USMLE Step 3 Set #1
What are findings of Turner syndrome? What are 5 further workups you should get at time of diagnosis?
45XO look for hypogonadism, short stature, webbed neck (nuchal folds), shield chest further workup: vision screening hearing screening echocardiogram (coarctation, MVP, bicuspid AV) renal ultrasound (horseshoe kidney) TSH measurement (prone to primary hypothyroidism)
What serum ferritin is associated with iron deficiency anemia?
15-30 --> suspect iron deficiency <15 --> very indicative of iron deficiency also look for a microcytic anemia with anisocytosis
It can be normal not to achieve the milestone of walking until age _____________
16 months
How would you screen a _______ year old woman for cervical cancer? 18 yo 23 yo 34 yo 37 yo 66 yo
18: don't screen until 21 23+34: pap every 3 years 37: pap every 3 years or pap + HPV cotest every 5 years 66: stop screening at 65 if last pap normal
What are 5 DMARDs used in rheumatoid arthritis? Which one is generally first line? What should you also prescribe?
1st line = methotrexate (also prescribe folate) also: azathioprine hydroxychloroquine sulfasalazine leflunomide
What is diagnostic for cervical insufficiency? Name 4 risk factors. What is the management?
2+ painless second-trimester pregnancy losses risk factors: cervical conization collagen defects (ehlers danlos) uterine abnormalities (septate, bicornuate) prior obstetric trauma management is placement of cervical cerclage at 12-14 weeks gestation until delivery
If you suspect exogenous thyroid hormone intake what are two helpful tests and what do they show?
24 hr radioactive iodine uptake: LOW thyroglobulin levels: LOW
What washout period is required when transitioning from fluoxetine to an MAOI like phenelzine? Why?
5 week washout required because fluoxetine has such a long half-life and you do not want to cause serotonin syndrome SS: vital sign instability, AMS, tremor, myoclonus, rigidity
How can a DVT lead to a stroke? How would you diagnose that this was the cause?
"paradoxical emboli" --> there must be an intracardiac shunt like a PFO or ASD more common cause of stroke in young than elderly diagnose with echo and bubble study
What are the typical symptoms of normal pressure hydrocephalus? What would you expect to see on imaging?
"wacky, wet, wobbly, weak" cognitive dysfunction, urinary incontinence, gait abnormalities would expect to see ventriculomegaly
What does a funnel plot tell you? Describe briefly how to interpret them.
A funnel plot helps determine publication bias If no publication bias is present most of the values should fall within the triangle--size of the study determines how high in the triangle it goes Should be symmetrical
What are the autoantibodies associated with Sjogren's syndrome? What is an associated malignancy?
Anti-La/SSA Anti-Ro/SSA leads to dry mouth, dry eyes, dental caries, vision issues associated malignancy = B cell non-Hodgkins lymphoma
What bacteria is common in cat and dog bites?
Pasteurella multocida also treat with amoxicillin-clavulanate
What is Budd-Chiari syndrome?
Portal HTN caused by thrombosis of the hepatic veins or suprahepatic inferior vena cava (IVC). Since portal HTN is present, would have SAAG >1.1 (serum albumin-ascitic albumin).
What are 2 EKG signs of prior MI? What medications should you start in a patient with evidence of prior MI to extend life expectancy?
Q waves and inverted T waves start a beta blocker (metoprolol), statin, anti-platelet therapy, and ACE or ARB
How can you use an ROC curve to compare tests to find the most sensitive and accurate one?
ROC curves plots sensitivity as a function of (1-specificity) the most sensitive test will be highest on the Y-axis (remember highly sensitive means low false negative rate and helps rule things out)
What does relative risk reduction tell you? How do you calculate it?
RRR tells you the reduction in risk attributable to a certain intervention/treatment RRR = (risk in unexposed - risk in exposed)/risk in exposed
In a patient with refractory angina, when is CABG preferred? When is PCI with drug-eluting stent preferred?
CABG if multi-vessel and LAD/left main coronary stenosis PCI if single or two vessel disease not involving proximal LAD
What would you suspect in an infant with repeated vomiting, low sodium, high potassium, and ambiguous genitalia?
CAH from 21-hydroxylase deficiency
What are 4 tests that you should get in any patient in whom you suspect dementia
CBC CMP TSH B12
What is the first line treatment for insomnia?
CBT!!!!! and sleep hygiene
What PFT findings would you expect in a patient with asthma? Why?
Reduced FEV1/FVC ratio with normal DLCO obstructive process! but lung tissue still healthy
What is a TIPS procedure and when might it be used? Why is it not the first-line treatment? What should you try first?
TIPS = transjugular intrahepatic portosystemic shunt creates a fistula between the portal and hepatic veins to relieve hydrostatic pressure in portal venous system not first line because increased risk of hepatic encephalopathy and decompensation first line: sodium restriction + furosemide + spironolactone
What would you suspect in a patient with fatigue, increased bruising, hemolytic anemia, and schistocytes on peripheral smear? How would you manage it?
TTP from autoantibodies against ADAMTS13 leads to platelet trapping and hemolysis treat with plasma exchange, glucocorticoids, and rituximab
What is a type I error? What is a type II error?
Type I error: "false positive"--rejection of the null hypothesis when there is not actually a difference present (also known as "alpha") Type II error: "false negative"--accepting a null hypothesis when in fact there is a difference present (also known as "beta")
What should you suspect in a patient brought in by police who is confused, has a broad based unsteady gait, and whose extraocular movements are not normal? What is the treatment?
Wernicke's encephalopathy give IV thiamine
When would you order a hysterosalpingography? What are 2 conditions that raise risk for causing fallopian issues?
When you suspect that the fallopian tubes may not be patent due to infertility highly associated with endometriosis and pelvic inflammatory disease
Descending paralysis makes you think of ________________ Ascending paralysis makes you think of _______________
Descending-->botulism (infant with progressive loss of tone starting with constipation and poor feeding who has been exposed to honey or soil...treat with IV botulism immunoglobulin) Ascending--> Guillain-Barre (often preceded by GI infection from Campylobacter jejuni...person with paralysis starts in lower extremities...treat with plasma exchange and IVIG)
What is the pathogenesis of Graves disease? What will show on a radioiodine study? What is the treatment?
Graves disease is caused by thyrotropin receptor autoantibodies that stimulate iodine update and TH synthesis. Radioiodine studies show diffusely increased uptake Treatment is radioactive thyroid ablation or methimazole/propylthiouracil.
Describe the common presentation of IgA nephropathy. Compare this to poststreptococcal glomerulonephritis.
Gross hematuria following an acute upper respiratory infection. There will be dysmorphic red blood cells in the urine. +/- flank pain. Poststreptococcal glomerulonephritis always has at least a 10 day gap following throat/skin strep infection. There is not gross hematuria. Urine sediment reveals RBCs and RBC casts. Complement levels are decreased.
What are the symptoms, CSF findings, and treatment of cryptococcal meningitis?
HIV + patient with headache, fever, malaise, cough CSF will have elevated opening pressure, low leukocyte count with lymphocytic dominance, elevated protein and low glucose postive india ink stain on CSF would confirm treat with amphotericin B and flucytosine --> don't start HAART until 2-4 weeks later bc it can worsen things initially --> after 2 weeks transition to fluconazole
What should you include on your differential for any young patient who presents with non-specific mono like symptoms, weight loss, disseminated rash?
HIV!
What is the management of ocular or neurosyphilis?
IV aqueous crystalline penicillin G for 10-14 days
What is the firstline treatment for symptomatic bradycardia per ACLS?
IV atropine
What are two things you can give a patient in cardiac arrest with hyperkalemia?
IV calcium gluconate and sodium bicarb
Compare the murmurs of mitral valve prolapse and mitral stenosis
MVP: non-ejection click followed by systolic murmur MS: accentuated S1, opening snap after S2, then rumbling diastolic murmur
What is the most common source of an embolic stroke? What would you suspect in a young patient with leg redness/warmth/swelling? How would you confirm your suspicion?
Most common source is atrial fibrillation causing emboli in the left atrium of the heart that travel to the brain. Also common are dislodged arterial plaques. In young patients, venous clots like DVT can travel and cause an embolic stroke if the patient has an intracardiac shunt like patent foramen ovale or atrial septal defect. Confirm suspicion of PFO/ASD with an echo and bubble study
What is the most reliable way to differentiate between different causes of ascites? What are the ranges and what is indicated by each?
Most reliable is calculating the Serum-Ascites-Albumin-Gradient (SAAG). Identifies presence or absence of portal hypertension. SAAG = serum albumin - ascitic fluid albumin High SAAG > or = to 1.1 --> indicates portal HTN (indicates CHF, cirrhosis, or hepatitis) Lower SAAG < 1.1 --> indicates absence of portal HTN (indicates peritoneal carcinoma, peritoneal TB, nephrotic syndrome, pancreatitis, serositis).
What should you suspect when a patient presents for chronic worsening headache and physical exam reveals lack of pupillary response, ataxia on tandem walk, and inability to look directly upwards?
Parinaud syndrome from PINEAL GLAND tumor at the base of the brain so it messes with eye motions, balance, and causes headaches from obstruction of CSF outflow
How should you confirm a suspicion of acute pancreatitis? What symptoms and risk factors would make you suspect this?
characteristic epigastric pain with radiation to the back plus elevated amylase/lipase is enough to diagnose (only go for CT/MRI if labs are inconclusive) symptoms are epigastric pain, vomiting, anorexia, fever
What is the usual presentation of cerebral palsy? How should you work it up and why?
child born prematurely (<37 wks) who has delayed motor milestones, spasticity or hypertonic muscles, hyperreflexia and clonus usually diagnosed around age 1-2 years work up with MRI of brain to look for periventricular leukomalacia or basal ganglia lesions
What is the typical presentation of hemolytic uremic syndrome?
child with recent siga-toxin producing E. Coli infection who develops MAHA, thrombocytopenia, and renal damage look for history of bloody diarrhea
What is the typical presentation of mastoiditis? How should you treat it?
child with symptoms of AOM (fever, ear pain) and bulging of the ear due to swelling behind auricle treat with drainage of infection (tympanostomy or mastoidectomy) and IV antibiotics
What is the first line treatment for ADHD by age?
children age 3-5 should have behavioral therapy first if child is 6 years old or older then stimulants can be firstline
What differentiates gallbladder disease with stones and choledocholithiasis? What is the treatment?
choledocholithiasis is caused by a stone in the common bile duct look for elevated bilirubin, higher alk phos than expected, and dilated common bile duct treat with ERCP
Describe a history that should make you suspect increased intracranial pressure
chronic headaches that are worse in the morning or after laying down; nausea and vomiting; vision change get a contrast MRI to work it up look for optic disc cupping on fundoscopy
What are two causes of elevated EPO? What else would you see on labs?
chronic hypoxia (CPOD, OSA) renal cell carcinoma also would see elevated hemoglobin (likely >16)
How does rosacea present? What should patients avoid and what is a treatment?
chronic inflammatory condition causing reddening and telangiectasias on central face avoid sunlight! treat with topical metronidazole
What should you suspect in a 65 year old male who has recurrent bouts of abdominal pain radiating to the back, bulky hard to flush stools, and weight loss? What is the workup?
chronic pancreatitis get CT abdomen or MRCP
How do you differential atrial fibrillation and atrial flutter?
a fib: irregularly irregular; no P-waves; tachy a flutter: saw tooth atrial flutter waves with ventricular rate of 150, 100, or 75
Who all should be immunized for Hep B?
all children under age 19 high risk groups including multiple sexual partners, MSM, IV drug use, hep C, HIV, pregnant women, healthcare workers, and inmates
What workup should you get at diagnosis of systemic sclerosis? Why? What are other symptoms/outcomes?
all patients should have pulmonary function testing at diagnosis as there is often pulmonary hypertension (most common with CREST) or interstitial lung disease (most common with systemic) other symptoms include: fatigue, telangiectasia, digital ulcers, sclerodactyly, calcinosis cutis, arthralgias, myalgias, contractures, dysphagia, esophageal dysmotility, dyspepsia, Raynaud phenomenon complications: pulmonary htn, intersitial fibrosis of lungs, hypertension, scleroderma renal crisis, myocardial fibrosis, pericarditis, pericardial effusion
What does the finding of HSIL on pap indicate the need for?
all patients with HSIL should have colposcopy
All pregnant women should receive ________ and _________ vaccinations. No pregnant women should receive these 4 ________
all pregnant women need influenza vaccine and Tdap varicella, MMR, live attenuated flu, and HPV vaccines should not be given during pregnancy
What are 3 vaccines all women should receive during pregnancy? What are 4 vaccines that are contraindicated?
all women should receive Tdap (best in 3rd trimester), influenza vaccine, and Rhogam vaccines contraindicated in pregnancy: varicella (live) MMR (live) --> give shortly after delivery HPV live attenuated flu (mist)
When should allopurinol be taken? What is the first line treatment for gout?
allopurinol lowers urate but shouldn't be taken during an acute gout attack--start after the pain has resolved and take as a preventative first line is NSAIDs (indomethacin) and second line is colchicine
How do dominant temporal lobe lesions usually present?
almost always have expressive aphasia with difficulty with both spoken and written language
What are some findings that distinguish tinea capitis from alopecia?
alopecia: well-demarcated areas of complete hair loss without scarring or irritation tinea capitis: erythema, scaling, cervical lymphadenopathy, "black dot" alopecia from hairs breaking near shaft
What should you suspect in a patient with anemia, low MCV, normal RDW, and target cells on smear?
alpha or beta thalassemia minor
What should you test for in a patient with cirrhosis and emphysema?
alpha-1-antitrypsin deficiency
What is the intrapartum and postpartum management of HIV in pregnancy based on viral load?
always continue HAART during pregnancy viral load < 1000 --> vaginal delivery with zidovudine for infant after delivery viral load > 1000 --> zidovudine for mom and cesarean delivery then AART for infant as well
What virus should you screen for prior to initiating antiretrovirals in a patient just diagnosed with HIV? Why?
always get Hep B serologies some ART has activity against both viruses, so you could treat both at once remember, HIV+ patients without Hep B immunity should be vaccinated
What is the best way to reverse warfarin in a patient with a dangerous active bleed like a subdural hematoma?
always give vitamin K, but it can take 12-24hrs for effect so you want to give prothrombin complex concentrate to quickly replace clotting factors and stop the bleed
What is the big differentiator in the ACLS flowchart?
always start CPR if VT/VF then defibrillate first then give epi if PEA/asystole then give epinephrine 1mg IV/IO every 3-5 min without shocking
What is the first line treatment of a prolactinoma? Why?
always start treatment of prolactinoma with dopamine agonists like bromocriptine or cabergoline leads to reduction in tumor size within days, usually no need for surgical intervention continue to do frequent visits for prolactin levels, MRI, and visual field exams
How should you treat a patient with erectile dysfunction, visual field defect, and highly elevated prolactin level who is found to have a large pituitary mass on imaging?
always start treatment of prolactinomas with dopamine agonists bromocriptine or cabergoline this will reduce the size and you may not need surgery
What should you suspect in an obese patient who develops hypercapneic and hypoxic respiratory failure shortly after surgery (low pH, high CO2, low O2)?
always suspect obstructive sleep apnea! flash pulmonary edema or pulmonary embolism would both initially cause respiratory alkalosis due to tachypnea and blowing off CO2
What is the approach to treating asymptomatic bacteriuria in pregnant women? Give 3 medications and the follow-up.
always treat in pregnant women fosfomycin single dose cephalexin 3-7 days amoxicillin-clavulanate 3-7 days always do a repeat urine culture in a week to test cure
When should you give potassium to someone in DKA/HHS?
always unless their serum K+ is over 5.3 remember that DKA causes potassium to shift
antimitochondrial antibody --> ______________________ anti-smooth-muscle antibody --> ______________________
antimitochondrial antibody indicates primary biliary cholangitis which causes fatigue, pruritus, inflammatory arthritis, RUQ pain, xanthelasmata anti-smooth-muscle antibody indicates autoimmune hepatitis
What type of medications are tolterodine and solifenacin? What is a third medication in this class that you know the name of? What are these often used to treat in women?
antimuscarinics like oxybutynin used to treat urge incontinence
What are three antibodies associated with systemic sclerosis?
antinuclear antibody anticentromere antibody anti-topoisomerase (aka anti-scl-70) antibody
Who should be screened for abdominal aortic aneurysm? When and how?
any men ages 65-75 who have ever smoked in their lifetime get abdominal ultrasound
Which patients with diabetes should be on a statin?
any over the age of 40
What is the recommendation for lung cancer screening with low dose CT?
any patient age 55-80 with >30 pack year smoking history who is still smoking or quit within the past 15 years yearly low dose CT
At what age should women with anovulatory bleeding be evaluated with endometrial biopsy?
any woman >45 yo with abnormal bleeding
Who should have a screening CT for lung cancer? What is the reduction in mortality from doing these screenings? What is the false-positive rate?
anyone age 55-80 with 30+ pack year history of smoking (unless they quit more than 15 years ago) 20% mortality reduction but 96% false-positive rate so if a nodule is found, there is only a 4% chance it is actually cancer
Who should be screened for lung cancer based on smoking history? How?
anyone age 55-80 with >30 pack years smoking history (unless quit over 15 years ago) screen with yearly low dose CT
At what age range is walking a normal milestone? When should you pursue further workup?
anywhere from 9 to 16 months start to worry at 16 months and evaluate
What 2 things cause a diastolic heart murmur?
aortic insufficiency mitral stenosis
What criteria define severe aortic stenosis for which you should refer the patient for valve replacement? (think about velocity, gradient, valve area, and clinical picture)
aortic jet velocity >4 gradient >40 valve area < 1cm also need to have symptoms like dyspnea, angina, or syncope and LVEF <50%
How do aphthous ulcers present in kids? What about herpangina? What about herpes virus gingivostomatitis?
aphthous ulcers: recurrent shallow ulcerations of anterior mucosa (lips, buccal, tongue) without systemic symptoms or fever herpangina: painful vesicles and ulcers of posterior pharynx that cause dysphagia; often accompanied by fever; caused by coxsackie virus herpes gingivostomatitis: painful vesicles and ulcers on anterior mucosa with perioral involvement (herpangina is pictured)
What findings suggest a left atrial myxoma? (most common primary tumor of the heart) How would you confirm the diagnosis?
apical diastolic murmur or "tumor plop" embolic event rapid onset heart failure new atrial fibrillation Get echocardiogram and then schedule surgery
What lab abnormality is associated with Alzheimer's dementia? What would you see in the brain on autopsy? What MMSE and Moca scores would you anticipate?
apolipoprotein E polymorphisms autopsy would show amyloid plaques and neurofibrillary tangles MMSE < 24/30 Moca <26/30
What are 3 cardiac effects that can occur with untreated hyperthyroidism? What is an important long-term effect to remember in women especially?
arrhythmias dilated cardiomyopathy mitral valve prolapse/regurgitation also think of osteoporosis!
What should you suspect in a patient with mid-systolic murmur and dilation of the right atrium and right ventricle on echo?
atrial septal defect causing right to left shunt
What are 2 signs that a tick bite is very unlikely to have transmitted Lyme disease?
attached less than 36 hours non-engorged a small rash at the site of the bite may be present but it represents a local inflammation --> the erythema migrans seen in Lyme disease takes 3 days to develop
What would you suspect in a 34 yo female with history of celiac disease who has an enlarged liver and elevated AST/ALT but normal bilirubin and mildly elevated Alk Phos? How would you test?
autoimmune hepatitis test for ANA and anti-smooth muscle antibodies
Why should you stop raloxifene and tamoxifen prior to scheduled surgeries?
both are SERMs that increase clotting risk should be stopped for 4 weeks prior to surgery
What are some high risk features that indicate need for imaging after a child has a head bump?
under 2 years old: fussiness/AMS loss of consciousness hematoma that is not on front of scalp severe mechanism of injury (height > 3ft) over 2 years old: somnolence/AMS loss of consciousness vomiting or severe headache fall from > 5 feet
What are the cervical cancer screening guidelines stratified by age?
under 21 --> do not test 21-34 --> only pap every 3 years 35-65 --> pap every 3 years OR pap with HPV cotest every 5 years 65+ --> no indication to keep screening if last test normal
When is percutaneous balloon valvuloplasty indicated for treating aortic stenosis? Why?
used only as a bridge to surgical or transcatheteric aortic valve replacement because associated with high rates of procedural complication and does not improve long-term mortality
What is the use of misoprostol in labor?
used to induce labor by cervical ripening and stimulation of contractions
How does pyoderma gangrenosum present and what is the treatment?
usually associated with IBD or arthritis inflammatory lesions that rapidly become very painful ulcers surgical debridement and IV abx
What are the symptoms of radiation proctitis? What is the usual history causing this? What is the acute and chronic managment?
usually associated with radiation to pelvis/abdomen symptoms are tenesmus, mucus discharge, and diarrhea within 6 mos of radiation exposure treat acute cases supportively (antidiarrheals, fluids) and chronic cases with glucocorticoid or sulfacrate enemas
What is the typical presentation of a bacterial joint infection? What is the workup?
usually cause fever, pain, inability to bear weight or use the joint get arthrocentesis --> WBC in bacterial joint infections is usually >50,000
What findings after a knee injury suggest rupture of the patellar tendon? What is the management?
usually caused by a sudden strong quadriceps contraction while the foot is planted (jumping etc) immediately causes pain, swelling, difficulty bearing weight, and sometimes "popping" sensation physical exam reveals inability to fully extend the knee or lift the leg off the exam table surgical repair is the treatment of choice and should be done quickly to maintain functionality
What usually causes otitis-conjunctivitis syndrome? How should you treat it?
usually caused by haemophilus influenzae treat with amoxicillin (amox-clav if that doesn't work)
What typically causes epiglottitis? What are the symptoms? What is the management?
usually caused by haemophilus influenzae B (Hib) symptoms include high fever, drooling/dysphagia, inspiratory stridor, sore throat, tripoding look for "thumb" sign on lateral x-ray make sure that you are ready to intubate because epiglottal edema can rapidly obscure the trachea then give IV antibiotics
What is the constellation of symptoms seen in sarcoidosis? What would a biopsy show? What might labs show?
chronic pulmonary issues (cough, dyspnea) accompanied by anterior uveitis (eye pain, constricted pupil, conjunctival injection, blurred vision) and erythema nodosum (painful red bumps on shins) biopsy --> non-caseating granulomas labs --> hypercalcemia
What should you suspect when a patient has a minor injury and later presents with pain out of proportion to the injury, temperature change, edema, and skin color change?
complex regional pain syndrome --> the thought is that a minor injury causes increased sensitivity of sympathetic nerve fibers treat with regional nerve block
What is Eisenmenger's syndrome?
complication of a longstanding unrepaired ventral septal defect that leads to pulmonary hypertension that eventually results in a left-to-right shunt you can see it in pregnancy with severe pulmonary hypertension
What is the management of a pulmonary nodule >0.8cm when there are malignancy risk factors (smoker, older age, family hx, upper lobe)? What about a nodule >0.8cm without concerning features?
concerned --> tissue diagnosis with biopsy or surgical excision non-concerning --> CT monitoring within 3 months
What is the management of a patient in labor who is found to have significant condylomata acuminata?
condyloma acuminata is due to HPV expectant management with vaginal delivery if able (C-section does not reduce risk of vertical transmission)
What are the symptoms of Wernicke encephalopathy? What should you always do first in treatment?
confabulation unsteady gait/frequent falls (wide based gait) lateral rectus palsy history of alcohol use always give IV thiamine first
How should you manage a patient who has been treated for H. pylori but continues to have symptoms like abdominal pain?
confirm eradication with fecal antigen testing or urea breath test
How can you confirm a suspicion of multiple myeloma? What workup should you do after the diagnosis?
confirm with bone marrow biopsy showing >10% monoclonal plasma cells after diagnosis get skeletal survey to look for impending pathologic fractures
What should you suspect when an infant has uneven gluteal folds? What is the workup and treatment?
congenital hip dysplasia get x-ray; look for Barlow/Ortolani treat with Pavlik harness
What is the constellation of symptoms found in tuberous sclerosis?
congenital hypopigmented macules (ash leaf spots), organ hamartomas/cysts, and glial proliferation autosomal dominant increased risk of seizures
What would you suspect if a patient with recent travel developed fever, muscle aches, severe bone pain, and was found to have thrombocytopenia?
dengue fever --> also look for rash and hemorrhage/petechiae can lead to shock/circulatory collapse
What dexa scores indicate osteopenia and osteoporosis?
dexa of -1 to -2.5 indicates osteopenia dexa of less than -2.5 indicates osteoporosis prescribe bisphosphonate, recommend weight bearing exercise, cessation of smoking/alcohol, and daily calcium and vit D
What are two things acanthosis nigricans is associated with?
diabetes mellitus and GI cancer
What dysphagia symptoms indicate a mechanical obstruction vs neuromuscular/motility issue?
dysphagia to solids first that then progresses to liquids as well indicates mechanical obstruction with a growing mass dysphagia to both liquids and solids from the get-go indicates motility issues
What are the symptoms and CXR findings associated with mesothelioma?
dyspnea, fatigue, chest pain CXR with nodular thickening of the pleura
What are 3 medications that can cause digoxin toxicity?
verapamil amiodarone quinidine
What are the common symptoms of a urethral diverticulum? How would you diagnose and treat it?
dysuria, postvoid dribbling, dyspareunia, anterior vaginal bulge/mass, and repeated UTIs often associated with prior trauma from surgery or vaginal delivery diagnose with imaging--> pelvic MRI or transvaginal ultrasound treat with surgery or needle decompression
What is the earliest sign of phenytoin toxicity? What is the therapeutic range?
earliest sign is horizontal nystagmus then you develop blurred vision, ataxia, slurred speech, dizziness, drowsiness, lethargy, and decreased mentation therapeutic range is 10-20
How should you treat an adult with bacterial meningitis? (fever, headache, nuchal rigidity, CSF with high leukocytes and neutrophil predominance, low glucose, high protein) What should you add if they are over age 50 and why?
empiric abx are ceftriaxone + vancomycin add ampicillin for adults over 50 as they are more susceptible to listeria
What does ingestion of "antifreeze" lead to? What might be a clue in how the patient is behaving? What is the antidote of choice?
ethylene glycol --> severe anion gap metabolic acidosis kussmaul's sign --> deep rapid breathing treat with fomepizole
What should you watch out for in a patient on an SGLT2 inhibitor (flozin) who develops a metabolic acidosis but has normal blood glucose?
euglycemic DKA! look for ketones in urine
What is the first step in working up suspected ankylosing spondylitis?
first change seen in AK is sacroiliitis get plain film XR of sacroiliac joint
When is Rhogam (anti-D immunoglobulin) supposed to be given?
first dose should be administered at 28 weeks (or earlier if there is some type of trauma where fetal blood could have been exposed to mom) another dose should be given within 72 hours of delivery--> dose depends on blood exposure because typical dose only protects mom from exposure to 30mL of fetal blood
What is the management approach to a patient who presents with signs/symptoms of an ectopic pregnancy?
first get quantitative beta-hcg, CBC, and blood type then if hemodynamically stable get TVUS (if TVUS is inconclusive and patient is stable then you can repeat beta-hcg because intrauterine pregnancy should be visible via TVUS by hcg >1500) if not stable (tachy or hypotension) then proceed directly to emergent laparotomy
If a patient with Parkinson's develops psychosis, what is the order in which you should try to cut back their dopaminergic meds?
first get rid of anticholinergics then get rid of amantadine then MAO-B and COMT inhibitors lastly carbidopa-levodopa
What is the stepwise progression in treating inflammatory acne?
first give topical retinoids + benzoyl peroxide then add topical antibiotic if severe and refractory add oral antibiotics
What is the first and second line treatment for allergic rhinitis?
first line = avoidance of the allergen second line = intranasal corticosteroids (fluticasone) third line = 2nd gen antihistamine
What are 3 medications used to treat patients with hypertrophic cardiomyopathy who develop symptoms of heart failure?
first line is beta blocker --> metoprolol second line are verapamil or disopyramide
What is the first line treatment for acute decompensated heart failure? What if that does not work?
first line is diuretics like furosemide/torsemide next line is vasodilators like nitroglycerin beta blockers are indicated for chronic heart failure, but can make acute heart failure worse due to their effects on the lungs (pulmonary edema is usually worst thing in acute decompensated heart failure)
What are the first and second line treatments for dysmenorrhea?
first line is naproxen (cramps are prostaglandin mediated and NSAIDs reduce prostaglandins) second line is OCPs
How should you treat a woman who is group b strep positive at time of delivery? What is the second line?
first line is penicillin vancomycin if allergic to penicillin
What is the first line treatment for gout? What if this treatment cannot be tolerated? What should you start to prevent future attacks?
first line treatment is NSAIDs like indomethacin if cannot take NSAIDs use colchicine start allopurinol to lower urate levels --but do not start it during an acute attack because it can make things worse!
What is the treatment of latent TB? What is a second line option?
first line treatment is isoniazid for 9 months second line treatment is rifampin for 4 months
A patient is in your ED with atrial fibrillation with RVR...what 4 drugs are firstline to treat it? A patient is in your ED with systolic heart failure and a fib...now what do you reach for?
first line: metoprolol, atenolol, verapamil, diltiazem if also have CHF then use digoxin
Describe the phases of the first stage of labor. What is defined as protraction of the active phase? What is the firstline treatment for this?
first stage of labor is from onset of regular painful contractions to full cervical dilation at 10cm latent phase: characterized by slow cervical change up to 6cm active phase: dilation greater than 6cm; should progress at >1cm every 2 hours cervical change less than 1 cm/2 hrs indicates protracted active phase --> most common cause is inadequate contractions (should be every 2-3 min a strong) --> treat with oxytocin and amniotomy (artificial rupture of membranes)
What is the first step in working up suspected gastroparesis? What study makes the definitive diagnosis?
first step in workup is to rule out mechanical obstruction (prefer to do with upper endoscopy or barium swallow, but can use CT/MRI if worried about external compression by a mass etc) definitive diagnosis is made via nuclear gastric emptying study
What is the first step in working up hypercalcemia? (even if the question gives enough info to basically diagnose cancer)
first step is ALWAYS repeat measurement of serum calcium level alongside PTH
How should you monitor a patient with Guillain-Barre who is having shortness of breath?
frequently measure vital capacity and negative inspiratory pressure
What is onychomycosis and the treatment?
fungal infection of the nail and nail base treat with oral griseofulvin or terbinafine
What is the treatment of CMV meningitis?
ganciclovir + foscarnet
What is the next step in working up an older patient with pain/stiffness primarily in the shoulders and pelvis? Why?
get CK and ESR polymyalgia rheumatica --> causes elevated ESR but normal CK; minimal tenderness over muscles; treat with corticosteroids and screen for temporal arteritis polymyositis--> more associated with proximal muscle weakness, not pain; CK and ESR will be elevated; treat with steroids statin myopathy --> CK will be elevated but ESR will be normal; tenderness present
What is the next step in treating any patient who has neurologic symptoms and positive syphilis test?
get CSF to check for neuro involvement
What is the next step in working up a normocytic anemia when you don't have any other clues?
get a reticulocyte count if reticulocytes are elevated this indicates hemolysis and you should order indirect bili, LDH (will be increased), haptoglobin (will be decreased) if reticulocytes are low this indicates myeloproliferative disorder like renal disease, hypothyroidism, or aplastic anemia
A 58 year old man in construction presents with a 3 week history of back pain that is worse at night. He also has lost weight recently. What is the next step?
get an ESR and x-ray of the spine red flags: age >50, nocturnal pain, fever/weight loss ***if ESR or x-ray is suspicious, progress to an MRI
What is the screening recommendation for children diagnosed with Kawasaki disease? Why?
get an echocardiogram at time of diagnosis, 2 weeks after completed treatment, and 6 weeks after completed treatment tx = IVIG + aspirin Kawasaki dz: child with fever >5 days rash (inguinal folds, trunk) swelling or redness of hands/feet strawberry tongue cervical lymph nodes bilateral conjunctivitis coronary artery aneurysm
What should you test in a young patient with recurrent infections of multiple types (pneumonias, bloody diarrhea)?
get quantitative count of serum IgG levels to look for selective immunoglobulin deficiencies
How should you manage a patient with a growth-restricted fetus? What is an indication for immediate delivery?
get serial ultrasounds with umbilical artery doppler every 3-4 weeks to monitor growth absent or reversed umbilical artery end-diastolic flow indicates impending fetal hypoxia and is an indication for delivery
What 3 things should you order to work up a patient with acute dysentery (bloody diarrhea)? What are the likely causes?
get stool culture, shiga toxin, and fecal leukocytes infectious causes: EHEC, shiga, campylobacter, salmonella non-infectious: irritable bowel disease; ischemic colitis
What is the initial workup of a thyroid nodule? How does TSH change things?
get thyroid studies and thyroid ultrasound If TSH normal or elevated then there is a higher malignancy risk because "cold nodule" and you should get fine needle aspiration
What is the first step in working up a suspected bowel perforation with peritonitis? What are the presenting symptoms?
get upright abdominal CXR to look for air-fluid level abdominal tenderness that is diffuse and worsens with any movement/jostling; guarding usually present
What other condition is highly associated with polymyalgia rheumatica? What symptoms would prompt workup? What is the diagnostic test and treatment?
giant cell ateritis / temporal arteritis headache, jaw claudication, vision loss, pain over temporal artery get temporal artery biopsy and treat with high dose steroids
Name 3 common herbal supplements that cause increased bleeding risk
gingko biloba ginseng saw palmetto
What are the findings in ovarian hyperstimulation syndrome?
history of treatment for infertility/IVF ovaries with multiple cysts ascites, abdominal pain, nausea/vomiting, decreased urine output, electrolyte imbalances
How should you manage menopause symptoms in a woman with strong family hx or personal hx of DVT?
hormone therapy is contraindicated use SSRI (citalopram etc) or SNRI (venlafaxine) to treat hot flashes
Describe the Hawthorne effect in research?
humans change their behavior because they know they are being studied
What is the treatment of CAH?
hydrocortisone + fludrocortisone
What is an electrolyte abnormality associated with lung cancer? Which type?
hypercalcemia from PTHrp secretion by squamous cell carcinoma
What is incident rate and how do you calculate it?
