of benign polyps, last colo was 6 months ago and 3 hyperplastic polyps were removed. Both parents died from colon cancer. No masses but fresh red blood in rectum. Next step?
Perform NG aspiration for acute lower GIB. Eval for lower GI bleed you should also always do NG aspiration bc 11% of the pts will have upper cause of their bleeding. If UGIB, then do EGD for lesions above the ligament of Treitz. - Colonoscopy is great but not if high volume bleed
Mitral stenosis vs. peripartum cardiomyopathy in pregnant pt at 29 wks
Peripartum cardiomyopathy causes rapid onset systolic heart failure at 36+ weeks. Pt in this question presented with acute severe SOB; felt flutterin in chest when woke up, has cough, progressive dyspnea, orthopnea some fatigue. No heart dz hx. Immigrand from India 5 yrs ago. BP 110.60 and HR 144, afib with RVR. Pt appears uncomfortable. She has pulm edema with rapid decompensation bc of new afib with RVR, hx of recurrent sore throat from country with high change of rheumatic heart disease, likely has mitral stenosis.
43 y.o. man with 4 days of fever, malaise, nausea, anorexia, RUQ abd pain. Dx'd with hep C 2 yrs ago and has had no tx. No other probs. Returned from South America trip recently where he had several episodes of diarrhea that improved with oral cipro. He has been home for 2 months and has not had recurrence of diarrhea. Does not use tobacco or alcohol but remote hx of IVDU. Abd soft and ND, but marked RUQ tenderness. US shows 6 cm hypoechoic lesion in right hepatic lobe. FNA shows thick, dark brown fluid. Gram stain negative for microorganisms. Dx?
Protozoal infx (Entamoeba histolytica). - SOUTH AMERICA, FEVER, RUQ PAIN, HYPOECHOICE LIVER LESION, maybe recent dysentery Dx: blood serology - Hydatid dz: takes YEARS to grow, asx until 10+ cm, fever is rare unless cyst ruptures
15 y.o. with murmur on sports physical. Great exercise capacity. Faint midsystolic murmur along LLSB when supine, when standing 3/6 systolic cresc-decresc murmur. What is the most likely mitral valve abnormality in this pt?
Pt has HCM (harsh cresc-decresc murmur); some pts have systolic anterior motion of the mitral valve leading to anterior - MVP: non-ejection click along with mid-to-late systolic murmur
60 y.o. stroke of MCA, uses ASA daily. Came to hospital 5 hrs after onset of neuro probs, head CT nl at that time. Carotid US shows 20% narrowing of both carotid arteries, LDL120. What med would most benefit the pt?
Pt with ischemic stroke already on aspirin, you can switch to clopi or add dipyridamole, DON'T add Plavix to aspirin for stroke or TIA (increases bleeding). - Not aspirin (stroke by itself is not equivalent to CAD in terms of lipid management) - Endarterectomy at 70-100% with sx carotid disease
18 y.o. routine physical. Mild dyspnea with stair climbing. No CP, LH, syncope, hx of menorrhagia controlled with OCPs. Younger sister had a hole in heart that colosed in infancy. BP 100/60, HR 92, No JVD. During expiration has high pitched sound after S1. 3/6 systolic crescendo decrescendo murmur at LUSB. S2 is split and splitting increases with inspiration. Murmur does not increase with standing. Pulses equal and palpable bilaterally. Type of murmur?
Pulmonic stenosis, can be right heart failure, maybe asx until early adulthood. Ejection click (high pitch sound after S1 best heard during expiration) followed by cresc-decresc systolic murmur at LUSB. Also get wide splitting of S2, eccentuated with inspiration - ASD: fixed split S2, mid systolic murmur - Bicuspid aortic valve: premature valvular calcification in 40s or 50s but not in this young of a person, also would get RUSB murmur not LUSB. - Tricuspid regurg: holosystolic murmur over LLSBworse with increased venous return.
28 y.o. with left testicular mass, present for 2 months, increased in size, painless, hard nodule in left testicle, no LAD, US shows solid, hypoechoic 5 cm left testic mass, next step?
Radical inguinal orchiectomy to confirm the dx of testicular cancer! - disseminated prostate ca: androgen deprivation therapy - transscrotal biopsy, scrotal orchiectomy, FNA have poor outcomes, can cause spread!!!!!
5 y.o. healthy kid here for annual physical exam. Maternal uncle died from MI at 56. Has grade II systolic ejection murmur at LLSB best heard when he is lying down, decreases with standing. No rubs or gallops are heard. Next step?
Reassurance; benign bc it decreases with valsalve/standing, also less than 3/6 (unlike HCM which worsens with standing), also worse if diastolic
Pt stung by bee, anaphylactic, gets IM epinephrine and improves, and then starts getting anaphylactic again. Next step?
