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84 Cards in this Set

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Child with irritability and fever. Mother describes upper respiratory symptoms, has had multiple ear infections treated with various antibiotics. Currently on prophylactic abx. PE: tympanic membrane is hyperemic, bulging, limited mobility on pneumatic insufflations. Next step in management?
Prescribe 10 day course of oral antibiotics.
Acute otitis media, patient on amoxicillin, so should get amox-clavulanate 1st line tx.
Then be referred for tympanostomy tube placement after treatment.
Imipenem side effect?
All carbapenems are associated with seizures, level builds up follow creatinine.
2 year old brought in for siezure, temperature was 102.9'F. Child is alert awake. Tympanic membrane is red and bulging. Remainder of exam is normal - including neuro. Next step in management?
Febrile seizures are generally tonic-clonic and last less than 15min. Occur in 6mth to 5 yrs.
Family History in 10%
Likely to have recurrence if temp >40/104 or 1st before 18mths.
Use acetaminophen and ibuprofen to control fever.
Leads to greatest rate of smoking cessation?
Varenicline - Chantix
Partial nicotinic receptor agonist.
Most common side effect, nausea, difficulty sleeping and abnormal dreams.
Low compliance bc of abdominal side effects flatulence and constipation
32 year old woman comes to the office for evaluation of epigastric pain for 6mths, with episodes of sore throat and hoarseness. Likely to be associated with patient problem?
Cough and Wheezing.
Just follow the acid up,
hypopharynx: sore thoat
back of toungue: taste
vocal cords: horseness
Carina: cough
Lungs: cough and wheeze
Cyclothymia
Depression and hypomania for >2yrs
Dysthymia
Depressed mood for most of the day, on most days of the year for >2yrs
Major Depression
Depressed mood, loss of pleasure, change in weight, change in sleep, feeling of worthlessness or guilt, decreased concentration, agitation/retardation, suicide ideation
>2 WEEKS
Bipolar
1 MANIC EPISODE = BIPOLAR
elated mood, grandiosity, excess talk, distracted, involvement, agitation, flight of ideas, sexual activity, goal oriented behavior
Drug proven to decrease suicide ideation in bipolar?
Lithium
Sclerodermoid changes on face and hands, no hypertrichosis on face, numerous hyperpigmented scars mixed wiht two to three tense bullae overlying normal skin on dorsum of the hands with 1-2 mm white papules around the scars. Denies hepatitis. Was taking a medication for pain.
Porphyria cutanea tarda, pseudoporphyria
-tense bullae (sun exposed)
-hyperpigmentation and sclerodermoid lesions
-precipitated by drugs (naproxen, furosemide, dapsone, pyridoxine)
-aquired Hep B/C, HIV, alcohol, estrogen, dialysis

GET A HEP PANEL and Urine porphyrin level.
Define complicated UTI?
Promote UTI?
Man, diabetic, HIV pos, pregnant or no responce after 3 days of simple UTI.
10-14 days of appropriate abx (culture sensative)

Promote UTI: spermicides, diaphragm, cervical cap, unlubricated sexual activity
Septal hematoma, what do you do?
Drained immediately to avoid permanent damage to the nasal cartilage. Ischemia secondary to compression of the blood supply by hematoma can lead to septal perforation or saddle nose deformity.
Cryoglobulinema?
Associate with hepatitis C, will be RF factor positive in 100% of cases.
When can physician violate confidentiality with HIV infections
ONLY if the person cannot be persuaded to discuss the matter.
Patient undergoing bone marrow transplantation or induction chemotherapy for AML, profound neutropenia with absolute neutrophil count <200. Without fever.
What do you do?
1st line - Prophylactic Oral quinolone Levofloxacin.
2nd line -Prophylactic antifungal agent.
Patient undergoing bone marrow transplantation or induction chemotherapy for AML, profound neutropenia with absolute neutrophil count <200. Febrile 103F
What do you do?
Febrile, consider Zocyn, Meropenem, Cefepime

