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166 Cards in this Set
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Which of the following is true regarding adult epiglottitis?
A) airway obstruction is usually caused by inflam of infraglottic tissues B) Drooling and stridor are infrequent presenting signs C) Disease is more common in winter D) Nebulized racemic epi decreases intubation E) lateral neck xray can safely exclude epiglotitis |
B) drooling and stridor are infrequent signs
Epiglottitis may involve several supraglottic structures including vallecula, aryepiglottic folds, arytenoids, lingual tonsils, base of tongue but does not extent to infraglottic tissues b/c robust attachments b/t. Therefore epiglottitis aka supraglottitis Most typically pts present w/ severe sore throat and painful dysphagia. No seasonal variance. More common in males and smokers Neither epi nor steroids shown to be beneficial. Caution when use epi as can get rebound upper-airway constriction after tx completed. 90% have abnl lateral neck film with classic thumb/thumbprint of inflamed epiglottits. Gold std for dx=nasopharyngoscopy Vallecula sign screen on lat neck films if find base of tongue and trace it inferiorly toward hyoid bone to locate vallecula and determine if vallecula not deep an droughly parallel to pharyngotracheal air column epiglottitis is present with 98% sens and 100% spec. |
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46yoM bit by snake with black, yellow, red coloring. No pain or swelling and never been bite by snake before. How manage?
a) Oberserve 6h then if asx d/c b) immediately give CroFab antivenin (crotalidae polyvalent immune fab ovine) c) wound should be irrigated with sterile saline and sterile suction catheter to remove venom d) pt should immediately receive North American coral snake antivenin e) pt should receive IM mixture of antivenins as close to bite site as possible |
"Red on yellow, kill a fellow"
Treat with coral antivenin even if no sx Neurotoxicity can be rapid or delay up to 12hrs. Pts can have N/V/HA/sweating with ptosis most frequent 1st sign then followed by delirium, tremors, drowsy, hypersalivation, multiple CN abnl. If severe can have paralysis resp. Pit viper bite can observe 4-6hrs then d/c if asx. |
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74 you M w/ h/o hyperlipidemia brought in by EMS with acute ischemic R hemispheric stroke. After HCT, has generalized sz which terminates w/o tx in 1min. What is true about this patient?
a) pt should be treated with prophylactic phenytoin as soon as dx of ischemic stroke was made b) pt should be given loading dose of phenytoin after sz c) status occurs more commonly in setting of ischemic strokes than in other settings d) phenytoin is contraindicated in pts with ischemic stroke due to its potential for causing ataxia e) although isolated sz are common in pts with ischemic strokes, tx with antiepileptic drugs is unnecessary b/c recurrence is uncommon |
b) give loading dose of phenytoin
Up to 13% sz after ischemic stroke and divide into early <7d after and late >7d after. Prophylactic doesn't reduce either sz. Prophylactic not recommended. Status rare. |
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What is the half-life of carboxyhemoblobin with NRB O2?
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1/2 life 90 minutes on NRB.
Room air 1/2= 6hours HBO 1/2= 30minutes |
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Retrobulbar hemorrhage can result in what devastating complication?
a) corneal abrasion b) hypopoyon c) central retinal artery occlusion (CRAO( d) hyphema e) corneal ulcer |
C) CRAO
Pressure on posterior portion of eye; proptosis on PE and inc pressure can compress central retinal artery/vein and lose vision. Secondary glaucoma can result from inc pressure in globe. Tx: lateral canthotomy and drain hematoma out of temporal border of globe; Failure to do so can get irreversible vision loss in 90min |
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Swan neck deformity occurs in what condition?
a) RA b) osteoarthritis c) SLE d) Reiter's syndrome e) psoriatic arthritis |
a) RA
Swan neck deformity=hyper extension at PIP and flexion at DIP. DIP joint flexion occurs due to elongation or rupture of extensor tendon attachment to the distal phalanx (similar to mallet injury) Both Swan neck and boutonniere deformities are common in RA. Boutonniere is hyperextension at DIP and hyperflexion at PIP |
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What is a sitz bath?
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Immerse only perineum an dbuttocks in water w/ rest body outside tube and no additives.
Anal canal pressure decreases with warm water 40C and improves Q. |
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12yo M with progressive testicular swelling and esxam shows varices. Which of the following is the most common complication of varices?
a) testicular torsion b) epididymitis c) infertility d) malignancy e) DVT |
c) infertility
Varicoceles from abnl dilation of testicular vein and pampiniform plexus of scrotum due to pooling venous blood from impaired drainage of L internal spermatic vein into L renal vein. Large varicoceles inc risk of infertility due to impaired Q and temperature of ipsilateral testis. Torsion can occur but is less common then infertility. |
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27 yo M presents to ED with pruritus ani, tenesmus, and yellowish mucoid discharge from rectum. He had recent unprotected anal sex. Tx?
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125mg IM ceftriaxone and 7d doxy 100mg BID
Dx=proctitis Podophyllin is for HPV. |
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Complications of IBD can develop what extraintestinal complications?
a) arthralgias b) episcleritis c) cholelithiasis d) pyoderma gangrenosum e) all of above |
E) all of above
20% have arthralgias. Episcleritis and anterior uveitis (aka iritis) most common ocular complciations. Episcleritis doesn't affect visual acuity but anterior uveitis can ultimately lead to dec vision if posterior segment is involvedd. Cholelithiasis and nephrolithiasis are common. Crohn's due to disease of terminal ileum which interrupts bile acid resorption results in oxalate malabsorption. Pyoderma gangrenosum and erythema nodosum are the most common cuctaneous manifestations. |
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62 yo M w/ h/o chronic EtOH c/o acute-onset gastric abd pain with WBC 19,000, nl chemistry and BS 168, LDH 400, AST 137, ALT 94, lipase 5xnl. Dx acute pancreatiits. What is true?
a) Ranson of 0 b) Ranson of 1 c) Ranson of 2 d) Ranson of 3 e) Elevated WBC suggests infectious etiology |
Ranson's best to exclude severe disease. >/=3 criteria indicates more severe disease as 3, 4, 5 criteria have 10% mortality vs <5% with <3 criteria. >/=6 criteria have 60% mortality.
5 criteria made on admission and 6 at 48hrs after. 5 criteria= GA LAW Glucose>200, Age >55, LDH >350, AST >250, WBC >16,000 |
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#1 complication of PUD
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GI bleeding
PUD is behind 1/2 of all UGIB. Perf is #2 most common complication of PUD. Gastric outlet obstruction occurs in only 2% pts w/ PUD. |
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What is true about treating acute asa toxicity?
a) urine pH goal 7.5-8 ideal b) forced diuresis effective c) activated charcoal ineffective d) whole bowel irrigation contraindicated e) hemodialysis no role |
a) urine pH goal 7.5-8
Tx is GI decontamination ,hydration , enhanced excretion of drug with urinary alkalinization with IV bicarb which inc amt of ionized salicylate which is excreted more easily by kidneys than unionized. Forced diuresis inc risk of cerebral and pulmonary edema and doesn't inc excretion. Activated charcoal and whole bowel irrigation are recommended in cases of acute intoxication and enteric-coated asa respectively. Hemodialysis can be life saving for those w/ severe salicylate toxicity, organ failure, or failure of std, noninvasive management. |
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What deficits are seen below the level of injury with anterior cord syndrome?
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Loss of pain and temperature sensation and motor function.
~hyperflexion injury with herniated vertebral discs or vertebral body fragments compress anterior aspect of s.c. or anterior spinal artery. Hit spinothalamic tract (pain and temp input) and corticospinal tract (descending voluntary motor signals) Spare proprioception and vibration of dorsal columns. |
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How many people have acute MI without h/o CP?
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25%.