incident rate is the number of cases per person time- usually 1,000 person-years (usually done in follow-up studies; ex 1 patient followed for 1 year would equal one person year) IR = # new cases / total # person years
__________ is a useful marker for medullary thyroid cancer
increased calcitonin
What is the effect of oral contraceptive use on risk for breast cancer? What about ovarian cancer? Endometrial cancer?
increased risk for breast cancer decreased risk for ovarian or endometrial cancer
What are 3 sequelae of untreated celiac disease? What lab finding would confirm this diagnosis?
increased risk of malignancy osteopenia/osteoporosis severe anemia anti-tissue transglutaminase antibody
What are normal, physiologic changes in thyroid hormone tests during pregnancy that can appear pathologic? What causes each one?
increased total T4 (estrogen increases thyroglobulin binding protein) low TSH (hcg directly stimulates TSH which lowers pituitary production of its own TSH)
Why should you treat constipation in children?
increases the risk of strain and of causing impaired bladder emptying leading to UTIs increase water, fiber, and titrate laxative
When is antibiotic prophylaxis indicated in treatment of UTIs? What are 3 antibiotics you would use for this?
indicated if >2 UTIs in 6 months or >3 UTIs in one year nitrofurantoin ciprofloxacin SMZ-TMP
What does direct/conjugated hyperbilirubinemia indicate? What are some conditions leading to this?
indicates a source related to the liver/gallbladder sepsis, hepatitis, cholestasis, biliary atresia, choledocolithiasis, malignancy, primary biliary cirrhosis, primary sclerosing cholangitis
What should you suspect in a patient with symptoms of Cushings (obesity, striae, hyperglycemia, plethoric face, fatigue) and whose ACTH level is undetectable?
indicates not due to pituitary lesion --> get imaging of adrenals
What is the history that indicates pyloric stenosis? What is the workup? What about treatment?
infant (usually male, firsterm, premature) with projectile vomiting after feeds +/- olive shaped mass in RUQ workup is abdominal ultrasound first correct electrolyte abnormalities (usually hypokalemia is present) and then go to surgery
How does RSV present? What is a major sequelae?
infant in the winter with runny nose, congestion, cough, wheezing major sequelae is recurrent wheezing treat w/hospitalization and supportive care
What are the usual findings in spina bifida? What is the biggest risk factor?
infant with myelomeningocele (defect of vertebral column where base of spinal cord is exposed and covered in red membranous sac) usually associated with maternal folate deficiency leads to neurogenic bladder/bowel; motor and sensory function issues; hydrocephalus; scoliosis (repair has to be done but usually causes hydrocephalus and requires VP shunt)
What is pylephebitis? What is the big risk factor?
infection of the portal vein (can be life threatening) big risk factor is untreated abdominal or pelvic infection
What are the MCV, RDW, and RBC count in iron deficiency anemia and thalassemia minor?
iron deficiency: low MCV, elevated RDW, low RBC count thal minor: low MCV, normal RDW, normal RBC count (cells are just smaller target cells but all are consistent size and there is normal total # of RBCs)
What does multifocal atrial tachycardia look like? Who should you suspect it in?
irregular, narrow-complex tachycardia ***look for variable p-wave morphology suspect in patients with underlying pulmonary disease like COPD
What PFT findings would you expect in a patient with pulmonary atery hypertension?
isolated reduced DLCO
What are common side effects of isoniazid (try for 2)? What about ethambutol?
isoniazid: hepatotoxicity and neuropathy (give B6/pyridoxine alongside INH) ethambutol: ocular toxicity
This medication is strongly associated with pseudotumor cerebri causing papilledema
isotretinoin
What do patients usually take the supplement ginkgo-biloba for? What is its most notorious side effect?
it has been touted to increase cerebral blood flow helping to boost memory most common side effect is increased bleeding risk because it inhibits platelet-activating factor
What would you suspect in a 15 year old female with new onset seizure activity, a history of muscle jerks in the morning, and EEG with bilateral polyspike and slow wave acitivity?
juvenile myoclonic epilepsy treat with Keppra or Depakote
What is the statistical measure of inter-rater reliability (how often 2 experts agree)?
kappa statistic kappa > 0 indicates agreement not based on chance alone
What does the kappa statistic represent and how should you interpret it numerically?
kappa statistic represents inter-rater reliability (aka how often two experts agree on something and whether it is by chance or not) kappa <0 indicates disagreement kappa = 0 indicates agreement by chance kappa >0 indicates agreement greater than chance
What is the blood pressure goal in acute aortic dissection? What history might make you think of this?
keep systolic below 100-120 mmHg consider in a patient with hypertension, smoking, marfan's who develops acute chest pain going through to the back BP may be higher in upper extremities than lower
What causes construction apraxia (difficulty copying simple line drawings, difficulty getting dressed)?
lesion in the non-dominant parietal lobe
"Assuming a patient has HIV, how likely is he to have a positive screening test compared to a patient who does not have HIV?" What is this question asking for and how can you calculate it?
likelihood ratio!!! positive likelihood ratio, specifically +LR = sensitivity/(1-specificity) -LR= (1-sensitivity)/specificity
What should you check in a patient on Depakote who develops abdominal pain and why?
lipase-->can cause pancreatitis liver function tests --> can cause hepatotoxicity
What can you advise a patient do to lower the risk of recurrence of pre-eclampsia?
low dose aspirin
What are the CSF findings in tubercular meningitis? What is the confirmatory test? What is the treatment?
low glucose <10 lymphocytic dominant high protein (like 100-500) confirm with acid fast bacilli stain treat with steroids to lower inflammation in the brain and 4-drug RIPE regimen for 2 months followed by 2-drug therapy for 9-12 months RIPE: rifampin, isoniazid, pyrazinamide, ethambutol 2-drug regimen: rifampin + isoniazid
What should you suspect when an elderly patient tells you they are having back pain with standing and walking that is made better by taking a rest to sit down or using a cart/walker?
lumbar spinal stenosis --> MRI confirms diagnosis
What are the most common sources of mets to the brain? What characteristics would you expect on imaging?
lung > breast > melanoma > colon cancer look for multiple well-circumscribed lesions with vasogenic edema
What are the typical fetal findings in congenital toxoplasmosis? What are the big risk factors to a pregnant woman? How should you treat it?
macrocephaly diffuse intracranial calcifications jaundice, growth restriction, blueberry muffin spots maternal risks are exposure to undercooked meats, cat feces, or unwashed fruits/veggies Treat with antiparasitics --> pyrimethamine, sulfadiazine, and folate
This is a common hematologic side effect of methotrexate __________ How should you prevent and treat it?
macrocytic anemia from folate deficiency methotrexate inhibits dihydrofolate reductase (DHFR) enzyme needed for conversion of folic acid to folinic acid for use by the cells prevent with supplemental folate but treat with folinic acid (leucovorin) because it is more effective
What are 5 bad outcomes associated with uncontrolled gestational diabetes?
macrosomia (shoulder dystocia) infant hypoglycemia infant polycythemia infant hypocalcemia respiratory distress (glycogen deposits causing thickened interventricular septum)
What should be started immediately in patients with pre-eclampsia or HELLP?
mag sulfate to prevent seizures
What is the standard management of systolic heart failure?
make sure they are on beta blocker and ACE/ARB
What should you suspect in a patient with recent travel who develops fever, headache, thrombocytopenia, and fatigue a week after returning?
malaria from plasmodium falciparum get peripheral smear
What is the cause and typical presentation of tinea versicolor? What are three treatment options?
malassezia furfur patient with rash that is asymptomatic or slightly itchy; worsens in the summer as skin darkens; usually involves upper trunk/neck/limbs treat with topical ketoconazole, selenium sulfide, clotrimazole, or terbinafine
What is the brain abnormality associated with Wernicke-Korsakoff?
mammillary body atrophy
Give 5 absolute medical contraindications to pregnancy in which you would advise an abortion
maternal heart failure class III-IV maternal LVEF < 40% prior peripartum cardiomyopathy severe pulmonary hypertension unstable aortic dilation >40mm
What are 5 major risk factors for abruptio placentae?
maternal hypertension cocaine use smoking trauma hx prior placental abruption
What is a maternal risk of gestational diabetes? What are 4 fetal risks? What are the blood sugar goals for moms with GDM? What should you start if they are not meeting these goals?
maternal: increased risk preeclampsia fetal: macrosomia, shoulder dystocia, hypoglycemia, polycythemia (there are even long term risks including obesity, DM2, and CVD) goals are fasting <95 1 hour post prandial <140 2 hour post prandial <120 first try dietary modifications, but if not meeting goal still then start metformin, insulin, or glyburide
What is the next step if a patient presents with biliary cholic but does not have visible gallstones on imaging?
may be due to lack of appropriate emptying of the gallbladder give CCK and then do scintigraphy to see if the gallbladder ejects it properly
What are the neurological changes that can be seen in late secondary syphilis?
meningitis symptoms, posterior uveitis (floaters and eye irritation), hearing loss look for diffuse rash including palms/soles
What is the primary metabolic abnormality associated with vomiting?
metabolic alkalosis (look for elevated bicarb and ph >7.4)
What is the first line antithyroid drug? Why? What is the first line in pregnancy? What should you worry about these antithyroid drugs causing?
methimazole (less risk of SE) is first line overall propylthiouracil (chance of liver toxicity) is first line for pregnancy because methimazole is teratogenic worry about them causing AGRANULOCYTOSIS (always get CBC before starting) ***always start a beta blocker as well!!! (radioactive iodine ablation is contraindicated in preg)
How would you treat severe psoriasis or psoriasis involving the nails or causing psoriatic arthritis?
methotrexate
What are 3 medications that can interfere with folate usage and cause macrocytic anemia?
methotrexate phenytoin trimethoprim supplement folate and treat deficiency with folinic acid
How does metoclopramide work? How would you treat a patient who couldn't move their neck after taking it?
metoclopramide is a dopamine-antagonist that promotes gastric emptying and decreases nausea it can cause an acute dystonic reaction --> treat with IV benadryl or cogentin (benztropine)
What are 4 drugs commonly used to treat atrial fibrillation? What if the patient has concomitant heart failure or hypotension?
metoprolol, atenolol, diltiazem, verapamil but if patient has CHF or hypotension you can't use these due to their negative inotropic effects digoxin is best in CHF or hypotension
What kind of anemia is associated with iron deficiency? What should you look for in patients with this?
microcytic --> reduced MCV <80 look for a source of bleeding consider colonoscopy in elderly patients with no known bleeding source
What are 3 heart sounds commonly heard in patients with an atrial septal defect?
mid-systolic murmur mid-diastolic rumble wide fixed splitting of S2
`What are the ranges and treatment for mild, moderate, and severe lead poisoning?
mild (5-44) --> no medication moderate (45-69) --> meso-2,3-dimercaptosuccinic acid (aka DMSA) severe (>70)--> Dimercaprol + Calcium disodium edetate (EDTA)
What is the treatment for mild to moderate psoriasis? What about severe plaque psoriasis? What if most of the patient's rash is on their face and intertriginous areas (armpits, back of knees)?
mild-mod: start with topical high-potency steroids (fluocinonide etc) severe: phototherapy + methotrexate face/intertriginous: low potency topical steroids (hydrocortisone etc) or topical tacrolimus
What is the stepwise progression in treating nodular/cystic acne?
milder cases give topical retinoids + benzoyl peroxide + topical antibiotics if persistent then add oral antibiotics if severe then go to isotretinoin
What are the symptoms of complex regional pain syndrome? What is the treatment?
minor injury and then later development of extreme pain, temperature changes, edema, and skin color changes treat with regional sympathetic nerve block
What is miosis? What is mydriasis?
miosis = small pupils mydriasis = dilated pupils
What two murmurs should you suspect when the sound is holosystolic?
mitral or tricuspid regurg
What should you suspect when there is a holosystolic murmur with a click in a patient with increasing dyspnea on exertion?
mitral valve prolapse from chronic mitral regurgitation
What would you suspect in a patient with risk factors for hepatitis C who presents with palpable purpura, weakness, and arthralgias? What would labs show?
mixed cryoglobulinemia syndrome rheumatoid factor will be high and complement levels will be low
What is the delivery mode of the following twin combinations: monoamniotic dichorionic with vertex/vertex dichorionic with vertex/breech dichorionic with breech/vertex dichorionic with breech/breech
monoamniotic --> always cesarean vertex/vertex --> vaginal delivery vertex/breech--> vaginal or cesarean based on physician comfort (can deliver first twin then try internal podalic version) breech/vertex --> cesarean breech/breech --> always cesarean
What would you start as a medication regimen for lupus in a patient whose primary symptoms are fatigue, arthralgias, serositis, or rash? What if their symptoms were blood in the urine, vasculitis, or CNS effects?
more cutaneous, arthralgias, fatigue --> hydroxychloroquine and prednisone more severe symptoms --> cyclophosphamide and prednisone
"monoclonal bands in CSF on lumbar puncture" --> think ___________
multiple sclerosis look for white matter lesions think about different neuro symptoms that come and go treat acute exacerbations with steroids and give interferon-B if needed to prevent
What 3 things does strict glycemic control slow the progression of in DM?
neuropathy nephropathy retinopathy
This cardiac medication has been associated with cyanide toxicity ________________
nitroprusside
What defines arrest of labor?
no cervical change in the active period of labor (>6cm) for over 4 hours with adequate contractions or over 6 hours with inadequate contractions indication for cesarean
What should you give someone with a bleeding esophageal varices?
octreotide
When is octreotide used to treat an adenoma? Why?
octreotide is used to treat adenomas causing acromegaly because it inhibits the release of growth hormone
What is commonly associated with rosacea?
ocular issues like conjunctivitis, blepharitis, keratitis, corneal ulcers, recurrent chalazion refer any patient with rosacea and ocular findings to an ophthalmologist
What is a common cause of large goiter? What are some signs that it needs to be surgically removed?
often caused by iodine deficiency if causing compressive symptoms (trouble swallowing, facial plethora if raise hands above head) avoid anti-thyroid meds and radioactive iodine ablation because these may actually increase goiter size
What are the symptoms that indicate chronic bacterial prostatitis? What is the diagnostic test and treatment?
older man with recurrent UTIs, pain with urination/ejaculation, leukocyte esterase, and bacteriuria urinalysis before and after prostate massage treat with 6 WEEKS of TMP-SMZ or cipro
How does HSV encephalitis usually present?
older patient with acute onset of hemorrhagic infarction in temporal lobe elevated red blood cells will be present on CSF
What are some signs and symptoms suggesting chronic mesenteric ischemia? If you suspect this in a patient what is the best next step?
older patient with atherosclerotic risk factors food aversion, weight loss, cramping epigastric pain worsened after eating next best step is angiography
How does renal artery stenosis usually present?
older patient with treatment refractory hypertension despite use of 3+ agents often there will be other atherosclerotic disease present
What is the typical presentation of reactive arthritis?
oligoarthritis that is inflammatory (elevated WBC) but sterile (culture negative) in a patient with recent chlamydia or gastroenteritis also look for uveitis, urethritis, and circinate balanitis (shallow ulcers going around penis) treat chlamydia if underlying and give NSAIDs
What lumbar puncture finding indicates MS?
oligoclonal bands and elevated IgG
What spinal rotation angle indicates scoliosis? What Cobb angle on spine x-ray indicates mild vs severe scoliosis? What is the approach to each?
on forward bend test, spinal rotation >7 degrees on x-ray Cobb >10 is scoliosis; if >40 that is severe mild --> observation and back brace severe --> surgery
Compare and contrast oropharyngeal dysphagia with esophageal dysphagia. What is the first step in working up oropharyngeal dysphagia?
oropharyngeal dysphagia causes difficulty with initiating swallow, coughing/choking, drooling, aspiration esophageal dysphagia causes delayed sensations of food sticking in throat or upper chest work up oropharyngeal with nasopharyngeal video laryngoscopy (endoscopy would not show the proximal areas well and could risk perforation)
At what age is an endoscopy indicated for dyspepsia? Try to name 7 other "red flags" that would warrant endoscopic workup in a patient under 60.
overt GI bleeding unexplained iron deficiency anemia weight loss persistent nausea persistent dysphagia papable abdominal mass family history of GI malignancy
What disease is associated with elevated alk phos but normal calcium?
paget disease of bone increased turnover mixed lytic/sclerotic disease can cause hearing loss, dizziness, bone pain, fracture, deformity treat with bisphosphonates or calcitonin
What defines postherpetic neuralgia? What are the first and second line treatments?
pain at site of shingles lasting >4 mos rash onset treat with TCAs first line (amitryptiline) avoid TCAs in elderly and give gabapentin
How does DeQuervain's tenosynovitis present? What is a test you can do to check for it?
pain at the base of the thumb the finkelstein test is when pain is reproduced by ulnar deviation at the wrist with the thumb held across the palm
What are the symptoms of compartment syndrome? How should you work it up? What is the definitive treatment?
pain out of proportion to injury parasthesias loss of distal pulses tense or rapidly increasing swelling work up with measurement of pressure in the muscle compartment (pressure >30mmHg is diagnostic) definitive treatment is fasciotomy
What description of back pain should make you think about lumbar spinal stenosis? What is the best way to confirm your suspicion?
pain that is relieved by sitting down or bending over usually occurs in older patients over age 60 confirm diagnosis with MRI
What are 3 important PE findings to differentiate orbital cellulitis with preseptal cellulitis?
pain with extraocular movement, proptosis, or inability to move the eye (opthalmoplegia) indicate orbital cellulitis and warrant CT scan
What are the symptoms of epidural spinal compression? If you suspect this, how should you proceed?
pain wrapping around the back and sides weakness or sensory changes in lower extremities late sign is bowel/bladder incontinence this is a medical emergency!! you should start high dose IV corticosteroids, get an MRI, and think about surgery
What are the typical findings in impetigo? Which bugs cause this? What is the treatment?
painful non-itchy pustules and honey crust caused by strep pyogenes or staph aureus treat with topical antibiotics like mupirocin
What is the most common cause of pathologic nipple discharge?
papillary tumor in breast duct lining if unilateral discharge, more concerning, get mammogram and ultrasound of breast
What are the findings in urinary schistosomiasis? What is the workup and treatment?
parasitic blood fluke transmitted by snails in water --usually a patient with travel to or immigration from Africa leads to bladder inflammation, dysuria, terminal hematuria, and elevated eosinophils +/- anemia work it up with urine sediment to look for eggs treat with praziquantel
What is the finding of parasternal heave associated with? What would cause that?
parasternal heave indicates right ventricular hypertrophy caused by pulmonary hypertension (primary vs COPD); mitral stenosis/regurg; chronic LVH/failure
What are 4 well-known risk factors that increase the risk of acute otitis media in kiddos?
parental smoking (cigarette smoke paralyzes the cilia, even if done outside) pacifier use lack of breastfeeding history daycare attendance
What part of the brain does Parkinson disease impact? What are some symptoms?
parkinsons impacts the basal ganglia pill-rolling tremor, rigidity, shuffling gait, REM disorders, masked facies
For what type of patient is CABG superior to PCI?
patients with left main coronary stenosis, LAD involvement, or multiple vessel disease have improved outcomes with CABG and higher long-term survival
What finding confirms an acute asthma exacerbation? How should you treat it?
peak expiratory flow reduction > 20% treat first with inhaled short-acting bronchodilators (albuterol) and if symptoms persist add a systemic corticosteroid (prednisone 40mg x5-10 days) if peak exp flow reduction >50%, patient having difficulty speaking, use of accessory muscles to breathe, or hypoxemic then send to ED no indication for CXR unless other symptoms of pneumonia present like fever, cough, chest pain, sputum production, crackles, dullness to percussion
What should you suspect when a young male patient presents with complaints of tiny little bumps in a ring around his penis?
pearly penile papules normal variant, reassure patient
What antibiotic should young kids (age 2-5) with sickle cell disease take prophylactically and why?
penicillin to protect against encapsulated organisms as these patients are often functionally asplenic
What should you perform in any patient with dermatomyositis or polymyositis? What antibody would you suspect?
perform pulmonary function testing due to the increased risk of interstitial lung disease (measures will be globally low) associated with ANA and anti-Jo antibodies
What is Fitz-Hugh-Curtis syndrome?
perihepatitis that is a sequelae of untreated pelvic inflammatory disease RUQ pain, fever, elevated LFTs
How should you manage a small pituitary mass that does not cause hormonal disturbance and remains within the sella not causing mass effects?
periodic monitoring with brain MRI every 6-12 mos
You should always check this lab value when a patient is diagnosed with medullary thyroid cancer __________. Why?
plasma metanephrines to check for pheochromocytoma (confirm with 24 hr urine fractionated metanephrines, catecholamines, and abdominal imaging) MEN2 syndromes
What should you suspect in a patient with recent travel who later develops fever, anemia, and splenomegaly?
plasmodium falciparum aka malaria
What is the criteria to indicate need for platelet transfusion?
platelet count < 50,000 with active bleeding or platlet count <10,000 with no bleeding
What causes a prolonged bleeding time? How would you treat a patient with prolonged bleeding time due to chronic kidney disease?
platelet dysfunction bleeding from CKD due to platelet dysfunction should be treated with desmopressin (increases VWF activity) if refractory to desmopressin and transfusions, can give cryoprecipitate infusion
What should you suspect in a patient with hypertension, displaced PMI, and family history of renal disease? What is the best workup? What is the management?
polycystic kidney disease best workup is kidney ultrasound (multiple simple bilateral kidney cysts) manage with aggressive control of BP with ACE inhibitors and aggressive control of lipids with statins
How does uterine rupture present? What are some risk factors?
presents as vaginal bleeding, fetal heart decelerations, loss of fetal station, loss of intrauterine pressure risk factors are prior abdominal surgery or c-section, induced or prolonged labor, fetal macrosomia treat with emergent laparotomy
What are some clinical features of dermatomyositis?
proximal muscle weakness elevated inflammatory markers elevated myositis markers (high CK, ALT, AST) heliotrope rash around the eyes "shawl sign" red rash on hands
What would raised yellow/white plaques scattered across the intestinal mucosa on colonoscopy make you suspect?
pseudomembranous colitis from C. diff
What should you suspect in a patient who went camping several months ago and had a tick bite and now presents with a swollen, red, painful knee but who can still bear weight and has no fever? What is the workup, treatment, and prognosis?
suspect Lyme causing mono-arthritis workup with arthrocentesis (WBC usually 20-40K) and ELISA/western blot for Lyme treat with 28 days oral doxycycline or amoxicillin 90% of cases resolve with treatment
What are some pregnancy complications associated with subclinical hypothyroidism?
recurrent miscarriages pre-term birth severe pre-eclampsia low birth weight placental abruption anti-TPO antibodies are associated with increased pregnancy losses even if the patient is clinically euthyroid
What is the definition of recurrent pregnancy loss? What is the most common uterine abnormality causing this? How should it be managed?
recurrent pregnancy loss = loss of more than 3 pregnancies prior to 20 wks gestation uterine anomalies can be worked up with hysterosalpinogram --> most common abnormality is a uterine septum do a hysteroscopic resection to remove the septum
What is the best workup of scoliosis if you are worried there may be a pathologic cause?
start with x-ray of spine, but MRI of spine is best and definitive red flags with scoliosis: back pain neuro symptoms >10 degree change in curvature within a year
You are evaluating a boy for a sports physical. He is tall and thin with longer arms than expected for his height. He also wears glasses. What do you suspect and what is the suggested workup?
suspect Marfan syndrome before engaging in sports he needs an echocardiogram to look for evidence of aortic disease
What should you suspect in a young patient with fatigue, fever, exudative pharyngitis, and posterior cervical nodes?
suspect Epstein-barr aka infectious mononucleosis (strep rarely causes posterior nodes)
A female patient with history of hypothyroidism presents with a gritty sensation in her eyes and dry mouth. What is your suspicion and a test you could order to try to confirm it?
suspect Sjogren's syndrome check anti-Ro and anti-La antibodies
What would you suspect in a young child with painless rectal bleeding? What is a good test to confirm your suspicion?
suspect a Meckel's diverticulum confirm with techentium-99m scan to see ectopic gastric mucosa in diverticulum
What would you suspect in an older female patient with children who presents complaining of dribbling after urination, pain with intercourse, and anterior vaginal bulging? What is your workup?
suspect a urethral diverticulum get a pelvic MRI or transvaginal ultrasound
What should you suspect when a patient complains of intermittent restrosternal pain, difficulty swallowing solid foods, and sensation of food "sticking" in the chest that is relieved by drinking fluids? What is the workup and treatment?
suspect GERD that lead to esophageal stricture workup is endoscopy or barium esophagram treat with PPI and balloon dilation
What should you suspect when a woman presents one week after normal vaginal delivery with abdominal pain, headache, vision change and is found to have low platelets and elevated liver enzymes? How do you treat her?
suspect HELLP syndrome (can present postpartum) hemolysis elevated liver enzymes low platelets accompanied by the HTN and proteinuria of pre-eclampsia first give magnesium sulfate to prevent seizures and then do supportive care
What should you suspect in a patient being treated for hypertensive crisis from cocaine use who develops worsened chest pain and upper extremity weakness? What is the workup?
suspect acute dissection of the ascending aorta --> can lead to carotid involvement and impaired bloodflow to the brain get CT angiography, MRI, or echo to confirm
What should you suspect in a child with fever, joint pain, subcutaneous nodules, and elevated ESR? What is the management?
suspect acute rheumatic fever treat with penicillin
What should you suspect in a patient with painful cramping, heavy menstrual bleeding, and an enlarged but normally shaped uterus on exam? What is the workup and treatment?
suspect adenomyosis get US/MRI to look for endometrium invading the myometrium layer of the uterus treat with hysterectomy if patient is finished childbearing or with progestin IUD or Depo-Provera (medroxyprogesterone acetate) if still desiring children
What should you suspect in a patient with other findings of scleroderma (telangiectasias, Raynaud phenomenon, GERD) develop sudden-onset of hypertension and elevated creatinine? What is the treatment?
suspect scleroderma renal crisis treat with ACE INHIBITOR CAPTROPRIL and an IV antihypertensive to acutely lower BP like IV sodium nitroprusside
What should you suspect in a middle age female patient who complains of difficulty swallowing, Raynaud's, shortness of breath, myalgias, and ulcers on her fingers?
systemic scleroderma --> get pulmonary function tests
What type of murmur is associated with hypertrophic cardiomyopathy?
systolic murmur due to left ventricular outflow obstruction
Take a moment to review your heart murmurs.
systolic murmur: mitral or tricuspid regurg and aortic or pulmonic stenosis diastolic murmur: mitral or tricuspid stenosis and aortic or pulmonic regurg
What are 2 EKG findings that might point towards acute PE?
tachycardia and new right bundle branch block
What are the symptoms of serotonin syndrome?
tachycardia, hyperthermia, rigidity, clonus, hyperreflexia, slow horizontal eye movements, and tremor
What should you advise a patient on calcium or iron supplementation about the timing of taking their thyroid replacement med?
take the thyroid replacement 30 mins before eating in the morning and then do not take calcium/iron for at least 3-4 hours after
When do you need to taper a patient off steroids instead of just discontinuing them?
taper is required after 3 weeks or if there are features of Cushings (moon facies, abdominal striae, buffalo hump, truncal obesity)
How should you counsel a woman who takes Synthroid when she calls to tell you she is pregnant and schedule an initial prenatal visit?
tell her to go ahead and increase her synthroid dose by 30% until her appointment then follow TSH every 4 weeks
How should you manage a patient who recently went camping and now present with a rash, headache, malaise and myalgia?
think about RMSF if rash is purpura involving palms/soles think about early Lyme if rash is large expanding macule with central clearing treat empirically with doxycycline
What would you suspect in an HIV patient with cough who is found to have a pleural effusion that is lymphocyte predominant? What lab findings on the fluid would strongly support your suspicion?
think about TB! look for elevated adenosine deaminase level confirm with pleural biopsy
How does varicocele present and what is the treatment?
"bag of worms" scrotum that does not illuminate treat with venous embolism
How do you calculate a positive and negative likelihood ratio (LR)? How do you interpret it?
+ LR = (sensitivity)/(1-specificity) - LR = (1-sensitivity)/specificity test result with LR > 1 indicates disease is likely present...this likelihood increases as LR increases
What are 3 things you should recommend to a patient asking for ways to eliminate their snoring?
--no alcohol before bedtime --stop smoking --lose weight
What does a DEXA scan score of -2.6 indicate? What about -1.3?
-1 to -2.5 indicates osteopenia anything undre -2.5 indicates osteoporosis
What would you diagnose in a patient with __________ on PFTs 1. Reduced FEV1 and reduced FEV1/FVC ratio; normal DLCO 2. Reduced FEV1/FVC ratio and reduced DLCO 3. Normal lung volumes but only reduced DLCO 4. Reduced total lung capacity; FEV1/FVC normal but both numbers decreased individually
1--asthma 2--COPD 3--Pulmonary arterial hypertension 4--restrictive lung disease
What would you suspect if a parent brought in a child with patchy hair loss and the following findings: 1. broken hair shafts of different lengths 2. well-circumscribed circles of total hair loss 3. fine scale over hair loss accompanied by posterior cervical nodes
1--trichotillomania 2--alopecia 3--tinea
What are 3 workups that need to be done after a stroke to try to find the source? What about in a patient who is young or has SLE?
1. MRI/CT/doppler ultrasound of carotid arteries 2. Echocardiogram 3. EKG If young patient or signs of SLE get hypercoag panel
What are 4 risk factors for C diff infection?
1. advanced age 2. recent hospitalization 3. recent antibiotic use 4. suppression of gastric acid
Name 4 medications you should start in a patient with history of MI to improve mortality?
1. beta blocker 2. high intensity statin (atorvastatin >40 or rosuvastatin >20) 3. ACE (lisinopril) or ARB (sartan) 4. anti-platelet therapy
What are 3 things that physicians should do to prevent misuse in patients they are prescribing opioids?
1. check the database at each visit 2. random urine drug screens 3. frequent follow up every 3 mos or less
What is the diagnostic criteria for acute stress disorder?
1. exposure to an actual/threatened trauma 2. duration of 3 days to 1 month 3. symptoms of --avoidance of memories or reminders --hypervigilence, flashbacks, nightmares --dissociation or derealization --insomnia and low mood after 1 month of symptoms the diagnosis is PTSD
What are the 5 further workups needed at the time of a medullary thyroid cancer diagnosis?
1. germline RET mutation testing 2. serum calcitonin 3. serum carcinoembryonic antigen 4. plasma metanephrines to workup PCC 5. neck imaging for parathyroid issues
Name 4 groups of people who need prophylaxis for meningitis if they have an exposure to a positive patient. What is the prophylaxis?
1. household members or roommates 2. childcare workers 3. medical professionals directly exposed (intubated or mouth to mouth) 4. persons seated next to patient > 8 hours prophylaxis is rifampin (other options include ciprofloxacin or IM ceftriaxone)
What are 3 major causes of anemia with reduced MCV (microcytic) (aka MCV <80)
1. iron deficiency (usually related to blood loss) 2. lead toxicity 3. thalassemia
What are the 4 main features of PCOS? What is the initial treatment if a patient with PCOS is desiring pregnancy? What if that doesn't work?
1. metabolic syndrome (obesity, DM) 2. excess estrogen and androgens (hirsutism, acne) 3. oligo-ovulation or anovulation (due to excess estrogen) 4. poly cystic ovaries on ultrasound first, advise patient to lose weight can use letrozole to induce ovulation
Try to name 8 absolute contraindications to oral contraceptive use
1. migraine with aura 2. history of breast cancer 3. history of clotting (or antiphospholipid syndrome) 4. liver cancer or cirrhosis 5. smoker and over age 35 6. HTN > 160/100 7. history of stroke 8. DM with end organ damage
What are 6 risk factors for abdominal aortic aneurysm? Which carries the strongest effect/prognosis?
1. smoker (strongest) 2. male 3. older 4. white ethnicity 5. family history 6. atherosclerotic disease
Give the 4 stepwise progression in treating peripheral artery disease (calf claudication, elevated ABI)
1. start aspirin and statin; advise to stop smoking; control HTN and DM 2. supervised exercise program 3. if refractory add cilostazol 4. if refractory to cilostazol refer for surgery
What is the stepwise treatment of an acute asthma exacerbation?
1. start with inhaled short acting beta agonist (albuterol) 2. add inhaled ipatropium 3. add systemic corticosteroids 4. add magnesium sulfate remember to use supplemental oxygen as needed and/or non-rebreather
What are 3 side effects to worry about with Depakote? Who should this medication not be used in and why?
1. thrombocytopenia 2. hepatotoxicity 3. pancreatitis Causes birth defects due to interfering with neural tube development so do not prescribe to women of childbearing age unless on birth control
What is the first and second line treatment of patients with hyponatremia from SIADH?
1. water restriction 2. furosemide (also supplement sodium)
How do you treat strep in children and why?
10 day course of oral penicillin to prevent acute rheumatic fever confirm with throat culture (preferred) or rapid antigen test prior to giving antibiotics
Who should be on the 10 year track for colonoscopies? What about the 5 year tract? 3 year tract?
10 year only if all that is found is small rectal hyperplastic polyps 5 year tract for those with a couple <1cm tubular adenomas 3 year tract for 3+ adenomas, any adenoma over 1 cm, or any adenoma with villous features
What is the approach to screening for gestational diabetes? Give the timing and both steps.
24-28 weeks gestation (unless risk factors for DM present, then earlier) Step 1 = Glucose Challenge Test = give 50g oral glucose then check in 1 hour --> if blood sugar remains <140 after an hour GDM unlikely so no further testing Step 2 = 3 hour Glucose Tolerance Test = give 100g glucose then check at 1, 2, and 3 hours GDM diagnosed when 2+ abnormal values on GTT Goals for 3 hour GTT fasting < 95 hour 1 < 180 hour 2 < 155 hour 3 < 140
Try to name 3 screening tests that should be performed at 24-28 weeks during pregnancy? What about at 35-37 weeks?
24-28 weeks: CBC (or at least hemoglobin/hematocrit) anti-Rh(D) screen if patient is Rh negative 50-gram 1 hour glucose tolerance test 35-37 weeks: Strep B screen
What is the treatment of active TB during pregnancy? Which typical RIPE medicine should you avoid? What supplement should you give and why?
3-drug therapy with Rifampin; Isoniazid; and Ethambutol Avoid pyrazinamide due to potential fetal toxicity Supplement pyridoxine (B6) to prevent isoniazid neurotoxicity
What is the recommended exercise routine during pregnancy? What are some activities that should be avoided?