Vanco started ONLY if skin infection or catheter sepsis.
68 male, diffuse muscle aches, proximal weakness, bony pain. Diagnosed with multiple myeloma, relatively asymptomatic until last week.
Labs Na 138, K 3.2, Cl 110, BiCarb 18, BUN 19, Cr 1.4, Phos 1.2 Ca 8.8

Urianalysis Ph 8, Urine protien electophoresis + for lambda chains. Appropriate treatment for this patient?
Bicarbonate, Potassium, Thiazide

Type 2 renal tubular acidosis, associated with Multiple Myeloma. Proximal tubula loses ability to reabsorb bicarb, replacement alone is not enough.
88 year old PMH CAD, Ventricular aneurysm repair, PPM. Developed acute onset right-sided eye pain with left sided hemiparesis 2 hours earlier. PE conjugate eye deviation to the right. Left sided facial droop. Decreased sensation in her left arm otherwise appears intact. CT negative for hemorrhage or acute infarction. Next step?
ACUTE STROKE, major neurological deficit, not rapidly improving, within 3 hours of onset, no intracranial blood or systemic bleed. Start tissue plasminogen activator, NOT ASPIRIN.
Yearly checkup for diabetic?
Urine microalbumin, foot, LDL and eye. ACE inhibitor use the albumin in the urine, statin for LDL >100mg/dL and laser photocoagulation.
Give the influenza vaccine to?
Everyone above the age of 6mths, annually.
Patient 1 week severe, unremitting headache, nausea, difficulty concentrating, fatigue and chest pain. 32 weeks pregnant. Headache dissipates during the day at work. Carboxyhemoglobin level 26%. Most appropriate next step?
Hyperbaric Oxygen Chamber,
Criteria: CO level >25% or >20%-pregnanat or fetal distress
Loss of consciousness
severe metabolic acidosis pH<7.1
possible end-organ ischemia (ekg changes, chest pain, altered mental status)
Define CHADS Score
Management of risk of stroke with atrial fibrillation.
C-CHF
H-HTN
A-Age >75
D-DM
S-Stroke (2 points)
0-1 just aspirin
>2 Warfarin or Dabigatran (INR 1-2)
Chest pain and ST segment depression or T-wave inversion, greatest mortality benefit?
Mortality benefit is from aspirin, clopidogrel, low mol weight heparin and possibly angioplasty.

Thrombolytics used with ST segment elevation or left bundle branch block.
Child with bilateral subdural hematomas, with acute blood on right and subacute blood on left.

Next step in management?
Medical and surgical needs must be met first! and you must protect the patient.
1- ADMIT will protect and meet medical/surgical needs
2- Child Protective Services notified.
3- Skeletal Survey after life saving measures take place.
Alarm symptoms with epigastric discomfort that require Upper Endoscopy?
Dysphagia
Unintended Weight loss
Anemia
Stool guaiac positive
Epigastric pain usually benign, endoscopy is not necessary.
Side effect of Linezolid?

Uses for Linezolid?
Myelosuppression most serious adverse effect. Most common side effect is thrombocytopenia.
MONITOR PLATELET COUNT