Elderly, DM, women. Dsypnea, nausea, diaphoresis may be anginal equivalents |
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22 yo M with L-sided CP 4hrs and resolved an hr ago. Dull, radiated L shoulder and used cocaine at party 12hrs ago. PE, VS, and EKG nl. How treat?
a) ntg b) metoprolol c) morphine d) asa e) tPA |
d) asa
Cocaine MI from vasospasm and hyper-aggregatory plts causing acute thrombosis. ASA indicated in cocaine-induced CP until known whether MI or ischemia is not present. BB contra for theoretic risk of dec cardiac output in face of inc peripheral vasc resistance. |
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3 yoM with VP shunt placed at 22mo due to hydrocephalus and has not been revised since c/o fever 38.2, HA, fussiness. What is true about this pt?
a) risk of VPS infection rises 1yr after insertion b) urgent LP indicated c) mortality of VPS infection is ~75% d) Hydrocephalus on CT scan r/o VPS infection e) Most pts with VPS infection have peripheral leukocytosis |
e) most pts with VPS infection have peripheral leukocytosis
Risk infection highest in 1st 6mo after insertion/instrumentation. <4yo or >61 have inc risk infection LP never w/o CT scanand reviewing findings w/ neurosurg. Mortality of VPS infection ~30-40% 1/3 have SSx obstruction or VPS failure +/-fever including sx of hydrocephalus, papilledema, HTN with concomitant bradycardia and irreg resp (Cushing response), personality changes, ataxia, CN palsies. >80% have peripheral leukocytosis. |
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85 yo F w/ R shoulder stiffness and dx w/ sprain 3wks ago after fall and wearing sling since. PE shows afebrile pt with restricted ROM in all direction s w/ mild pain. Dx?
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Adhesive capsulitis
Stiff w/ or w/o pain in alldirections Rotator cuff get sig pain in one direction. |
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What is the most common serious complication of edrophonium (Tensilon test)?
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Bradycardia
Edrophonium is cholinesterase inhibitor and can produce sx of cholinergic toxicity including bradycardia, excessive airway/oral secretions, tearing, dyspepsia with assoc N/V. Bradycardia rare but serious. Atropine at bedside when give this. Beware in lung disease. |
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Which of the following is assoc with carpal tunnel syndrome?
a) HTN b) DM c) CHF d) CAD e) osteogenesis imperfecta |
b) DM
Carpal tunnel=median nerve neuropathy from compression RF: DM, hypothyroidism, pregnancy, RA. Paresthesia/pain in thumb index, and long fingers. Phalen's test (60s) more sens then Tinel's but neither reliable to r/o or rule in dx. Nerve conduction studies are gold std. Tx =splint and refer |
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50 yo M with acute onset severe R flank pain and CT shows passed kidney stone in bladder and pt never had stone b/f. What is risk of getting another stone?
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50%
RF=middle age, men, FH, condition to inc serum/urinary calcium Types of stones 1) calcium oxyalate (2/3), inc with hypercalcemia syndromes including hyperparathyroidism, mild-alkali syndrome, laxative abuse, sarcoid, IBD from malabsorption-->hyperoxaluria. 2) MAP (magnesium, ammonium, phosphate (aka struvite), in pts with UTIs due to Proteus, Klebsiella, Pseudomonas. 1/5 stones 3) Uric acid assoc w/ gout and radiolucent 4) Cysteine--rare and due to hypercystinuria inborn error metabolism |
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What is true regarding post-MI pericarditis?
a) occurs in majority of pts w/ MI b) Concave STE are usually seen on EKG c) Tx is NSAID d) pericardial friction rub almost nevere audible e) etiology likely infectious |
c) Tx is NSAID
post-MI pericarditis ~w/i 4d MI with change in quality of CP. <25% pts with MI develop this EKG changes usually absent Pericardial friction rub usually heard Dressler's syndrome: pericarditis from autoimmune 2-3wks after MI. Treat all pericarditis with NSAIDS |
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After physiologic jaundice of newborn (icterus neonatorum) what is the most common cause of neonatal jaundice?
a) breast milk jaundice b) cephalohematoma c) sickle cell anemia d) gilbert's syndrome e) biliary atresia |
a) breast milk jaundice
#1 physio jaundice in newborn and #2 is breastmilk. Breast milk jaundice develops in 2% AFTER 7th day with peak 2nd/3rd wk and as high as 10-30mg/dL. Stop BF 1-2d and sub bottle with formula leads to rapid decline and then resume nursing. Generally benign, but can use phototherapy if >18-20mg/dL. Vs Breast-feeding juandice: early onset unconj hyperbilirubinemia that occurs <7d in 1st wk and mechanism unclear but possibly related to dec mild intake with dehydration or reduced caloric intake. Hyperbilirubinemia: conjugated direct bilirubin >2mg/dL or >20% total bili. |
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Erosion into the carotid artery is most commonly a complication of which of the following?
a) Ludwig's angina b) parapharyngeal abscesses c) peritonsillar abscesses d) retropharyngeal abscesses e) epiglottitis |
b) parapharyngeal abscesses
Posterior parapharyngeal space infections are more dangerous than anterior infections as they can encroach on cerrvical sympathetic chain and carotid and jugular. Infections may develop ipsilateral Horner's syndrome or CN neuropathies of 9-12. Jugular vein thrombosis may occur along with erosion of carotid leading to hemorrhage/aneurysm. Lemierre's syndrome occurs with septic thrombophlebitis of jugular veing resulting in septic thrombophlebitis and postanginal septicemia. Get severe sepsis after sx of pharyngitis have resolved. |
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55 yo M with R arm and leg weakness and L sided facial droop. Which artery affected?
a) Anterior cerebral artery b) anterior communicating artery c) middle cerebral artery d) posterior cerebral artery e) basilar artery |
e) basilar artery
Crossed signs with unilat CN deficits but contra hemiparesis and hemisensory loss dx of brainstem infarct Vertebral arteries orgin from subclavian and merge to form basilar artery at pontomedullary junction. At junction of pons and midbrain, basilar forms 2 posterior cerebral arteries. BS from medulla to midbrain is supplied by branches of verebrobasilar artery. Facial nucleus originates w/i pons and may be infarcted when branches of basilar are occluded. As infarct involves facial nucleus, entire face including forehead is affected. When this syndrome includes a ipsilateral rectus palsy, aka Millard-Gubler syndrome due to infarct of both facial and abducens nuclei which are very close to pons. Infarct of basilar ~catastrophic with quadriplegia and often resp failure and death. |
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#1 arrhythmia of PE
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Sinus tachycardia
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Which of the following is true regarding use of corticosteroids in asthmatics?
a) IV steroids have proved to be greater efficacy than oral b) d/c pts who receive systemic steroids need taper up to 10d c) LT systemic steroid use may be complicated by wt gain, aseptic necrosis of femur, PUD d) inhaled steroids are not useful in LT asthma control e) onset IV steroids is 1hr |
c) LT steroids may be complicated by wt gain, aseptic necrosis of femur, PUD
Also get mood distrubances, and long-term use get muscle weakness/wasting, IS, Cushing's syndrome, cataracts, DM, HTN, growth retardation in kids, adrenal axis suppression. It takes 6-24hrs for corticosteroids to exert effect on pulmonary mechanics. |
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Which pt with febrile sz needs LP to r/o infection?
a) 12mo b) 18 mo c) 2yo d) 4yo e) 5yo |
a) 10mo old
<12mo old with febrile sz higher risk of meningitis as cause. Per AAP all <12mo get LP and consider in M18mo. Other high risk to get LP are focal/prolonged sz, abnl PE, toxic appearance. 1/3 febrile sz will have at least one more febrile sz episode. RF's for repeat are young age for 1st sz, lower temp with sz episode, 1st degree relative with febrile sz, short duration b/t fever onset and sz event. Pts with febrile sz's are 2x>likelihood of developing epilepsy. |
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5yoM with confirmed rotavirus diarrhea with tachycardia, lethargy, sunken eyes, poor skin turgor, dry mm. How give IVF?
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20ml/kg bolus NS
4:2:1 for maintenance after bolus. 4ml/kg/hr for first 10kg wt, then 2ml/kg/hr for next 10kg, then 1ml/kg/hr for every 10kg after that. Composition varies by age--look up in reference. |
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Most common cause of death in recipients of solid-organ transplant?
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Infection.
Powerful immunosuppressants inc infection risk. 3 time periods for infection: a) 1st mo. Nosocomial prominent although CMV most prevalent between 1-6mo, esp CMV pneumonitis b) 1-6mo c) >6mo |
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44 yo M with AIDS and chronic diarrhea, flatulence, generalized maliase x1mo. What is the most likely cause?
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Cryptospiridium spp.
#1 cause chronic diarrhea in AIDS. Less common with antiretrovirals. ~self-limited in immunocompetent and CD4 >180. CD4 <100 usually chronic course diarrhea and wt loss CD4<50 may have fulminant diarrhea. |
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Which is the major complication of ischemic central retinal vein occlusion (CRVO)?
a) conjunctivitis b) iritis c) glaucoma d) lens dislocation e) corneal ulcer |
c) glaucoma
Backup of Q into eye inc IOP-->glaucoma Classic h/o CRVO: acute/subacute painless loss of vision RF's CRVO: HTN, DM, thrombophilia. Fundo exam: disc edema with tortuous veins and retinal hemorrhages. ED tx: supportive with optho consult. |
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Which of the following represents correct medial to lateral configuration of permanent teeth?