30 mins of moderate intensity aerobic exercise most days of the week avoid: anything with fall risk (gymnastics, skiing, horseback riding, rafting, climbing, etc); scuba diving (risk of fetal decompression sickness); no contact sports weight lifting is okay but should be limited to 10 lbs due to risk of Valsalva stopping blood flow through umbilical cord if patient is already conditioned for more exercise then she can continue
How long must a tick be attached to pass along Lyme?
36 hours
What is the management of a healthcare worker exposed to body fluids from an HIV+ person?
4 weeks of 3-drug post exposure ppx highest risk: blood, semen, vaginal secretions medium risk: CSF, amniotic, synovial/pericardial/pleural low risk: urine, feces, vomit, tears
What platelet count is a contraindication to epidural placement in pregnancy and why? What platelet count indicates need for transfusion? What about need to cancel planned surgery?
< 70,000 --> don't give epidural due to increased risk of spinal epidural hematoma transfuse platelets if <10,000 or <50,000 with active bleeding cancel surgery at platelet count <50,000
At what size is it okay to monitor a thyroid nodule with ultrasound?
<1cm
What blood sugar level defines hypoglycemia?
<60
What lab finding defines asymptomatic bacteriuria? When do you treat asymptomatic bateruria? What are three first line regimens?
>100,000 CFUs in clean catch specimen when the patient is pregnant! has been linked to worse fetal outcomes treat with: cephalexin 3-7 days amoxicillin-clavulanate 3-7 days fosfomycin single dose ***be sure to repeat urine culture a week later to test for cure
A patient is found to have prolactin level of 212. What does this indicate? What are 2 medications that might help?
>200 is indicative of prolactinoma treat with dopamine agonists cromocriptine or cabergoline
What dose of prednisone is considered high enough to increase risk for psychiatric complications?
>40mg/day reduce corticosteroid doses as much as possible!
What is the reading from a PPD you are looking for to diagnose TB? What is the most common side effect of isoniazid? What is a side effect we prophylactically treat for and how?
>5mm if close contact or immunosuppressed >10mm if "exposed" ie homeless, incarcerated, healthcare provider, travel to endemic area most common side effect of INH is hepatotoxicity we prevent neuropathy by giving B6 (pyridoxine) alongside INH
What number of cafe au lait macules would be concerning for neurofibromatosis in a patient you are working up for scoliosis?
>6
What is the diagnostic criteria for illness anxiety disorder?
>6 months of persistent worrying about having or being diagnosed with a severe illness
What grade of carotid artery stenosis is considered severe enough to indicate need for carotid endarterectomy?
>70% stenosis
What history would make you suspect allergic bronchopulmonary aspergillosis? What is the workup and treatment?
A patient with history of asthma or cystic fibrosis that has recurrent exacerbations with fever, malaise, cough +/- brownish tinged sputum, and wheezing workup is either skin testing for reaction to Aspergillus or analysis of IgE concentrations treat with systemic glucocorticoids and Itraconazole or voriconazole
What do Medicare parts A, B, and D cover?
A= inpatient hospitalization B= outpatient care (and hospital observation) D= prescription medications
How can you calculate absolute risk reduction? What about relative risk reduction?
ARR = rate in control group - rate in test group RRR = ARR / control rate number needed to treat is 1/ARR
What should you suspect in a patient with myalgias, weight loss, hyperpigmented skin, fatigue, and low sodium? What is the workup?
Addison disease (chronic adrenal insufficiency) work up with low morning plasma cortisol and elevated ACTH
What is a good test to run in someone with progressive liver failure and emphysema?
Alpha-1-antitrypsin deficiency
What is indicated for recurrent/severe otitis media that has failed amoxicillin?
Amoxicillin-clavulanate
How long can an effusion persist after treatment of acute otitis media? What does an effusion look like and how should you treat it?
An effusion can persist up to 3 months following acute otitis media. Retracted tympanic membrane with yellow fluid behind and reduced movement. Referred to a serous otitis media or otitis media with effusion. Treatment is watchful waiting as long as no other symptoms and less than 3 mos duration.
What test is sensitive/specific for primary biliary cirrhosis? What are the typical lab findings as far as liver?
Antimitochondrial antibodies expect normal AST/ALT and elevated alk phos
What is the first step in treating an HIV+ patient with low platelets?
Antiretrovirals--HIV can cause low platelets if untreated If does not respond to ART, consider splenectomy
What heart condition should you suspect in a child who develops leg pain with exercise? What PE findings would reflect this (try for 3)?
Aortic coarctation! Look for elevated right arm BP, lower extremity hypotension, heart murmur, and delayed distal pulses
What are some features of tabes dorsalis? What causes it?
Argyll-Robertson pupil (reacts to accommodation but not to light) sensory ataxia impaired vibration/proprioception in legs instability during Romberg can have shooting pains caused by treponema pallidum (syphilis)
What malignancy is associated with Sjogrens syndrome?
B-cell non-hodgkin lymphoma
How could B12 deficiency lead to mild indirect hyperbilirubinemia?
B12 deficiency leads to issues with cell development and hematopoiesis --> this causes megaloblastic transformation of bone marrow and intramedullary hemolysis
What should you suspect in any older patient with symptoms of dementia and megaloblastic anemia?
B12 deficiency!
What should you suspect in an elderly patient with dementia symptoms, gait instability, reduced sensation in limbs, and hyperreflexia?
B12 or folate deficiency! Interferes with DNA cell synthesis
What would you expect the MCV to be for each: B12 deficiency iron deficiency thalassemia folate deficiency lead poisoning
B12/folate --> macrocytic iron/lead/thal--> microcytic
What does it mean when a patient with hearing loss has bone conduction > air conduction on Rinne test? What would you expect the Weber test to show?
BC > AC indicates conductive hearing loss (something in the ear) Weber will localize to the AFFECTED ear
What medications should you start any patient with symptomatic Graves disease on?
BETA BLOCKER plus methimazole (usually first-line; teratogenic) propylthiouracil (can cause hepatotoxicity) OR thyroidectomy OR radioactive thyroid ablation (may cause transient increase in hyperthyroid symptoms) really, you want to use methimazole/PTU at first to prepare for radioactive iodine or thyroidectomy as a definitive treatment but if case is severe or lots of opthalmopathy you need to just go to thyroidectomy
What blood pressure indicates need for antihypertensives in pre-eclampsia/HELLP? What two agents are preferred?
BP > 160/110 mmHg preferred are IV labetalol or hydralazine
What is the blood pressure at which TPA is contraindicated? Try to name 4 other contraindications
BP > 185/110 means do not give TPA! active internal bleed recent surgery intracranial surgery in past 3 months hemorrhage on CT platelets <100,000 anticoagulation
What are 2 genetic risk factors that massively increase the risk of male breast cancer? What are 3 lifestyle factors?
BRCA gene mutation increases risk 100x (look for family hx of breast and ovarian cancers; autosomal dominant) personal hx of Klinefelter syndrome (XXY) increases amount of estrogen present and raises risk 20x hepatic dysfunction, marijuana use, and obesity also increase the risk but only slightly
What BUN/Creatinine ratio, FENa, and osmolality suggests prerenal cause of acute kidney injury?
BUN/Creatinine ratio > 20 FENa <1% osmolality > 500
What is the BUN/Creatinine ratio, FENa, and osmolality associated with acute tubular necrosis? What other finding might help make this diagnosis?
BUN/Creatinine ratio of 10-15 FENa >2% osmolality around 300 look for muddy brown casts
Take a moment to review the differential dx of vaginitis.
BV --> metronidazole or clindamycin Yeast --> fluconazole Trich --> metronidazole
How does postpartum thyroiditis present? How would you differentiate it from subacute granulomatous thyroiditis?
Both cause low TSH, high T4, and low radioactive iodine uptake but subacute granulomatous thyroiditis causes a painful/tender gland and is associated with recent viral infection
What are 5 other screening tests you should get at time of diagnosis of HIV?
Hep B Hep C tuberculosis gonorrhea/chlamydia syphilis (treponema pallidum)
What PFT findings would you expect in COPD and why?
Reduced FEV1/FVC ratio and reduced DLCO obstructive process accompanied by damage to lung tissue
What is the usual cause of high GGT? How can it be useful?
Cholestasis GGT can help determine whether elevated alkaline phosphatase is coming from liver or bone
What causes chronic myeloid leukemia (CML)? How can you diagnose it and what is the treatment?
CML is caused by a translocation of chromosomes 9 and 22 to make the bcr-abl fusion protein which causes unregulated tyrosine kinase activity detection of bcr-able is diagnostic treat with tyrosine-kinase inhibitors like imatinib--> then once disease is stable and you find a donor do bone marrow transplant
What is the most sensitive modality for diagnosing a renal stone?
CT scan --> avoid in pregnancy and do ultrasound
What are some CV diseases, cancers, and STIs that are more common in women who have sex with women?
CV disease: obesity type II DM CAD cancers: ovarian breast cervical STIs: bacterial vaginosis (most other STIs like HIV, HSV, syphilis, G/C are lower in the WSW population)
A patient with history of bloody diarrhea and abdominal pain is being sent for colonoscopy. What are 3-4 characteristics that would indicate Crohn's disease or ulcerative colitis?
Crohn's disease -skip lesions (areas of spared intestine) -aphthous ulcers -cobblestoning -rectum spared -can lead to fistulas/transmural lesions Ulcerative colitis -usually involves rectum -contiguous lesions -superficial ulcerations
What is the risk of Hep C progression to chronic infection in adults? What about Hep B?
Hep C has 75-80% risk of becoming chronic Hep B has 5% risk of becoming chronic
This type of diabetes medication should be avoided in anyone with a history of pancreatitis
DPP4 inhibitors --> increased risk of pancreatitis aka "gliptins" work by reducing breakdown of incretins to promote satiety
What is the presentation and cause of spinal muscular atrophy?
Degeneration of the anterior horn cells that leads to flaccid paralysis, hypotonia, and fasciculations. "Floppy baby"
What is the management of a patient with epigastric pain, nausea, vomiting, fever, elevated amylase, and gallstone on US?
ERCP to diagnose the pancreatitis and remove the gallstone all at once (ERCP should be avoided in other causes of pancreatitis due to its associated risks)
What are three conditions that increase your risk for angiodysplasias in the intestinal tract? How does each increase risk? What do these look like on colonoscopy?
End stage renal disease causes platelet dysfunction Both aortic stenosis and von willibrand disease cause loss of von willibrand factor which is needed for platelet aggregation look like small flat cherry red spots
What is a medication that greatly increases the risk of pyloric stenosis if given in the first few weeks of life? Why might this medication be given to a newborn?
Erythromycin usually given for prophylaxis against pertussis
What is Light's criteria?
Exudative if: - fluid protein/serum protein ration is >0.5 - fluid LDH/serum LDH is >0.6 - pleural fluid is greater than 2/3 the upper limits of normal serum LDH Exudates are caused by increased capillary permeability while transudates are caused by increased hydrostatic or decreased oncotic pressure
What test can you order to determine if an elevated alk phos level is coming from liver or bone?
GGT high indicates cholestasis
What is the typical presentation of juvenile myoclonic epilepsy? How should you treat it? What would you expect to see on EEG?
Generally an older child/adolescent with absence seizures, myoclonic jerking in the morning, and generalized tonic-clonic seizure treatment is Depakote/VPA and to avoid triggers like lack of sleep and alcohol EEG shows bilateral polyspike and slow wave activity
What are the indications for HPV vaccination?
Girls age 11-26, but may be given up to age 45 Boys age 11-21, but up to age 26 for MSM Immunocompromised (HIV etc) age 11-26 prevents genital warts (HPV 6 + 11) and anogenital cancer (HPV 16 + 18)
What genetic marker is associated with ankylosing spondylitis? What spine deformity? What pain history would you expect to hear from a patient?
HLA-B27 kyphosis would expect to hear that pain is worse in the morning and after periods of prolonged inactivity then improves with activity look for limited spine mobility and hip/shoulder pain xray will show "bamboo spine"
How should you manage a patient found to have HSIL? What about a patient found to have ASCUS or LSIL?
HSIL --> go to colposcopy ASCUS/LSIL--> HPV co-test for high risk strains and if positive then do colposcopy
Take a moment to review lumbar puncture CSF findings and what they indicate Summarize the findings in WBC count/type, protein, and glucose for the following: HSV encephalitis Bacterial meningitis Viral meningitis
HSV: normal glucose +/- protein WBC may be elevated or not but will be lymphocytic Bacterial: low glucose elevated protein elevated WBC with neutrophils Viral: normal glucose elevated protein elevated WBC with lymphs
Toddler who recently started daycare and presents with fever, decreased activity, oral and hand/foot blistering, and decreased intake. What do you suspect?
Hand foot mouth aka Cocksackie virus fecal-oral route; usually self-limited to one week; handwashing very important bc highly transmissible
What does a Hazard Ratio indicate and what are the ranges and meanings?
Hazard Ratio is used in survival or time-to-event measurments interpret similar to relative risk HR < 1 indicates less risk (protective) HR > 1 indicates increased risk (detrimental)
At what value for the following can you diagnose diabetes? What about pre-diabetes? HbA1c fasting glucose random glucose glucose tolerance test
HbA1c > 6.5% is diabetes (5.7-6.4 is prediabetes) fasting glucose >126 is diabetes (100-125 is pre) random glucose > 200 plus symptoms oral glucose tolerance >200 at 2 hours is diabetes
How does intrahepatic cholestasis of pregnancy present? What is the management?
ICP causes intense itching without a rash that is worst on the palms and soles also look for elevated serum bile acid levels manage by delivery at 37 weeks as intrahepatic cholestasis increases risk of fetal demise
What INR indicates a need for fresh frozen plasma?
INR > 2.0
What INR indicates a need for fresh frozen plasma
INR >2
What are the 5 important considerations in treating DKA? Review them for a minute
IV fluids --> give rapid infusion of 0.9% normal saline and then add dextrose 5% when serum glucose <200 Insulin --> continuous IV insulin (hold if K+ <3.3) then switch to basal-bolus when anion gap <12, serum glucose <200, and serum bicarb HCo3- >15 Potassium --> always give IV potassium unless serum K+ is over 5.3 (remember external cell shift of K+) Bicarbonate --> consider if ph <6.9 Phosphate --> consider for serum phos <1.0, cardiac dysfunction, or respiratory distress
What is the first line therapy for torsades?
IV magnesium sulfate (even if mag levels are normal!)
What is the treatment for C diff causing something like hypotension, ileus, shock, or megacolon?
IV metronidazole + high dose PO vancomycin
What is an option to treat a patient with recurrent DVTs who cannot be anticoagulated?
IVC filter biggest complications are recurrent DVT and IVC filter thrombosis
How should you treat someone who may have been exposed to rabies (bats, dog bite, etc?) Does it differ based on vaccine status?
If patient never received rabies immunization before, then give rabies IVIG and 3 rounds of vaccine If patient has been vaccinated before then only give 2 doses of vaccine (IVIG may blunt natural immune response)
When do we primarily use radionuclide thyroid scans?
In cases of HYPERthyroidism to decide whether it looks like Graves disease (diffuse uptake) or a "hot" nodule
What does indirect/unconjugated hyperbilirubinemia indicate? What are some conditions that lead to this?
Indicative of ruptured blood cells (HEMOLYSIS) Intravascular hemolysis; drug toxicity; Gilbert syndrome (harmless cause); hematoma can be due to things like G6PD deficiency, spherocytosis, thalassemia, polycythemia, hypothyroidism, Rh/ABO incompatability, splenomegaly, Sepsis, AV malformation
What are 3 situations in which prophylactic palivizumab to protect against RSV is indicated?
Infant born <29wks gestation, infant with lung dz due to lung immaturity, significant congenital heart dz
What history would make you expect infant botulinum toxin poisoning? How does this toxin harm the body?
Infant with progressive loss of muscle tone who has been fed honey or lives near a farm/construction (clostridium botulinum spores in soil). Botulinum toxin inhibits presynaptic acetylcholine release into the NMJ-->descending paralysis. First sign is often constipation and poor feeding/suck which progresses to hypotonia, paralysis, and respiratory failure. ***get a confirmatory stool study
What is our most effective acne medication? When should it be used? What cautions should be taken?
Isotretenoin is the most effective but should only be used in severe nodulocystic acne that has failed other therapies. Side effects include dry skin/mouth, teratogenicity, and increased risk of pseudotumor cerebri (increased ICP for no reason). Due to teratogenicity, patients must have 2 negative pregnancy tests prior to initiation. All sexually active female patients on Isotretenoin should use 2 forms of contraception. Often acne will worsen for 2-3 weeks at start of Isotretenoin therapy and then improve.
What is one situation in which you should give a child high dose aspirin? What are some findings that would make you suspect this?
Kawasaki disease fever > 5 days bilateral conjunctivitis strawberry tongue cervical adenitis rash mucositis swollen hands/feet dangerous because can lead to coronary aneurysm
What is the first-line contraceptive option for adolescent girls? Why?
LARC (long acting IUD or implant) Progestin-containing recommended for patients with heavy menstrual bleeding or dysmenorrhea Copper indicated for those with light menstrual periods and wish to avoid hormones
At what LDL should a patient be placed on a statin?
LDL > 190
What symptoms would make you think a patient may have diverticulitis? What is your management?
LLQ abdominal pain fever, nausea, and vomiting work up with CT abdomen (oral and IV contrast) treat with IV cipro + flagyl and clear liquid diet
What would you suspect in a patient with pneumonia-like symptoms who recently had GI distress and is noted to have low sodium on labs? How would you treat it?
Legionella treat with azithromycin, cipro, levofloxacin
What is a Likelihood Ratio and how do you calculate it?
Likelihood Ratios give the probability of a test result occurring in a patient with a disorder compared to the probability of that test result in a patient without the disorder Positive LR: LR = sensitivity/(1-specificity) Negative LR: LR = (1-sensitivity)/specificity
What treatment would you choose for a patient currently receiving chemo who develops cough, shortness of breath, pain with inspiration, and hemoptysis whose CXR shows nodules surrounded by ground glass opacity? Why?
Likely aspergillosis treat with voriconazole
What is the first-line treatment for hypertension in patients with gout? Why? What meds should be avoided?
Losartan, an ARB, is first-line because it has a mild effect of increasing uric acid secretion in urine Avoid diuretics like HCTZ or furosemide because they decrease the excretion of urate
acute onset of one-sided motor weakness indicates a likely stroke in this territory __________ when would it be appropriate to treat with TPA?
MCA treat with TPA if within 3-4 hours of onset of symptoms and there are no contraindications (active internal bleed, platelets <100,000, intracranial hemorrhage on CT, intracranial surgery within 3 months, blood pressure > 185/110)
What injury should you suspect in a patient who was playing soccer and took a tackle from the side who now has pain but is able to ambulate? On PE there is laxity with valgus stress test.
MCL (medial collateral ligament) injury
What are the diagnostic criteria for MDD? How does this differ from grief reaction?
MDD >2 weeks of at least 5 of 9 symptoms SIGECAPS (sleep disturbance, loss of interest/anhedonia, guilt/hopelessness, low energy, difficulty concentrating, change in appetite, psychomotor changes, suicidal ideation) normal grief will not show 5 of these, mood disturbance will be related to the loss, usually improves with time
What are the diseases associated with: MEN Type 1 MEN Type 2A MEN Type 2B
MEN Type I = 3P's Pituitary tumors Primary hyperparathyroidism Pancreatic tumors MEN Type 2A = PPM Parathyroid hyperplasia Pheochromocytoma Medullary thyroid cancer MEN Type 2B = PMM Pheochromocytoma Medullary thyroid cancer Marfanoid habitus Mucosal/intestinal neuromas
Name 2 other diseases a patient found to have a pituitary tumor is at increased risk for. What genetic condition?
MEN1 pituitary tumors primary hyperparathyroidism pancreatic tumors test for germline RET mutations
Name 4 other diseases a patient diagnosed with medullary thyroid cancer is at increased risk for. What genetic condition?
MEN2 syndrome MEN2A MTC + parathyroid hyperplasia + pheochromocytoma MEN2B MTC + pheochromocytoma + marfanoid habitus + mucosal/intestinal masses
What lab findings can help you differentiate multiple myeloma and paget disease of bone?
MM: hypercalcemia Paget: normal calcium, elevated alk phos
What are 3 cognitive tests to screen dementia and the scores than indicate dementia with each?
MMSE --> less than 24/30 MOCA --> less than 26/30 Minicog --> abnormal 3 word recall or clock
If a patient presents with thyrotoxicosis with a normal or elevated TSH you should do this work up__________. Why?
MRI brain to check for pituitary adenoma
Acetylcholine receptor antibodies in the neuromuscular junction cause this disease _________________ which leads to slow progression of fluctuating muscle weakness and fatigue. What is the treatment?
Myasthenia Gravis (autoimmune) Cholinesterase inhibitors (pyridostigmine and neostigmine), corticosteroids, thymectomy.
Name 3 drugs that commonly increase lithium levels
NSAIDs Thiazide diuretics (HCTZ, chlorthalidone, metolazone) ACE inhibitors
What is the treatment for subacute thyroiditis?
NSAIDs + beta blocker exam will show tender goiter; TSH low and T4 high; patient will report fever and hyperthyroid sx
How do you calculate number needed to treat?
NTT = 1/ ARR ARR is absolute risk reduction ex: risk in control group is 20% and risk in test group is %15 this means the ARR is 20%-15% = 5% so NTT would be 1/0.05 = 20
What should you suspect in a patient with history of Cushing's disease who presents with hyperpigmentation and vision disturbance following adrenalectomy? What is the workup?
Nelson syndrome from an undiagnosed pituitary microadenoma growing rapidly after the negative feedback from the adrenals is removed workup is MRI and plasma ACTH MRI will show microadenoma and ACTH will be extremely high
What is Nelson's syndrome?
Nelson syndrome usually presents after bilateral adrenalectomy for Cushings --> it happens when there was a pituitary microadenoma present at the time of the adrenalectomy because there is no longer excess ACTH from the adrenals, the microadenoma no longer has negative feedback and grows very quickly this causes mass effects (bitemporal hemianopsia, headache, etc) and hyperpigmentation of the skin
When should you treat salmonella enteritis?
No need to treat in immunocompromised patients over 12 months of age
Does tight glycemic control reduce the risk of MI, stroke, etc in patients with DM?
Nope--evidence has not shown benefit for macrovascular changes nephropathy and retinopathy are slowed by tight glycemic control though
This is a common elbow injury in children after traction on extended arm _________. Describe the treatment.
Nursemaid's elbow aka radial head subluxation Treat with manual reduction by FLEXION and SUPINATION
What would the blood gas findings be in a patient with postsurgical respiratory distress due to: OSA PE acute heart failure
OSA: Respiratory acidosis --retention of CO2 --poor air exchange causes low O2 PE: Respiratory alkalosis --tachypnea blows off too much CO2 acute HF: Respiratory alkalosis --pulmonary edema causes tachypnea
Summarize the healthy worker effect. How can you try to control for it?
Overall, a group of people who are able to work is going to be healthier than the total population (this makes rates of things caused by occupational exposure seem lower than they really are) To control for this you can make your control population be workers from another field without the occupational exposure you are studying
What does the mnemonic PAIR mean to you when thinking of genetic markers? (clue = HLA B27)
PAIR psoriatic arthritis ankylosing spondylitis inflammatory bowel disease reactive arthritis
What is population attributable risk percent and how do you calculate it?
PAPR = (risk in total population - risk unexposed)/risk in total population
What are two bad outcomes associated with use of phencyclidine (PCP)? What is the management?
PCP can cause seizure and rhabdomyolysis give benzo for seizure and IV fluids for rhabdo to protect the kidneys
What are physical exam findings in Marfan syndrome? What are complications you worry about in these patients?
PE will show tall stature, pectus excavatum, long arms, long fingers, hyperextinsible joints worry about diseases of the aorta and lens subluxation
Patient with fever, tachycardia, hot flashes, sweating and history of recent viral illness. Labs show low TSH and high T4. What physical exam findings and labs do you expect? What is the likely diagnosis?
PE: diffusely enlarged thyroid that is tender. Labs: elevated ESR/CRP Imaging: low radioiodine uptake Subacute thyroiditis (aka De Quervains)--> inflammation of thyroid leads to release of stored thyroid hormone; often post-viral Treat with NSAIDs and beta blocker if needed
What is the best test to get when you suspect polymyalgia rheumatica? Why? What is a big feature that differentiates this from polymyositis?
PMR --> get ESR (remember it is associated with giant cell arteritis) PMR usually has significant pain and normal CK polymyositis usually has no pain and elevated CK
What are 3 common medications that reduce the absorption of levothyroxine? What about 3 less common medications?
PPI, calcium supplement, iron supplement cholestyramine, aluminum hydroxide, sulfacrate
What are the findings in Paget's disease? Try to remember symptoms, imaging findings, and lab abnormalities. What is the workup and treatment?
Paget disease causes increased bone turnover imaging shows mixed lytic/sclerotic lesions in bone wiht "cotton wool" appearance labs show elevated serum and bone-specific alk phos; calcium and phosphorous are usually normal diagnose with bone scan and alk phos treatment is bisphosphonates (alendronate)
What should you suspect in a patient whose x-rays show "cotton wool" spots with areas of lytic and sclerotic bone processes? What other symptoms would you ask about? What is the treatment?
Paget disease of bone --> increased turnover can cause skull deformity, hearing loss, dizziness can cause bone pain, increase fracture risk, deformity associated with osteosarcoma and giant cell tumors treat with bisphosphonates
What should you suspect in a patient with bone pain, normal calcium, and elevated alk phos? What about bone pain, high calcium, and anemia?
Paget disease of bone causes bone pain with normal calcium and elevated alk phos --> look for sclerotic lesions and thickened cortex on imaging --> treat with alendronate/risedronate/zoledronic acid Multiple myeloma causes bone pain with high calcium and anemia. >10% monoclonal plasma cells on bone marrow biopsy diagnoses.
How does Dengue Fever usually present? What is a lab finding and a big physical exam clue? What can it lead to?
Patient with recent travel (Asia, Pacific Islands, Caribbean, S America) who has fever, bone/joint pain, rash, thrombocytopenia, and pain behind the eyes platelets <100,000 is a lab clue petechiae when you apply BP cuff is another can lead to increased capillary permeability, shock, and circulatory collapse
What are the symptoms of Chikungunya fever?
Patient with recent travel who develops high fever, severe persistent polyarthritis, and rash up to 50% may develop persistent arthritis requiring use of methotrexate
When would laparoscopic fundiplocation be indicated?
Patients with GERD that is refractory to twice daily PPI
What is the clinical picture of pertussis? What is the treatment?
Pertussis causes relentless coughing with post-coughing emesis and apnea Patients usually have leukocytosis >20,000 with 50% lymphocytes and sick contacts Treat with macrolides (azithromycin, erythromycin)
This is a new medication approved by FDA to treat psychosis in Parkinsons disease
Pimavanserin (aka Nuplazid)
What type of medication is spironolactone and by what MOA can it help treat acne?
Potassium-sparing diuretic that can be used to treat acne in women due to its anti-androgen effects
What is Potter sequence and what causes it?
Potter sequence is caused by oligohydramnios and leads to pulmonary hypoplasia, flat face, bilateral renal agenesis
How can you calculate the power of a study?
Power is 1-beta where beta = probability of making a type II error (failure to reject null hypothesis when a difference really dose exist) aka false negative
What would you suspect in an infant who is brought to ED with intermittent respiratory pauses and cyanosis in the winter whose family recently had URI without fever/aches/cough? What is the treatment?
RSV (respiratory syncytial virus) causing bronchiolitis Infants <2 months are at high risk of dangerous apnea Care is supportive If an infant is preterm <29 wks, has lung immaturity, or congenital heart disease then you can give palivizumab for RSV prophylaxis
What causes bronchiolitis? What is the management?
RSV --> leads to nasal congestion, runny nose, cough, coarse breath sounds and wheezing hospitalize the patient w/ contact + airborne precautions supportive care with IVF, nasal bulb suctioning, and humidified oxygen
What should you suspect in a patient with fever and fear of drinking water due to throat tightening?
Rabies!! Hydrophobia is caused by pharyngeal spasms from the virus. Bats are most common vector--think of caves!
What would you suspect in a patient who hikes and then develops a fever and headache with rash that is petechial (non-blanching) and involves the palms and soles? How would you treat?
Rickettsia aka Rocky Mtn Spotted Fever always treat with DOXYCYCLINE!
What is the go-to for prophylaxis against bacterial meningitis? What are 2 alternative options?
Rifampin is first-line oral ciprofloxacin or IM ceftriaxone are second line
What type of heart issue should you suspect in an IV drug user with fever, shortness of breath, and chest pain? Describe parts of the heart affected. What is the diagnostic test?
Right sided endocarditis affecting tricuspid valve Often leads to septic pulmonary embolisms and shortness of breath/cough diagnose with echocardiogram
What do the Rinne and Weber tests show in regards to hearing loss? What is the normal finding in each? What finding indicates sensorineural or conductive hearing loss?
Rinne shows whether air or bone conduction is greater Weber shows localization to one side or not Normal Rinne: both ears AC > BC Normal Weber: midline Sensorineural loss Rinne: AC still greater than BC Weber: Will lateralize to UNAFFECTED ear Conductive loss Rinne: BC > AC in the affected ear Weber: Will lateralize to the AFFECTED ear
What Rinne/Weber findings indicate sensorineural hearing loss? What should you management be?
Rinne with AC>BC in both ears Weber lateralize to UNAFFECTED ear need urgent referral to ENT/otolaryngology, MRI, and start corticosteroids
What is caused by human herpes virus 6? What is the typical presentation?
Roseola infantum high fever followed by rash once fever resolves rash starts on neck/trunk and spreads down usually sparing the palms can be associated with infantile seizures
What are 3 side effects of SGLT2 inhibitors? Why?
SGLT2 inhibitors increase the amount of glucose excreted in the urine by blocking reabsorption at the proximal renal tubule side effects of this include polyuria, increased risk of UTIs, and increased risk of vulvovaginal candidiasis aka "the flozins" --> glucose "flows in" to your urine
What is a standardized incidence ratio and how do you calculate it?
SIR is used to determine if the occurrence of a rare disease in a small population is high or low when compared to an expected incidence in larger population SIR = cases observed / cases expected
These medications can be used to treat hot flashes as an alternative to hormone therapy ____________ and __________
SSRIs (escitalopram etc) SNRIs (venlafaxine)
How does seborrheic dermatits present? What about seborrheic keratosis? What is the treatment for each?
Seborrheic dermatitis= erythematous patches with oily scales usually involving areas with many sebaceous glands like the scalp/face/eyebrows --> treat with topical antifungal or shampoo (selenium sulfide, ketoconazole, zync pyrithione) Seborrheic keratosis are little "stuck on" growths that look like pieces of gum. Not usually pre-malignant. No treatment except removal of pesky ones.
How do you calculate a SAAG? How is it used clinically? Name 4 conditions associated with high SAAG and 5 associated with low SAAG.
Serum-Albumin-Ascitic-Gradient SAAG = serum albumin - ascitic albumin SAAG > 1.1 indicates portal HTN (cirrhosis, CHF, hepatitis, Budd-Chiari syndrome). SAAG <1.1 means no portal hypertension is present (peritoneal carcinoma, peritoneal TB, nephrotic syndrome, pancreatitis, serositis). ***Budd-Chiari syndrome is Portal HTN caused by thrombosis of the hepatic veins or suprahepatic inferior vena cava (IVC).
What is Sheehan syndrome and how does it present?
Sheehan syndrome is pituitary gland infarction due to hypotension/massive hemorrhage symptoms are amenorrhea, hypothyroidism, adrenal insufficiency (electrolyte abnormalities, hyperpigmentation)
What elbow fracture would you suspect in a patient with a FOOSH? (fall onto outstretched hand). What are some X-ray findings associated and what is the treatment? What complication do you worry about?
Supracondylar fracture --posterior fat pad on x-ray (occult) --fracture line or displaced humerus Non-displaced--> splint for immobilization Displaced --> reduction with percutaneous pinning Can lead to issues with distal perfusion due to proximity of brachial artery and median nerve. Check for capillary refill and hand flexion.
What should you suspect in a patient who is on immunosuppressant meds and develops low grade fever, dry cough, dyspnea on exertion, and hypoxia? What would you expect to see on CXR and how should you treat it?
Suspect PCP (pneumocystis jiroveci penumonia) and treat with TMP-SMX CXR shows ground glass opacities bilaterally
What should you suspect in a patient with recent severe physical trauma (MVA etc) who develops a GI bleed? How can this be prevented?
Suspect a stress ulcer (head trauma increases gastrin release; shock is associated with mucosal ischemia; also associated with mechanical intubation) and give prophylactic PPI
What causes thrombotic thyrombocytopenic purpura? What is the presentation? How should you treat it?
TTP is caused by formulation of autoantibodies towards ADAMTS-13 --> leads to lack of ADAMTS13 to cleave vWF from the vessel wall which leads to platelet trapping and hemolysis look for increased bruising, fatigue, low platelets, elevated LDH, elevated indirect bilirubin --> can eventually lead to renal failure will see schistocytes on peripheral smear treat with plasma exchange and glucocorticoids and rituximab
What are 3 acne medications that cause sun sensitivity and increased risk of sunburn?
Tetracyclines (doxycylcine, minocycline) Retinoids Benzoyl peroxide
What is the diagnostic criteria for Tourette's disorder? What are the two most common comorbidities? What is the treatment?
Tourettes = multiple motor tics and at least one vocal tic lasting > 1 year ADHD and OCD are common comorbidities treat with antipsychotics, tetrabenazine, behavioral therapy
What would you suspect in a patient with hematuria and flank pain shortly after a URI? What would you suspect if hematuria was 12 days after URI?
URI followed quickly by hematuria = IgA nephropathy --dysmorphic RBCs in urine --usually benign URI with hematuria 10+ days later = postinfectious glomerulonephropathy --urine sediment with RBC casts --complement levels decreased
What ultrasound and PE findings are consistent with posterior urethral valves? What is the workup and treatment?
US: dilated ureters/kidneys and dilated bladder with thickened wall (bladder dilation/thickening is specific) workup is voiding cystourethrogam treat with foley cath insertion until stabilized and then cystoscopy to visualize and remove posterior valves
What are the typical history/findings in fibroadenoma of the breast?