Gram + infections, DR-Enterococcus, Staph and Pneumococcus.
32 year old man brought to ER found "in a daze". Hx Depression on Amytriptyline. Pulse 115/min, PE dry skin, mydriasis, absent bowel sounds. EKG frequent premature ventricular contractions. Expected with foley catheter?
Polyuria, secondary to urinary retention from amytripaline toxicity.
Prolonged Ileus post operative abdominal surgery. On PCA pump. Next step?
PLACE PATIENT NPO, STOP PCA, switch to non opiod analgesia. Does the patient need NGTube for decrompression?
Rule out - Neurogenic, metabolic infectious, and pharmacologic sources.
Newly diagnosed nephrotic syndrome, what is this patient susceptible to?
THINK LOSS OF PROTIENS
Infections - Hypogammaglobulinemia
Cardiovascular complications - Hyperlipidemia (loss of lipase)
Hypercoagulable - loss of protien C/S and coag factors
Protien malnutrition - loss
RENAL FAILURE
27 year old, ER progressive scrotal pain and swelling. Pain 8/10, developed yesterday, radiating up to right inguinal region. No history of genitourinary disease or PMH. Temp 101, BP 150/80, PE enlarged right testicle and epididymis, WBC 13,500 UA LE positive, US: increased blood flow to right hemiscrotum. Treatment?
Epididymoorchitis,
Clamydia and Gonorrhea
Ceftriaxone 250mg IM
Doxycycline 100mg po bid for 10days.
Patient with targetoid, bull's eye or iris lesions, with recurrent nature.
Erythema multiforme minor usually on palms.
Herpes-associated EM
HSV infections that usually shows up 1-3 weeks after outbreak of herpes labialis, or genital herpes.
Long term supression with acyclovir is effective to eliminate recurrence of EM minor.
4 year old girl with sudden episode of drooling and coughing that began suddenly after she was left alone in the kitchen. Otherwise healthy vaccines up to date. PE mild respiratory distress and mild stidor. Nothing in the mouth, lungs clear, chest xray normal, 20 min later still in mild respiratory distress but is improving. O2sat 97% on room air. Next step?
Lateral xray of the neck. Croup suspected other causes must be ruled out. Foreign body such as a coin. Endoscopy may be necessary if object is not radio opaque.

Intubate if respiratory failure or protect the airway.
Treatment of cryptococcus?
Amphotericin with Flucytosine, 2nd line Flu/Vori/intra-conazol
Echinocandins (caspofungin, micafungin, anidulafungin) are first line for, and which fungals do they NOT cover?
1st line Canidda
-emperic neutropenia and fungi
-also cover aspergillus

DO NOT COVER Cryptococcus
41 year old transfused 1 unite of PRBC, within few minutes complains of wheezing and chest and flank pain. PE patient flushed BP 110/62 Tem 100.9'F. Erythema around IV access site and dark urine in foley catheter bag. Next step?
Acute Hemolytic Reaction

1- Discontinue blood transfution
2- Dieresis with large volume hydration
3- Monitor for hypotension, RF and intravascular coagulation.

Nonhemolytic febrile reactions, consider benadryl and acetaminophen