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central incisor, lateral incisor, canine, premolar, molar
Number from R upper posterior to L side then back down from lower L posterior to R. 3 molars, 2 premolars, 1 canine, 1 lateral incisor, 1 central incisor |
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Which of the following is true regarding perimortem c/section?
a) fetus should be delivered w/i 5min b) family consent should be obtained 1st c) should only be performed if fetal age >20wk d) low horz abd incision affords best opportunity for fetal recovery e) lateral approach best in cases suspected anterior placenta |
a) fetus should be delivered w/i 5min of maternal cardiac arrest
Perimortem c/s should be performed in >24wks or unknown and fundal ht exceeds umbilicus. 70% fetuses survive if out in 5min and none after 25min. Consent not needed. Lg midline vertical incision from subxiphoid process to symphysis pubis. If anterior placenta encountered incise to reach fetus. Ideally get FTH b/f but should not delay. Maternal resus precidence over fetus. |
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6 yo M with L hip pain and limp. No h/o trauma. Pain relieved by rest. What is true of avasc necrosis of femoral head (see pic 9-5 pg 253)
a) more common in boys b) usually bilateral c) etiology viral 50% cases d) almost all require surgery e) joint aspiration confirms dx |
a) more common in boys
Legg-Calve-Perthes (LCP)=avascular necrosis femoral head. >boys, ~unilat, young children more common than adolescent, pain referred to groin/knee, tio unknown, case-bycase whether surgery. Tx=surgery consult Complications: leg-length discrepancy, deformity, limitation movement. |
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22 yo F with severe sore throat and difficulty swallowing. PE with pharyngitis. Which of the following criteria make GAS more likely the cause of illness?
a) tender anterior cervical lymphadenopathy b) concomitant otitis media c) nonexudative tonsillitis d) cough e) atypical lymphocytes on peripheral smear |
a) tender cervical lymphadenopathy
Centor criteria: use to r/o GAS and 0/4 have 2.5% chance positive throat culture vs all 4 have 56% chance positive cx for GAS. Complications of GAS <common in adults than children so reasonable that goal of tx low-risk should be sx relief rather than prevention of sequelae. 4 criteria: fever (b/f antipyretic use), absent cough, tender anterior cervical lymphadenopathy, exudative tonsillitis. McIsaac modified gives 1point for <15yo and -1 point for >45yo. With these, 0-1 have 1% chance positive Cx. Posterior lymphadenopathy, nonexudative tonsillitis, atypical lymphos are all features of EBS. Cough, rhinorrhea, conjunctivitis make GAS less likely |
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62 yo M with R eyelid swelling and crusting w/o pain/redness of eye itself. Figure 9-6 pg 254. How treat?
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topical erythromycin
Dx=blepharitis evidence by crusting and edema of upper eyelid. Staph #1 etiology. Tx=soap gentle cleaning and topical erythromycin ointment to eyelids |
FYI: Acetazolamide is used w/ acute angle closure glaucoma that often presents w/ eye pain, HA, cornea/conjunctival abnl.
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Main problem posed by breech presentations is:
a) inadequade cervical dilation b) entrapment of fetal head c) umbilical cord prolapse d) fetal spinal cord injuries e) all of above |
e) all of above
Perinatal mortality assoc w/ breech is as high as 25% largely due to fatal fetal anomalies and premie deliveries. Breech itself adds little risk if expert. Breech=infant in longitudinal lie but head in uterine fundus whereas buttocks presenting and less effective at dilating cervix. Commonly get inadeq dilation which can result in entrapment of fetal head,. In complete and footling breech presentations (as opposed to frank breech) fetus doesn't completely occlude cervix, inc risk of umbilical cord prolapse (risk grestest w/ footling). Cord prolapse greater if premie/low birth weight which is 1/3 breech presentations. Small inc risk of hyperextension of fetal head w/ 21% risk of fetal s.c. injuries when occurs. |
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22 yo M presents w/ forearm pain after assault and xray shows proximal ulnar fx with dislocation of radial head. Most likely nerve injury is?
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Radial nerve.
Pt has Monteggia's fx with proximal unlar fx with dislocation of radial head from capitellum. Mechanism usually blow to forearm or fall on outstretched hand. Significant displacement of radial head can put pt at risk radial nerve injury, exhibited by wrist drop. Tx surgical in most cases. |
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Which is true of osteomyelitis
a) toxic appearance b) sensitivity of ESR 50% c) sens of xray higher early in illness than later on d) CT superior to MRI to dx e) Staph aureus #1 cause |
e) staph aureus is #1 cause
Osteo is usually subacute and pts usually c/o pain in affected bone but don't appear toxic and often lack VS abnl. Sens of ESR is ~90% and sens CRP is even higher. Xray poor sens in 1st week after sx. Bone scintigraphy and MRI dx of choice. |
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Which is true regarding intussussception?
a) 30% cases in adults b) kids are more likely to have anatomic abnormality of intestine than adults c) classic triad of abd pain, V, bloody stools occurs in majority of pts d) U/S most useful noninvasive diagnostic means e) all of above |
d) U/S most useful diagnostic means
Only 5% intussussception occurs in adults and adults have 95% anatomic abnl w/ 75% neoplastic (vs 2-8% in peds). Classic triad: abd pain, V, bloody stools is only present in 1/3 peds cases U/S very sens, fast, noninvasive, easy to use Air enemas are equally efficacious adn dec rate of perf and can dx and tx. |
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What is strongest RF ectopic?
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h/o prior ectopic is strongest RF. Most common RF is PID with 50% cases having PID.
c/s inc risk of placenta previa but not ectopic OCP reduce sx of PID |
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23 yo F with sickle cell presents with pain in R shin and fevers x2wks. Never had leg pain with crisis before and xray shows osteomyelitis. Likely agent?
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Staph aureus #1 in all pts
Salmonella is more common in sickle than healthy pts but still S aureus more common. Pseudomonas causes osteo in pts w/ puncture wounds to feet and IVDA. |
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Which is true regarding Myasthenia Gravis and Lambert-Eaton Myasthenic syndrome (LEMS)?
a) ocular muscle weakness is most common presentation in both MG and LEMS b) autonomic dysfunction is common in MG but not LEMS c) colon ca is most common neoplastic disease assoc with LEMS d) Distinguishing feature of LEMS is proximal muscle weakness that is most prominent in lower extremities e) DTRs in both MG and LEMS are preserved |
d) Distinguishing feature of LEMS is proximal muscle weakness that is most prominent in lower extremities
LEMS autoimmune targets presynaptic voltage-gated calcium channel receptors vs MG autoimmune targets postsynaptic acetylcholine receptors. In both, muscle weakness is most predominent feature. IN MG, ptosis/diplopia #1 sx. In LEMS, ocular sx uncommon and proximal muscle weakness of lower extremities more than upper extremities is most common sx--difficulty rising from seated position/climbing stairs. Autonomic dysfunction is common in w/ LEMS and not MG. LEMS occus as paraneoplastic syndrome in 50-70% and commonly assoc with small lung cell carcinoma. DTRs in MG are preserved but reduced/absent in LEMS-->briefly exercising b/f test DTRs can restore or normalize reflexes. |
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Which of the following is more characteristic of subdural hematoma than epidural hematoma?
a) lucid interval b) coma c) focal neuro deficits d) inc ICP e) delayed presentation |
e) Delayed presentation
Subdural are from cranial bridging veins from trauma causing blood to collect deep to the dura. Elderly at higher risk than avg population due to brain atrophy which causes bridging veins to stretch and are susceptible to even minor trauma. Due to low pressure venous bleeding, pts may have subacute/chronic presentation w/ mild initial clinical manifestations of injury. Many, esp elderly/etoh doe not recall antecedent trauma. Many have lucid interval (which is more classically epidural). Epidural ~arterial and SSx almost immediately after trauma. |
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Which is true regarding traumatic hemothorax?
a) cont chest tube output of 300ml/hr for 4hrs is indication for thoracotomy b) costophrenic angle blunting occurs on upright CXR with as little as 50ml intrapleural blood c) subclavian artery #1 source of bleeding d) 7Fr pigtail adequate for most hemothoraces drainage e) PTX almost never occurs concomitantly wtih HTX |
answer A
Surgery is warranted for chest tube drainage initial 1500ml out, 250/hr x4hrs, worsening HTX, hemodynamic instability, cardiac arrest-->thoracotomy Costophrenic angle blunting on upright with at least 200ml blood. Want 36Fr or greater in 5th intercostal. PTX occurs in 1/3 of HTX concomitantly. |
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Which of the following occurs in most pts with myocarditis?