Usually a younger woman with a single breast nodule that fluctuates in size with menstruation often rubbery, mobile, well-circumscribed nodule
A patient presents with hypercalcemia. You test PTH and find it to be low. What are 4 other workups to consider and why?
Vit D level (exogenous intake, granulomatous dz) chest x ray (malignancy, sarcoid) PTHrp (rule out small cell lung cancer causing) serum and urine electrophoresis (Multiple Myeloma)
What are the CSF findings you would expect in Guillain-Barre?
WBC 0-5 Glucose 40-70 Protein 45-1000
What arthrocentesis finding should make you suspect bacterial cause?
WBC > 50,000
What should you suspect in a young patient with simultaneous onset of both liver disease and psychiatric symptoms? What physical exam finding do you look for? What tests do you order?
Wilson's disease impairing copper excretion look for Kayser-Fleischer rings around cornea order serum ceruloplasmin (will be decreased) urine copper excretion (increased)
What is Klinefelter syndrome and how does it present?
XXY (usually spontaneous) usually a male patient with less body hair, poor beard growth, narrow shoulders, long arms, small testicular size
What is the typical presentation of autoimmune hepatitis? What test should you order?
Young to middle age female with other autoimmune findings (thyroid, arthritis, anemia, etc) and elevated AST/ALT but near-normal alk phos and normal bilirubin levels Test for antinuclear antibodies and anti-smooth muscle antibodies
What do phenytoin, carbamazepine, ethosuximide, topiramate, and phenobarb have in common? Name 2 things.
all are anti-seizure medications all cause reduced levels of OCPs
What type of test is best for ruling out a condition and why?
a highly sensitive test (SnOUT) because it will have a low false negative rate highly specific tests (SpIN) are used to rule things IN because they have low false positive rates
What murmur is associated with mitral valve prolapse?
a non-ejection click followed by systolic murmur of mitral regurgitation timing of click varies with body positioning
What would you suspect in a patient with history of alcohol use who presents with ketones in their urine and mildly elevated blood glucose?
alcoholic ketoacidosis give thiamine and then D5NS IV fluids
What is the first line test for appendicitis?
abdominal CT (if pregnant, graded compression US or MRI)
How many patients will have bile-salt induced diarrhea following cholecystectomy? What is the treatment?
about 10% treat with cholestyramine or cholestipol
What should you suspect when a patient has difficulty swallowing both solids and liquids?
achalasia (upper esophageal sphincter with too much tone) could also be something like myasthenia causing weakness of esophageal muscles
This type of tumor that impacts hearing is highly associated with neurofibromatosis type 2
acoustic neuroma / vestibular schwannoma made up of Schwann cells (myelinate peripheral axons)
What are 6 contraindications to breast feeding?
active HIV herpetic breast lesions chemo/radiation active TB active varicella active substance use disorder
How rapidly do you want a woman's cervix to dilate during active labor? What defines this phase?
active labor is when cervix is >6cm dilated should continue to dilate at rate greater than 1cm/2hr most common cause of protraction is inadequate contractions every 2-3 min --> oxytocin + amniotomy
When would oxytocin and artificial rupture of membranes be indicated during the active phase of the first stage of labor?
active phase is defined by cervix > 6cm cervix should continue to progress at 1cm/2hr or more...if not this is protraction and you should give oxytocin and do amniotomy
What should you suspect in a patient who is sexually promiscuous and who develops fatigue, sore throat, myalgias, lymphadenopathy, an oral ulceration, and a diffuse maculopapular rash involving the entire body?
acute HIV infection reaction test viral load, not antibodies
What would you suspect in a patient with acute loss of vision in one eye who also has red eye, headache, pain with eye movement? Try to give 3 topical options for treatment and 2 systemic options.
acute angle closure glaucoma topical: timolol pilocarpine apraclonidine systemic: acetazolaminde mannitol
What antibiotic combo would you reach for in a sickle cell patient with acute chest syndrome? What about with osteomyelitis?
acute chest syndrome: ceftriaxone + azithromycin osteomyelitis: ceftriaxone + clinda/vanc
What is the presentation of acute fatty liver of pregnancy? What about HELLP syndrome?
acute fatty liver of pregnancy generally occurs in the third trimester and causes nausea/vomiting, RUQ pain, and elevated ALT/AST (300-500 level) HELLP syndrome (hemolysis, elevated LFTs, low platelets) usually presents with nausea/vomiting, mid-epigastric pain, HYPERTENSION, PROTEINURIA, and platelets <100,000
What are the two big findings in Goodpasture disease and what are the antibody findings?
acute glomerulonephritis with lung findings like hemoptysis anti-basement-membrane antibodies
What is fomepizole used to treat?
acute metabolic acidosis from ethylene glycol or methanol ingestion
What is the typical presentation of acute mitral regurgitation? What usually causes it?
acute onset of pulomary edema, cardiogenic shock, and hemodynamic collapse usually caused by an MI which leads to rupture of chordae tendonae or papillary muscles
What is required to make the diagnosis of acute pancreatitis? What are 5 risk factors for developing acute pancreatitis?
acute pancreatitis diagnosis requires 2 of 3: --characteristic epigastric pain (radiates to back) --lipase or amylase >3x normal limits --imaging indicating pancreatitis risk factors include: alcohol use, high triglycerides, gallstone disease, high calcium, valproic acid, furosemide
How do renal ischemia, nephrotoxins, and sepsis usually damage the kidneys? What is the associated finding on inspection of the urine?
acute tubular necrosis muddy brown casts
"Muddy brown casts" should make you think of ___________. What are 3 possible causes? How can you distinguish this from a pre-renal cause?
acute tubular necrosis renal ischemia nephrotoxins sepsis do a fluid challenge and if numbers improve it was pre-renal
What is a way to help increase calcium levels in a patient with hypoparathyroidism who is already taking 25,000-100,000 units of vitamin D a day and calcium replacement but who is losing a lot of the calcium through their urine?
add a thiazide diuretic to decrease urinary loss of calcium and increase serum calcium
What are the symptoms, physical exam findings, workup, and treatment of adenomyosis?
adenomyosis: endometrial tissue invasion of the myometrium (uterine muscle layer) symptoms: dysmenorrhea, pelvic pain, heavy menstrual bleeding PE: globally enlarged boggy uterus workup: ultrasound or MRI to show increased thickness of myometrium treatment: hysterectomy is the definitive treatment, but women who have not completed child bearing can start with a progestin (progestin IUD or medroxyprogesterone acetate aka Depo-Provera)
Describe the symptoms and findings in adenomyosis. What about leiomyosis?
adenomyosis: invasion of endometrium into the myometrium (muscle layer) of the uterus causes pelvic pain, heavy menses, globally swollen boggy uterus on exam work up with ultrasound/MRI showing thickened myometrium leimyoma is a uterine fibroid and cause an irregularly shaped uterus on exam...they also lead to dysmenorrhea and heavy bleeding
How should you manage a patient with shingles on their left lower back who returns to clinic with rash also on the right side now?
admit to hospital for IV acyclovir because it is now a disseminated infection can be transmitted through respiratory so until lesions are crusted over use standard, contact, and airborne precautions
How should you manage a woman who presents with her 4th UTI of the year?
advise her to always do postcoital urination, drink cranberry juice, and start antibiotic prophylaxis with either nitrofurantoin, cipro, or SMZ-TMP
If a patient is found to have a villous adenoma on colonoscopy, when should they be scheduled for repeat?
after 3 years
When is nocturnal urination (enuresis) considered abnormal? What is the workup?
after age 5 get a urinalysis
When should you screen smokers for lung cancer? How? What qualifies you?
age 55-80 via low dose CT if they have >30 pack year history (unless they quit over 15 years ago)
What are typical features of polymyalgia rheumatica? What is a lab study to order? How should you treat it?
age > 50 subacute-to-chronic onset (>1 month) pain and stiffness in shoulders and hips symptoms are worse in the morning constitutional symptoms (low grade fever, fatigue) check for elevated ESR treat with low dose steroids
What are 7 "red flags" that you should get imaging for low back pain?
age >50 constitutional symptoms (fever, weight loss) pain worse at night history of malignancy history of IV drug use immunosuppression recent bacterial infection
What are the most important prognostic factors in COPD?
age and FEV1 FEV1<40% indicates a poor prognosis COPD is associated with increased residual volume, but it is not prognostic
What should you suspect in a patient who presents with fever and sore throat who recently started an antithyroid drug?
agranulocytosis (risk of this in the first 90 days) --> get CBC with diff and if it confirms agranulocytosis then stop the methimazole/PTU
What is Pimavanserin used to treat?
aka Nuplazid used to treat psychosis associated with parkinson
What is lichen simplex chronicus and how does it present?
aka neurodermatitis associated with anxiety disorders-->caused by repetitive scratching and rubbing which leads to thickened plaques on the skin (usually easily reached areas like arms, legs, neck)
What do saw palmetto, ginseng, and gingko biloba have in common?
all are herbal supplements that increase bleeding risk
What urine finding indicates chronic prostatitis? What differentiates chronic bacterial prostatitis from chronic prostatitis/chronic pelvic pain syndrome?
always work up suspected chronic prostatitis (sx >3 mos) with a urinalysis and urine culture prior to and after prostate massage finding of 20+ leukocytes indicates chronic prostatitis if urine culture shows bacteria >10x the number prior to prostate massage then it is bacterial if it is aseptic with no growth then it is CP/CPP
Which calcium channel blockers are associated with peripheral edema? What is something you can do to alleviate it?
amlodipine and nifedipine can add small dose of ACE inhibitor to counter edema effect
What defines polyhydramnios? What are 4 things that can lead to this?
amniotic fluid index >24cm maternal DM/gestational DM multiple gestation congenital anomalies
What skin conditions are imiquimod usually prescribed for?
anal/genital warts; actinic keratosis (scaly pre-SCCs); superficial basal cell carcinoma
What should you suspect in a patient with fatigue, nausea, lower extremity edema, and florid proteinuria and WBCs/casts who also has a history of joint pain?
analgesic-induced neuropathy
What should you suspect when working a teenage girl up for primary amenorrhea if she has breast development but no pubic or axillary hair?
androgen insensitivity syndrome patient is actually 46XY
Why might a patient with chronic kidney disease have pale skin and fatigue?
anemia from low EPO production
What do angiodysplasias look like on colonoscopy? What are three conditions commonly associated with a bleeding angiodysplasia?
angiodysplasias are abnormal collections of blood vessels that look like small, flat, cherry-red lesions when they bleed look for: 1. end stage renal disease -- platelet dysfunction 2. aortic stenosis -- loss of VW factor 3. von willibrand disease --loss of VW factor required for platelet aggregation
What are some causes of anion gap metabolic acidosis? How do you calculate anion gap?
anion gap = sodium - (chloride + bicarb) MUDPILES methanol uremia DKA propylene glycol ingestion iron/isoniazid lactic acidosis ethanol salicylates
What acid-base disturbance is caused by ethylene glycol ingestion? How would you treat this or a methanol ingestion?
anion gap metabolic acidosis treat with fomepizole look for kussmauls respiration with rapid deep breathing
What would you suspect if patient with history of ankylosing spondylitis develops: trouble seeing ________________ heart murmur ______________ shortness of breath _____________ episodic hematuria ______________
anterior uveitis aortic regurgitation restrictive lung disease or pulmonary fibrosis IgA nephropathy
What should you suspect as the cause of blurred vision and eye pain in a young African American woman also found to have chronic cough, perihilar lymphadenopathy, and hypercalcemia?
anterior uveitis related to sarcoidosis also look for erythema nodosum
What autoantibody in lupus correlates the best with diseases activity level?
anti-DS-dna is also associated with lupus nephritis
What antibody has the best sensitivity/specificity combo as a screening test for SLE?
anti-doublestranded-DNA anti-DSdna
What are 3 medications used to treat urge incontinence? What class of medications are they? What are a few common side effects?
anti-muscarinic oxybutynin tolterodine solifenacin side effects include dry mouth, dry eyes, blurred vision, and constipation
What should you suspect in a patient with fever, dry mucuous membranes, urinary retention, vision change, and AMS? What is the treatment?
anticholinergic toxicity treat with physostigmine
What should you suspect in a patient with acute pain, diminished pulses, paleness, and coolness of the foot? What is the most likely cause if the patient is young?
arterial occlusion in young patients, usually due to embolic event, not atherosclerotic plaque most emboli are cardiac in origin from atrial fibrillation, left atrial myxoma, endocarditis, or prosthetic valve
What are the typical findings in mono-arthritis caused by Lyme? How should you treat it?
arthritis usually presents months to weeks after Lyme infection --> knee is most common look for afebrile patient who is well-appearing and can bear weight on the joint, but with erythema and localized swelling arthrocentesis usually shows WBC count 20,000-40,000 confirm diagnosis with ELISA or western blot treat with 28 day course of doxycycline or amoxicillin (over 90% of cases resolve)
What is the best way to diagnose gout?
arthrocentesis of inflamed joint showing urate crystals, negative birefringent needle shaped first line treatment is NSAIDs
What should you do when an adolescent expresses a psychosocial concern at a visit?
ask the parents to leave and then investigate more
What should you suspect in an elderly patient with recurrent pneumonia of the right middle/lower lobe? What is the best workup?
aspiration pneumonia get a videoscopic swallow study get blood and sputum cultures and start treatment with something that covers anaerobes like clindamycin
What is the empiric treatment of choice for suspected aspiration pneumonia? What are some clues to this?
aspiration pneumonia --> IV clindamycin think older patient with history of neuro issues; right lower lobe pneumonias; recurrent
What are the findings in Korsakoff syndrome? What would brain MRI show?
associated with Wernicke's encephalopathy significant amnesia and confabulation MRI will show mammillary body atrophy
Why do you want to avoid doxycycline while pregnant or breastfeeding?
associated with tooth discoloration and long bone abnormalities
What is a way to differentiate asthma and COPD on PFT?
asthma has reduced FEV1/FVC but preserved DLCO COPD has reduced FEV1/FCV and reduced DLCO
What PFT findings indicate asthma? Restrictive lung disease? Pulmonary artery hypertension? COPD?
asthma: Reduced FEV1 and FEV1/FVC ratio with preserved DLCO --> bronchodilator should improve by 15%; if patient not in exacerbation at time of PFT can use methacholine to induce reaction restrictive: Reduced total lung capacity; FEV1 and FVC both reduced but proportionally so FEV1/FVC is normal PAH: reduced DLCO with normal lung volumes COPD: Reduced FEV1 and reduced FEV1/FVC ratio but reduced DLCO is still present because of destruction of lung tissues by smoke and/or recurrent infections
When should external cephalic rotation be offered to a woman with a breech presentation?
at 37 weeks or later
When should bone density scanning be recommended?
at age 65 z score >-2.5 is osteoporosis x score -1 to -2.4 is osteopenia
What cardiac outcome are Marfan patients at increased risk for? What genetic change is associated with Marfan syndrome?
at increased risk for dilation of ascending aorta leading to aortic aneurysm and rupture mutation in fibrillin gene
A patient presents due to missed menstrual period and is found to be pregnant with beta hcg >1500 and visible gestational sac. What are the screening tests you should order now? What about at 24-28 weeks? What about at 35-37 weeks?
at time of pregnancy discovery: anti-RhD antibody HIV/HepB/RPR chlamydia screen urine culture CBC thyroid function tests varicella and rubella immunity at 24-28 weeks: CBC (or H&H) Anti-RhD antibody 50 gram 1 hr glucose tolerance test at 35-37 weeks: group b strep swab
What are the symptoms, lab findings, and radioiodine uptake in chronic autoimmune thyroiditis and subacute thyroiditis?
autoimmune/Hashimotos -hypothyroid symptoms and diffuse goiter -labs will show TPO antibody (thyroid peroxidase) -radioiodine uptake is variable subacute/De Quervains -hyperthyroid symptoms and fever usually following a viral illness with painful/tender goiter -elevated ESR & CRP -radioiodine uptake is low
What are the genetics of BRCA?
autosomal dominant -- increases risk of breast or ovarian cancer massively
What is the genetic cause of tuberous sclerosis? What are physical exam findings? What should be your initial workup if you suspect tuberous sclerosis?
autosomal dominant TSC genes look for ash leaf spots (hypopigmented), milestone delays, angiofibromas, shagreen patches, rhabdomyomas initial workup is brain MRI (look for masses) and EEG (seizures kill many patients with TS)
Take a moment to review the findings in Wilson's disease. What is the usual lab abnormality?
autosomal recessive mutation in copper excretion causes rings in eyes, liver disease, psychiatric symptoms treat with copper chelation
What organisms are sickle cell patients at increased risk of infection with? Why?
autosplenectomy means they do not have good defense against ENCAPSULATED organisms
If a patient with pancreatitis cannot keep down any liquids or foods and is starting to have signs of wasting...what is the best way to feed them?
avoid parenteral nutrition during pancreatitis because it is associated with worse outcomes feed via nasogastric tube
What are 4 findings that would concern you for a pathologic etiology on a child who is being diagnosed with scoliosis?
back pain neurologic symptoms rapid progression (>10 degrees further curvature each year) vertebral anomalies on x-ray
What are some medications that can help with spasticity from CP? What is a common comorbid condition?
baclofen and botulinum toxin often patients will also have a seizure disorder
What are the CSF findings for WBC, glucose, and protein you would expect for each of the following: bacterial meningitis TB meningitis viral meningitis
bacterial WBC >1000 glucose <40 protein <40 viral WBC 100-1000 glucose 40-70 protein <100 TB WBC 5-1000 glucose <10 protein >250
What are 5 infectious causes of stroke in young patients?
bacterial meningitis endocarditis neurosyphilis (meningovascular syphilis) varicella-zoster virus tuberculous meningitis
How does croup present and what is the most common cause? How do you treat it?
barking cough with inspiratory stridor in a kiddo due to upper airway inflammation parainfluenza virus is most common cause treat with cool humidified air, inhaled racemic epinephrine, and corticosteroids (dexamethazone)
What causes cat scratch fever and what is the treatment?
bartonella henslae treat with azithromycin
Why should you not just start a patient with osteopenia on bisphosphonates? What would help you decide whether they are needed? What DEXA defines osteopenia?
because there are serious risks of bisphosphonate therapy like pill esophagitis and jaw osteonecrosis get 10 year fracture risk if >3% risk of hip fracture or >10% risk of combined major fracture then give bisphosphonates osteopenia is DEXA scan score between -1 and -2.5
Why should you always check an iron level before starting a patient with chronic kidney disease on EPO for their anemia?
because when you first start EPO it can rapidly use up iron stores in hematopoiesis
How should you manage a patient who develops a clot while on warfarin but who was undercoagulated (INR <1.5)
being under-coagulated does not equal failure of anticoagulation admit for heparin bridge and get them back on warfarin at a therapeutic dose
What are 4 beneficial effects of hormone replacement therapy? What are 5 detrimental effects?
benefits: increase bone mass/lower fracture risk decrease risk of type II DM decrease risk of colon cancer decrease all-cause mortality if under 60 years old detrimental: increase risk of breast cancer increase risk of stroke increase risk of venous thrombosis/DVT increase risk of gallbladder disease increase coronary artery disease after age 60
What defines gestational thrombocytopenia? What is the management?
benign, asymptomatic condition where a woman with no history of low platelets develops thrombocytopenia between 70,000-150,000 platelet count resolves after delivery --> manage with serial CBCs still fine to do an epidural as long as platelet count is above 70,000 and stable
What are some characteristics of a pulmonary nodule on imaging that would make you think it is likely benign? What about characteristics that raise suspicion for malignancy?
benign: popcorn calcification, concentric, central, or diffuse calcification malignant: eccentric, reticular, punctate, or spiculated calcifications raise suspicion for malignancy
What is the best way to work up someone with stable angina? What is the second best?
best is exercise stress test but if they cannot walk, then get a chemical stress test like adenosine myocardial perfusion imaging or dobutamine echocardiography
What is the best measurement of central tendency in a skewed distribution? What does negatively and positively skewed mean?
best measure if distribution is very skewed is the MEDIAN negative skew = tail towards left/negative positive skew= tail towards right/positive
What are 4 medications every patient with heart failure should be on? What should you add as they progress in their disease?
beta blocker ACE inhibitor spironolactone/epleronone furosemide add isosorbide dinitrate
What beta-hcg count is associated with ability to visualize intrauterine pregnancy on TVUS? Why is this important?
beta-hcg > 1500 If woman is having abdominal pain and you cannot see a gestational sac but their beta hcg >1500 then suspect ectopic pregnancy!
What are 2 treatment options for relapsing-remitting MS to reduce frequency of brain lesions?
beta-interferon glatiramer acetate
What is the most common congenital heart disease in adults? What is a physical exam finding? What is the workup and why?
bicuspid aortic valve ejection type murmur right upper sternal border workup includes either CT/MRI or echocardiogram because bicuspid aortic valve increases risk of aortic dilation, thoracic aortic aneurysm, and AAA rupture
What is a "positive Babinski" reflex? When is it normal?
big toe UPGOING and fanning of other digits normal until age 2
What does conjugated bilirubin >20% total make you wary of in an infant? What is the workup?
biliary atresia --> get ultrasound of hepatobiliary tree
This is a focal facial dystonia that causes involuntary closing of the eyelid in response to triggers like airflow, bright light, or irritants _______________. What is the treatment?
blepharospasm treat with botox
What are the symptoms of Paget disease? What are the typical lab and imaging findings? What is the first and second line treatment?
bone pain, bone deformity look for normal calcium but elevated alk phos look for sclerotic bone lesions, thickened cortex treat first with bisphosphonates (alendronate, risedronate, zoledronic acid) --> use calcitonin second line
What are Marasmus and Kwashiorkor? How should you treat a child who presents this way initially?
both are types of severe malnutrition Marasmus = wasting malnutrition Kwashiorkor = edematous treat with rewarming for hypothermia, oral rehydration if able, antibiotics for presumed systemic infection, and very slow refeeding do not go straight to IVF because fluid overload could cause heart failure
When are low radioactive iodine uptake and low thyroglobulin seen? When are high radioactive iodine update and high thyroglobulin seen?
both low --> think exogenous thyroid hormone both high --> think Graves disease
What is the treatment of toxic megacolon in patients with a history of ulcerative colitis?
bowel rest, NG tube, admit to ICU, and give IV glucocorticoids can give prophylactic antibiotics to mitigate risks of possible intestinal rupture hold anticholinergics and opioids bc they may worsen things
What are 2 arrhythmias and 2 electrolyte disturbances that raise the risk of torsades de pointes?
bradycardia, premature ventricular beats low potassium or low magnesium treat with sodium bicarb and transvenous pacing if needed
Name 5 cancers that commonly metastasize to the spinal column
breast lung renal cell carcinoma prostate non-hodgkins lymphoma
Compare breastfeeding jaundice and breastmilk jaundice
breastfeeding jaundice is due to a failure in breast feeding --> leads to impaired excretion of bilirubin and occurs in the first week of life breastmilk jaundice is due to increased levels of beta-glucuronidase in breast milk that deconjugates circulating bilirubin --> occurs after 3-5 days and peaks at 2 weeks--> not dangerous, continue breast feeding (encourage parents spontaneous resolution usually occurs around age 3 months)
What are two options for switching a patient from an SSRI who has developed sexual side effects?
bupriopion or mirtazapine also consider adjunct sildenafil
What type of crystals are seen in painful swollen joints of patients with hereditary hemochromatosis?
calcium pyrophosphate positively birefringent rhomboid shaped crystals
How can you figure out if a patient with a DEXA scan score between -1 and -2.5 needs bisphosphonate therapy? What lifestyle modifications would you recommend?
calculate the 10 year fracture risk if >3% chance of hip fracture or >10% chance of combined major fracture then give alendronate also recommend regular weight-bearing exercise, avoidance of smoking and alcohol, and daily intake of 1200mg calcium daily and 800mg vit D
What are the findings in peripheral artery disease? What is the management?
calf pain with walking alleviated by rest elevated ankle brachial index first start aspirin and a statin and smoking cessation--> then recommend supervised exercise regimen if refractory, can add cilostazol
What is a great test to do to rule out psychogenic coma? Describe how it works and what a "normal" finding is?
calorimetric oculovestibular testing irrigate external auditory canal with cold water --normal response is transient CONJUGATE SLOW gaze deviation TOWARDS stimulus followed by SACCADIC correction to the midline this cannot be voluntarily suppressed which indicates psychogenic coma
Why is nitrofurantoin not a good choice for pregnant women to treat bacteriuria or cystitis?
can be teratogenic in first trimester and is associated with increased risk of hemolytic anemia in newborn in third trimester
Why is the treatment of strep throat 10 days of oral penicillin in children? What is an alternative for a kiddo who can't swallow pills? What about kids with an allergy to penicillin?
can give a single dose of IM penicillin (active for 30 d) can also give 5 days azithromycin
What should you order if a patient presents with sudden onset of severe psoriasis or seborrheic keratosis?
can indicate underlying HIV!!!
How does long-term use of NSAIDs impact the kidney? What is the typical presentation?
can lead to papillary necrosis causing a bump in BUN/creatinine usually patients will have hematuria, proteinuria, and sterile pyuria (WBCs but no bacteria present)
What are the neuro symptoms of B12 deficiency?
can lead to symptoms of dementia including poor memory and unusual behavior--> can even cause ataxia and delirium
What generally causes intertrigo? What are 3 treatment options?
candida infection in the skin folds in an person with immunocompromise (especially DM) treat with topical nystatin, terbinafine, myconazole
What are the 3 medications that should be prescribed to patients with Lewy Body dementia? What if you have to use an antipsychotic?
carbidopa-levodopa cholinesterase inhibitors to improve cognition (rivastigmine, donepezil, galantamine) melatonin for REM sleep disorders if you have to use an antipsychotic reach for quetiapine, not a first gen
How does carbidopa-levodopa work? What about amantadine?
carbidopa-levodopa directly stimulates dopamine receptors amantadine causes increased dopamine release
What is the workup that needs to be done before initiating a stimulant medication for ADHD?
cardiac exam and history baseline weight and vital signs physical exam
What are the symptoms of cardiogenic shock? What may have caused it in a patient being treated for a STEMI?
cardiogenic shock presents as hypotension, JVD, and clear lung fields may be caused by giving nitroglycerin or opioid to a patient with a right ventricular MI optimize preload with IVF to pull them through
What are some clues that an episode of syncope is cardiogenic? What would you suspect as the cause in a patient with history of MI?
cardiogenic syncope usually has no prodromal symptoms (nausea, dizziness, tachycardia) if prior structural abnormality of heart is present (hx of MI, cardiomyopathy) then suspect VT workup is telemetry monitoring and echocardiogram
What is case fatality rate? What is mortality rate?
case fatality rate is the % of people with a certain condition who end up dying from it mortality rate is the probability of dying from a particular disease in the general population so if 2% of the population dies of AIDS then it has a 2% mortality rate...but if 90% of people diagnosed with AIDS die from AIDS then it has a 90% case fatality rate
What is the main measure of outcome in a case-control or cross-sectional study? What about in a cohort study?
case-control or cross-sectional studies use ODDS RATIO cohort studies use RELATIVE RISK
What is the treatment for invasive candidiasis?
caspofungin
Name several common abnormalities caused by congenital rubella
cataracts sensorineural hearing loss patent ductus arteriosus microcephaly
What is the recommended treatment for patients with WPW causing confirmed runs of supraventricular tachycardia, symptoms, etc
catheter ablation
What causes myasthenia gravis? How does it usually present? How is it diagnosed?
caused by antibodies to acetylcholine receptor (post-synaptic NMJ autoimmune disease) presents as fluctuating weakness that greater in arms than legs and fatiguable (get worse with use) along with ptosis, diplopia, dysarthria, and dysphagia diagnose with edrophonium (tensilon) test --> administration should lead to short-term improvement in weakness also be on lookout for a thymoma
What are the two major causes of vulvar cancer? What does it look like and how should you work it up?
caused by chronic HPV infection or chronic inflammation (lichen sclerosus, tobacco use) it will usually look like a single raised red plaque over the vulva get a biopsy to look for malignancy!
What causes functional hypothalamic amenorrhea?
caused by extreme exercise or low weight or stress often seen in elite athletes causes amenorrhea accompanied by delayed breast development
What causes variable decelerations and how should you respond?
caused by umbilical cord compression do amnioinfusion
What are the symptoms of McCune-Albright syndrome? What causes it?
causes precocious peripheral puberty, cafe-au-lait macules with irregular borders, and fibrous dysplasia (bent legs) caused by mosaicism in the GNAS gene
What is the standard treatment for community-acquired pneumonia requiring hospitalization?
ceftriaxone and azithromycin
Anti-endomysial IgA antibodies are associated with__________
celiac disease also anti-tissue-transglutaminase
If you start a patient on levothyroixine for autoimmune hypothyroidism and they do not show a response despite increasing dosages, what is another autoimmune dz to suspect? What are 2 antibody tests that would show this diagnosis?
celiac disease causing malabsorption test for anti-tissue transglutaminase and anti-endomysial IgA antibodies
What is the most common cause of cellulitis? What about abscess? How should you treat each?
cellulitis --> strep pyogenes (cephalexin) abscess --> MRSA (vancomycin/clinda)
What would you suspect in a patient with cardiovascular risk factors who suddenly has a painless loss of vision in one eye? What are the fundoscopic findings?
central retinal artery occlusion (biggest risk factor is carotid atherosclerosis but also associated with cardiogenic embolism, clotting disorders, and vasculitis like giant cell arteritis) fundoscopy shows pale fundus with a "cherry red spot"
Which lung cancers like the middle and the periphery? What is a common sequelae caused by both of the central ones?
central: small cell carcinoma; squamous cell carcinoma small cell --> SIADH squamous cell --> PTHrp causing hypercalcemia peripheral: large cell carcinoma
What would you diagnose in a patient with unexplained hives >6weeks. How should you treat it? What is the outlook?
chronic urticaria triggered by mast cell activation and histamine release in upper epidermis treat with daily second gen antihistamine (lorantadine, cetirizine) and avoidance of triggers most patients have resolution in 2-5 years but more severe cases and those linked to hashimotos last longer
What is the treatment for H. Pylori?
clarithromycin PPI either amoxicillin or metronidazole
Describe the findings in aortic coarctation? Who is most likely to have this malformation? What is it associated with? What test confirms the diagnosis?
claudication with exercise elevated right upper extremity BP decreased lower extremity BP delayed distal pulses heart murmur most commonly spontaneous in boys, but also associated with Turner's Syndrome in girls echocardiogram confirms dx (CXR can show rib notching and "figure 3" sign but isn't definitive)
How would you treat a woman who develops a fever 2 days after delivery of her child with physical exam showing uterine fundal tenderness and increased vaginal bleeding/lochia?
clindamycin and gentamicin most likely endometritis
How is shingles diagnosed? What would you look for? What causes it?
clinically --> look for a rash preceded by pain in distribution of a dermatome that develops fluid-filled blisters caused by reactivation of varicella-zoster in the dorsal root ganglion treat with oral valacyclovir
What should you suspect in a patient with multiple headaches per day lasting under 1 hour who on physical exam has a watery eye?
cluster headache inhaled oxygen verapamil
___________ should be the first line treatment for insomnia
cognitive behavioral therapy
What are some signs of B12/folate deficiency?
cognitive impairment (may mimic dementia) reduced vibratory sense (less balance) positive romberg hyperreflexia spastic paresis
What workup should be done 6-8 weeks after diverticulitis?
colonoscopy to rule out malignancy don't get colonoscopy while diverticulitis is flaring because of increased risk of rupture treat with clear liquids and IV cipro + flagyl
When you are determining management of a patient found to have HSIL, when would going directly to LEEP be okay?
colposcopy or LEEP is indicated for HSIL LEEP can be considered in women over age 25 who have completed childbearing
What is the best approach to treatment in a patient with head and neck cancer that has been deemed inoperable by surgery?
combination chemo and radiation
What are the first and second line treatments for comedonal acne? What about inflammatory acne?
comedonal: first topical acids; then topical retinoids (ask about pregnancy plans before doing retinoids) inflammatory: topical retinoids + benzoyl peroxide --> then progress to systemic clindamycin/erythromycin
Name 2 common patient groups needing antibiotics before a dental procedure. Try to name 3 less common groups. Which antibiotic would you use and why?
common: artificial valve or hx of endocarditis uncommon: valve issue in transplanted heart, unrepaired congenital heart dz, repaired congenital heart dz with residual defects give amoxicillin bc it has good action against viridans strep
What do these types of cancer have in common: breast, lung, prostate, renal cell carcinoma, non-hodgkins lymphoma
commonly metastasize to spine
What is required for a patient to meet criteria for home health care?
complex medical condition limiting ability to leave their home must be homebound which means cannot leave home without assistance, have to use walking device like cane/walker/wheelchair
What should you suspect in a newborn who has head circumference in the 98th percentile but length/weight in the 40th percentile and who also has jaundice and diffuse blue spots on skin? What medications should you give (3)
congenital toxoplasmosis brain imaging will likely show intracranial calcifications treat with pyrimethamine and sulfadiazine with supplemental folate
What are 4 important protective factors against suicide?
connection to friends or family pregnancy parenthood religious/spiritual belief
What does consistent RBC count on consecutive tubes mean during a lumbar puncture? What if the RBCs decrease with each tube?
consistent --> worry about subarachnoid hemorrhage decreasing --> indicates a traumatic tap
What exercise advice should you give people with back pain?
continue moderate exercise no indication for physical therapy
What are 3 factors that predict higher risk of AAA rupture?
continued smoking size > 5.5cm growing more than 0.5cm in 6 months
Describe the murmur associated with PDA
continuous machine like whirring
What should you give a woman who goes into labor prior to 37 weeks gestation?
corticosteroids --> mature fetal lungs magnesium --> reduce risk of cerebral palsy
What defines chronic cough in a child? What is the initial workup?
cough lasting longer than 4 weeks workup is spirometry and CXR
What would you suspect in child with a hoarse cough, noisy inspiration, and a "steeple sign" on x ray of neck?
croup caused by parainfluenza give humidified cool air, inhaled racemic epi, and dexamethazone
What should you suspect in an HIV positive patient with headache, nuchal rigidity, elevated CSF opening pressure and rash of umbilicated papules?