34 year old woman with fatigue over the last several weeks. Hematocrit of 26%, MCV is 70fL, Reticulocyte count low at 1%, Platelet count 535, 000. Likely etiology?
Iron deficiency is associated with elevated platelet count.
Thrombocytosis - acute phase reactant.
>1million REACTIVE thrombocytosis look for hematologic malignanacy essential thrombocythemia.
Ankylosing spondylitis, most common extra skeletal abnormality?
Uveitis (30-40%)- photophobia and blurry vision
Aortitis (2-5%)- ACE Inhibitors then valve relplacement or repair.
Restrictive Pulmonary Disease secondary to chest wall immobility (2-15%)
Spontaneous Subluxation of atlantoaxial joint 2% - Xray, CT or MRI for degree.
Prosthetic valve endocarditis?
Vanco Rifampin and Gentamicin
Native valve endocarditis or culture negative endocarditis Tx?
Vanco 4-6 weeks, gentamicin 2 weeks.
20 year old, not able to concentrate bc she continually is making sure door is locked. Checks an average of 15times an hour while trying to study. Counts 100 times backwards in order to distract herself. Denies hallucinations. Treatment?
Obsessive- compulsive disorder characterized by and impulsive action to relieve anxiety Tx SSRI Paroxetine, Fluvoxamine, Sertraline, Citalopram and fluoxetine.
Person who is a perfectionism and has control issues. Inflexible, strict, perfectionists who do not like to relegate tasks to other, leads to difficult interpersonal relationships.
Treatment?
Intensive psychotherapy
Any woman <20 with atypical squamous cell of undetermined significance or low-grade squamous intraepithelial lesion. Follow up?
REPEAT CYTOLOGY IN 1 YEAR.
Any woman <21 with atypical squamous cell of undetermined significance or low-grade squamous intraepithelial lesion. Follow up?
REPEAT CYTOLOGY IN 6MTHS AND AGAIN IN 1 YEAR
66 man in ICU for shortness of breath initially admitted with community-aquired pneumonia. Temp 101.3 BP 74/42, PE bilateral crackels in lungs and decreased heart sounds. Intubated on mech ventilation. IV fluids and bp normalizes. Cardiac cath will show? CO? PAWP? SVR?
Likely Septic Shock,
Cardiac Output (4-7) high normal or low
Pulmonary Artery Wedge Pressure (4-12) normal/low
SVR (900-1200) <900 expect around 750
Differential for distributive shock?
anaphylaxis, neurogenic and adrenal insufficiency
Hypertension found on clinic visit. What do you do?
1- Council the patient, stop smoking, diet and exercise
2- Reevaluate within 2 months.
Patient has
LDL 130
HDL 28
Triglycerides 143
Glucose 89
Most appropriate action?
Isolated low HDL, known risk factor for CAD. Goal HDL in men is 40mg/dL most effective medication for increasing HDL is niacin, followed by gemfibrozil and then statin.
Patient develops new rash with slowly progressed to conver the entire anterior and postior trunk as well as face and arms. Pt on medications including Prednisone. On exam small pinpoint pustules and inflammatory papules of the same stage, scattered over trunk of the proximal arms. Treatment?
Steroid acne, topical tretinoin cream may help.