a) CP b) fever c) antecedent viral syndrome d) S4 heart sound e) leukocytosis |
c) antecedent viral syndrome
Commonly after coxsackie B, adenovirus, influenza >50% have nonspec viral syndrome Myocarditis may lead to dilated cardiomyopathy -->HF. Leukocytosis uncommon EKG nonspec and echo shows global hypokinesis. Gold std=endomyocardial bx but many false negatives due to patchy nature of inflammation. |
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Which of the following effects does dig exhibit at therapeutic levels?
a) dec intracellular Ca b) dec intracellular Na c) inc intracellular K d) inc HR e) T wave inversion |
e) T wave inversion
Dig inhibits membrane Na-K ATPase that pumps Na out and K in. Dig inc intracellular Na and calcium while dec intracellular K. Inc Calcium produces positive inotropic effect In therapeutic doses dig dec HR, slight ST depression and T wave inversions |
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Which of the following is true in infants w/ GERD?
a) most fail to respond to conservative measures of smaller, thickened feeds and frequent burping b) vomiting is typically nonbilious and progressive resulting in projectile emesis c) ranitidine and reglan are mainstays of tx d) most infants with GERD ultimately suffer from FTT e) infant GERD typically persist into adulthood |
c) ranitidine and reglan are mainstays of tx
Emesis ~nonbilious and begnis early infancy and fairly consistent over time and most respond to conservative measures and peaks at 4mo and resolves by 12mo in nearly all cases resolved by 24mo. FTT is rare. |
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Which cardiac chamber most commonly injured in penetrating thoracic injury?
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RV then LV then equally both of the atrium.
Multiple chambers injured in 1/3 cases. Death from exsanguination or pericardial tamponade |
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Mother brings 3yo daughter to ED for foul-smelling, bloody vag d/c. #1 diagnosis?
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FBO
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32 yo F with recurrent HA, palpitations, profuse diaphoresis. PCP dx of anxiety d.o. but various SSRIs ineffective. VS 99F, HR 90, BP 175/100. What's best agent to treat?
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Phenoxybenzamine
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Concerned mom brings 15yo daughter to ED with irreg vag bleeding since 13. REcently bleed is heavier adn more ireeg than nl. No h/o bruising/petechiae. Hgb 11. #1 cause of sx?
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Anovulation
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Which of the following can be prevented by treating GAS strep throat with ABx?
a) erythema marginatum b) endocarditis c) migratory arthritis d) glomerulonephritis e) A, B, and C only |
e) A, B, and C only.
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Which ABx most likely to cause aplastic anemia?
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Chloramphenicol
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14 yo M c/o ED for diffuse rash. PCP saw pt for sore throat and fatigue and told he had viral inf and given ABx. What ABx pt taking?
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Amoxicillin when has EBV
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Which traumatic injury is more common in elderly?
a) subdural b) odontoid fx c) flail chest d) central cord syndrome e) all of above |
e) all of above
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22 yo primigravida presents to ED 34wks with CC HA and mild crampy abd pain and bp 160/100. Suspecting pre-eclampsia, you start Mg gtt and pt awaits transfer 2hrs away when pt becomes toxic. What are the signs of Mg toxicity
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somnolence, dec DTRs, hypoventilation
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Mother brings 3yo daughter to ED for foul-smelling, bloody vag d/c. #1 diagnosis?
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FBO
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What finding is seen most in pts with miningococcemia?
a) bilat adrenal infarct b) skin lesions c) hypothermia d) sz e) arthritis |
b) skin lesions
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32 yo F with recurrent HA, palpitations, profuse diaphoresis. PCP dx of anxiety d.o. but various SSRIs ineffective. VS 99F, HR 90, BP 175/100. What's best agent to treat?
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Phenoxybenzamine
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Concerned mom brings 15yo daughter to ED with irreg vag bleeding since 13. REcently bleed is heavier adn more ireeg than nl. No h/o bruising/petechiae. Hgb 11. #1 cause of sx?
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Anovulation
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Which of the following can be prevented by treating GAS strep throat with ABx?
a) erythema marginatum b) endocarditis c) migratory arthritis d) glomerulonephritis e) A, B, and C only |
e) A, B, and C only.
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Which ABx most likely to cause aplastic anemia?
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Chloramphenicol
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14 yo M c/o ED for diffuse rash. PCP saw pt for sore throat and fatigue and told he had viral inf and given ABx. What ABx pt taking?
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Amoxicillin when has EBV
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Which traumatic injury is more common in elderly?
a) subdural b) odontoid fx c) flail chest d) central cord syndrome e) all of above |
e) all of above
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22 yo primigravida presents to ED 34wks with CC HA and mild crampy abd pain and bp 160/100. Suspecting pre-eclampsia, you start Mg gtt and pt awaits transfer 2hrs away when pt becomes toxic. What are the signs of Mg toxicity
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somnolence, dec DTRs, hypoventilation
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Mother brings 3yo daughter to ED for foul-smelling, bloody vag d/c. #1 diagnosis?
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FBO
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What finding is seen most in pts with miningococcemia?
a) bilat adrenal infarct b) skin lesions c) hypothermia d) sz e) arthritis |
b) skin lesions
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32 yo F with recurrent HA, palpitations, profuse diaphoresis. PCP dx of anxiety d.o. but various SSRIs ineffective. VS 99F, HR 90, BP 175/100. What's best agent to treat?
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Phenoxybenzamine
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Concerned mom brings 15yo daughter to ED with irreg vag bleeding since 13. REcently bleed is heavier adn more ireeg than nl. No h/o bruising/petechiae. Hgb 11. #1 cause of sx?
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Anovulation
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Which of the following can be prevented by treating GAS strep throat with ABx?
a) erythema marginatum b) endocarditis c) migratory arthritis d) glomerulonephritis e) A, B, and C only |
e) A, B, and C only.
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Which ABx most likely to cause aplastic anemia?
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Chloramphenicol
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14 yo M c/o ED for diffuse rash. PCP saw pt for sore throat and fatigue and told he had viral inf and given ABx. What ABx pt taking?
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Amoxicillin when has EBV
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Which traumatic injury is more common in elderly?
a) subdural b) odontoid fx c) flail chest d) central cord syndrome e) all of above |
e) all of above
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22 yo primigravida presents to ED 34wks with CC HA and mild crampy abd pain and bp 160/100. Suspecting pre-eclampsia, you start Mg gtt and pt awaits transfer 2hrs away when pt becomes toxic. What are the signs of Mg toxicity
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somnolence, dec DTRs, hypoventilation
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What finding is seen most in pts with miningococcemia?
a) bilat adrenal infarct b) skin lesions c) hypothermia d) sz e) arthritis |
b) skin lesions
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Which of the following is most useful in differentiating a pt w/ acute cholecystitis from cholangitis?
a) jaundice b) fever c) abd tenderness d) leukocytosis e) murphy's sign |
a) jaundice
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45 yo M after MVC, unrestrained at 70mph adn struck chest on wheel and no airbag with severe c/o CP. Primary survey nl with VSS. CXR nl and FAST neg. Secondary survey nl. What is most important next step in management?
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CTA to r/o traumatic aortic injury.
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55 yo F w/ wrist pain after fall on outstretched hand with lateral xray shown figure 9-7, pg 257. #1 diagnosis?
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lunate dislocation
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Direct synthesis of which of the following clotting factors is inhibited by coumadin
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2 (pro-thrombin), 7, 9, 10
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Which of the following is true of myasthenia gravis (MG)?
a) incidence peaks at 8th decade b) sensory deficits most severe in lower extremities c) most frequent initial sx is dysarthria d) cooling decreases sx e) muscle weakness tends to worsen after long periods of rest |
d) cooling decreases sx
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#1 place for compartment syndrome
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Leg--tibial fx
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15yo M with severe sore throat and scarlatiniform rash. Troat cx taken and pt treated for presumed GAS with oral PCN V. 3d later returns w/o improvement and culture is negative. He has exudative tonsillitis and no posterior lymphadenopathy or splenomegaly. Has diffuse, pruritic, scarlatiniform rash. Likely organism?