cryptococcal meningitis!!! treat with amphotericin B and flucytosine
What are 2 contraindications to starting naltrexone to reduce alcohol cravings? What is a second first line medication option?
current drinking hepatitis or liver failure
What should you suspect in a 17 year old female with recurrent pneumonia, episodes of GI distress, and a history of meconium ileus as a newborn? How would this change your antibiotic regimen for a pneumonia?
cystic fibrosis from CFTR detalF508 mutation! treat with vancomycin + cefepime/ceftazidime + amikacin/tobramycin
What should you suspect when a patient has tongue deviation on protrusion following carotid endarterectomy?
damage to the hypoglossal nerve on the same side the tongue is deviating towards
What are 2 things that decrease thyroid binding globulin decreasing needed Synthroid dose? What are 5 things that increase TBG binding increasing needed Synthroid dose?
decrease TBG: corticosteroids and androgens increase TBG: estrogen, tamoxifen, ramoxifene, heroin, methadone
What are the findings in an acoustic neuroma? What type of cell is it made up of? What is a condition highly associated with acoustic neuromas?
decreased hearing +/- headache cerebellopontine angle mass made up of Schwann cells (schwannoma) --> schwann cells usually responsible for myelinizing peripheral neuron axons highly associated with neurofibromatosis (look for subcutaneous nodules, ash spots, family hx)
What causes galactosemia? What are the symptoms?
deficiency of galactose-1-uridyl transferase infant with repeated vomiting, hypoglycemia, dehydration
What are the findings in porphyria cutanea tarda?
deficiency of uroporphyrinogen decarboxylase leads to painless blisters, increased fragility of skin on back of hands, hyperpigmentation, and hypertrichosis of face (this is where werewolf legends came from) advise avoidance of ethanol and estrogen as these can be triggers treat with phlebotomy or hydroxychloroquine associated with Hep C
What is the definitive way to diagnose sarcoidosis? What are characteristic symptoms, physical exam findings, and imaging findings?
diagnose via biopsy showing non-caseating granulomas (try to get biopsy from lymph node, but can do flex bronch if needed) symptoms: erythema nodosum, fatigue, joint pain, dyspnea, facial nerve palsy PE: hilar lymphadenopathy, uveitis, enlarged liver
What are two situations in which an abdominal aortic aneurysm should be repaired?
diameter > 5.5 cm rapidly growing by over 0.5cm in 6 months
What are the first line antibiotics for lactational mastitis
dicloxacillin and cephalexin
What are some causes of anemia with normal MCV? How would you differentiate them?
differentiate with reticulocyte count low retic: leukemia aplastic anemia infection medications causing myelosuppression elevated retic: hemolysis hemorrhage
What is the EKG finding in pericarditis?
diffuse ST elevation with PR depression
What neuroimaging finding is associated with Alzheimer's dementia? What causes these changes?
diffuse cortical atrophy look for amyloid plaques and neurofibrillary tangles
What should you suspect in a 17 year old patient with sore throat, fatigue, and fever who is found on PE to have cervical lymphadenopathy and spots of grey exudate on the throat? What is the treatment? What complication could be life-threatening?
diphtheria treatment is erythromycin or penicillin G worry about myocarditis, kidney disease, neuritis
What should you suspect in a patient who developed vision change that later went away, then had trouble walking for a while but it got better, and who now has pain with eye movement?
discrete neuro symptoms that are separated by periods of normalcy should make you suspect MS!! get MRI to look for periventricular white matter lesions
What class of antihypertensives has been most associated with drug induced pancreatitis? Give 3 examples
diuretics are most associated HCTZ, chlorthalidone, furosemide
What is your next step in the workup of an elderly patient with an MMSE of 23/30, history of alcohol use disorder, and concern from family for dementia?
do routine dementia labs: CBC, CMP, TSH, B12 also check folate because of alcohol use history also get a CT scan or MRI of brain
What should you do in a patient with confirmed cryptococcal meningitis who is worsening with increased AMS, nausea, vomiting, and lethargy
do serial lumbar punctures cryptococcal fungi can clog arachnoid villi to where CSF cannot drain causing hydrocephalus sometimes you have to place a VP shunt
What causes Gerstmann Syndrome (difficulty doing math, inability to name fingers, difficulty writing, trouble with "Right vs Left")
dominant parietal lobe lesion
What defines orthostatic hypotension? Name 3 drugs that are known to cause this side effect often.
drop >20 systolic or >10 diastolic in BP when standing accompanied by increase in pulse known to occur with: diuretics alpha blockers nitrates
What are the treatments for: primary, secondary, early latent (<1 yr) syphilis tertiary/neurosyphilis latent syphilis of unknown duration
early syphilis (primary, secondary, <1 yr) should be treated with a single dose of IM penicillin G tertiary/neurosyphilis requires IV aqueous crystalline penicillin G for 10-14 days patients with latent syphilis of unknown duration should get IM penicillin G weekly for 3 weeks
This is a parasitic infection that often causes liver cysts ____________ what are the typical imaging findings?
echinococcus imaging usually shows a cyst with fluid, septations, and peripheral calcifications
What is effect modification bias? How can you try to reduce it?
effect modification bias is when an extraneous variable changes the strength or direction of an association in a study you can reduce by stratification of the population into groups which have and don't have the extraneous variable
What are the hallmarks of a collateral ligament injury in the knee? What test should you do to differentiate medial vs lateral?
effusion uncommon medial: instability with lateral movement; valgus laxity lateral: instability with medial movement; varus laxity
What are 2 bugs commonly found in human bites? What is the treatment?
eikenella corrodens (anaerobe) staph aureus treat with amoxicillin-clavulanate
Describe the murmur of aortic/pulmonic valve stenosis
ejection click followed by crescendo-decrescendo systolic murmur
What is the typical PE finding that indicates bicuspid aortic valve? What is the recommended management/workup?
ejection murmur or click get transthoracic echo and recommend first degree relatives do the same
Why should you get a CT/MRI/echo on any patient found to have bicuspid aortic valve? What is the murmur?
ejection murmur upper right sternal border increased risk for aortic dilation leading to aneurysm or rupture
What lab finding indicates a higher risk for neural tube or ventral wall defects? What is the next step in workup? What about if that is inconclusive?
elevated AFP first repeat the test--> if still elevated do US for anatomy scan --> if inconclusive do amniocentesis for AFP level
What does an elevated AFP in a pregnant woman indicate? What about a low AFP? What is the workup?
elevated AFP indicates possible neural tube defect or ventral wall defect (can also be high in multiparity) work up elevated AFP with repeat test and if still elevated do ultrasound for anatomy scan --> if inconclusive then get amniocentesis for AFP low AFP indicates possible aneuploidy (trisomy 18 or 21) work up low AFP with amniocentesis for karyotyping
What are the 3 criteria for acute liver injury?
elevated AST/ALT INR >1.5 encephalopathy
What defines subclinical hypothyroidism? What is the next step in workup? When should it be treated?
elevated TSH and normal free T4 check anti-TPO for Hashimoto's treat if high anti-TPO, symptoms of hypothyroidism, or growing goiter
What lab findings indicate cholestasis?
elevated alk phos (out of proportion for normal gallbladder disease) elevated bilirubin
What finding on maternal labs is suspicious for neural tube defect?
elevated alphafetoprotein confirm with ultrasound
What would you suspect as the cause of polycythemia in a patient with elevated carboxyhemoglobin? What about in an obese male with Sp02 of 95% on exam? What about in an older patient with Sp02 of 94% on exam?
elevated carboxyhemoglobin = SMOKER with carbon monoxide toxicity obese male with slightly low O2= OSA older patient with low O2= COPD etc
How does acute glomerulonephritis usually present?
elevated creatinine hypertension heamturia with dysmorphic red cells + RBC casts proteinuria arthralgia or rash may also be present
What LP findings indicate subarachnoid hemorrhage?
elevated opening pressure xanthrochromia (yellow-pink tint) RBCs that do not decrease in number with serial vials
What are 4 CSF findings associated with bacterial meningitis?
elevated opening pressure neutrophilic leukocytosis high protein low glucose
What is the most common embolic source in young patients?
emboli lead to arterial occlusion most common source in young patients is the heart so look for atrial fibrillation, endocarditis, valvular disease, or left atrial myxoma
What causes pseudohypoparathyroidism? What are the usual lab findings?
end-organ resistance to PTH elevated phosporous and PTH with low calcium low calcium causes tetany, bilateral cataracts, seziures, cramping, hyperreflexia, QT prolongation, psychosis
What is the workup of a 52 year old woman who is experiencing hot flashes, has not menstruated in 4 months, and now has vaginal bleeding?
endometrial biopsy in any woman over age 45 with abnormal uterine bleeding
What condition should you suspect in a younger female patient with dysmenorrhea, deep pelvic pain with intercourse, dyschezia (straining with stools), and infertility? What would be your first line treatment?
endometriosis first try NSAIDs + OCPs
What are 3 emergent things to think about doing in a patient with a bleeding esophageal varices?
endotracheal tube placement CBC and type/screen get 2 large bore IVs in place GIVE IV OCTREOTIDE to decrease splanchnic bloodflow
How does breast engorgement usually present? What would differentiate it from lactational mastitis? What is the firstline treatment for each?
engorgement is usually bilateral swelling and tenderness of breasts --> treat with cold compresses, NSAIDs, and and pumping lactational mastitis usually fever, redness, unilateral, possible fluctuance --> treat with dicloxacillin or cephalexin
What is the typical presentation of a basal cell carcinoma?
enlarging fleshy nodule with rolled edges and ulceration
If a patient with history of cancer presents to your office complaining of back pain that wraps around her sides, difficulty walking well, and loss of sensation in her feet what should you suspect? What would you do?
epidural spinal cord compression from mets give IV corticosteroids (especially dexamethasone), get an MRI, and call the surgeon
How does biliary cholic present? What is the workup?
epigastric or right upper quandrant pain worsened by eating +/- vomiting usually radiates to back and right shoulder work up with transabdominal ultrasound
What is the classic triad of symptoms in pheochromocytoma? What are the steps in workup?
episodic headache, sweating, and tachycardia first get plasma metanephrines or 24 hour urinary catecholamines and metanephrines then get MRI/CT abdomen to look for adrenal masses
What is a complication of GERD that can cause obstructive aphasia? What type of symptoms do patients complain about?
esophageal erosion can lead to stricture patients complain about dysphagia to solids "food sticking in my chest" and that they have to take small bites, chew well, and drink more to get food down (this is in contrast to achalasia which causes dysphagia to both solids and liquids)
Thrombosis of which vein usually leads to esophageal varices? What is the associated history? Thrombosis of which vein usually leads to gastric varices? What is the associated history?
esophageal varices --> portal vein thrombosis from cirrhosis gastric varices --> splenic vein thrombosis from pancreatitis
How does pregnancy increase demand for levothyroxine?
estrogen and pregnancy both increase thyroid binding globulin
What are 5 things that increase thyroid binding globulin? Why is this important?
estrogen, tamoxifen, raloxifene, heroin, methadone matters because you will need to increase dose of thyroid supplementation
What is the first line treatment for absence seizures?
ethosuximide
What CT findings would you expect to see in a patient with allergic bronchopulmonary aspergillosis? What history would you expect? What is your workup and treatment?
expect to see bilateral upper lobe infiltrates, atelectasis due to mucus plugging, and prominent bronchial markings/thickening do aspergillus skin reaction test and measure IgE treat with glucocorticoids + itraconazole/voriconazole
What is one of the leading causes of acute dissection of the ascending aorta in young people? How should you lower their blood pressure?
extreme hypertension from cocaine use lower BP with benzos and nitroglycerin
What is the big differentiator on physical exam between Bell's Palsy and an upper motor neuron lesion?
eyebrow involved = GOOD = Bell's palsy eyebrow spared = BAD = UMN lesion
A patient presents with a "funny feeling" in their face and on physical exam their mouth is downturned on one side and their facial muscles are drooping. What PE finding tells you whether to get imaging or treat supportively?
eyebrow sparing indicates intracranial lesion needing CT/MRI eyebrown involvedment indicates Bell's Palsy and you can treat with prednisone, eye drops, and eye patching
What are the manifestations of Sturge-Weber syndrome?
facial port wine stain leptomeningeal angiomatosis (venous malformations) dx with MRI brain
What should you suspect when an immuno-competent patient develops recurrent polymicrobic bacteremia? Who is this disorder most common in?
factitious disorder more common in women and healthcare workers
How can you calculate false positive and false negative rates from sensitivity and specificity?
false positives = 1-specificity false negatives = 1-sensitivity
What are the blood sugar goals for women with gestational diabetes for fasting and 1 and 2 hours after meals? What are 3 agents that are approved for treating GDM?
fasting <95 1 hour < 140 2 hours < 120 insulin, metformin, glyburide
What are 4 factors associated with a terminally ill patient requesting physican assisted suicide?
fear of future pain/suffering loss of autonomy loss of dignity loss of ability to engage in pleasurable activities
This type of hernia has a very high risk of strangulation __________________. Why should you refer to surgery early?
femoral hernias have high risk of strangulation want to do early surgery because the risk of strangulation is highest when hernia is small
What is a test you can run in a patient with preterm contractions to decide the risk of preterm delivery?
fetal fibronectin
What causes late decelerations in fetal tracings?
fetal hypoxia
How should you manage a patient who developed fever after administration of their last round of childhood vaccinations?
fever and rash are not contraindications to future vaccination do not give acetaminophen as it may reduce the immune response to the vaccine and cause less immunity
Describe how hyperthyroidism should be managed medically in pregnancy and explain why.
first trimester: propylthiouracil because methimazole can be teratogenic second and third trimesters: switch back to methimazole because PTU can cause hepatotoxicity DO NOT USE BETA BLOCKERS IN PREGNANCY RADIOACTIVE THYROID ABLATION IS ABSOLUTELY CONTRAINDICATED --> it can kill the fetal thyroid
What is the best treatment (give two options) for chest pain and hypertension arising from cocaine use? Why?
first try an IV benzo (probably lorazepam) and then if refractory give nitroglycerin Never give a beta blocker in setting of cocaine use because of unopposed alpha vasoconstriction
What should you try first for symptomatic bradycardia? What if that doesn't work?
first try atropine if refractory then go to transcutaneous pacing
What is the treatment for a human bite and why?
first, debride and irrigate the wound do not close with sutures unless facial injury--> healing by secondary intention has improved outcomes give amoxicillin-clavulanate to treat staph aureus and eikenella corrodens
What are the 3 firstline treatments for diabetic neuropathic pain? What are 2 other options?
firstline: duloxetine vs pregabalin vs TCA can also use gabapentin or carbamazepine
What are 3 ways to treat a nosebleed that is refractory to nostril pinching? What order would you try them in?
firstline: topical vasoconstrictor (oxymetazoline) second: silver nitrate or electric cautery third: anterior nasal packing
What are some physical exam findings consistent with endometriosis? What would you reach for first to treat?
fixed, immobile uterus pain with lateral motion of cervix adnexal masses uterosacral nodularity but often physical exam is normal first try treating with OCPs and NSAID
What are the physical exam findings that would support a suspicion of endometriosis?
fixed, immobile uterus (due to adhesions) rectovaginal nodularity adnexal mass
What is the treatment of choice for painful metastatic disease of the bone from underlying prostate cancer who has not responded to analgesics?
focal external beam radiation therapy
What does focal radioiodine uptake in the thyroid represent? What about patchy uptake? Poor uptake? Diffusely increased uptake?
focal with a "cold" background--hyperfunctioing thyroid adenoma patchy--multinodular goiter poor--subacute thyroiditis (painful goiter, recent virus, release of stored thyroid hormone); painless thyroiditis (aka "silent"); iodine-induced thyroiditis Diffusely increased uptake--Graves disease (thyrotropin receptor autoantibodies that stimulate iodine uptake and thyroid hormone synthesis)
What are 2 causes of macrocytic anemia (elevated MCV)?
folate deficiency B12 deficiency
What is the preferred workup of suspected pneumothorax in the acute setting (ED or ICU) or with an unstable patient?
forget chest x-ray because it takes too long and requires the patient to stand up! get ultrasound of the lungs--> look for sliding of the pleural layers...if absent this confirms pneumothorax and proceed with needle thoracostomy
What injury usually results from a fall onto an outstretched hand? What are 3 common complications?
fracture of distal radius (colles fracture) increases risk of ulnar styloid fracture, scaphoid fracture, and carpal tunnel syndrome
What is a Colle's fracture? What is the workup?
fracture of the distal radius sustained via FOOSH besides x-ray and treatment of the fracture, this indicates increased risk for osteoporosis so any patient with this fracture should have bone density tests 3 associated outcomes: ulnar styloid fracture, hidden scaphoid fracture, development of carpal tunnel syndrome
What is the best way to monitor thyroid functional status in a patient with Graves disease?
free T3 and T4 TSH may remain inappropriately suppressed for several months after treatment and thyroid stimulating antibodies may persist
What is the common adverse effect of each: ginseng black cohosh st johns wart gingko biloba kava saw palmetto
ginseng: increased bleeding risk black cohosh: liver damage st johns wart: hypertensive crisis, serotonin syndrome (if combined with SSRI), blocks anticoagulants gingko biloba: increased bleeding risk kava: severe liver damage saw palmetto: increases bleeding risk
How should you approach scheduled vaccinations for a child whose mother is currently pregnant?
give all vaccines as scheduled; pregnant women should not receive live vaccines but their household members can live vaccines: varicella, rotavirus, measles, mumps, rubella
A patient presents with active bleeding who is on warfarin....how should you reverse it?
give prothrombin complex concentrate and vitamin K
A 52 year old male patient presents to your office for 3 weeks of upper abdominal pain. He reports an 8 lb weight loss and nausea occurring most nights. There is a history of gastrinoma in his uncle. Physical exam is benign. What is the workup and why?
go for endoscopy due to "red flag" history --weight loss --persistent nausea --family history of GI malignancy Other "red flag" symptoms that would warrant endoscopy: --overt GI bleeding --unexplained iron def anemia --palpable abdominal mass --persistent dysphagia
What is your suspicion when a young male presents with penile pain and painful urination and exam shows purulent fluid? What would you expect to see on fluid staining? What is the treatment?
gonococcal urethritis (purulent fluid) expect stain to show intracellular gram negative diplococci treat with ceftriaxone + azithromycin
What are the urethral fluid and stain findings in gonococcal urethritis? What about non-gonococcal?
gonococcal: purulent fluid stain shows intracellular gram negative diplococci treat with ceftriaxone plus azithromycin non-gonococcal: watery scant fluid aseptic stain with leukocytes present treat with azithromycin
What disease is associated with negatively birefringent needle shaped crystals? What is the first line treatment? What should be added for patients with recurrent gout attacks or tophi?
gout treat with NSAID like indomethacin If patient has contraindication to NSAID use colchicine recurrent attacks/tophi --> give allopurinol to lower urate
How does optic neuritis generally present? What are the fundoscopic findings? How should you treat it?
gradual progressive loss of vision in one eye associated with pain with eye movement fundoscopy shows optic disc edema treat with IV corticosteroids
What does bartonella henslae cause? Give the common clinical picture and treatment
gram negative bacilli that causes cat scratch disease child with cat and fever who has a swollen lymph node and papular rash at site of cat scratch treat with azithromycin
Describe the murmur associated with hypertrophic cardiomyopathy
harsh crescendo-decrescendo murmur that is systolic and increases with Valsalva
Describe the murmur associated with ventricular septal defect
harsh holosystolic murmur +/- palpable thrill
What defines neonatal polycythemia? What are risk factors for development (try to name 6-7)? What is the first step in workup?
hematocrit > 65% can be caused by maternal smoking, maternal HTN, maternal DM, twin-twin transfusion syndrome, delayed cord clamping, thyroid disorder, or genetic trisomy first step is to get a peripheral venous blood draw to confirm hematocrit is really over 65%
What should you suspect in a child who had a diarrheal illness recently and now has anemia, increased indirect bili, low platelets, and elevated creatinine?
hemolytic uremic syndrome caused by shiga-toxin producing E-coli
What should you suspect in a younger female on OCPs who develops occasional right flank pain and is found to have a liver mass but has normal LFTs?
hepatic adenoma (OCPs raise risk) discontinuing the OCP can lead to resolution fine to do watchful waiting on masses <5cm only 10% transform to malignancy --> monitor with serial imaging and alphafetoprotein
What malignancy kills 30-40% of patients with hereditary hemochromatosis?
hepatocellular carcinoma
What lab findings do you expect in Vitamin D deficiency?
high parathyroid hormone but low phosphorous and calcium
What are 5 patient groups that are considered high-risk cardiac conditions needing prophylaxis for bacterial endocarditis? What are the procedures they would need it for?
high risk conditions: prosthetic heart valve history of infective endocarditis valve abnormality in a transplanted heart unrepaired cyanotic congenital heart disease repaired congenital heart dz with residual defect procedures needing ppx: dental procedures (amoxicillin) GI procedure with ACTIVE INFECTION (ampicillin) surgery on infected skin or muscle (vancomycin) surgery to place prosthetic heart valve (vancomycin)
What is the workup for suspected pheochromocytoma? What malignancy is it highly associated with?
highly associated with medullary thyroid cancer workup is plasma metanephrines followed by confirmatory 24 hr urine metanephrines and abdominal imaging
What does a highly accurate test do? What does a test with high validity do?
highly reliable tests mean the result is reproducible (consistent results, but may not be accurate) high validity tests mean the result is accurate
What are 3 lab abnormalities associated with Cushing syndrome? What physical findings would you expect? What is the workup and treatment?
hyperglycemia hypokalemia metabolic alkalosis you would expect to see moon face, edema, thin skin, striae, buffalo hump, large abdomen, mood swings look for an adrenal, pituitary, or ectopic source of corticosteroids and treat accordingly
What is the cause of stress incontinence?
hypermobility of the urethra usually caused by longstanding increased intraabdominal pressure
What are 4 risk factors for carotid artery dissection? What are some symptoms you might see?
hypertension smoking connective tissue disease recent infection look for Horner syndrome (ipsilateral miosis and ptosis), focal weakness, transient loss of vision, unilateral head/neck pain
What are some of the common symptoms of Cushing syndrome? How would you diagnose it?
hypertension, hyperglycemia, osteopenia, weight gain, striae, mood swings, hypokalemia, and metabolic alkalosis diagnose with overnight dexamethasone suppression test or 24 hour urinary free cortisol normal means serum cortisol will be <3 after dexamethasone suppression test
What is a common adverse effect of st johns wart? What are some meds it interacts with?
hypertensive crisis interacts with SSRIs (serotonin syndrome) and anticoagulants (reduces INR)
A patient presents with shortness of breath on exercise and is found to have a family history of sudden cardiac death and a thickened interventricular septum. What is your first line medication? What about second line?
hypertrophic cardiomyopathy start with metoprolol second line is verapamil or disopyramide
What should you suspect when a patient with multiple myeloma develops headache, vision change, and sensory changes?
hyperviscosity syndrome and impaired platelet function get rapid plasmapheresis
What should you suspect in a patient who received multiple blood transfusions who is having muscle cramps, hyperreflexia, and who hand draws up when you attempt to take BP? What is the treatment?
hypocalcemia treatment is calcium chloride or calcium gluconate
What electrolyte abnormality can be caused by HCTZ?
hyponatremia
What are the lab findings associated with the most common congenital adrenal hyperplasia?
hyponatremia ("salt wasting") hyperkalemia (lack of aldosterone) hypoglycemia (lack of cortisol) 21-hydroxylase deficiency 17-hydroxyprogesterone will be high also remember ambiguous genitalia in girls and precocious puberty in boys
What lab abnormality should you be on alert for when a patient is taking oxcarbazepine?
hyponatremia due to inappropriate release of ADH
What electrolyte disturbances are associated with refeeding syndrome?
hypophosphatemia hypokalemia can lead to breathing difficulties and arrhythmias
What is the presentation of Legg-Calve-Perthes disease? What is the workup?
idiopathic avascular necrosis of the hip child age 3-12 with insidious hip pain and limp deformity of femoral head on MRI/XR treat with surgery, bracing
What is the indication for DVT treatment/prophylaxis in a patient who develops and idiopathic DVT? What about a patient who develops DVT due to surgery/trauma/pregnancy?
idiopathic: Indication for at least 6 months anticoagulation with warfarin etc secondary: Indication for 3-6 months anticoagulation
When should you start a patient with low TSH but normal T3/T4 on antithyroid meds?
if TSH <0.1 or if they are elderly with heart disease, osteoporosis, etc if mild reduction in TSH can monitor with T3/T4 level checks every few weeks
What are the first, second, and third line treatments for nosebleed?
if nostril pinching for 10 mins does not stop bleeding: 1. topical vasoconstrictor use with cotton pad (oxymetazoline) 2. silver nitrate or electrical cautery 3. anterior nasal packing as last result
When is it safe for a patient who has recently had an MI to resume sexual activity given they can perform light-intensity exercise without symptoms? What if they are high risk (refractory angina, class IV heart failure, significant arrhythmia, severe valvular disease)?
if patient can tolerate light intensity exercise without symptoms they are low-risk and can resume sexual activity within 3-4 weeks of procedure high risk need a detailed clinical assessment intermediate need an exercise stress test first
When is a platelet transfusion indicated in a patient with GI bleed?
if platelets are <50,000
What is the treatment of choice for shingles?
if present within 72 hours of symptom onset then give 7 day course of oral valavcyclovir
When should a boy with undescended testicle be referred for surgery? Why should this be done?
if still undescended by age 6 months then refer for orchiopexy reduces risk of testicular torsion, inguinal hernia, and infertility risk of malignancy remains increased in that testicle, but now it will be able to be monitored with testicular exams
What is the postexposure prophylaxis for healthcare workers exposed to varicella?
if varicella immunocompetent (prior varicella infection or hx of 2 vaccinations) then no treatment needed if no evidence immunity then give varicella vaccine within 5 days of exposure if no evidence of immunity and person is pregnant or immunocompromised then give varicella IVIG or valacyclovir
What is the management of a suspected STEMI in a rural setting without access to PCA?
if you can get them transferred to somewhere with PCA within 120 minutes then transfer if not then give fibrolytic therapy (tenecteplase, alteplase, reteplase)
Why is the first step in evaluating papilledema neuroimaging and not lumbar puncture?
if you do an LP on someone with increased ICP and they have a mass lesion it could cause brainstem herniation
What is the appropriate management of a sharper object stuck in the esophagus (fish bone, chicken bone, toothpick, etc)?
immediate endoscopy to remove and lessen chance of esophageal perforation
What is lichen planus? What is it associated with?
immune-mediated skin disorder that primarily affects middle age adults and causes very pruritic, shiny, purple/violaceous, plaques and papules most frequently on the flexural surfaces of the extremities associated with liver disease, especially advanced Hepatitis C
How does ecthyma gangrenosum usually present? What is the managment?
immunosuppressed patient with low neutrophil count bacteria invade adventitia of artery/veins and cause ischemic necrosis --> look for rapidly expanding painless red macules that turn into ulcers with purulent material and red edges treat with IV antibiotics --> most commonly caused by pseudomonas so give piperacillin-tazobactam and gentamicin
How should you manage a patient with hypertrophic cardiomyopathy, a family hx of sudden cardiac death, and a personal history of syncope while exercising?
implant a cardioverter/defibrillator
When would you instill methylene blue in to the bladder to work up incontinence?
in a woman where you are worried about a vesicovaginal fistula (symptom most common is constant dribbling of urine) instill methylene blue into the bladder then place a tampon in the vagina...if tampon becomes blue at all that is a positive test
What is the inactive form of vitamin D? What converts it to the active form?
inactive form is 25,hydroxyvitamin D then PTH converts it to 1,25-dihydroxyvitamin D
What is polymyositis? How does it present? How do you diagnose it?
inflammatory myopathy usually presents with weakness of proximal muscles, elevated CK, elevated ALT/AST, and positive inflammatory markers (CRP/ESR) usually there is not significant pain patients may have anti-nuclear antibodies or Anti-Jo, but definitive diagnosis is via muscle biopsy treat with methotrexate, azathiopurine, or corticosteroids
How does dermatomyositis present? What underlying condition should you think about?
inflammatory myopathy (muscle pain) with heliotrope rash (purple around eyes) and gottron papules (lesions on fingers) dermatomyositis is associated with underlying malignancy, especially of the lung, colon, and ovary treat with glucocorticoids
How does disufiram help cut down on alcohol use? Who should it be used it?
inhibits aldehyde dehydrogenase so that when you drink it makes you feel sick best used in patients with supportive environments or who are highly invested (have to take every day) and in patients who are currently already abstinent from alcohol
How should you manage a patient with hypothyroidism when they become pregnant?
instruct them to increase levothyroxine dose by 30% at time of positive pregnancy test then measure TSH every 4 weeks and adjust to norm curves for stage of pregnancy
What are the usual symptoms of paroxysmal supraventricular tachycardia (PVST)? Take a moment to review the EKG. What is the treatment for hemodynamically unstable patients? What is the definitive treatment?
intermittent abrupt-onset palpitations with appropriate ventricular response narrow-complex tachycardia with regular R-R interval treat unstable patients with synchronized cardioversion but the definitive treatment is ablation of the accessory pathway
What is an option for treating internal condyloma acuminata? What about external?
internal = trichloroacetic acid application (may have to be done multiple times) --> safe in pregnancy external = podophyllin --> not safe in pregnancy
What PFT findings would you expect in a patient with interstitial lung disease and why?
interstitial lung disease is a RESTRICTIVE process so you would expect decreased total lung capacity, decreased FEV1 and FVC, but normal FEV1/FVC ratio
What is the most common cause of intestinal obstruction in patients with a history of abdominal surgery?
intra-abdominal adhesions
What is the best approach to treating gout in a patient who recently had a renal transplant?
intra-articular steroid injection is preferred, but can use systemic steroids if needed
What is the best way to treat a keloid?
intralesional glucocorticoid injections can resolve up to 70% of keloids
What is the first line treatment in a patient with "flash" pulmonary edema caused by hypertension > 180/120 mmHg?
intravenous vasodilators like nitroglycerin
What is the only intervention that has been shown to significantly reduce the risk of kidney injury from use of IV contrast?
intravenous volume expansion with isotonic solution before and after the contrast is given
What does intrinsic aging of the skin look like? What about aging from photodamage? What is a treatment for aging from photodamage?
intrinsic = fine wrinkles on otherwise smooth skin photodamage = deeper wrinkles on rough skin surface +/- telangiectasias, hyperpigmentation, actinic keratosis treat with tretinoin (reduces brown spots, actinic keratosis, and roughness)
What can be considered to reduce risk of complication in surgery in a patient with known hyperthyroidism?
iodine loading prior to surgery
What serum ferritin and MCV would you expect to see in a patient with anemia from chronic bleeding colon mass?
iron deficiency anemia microcytic--> low MCV low ferritin (<30)
What does performing an intention to treat analysis do?
keeps patients assigned to the same group they were first randomized to desite outcome during the trial (lost to follow up etc) this usually leads to a more conservative estimate of the effect of the intervention (skews towards null hypothesis and reduces chance of false positive/type I error) but results will be more likely to reflect the real effect in the population (because humans don't use things perfectly)
This is a serious complication of compartment syndrome unrelated to the affected limb _______________
kidney failure due to rhabdomyolysis causing the release of myoglobin and heme heme is nephrotoxic
This is a painful side effect of Topirimate____________
kidney stones (inhibits renal carbonic anhydrase)
How does IVIG impact vaccination?
kids who have received IVIG (for Kawasaki etc) should have all live immunizations delayed for 11 mos due to poor immune reactivity
What is the classic lab and colonoscopy finding associated with celiac disease?
lab= positive anti-tissue transglutaminase antibody colonoscopy= duodenal villous atrophy if patient avoids gluten, antibodies should reduce by 50% at 8 weeks and resolve by 12 months gluten free
What would you suspect in a child with fever, ear pain, dizziness, and vomiting?
labrynthitis causing vertigo
What are the lab findings in hemochromatosis? what are the genetics?
labs: elevated iron, elevated ferritin, elevated transferritin saturation genetics: autosomal recessive, more common in men
What would you suspect in a lactating patient who presents with fever and painful red swelling of a segment of her breast? How would you treat it?
lactational mastitis usually caused by staph aureus--> treat with dicloxacillin or cephalexin (safe during breastfeeding)
What are 2 medications that may help hepatic encephalopathy?
lactulose and rifamixin
What is it called when a screening test detects disease earlier making it look like there is improved survival, when the patients would have survived the same time anyways?
lead time bias
What is lead time bias? What is length time bias?
lead time bias is when a test diagnoses a condition earlier and makes it look like the patient had improved time until death but there is really no difference in survival length time bias is when patients with milder more indolent disease courses are more likely to be picked up by a screening test instead of clinical symptoms so it makes it look like the test improves survival when it does not
What is it called when a screening test detects more slowly progressive cases of a disease which makes survival look improved?
length time bias --> increased detection of less aggressive cases leading to false improvement in survival rates
Give 3 indications for hemodialysis in a patient with lithium toxicity
lithium level > 4.0 lithium level >2.5 accompanied by AKI or severe neuro symptoms rapidly rising lithium levels despite aggressive IVF
What is a common adverse effect of black cohosh?
liver damage
What are the symptoms of acute paronychia? What is the usual cause and best treatment? What can it progress to?
localized bacterial infection of nail folds that causes pain, erythema, and edema usually caused by skin flora (gram positive; staph) and best treated by soaks in water and antiseptics can progress to felon which is an abscess in the digital pulp and causes major swelling, cellulitis, fluctuance --> treat with surgical debridement and systemic abx
What are the hallmarks of a knee meniscus injury?
locking sensation with extension small effusion inability to fully extend leg joint line tenderness positive McMurray test
What are the typical history and exam findings in someone with polycystic kidney disease? What are the genetics of this? What are 2 medications you should put them on?
longstanding hypertension bilateral flank mass/pain displaced PMI family hx renal disease autosomal dominant PKD gene mutation (genetic testing not indicated unless unclear US findings) manage with ACE inhibitor to control BP and statin to control lipids
What lab value can help you differentiate splenic sequestration and aplastic crisis in a patient with sickle cell and abdominal pain?
look at the reticulocyte count!! both conditions cause anemia, but in splenic sequestration reticulocyte count is very high and in aplastic crisis it is very low
What is the presentation of ileus? What electrolyte abnormality can cause a paralytic ileus?