Repeat IM epi!!! Long term should get venom immunotherapy
53 y.o. with ED after coughing up blood at work. No prior episodes. JVP 9 cm, normal apical impulse with loud 1st heart sound and short apical low pitched diastolic rumbling murmur with bilateral crackles. CXR shows pulm edema, prominent pulm arteries at the hilum, elevation of the left mainstem bronchus, LA enlargement with flattening of left heart border. Dx?
Rheumatic heart dz (MITRAL STENOSIS = LOW-PITCHED DIASTOLIC RUMBLE AT APEX!!!)
SVT vs. Afib
SVT: no p waves, narrow complex tach, *regular* AVRT can lead to WPW (WPW pattern plus symptomatic tachyarrhythmia = WPW syndrome) Afib: no p waves, narrow complex, irreg irreg
Congenital umbilical hernia tx
Small ones close spontaneously!! if larger than 1.5 cms, can do surgery at age 5ish. Associated with down syndrome - Immediate surgery for gastroschisis and omphalocele! - Surgery within 1-2 weeks with inguinal hernia! - (elective surgery for femoral hernia in adults)
Anesthetic adverse effects
Succ: hypokalemia Etomidate: adrenal insufficiency (11-beta hydroxylase inhib) Halothane: acute liver failure Nitrous oxide: inactivates B12 and methionine synthase -> neurotox Propofol: hypotension
53 y.o. with DM had large AAA repair 8 hrs ago, no complics. But now unable to move legs and they feel numb. Flaccid paresis of both LE and impaired pinprick sensation to T9 bilaterally, sparing proprioception. Next step?
Supportive care, call neurology; pt has anterior spinal artery infarction, sparing proprioception (posterior cord)
60 y.o. with right shoulder pain last 3 days, after tripped and fell while moving boxes. Full passive ROM, weakness with resisted abduction of right shoulder compared to left side. Arms up and slowly lowers, then drops when below horizontal. What is damaged?
Supraspinatus!!!! muscle (rotator cuff tear). Dx: MRI
70 y.o. with 3 hrs intense constant chest and neck pain that radiates to the interscapular area, described as sharp, appears anxious, 10 yr hx of T2DM. BP 189/110 in right arm, 181/113 on left, HR 105, early decrescendo diastolic murmur on LLSB. EKG shows sinus tach, LVH, T wave inversions in V5 and V6, creatinine 2.1. Next step?
TEE; severe CP raidating to back, severe HTN, aortic regurgitation murmur (decrescendo diastolic murmur) due to proximal extension f dissection into aortic valvular annulus. TEE has great sens and spec, esp good if ppl have elevated creatinine or hemodynamic instability
Pt with bicuspid aortic valve. Tall. What condition should he be evaluated for?
Thoracic aortic aneurysm
What chemo is reversible cardiotoxicity vs which is dose dependent
Trastuzumab is reversible, anthracyclines (daunorubicin) are reversible and dose dependent
ITP treatment plt <10,000 but no bleeding. Also what illnesses is ITP associated with
Treat with prednisone, IVIG or Rhogam; assoc'd with EBV, HSV, CMV
34 y.o. with HIV has GIB, 2 months ago admitted for HIV tx, had been ok since then. 2 days ago, had nonspecific abdominal discomfort, attributed to food poisoning and self-treated with lots of hydration. Abd discomfort persisted and now has BRBPR. Worse the next morning, has hct drop from 34% to 28%. NGT returns clear fluid. Next step in dx?
UGI endoscopy; pts with hematochezia or suspicion of lower GIB should undergo NGT to rule out upper GI source since it's easy to rule out. If BILIOUS fluid returned, consider that negative otherwise if no bilious fluid obtained, do upper GI endoscopy since a closed pylorus can mask bleeding in the duodenum. If negative, could do colonoscopy and/or bleeding can't be controlled, angiography is used for dx and therapy. If still no active bleed, ppx embolization of left gastric artery or gastroduodenal artery may be performed to control gastric or pyloroduodenal bleeding respectively
Neonatal herpes
Vesicles MAYBE; might have absent skin findings in CNS and disseminated disease. Pt typically has encephalitis, seizure, lethargy, full fontanelle (increased ICP); TEMPORAL LOBE HEMORRHAGE AND EDEMA. - Zika: seizures, microcephaly, hypertonia, contractures, ocular, hearing loss
short PR interval, delta wave, QRS widening with ST and T wave changes
WPW, accessory re-entrant pathway
65 y.o. with esophageal perforation probs. Imaging?
Water soluble contrast esophagography
Young pt with stiff neck and HA, AMS, high fever, BP 70/40 HR 140, diffuse petechial rash on hands, face, arms. Intubated, given blood but BP 65/35. Next step?
Waterhouse-Friderichsen syndrome - meningococcemia and adrenal hemorrhage tx: high dose IV steroids!
Hepatitis B breastfeed?
Yes, don't have to wait until they receive immunizations
Compartment syndrome of the arm?
Yes. in this pt she has a fracture of the radius and ulna with likely hemorrhage in the forearm.