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Arcanobacterium haemolyticum
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23 yo F with R ear pain and drainage after struck in side of head with basketball. TM and membrane with perf (fig 9.8 pg 257). Next step in management?
a) prednisone 40mg po x4d b) doxy 100mg po BID x10d c) gentamicin 100mg IV TID x7d d) copious irrigation e) no specific tx |
no specific tx
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45 yo M presents in coma after smoke exposed. ABG wtih metabolic acidosis adn extremely elevated lactate. Most imp med to give is?
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sodium thiosulfate
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Which is true in drug-induced gingival disease?
a) gingivitis can complicate drug-induced gingival hyperplasia b) almost all pts on phenytoin eventually develop gingival hyperplasia c) phenytoin-assoc gingival hyperplasia is dose dependent d) good oral hygiene is unlikely to improve condition e) phenytoin is only drug to cause gingival hyperplasia |
a) gingivitis can complicate drug-induced gingival hyperplasia
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Which is true of suspected globe rupture?
a) succinylcholine is paralytic of choice for RSI b) tonometry indicated to assess for glaucoma c) eye shielding avoided due to infectious risk d) IV ABx should be given e) tetanus is contra |
d) IV ABx should be given
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Which is the #1 opportunistic infectious agen in AIDS pts
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Pneumocystis carinii
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Which of the following is indicated for tx of acute angle closure glaucoma?
a) topical cycloplegics b) topical antivirals c) asa d) acetazolamide e) lateral canthotomy |
d) acetazolamide
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Which of the following is true regarding hemoptysis?
a) massive hemoptysis is expectorated blood >1L in 24h b) CXR help localize site of bleeding in 90% pts c) #1 source bleeding in massive hemoptysis are bronchial arteries d) if the site of bleeding is limited to 1 lung, pt should be placed in lateral decubitus position w/ affected side up to promote drainage e) most effective nonsurgical approach to hemoptysis is laser photocoagulation |
c) most common source of bleeding in massive hemoptysis are the bronchial arteries
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Institutionalized pt wtih psych disease presents w/ abd pain, distension, N without V. Figure 9-9 pg 258. Diagnosis?
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Sigmoid volvulus
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3wk old term neonate with fever 102, active, nontoxic, R TM red, PE nl. Most appropriate next step?
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Admit for observation w/ prophylactic ABx, and blood, urine, and CSF Cx.
Admit all pts <8wks with fever to hospital for observation, Cx analysis, prophylactic ABx. In this age, serious bacterial infection is common and often completely undetectable by PE or routine blood tests. Pts b/t 8-12wks may be assessed for toxic appearance b/f further evaluation but aggressive managment w/ Cx and ABx is prefered. Potential presentce of otitis media should never result in outpt management of febrile neonate. ABx w/o appropriate Cx and lab analysis results in inability to dx serious bacterial infection. |
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Intussusception in adults?
a) most often presents w/ sx of partial intestinal obstruction b) most commonly occurs in lg intestine c) most commonly idiopathic w/o identifiable lead point d) is 2nd most common cause of lg bowel obstruction e) is best dx with barium/water contrast enema |
a) most commonly presents w/ sx of partial intestinal obstruction
Only 5% intussusception cases in adults and most in small intestine and almost always have lead point (75% malignancy) vs peds. Other lesions include inflammatory lesions and meckel's diverticulum. In adults, best to dx with CT scan. Barium/water contrast enemas may dx and reduce but not as useful in adults b/c most leaseions in small intestine and thought that contrast may help spread malignant cells. Most pts presnt w/ signs of incomplete obstruction (only 20% have complete obstruction) with cc of abd pain. Lg bowel obstruction in adults most commonly due to malignancy w/ volvulus and diverticulitis next most common causes. |
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42 yo M w/ HTN presents with sig swelling of lips and tongue and takes lisinopril x8mo. What is true?
a) adverse drug event is most common in 1st week after therapy b) Pt's sx may be resistant to tx with epi c) Pts typically don't have urticaria d) ARB are unsafe to use in this pt e) all of above |
e) all of above
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64 yo F with h/o sick sinus syndrome w/ recent pacemaker presents with neck pain after low-speed MVC w/ midline cspine tender at C6-7. Cspine films inadequate to see so CT done and nl. Pt still has pain in neck. Next step?
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MRI of cspine
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34 yo M c/o CP and SOB after struck in R chest with baseball bat. CXR with 30% PTX on R. How manage at this time?
a) needle thoracostomy 2nd intercostal midclavicular b) needle thoracostomy at 5th intercostal space, midclavicular c) tube thoracostomy 2nd intercostal midaxillary d) tube thoracostomy 5th intercostal midaxillary e) observation only |
d) Tube thoracostomy at 5th intercostal space midaxillary
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12 mo F w/ pain on urination. Most appropriate urine collection?
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urethral catheterization
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26 yo F w/ SOB and pleuritic CP subsequently dx w/ PE. Not prego, no OCPs, nonsmoker, mother with h/o 2 PE's. Most likely cause of pt's PE?
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Factor V Leiden
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Pts w/ tibial shaft fx's, which is most common associated finding?
a) fibular fx b) common peroneal nerve injury c) posterior tibial nerve injury d) dorsalis pedis artery injury e) posterior tibial artery injury |
a) Fibular fx
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Fx of which of the following structures is readily ID by oblique views of cspine?
a) spinous process b) lamina c) pedicle d) vertebral body e) dens |
b) lamina
Obliques are used to evaluate lamina fx's and better characterize unilateral facet dislocations that can be ID on CT. Spinous process and pedicle fx's best seen on lateral Vertebral fx's well seen on AP and lateral Dens fx's are primary reason for getting open-mouth odontoid view |
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34 yo F presents to ED w/ inc low abd pain. Seen in clinic 1wk ago and dx w/ ectopic in L fallopian tube. OB consulted and pt started MTX. Most likely cause of abd pain?
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Normal separation pain from MTX use.
Lg percent of women, 30-60% get abd pain ~1wk after starting MTX for ectopic. Separation pain thought to result from tubal distension as result of tubal abortion or hematoma formation. All women w/ h/o MTX tx who present w/ abd pain need U/S to r/o tubal rupture. The size of ecompic may inc b/f involution but this has not been shown to be assoc w/ tx failure. If pts have inc in amt of pelvic free fluid or dec in Hgb, presumptive dx of tubal rupture should be made and OB urgent consult. PID at same time as prego is extremely rare. |
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50 yo F w/ sudden crushing CP at rest and no h/o CP. EKG with 5mm STE all anterior leads. Angio performed and clean. Dx of vasospasm made. What proportion of acute MI is due to coronary vasospasm alone?
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10%
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22yo M ingested 20-30 condoms w/ 1kg cocaine 12hrs ago. Pt concerned about rupture and wants them out of body and he is asx. VSS and PE nl. What's next step?
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Polyethylene glycol
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65 yo F w/ HTN, afib, DM2 presents with acute vision loss R eye and no pain. Visual acuity markedly dec and pt with striking afferent pupillary defect and R carotid bruit. Next step?
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Globe massage. Pt has CRAO (central retinal artery occlusion) probably from thromboembolus from afib/carotid atherosclerosis. ASA, heparin, TPA show no improvement in CRAO.
Intermittent globe massage indicated to inc ocular carbon dioxide content to cause vasodilation of retinal arteries. lateral canthotomy for retrobulbar hematoma |
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What is most appropriate outpt management of corneal abrasions?
a) patch b) topical anesthetic c) topical steroids d) topical ABx e) topical saline |
d) topical ABx
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In healthy adults, nl CSF opening pressure is?
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Adults: 8-18cm
Kids: 3-6cm For accuracy, should be done in lateral decubitus position. |
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28 yo F 29wks gestation in by EMS after very minor MVC w/o complaints except discomfort from board/collar. Next step in management?
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Perform 4hrs of cardiotocographic monitoring b/f discharge.
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Which is most common cause of upper GI bleed
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c) PUD
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44 yo M w/ h/o kidney stones presents w/ worse L flank pain several days, dysuria, N/V, fever 101. U/A 50WBC, +leukocyte esterase, +bacteria. CT 7 mm stone at L ureteropelvic junction. Next step in management?
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e) emergent urology consult
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17 yo F presents w/ bilat lower quadrant abd pain and vag d/c 3d. Sexually active, multiple partners. LMP 3d ago. No fever, V, dysuria, diarrhea, UPT neg. Which is most likely to yield correct dx?
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a) physical exam
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In most pts dx w/ CA pneumonia, which contributes to pt's Pneumonia Severity Index (PSI)?