look for abdominal pain/bloating, constipation, decreased bowel sounds, abdomen soft and distended gaseous distention and loops of bowel on x-ray can be caused by hypokalemia
What is the workup that needs to be done after a diagnosis of acute pancreatitis is established?
look for cause ask about alcohol use history get imaging for gallstones (abdominal US) check triglycerides and calcium level
What are the usual findings in a patient who had syncope due to WPW?
look for episodes of tachycardia with wide QRS and delta curve if symptomatic then treat with catheter ablation
What are the steps in confirming suspicion of pseudotumor cerebri?
look for papilledema on fundoscopy then get imaging to make sure no herniation present do LP to see if opening pressure > 20-25
What are expected findings in a patient with acute decompensated heart failure? What are the first two things you reach for to treat it? What is the workup after you stabilize the patient?
look for pulmonary edema (SOB, bilateral crackles, tachypnea, hypoxia, vascular congestion on CXR) JVD is usually present, but there may not be lower extremity edema first give a diuretic like furosemide --> if refractory then try intravenous vasodilator like nitroglycerin workup is echocardiogram to look for LVH and valve abnormalities and assess LVEF
What is a quick physical exam finding to look for if you suspect coarctation of the aorta in a neonate?
look for weak femoral pulses and decreased oxygen saturation beyond the aorta
How does macular degeneration typically present?
loss of central vision with peripheral sparing can lead to retinal detachment
What are the symptoms of acute angle closure glaucoma? What are some physical exam findings? Try to name 5 treatment choices.
loss of vision in one eye (may be preceded by seeing "halos") that is painful fixed dilated pupil and conjunctival redness treat with acetazolamide, timolol, pilocarpine, mannitol, appraclonidine
What are the hallmarks of a cruciate ligament injury in the knee? What test should you do to differentiate ACL vs PCL? What usually causes ACL issues? PCL?
loud "pop" sound large bruising/swelling with rapid onset positive anterior drawer test = ACL positive posterior drawer test = PCL ACL usually caused by pivot/twisting force or rapidly stopping PCL blow to tibia with knee flexed
What lab finding indicates a higher risk for aneuploidy in pregnancy?
low AFP get amniocentesis for karyotyping
How should you evaluate a patient with a thyroid nodule and low TSH?
low TSH means "hot" nodule thyroid uptake/scintigraphy with radioiodine
What is the most common bacterial cause of travelers diarrhea? How does it present and how should you manage it? What is the most common viral cause of traveler's diarrhea?
most bacterial traveler's diarrhea is caused by ETEC (enterotoxigenic E coli) which has symptom onset in 1-3 days and causes watery diarrhea, crampy abdominal pain, and sometimes nasuea usually ETEC is self-limited and symptoms resolve in several days with supportive therapy the most common viral cause is rotavirus
What is the most common cause of CAH (congenital adrenal hyperplasia)? What are the usual symptoms? Treatment?
most cases caused by autosomal recessive 21-hydroxylase deficiency symptoms include ambiguous genitalia in girls or precocious puberty in boys, hypotension, vomiting, hyponatremia, hyperkalemia, and hypoglycemia treat with glucocoricoid (hydrocortisone/prednisone) and mineralocorticoid (fludrocortisone)
What is the most common cause of osteomyelitis? How should you treat it with antibiotics? What is an important exception? How should you treat these patients?
most cases of osteomyelitis are caused by staph aureus and should be treated with clindamycin/vancomycin if any concern for MRSA however, kids with sickle cell disease are more likely to have salmonella (lack of functional spleen) and should receive ceftriaxone/cefotaxime AND vanc/clinda
What is the most common cause of unilateral lymphadenitis in children? What is one that you should remember because it can be deadly?
most common = cat scratch fever from bartonella henslae (tx with azithromycin) dangerous = Kawasaki disease with fever, mucous membrane change, and rash (tx with high dose aspirin and IVIG) can lead to coronary aneurysm
What bacteria is most commonly cultured from corneal foreign bodies? Why is this important?
most common is staphylococcus it matters because you need to give prophylactic antibiotics like topical erythromycin, cipro, ofloxacin
What is the most common secondary cause of dilated cardiomyopathy? How does this impact the workup needed?
most common secondary cause is CAD (coronary artery disease) therefore all patients with unexplained new-onset heart failure should undergo exercise stress testing or coronary angiography
What is the cause of most cases of non-gonococcal urethritis (scant watery fluid, aseptic but with leukocytes) that does not respond to treatment with azithromycin? What is the treatment?
most commonly due to mycoplasma genitalium treat with moxifloxacin also consider trichomonas
What is the prognosis of polycystic kidney disease?
most patients progress to renal insufficiency and 50% need a renal transplant by age 60
What are 5 causes of acute hypocalcemia? What symptoms would you expect? How can it be tricky to diagnose?
multiple blood transfusions (citrate) recent neck surgery sepsis tumor lysis syndrome pancreatitis look for tetany, hyperreflexia, arrhythmia, QT prolongation, seizures, muscle cramps, parasthesias can be tricky to diagnose because you need an ionized calcium level, free calcium may be normal
What should you suspect in a patient being properly treated for osteoporosis with alendronate who presents with a stress fracture, hypercalcemia, and elevated serum protein? What is the workup?
multiple myeloma get serum/urine protein electrophoresis
What should you suspect in an older patient who presents for back pain and is found to have hypercalcemia, anemia, and elevated creatinine? What would your workup be?
multiple myeloma serum electrophoresis showing M-spikes
What should you suspect in an older patient with bone pain, anemia, hypercalcemia? What is the test?
multiple myeloma test is serum or urine protein electrophoresis to look for monoclonal M lines alk phos is normal because it causes lytic lesions with bone resorption instead of bone turnover
What are the symptoms of multiple myeloma? What is the workup?
multiple myeloma causes scattered lytic lesions and osteopenia in bone CRAB symptoms C= hyperCalcemia R= renal insufficiency A= anemia B= bone lytic lesions / bone pain caused by clonal gammopathy--> serum electrophoresis showing M-spikes (also associated with rouleaux formation of RBCs stacked like coins and Ig light chains in urine)
What history/symptoms should make you suspect carbon monoxide poisoning? What is your workup and initial treatment?
multiple people in same home with headache, nausea, lightheadedness someone who works in parking garage or heavy smoker look for elevated carboxyhemoglobin treat with high flow oxygen via nonrebreather--> if refractory consider intubation or hyperbaric oxygen
What does lichen sclerosus look like? What is the treatment? What does it raise the risk for?
multiple plaques overlying thin skin on the vulva treatment is corticosteroid creams monitor closely for signs of vulvar cancer (single raised plaque)
What are the biopsy findings in muscular dystrophy? What is the genetic abnormality? What is the prognosis?
muscle biopsy will show fibrosis, fat, and muscle degeneration screening test is serum creatinine kinase, but genetic testing will show exon deletion on dystrophin gene prognosis is poor --> wheelchair dependent by adolescence and death from pulmonary or heart failure age 20-30 (often causes progressive dilated cardiomyopathy)
What are 5 symptoms of hypocalcemia? How should you treat it?
muscle cramps tetany/hyperreflexia (Chvostek and trousseau signs) parasthesias seizures treat with calcium gluconate or calcium chloride
What are 3 common side effects of statins?
myalgias abnormal liver studies ***rhabdomyolysis
What are the 2 first line medication treatments for alcohol use disorder and how does each work?
naltrexone (opioid antagonist) acamprosate (glutamate modulator)
What is the first line treatment for narcolepsy? What about the cataplexy associated with it?
narcolepsy --> modafinil cataplexy --> SNRI (venlafaxine), SSRI, or TCA
How should you work up a wrist injury if there is preserved range of motion, decreased grip strength, and tenderness over the dorsal radial wrist? What is the management? What are the most common complications?
need either an MRI or splint wrist and repeat xray in 2 weeks spica cast and then monitoring xrays every 2 weeks for healing most common complications are avascular necrosis or nonunion of the fracture
The workup of all patients with new-onset unexplained heart failure should include ______________ and ____________. (assume they have already had an echo to confirm low LVEF)
need to get either exercise stress test or coronary angiography to look for evidence of CAD CAD is most common secondary cause of heart failure
Describe the deposits seen in gout
negatively birefringent needle-shaped crystals
When a patient presents with low TSH and high T4 and radioactive iodine scan shows increased uptake in a nodule, what is the next step in treatment/workup?
no need to get FNA biopsy of "hot" nodules because it is very low risk of malignancy always treat with antithyroid drugs (methimazole unless first trimester of pregnancy then use PTU) to achieve a euthyroid state before definitive treatment with surgery or radioactive iodine ablation
What 4 body fluids are considered non-infectious for HIV if there is no visible blood mixed with them? What about low risk? What about high risk? If a healthcare worker is exposed to a higher risk fluid what is the treatment?
no risk: urine, vomitus, feces, tears low risk: CSF, amniotic fluid, synovial fluid, pleural fluid, pericardial fluid high risk: blood, semen, vaginal fluid if exposed do 3 drug post exposure prophylaxis for 4 weeks
Is amnioinfusion used for oligohydramnios?
no, it cannot correct chronic placental insufficiency it is indicated during labor for variable decelerations to alleviate umbilical cord compression
What symptoms might you see in a patient with a non-dominant parietal lobe lesion? What about a dominant parietal lobe lesion?
non-dominant parietal lobe --construction apraxia (difficulty copying simple line drawing, difficulty getting dressed) dominant parietal lobe --Gerstmann syndrome (cannot do simple arithmetic, difficulty writing, difficulty differentiating right and left side of body)
What medical treatment should be provided to patients with esophageal varices to prevent recurrence?
non-specific beta blockers like nadolol and propranolol oral nitrate can help too
What are the most common complications of a scaphoid fracture? (name 2)
nonunion avascular necrosis of scaphoid
Does an obstructive kidney stone usually lead to elevation in BUN and creatinine?
nope--> at least one functional kidney is usually enough
What do you expect the MCV to be in a patient with hemolysis or hemorrhage?
normal
What is a normal post-void residual volume for a woman? If elevated, may indicate ____________ incontinence
normal <200ml overflow incontinence
What is a normal amniotic fluid index (AFI)? What does an elevated AFI indicate? What are 4 common causes?
normal AFI is 5-23cm and indicates good function of placenta, fetal lungs, fetal kidneys AFI >24cm is suggestive of polyhydramnios polyhydramnios is commonly caused by maternal DM, multiple gestation, and congenital anomalies (anencephaly, duodenal atresia)
What is a normal Cobb angle on workup of scoliosis? What are the treatments for low/moderate and for severe scoliosis?
normal cobb angle (on xray) is <10 degrees 10-40 degrees observe and use back brace >40 degrees is severe and warrants surgical referral
What is the normal blood sugar range? What defines hypoglycemia?
normal is 70-100 <60 is hypoglycemia
What is the diagnosis for an HbA1c of 4.8? 5.8? 6.8?
normal is <5.7 prediabetes is 5.7-6.49 diabetes is 6.5 and higher
What does a normal kidney cyst look like on imaging? What about renal cell carcinoma?
normal kidney cyst NON-ENHANCING smooth-walled and round and sharply demarcated renal cell carcinoma ENHANCING thickened/irregular walls or septa
What is the workup for a patient with a thyroid nodule and elevated TSH?
normal/elevated TSH in presence of thyroid nodule indicates that it is a "cold" or hypofunctioning nodule and at higher risk for cancer --> get FNA nodules under 1cm are less suspicious and can be monitored with ultrasound
What type of anemia can patients with chronic kidney disease develop? What is the first step in workup/treatment if you suspect this?
normocytic, normochromic, hypoproliferative anemia from reduced levels of EPO or iron deficiency always check iron studies, B12/folate, and fecal occult blood to look for other causes of anemia that could be corrected treat with EPO
What are the hospital precautions for varicella? What about disseminated varicella?
once a patient with shingles has the rash cross the dermatome, it is now disseminated and can be present in the respiratory system they must be admitted for IV acyclovir due to increased risk of complications like ocular infection standard precautions plus contact and airborne until the lesions have crusted over
What is the medical management of syphilis that is primary, secondary, or in the early latent phase (<1yr)?
one dose IM penicillin G
What is a factorial study design?
one that separate patients into multiple groups designed to cover all the treatment options including combinations and placebo ex: a study of drug A and drug B would have 4 groups in a factorial design 1. group receives only A 2. group receives only B 3. group receives both A and B 4. group receives placebo and neither A or B
What is the management strategy for Hep B infection? Why?
only 5% progress to chronic Hep B in adults (if they do not clear virus in 6 mos it is considered chronic) so most spontaneously resolve --> do close outpatient follow up and supportive care
What ages define precocious puberty? What development would you expect to see first in central vs peripheral precocious puberty?
onset of puberty before age 8 in girls or 9 in boys central (early activation of hypothalamic-pituitary-gonadal axis) --> first see breast and testicular development peripheral (due to extra hormones from gonads, adrenal glands, or outside source) --> first can see pubic hair or acne
What defines preterm labor? What are 2 things you would want to give to a woman in preterm labor and why?
onset of regular contractions and cervical change prior to 37 weeks gestation give corticosteroids to improve fetal lung maturity and magnesium to reduce the risk of cerebral palsy
What are the diagnostic criteria for adjustment disorder?
onset within 3 months of identifiable trigger must cause impairment in social/occupational functioning
What are the symptoms of cholinergic toxicity? What is a common exposure causing it? What is the treatment?
opposite of anticholinergic watering eyes diarrhea sialorrhea sweating miosis bradycardia often caused by exposure to pesticides/organophosphates treat with ATROPINE
What is the first line treatment for DVT? Why?
oral anticoagulation with direct factor Xa inhibitor like rivaroxaban no heparin bridge needed like for warfarin, no INR monitoring, faster onset
What is the most sensitive test for diabetes? What is the value that diagnoses?
oral glucose tolerance test give 75g glucose load then test 2 hours later >200 is diabetes
What should you suspect when a patient presents with bilateral arthritis of the hands/wrists a week or so after URI symptoms? What else may be seen on exam?
parvo B19 also look for erythematous reticular rash
What is most associated with aplastic crisis in sickle cell? What are the lab findings?
parvo B19 infection anemia, low retic count, normal WBCs/platelets
What is pretibial myxedema and what is it associated with?
patchy non-pitting edema in the lower legs usually associated with Graves disease
Try to name 7 poor prognostic factors for low back pain
patient age poor baseline functionality severe rating of pain and impairment poor patient attitude towards recovery use of opioids prolonged bed rest psychiatric comorbidity
A 5 year old girl presents for 6 days of fever. She is noted to have a rash and bilateral conjunctivitis. What other things should you ask about? What is the next step?
patient has 3 symptoms of Kawasaki disease but needs 4+ for diagnosis also ask about rash, strawberry tongue, cervical lymphadenopathy get a CRP and ESR then schedule next-day follow up (if elevated you should dx Kawasaki and give IVIG and aspirin and get echo to look for coronary artery issues)
How does androgen insensitivity syndrome present?
patient who presents with amenorrhea (no period by age 15) and who is found to have no pubic/axillary hair, vagina ending in blind pouch, and cryptorchid testes patient will be 46 XY but their body cannot respond to androgens so they developed via female default pathway
What is the usual presentation of chronic pancreatitis? What is the best workup (give 2 options)?
patient with bouts of epigastric abdominal pain radiating to the back, a history of alcohol use, weight loss, fat malabsorption (steatorrhea) pancreatic pain may be alleviated by sitting up or leaning forward best tests are CT abdomen or MRCP (magnetic resonance cholangiopancreatography) ***remember that in chronic pancreatitis lipase and amylase are not usually elevated
What are the symptoms of acute cholangitis? What is the workup/management?
patient with fever, RUQ pain, jaundice, hypotension, confusion give IV antibiotics and take for ERCP
What is the typical presentation of polycystic kidney disease? What are the genetics and what is the treatment?
patient with flank pain and hematuria found to have multiple bilateral kidney cysts on CT that are non-enhancing, thin-walled, and round autosomal dominant due to PKD gene mutation treat with ACE inhibitor to reduce risk of chronic renal insufficiency
How does a patient with a toxic thyroid nodule present? What is the workup? What are the steps in treatment?
patient with low TSH, high T3/T4, and possible hyperthyroid symptoms who has a nodule on thyroid exam first get radio-iodine scan to show concentrated uptake in nodule instead of diffuse (Graves) then treat with methimazole to achieve euthyroid state then proceed to surgery or radioactive iodine ablation
What are the symptoms, lab findings, and treatment for primary biliary cholangitis?
patient with pruritus, fatigue, RUQ pain, hyperpigmentation, arthritis, xanthelasma labs show elevated alk phos and positive antimitochondrial antibody treat with ursodeoxycholic acid
What is the usual presentation of mucormycosis? What is the bug? What is the treatment?
patient with recent DKA who develops a rapidly progressing necrotic sinus picture (fever, periorbital swelling, necrotic rash at nose) usually caused by Rhizupus treat with sinus endoscopy for surgical debridement and IV liposomal amphotericin B
How does a right subphrenic abscess usually present? What is the workup?
patient with recent abdominal surgery who has a swinging fever, leukocytosis, and pain under the right shoulder blade get abdominal ultrasound to work it up
How does rosacea typically present? What is the treatment?
patient with redness, thickened skin, worsens with sun exposure, telangiectasias treat with metronidazole cream or oral doxycycline/tetracycline/minocycline
What indicates a need for carotid endarterectomy?
patient with symptoms (TIA/stroke) and occlusion >70% of the carotid artery and life expectancy >5 yrs
When would a patient with mastitis start to worry you that they had developed a breast abscess? What is the workup?
patient with unilateral breast pain, swelling, and fever who then develops an area of induration or fluctuance get an ultrasound to work it up if confirmed then do US-guided aspiration under local anesthesia
How does dermatomyositis present? What is the workup to confirm your suspicion? What else should you screen for (2 things)?
patient with weakness in shoulders and pelvis, elevated CK, violaceous papules on backs of hands, heliotrope rash around eyes usually not much pain present workup with antibody testing like ANA (if negative, then do tissue biopsy) also screen for interstitial lung disease at time of diagnosis (if no pulm sx get CXR; if pulm sx get CT) also screen for malignancy because they are commonly comorbid --> cervical, ovarian, lung, etc
What should you suspect in a 32 year old woman who is 34 weeks pregnant and develops shortness of breath with exertion and leg swelling? How should you manage and monitor the patient?
peripartum cardiomyopathy --> get an echo and check to see if LVEF <45% treat like normal heart failure, delivery timing based on maternal stability monitor with serial echocardiograms
What should you think about when an older patient has calf pain with walking? What should you measure? What medication should be started and what should you advise the patient?
peripheral artery disease causing claudication get ankle-brachial-index start aspirin and statin and advise the patient to complete a supervised exercise regimen and stop smoking if they do
What is the most accurate way to confirm appropriate placement of an endotracheal tube?
persistent wave capnography and/or color change with calorimetric CO2 detection (will change purple to yellow)
What are the phalen and tinel tests for? If they are positive what does this indicate is happening anatomically? What is the first line treatment?
phalen test = flexion of wrists causes symptoms of carpal tunnel within 1 minute tinel test = tapping middle of wrist elicits symptoms indicates that the median nerve is compressed as it crosses under the transverse carpal ligament treat initially with wrist braces
What are 2 common clinical tests for carpal tunnel? What causes it physiologically?
phalen test: flexion of wrists leads to numbness/tingling after 1 minutes tinel sign: tapping medial wrist elicits symptoms caused by compression of the median nerve as it passes under the transverse carpal ligament
What are the guidelines on pharma companies paying for travel, speaking engagements, etc?
pharma can only pay for travel and honorarium if you are presenting at a conference (not if just attending) you cannot use their slides--> must develop your own material! must fully disclose all financial connections
Which antiepileptic drug is associated with gingival hyperplasia?
phenytoin
Name 5 anti-seizure drugs that reduce the efficacy of OCPs
phenytoin carbamazepine ethosuximide topirimate phenobarb
What kind of tumor usually causes Parinaud's syndrome? What are the symptoms?
pineal gland tumor Parinaud Syndrome: loss of pupillary activity vertical gaze paralysis loss of nystagmus ataxia can often lead to obstructive hydrocephalus causing a headache
What is the typical presentation of pityriasis rosea? How should you treat it?
pityriasis rosea usually presents with a "herald patch" followed by a rash on the back in a christmas tree pattern usually post-viral and self-limiting; treatment is supportive with antihistamines or topical steroids for itching
What is the treatment of Guillain-Barre?
plasma exchange or IVIG
What should you diagnose when a female has hemoglobin > 16.5 or a male >18.5? What is the next steps in workup?
polycythemia repeat hemoglobin testing and if still elevated then check erythropoetin (EPO) level if EPO elevated this indicates the polycythemia is due to chronic hypoxia (most common cause) or renal cell carcinoma secreting EPO low EPO suggests polycythemia vera which is a myeloproliferative disease
What would you suspect in a patient who complains of swollen red hands/feet, ruddy facial complexion, and who has hypertension? What lab tests would you run? What historical question would you ask?
polycythemia vera ask about aquagenic pruritis check CBC for hemoglobin and get JAK2 mutation
What should you suspect in an older patient with a month of shoulder and hip pain that is worse in the mornings accompanied by fatigue? What would a lab finding be to give you a clue? Treatment? What other condition should you screen for?
polymyalgia rheumatica look for elevated ESR treat with NSAIDs and low dose steroids also screen for giant cell arteritis (temporal artery) that can lead to blindness if not caught
What is the prognosis when a patient presents with cervical insufficiency and prolapsing membranes?
poor prognosis, even if cerclage is performed (cerclage is a relative contraindication due to risk of iatrogenic membrane rupture
What are the findings in porcelain gallbladder and how do they change your treatment of gallstones?
porcelain gallbladder refers to calcifications within the gallbladder wall due to longstanding cholelithiasis increases risk of malignancy so patients with calcifications and symptoms or any punctate calcifications should be referred for prophylactic cholecystectomy
Give the 2 calculations for likelihood ratios
positive LR = (sensitivity)/(1-specificity) negative LR = (1-sensitivity)/(specificity)
What are signs of acute cervicitis? What is first line treatment?
postcoital spotting pain with intercourse friable cervix with discharge on exam treat with azithromycin
What is the most common cause of postpartum fever? What are the symptoms? What is the biggest risk factor for this? What antibiotics are you going to prescribe?
postpartum fever is most commonly due to endometritis symptoms are fever, increased vaginal bleeding, uterine fundal tenderness, "boggy uterus" biggest risk factor is cesarean delivery treat with clindamycin + gentamicin
How do you define power in a study? What is a simple way to increase a study's power?
power = the ability of a study to detect a difference in the outcome being observed between two groups if it exists can increase power by increasing sample size
When is use of magnesium sulfate indicated during labor?
pre-eclampsia with severe features (BP > 160/110mmHg +/- signs of end organ damage)
What are actinic keratoses? What do they increase the risk of?
pre-malignant condition from UV exposure that causes small rough erythematous lesions covered with scale Increase risk of squamous cell carcinoma-->remove with liquid nitrogen or surgically as many will progress
What does a BUN/Creatinine ratio over 20 indicate in a patient with elevated creatinine?
pre-renal cause look for hypovolemia, hypotension, heart failure
What are 3 things multiple skin tags are associated with?
pregnancy crohn's disease diabetes mellitus/insulin resistance
What do you usually see in non-classical congenital adrenal hyperplasia?
premature peripheral puberty (pubic/axillary hair, advanced bone age, severe acne, hirsutism and oligomenorrhea in girls) increased 17-hydroxyprogesterone treat with corticosteroids (hydrocortisone)
What are 4 causes of iron deficiency anemia in children under age 2? What would you see on blood studies?
prematurity, lead toxicity, cow's milk, delayed introduction of solid foods look for microcytic anemia with elevated RDW
How does Bell's palsy present? How should you treat it? What if the patient is from the upper midwest or northeast?
presents as facial paralysis INVOLVING THE EYEBROW give prednisone, artificial tears, and have patient wear eye patch if in Lyme endemic area or they have other symptoms like fever or erythema migrans then get Lyme serum ELISA
How does injury to the hypoglossal nerve present? What medical procedure is this associated with?
presents as tongue deviation towards the affected side can occur during carotid endarerectomy
How does scarlett fever present? What is the treatment?
presents with "sandpaper" rash (small papules), strawberry tongue, and circumoral pallor caused by strep --> treat with amoxicillin
What are 4 things associated with priapism? What is the first line treatment? What if that doesn't work?
priapism = erection longer than 4 hours associated with sildenafil, trazodone, sickle cell first try aspiration of the corpora cavernosa and irrigation of cold water if that does not work then do intracavernosal injection of phenylephrine
This is a cause of hypertension that also leads to hypokalemia and low levels of plasma renin __________________
primary hyperaldosteronism
What are 3 findings that indicate a need for primary use of statins to prevent CAD complications? What are 4 conditions that warrant initiation of a statin after they are diagnosed/treated?
primary prevention: LDL > 190 over age 40 with DM estimated 10 year risk >7.5% secondary prevention: acute coronary syndrome (MI, NSTEMI) stable angina history of CABG stroke/TIA
A patient with a long history of ulcerative colitis presents for several weeks of itching skin and is found to have high elevations in AST/ALT. What should you suspect? What is an imaging workup and what would you see?
primary sclerosing cholangitis cholangiography shows "beads on string" of bile ducts due to multifocal strictures
This liver condition is strongly associated with ulcerative colitis _______________. Take a moment to review its features.
primary sclerosing cholangitis symptoms are fatigue, skin pruritis, elevated ALT/AST (often in 200-300s), and imaging shows multifocal stricturing of bile ducts "beads on string" pattern
What is primary prevention? Secondary? Tertiary?
primary: aimed at avoiding disease occurring (ex: statin in patient with HLD to reduce risk of MI) secondary: aimed at halting disease progression to prevent complications (ex: statin or aspirin after treatment of MI) tertiary: taking all actions possible to avoid bad outcomes in an already progressed disease (ex: CABG for MI)
What are the symptoms of the stages of syphilis? Review primary, secondary, and tertiary.
primary: painless hard solitary lesion secondary: rash, condylomata lata (warts), and hair loss rash involves hands and soles tertiary: neuro effects, gummas
How would you manage a woman with history of 2 painless pregnancy losses in the second trimester? How would you manage a woman found to have short cervix on ultrasound at her first pregnancy?
prior losses --> cervical cerclage at 12-14 weeks no prior losses --> weekly monitoring of cervical length with ultrasounds
What is the cardiac finding found in advanced muscular dystrophy?
progressive dilated cardiomyopathy death by pulm/heart failure in 20s-30s
What is the leading cause of death in patients with tuberous sclerosis?
progressive neurologic impairment from masses and seizures always get brain MRI and EEG at time of diagnosis
What prolactin level indicates a probable prolactinoma? What are some symptoms? What are 2 medications that might help?
prolactin > 200 symptoms include gynecomastia, vaginal dryness, hot flashes, OSTEOPOROSIS, hypogonadism often responds to dopamine agonists like bromocriptine or cabergoline
Where do prostate cancer mets tend to go in the skeleton? What does bony met pain feel like? What is the best way to work it up?
prostate cancer mets tend to go to the axial skeleton (shoulders, pelvis, spine) usually pain is dull/aching and worsens at night best workup of prostate mets is a radioisotope bone scan
esophageal carcinomas.....if proximal and in a smoker think ____________ but if distal think ____________________
proximal and hx smoking/drinking --> squamous cell carcinoma distal and hx GERD --> adenocarcinoma
What should you suspect in a patient with arthritis of the hands primarily impacting the distal interphalangeal joints who also has thickened yellow nails? How would you treat and what should you avoid?
psoriatic arthritis treat with methotrexate avoid oral glucocorticoids because you could trigger a psoriatic pustule attack
Compare the findings in psoriatic arthritis of the hands with rheumatoid arthritis
psoriatic: affects distal interphalangeal joints and associated with nail pitting, onycholysis, and dactylitis rheumatoid: affects metacarpophalangeal and proximal interphalangeal joints
What are 2 types of seafood poisonings and how they usually present?
puffer fish toxicity: neuro symptoms like tingling, weakness, incoordination scombroid poisoning (from storing fish above 15C) flushing, throbbing headache, abdominal cramps, diarrhea, palpitations and oral burning (usually 10-30 min after ingestion and self-limited)
What should you suspect in a patient with pleural pain who has a friction rub and prominent P2 on inspiration?
pulmonary embolism remember pleuritic pain worsens with deep breathing or movement and is improved by leaning forward slightly
What is pulsus paradoxus and what does it indicate? What other findings would you expect?
pulsus paradoxus is a decrease >10mmHg in BP during inspiration usually occurs with cardiac tamponade--> expect hypotension, JVD, chest pain, dyspnea, muffled heart sounds
What are 2 antipsychotic agents preferentially used in patients with Parkinson disease who are experiencing hallucinations?
quetiapine and clozapine (least risk of causing worsened Parkinsonism)
What is raloxifene and how does it work?
ramoxifene is a selective estrogen modulator that stimulates estrogen receptors on bone to improve bone density used in post-menopausal women with osteoporosis
What is the initial goal in lowering blood pressure during hypertensive emergency?
rapidly lower diastolic pressure to 100-105mmHg over 2 -6 hours with total drop in BP being no greater than 25% max BP
What would you expect to see in a patient with fat embolism?
recent long bone fracture shortnes of breath, PETECHIAL RASH, neuro effects like confusion CXR without airspace findings
What are 3 big risk factors for intussusception? How does it usually present? What is the workup/treatment?
recent viral illness, rotavirus vaccination, lead point from meckels diverticulum or HSP presents as child age 6 mo - 3 yrs with bouts of severe abdominal pain that make them curl up and then go away quickly can also see currant jelly stools or sausage shaped abdominal mass work up with upright abdominal/chest x-ray to rule out perforation (ultrasound can confirm cases that are less clear clinically) treat with air or water-soluble enema
What is the treatment of C diff in the following cases: 1. recurrent C diff after treatment and discharge 2. recurrent C diff after 2 rounds of initial treatment 3. fulminant C diff with hypotension/shock/ileus/megacolon
recurrent C diff --give another course PO vancomycin with taper --or give fidaxomicin if vanc was initially used multiple recurrences --give vancomycin + rifamixin --fecal transplant fulminant C diff --IV metronidazole + high potency PO vancomycin
What are the diagnostic criteria for narcolepsy? What is the firstline treatment?
recurrent lapses into sleep or napping multiple times in the same day occurring at least 3 times weekly for 3 months PLUS one of the following: --cataplexy (loss of tone precipitated by emotions or laughter) --REM latency < 15 min --CSF studies with hypocretin-1 deficiency first line treatment is modafinil
Describe the constellation of symptoms that should make you consider cystic fibrosis? What is the associated mutation? What two organisms are patients at increased risk of infection from?
recurrent pulmonary infections, failure to thrive, intestinal obstruction (meconium ileus), pancreatic deficiencies (GI distress) that can lead to diabetes, male factor infertility, sweaty tasting skin autosomal recessive mutation in CFTR gene (delta F508 is most common) diagnose with genetic testing or increased sweat chloride levels increased risk of staph aureaus and pseudomonas (treat infections with vancomycin + cefepime/ceftazidime + amikacin/tobramycin (or can use piperacillin tazobactam)
What are 3 situations that indicate need for myringotomy and placement of tubes?
recurrent treatment failure for otitis media persistent effusion > 3 months 3+ episodes of AOM within 6 months
What does scabies rash look like? Where is it most likely to be located?
red rash sometimes with a scale and linear burrows most commonly between fingers, at waistline, wrists, ankles
What is the typical presentation of erysipelas? What causes it?
red, painful, edematous, raised cellulitis most commonly on the face or lower legs caused by group A strep treat with a 10-14 day course of antibiotics
How do you define metabolic acidosis? How do you calculate anion gap?
reduced bicarb and ph <7.4 anion gap = sodium - (chloride + bicarb)
When should you consider surgery for carpal tunnel? What is the confirmatory workup first?
refractory cases with symptoms longer than 6 months despite conservative measures (wrist splinting) or who have significant neural impact always get nerve conduction studies with an EMG first
What is the big clue that should make you suspect multiple sclerosis? What is the best way to diagnose it?
relapsing and remitting neurologic deficits look for optic neuritis (vision loss on one side with eye pain that worsens with movement) diagnose with MRI revealing hyperintense periventricular white matter lesions
What is the primary measure of outcome in exposure studies (usually cohort studies)?
relative risk is what is measured in cohort studies RR = risk in exposed group/ risk in unexposed group (pay close attention to what is considered the "exposed" group in the question)
What causes polycythemia vera and what are the findings? What is a confirmatory test?
remember aquagenic pruritis! ("I itch when I shower") hypertension burning redness in hands/feet + facial plethora gouty arthritis elevated hemoglobin + splenomegaly test = JAK2 mutation testing
What 4 labs should you get to help differentiate the cause of hypoglycemia in a healthy patient?
remember to warrant workup they must be symptomatic labs: exogenous hypoglycemia agent screen C-peptide (should be high if endogenous) proinsulin (should be high) insulin (should be high) if all of these are negative then suspect insulinoma and get abdominal CT/US
How should you manage a hydatidiform mole?
remove with suction/curretage and then monitor serial beta-HCG levels because of increased risk for gestational trophoblastic neoplasia
How do patients with renal colic usually appear? What about patients with pneumoperitoneum?
renal colic --> usually writhing around in pain peritonitis --> usually lay flat and still to limit irritation
What are the usual presenting symptoms of mixed cryoglobulinemia syndrome? You should test for __________ and treat if present.
renal insufficiency with palpable purpura, elevated rheumatoid factor, and low complement levels test for Hepatitis C!!!