Medications: Ionides, Bromides, Testosterones, Cyclosporin, Antiepileptics, Lithium and systemic Corticosteroids may lead to acneform eruptions.
Folliculocentric inflammitory papules on the trunk, after prolonged bed rest.
Miliaria, retention of sweat as a result of occlusion of eccrine sweat ducts and pores, producing erruption that is comon in patients with prolonged bedrest.
76 year old being discharged from the hospital, admitted for a fall has multiple medical issues. Multiple medications. Patient is going back to her apartment. Most appropirate intervention?
Is the patients home safe to return to? Schedule a home safety evaluation.
What can a 5mth baby do?
babble, vowel sounds, control head and arms, roll over and meaningful grasp.
74 year old comes to ER 5 hour history of right sided weakness. Sudden weakness while in the the bath. Husband had 2 strokes in the past, symptoms resovle spontaneously. Able to ambulate and no residual functional loss. Neuro exam is unremarkable. Next step?
Auscultate of carotids listen for bruit, likely had a TIA (lasts <24 hours). Often due to atherosclerotic disease at carotid bifurcation.
Large decrease in blood pressure on inspiration.
Pulsus paradoxus, fall >10 mmHg during inspiration. Seen in cardiac tamponade.
50 year old annual check up, most appropirate health screening to be done at this time?
Full Colonoscopy, to be done every 10 year.
31yo 2 week history of low grade fevers, weight loss, malaise, nocturnal cough, tightness in his chest with some shortness of breath. Small amount of leg swelling and scrotal swelling. Denies sinusitis, hemoptysis, and sinus infections. Temp 100.2 BP 170/95. Bilateral wheezes are appreciated. sK 5.1, Cr 2.5, Eos mildly elevated. UA Protien +2, many red cell casts, 24HR Ptn 1,900. Immune marker to confirm diagnosis?
P-Anca, Churg-Strauss syndrome. Vasculitis associated with eosinophilia and asthma.
Typical presentation: Asthma, Nephritic syndrome and elevated Eos.
New born with jaundice, Bilirubin 18mg/dL. Next step?
>15mg/dL require phototherapy, after 6 hours of therapy check leves to make sure they are trending down. (Should decrease 1-2mg/dL)
Rise in neonatal jaundice, and causes?
max of 5/day for 3 days to max at 15 is normal. Anything else, think MC Direct coombs (maternal hemolysis), hemoglobinopathy, polycythemia, extravascular blood loss, sepsis, increased enterohepatic circulation, disorder of bilirubin metabolism, endocrine disorder - hypothyroid.
31yo 5 days of red and painful right eye. Complaint of photophobia, tearing, decreased visual acutiy denies trauma. Similar episodes in the past. PE decreased acuity in the rt eye, conjunctiva diffusely injected with water discharge, fluorescein shows uptake in a dendritic pattern, cornea clear. Lt eye normal. Underlying cause?
Herpes simplex virus keratitis.
Suspected in recurrent, unilateral pain, redness and photophobia, in presence of stain defect - "dendritic". REFER TO OPTHALMOLOGIST. NEVER GIVE STEROIDS.
Needed for post strep GN Dx?
Hypertensioin, edema, hematuria. Proof: ASO titer or anti-DNase B antigen.
57yo with days of red warm tender face on one side. Best treatment?
IV Cefazolin, for Erysipelas.
Erysipelas, more severe than impetigo. Deeper can develop into bacteremia, therefor need systemic abx, topical will not reach.
27yo female, comes to clinic with "crampy lower abd pain" begins with onset of menses and resolves by 3rd day. Menstural pain gotten progressively more severe over the past 8 mths. Nausea, diarrhea, backache. Salicylates do not decrease the pain. Condoms for contraception. Pelvic exam, unremarkable. Next step?
Recommend Ibuprofen or OCP(not trying to concieve) and application of heating pad or hot water bottle to lower abdomen. Patient has primary dysmenorrhea, secondary to excess prostaglandins - uterine and smooth msl contratctions.
Primary versus Secondary dysmenorrhea?
Primary - Prostaglandins give NSAIDS
Secondary - Identifiable cause, polyps, leiomyomas, endometriosis ( inc flow, dyspareunia, abdominal contour)
Schizophrenia treated with long term Thioridazine. Next step in management?
EYE EXAM, can lead to abnormal retinal pigmentation and loss of vision.
32yo female, lower abd tenderness and pain. LMP 2 weeks and before that 4 wks earlier. PE significant discharge from cervical os, with cervical motion tenderness. MOST ACCURATE TEST?
Laparascopy most accurate test for PID. Only done if the diagnosis is unclear or no responce to therapy.
5 month old brought into office after being exposed to immunocompromised father, who had fever, malaise, conjunctivitis, cough and coryza. Treatment?
Administer measles immunoglobulin.
Infants younger than 6mth should recieve Igg to Measles. Older than 6mths give MMR vaccine also.
(Normal first dose of MMR is 1yr)
31yo double vision, right eye is droopy. PE ptosis of rt eye, with asymmetric dilitation and lateral deviation. Faint hirsutism, prominent fat on posterior neck with central obesity and strae. Next step?