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c) age
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65 yo M w/ emergent CT with contrast. Which is a RF contrast-induced acute tubular necrosis?
a) HTN b) pheochromocytoma c) UTI d) DM e) IC state |
d) DM
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23 yo F twists R knee playing tennis and swelling immediately after but can ambulate. PE moderate effusion w/o definite ligamentous instability. What should you tell pt?
a) You will require surgery b) You have a ligament tear c) You have knee dislocation d) Your knee will heal just fine e) I can't make definite dx at this time |
e) I can't make definite dx at this time
Knee dislocation would make gross knee instability in all directions |
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50 yo M w/ R lower facial swelling x3d. R lower molar pain several wks but not seen dentist. H/o etoh. PE with low firm swelling in bilat submandibular and submental regions. What's true?
a) Most commonly affected teeth with this condition is lateral incisors b) Pseudomonas species most common cause c) most common cause of death is septic shock d) fiberoptic nasotracheal intubation preferred method airway control e) steroids clearly assoc w/ better outcomes |
fiberoptic nasotracheal intubation preferred method of airway control
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10 yo M w/ fever, diarrhea, pallor, weakness with renal function abnl and pt anemic. Peripheral blood smear w/ schistocytes shown figure 9-10 pg 261. What is most likely dx?
a) HSP b) HUS c) DIC d) Idiopathic thrombocytopenic purpura e) Nephrotic syndrome |
HUS. Periph w/ schistocytes w/ renal dysfunction, anemia, diarrhea indicates HUS.
Triad of RAT--renal insufficiency, anemia, thrombocytopenia should prompt eval for either HUS/TTP. Fever and neuro ssx are more common in later. 2 are thought to be spectrum of same disease. E Coli 0157:H7 cause most cases. Tx supportive. Plasmapheresis for cases of idiopathic HUS or TTP. |
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4yo M with penile pain and PEP shows figure 9-11 pg 262. Which is diagnosis?
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Paraphimosis. Symmetric swelling of foreskin b/h glans w/o active retraction. Urologic emergency that can occur in uncircumcised pts which requires prompt reduction to prevent necrosis of glans. Reduce by squeezing glans for several minutes to clear capillaries of blood and pulling foreskin over the glans. Dorsal slit procedure may need to be performed if noninvasive reduction unsuccessful.
Phimosis is inability to retract foreskin over glans and doesn't require emergent reduction Balanitis is bacterial/fungal infection of glans w/o concomitant foreskin infection (which is called balanoposthitis) Testicular torsion and scrotal hernia are not often evident on simple inspection and require palpation and U/S to definitively dx. |
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HSP
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vasculitis heralded by renal dysfunction in setting of lower extremity palpable purpura, abd pain, arthralgias
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DIC
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Distortion of clotting cascade from severe assoc illness
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ITP (idiopathic thrombocytopenic purpura)
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Thrombocytopenia w/o schistocyte formation.
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Nephrotic syndrome
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renal dysfunction w/o hemat abnl
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Which is true regarding TMJ syndrome?
a) is extremely rare cause of facial pain b) young women highest risk c) pain ~bilateral d) muscle relaxants not helpful e) avoiding hard foods rarely necessary |
B) Young women highest risk
TMJ vague disorder with pain, joint locking, dislocation. Most common cause of facial pain after dentalgia. Young women highest risk and many pts w/ concomitant psych d.o. ~ Unilateral and imaging for abnl and labs should be done to check for assoc diseases including RA, DJD, and ankylosis. Tx=NSAIDs, muscle relaxants, soft diet during acute episodes to prevent further exercise of muscles of mastication. |
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Pt has EKG with WPW. What is the mechanism, what does EKG show, and what meds contra?
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Preexcitation and get reentrant dysrhythmias from
a) retrograde, orthodromic pattern with narrow QRS; OR b) anterograde, antidromic, wide QRS (AV node conducts backwards) V1-V6 gradual delta wave with shortened PR. BB and CCV contraindicated Use procainamide or amio If unstable cardiovert |
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What is the drug of choice for cluster HA?
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Verapamil.
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What is the most common cause of death in Hemophilia A?
a) sepsis b) MI c) GI bleeding d) ICH e) CHF |
Intracranial hemorrhage.
Deficiency of F8 and is most common cause of death from head trauma causing ICH. Tx=F8 after trauma. |
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Which of the following results from a lesion of the pons?
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Ipsilateral facial droop with contralateral hemiparesis
Hallmark=crossed signs Ipsilateral BS lesions w/ contralateral hemiparesis and hemisensory loss. ***The oculomotor nucleus is located in midbrain whereas hypoglossal nucleus in medulla. Therefore, neither of these nerves is affected by pontine lesions. And, while abducens nucleus is in pons, a pontine lesion causes ipsilateral gaze palsy should be accompanied by contralateral hemiparesis. B/c brainstem lesions affect CN nuclei (or lower motor neurons of CNs) such lesions result in a complete deficit in the distribution of the nerve. With respect to the facial nerve, this results in complete facial droop rather than forehead sparing seen w/ cortical lesions (due to bilateral innervation of the facial nucleus). |
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Pts w/ botulism classically present how?
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Descending symmetric paralysis that starts with bulbar muscles. Often dysarthria, diplopia, dysphagia progressing to generalized weakness. +/-GI upset. Sx 6-48hrs after ingestion. Mental status intact.
No affect on pupils vs MG that may have dilated unreactive pupils. Botulinum toxin irreversibly binds presynaptic membrane of peripheral and cranial nerves where it inhibits the release of ACh. Pt improves as new receptors are manufactured. Disorder is localized to neuromuscular junction so no sensory findings |
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What are the indications for ABx prophylaxis with prosthetic heart valves?
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ERCP, dental procedures, rigid bronchoscopy, cystoscopy
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Ischemic stroke bp goals?
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CPP=MAP-ICP
If not tPA candidate, do not treat bp unless >220/120 or MAP >130. If tPA candidate, lower to < 185/105. May also want lower if concomitant MI, dissection, ARF due to malignant HTN. Moderate HTN is neuroprotective by maintaining adequate CPP. If need to lower bp give nitroprusside, labetalol, IV enalapril. If SAH, use nimodipine as may be protective in reducing vasospasm. |
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34 yo M with schizophrenia brought to ED by family b/c "keeps ignoring" family. Happened last few hrs and when they argue with him about taking his meds, he stares off into space and doesn't acknowledg them for a few minutes time, then resolves until next conversation. VS and PE nl but when angry eyes look to ceiling and when calms eyes are nl contact and nl conversation. What's next step?
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Benzotropime 1mg IM or benadryl.
Dx=oculogyric crisis w/ eyes staring up and fluctuate based on emotions. Dystonic rxns ~ due to excess cholinergic activity by overblocking dopaminergic receptors by psych meds. The normally inhibitory effect of dopamine on cholinergic neurons is reduced w/ use of antipsychotics. |
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What lab abnl seen in hyperemesis gravidarum?
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Elevated LFT's in 25% but not nl inc beyond 4x nl. It occurs more often when hyperthyroidism accompanies hyperemesis. Hyperthyroidism complicating hyperemesis is transient and ~ resolves by 14-16wks gestation along w/ sx of hyperemesis. Elevated thyroid hormone thought to result from high beta-hcg which is known to stimulate TSH receptor
Can get wt loss, starvation ketoacidosis, lyte imbalance, alkosis from vomiting, dehydration. |
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67 yoF w/ h/o HLD, CAD, HTN, with sx acute vertigo, ataxia verring to L, N/V, but no tinnitis/hearing problems. Exam w/ mild dysarthria, unable to stand/walk from imbalance, R arm clumsy and L arm nl. Acute fall w/o LOC 2wks ago. What do you see on HCT?
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Right cerebellar infarct
Ischemic/hemorrhagic cerebellar infarct frequently assoc w/ vertigo due to disruption vestibulocerebellar pathways. Typical sx HA, N/V, ataxia, unable to walk (truncal ataxia), vertigo, dysarthria. Fall pt had 2wks ago, likely drop attack due to ischemia w/i vertebrobasilar arterial system. Lesions w/i cerebellum result in ipsilateral clinical deficits due to double crossing although many paths have bilat projections. Pts deteriorate rapidly and require vigilant observation in ICU. |
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Define pulsus paradoxus?
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Heart sounds are heard but no peripheral pulse with measurement of SBP. Caused by physio decrease in amplitude of teh pulse up to 10mmgHg during inspiration and an inc amplitude during expiration. A difference of >10mmHg pathologic.