What is the preferred evaluation of renal colic in pregnancy?
renal stones more common in 2nd-3rd trimesters want to avoid radiation so we do ultrasound of kidneys and pelvis (usually a stone is not seen on ultrasound, so you are looking for hydronephrosis and hydroureter)
How should you always start the work up of hypercalcemia?
repeat calcium level alongside PTH level
What is the primary acid base disorder in hyperventilation? Why?
respiratory alkalosis from blowing off too much CO2
What are 5 common extraarticular complications of ankylosing spondylitis?
restrictive lung disease aortic regurgitation anterior uveitis pulmonary fibrosis IgA nephropathy
What are 4 tests you can order to look for signs of hemolysis? What would each show if hemolysis is occurring?
reticulocyte count (elevated) LDH (elevated) haptoglobin (low) indirect bili (elevated)
When is screening for diabetic retinopathy indicated for type I and type II? When is screening for diabetic nephropathy indicated for type I and type II?
retinopathy screen (send to ophthalmology) type I = 5 years after original diagnosis type II = at time of diagnosis nephropathy screen (get urine microalbumin) type I = 5 years after original diagnosis type II = at time of diagnosis (if any evidence, then start an ACE inhibitor)
What is the most common complication of transurethral resection of the prostate?
retrograde ejaculation
What would you suspect in a patient who was recently partying who presents with recent seizure and hemoglobinuria? What is the managment
rhabdo from PCP use (phencyclidine) give AED and IVF
How does compartment syndrome lead to kidney failure?
rhabdomyolysis releases myoglobin and heme which is toxic to the kidney
What are three medications that increase thyroid hormone metabolism?
rifampin carbamazepine phenytoin
Name 3 bisphosphonates. What are 2 diseases they treat?
risedronate alendronate zoledronic acid treat osteoporosis and Paget disease
What are 2 risk factors for congenital hip dysplasia? What are 3 physical exam findings?
risk factors include breech presentation and female sex (and of course family history) positive Barlow and Ortolani tests with hip dislocation (clicking, catching) limited abduction of hip unequal gluteal folds treat with Pavlik harness
What are some risk factors for aspergillosis? What is the classic triad of symptoms? What is the typical imaging finding? Treatment?
risk factors: HIV+; immunosuppressed sx: cough, pleuritic chest pain, hemoptysis imaging: nodules with halos of surrounding ground glass or cavitations with air-fluid levels tx: voriconazole
What 3 drugs are the first line therapy for cognitive decline related to dementia? What about once it progresses to moderate-severe?
rivastigmine donepezil galantamine moderate to severe --> add memantine (NDMA receptor antagonist)
Name 3 drugs that may help improve cognition in dementia. What about after it progresses?
rivastigmine galantamine donepezil after it progresses to mod/severe you can add NDMA receptor antagonist memantine
If you have a patient who has facial redness and uses topical metronidazole, what are they likely treating?
rosacea--> avoid sunlight as well
What are 4 lab tests that should be done routinely when working up suspected dementia? What are 3 tests that should be use in special populations?
routine: CBC, CMP, TSH, B12 special: folate (alcohol use); syphilis (promiscuous or rash hx); vitamin D level (nephrotic syndrome)
Try to name 8 screening tests indicated at the time pregnancy is diagnosed
rubella and varicella titer for immunity HIV/RPR/Hep B screen CBC thyroid function tests chlamydia screen urine culture anti-rh(D) antibody screen dipstick urine for protein
What are the symptoms of salicylate toxicity?
salicylate crosses blood brain barrier and stimulates the respiratory chemoreceptor this causes tachypnea, respiratory alkalosis, nausea/vomiting, tinnitus, lactic acidosis, hyperthermia give sodium bicarb if severe, activated charcoal if within 2 hours of ingestion
What should you suspect in a polydrug overdose where the patient complains of tinnitus, has tachypnea, respiratory alkalosis, and nausea/vomiting? What should you administer IV?
salicylate toxicity --> can also lead to hyperthermia and lactic acidosis give IV sodium bicarb
What symptoms/findings point towards sarcoidosis?
sarcoidosis = non-caseating granulomas but we don't know why body is making them look for hilar lymphadenopathy shortness of breath/exertional dyspnea cough hypercalcemia and elevated markers of inflammation mixed restrictive (low CO diffusing capacity) and obstructive (reduced FEV1 and FEV/FVC) picture on pulmonary studies
How should you treat young women with primary ovarian insufficiency? Why?
start on estrogen (and progesterone if they have a uterus still!) until age 50 benefits outweigh risks --> need to minimize bone loss and alleviate symptoms
What are the findings in scabies? How would you work it up and treat it?
scabies is very itchy and usually on the hands (between fingers) and wrists and waistline look for scattered small crusted red papules or burrows work up with scraping to see mites/ova/feces under microscope treat with permethrin cream if localized and patient able to apply it or oral ivermectin if nursing home patient etc
What causes scombroid poisoning and how does it present?
scombroid poisoning is caused by improperly stored seafood (never let seafood get above 15C) causes quick onset (10-30min after ingestion) of flushing, palpitations, headache, oral burning, abdominal cramping, and diarrhea usually self-limited
What is the screening protocol for chlamydia in pregnancy? What is the treatment? What outcomes are we trying to avoid?
screen at initial OB visit and again in third trimester if patient is high-risk treat with azithromycin trying to avoid PPROM (preterm premature rupture of membranes); preterm labor; postpartum endometritis; neonatal conjunctivitis; neonatal pneumonia
What is the screening test (name 2) and gold standard to diagnose celiac disease?
screening: anti-endomysial antibody anti-transglutaminase antibody definitive: colonoscopy with small bowel biopsy showing villous blunting
What is the EKG finding in right bundle branch block? What can a new one represent?
second R wave in V1 + widened S wave V6 can indicate acute PE or pulmonary HTN
What is the most common cause of brain tumors? What features are suggestive of this?
secondary brain tumors from mets are most common look for multiple lesions, well-circumscribed lesions, and a lot of vasogenic edema surrounding the lesion most common mets to brain: lung > breast > melanoma > colon cancer
What should you suspect in a patient with a rash involving the hands and soles, multiple warty growths, and hair loss?
secondary syphilis! Get an RPR and give penicillin G
How long do you need to keep a patient on anticoagulation if they had a DVT following a long surgery? What if they developed one suddenly without precipitating factors?
secondary to surgery etc --> anticoagulation for at least 3 but no longer than 6 months idiopathic --> anticoagulation for 6 months
What is a sensitivity analysis and what does it help tell you?
sensitivity analysis is when you make small changes to the study parameters/ranges/criteria and see if the results are still reproducible if results remain similar, then your study is very robust
This is a measure of "true positives" ______________. Describe how it is calculated.
sensitivity measures the likelihood of a positive test actually meaning the patient has the disease sens = true positives/ (true positives + false negatives) a highly sensitive test will pick up on almost all cases, but there may be some false positives---but if a patient tests negative with a highly sensitive test they likely do not have the disease a highly sensitive test is good to rule things OUT
What are the definitions and calculations for: sensitivity specificity positive predictive value negative predictive value
sensitivity: how likely is a person with the disease to test positive aka true positive rate (sensitivity = true positives/(true positives + false negatives) specificity: how likely is a person without the disease to test negative aka true negative rate (specificity = true negatives/ (true negatives + false positives) positive predictive value: if a test is positive, what is the likelihood that the patient actually has the disease (PPV = true positives/all positives) negative predictive value: if a test is negative, what is the likelihood that the patient does not have the disease (NPV = true negatives/all negatives)
What is the workup of bilateral Bells palsy? Why?
serum ELISA to look for Lyme disease Remember, Bell's palsy does not spare the forehead/eyebrow
What are the tests to diagnose Wilson disease and the indicative finding in each?
serum ceruloplasmin will be LOW urine copper excretion will be HIGH most definitive is liver biopsy showing copper deposition
What is a common adverse effect of kava kava?
severe liver damage
What is the preferred workup for suspected abusive head trauma (aka shaken baby syndrome)?
start with a head CT most common finding is subdural hematoma with mixed-density pattern
What defines severe hyperbilirubin in a newborn? What is the best treatment? What would you suspect as the cause in a baby whose blood type is A/B and whose mother was O?
severe means bilirubin >20-25 treat with exchange transfusion to rapidly reduce bilirubin levels and prevent kernicterus (brain damage from bilirubin depositing) suspect ABO hemolytic disease (look for positive direct antiglobin test)
What are the EKG signs of WPW syndrome?
short PR, slurred upstroke delta wave and widened QRS
How should patients with a family history be screened for polycystic kidney disease?
should wait until age 18, complete counseling first, and then screen with renal ultrasound
What should you suspect in a patient with sickle cell disease who has recently had a GI illness and now has right upper quadrant pain and fever? How would you approach treatment?
sickle cell hepatic crisis --> dehydration from GI bug leads to increased sickling and intravascular hemolysis --> sickled cells accumulate in the hepatic sinuses causes liver damage with elevated LFTs, RUQ pain, and fever treat with IV hydration, analgesia, and possibly DVT prophylaxis
What are the symptoms of acute chest syndrome in patients with sickle cell disease? What is the initial management?
sickle cell patient with fever, chest pain, dyspnea, and new consolidation on CXR treat with ceftriaxone/cefotaxime + azithromycin
What is the most effective way to screen for alcohol use disorder?
single question "How many times in the past year have you had more than 4/5 drinks in a day?"
How should you manage a patient who was hospitalized for DKA and then developed fever, sinus pain, and bad rash on face with a black eschar? Why?
sinus endoscopy for surgical debridement and then IV liposomal amphotericin B likely mucormycosis caused by Rhizophus
What defines a solitary pulmonary nodule and what should you do if you find one in a patient?
size < 3cm (bigger is a mass not a nodule) rounded opacity surrounded by pulmonary tissue no lymph node enlargement first compare to prior imaging, if no change then just monitor if no prior imaging then get CT chest
What is erythasma? How does it present? What is the cause?
skin infection by Corynebacterium that is usually in the intertriginous areas --> looks like pruritic, finely wrinkled, reddish brown areas use Wood lamp to look for coral-red
Try to name 5 different organ system manifestations of hereditary hemochromatosis. What is the treatment?
skin: hyperpigmentation/bronzing abdomen: liver issues, cirrhosis endocrine: diabetes, hypothyroidism, hypothalamic hypogonadism heart: dilated or constrictive cardiomyopathy MSK: arthralgias treat with therapeutic phlebotomy labs will show elevated iron, transferritin saturation, ferritin
What are some important distinguishers between nightmares and sleep terrors? What is the prognosis for sleep terrors?
sleep terrors occur during first third of sleep in the slow wave phase--> kiddos do not remember them happening --> prognosis is good, most resolve on own within 1-2 years nightmares occur during second half of sleep in REM and can usually be recalled
What should you suspect in a patient with a significant smoking history who presents with increased shortness of breath, weight loss, low grade fever, and euvolemic hyponatremia?
small cell carcinoma of the lung causing SIADH treat initially with water restriction
This type of cancer has a predilection for early mets to brain _______
small cell lung cancer
What are 3 risk factors for subarachnoid hemorrhage? What is the first step workup? What if this is inconclusive?
smoking history hypertension family hx of aneurysm/rupture first step is to get a noncontrast head CT if this is inconclusive then proceed to lumbar puncture to look for xanthrochromia
How can you calculate a negative or positive predictive value when given sensitivity/specificity/prevalence?
so if prevalence is 40% pick an easy population size like 1000 ---> then you know there will be 400 total positive + false negative and 600 total negative and false positive make your 2x2 table using these numbers (if sensitivity is 90% then you know 360 of 400 will be true positives etc) and calculate PPV or NPV
What should you give a patient with cardiac arrest due to TCA overdose?
sodium bicarb
Which BP medicine is associated with cyanide toxicity? What are the symptoms? Treatment?
sodium nitroprusside look for AMS or unexplained metabolic acidosis treat with sodium thiosulfate
What is the first line treatment for decompensated cirrhosis?
sodium restriction, loop diuretic (furosemide), and potassium-sparing diuretic (spironolactone)
What are 3 physical exam findings that indicate severe aortic stenosis?
solitary soft S2 delayed and diminished carotid pulse ("parvus et tardus") loud and late-peaking systolic murmur
What would you suspect in a patient with worsening headache (worse in the mornings), nausea, and blurry vision? How could you confirm this? What is the next step in workup?
sounds like increased intracranial pressure --> do fundoscopy to look for papilledema next step is to get a brain MRI with contrast to look for a mass or venous sinus thrombosis
What workup should you do in a patient who complains of nightly tingling and pain in the legs that disrupts sleep and is improved by moving her legs? Why?
sounds like restless leg syndrome often associated with iron deficiency so get CBC and iron studies
How should you treat a 23 day old infant who presents with lethargy, poor feeding, high fever, and low blood pressure?
sounds like sepsis treat empirically for e coli, group b strep, listeria give ampicillin + gentamicin/cefotaxime
How should you treat a 31 day old infant who presents with lethargy, poor feeding, high fever, and low blood pressure?
sounds like sepsis treat empirically for strep pneumo or neisseria give ceftriaxone/cefotaxime + vancomycin
What is a big clue that you are dealing with diaper contact dermatitis and not candidiasis? What is the treatment?
sparing of the inguinal folds!!!! treat with frequent diaper changes, exposure of skin to air, and topical barrier creams (zinc oxide, petrolatum)
What are 2 options to treat spasticity in a patient with MS? What about fatigue?
spasticity = baclofen or tizanidine fatigue= amantadine
What does "SpIN" and "SnOUT" help you remember?
specific tests help rule things IN because they have a low false positive rate sensitive tests help rule things OUT because they have a low false negative rate
This is a measure of "true negatives" _______________. Describe how it is calculated.
specificity measures the likelihood of a negative test actually meaning the patient does not have the disease spec = true negatives / (true negatives + false positives) a highly specific test will not pick up on all cases, but the cases it does pick up on are likely to be true because it has a low false positive rate a highly specific test is good to rule things IN
What are 4 features that make a pulmonary nodule more likely to be malignant? What are 2 that make it less likely?
spiculated edges partially solid (heterogeneous) upper lobe location size >0.8 cm less likely --> ground glass texture size < 0.6cm
What degree of spinal rotation on forward bend test indicates scoliosis? What is the next step in workup?
spinal rotation >7 degrees indicates scoliosis get PA and lateral spine x-rays
What should you suspect when a patient with history of alcohol use disorder has isolate gastric varices but no esophageal varices? What would you ask about in their history?
splenic vein thrombosis ask about history of pancreatitis (splenic vein runs along posterior pancreas and pancreatic inflammation causes compression/thrombosis) most common presentation of splenic vein thrombosis is gastric variceal bleed, but can also cause splenomegaly and left-sided portal HTN
What should you suspect in a patient who has drunk 7 beers a day for years who develops blood tinged vomit but does not have esophageal varices? What is the standard treatment?
splenic vein thrombosis causing isolated gastric varices look for history of pancreatitis treatment is splenectomy if there is gastric hemorrhage
What is the most common cause of spontaneous abortion? What are 4 maternal risk factors for spontaneous abortion?
spontaneous abortion = pregnancy loss <20 wks most common cause is fetal chromosome abnormality risk factors: -history of prior spontaneous abortion -advanced maternal age (>35) -extremes in BMI -maternal substance use disorder
What is the most common complication seen in patients with alcohol use disorder who are admitted for recurrent varices? What are two others we worry about?
spontaneous bacterial peritonitis (can give ppx abx with cipro/ofloxazine for 7 days) two others: hepatic encephalopathy and renal failure
What is an abnormality often encountered in patients with squamous cell carcinoma of the lung? What about small cell?
squamous cell --> think about hypercalcemia from PTHrp small cell --> think about SIADH
What are the 2 primary malignancies causing esophageal carcinoma? What is the location and history associated with each?
squamous cell carcinoma is usually in the proximal esophagus and is associated with chronic alcohol and tobacco use as well as history of other SCCs of head adenocarcinoma is usually in the mid to distal esophagus and associated with GERD/Barrett's
What is the Thompson test?
squeezing the back of the gastrocnemius the foot should plantar flex if it does not this indicates an Achilles tendon rupture
What defines a stage I, II, III, and IV pressure ulcer? What is the management of each stage?
stage I: erythema of intact skin stage II: superficial ulcers (partial thickness) for stage I and II treat with semipermeable or occlusive dressing to maintain wound moisture stage III: full thickness ulceration through skin, but not through underlying fascia stage IV: deep ulcers with adjacent tissue damage to fascia/muscle/tendon/bone treat stage III and IV with debridement of necrotic tissue and wound care
This statistical measure is the rate of observed to predicted deaths in a certain population ________________.
standardized mortality ratio = observed/expected SMR < 1 means less deaths than expected SMR > 1 means more deaths than expected remember that to be statistically significant, the confidence interval for SMR must not pass 1.0
What is the management of scleroderma renal crisis (HTN and elevated CK)?
start IV CAPTOPRIL (ACE inhibitors are first line in scleroderma patients) and IV SODIUM NITROPRUSSIDE (need something to lower BP acutely while waiting on captopril effects)
What should you prescribe an immobilized patient who develops hypercalcemia from bone turnover?
start alendronate
What should you do prior to surgery for any patient with pheochromocytoma?
start an alpha blocker to control BP for 10-14 days prior to surgery aggressive IV hydration with fluids and salt
When should hormone replacement therapy be done in patients with Turner syndrome and why? What are some other common comorbidities?
start at age 14 --> if you start too early it will lead to less stature overall due to early close of epiphyseal plates look for renal issues (horseshoe kidney); hypothyroidism; heart issues (coarctation of aorta, mitral valve prolapse, bicuspid aortic valve)
What should you do in a patient with confirmed perforated peptic ulcer?
start broad spectrum IV abx and then go to surgery also start PPI
What is the progression in using ADHD agents?
stimulants --> atomoxetine --> clonidine remember in kiddos under age 6 the first treatment you should try is behavioral therapy
What are the 3 most common pathogens in acute otitis media? What is the treatment? What if this fails?
strep pneumo non-typable haemophilus influenzae, Moraxella first treat with amoxicillin; if infection returns start amoxicillin-clavulanate
What is the most common bacterial cause of pneumonia?
strep pneumonia --> usually lobar
What are the typical presentations of stress, urge, and overflow urinary incontinence? What is the treatment for each?
stress: occurs with cough/valsalva/position change/laughing (treat with pessary, pelvic floor exercises, lifestyle mod) urge: sudden overwhelming need to urinate frequently (treat with antimuscarinics, bladder training) overflow: constant slight dribble and incomplete bladder emptying (evaluate with post-void residual volume and treat by controlling DM etc)
What is the most important thing to do for a patient with heat stroke?
strip them and start evaporative cooling ASAP!
Give the effect of hormone replacement therapy on each: ischemic stroke breast cancer colon cancer type II DM blood clots osteoporosis
stroke = increased risk breast cancer = increased risk colon cancer = decreased risk type II DM = decreased risk blood clots = increased risk osteoporosis = decreased risk
What is the most common CT finding in shaken baby syndrome?
subdural hematoma (crescent) with mixed-density pattern (accidental head trauma usually has uniform density)
How does retinal detachment present?
sudden onset of photopsia (flashes of light) and floaters. Most classic description is "curtain coming down over my eyes" associated with trauma, prior eye surgery, history of macular degeneration
What is the presentation of central retinal artery occlusion? What is the initial management?
sudden painless loss of vision in one eye with a fundoscopic exam showing pale fundus and cherry red spot give acetazolamide, do ocular massage, consult opthalmology (attempt to reduce eye pressure)
What clinical findings suggest superior vena cava syndrome? What is the best diagnostic test to confirm?
superior vena cava syndrome usually begins with dyspnea, persistent cough, facial/neck fullness, and progresses into hoarse voice, dysphagia, and chest pain PE findings include edema and erythema of the neck and dilates veins in the arm/neck get a CT scan of the chest and neck to look for a thrombus, a mass in the upper lobes, or metastatic nodes
What defines subclinical hyperthyroidism? When should it be treated and why?
suppressed TSH with normal T3/T4 if TSH is <0.1 always start antithyroid medications because it usually progresses also treat patients with comorbidities like heart disease, osteoporosis, or advanced age
What should you suspect in a patient with history of asthma who develops recurrent exacerbations with cough, fever, malaise, brownish mucus, and wheezing? What tests would you order? What 2 things should you prescribe?
suspect allergic bronchopulmonary aspergillosis workup with skin aspergillus reaction test or IgE studies treat with 1. systemic glucocorticoids and 2. itraconazole or voriconazole
A 26 year old male with history of asthma presents for hospital follow up after a recent ED visit for an exacerbation. Previously he utilized only rescue inhaler, but recently he has had several exacerbations requiring corticosteroids and a diagnosis of "walking pneumonia". What should you suspect and what mediates it? What is the treatment?
suspect allergic bronchopulmonary aspergillosis in any patient with hx of prior well-controlled asthma who develops recurrent exacerbations, fever, brownish mucus, and central bronchiectasis caused by over-reactivity of IgG and IgE to aspergillus antigen --treat with steroids and itraconazole
A patient in their 30s-40s presents with chronic low back pain that is worse in the mornings, limited range of motion to bend over, and a family history of the same. What do you suspect and what is the first step in working it up?
suspect ankylosing spondylitis workup starts with plan film x-rays of the sacroiliac joints because the first change you can see is sacroiliitis
What should you suspect in any pregnant patient with right side abdominal pain, fever, and leukocytosis? What is the workup?
suspect appendicitis!!! peritoneal pain and mcburny's sign may be absent in pregnancy work up with graded compression abdominal ultrasound (if not definitive get MRI)
What should you suspect when two people who share the same home present with concurrent headaches, nausea, and lightheadedness? What is a lab finding that you would expect? What is the treatment?
suspect carbon monoxide poisoning look for elevated carboxyhemoglobin on ABG treat with high-flow oxygen and hyperbaric oxygen or intubation if severe
What should you suspect in a patient who presents with unilateral headache and neck pain, constricted pupil (miosis), transient vision loss, and weakness in the arms? What is the workup and treatment?
suspect carotid artery dissection get head and neck CT angiogram give thrombolytics if under 4hrs from symptom onset
What would you suspect in an older male with 4 month history of recurrent UTIs, pain with urination, and pain with ejaculation? What would you do next?
suspect chronic bacterial prostatitis you should get a UA before and after prostate massage you should treat with 6 weeks of cipro or TMP-SMZ
What should you suspect in an older patient with multiple atherosclerotic/cardiac risk factors who develops dull cramping spigastric pain that is made worse by eating? What is the workup of choice and why?
suspect chronic mesenteric ischemia increased blood demand in GI tract after eating is not met due to stenoses in the mesenteric vessels; can lead to avoidance of eating and weight loss workup of choice is MRI or CT angiogram so that intervention with angioplasty/stenting can be done at time of diagnosis
What should you suspect in a newborn who has hearing abnormality, congenital heart defect, and eye abnormalities whose mother had a febrile illness with rash during pregnancy?
suspect congenital rubella
What should you suspect when a patient receiving sodium nitroprusside develops AMS or unexplained metabolic acidosis? What is the treatment?
suspect cyanide toxicity treat with sodium thiosulfate
What should you suspect in a patient with proximal muscle weakness, red rash, and elevated AST/ALT/CK?
suspect dermatomyositis
What should you suspect in a patient with dark red rash over the backs of their hands and weakness when rising from seated position? What screening test would you order? What other things should you look for?
suspect dermatomyositis (proximal muscle weakness, gottron papules on hands, heliotrope rash, fatigue) screen for elevated CK and ANA also look for interstitial lung disease (CXR if asymptomatic or CT if pulmonary sx present) and malignancy
What should you suspect in a child with fever, recent sore throat, and inspiratory stridor who is leaned over breathing heavily and drooling?
suspect epiglottitis from Hib!! get lateral neck x-ray to look for thumb sign and prepare for endotracheal intubation
What would you suspect in an African American patient who presents with facial nerve policy, enlarged liver, and multiple lymph nodes? What is the workup?
suspect extrapulmonary sarcoidosis also look for erythema nodosum, uveitis, joint pain usually prominent fatigue is present workup with CXR for hilar lymphadenopathy and then get definitive diagnosis with biopsy of lymph node to show noncaseating granulomas
What should you suspect in a patient who recently traveled to central/south America who presents with GI symptoms, fecal occult blood, and eosinophilia? What other symptom might you ask about? What is the treatment?
suspect helminth infection --> diagnose with a stool O&P ask about transient pulmonary symptoms treat with abendazole
What should you suspect when a patient with decompensated cirrhosis develops a pleural effusion? What is the first-line treatment?
suspect hepatic hydrothorax --> peritoneal ascites passes through the diaphragm treat like regular decompensated cirrhosis with sodium restriction, loop diuretics (furosemide), and potassium-sparing diuretics (spironolactone) this is a sign of advanced liver disease and should prompt consideration for transplant
What should you suspect in a patient who presents with complaints of joint pain and who has a history of DM and palpable liver below the costal margin? What would arthrocentesis show?
suspect hereditary hemochromatosis!!! HHC commonly causes DM, enlarged liver, and arthritis (usually the joint pain doesn't lessen with phlebotomy unfortunately) arthrocentesis will show positive birefringent rhomboid shaped crystals --> calcium pyrophosphate
What should you suspect in young patient with exercise intolerance, syncope, and then sudden cardiac death? What if echo is normal?
suspect hypertrophic cardiomyopathy if echo is normal then suspect anomalous coronary arteries confirm with CT angiography
What are 4 things that would make you suspect septic arthritis in a child with unilateral hip pain? What is your workup? Treatment?
suspect if fever > 101.3 ESR >40 or CRP >2.0 non-weight bearing leukocytosis get arthrocentesis (will likely show WBC >50k) to immediately aspirate the joint once confirmed, you need surgical debridement of the joint space and give IV vancomycin (add IV cefotaxime if patient is under 3 mos old)
What should you suspect when a well-appearing child is brought to clinic for spontaneous bleeding of nose/gums and increased bruising or petechial rash? What is the treatment?
suspect immune thrombocytopenia if no bleeding and platelets >30k observe if bleeding or platelets <30k give IVIG
What is the constellation of symptoms seen in carotid artery dissection? How would you work it up? What is the treatment?
suspect in any patient with unilateral neck pain, transient vision loss, Horner's syndrome (miosis, ptosis), and signs of cerebral ischemia like focal weakness get CT angiography of head and neck treat with thrombolysis if <4hrs from symptom onset and then give antiplatelet therapy (aspirin)
What would you suspect in a pregnant patient who reports generalized pruritis without a rash that itches the most over the palms and soles? What is a lab finding? What is the treatment?
suspect intrahepatic cholestasis of pregancy lab finding: elevated serum bile acids treat with delivery at 37 weeks as it increases the risk of fetal demise
What should you suspect in child with arthritis in multiple symmetric joints that comes and goes? What is the workup?
suspect juvenile idiopathic arthritis get serum anti-citrullinated peptide antibodies
What should you suspect in a patient in middle age with a history of IV drug use who develops very itchy, purple-ish, raised, plaques and papules on their inner wrist? What tests should you run?
suspect lichen planus run liver function tests and Hep C tests
What should you suspect in a patient with a long smoking history who develops chronic cough, weight loss, night fevers, and hypercalcemia? What type might they have?
suspect lung malignancy specifically, squamous cell carcinoma of the lung due to elevated calcium (squamous cell masses can secrete PTHrp which mimics parathyroid hormone causing increased calcium)
What should you suspect in a child with ear pain, fever, and swelling behind the ear making it stick out? What is the workup and treatment?
suspect mastoiditis (infection of mastoid air cells in skull) can diagnose clinically, but if unclear presentation or concern for neuro involvement (neuro findings, nuchal rigidity) get CT or MRI treat with drainage of middle ear via tympanostomy or mastoidectomy and IV antibiotics
What should you suspect in a patient being worked up for elevated creatinine who is also found to have hypercalcemia and anemia?
suspect multiple myeloma (would also have bone pain) get serum/urine protein electrophoresis
What would you suspect in a patient with a leg wound that is more tender than you would expect, fever, hypotension, and eryhthema? What are the bugs? What is the treatment?
suspect necrotizing fasciitis caused mostly by group A strep if crepitus is present think about clostridium treat with surgical debridement and IV broad spectrum antibiotics
What should you suspect when a patient recovering from pancreatitis has persistent low grade fevers and recurrence of abdominal pain? What is the workup?
suspect necrotizing pancreatitis or pancreatic infection get a contrast-enhanced CT!
What should you suspect when an athlete presents with a knee injury and tells you that they felt a "pop" and then could not walk....there is pain and swelling...they cannot fully extend the knee or lift the bent leg against gravity...
suspect patellar tendon rupture surgical repair is indicated and should be sooner rather than later
What should you suspect when a pregnant patient complains of itchiness and then develops a rash on her abdomen of uticarial plaques and pustules?
suspect pemphigoid gestationis treat with topical steroids and antihistamines (lorantadine or cetirizine) for itching
What should you suspect when a patient presents with painless blisters and torn skin on the back of their hands as well as hyperpigmentation or unwanted hair on the face? What should you test for?
suspect porphyria cutanea tarda (heme synthesis pathway defect) caused by deficiency of uroporphyrinogen decarboxylase TEST FOR HEPATITIS C!!!!! treat with avoidance of alcohol, estrogen, and phlebotomy or hydroxychloroquine
What should you suspect when a patient has a huge bump in creatinine after initiation of an ACE inhibitor? Why does this occur?
suspect renal artery stenosis the stenosed renal artery has been signaling to the RAAS system to increase blood flow which has maintained the kidney perfusion....but once you give an ACE inhibitor you have blocked the RAAS system from increasing blood flow and the kidney gets injured
What should you suspect in a patient with treatment-resistant HTN and signs of systemic atherosclerosis? What is the best workup?
suspect renal artery stenosis! get renal duplex ultrasound (especially if elevated creatinine is present) or MRA/CT angiography
What should you suspect when a patient with STEMI symptoms suddenly crashes after being given aspirin, oxygen, morphine, and nitroglycerin? What is the best management?
suspect right ventricular MI leading to cardiogenic shock your best bet is to increase preload by giving IV bolus
What should you suspect when a patient complains of lateral shoulder pain? What if they also have weakness with external rotation or abduction at the shoulder?
suspect rotator cuff tendonitis (pain usually amplifies with reaching or lifting arm over head) suspect rotator cuff tear if pain is accompanied by weakness
What would you suspect when a patient with multiple sexual partners develops symptoms of meningitis (headache, photophobia, neck stiffness) accompanied by changes in hearing/vision? What are some other findings to look for?
suspect secondary syphilis causing meningitis also look for diffuse maculopapular rash including palms/soles tertiary syphilis causes tabes dorsalis (unsteady balance, walking) and pupillary changes (argyl-roberson--pupil reacts to accommodation but not light)
What should you suspect in an infant with fever, increased fussiness, poor feeding, and who is holding the leg still in an unusual position? What are the lab findings?
suspect septic arthritis get ultrasound/MRI to look for effusion drain the septic joint then give IV abx
What should you suspect in a child who is fussy, will not stand, and cries when you attempt to examine the hip? They are febrile and have leukocytosis? How should you manage the case (3 steps)?
suspect septic hip arthritis 1. immediate arthrocentesis to aspirate joint and look for bacteria and WBCs (usually >50k) 2. surgical debridement 3. IV vancomyin (or IV vanc + cepfotaxime if under 3 mos)
What should you suspect if an adolescent obese male presented for unilateral thigh and knee pain and was holding their leg in external rotation? What is the initial workup and what do you expect to see? What is the management?
suspect slipped capital femoral epiphysis get x-ray which will show "ice cream scoop falling off" surgical pinning is needed quickly to avoid avascular necrosis or osteoarthritis (patient should be non-weight bearing until surgery can occur)
What should you suspect when a patient complains of chronic cough, shortness of breath with exertion, hoarse voice, and a feeling of facial/neck fullness? What are 3 physical exam findings you would look for? What is the workup?
suspect superior vena cava syndrome look for dilated veins of neck/arms and edema/erythema of the face workup is CT chest and neck
What should you suspect when a male patient presents with a painless, hard, swollen testicle that does not transilluminate? What is the workup?
suspect testicular cancer start with US of scrotum --> if mass is found to be solid get CT scan and go straight to radical orchiectomy (trans-scrotal biopsy increases risk of metastasis)
If a patient has multiple bouts of pneumonia that occur in the same anatomic location but clear with use of antibiotics what should you suspect? What is the workup?
suspect that there is something obstructing the bronchus like bronchogenic carcinoma or carcinoid tumor next step is to get CT scan, but definitive diagnosis is best made with flexible bronchoscopy
What should you be concerned about in a patient with history of ulcerative colitis who develops severe abdominal pain, tachycardia, and fever? What is the first step in workup?
suspect toxic megacolon get imaging (abdominal x-ray to diagnose and CT to look for complications) avoid colonoscopy due to risk of perforation
What should you suspect in a patient who post-operatively develops abdominal distention and suprapubic tenderness with poor urine output? What is the workup/management?
suspect urinary retention especially if over age 50 insert a foley cath---if large amount of urine comes out this is diagnostic
A 27 year old patient who immigrated from Africa several years ago presents with fatigue, painful urination, and occasional blood in the urine. What do you suspect? How would you work it up and treat?
suspect urinary schistosomiasis in any patient with connection to Africa, dysuria, terminal hematuria, anemia workup includes CBC for eosinophilia and urine sediment to look for eggs treatment is praziquantel
What should you suspect in a postmenopausal woman who develops pelvic pressure or pain, uterine mass, and ascites? What is the treatment?
suspect uterine sarcoma --> especially if there is a hx of pelvic radiation or tamoxifen use! treatment is hysterectomy
What are symptoms of anticholinergic toxicity? What antidepressant overdose often causes this?
symptoms are fevers, dry mucous membranes, tachycardia remember "dry as a bone, hot as a hare, blind as a bat, mad as a hatter, red as a beet" TCA overdose --> sodium bicarb
Describe the findings in HELLP and the first line treatment
symptoms of pre-eclampsia (headache, HTN, proteinuria) also accompanied by: Hemolysis Elevated Liver enzymes Low Platelets first line treatment is magnesium sulfate to prevent seizures then provide supportive care and delivery the baby
What are 5-6 symptoms and 2 lab findings in acute HIV infection?
symptoms: fatigue myalgias sore throat maculopapular rash (may involve palms/soles) oral ulcerations lymphadenopathy labs: leukopenia thrombocytopenia
What are the symptoms and treatment of gastroparesis?
symptoms: nausea/vomiting, early satiety, bloating, abdominal pain, labile glucose treatment: multiple small meals with low fat and only soluble fiber; metoclopramide; erythromycin
What features indicate a scaphoid fracture as the injury in a FOOSH? How should you manage it?
tenderness at radial dorsal aspect of wrist, minimally decreased ROM, and reduced grip strength get x-ray and if that doesn't show it then get MRI or splint the wrist and then repeat x-ray in a week if scaphoid fracture is found you should place a spica cast and continue x-rays every 2 weeks to monitor healing
What is grabbing a knife with your hand most likely to injure and why?