Acute vs. chronic tamponade
acute has nl cardiac silhouette on CXR
57 y.o. with months of progressive difficulty walking, wk and stiff in both legs, hard to walk; numb and tingling in arms and legs, long term smoker and IVDU, mild atrophy of upper arms and decreased triceps reflex, decreased vibration and pain in both legs and hands, upgoing babinski bilaterally. What else would you see in this pt?
advanced spondylosis of cervical spine in radiography; pt has cervical myelopathy degenerative spine/discs -> canal stenosis -> cord compression gait dysfunction then weakness/numbness, LMN and UMN signs, decreased proprioeception/pain/vibration tx: immobilization or surgical decompression
Zinc deficiency
alopecia, perioral pustular rash and on extremities, change in taste, hypogonadism, higher risk in cirrhosis, can cause acrodermatitis enteropathica
Prostate cancer treatment
androgen deprivation therapy like leuprolide or goserelin only if METastatic. Otherwise if localized, do radiation or prostatectomy. No chemo - brachytherapy is kinda like an implant to control local disease
How much to decrease insulin by in insulin dependent diabetes prior to surgery?
by one third!!! also give IV D5 nad IV reg insulin to maintain optimal level
Marfan's murmur
diastolic decrescendo murmur
verapamil plus dig =
dig toxicity (nausea, vomiting, confusion)
Hemoptysis
elevated pulm capillary pressure - from mitral stenosis or left heart failure mucosal inflammation and rupture of superficial vessels - chronic bronchitis
Ribavirin side effect
hemolysis, esp in ppl with HIV or renal probs -> reduce the dose
Pt with partial pancreatectomy for cancer. pRBC and NS during surgery bc excessive bleeding. Successfully extubated. 12 hrs later, desats, got lots of morphine for pain. Hypotensive, tachycardic and tachypneic. 87% on 4L, distended abd, decreased bowel sounds. PA artery shows low CI, and high PCWP
high pcwp = cardiogenic shock (pt had MI)
Why do old ppl have isolated systolic hypertension
increased rigidity or decreased elasticity of arterial wall
Insulin drives P, K where
intracellular (hypophos is complication of DKA tx)
acute bacterial prostatitis tx
levofloxacin; often need suprapubic catheter for decompression bc foleys can cause sepsis or prostate rupture!!!! Often due to colonic pathogen; could also use bactrim but not nitrofurantoin bc poor penetration - Azithro and doxy in GU infections can cause urethritis or epididymitis due to chlamydia
Winged scapula
long thoracic nerve probs, serratus anterior
Cerebral edema in DKA tx
mannitol and dexamethasone
12 y.o. boy with dark urine over past 2 days, no abd pain, dysuria, or urgency. 3 weeks ago had fever and sore throat that resolved after a week. No medical probs. Paternal uncle had sensorineural hearing loss and cousin with recent renal transplant. Afebrile, BP 150/90, has periorbital edema, clear lungs, 1+ pitting edema in the bilateral LE. UA shows no bacteria, WBC 1-2/hpf, many RBCs. Pathological finding in this pt?
mesangial immune complex deposits; PSGN!!! 1-4 weeks after GAS or impetigo, get immune complexes in glomerular basement membrane and mesangium causing low C3 in the blood - Alport syndrome ix X linked, type 4 collagen; pt does not himself have hearing loss or vision probs.
Bone bx in pt with known osteo on imaging and bacteremia?
no! pos blood culture gives you your answer. Low sensitivity though - GIVE CEFAZOLIN if sensitive Use ESR or CRP to monitor response to therapy! - NM BONE SCAN is super sensitive in detecting osteomyelitis
MMR vaccine in age <6 months?
no, only ivig
Baby swallows coin, asx, flat coin in esophagus on cxr. Next step? (<24 hrs)
observe, repeat CXR in 24 hrs.
when to do a nasal fiberobtic intubation
only if concern for violation of cribiform plate
Scabies tx not including permethrin
oral ivermectin
acute pulmonary edema
oxygen, furosemide, nitrates, morphine
exercise contraindicated in preg if
placentia previa, preeclampsia, cervical insufficenty, PPROM, restrictive lung dz, severe anemia - RISK FACTOR OF PLACENTA PREVIA IS C SECTION IN THE PAST!!!
otitis media bugs
pna bugs in kids, s. pneumo, moraxella (which nl flora gnr)
TTN risk factors
prematurity OR c-section, right sided prominent horizontal fissures with mild cardiomegaly, hyperinflation
Prolonged QT tx
propranolol and pacemaker
Plateau pressure represents
pulmonary compliance
Succussion splash
pyloric obstruction
anterior, middle, posterior mediastinum mass, causes?
thymoma, bronchogenic cyst, neurogenic tumors
Lower brachial plexus injury
ulnar nerve distribution; hypothenar atrophy and interosseous muscles and claw hand deformity