The negative intrathoracic pressure w/ inspiration causes inc venous return and RV distension to dec LV volume causing CO to fall and dec bp. Seen in tension PTX but #1 extracardiac cause is asthma due to hyperinflation and exaggerated difference in chest pressure w/ respiration. Measurement of PP depends on pt effort, so deteriorating asthmatic probably won't see this well. |
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Lipase vs amylase in pancreatities
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Lipase has same sensitivity but more specific b/c ~all lipase comes from pancreas (sm amt from stomach which elevates w/ gastric/duodenal ulcer, severe renal insuff, bowel obstruction).
Lipase remains elevated for 8-14d while amylase only 5-7d. Degree of elevation w/ lipase or amylase doesn't correlate w/ disease severity. |
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What is one way to diagnose gastric volvulus?
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NGT can't be passed into stomach in most cases
Gastric volvulus is rare, ~older people and twists on long axis (organoaxial). 20% cases <1yo from congenital diaphragm defect. In older people, freq assoc with lg paraesophageal hiatal hernia Classic Borchardt's triad: distension, vomiting, inability to pass NGT. If suspect, try to pass NGT b/c occasionally reduces volvulus. As it has redundant blood supply, infarct uncommon, even in delay occurring in as many as 25%. |
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Most cases of pseudogout are from what cause?
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Idiopathic
aka calcium pyrophosphate dihydrate crystal deposition disease attacks typically not as severe as gout but same management Tx acute gout= SAC steroids, anti-inflam (NSAID), colchicine vs prevention gout with allopurinol, probenecid, febuxostat, vitamin C |
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62 yo F w/ h/o PUD and cc hematemesis and black stools. HR 105, SBP 115, no h/o HTN, hgb 9.6. What med most useful to treat?
a) famotidine infusion b) MN tube c) Ewald tube d) Cont octreotide infusion e) Cont pantoprazole infusion |
Continuous pantoprazole infusion that maintain pH >4. Boluses allow pH to fluctuate and episodes of inc acidity may disrupt clot formation.
Ewald tubes are lg bore NG tubes for gastric lavage Octreotide primarily used for acute variceal hemorrhage although it can be adjunct in nonvariceal UGIB. |
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What labs expected in pyloric stenosis?
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Hypochloremic, hypokalemic, metabolic alkalosis
Typically present b/t 2-6wks, with progressive, projectile, nonbilious emesis. |
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56 yo M w/ HTN, and mild renal insuff cc fatigue and malaise. What #1 med in managing pt with peak T waves on EKG and mildly wide QRS?
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CaCl
Peaked T early and usually at level >6.5. In general, hyperkalemia decreases cardiac excitability resulting in flat P waves, prolonged PR, wide QRS. Calcium stabilizes membrane in 1-3min. CaCl has 3x the calcium of calcium gluconate but CaCl can cause tissue necrosis if extravasation of IV lines and is irritating. |
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When can you hold psych pt?
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SI/HI, acute mania, acute psychosis, inability to cooperate with tx or care for self.
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Vasculitis w/ mononeuritis multiplex and mesenteric ischemia and cutaneous lesions common.
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Polyarteritis nodosa (PAN).
Medium sized vessels affected. |
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What vasculitis assoc w/ coronary ischemia and Japan, F 8-9x more than M, narrows large vessels and can cause pulseless upper extremities?
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Takayasu's arteritis
Takayasu's arteritis can present as pulseless upper extremities (arms, hands, and wrists with weak or absent pulses on the physical examination) which may be why it is also commonly referred to as the "pulseless disease." |
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What vasculitis assoc w/ upper airway problems such as sinusisits, otitis, nasal congestion while developing glomerulonephritis at a later stage
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Wagener's granulomatosis
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autoimmune attack by an abnormal type of circulating antibody termed ANCAs (antineutrophil cytoplasmic antibodies) against small and medium-size blood vessels. Apart from Wegener's, this category includes Churg-Strauss syndrome and microscopic polyangiitis.[1] Although Wegener's granulomatosis affects small and medium-sized vessels, classified as small vessel vasculitides.
Kidney: rapidly progressive glomerulonephritis (75%), leading to chronic renal failure Upper airway, eye and ear disease: Nose: pain, stuffiness, nosebleeds, rhinitis, crusting, saddle-nose deformity due to a perforated septum Ears: conductive hearing loss due to auditory tube dysfunction, sensorineural hearing loss (unclear mechanism) Oral cavity: strawberry gingivitis, underlying bone destruction with loosening of teeth, non-specific ulcerations throughout oral mucosa Eyes: pseudotumours, scleritis, conjunctivitis, uveitis, episcleritis Trachea: subglottal stenosis Lungs: pulmonary nodules (referred to as "coin lesions"), infiltrates (often interpreted as pneumonia), cavitary lesions, pulmonary hemorrhage causing hemoptysis, and rarely bronchial stenosis. Arthritis: Pain or swelling (60%), often initially diagnosed as rheumatoid arthritis Skin: nodules on the elbow, purpura, various others (see cutaneous vasculitis) Nervous system: occasionally sensory neuropathy (10%) and rarely mononeuritis multiplex |
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What vasculitis assoc with recurrent oral and genital ulcerations and recurrent hypopyon (rarely seen but pathognmonic finding)
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Behcet's
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mucous membrane ulceration, and ocular involvements (involvement of the eyes). As a systemic disease, it also involves visceral organs such as the gastrointestinal tract, pulmonary, musculoskeletal, and neurological systems. This syndrome can be fatal; death can be caused by complicated rupture of the vascular aneurysms, or severe neurological complications,
Integumentary system (Skin and mucosa) Nearly all patients present with some form of painful oral mucocutaneous ulcerations in form of aphthous ulcers or non-scarring oral leisons.[2] The oral leisons are similar to those found in inflammatory bowel disease and can be relapsing.[2] Painful genital ulcerations usually develop on the vulva and the scrotum and cause scarring in 75% of the patients.[2] Additionally, patients may present with erythema nodosum, cutaneous pustular vasculitis, and leisons similar to pyoderma gangrenosum.[2] Ocular system (eyes) A patient depicting hypopyon which can be seen in anterior uveitis in a patient with Behcet's disease. Inflammatory eye disease can develop early in the disease course and lead to permanent vision loss in 20% of the cases.[2] Ocular involvement can be in form of posterior uveitis, anterior uveitis, or retinal vasculitis. Anterior uveitis presents with painful eyes, conjuctival redness, hypopyon, and decreased visual acuity, while posterior uveitis presents with painless decreased visual acuity and visual field floaters. A rare form of ocular (eye) involvement in this syndrome is retinal vasculitis which presents with painless decrease of vision with possibility of floaters or visual field defects.[2] Gastrointestinal tract (bowels) GI manifestations include abdominal pain, nausea, diarrhea with or without blood and often involves the ileocecal valve.[2] Pulmonary (lungs) Lung involvement is typically in form of hemoptysis, pleuritis, cough, fever, and in severe cases can be life threatening if the outlet pulmonary artery develops an aneurysm which ruptures causing severe vascular collapse and death from bleeding in the lungs.[2] Musculoskeletal system (muscle, joint) Arthralgia is seen in up to half of patients, and is usually a non-erosive poly or oligoarthritis of primarily the large joints of the lower extremities.[2] Neurological system Neurological involvements range from aseptic meningitis, to vascular thrombosis such as dural sinus thrombosis and or organic brain syndrome manifesting with confusion, seizures, and memory loss.[2] They oftern appear late in the progression of the disease but are associated with a poor prognosis. |
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Vasculitis with lung sx and pts get asthma w/i 2yrs of diagnosis
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Churg-Strauss
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HIV pt w/ PCP with sulfa allergy precluding use of TMP-SMX, which is best outpatient regimen?
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Clinda + primaquine
or Pentamidine (only comes IV or inhalation) TMP-SMX has many side effects including high incidence of skin rash and bone marrow suppression. Primaquine combo with clinda as primaquine lacks activity against community-acquired pathogens. And, b/c those with mild-moderate disease d/c home, need to cover CAP. And, if CD4 hovers around 200, hard to tell PCP from CAP. |
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What is the best test to determine TAI (traumatic aortic injury)?
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CTA
TAI most common from blunt high-speed MVC. Most ruptures immediately fatal and if survive to ED ~survive. Descending just distal to SC artery most common site. CP and back pain most common sx. Sens of CSR 85% and CTA has sens 100%. TEE used in cases where /Ct not possible. Manage by repair and bp/HR control with BB essential |
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Describe position necessary for successful vaginal delivery?
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Longitutinal lie (fetal spine longitudinal to uterus). Only this lie can deliver safely .