tendons because they run along anterior surface of fingers arteries, veins, and nerves run along the sides
What are 3 congenital causes of DVT? When would you test for them?
test if young patient with no risk factors or recurrent DVTs or strong family hx DVTs protein S protein C antithrombin III all these deficiencies cause hypercoagulable state
What would you suspect in a male patient who has sudden onset of scrotal pain and swelling with no trauma? What is the workup?
testicular torsion get scrotal ultrasound and then go for orchipexy usually there will be lack of cremasteric reflex
What is the recommended workup for a scrotal/testicular injury with severe pain and visible bruising?
testicular/scrotal ultrasound and urinalysis to look for hematuria
Do you remember how to count boxes on EKG? What is a normal PR interval? QRS size?
the count of big boxes goes: 300-150-100-75-60 normal PR interval is 3-5 small boxes QRS should be narrower than 1 small box
What are the symptoms of sickle cell trait?
there aren't any --> usually asymptomatic and doesn't cause anemia
What do these medications have in common: rifampin, phenytoin, carbamazepine
they all increase metabolism of thyroid hormone will need to increase Synthroid dose
Why should ceftriaxone and sulfonamides be avoided in neonates under 28 days old?
they both lead to increased risk of kernicterus
What do methotrexate, phenytoin, and trimethoprim have in common?
they can all cause folate deficiency! don't use them in pregnancy, supplement folate, and treat deficiencies that arise with folinic acid
What is the ethical standing on allowing incarcerated patients to participate in clinical trials?
they have a right to participate like anyone else but you must make sure there are no coercive factors present (early release, financial gain, etc) also must be approved by IRB
How do organophosphates cause toxicity? What are the symptoms? What is the treatment?
they inhibit acetylcholinesterase in the NMJ to lead to acetylcholine overdrive cause: sweating, diarrhea, miosis, drooling, urination, emesis, bradycardia treat with atropine and pralidoxime; give activated charcoal if you are within one hour of ingestion
How should you manage all patients with heart failure and LVEF <40%?
they should all be started on an ACE (lisinopril) or an ARB (losartan)-->start at small dose and titrate as their blood pressure can tolerate it; then add a beta blocker when able
What happens if you give a patient with renal artery stenosis an ACE inhibitor?
they will have decreased response of the RAAS system to hypoperfusion and will develop acute kidney injury
Name some antihypertensives that are associated with pancreatitis (try for 4-5)
thiazides: HCTZ, chlorthalidone loop diuretics: furosemide ACE: enalapril ARB: losartan
Name 4 conditions associated with HLA-B27
think "PAIR" psoriatic arthritis ankylosing spondylitis inflammatory bowel disease (crohns/UC) reactive arthritis
What should you suspect in a child with dark red blood found in their diaper and intermittent periods where they scream and cry for seemingly no reason? What is the initial workup and treatment?
think about intussusception!! get upright x-ray to look for free air under diaphragm and make sure there is no perforation treat with air or water-soluble enema big risk factor is recent rotavirus vaccine or viral illness (cause Peyers patches which serve as lead point)
What are the symptoms of lead poisoning in kiddos?
think decreased alertness, fussiness, less appetite, vague abdominal pain, anemia, blue spots on fingers get CBC, serum iron and ferritin, and reticulocyte count
What should you do if a patient who received BCG vaccine against tuberculosis has a PPD skin test >15mm? What is the workup and treatment?
this indicates high chance of latent TB get a chest x-ray treat with isoniazid for 9 months
What does it mean when a patient has hearing loss and Rinne test shows AC > BC in both ears but Weber lateralizes to the right ear?
this indicates sensorineural hearing loss and Weber will lateralize to UNAFFECTED ear so the left ear has sensorineural loss
What determines whether a mother with HIV should have a vaginal or cesarean delivery? What HIV med should the baby be given?
this is all determined by viral load at time of delivery <1000 = vaginal delivery and zidovudine for infant >1000 = cesarean and zidovudine + AART for infant
How would you treat a farmer who showed up with uncontrollable crying, sweating, runny nose, diarrhea, and bradycardia? What would their pupils look like?
this is cholinergic poisoning from organophosphates blocking acetylcholinesterase give activated charcoal if within one hour of ingestion and then treat with atropine and pralidoxime pupils should be pinpoint (miosis)
What would be your first line treatment for a 20 year old patient who has excessive daytime sleepiness, hypnogogic hallucinations, and loss of muscle tone when upset or surprised? What would you expect a sleep study to show? What CSF finding would support your diagnosis?
this is narcolepsy --> first line med is modafinil sleep study should show decreased REM latency < 15 min CSF may show hypocretin-1 deficiency
A patient presents with RUQ pain and nausea. Abdominal ultrasound reveals multiple small gallstones and calcifications of the gallbladder wall. What is the next step?
this is porcelain gallbladder and shows increased risk of cancer --> prophylactic cholecystectomy
A concerned parent presents with their teenager--they are worried that their child's poor posture is giving them a "hump back". On exam, thoracic kyphosis is present. However, when you ask the teenager to lie supine or to extend their back the kyphosis corrects itself. What is the prognosis and treatment?
this is postural kyphosis, a common finding in adolescents correctable by posture, so no treatment indicated
What do you suspect when a patient presents after an episode of syncope and tells you that they don't remember any unusual symptoms or feelings prior to passing out? What is the workup?
this sounds cardiogenic because there was no prodromal nausea, dizziness, hotness, palpitations workup is heart telemetry monitoring and echocardiogram
What underlying condition should you do a workup for on a patient who presents with muscle pain, purple discoloration around the eyes, and painful lesions on the fingers? Why?
this sounds like DERMATOMYOSITIS look for underlying malignancy, esp of lungs or colon or ovary and then treat with glucocorticouds
What is the first step in working up a patient with epigastric pain after meals that radiates to her shoulder?
this sounds like biliary cholic --> get abdominal US
What is the medical management of patients with latent syphilis of unknown duration or duration >1yr?
three doses of IM penicillin G weekly for 3 weeks
What would you suspect in a patient with schistocytes and low platelets?
thrombotic thrombocytopenic purpura caused by autoantibodies to ADAMTS13 (cannot cleave vWF resulting in platelet trapping and hemolysis) treat with steroids, plasma exchange, rituximab
What are 4 skin conditions that should make you suspect HIV?
thrush acute-onset severe psoriasis recurrent herpes zoster disseminated molluscum contagiosum
What would you suspect in a patient training for a marathon who develops pain over the lower tibia? What will x-ray likely show and what is the management?
tibial stress fracture "aka shin splints" x-ray usually is negative manage with splinting, reduced weight bearing, and graduated exercise regimen
What long-term complications of DM can be prevented by tight glycemic control (HbA1c around 7%)?
tight glycemic control only improves prognosis of microvascular changes like nephropathy/proteinuria and retinopathy
What is the purpose of the "intention to treat" approach in research?
to preserve randomization!! means that you analyze all participants enrolled regardless of whether they dropped out etc
Why is prophylactic pituitary radiation sometimes performed after adrenalectomy?
to prevent Nelson's syndrome
What is the treatment for comedonal acne? Aka acne vulgaris
topical retinoid + topical acid
Name 3 pathogens commonly associated with in utero infection that lead to increased risk of fetal demise
toxoplasmosis listeria parvo B19
What is the treatment for a non-functioning pituitary adenoma? What is the preferred treatment for a prolactinoma?
trans-sphenoid surgical removal radiation is too slow, can damage nearby structures, and may cause hypopituitarism prolactinoma (look for prolactin >200) are treated with cabergoline/bromocriptine (dopamine agonists)
What would you suspect in a newborn whose mother had uncontrolled gestational diabetes who develops respiratory distress, tachypnea, and a heart murmur? What is the prognosis?
transient cardiomyopathy caused by increased glycogen deposition on interventricular septum get echo to show thickened interventricular septum prognosis is generally good, most babies will have spontaneous resolution as periods of fasting lead to use of the extra deposited glycogen
What is amaurosis fugax? What should you look for on physical exam?
transient painless vision loss due to ischemic event involving retinal artery look for carotid artery bruit
What genetic change causes CML? What is the treatment?
translocation of chromosome 9 and 22 leading to bcr-abl fusion protein treat with imatinib (tyrosine kinase inhibitor) and later bone marrow transplant
What does a bcr-abl fusion protein cause? How does it lead to cancer? What is the treatment?
translocation of chromosomes 9 and 22 that leads to unregulated tyrosine kinase activity treat with tyrosine kinase inhibitors like imatinib to stabilize and then go for bone marrow transplant once you find a match
What is a side effect of trastuzumab you should know? What should you counsel patients if they develop this side effect?
trastuzumab = monoclonal antibody use as adjunct to target HER2 breast cancers causes loss of myocardial contractility that can lead to reduction in LVEF and heart failure symptoms hold trastuzumab for 4 weeks if LVEF drops >15% or patients have symptoms of heart failure counsel patients that cardiotoxicity fully reverses in most patients once trastuzumab is stopped it responds well to typical CHF tx like beta blockers and ACE inhibitors
How does giardia infection usually present? What is the treatment?
travelers diarrhea with onset of symptoms at least one week after exposure watery diarrhea with fatty and foul-smelling stool, abdominal cramping, and malaise treat with metronidazole
What skin condition do tar-based creams treat? How does it present?
treat seborrheic dermatitis --> presents as dry flakey oily patches in areas with lots of sebaceous glands (nose folds, forehead, scalp)
How are acute MS exacerbations treated? When is IV route indicated? What if symptoms do not respond?
treat with corticosteroids (oral or IV) give IV steroids if optic neuritis is present (vision change/loss and pain with eye movement) if patient doesn't respond to steroids you can do plasmapharesis
What is the best first line treatment for platelet dysfunction caused by chronic kidney disease? What bleeding study would be altered?
treat with desmopressin to increase VWF action there will be prolonged bleeding time
How should you manage lithium-induced hypothyroidism?
treat with levothyroxine, not usually an indication alone to stop lithium (especially if patient has had multiple prior medication trials or has severe bipolar)
What is the treatment for chronic prostatitis that is not caused by bacterial infection?
treat with medications for BPH including tamsulosin, antibiotics, and anti-inflammatories
What is the treatment for Wilson's disease? How does it manifest?
treat with penicillamine to increase copper excretion look for young patient with chronic liver disease, neuropsych issues, rings around iris
What is the prognosis for sarcoidosis?
treat with steroids for 6-12 months about 75% of cases resolve over time and do not occur
What is a good medication for trigeminal neuralgia? How about cluster headaches? How about migraines?
trigeminal neuralgia --> carbamazepine cluster HA --> verapamil migraines --> triptans, caffeine, NSAIDs
What defines severe hypertriglyceridemia? What medication should be started?
triglycerides > 800 start fenofibrate or gemfibrozil
What should you suspect in a patient from Asia who had several weeks of lethargy and dry cough and now presents with headache and nuchal rigidity? What would CSF show? What would your confirmatory test be?
tubercular meningitis (look for white/yellow nodules on fundoscopic exam) CSF will show high protein (like 300+), lymphocytic dominance, and low glucose (<10) brain imaging will reveal basilar meningeal enhancement confirm with CSF acid-fast bacilli
What is a good way to work up suspected diabetic neuropathy? Give 3 possible treatments?
tuning fork test treat with: duloxetine, pregabalin, or TCA can also use gabapentin or carbamazepine
What should you offer all victims of sexual assault? Name 5 medications.
ulipristal (can be taken up to 5 days later) or copper IUD if there is no evidence of cervical inflammation ceftriaxone azithromycin HIV AART metronidazole also prophylactic Hep B vaccine if not vaccinated
Describe how damage to the ulnar nerve would present? What about the median nerve? What about the radial nerve?
ulnar nerve --> sensation to pinky and ring finger median nerve --> sensation to palmar surface of first three fingers radial nerve --> dorsal surface of first three fingers extending into forearm
What should be done for any patient diagnosed with thyroid cancer? What is the typical management based on size?
ultrasound of the neck and cervical lymph nodes for staging tumor <1cm --> thyroid lobectomy tumor >1cm --> total thyroidectomy
What causes variable decelerations on fetal tracings? How can you treat it?
umbilical cord compression can treat with amnioinfusion
What are the most common pathogens causing sepsis in infants under 28 days old? What is the empiric antibiotic regimen? What are the most common pathogens in infants over 28 days old? What is the empiric antibiotic regimen?
under 28 days old --E coli (E coli UTI is most common cause) --Group B strep --Listeria ***treat with ampicillin + gentamicin or cefotaxime over 28 days old --strep pneumo --neisseria meningitidis ***treat with ceftriaxone/cefotaxime + vancomycin
Name the most common pathogens causing sepsis in infants by age category and give the empiric treatment for each
under 28 days old --E coli --Group B strep --Listeria treat with ampicillin + gentamicin/cefotaxime over 28 days old --strep pneumo --neisseria meningitidis treat with ceftriaxone/cefotaxime plus vancomycin
What is the workup of a breast mass based on age? What are some characteristics that would raise your suspicion that a mass may be malignant?
under age 30 --> ultrasound to start over age 30 --> mammogram to start characteristics that indicate malignancy: ill-defined borders, immobile, location in upper outer quadrant, lymphadenopathy, associated skin changes, nipple discharge, new nipple inversion
What is the workup protocol for dyspepsia in patients under age 60? What about patients over age 60?
under age 60 start with H. pylori testing (stool antigen, urea breath test) and treat if positive --> if not positive then give empiric PPI over age 60 go for endoscopy (H pylori treatment is clarithromycin + PPI + amoxicillin or metronidazole)
What should you suspect when a patient has an abrupt appearance of multiple very itchy seborrheic keratosis?
underlying malignancy (especially GI)
How should you manage a patient who is found to have elevated TSH and low T4 on labs just prior to a necessary surgery?
undiagnosed hypothyroidism only increases risk of postoperative issues by a little bit if you treat with levothyroxine before the surgery it can increase myocardial oxygen demand and cause an MI or arrhythmia the best approach is to proceed with surgery as planned (if emergent) and then correct hypothyroidism afterwards
What is the workup of nipple discharge based on unilateral vs bilateral?
unilateral is more concerning so you want to get an ultrasound (with a mammogram if >30 yo) bilateral is more likely to be due to hormonal effects so get a pregnancy test and check for galactorrhea (prolactinoma, hypothyroidism, med effect)
What does damage to the recurrent laryngeal nerve cause?
unilateral paralysis of vocal cords and voice change
Why do we give hormone replacement therapy as a combination of hormones instead of just estrogen in women who still have a uterus?
unopposed estrogen increases the risk of endometrial cancer
What amount of weight loss is considered normal in the first week of life?
up to 10% loss from birth weight should keep encouraging breastfeeding
Where does TB like to go in the lungs?
upper/apical lobes
What causes urge incontinence? What are the 4 things you should recommend to a patient as initial management? If this fails, what are 3 medications you can prescribe?
urge incontinence is caused by overactivity of the detrusor muscle start with recommending: bladder training with timed voids avoidance of alcohol/coffee weight loss cessation of smoking if this fails then you can prescribe an antimuscarinic: tolterodine oxybutynin solifenacin
What are the common symptoms of bacterial prostatitis? what is the treatment?
urinary symptoms (dysuria, frequency, etc) with pain in the perineum treat with a 6 week course of TMP-SMZ
What is the treatment for primary sclerosing cholangitis?
ursodeoxycholic acid (and liver transplant) PSC is highly associated with irritable bowel disease elevated alk phos
What is the best way to use hormone replacement therapy as someone enters menopause?
use for only 3-5 years and in women under age 60 remember it increases risk of blood clots, stroke, breast cancer, and CAD (it is protective against osteoporosis, type II DM, and colon cancer)
What are the most common risk factors for osteonecrosis of the femoral head (aka avascular necrosis)? What is the preferred imaging? What is the usual treatment?
use of corticosteroids long-term, especially in SLE pts excessive alcohol use trauma sickle cell disease hemodialysis or post renal transplant HIV infection best imaging is MRI treat with total hip replacement if stage 4 treat with core decompression if early stage 1-2
What is the best way to screen for alcohol use disorder?
use the single-question method "how many times in the past year have you had more than 4/5 drinks in one day?" (5 for men; 4 for women) 1+ is a positive result and indicates need for further screening
How does pemphigoid gestationis present? How should you treat it?
usually 2nd-3rd trimester that starts with generalized itching and then a rash develops rash is usually periumbilical with uticarial papules and plaques that later form vesicles/bullae rash spreads quickly over body but spares mucus membranes treat with topical steroids like triamcinolone +/- lorantadine/cetirizine
What is the typical presentation of Duchenne muscular dystrophy? What is a good screening lab if you are concerned for this?
usually a boy 2-3 years old with delayed milestones, proximal muscle weakness, calf pseudohypertrophy due to defective dystrophin gene on X chromosome test for elevated creatinine kinase from muscle breakdown confirm with genetic testing showing 1+ exon deletions in the dystophin gene
What is the usual clinical scenario for cat-scratch disease? What is the bacteria and treatment? Common complication?
usually a child with exposure to a cat who develops a swollen lymph node and persistent fever (often a papule at site of injury, but not always) Bartonella henslae is a gram negative bacilli Treat with azithromycin Complication can include suppurative lymphadenitis which may benefit from needle drainage
How does immune thrombocytopenia usually present? What is the treatment strategy?
usually a child with recent viral illness who develops petechiae and bruising +/- mucosal bleeding but is otherwise asymptomatic platelets will be <100,000 if no bleeding is present then monitor and recheck platelets if bleeding is present or platelet count <30,000 then treat with IVIG
What symptoms would you expect a patient to report who has a bamboo spine on imaging? What is their likely age/gender?
usually a male in 30s-40s who presents with back pain that is worse at rest or after inactivity and improves with movement....they will usually also have hip and shoulder pain...exam will show limited spinal motility think about HLA-B27
How do posterior urethral valves present?
usually a male infant with recurrent UTIs, strain to urinate, incontinence, and bilateral hydronephrosis
What is the typical presentation of a cluster headache? What is an acute treatment? What about a preventative treatment?
usually a male patient headaches lasting <3 hours; often multiple per day severe headaches that are always unilateral may cause lacrimation, miosis, conjunctival injection, and runny nose treat acutely with inhaled oxygen prevent with verapamil
How does hemochromatosis usually present? What are the lab findings?
usually a middle age male with "bronze diabetes" leads to darkened skin, diabetes, liver enzyme elevations look for elevated iron
How does parvo B19 typically present in adults? What is the prognosis?
usually a mild viral illness and then later development of bilateral arthritis in the hands and wrists---also look for a faint erythematous reticular rash prognosis is good with spontaneous resolution in a few weeks...can take NSAIDs in meantime
What are the 3 steps in working up/treating a suspected testicular mass?
usually a painless, firm, mass that doesn't transilluminate 1. scrotal ultrasound to ID nodule 2. if solid nodule then get CT and AFP/b-HCG 3. radical orchiectomy to remove affected testicle
What is the typical presentation of Crohn's disease? What are the usual findings on colonoscopy?
usually a patient age 15-40 who presents with recurrent diarrhea, abdominal pain, bloody stools colonoscopy usually shows cobblestoning, aphthous ulcers, and skip lesions rectum is usually spared in Crohn's disease
What are the typical findings in pulmonary contusion? What is the management?
usually a patient with blunt trauma to the chest who develops chest pain, shortness of breath, maybe hemoptysis CXR shows irregular, localized opacification care is supportive: admit and monitor, give pain meds to allow breathing, respiratory therapy for supplemental O2 etc
What is the typical presentation of uterine sarcoma? What are 2 risk factors? How should you treat it?
usually a postmenopausal woman with new onset pelvic pressure or pain, a uterine mass, and ascites tamoxifen use and history of pelvic radiation are risk factors treat with hysterectomy
What is the typical presentation of pseudotumor cerebri? What would your work up be?
usually a young child-bearing age female with obesity presents with headache, nausea, sometimes visual disturbance first do ophthalmoscopy to look for papilledema --> then get imaging to make sure no herniation is present --> finally, do LP to confirm diagnosis with opening pressure > 20-25cm H2O
What is the typical presentation of pseudofolliculitis barbae? How should it be treated?
usually an African American male with tightly curled facial hair who develops bumps on neck after shaving treat with cessation of shaving --> usually resolves in a few weeks
What is the usual presentation of slipped capital femoral ephiphysis? What is the management and why?
usually an obese adolescent with thigh pain that refers down to the knee difficulty internally rotating hip (hold leg in external rotation) and altered gait make patient non-weight bearing and refer for surgical pinning early to avoid avascular necrosis or osteoarthritis sign on x-ray is "ice cream scoop falling off"
What is the common presentation of diphtheria? What is the treatment? What are complications you worry about?
usually an older child with fever, malaise, sore throat, lymphadenopathy and GREY PSEUDOMEMBRANE over the throat treatment: erythromycin or penicillin G (give diphtheria immunoglobulin if severe) complications we worry about are toxin mediated myocarditis, neuritis, or kidney disease
What is the clinical picture associated with blepharospasm? What is the treatment?
usually an older female states she cannot keep her eye open in response to stimuli like sunlight or irritants treat with botox injection
What is an ocular melanoma and how do they present? What is the management?
usually are asymptomatic and found on screening for other things as a small pigmented lesion in the choroid can cause progressive painless blurry vision change asymptomatic patients with lesions <10mm can be watched with repeat exams in 3mos and then every 6 mos symptomatic patients or those with a lesion >10mm should have radiation treatment
What does a harsh holosystolic murmur with a palpable thrill indicate?
ventral septal defect
Describe the findings of perinatal cardiomyopathy? How is it diagnosed, managed, and monitored? How should you counsel a patient with history of this who is considering another pregnancy?
usually in women >30 years old or multiple gestation usually occurs 36wks to 5mos postpartum diagnose with echo treat with standard systolic heart failure regimen monitor with serial echocardiograms counsel patients with persistent (>5wks post partum) or recurrent cases to avoid pregnancy
What is the classic pattern of pain in rotator cuff tendonitis? What finding on PE makes a rotator cuff tear more likely?
usually lateral and deltoid pain aggravated by reaching for an object or lifting the arm above the head if pain is accompanied by weakness or loss of strength with external rotation or abduction of shoulder this indicates a rotator cuff tear
What is considered a normal LVEF for someone with mitral regurg? Why is this important?
usually normal LVEF is >45% in MR patients it LVEF should be > 60% to be normal this is important becaues mitral valve repair is indicated at LVEF < 60%
What are 6 symptoms that should make you suspect Kawasaki disease? How should you treat/manage these patients?
usually patient under age 5 with: fever lasting 5+ days bilateral conjunctivitis strawberry tongue swollen hands/feet rash of inguinal folds, trunk, perineum cervical lymphadenopathy treat with IVIG + aspirin get echo to look for evidence of coronary artery aneurysm
What is the typical presentation of Guillain-Barre? What causes it? What is the treatment?
usually preceded by a respiratory or GI illness-->presents as ascending weakness, mild numbness/parasthesias, and later bulbar and diaphragmatic involvement causing autonomic disturbance autoimmune demyelination of peripheral nerves treat with plasma exchange and IVIG
What is the therapy for genitopelvic pain disorder? How does it usually present?
usually presents as SHALLOW introital pain treat with pelvic floor physical therapy
What are the presenting symptoms of epididymitis? What is the usual cause by age range? What is the workup?
usually presents as unilateral posterior testicular pain that is relieved by testicular elevation and epidydimal swelling and tenderness if under age 35 usually due to chlamydia/gonorrhea if over 35 usually due to bladder outlet obstruction and coliform bacteria get G/C screen and urinalysis/culture
What defines a threatened abortion?
vaginal bleeding at <20 gestation with a closed cervix and reassuring fetal heartbeat on ultrasound
What are 5 criteria that define severe aortic stenosis and warrant valve replacement? What are some physical exam findings?
valve replacement is warranted for: aortic jet velocity >4 transvalve gradient >40 valve area <1cm symptomatic (dyspnea, angina, syncope) LVEF < 50% physical exam will show a harsh murmur at the base of the heart, delayed carotid pulses, soft second heart sound
What is the empiric treatment of bacterial meningitis in a patient over age 50? What would you expect CSF to show?
vancomycin + ceftriaxone + ampicillin (increased risk of listeria) CSF should show high WBC (neutrophils); low glucose; high protein
What are the findings in Osler-Rendu-Weber syndrome?
vascular CNS lesions multiple telangiectasias
Try to name some differentiating characteristics of each: vascular dementia frontotemporal dementia lewy body dementia prion disease
vascular dementia: step-wise; look for things like HTN, CAD, or stroke; early executive dysfunction (math etc) frontotemporal: early behavioral changes; hyperorality; apathy/disinhibition/impulsivity lewy body: visual hallucinations; parkinsonism (flat facies, shuffling gait, muscular rigidity); REM sleep disorders prion disease: rapid progression; myoclonus and/or seizures
What supports a diagnosis of antiphospholipid syndrome? What are associated antibodies (try for 3)? What is the best birth control option for these patients?
vascular thrombosis + recurrent pregnancy loss lupus anticoagulant anticardiolipin antibody anti-beta2-glycoprotein antibody all estrogen-containing birth controls are contraindicated so the best options are progesterone IUD/implant (esp if hx of heavy menstrual bleeding) or copper IUD
What should you suspect first in a child with sickle cell disease who develops pain of an extremity?
vaso-occlusive pain crisis give IVF and IV pain meds
What is the most common complication of sickle cell disease? How does it present and how should you manage it?
vaso-occlusive pain spells can be triggered by dehydration, infection, stress, weather changes, or menstruation treat with IV opioids (morphine), aggressive IV hydration, and NSAIDs
Factor V Leiden deficiency increases the risk of _______________
venous thrombosis
What is verification/workup bias? How can you try to eliminate it?
verification bias is a type of measurement bias that occurs when a study uses a gold standard diagnostic test selectively to confirm a positive/negative preliminary test you can eliminate it by doing the confirmatory test on everyone, or by performing the gold standard test on a random cohort of participants who had a negative preliminary test --> then you extrapolate the number of positives found to see how many patients who screened negative would have had something found with gold standard testing
What percentage of vertically transmitted Hep B cases become chronic? What about people infected as a child? Adult?
vertical transmission 90% become chronic child 20-50% become chronic adult <5% become chronic
What CSF findings indicate a traumatic LP?
very high RBC ( >6,000) without xanthochromia points away from subarachnoid hemorrhage which is the other finding that could cause high RBC protein and glucose are both usually high
What should you suspect in a male infant with recurrent UTIs? What is the workup?
vesicouretal reflex (urine initially flows backwards) posterior urethral valves (weak stream, distended bladder) work up with voiding cystourethrogram
When do patients with viral conjunctivitis stop being contagious? What are signs that differentiate this from bacterial or allergic conjunctivitis?
viral conjunctivitis is contagious until the eye discharge resolves look for purulent discharge (bacterial) or itching (allergic)
What is considered virologic failure when an HIV patient has taken ARTs consistently for 6 months
viral load >200
What are the distribution, discharge, and associated findings in: viral conjunctivitis bacterial conjunctivitis allergic conjunctivitis
viral: unilateral or bilateral; watery to mucoid discharge that may crust in morning; usually sick recently with URI sx bacterial: unilateral or bilateral; purulent discharge that accumulates soon after being wiped away; no recent sickness allergic: always bilateral; watery discharge that usually does not crust; ITCHING
What are 3 situations in which ERCP is indicated for working up gallbladder disease?
visualized choledocholithiasis (stone in bile duct) high risk features (dilated common bile duct, elevated bilirubin or alk phos) symptoms of acute cholangitis (fever, RUQ pain, jaundice, hypotension, confusion)
What are two common skin manifestations of celiac disease?
vitiligo and dermatitis herpetiformus
How should you advise patients with acne to care for their skin?
wash gently twice daily with warm water and pH-neutral cleansers (avoid scrubbing!) use water based lotions and cosmetics
What is the best management of cryptorchidism? What are the increased risks from having this condition?
watch until age 6 months and then refer to surgery for orchiopexy (should be done before age 1) surgery decreases the increased risk of infertility, inguinal hernias, and testicular torsion but the risk of malignancy remains increased
What are findings in an infant with posterior urethral valves? What is the workup?
weak urine stream, recurrent UTIs, bladder distention ultrasound may show dilated kidneys/ureters and dilated bladder with thickened wall workup is voiding cystourethrogram
How should you manage a newborn whose weight is 8% lower than at birth on their one week followup?
weight loss up to 10% of body weight at birth is normal colostrum is nutrient dense but has less volume leading to some weight loss schedule close follow up in 2-3 days and encourage on demand breast feeding
What are the symptoms of chronic adrenal insufficiency? What are 3 lab findings? What is the best test to work it up?
weight loss, abdominal pain, muscle weakness, increased pigmentation, decreased axillary/pubic hair hyponatremia, hyperkalemia, hyperchloremic metabolic acidosis workup with morning plasma cortisol (will be low) and simultaneous ACTH (will be elevated)
What is the classic description of alopecia? What is an associated finding in the hands?
well-demarcated, often round, non-scarred patch of complete hair loss nail pitting is also associated
When should you suspect mitochondrial inheritance on a pedigree?
when all of an affected females children are positive, but none of an unaffected females children are positive
What causes Barret's esophagus? What is the strategy for monitoring/treating?
when the esophageal linings transforms from stratified squamous epithelium (normal) to metaplastic columnar epithelium (pre-cancerous) normal esophagus is pink and shiny but Barret's is darker red and velvety get a biopsy and if there is no dysplasia then start a PPI and recheck endoscopy in 3-5 years if there is low-grade dysplasia then give PPI and monitor every 6-12 months or proceed with endoscopic eradication if there is high-grade dysplasia then proceed directly to endoscopic eradication treatment
What is ascertainment bias? What is another name for it?
when the results from a study are extrapolated to a population when they do not actually reflect that population aka results found in an atypical population are expanded to the entire population also called sampling bias because the sample you selected to participate in the study doesn't match the general population well
What is the most sensitive finding that points to complete Achilles tendon rupture? What is the next step in workup?
when you squeeze the calf (gastrocnemius) the foot should plantar flex if no plantar flexion with calf squeeze this indicates complete rupture next step in workup is MRI
What is the typical presentation of fibromyalgia? What workup should be done at time of diagnosis?
widespread muscular pain point tenderness on exam fatigue impaired concentration or psychiatric sx at time of diagnosis also get CBC, TSH, and ESR to rule out conditions with similar symptoms
When is the Q-tip test performed and what is considered a positive?
women with stress incontinence to assess for urethral hypermobility --> >30 degree displacement with Valsalva is positive
How should you work up a patient you suspect has diverticulitis? What is the initial treatment? What if they still have symptoms after 2-3 days of treatment?
work up with colonoscopy treat with clear liquid diet, IV antibiotics (cipro and flagyl), and hospitalization if symptoms are present 2-3 days after starting treatment worry about colonic abscess and get a repeat CT abdomen
What symptoms would you expect to see in a neonate with neonatal polycythemia? What is the workup and treatment if needed?
would expect ruddy complexion, hyperbilirubinemia, hyperglycemia, respiratory distress, cyanosis, apnea first workup is to confirm with peripheral blood draw then can do partial exchange transfusion
What is the best way to prepare a severed digit for transport to a surgical center for re-attachment?
wrap in gauze moistened with saline, place in sterile plastic bag, place in cooler filled with mixture of ice and saline (just ice increases risk of frostbite)
What levels should you target when treating a patient with Graves disease during pregnancy? What drugs are preferred and when?
you don't want to too tightly regulate the thyroid hormone control because over treatment can lead to fetal hypothyroidism and goiter so you want to keep the patient at a mildly hyperthyroid state (TSH a little low, T4 a little high) give propylthiouracil (PTU) for first trimester and methimazole for second and third trimesters --> we do it this way because methimazole is teratogenic but PTU commonly causes liver issues...so in first trimester the avoidance of teratogenicity makes the risk to the liver worth it
How should you manage a patient with unstable angina or NSTEMI?
you have to risk stratify them low risk --> exercise stress test high risk --> early coronary angiography (within 24 hr) hemodynamic instability, recurrent chest pain, heart failure, new mitral regurg, and ventricular arrhythmia are all indications for emergent coronary angiography
What are the diagnostic criteria for acute rheumatic fever? What is the treatment?
you need either 2 major or 1 major and 2 minor criteria major: JONES J=joints=migratory arthritis O=heart=carditis N=nodules (subcutaneous) E=erythema marginatum (pink ring rash) S=Sydenham chorea (writhing motions of body) minor fever arthralgias elevated ESR/CRP prolonged PR interval treat with penicillin!
When would it be appropriate to use a tagged red blood cell scan for suspected GI bleed?
you need it to be a pretty steady/rapid bleed
What is the workup of any pulmonary nodule suspected to be cancerous prior to selecting a treatment?
you need to know the stage before you know whether localized or systemic treatment is best you need to get: 1. CT or PET scan 2. radionuclide bone scans
What is the treatment approach to actinic keratoses?
you need to treat because 20% progress to SCC if solitary lesion, you can surgically remove or do cryotherapy if diffuse, then use 5-fluorouracil cream topically for 3-6 weeks or imiquimod cream or topical diclofenac
A woman with Grave's disease presents to your office because she has had a positive home pregnancy test. You confirm with a UPT. How should you counsel her about taking her antithyroid drugs during pregnancy?
you should switch her to propylthiouracil for the first trimester because methimazole can be teratogenic but you should switch her back to methimazole for trimesters 2 and 3 to prevent risk of hepatotoxicity from propylthiouracil avoid use of beta blockers if possible during pregnancy
What are the typical symptoms of Parvo B19 in children? What about adults?
young children usually get a "slapped cheek" rash and a mild pink reticular rash and viral URI symptoms (they rarely develop arthralgias) adults are more likely to have a mild URI followed later by joint pain bilaterally in hands and wrists
Describe the typical case of a hepatic adenoma. What are the imaging findings? How should you treat it? How should you monitor a patient known to have one?
younger female on OCPs with a hepatic mass and normal LFTs imaging will show a mass with well-demarcated peripheral enhancement treat by stopping OCPs if mass is <5cm; if mass is symptomatic or >5cm then surgical resection monitor with serial imaging and alpha-feta-protein
What medication should all infants born to HIV+ mothers be given and for how long?
zidovudine for at least 6 months