MRI of the brain, 3rd cranial nerve palsy, with symptoms consistent with cushing syndrome. Buffalo hump, hirsutism, HTN, central obesity and abdominal striae. Pituitary ACTH adenoma.
Patient difficulty swallowing, food gets stuck in the center of the chest. Does not happen everytime he eats. Hx of reflux, on omeprazole. Abnormality on barium study. Likely dx?
Schatzki's ring, Narrowing of distal esophagus, no pain, dysphagia is intermittent.
Difference btw amphotericin and lyposomal amphotericin?
lyposomal is less nephrotoxic
4 year old with moderate respiratory distress and decreased breath sounds on the right side with mild wheezing. Next step?
Bronchoscopy, for foreign body aspiration ( suddne onset respiratory distress, unilateral dec breath sounds, drooling)
69 COPD, office for follow up after recent hospitalization. Short course of azithromycin, aggressive nebulized bronchodilators, tapering course of steroids. On oral steroids and no distress. Mild expiratory wheezing, PFT FEV1 45%. ABG on room air, 7.38 PCO2 45 PO2 70.
Most approriate therapy?
Inhaled corticosteroids, scheduled use of inhaled corticosteroids shown to decrease frequency of COPD and improve overall health status. Not shown to reduce mortality.
HIV pt with Ring enhancing lesion with minimal mass effect. Next step in mgmt?
Pyrimethamine and sulfadiazine.
Ring enhancing lesion: lymphoma or Toxo. Start treatment if no improvement in 2-4 weeks then stereotactic biopsy is done for CNS lymphoma. (EBV PCR is highly senstive but not specific enough)
Plummer Vinson syndrome, esophageal web. Long term complication?
Squamous cell carcinoma of the esophagus.
48 yo severe headache, "halos". PE edematous left eyelid, cornea apears "steamy", pupil is fixed and mid-dilated. Left eye is tender and firm on palpation and tonometric testing reveals intraocular pressure of 67mmHg. Immediate management?
Mannitol IV, for acute angle-closure glaucoma. Ocular emergency requireing immediate treatment to prevent blindness.
35yo come to clinic with dysuria, developed knee pain and swollen, red, painful. Tendernes at insertion point of achilles tendon of the foot. Emperic treatment with ceftriaxone and azithromycin, sned UA for NAAT. One week later urinary symptoms have resolved and NAAT positive for chlamydia. Best therapy for this patient?
Ibuprofen, (NSAIDS) to control the pain and inflammation of reactive arthritis, no definitive treatment. No known therapy to reverse RA.
Patient on mag sulfate, side effects? what do you check?
CHECK REFLEXES!! Loss of deep tendon reflexes, as mag tox worsens progresses hypotension, complete heart block, muscle paralysis, resp paralysis, and cardiac arrest.
3 day infant with bilious vomiting. Barium enema demonstrates cecum in the left upper quadrant. Next step in managment?
Laparotomy for VOLVUS, malrotation cecum in left upper quadrant confirms diagnosis. Associated with duodenal atreasia, annular pancreas and duodenal diaphragm. Immediate surgery to prevent death and loss of to much bowel.
Most sensative test for DM?
OGTT, usually only performed in pregnant women who cannot wait for diagnosis and need to be started on therapy immediatly.
26yo woman with breast lump. Found while doing self breast exam. 2cm mobile mass, no abnormalities or lymphadenopathy. Management?
UNDER 30 palpable breast mass, Initial evaluation:
Observe 1-2 menstrual cycles (nonmalignancy)
Aspiration (fluid or cells)
Breast Ultrasound (persists or grows)
Paitent with severe cellulitis, admitted several times in last year for respiratory and skin infections. Anaphylaxis to penicillin. Temp 102. Appropriate therapy?
Tigecycline, active against both methicillin sensitive and methicillin resisitant staph aureus. Also, effective agianst most gram negatives EXCEPT pseudomonas. Daptomycin also a correct choice.
Pt has multiple hospitalizations. Uncomplicated erysipellas give Cephalexin - oral
Restriction in upward gaze after trauma. Complication in this type of orbital injury?
Entrapment of inferior rectus muscle.
Treatment of Neuroleptic Malignant Syndrome that is not controversial?
CESSATION OF OFFENDING AGENT.
SUPPORTIVE MEASURES,
- IV fluids (protect kidneys from rhabdo)
- Cooling blankets (reduce fever)
- Antiarrythmics, Mech vent, Pacemaker (cardio-resp stability)
-Heparin to prevent DVT
19yo female comes for sore thoat, no fever, cough or hoarseness. PE tender adenopathy and exudate. Rapid strep test is positive for group A strep. Explain why she should be treated for infection?
GOAL: of group A strep treatment is to eleminate risk of acute rheumatic fever.
78 year old nursing home resident, abdominal pain, bloody diarrhea, no fever or vomiting. BP 90/64 No peritoneal signs, guaiac positive, flex sigmoidoscopic examination reveals patchy depigmented mucosa. Initial managment of patient?
IV fluids and bowel rest . Ishemic bowel comon in elderly due to hypotension.