Presentation refers to the fetal part that overlies the maternal pelvis with approx 95% cephalic and any not cephalic presentation=malpresentation Smallest possible diameter occurs when fetal head maximally flexed. Attitude refers to relation of fetal head to its spine (flexion/extension) Position refers to relationship of presenting part of fetus to maternal pelvis. In cephalic presentations the occiput is the reference point whereas in breech the sacrum is the reference point Station refers to the distance of the fetal presenting part from the maternal ischial spines. Station of 0 implies that bony edge of fetus is at the level of the ischial spines. |
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#1 cause of adult diarrhea?
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Noroviruses w/ Norwalk 50-80%.
Most pts w/ acute infectious diarrhea don't seek medical tx, so those that do, usually have bacterail cause, ~ campylobacter spp. |
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What is the number one cause of diarrhea in AIDs pt? What is the best way of treating it?
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Cryptosporidium parvum: parasite causing subacute and chronic diarrhea in AIDS.
HAART is best tx for Cryptosporidium. Sx virtually eliminated if CD4 >100cells/microL. Antidiarrheal agents and ABx work w/ only varying degrees of success and sx often recur after drugs stopped. |
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Pyogenic liver abscesses etiology?
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#1 etiology is complication of biliary tract infections (cholangitis, cholecystitis). Sizeable number are cryptogenic.
In past, untx appi complicated by pylephlebitis was very common in young people. Most infections are polymicrobial and many organisms involved. Tx: surgical drainage and broad ABx. |
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45 yo F w/ h/o untreated hypertyroidism presents w/ acute onset L foot pain and PE shows nl VS, irreg heart rhythm, clear lungs, loss of pulse in L foot w/ dec cap refill, blue, paralyzed toes. What's next step?
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Anticoagulation and emergent embolectomy.
Pt has acute arterial occlusion from arterial embolism, likely 2/2 afib 2/2 to hyperthyroidism. Vs bypass that is ~ for ps with in situ thrombosis. |
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Which of the following toxins is most assoc w/ sz?
a) cocaine b) etoh c) opiates d) ecstasy e) ephedra |
b) EtOH
withdrawal ~6-48hrs discontinuation but can have sz up to 7d after, esp abuse w/ Bz and barbiturates. Acute alchohol intoxication can also provoke sz and some EEG evidence that it lowers sz threshold |
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Which is true regarding PE asthmatic?
a) cyanosis common b) RR correlates poorly w/ severity of asthma exacerbation c) pulsus paradoxus is present in 90% w/ severe asthma d) pts w/ refractory severe asthma who progress to status have inc wheezing e) accessory muscle use ~ mild asthmatics |
b) RR correlates poorly to severity of asthma exacerbation
Cyanosis is only visible when hgb unsaturated exceeds 4g/dL. Pts with asthma have resp alkalosis from hyperventilation that shifts oxyhemoglobin dissociation to L which means at any partial pressure of O2, there is more saturated hgb. RR>40 always have severe asthma exacerbation. Pulsus paradoxus absent in 50% severe asthma. PP >10mmHg in severe obstruction (nl value) but only extremely high PP (>@5) correlates w/ severe asthma. |
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47 yoF, healthy, w/ several days progressive worsening L eye pain, blurry, redness. Acuity reduced and exposure to light in R eye causes inc pain in L eye. L pupil constricted and minimally reactive to light and perilimbic conjunctival injection w/o discharge. What's most appropriate tx?
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Pt has iritis treated with topical steroids and mydriatics and optho b/f start steroids.
H/o consensual photophobia (inc pain affected eye with light shown in other eye and pupil constricted) and PE demonstrating perilimbic conjunctival injection (ciliary flush) is characteristic. |
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What is the most common cause of death in sickle cell?
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Sepsis--usually pneumonia.
Owing to autoinfarct of spleen, pts at risk encapsulated organisms, Strep pneumo, E coli, H influ. Sickle trait 10% AfAmerc. Acute crises: vaso-occlusive, acute chest syndrome, splenic sequestration, aplastic. |
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Which is true regarding traumatic iridocyclitis
a) painless b) fixed and dilated pupil c) involves long-acting cycloplegics d) steroids play no role e) resolution generally in 1 mo after onset sx |
c) long-acting cycloplegics
Inflammation of iris caused by trauma causes constant pain and photophobia, especially consensual photophobia (lt exposure to unaffected eye causes pain in affected eye due to consensual constriction). Long-acting cycloplegigs and steroids are mainstay. The pupil is reactive and constricted adn ciliary flush (conjunctival injection in circular rim around limbus) is prominent. Resolution should occur w/i 1 week. |
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Most common cause of immediate postpartum hemorrhage?
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Uterine atony
Postpartum hemorrhage=blood loss w/i first 24hrs delivery RF's multiparity, prolonged labor, excessive uterine manipulation, general anesthesia, halogenated anesthetic agents Manage by abd or bimanual uterine massage, oxytocin, methylergonovine maleate or ergonovine maleate, or carboprost tromethamine. Tears from birth canal #2 cause. Retained POC only 10% of hemorrhages. |
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35yoM w/ severe head injury from baseball bat wtih VS HR 135, BP 82/45, RR20. Likely cause of hypotension?
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Extracranial cause
Head injury alone shouldn't cause hypotension |
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What is true regarding urine analysis?
a) dipstick 99% sens for microscopic hematuria b) RBC casts indicate interstitial cystitis c) WBC casts indicate renal parenchymal inflammation d) transitional cells indicate bladder ca e) nl pH is 9-11 |
c) WBC casts indicate renal parachymal inflammation
RBC casts assoc w/ glomerulonephritis WBC casts assoc w/ parenchymas inflammation like pyelonephritis Urine dipstick is rapid screening tool to detect presence of glucose, leukocytes, protein, and blood. Sensitivity is only 75-85% and negative dipstick doesn't r/o their presence. Transitional cells can be nl finding Nl pH is 5-8 and usually mirrors serum pH except if UTI/RTA |
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What joint most commonly affected in RA
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Arthritis is typically polyarticular and symmetric with hands MCP and PIP, wrists, and elbows most often and DID never involved (is in OA)
RA 2x>W and peaks 40's-60's with 2/3 developing c-spine disease although T and L disease are uncommon. Disease commonly involves occipitoatlantoaxial junction and anterior atlantoaxial subluxation may occur. Rheumatoid factors are autoantiboidies directed at crystallizable fragment (Fc) of human immunoglobulin molecules. In general 15% of pts w/ RA will be seronegative and those pts have milder disease. |
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24 yo M w/ dyspnea and pleuritic CP x10d with breathing getting worse and pt has 40% R PTX and you place CT connecting it to wall suction and pt better but 1hr later starts coughing vigorously and appears w/ high RR and SOB. Assuming not recurrence/worsening of PTX, what's next most likely cause?
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Reexpansion pulmonary edema.
Rare, potentially fatal, incidence as high as 14%. Pts w/ PTX >30% are greatest risk for developing REPE. Use small bore 16-22Fr and place on water-seal only or to Heimlich valve. Rate of reexpansion may also play role, vacuum suction should not be used. Because negative pressure is not appplied, lung reexpansion may not occur and suction may be required especially if the pt is clinically unstable. Presence of PTX for >3d before reexpansion is also a RF. If REPE develops, tx is supportive as w/ other causes of noncardiogenic pulmonary edema. |
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What is the average duration of generalized tonic-clonic seizure
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1 minute
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55 yo M w/ palpitations x1wk and EKG at PCP shows a flutter with nl rate. What's next step in management?
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Enoxaparin 1 mg/kg SC. Risk of atrial thrombus inc w/ amt time pt in afib/flutter. Emergent management of afib/flutter is to reduce rate <100 and anticoagulate if duratio nof dysrhythmia longer than 48hrs unless echo indicates no cardiac thrombus. Pt is not tachy and requires no rate control like dilt/esmolol. Amio not indicated for flutter and puts pt at risk of converting and thromboembolus. Adenosine indicated for PSVT but no role in aflutter.
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85 yo F with painless mass R side neck noted when brushing teeth 3d ago, pain in ear x1wk, no fevers, wt loss, travel, night sweats, smoking, dysphagia, odynophagia, stridor, globus. 4x2cm firm, immobile, nontender mass lateral to R sternocleidomastoid at level thyroid cartilage. R TM with serous effusion. Most likely dx?
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Malignancy
80% rule of neck masses: 80% in kids; 80% nonthyroid neck masses in adults are neoplastic and 80% of those are malignant. Referred ear pain and signs of otitis media with effusion inc likelihood of ca. Any stridor, dysphagia, hoarseness mandates immediate ENT |
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