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486 Cards in this Set

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What is the proper follow up of a palpable breast lesion for patient over 30? Under 30?
over 30 mammogram and ultrasound. Under 30 ultrasound alone, and mammogram only if US is concerning.
patients with spontaneous hypokalemia and htn should be evaluated for? what is the best screening test?
Hyperaldosteronism, screen with plasma aldosterone to plasma renin activity (not renin levels) ratio
A febrile reaction (not hemolytic reaction or bacterial contamination) to blood transfusion is caused by? What can decrease the probability of this happening? Treatment?
reaction of antibodies in the pt's plasma to donor leukocytes. Decreased by leukocyte depletion (cell washing). Treat with NSAID & acetaminophen
Human bites are often associated with which bacteria?
alpha-hemolytic strep, staph aureus, eikenella corrodens, haemophilus species and anerobes (bacteroides species, peptostreptococcus actinomyces species and fusobacterium)
What is the parenteral drug of choice for wound infection due to human, cat or dog, bites?
Ampicillin-sulbactam, it is broad spectrum for both aerobes and anaerobes
What are the current USPSTF mammo screening guidelines (2011)?
with or without clinical breast exam every two years for women aged 50-74
Treatment of mild swelling due to acute stroke, should mannitol be used?
No, for mild swelling mannitol is unnecessary, and there is not enough evidence to currently recommend it. DVT prophylaxis for at-least 2 weeks is the initial tx if pt is outside fibrinolytic therapy window
Lethargy, vomiting, and apnea in a baby are consistent with
Increased intracranial pressure, most likely due to intentional head trauma or shaking baby in a baby too young to walk.
Diagnostic evaluation of breast cyst.
Aspiration reveals bloody and or there is residual mass after aspiration, then follow with mammogram and excision. Otherwise follow up in 4-6 wk with US. If cyst has returned then pursue mammo and excision. If resolved return to routine screening.
Acute unilateral deterioration of vision, hypopyon, conjunctival and lid edema/erythema most likely diagnosis?
Endophtalmitis. Immediate optho consult, then aspirate & vitrectomy followed by intravitreal abx.
MELD Score.
Three Values used in calculation?
Equation?
Score meaning if <15, 30, 40.
TIPS indication?
bilirubin, INR, Cr
3.8(Ln bili)+11.2 (ln INR) +9.6 (Ln Cr) + 6.4
90 day survival of 95% for <15, 65% for 30, 10-15% for 40
TIPS def indicated for <14, avoid in pt with MELD>24
classic findings of postpartum endometritis
fever, uterine tenderness, foul smelling vaginal discharge, leukocytosis
what is the gold standard for tx of endometritis
clindamycin and gentamycin (NOTE metronidazole is contraindicated in breastfeeding)
most important risk factor for postpartum endometritis
route of delivery (vaginal is 3%, 15-30% for cesarean)
most common source of diverticular bleeding
erosion of artery (not venous bleeding, seen in hemorrhoids;)
Most common cause of acute bacterial meningitis in children/adolescents
Neiserria Meningitidis
Gold standard for chemoprohpylaxis for exposure to meningococcal meningitis?
PO Rifampin (2nd line include PO cipro, IM ceftriaxone). All pts with close contact to resp secretions should receive prophylaxis.
Most well known anatomical predisposing factor for mallory weiss syndrome
hiatal hernia
Tx protocol of infant born to mother with hep B?
hep B IG and hep B vaccine 12 hrs after birth, 2nd vaccine 1-2 mo, 3rd vaccine at six months; Check titers at 9-15 mo. NOTE: reduces transmission rate from 30% to 2%
Tx of herpes zoster
PO acyclovir 800mg 5xday. Corticosteroids is controversial and for test purposes should be avoided if pt has HTN, DM, glaucoma, & osteoporosis.
Define postherpatic neuralgia, what is tx?
pain for more than one month after resolution of skin lesions (or 4 months from initial onset of rash). Tx include tricyclic antidepressents (desimipramine, amitriptyline), topical capsaicin, gabapentin, long acting oxycodone.
Fever, dysphagia, drooling and later neurological symptoms describes? Prognosis?
Rabies, universally fatal once symptomatic.
Quit smoking treatment recs?
Nicotine replacement in early stages then transition to drug like bupropion.
Complication of chronic recurrent pancreatitis presents with isolated gastric varices (without evidence of esophageal varices)?
Splenic vein thrombosis
Pt has previous surgical tx of CIN before conception, what are complications and management?
leads to cervical incompetence and preterm birth inc 2-3x. Cervix should be visually examined frequently in 2nd trimester, then determine if pt needs cerclage or c-section.
Nonspecific symptoms in a young patient, think of?
HIV
Liver dysfunction, central hypogonadism, DM, arthropathy, and skin pigmentation classic for? Screening? Gold standard test?
Hemochromatosis; serum iron studies, transferrin sat for screening; gold standard is liver biopsy; other buzz words include arthritis in 2nd and 3rd metacarphophylangeal joints, hook like osteophytes; familial hemochromatosis is on gene (c282Y and H63D).
Good prognostic indicators of psychotic patients
acute onset, good premorid function, no psychiatric hx, no fam hx, hx of precipitating event
Pt presents with a single elevated PSA, what is best course of action
PSA can be acutely elevated due to inflammation (urinary retention, cystoscopy, ejaculation, etc). It should decrease over 2-6 wks (recheck). If still elevated, THEN work up chronic causes.
coughing with swallowing, ear pain, is suggestive of
oropharyngeal or proximal esophageal dysphagia. Other orophyarngeal dysphagia buzz words include drooling, difficulty initiating a swallow.
How do you distinguish mechanical versus motility cause of dysphagia per history?
Initial dysphagia with both solids and liquids is suggestive of motility disorder while dysphagia initially for solids which progresses to liquids is seen with mechanical obstruction.
adenocarcinoma of esophagus is associated with? while squamous cell carcinoma of esophagus is associated w/?
adeno: chronic GI reflux in the distal esophagus (occasionally in mid w/ barret's). SC: seen in alcohol and tabacco users and are typically upper esophageal lesions.
If a patient presents with this EKG and his previous was read as normal. What is the management
This is LBBB (supra-ventricular rhythm, wide QRS, QS or rS complex in V1, RsR' in lead V6). If previous EKG was normal this is highly suspicious for MI (also aortic stenosis, dilated cardiomyopathy, CAD, electrical abnormality, aortic root dilation), immediate coronary angio and aggressive medical therapy
Medications of choice for OCD tx?
SSRI (ie fluoxetine). tricyclic antidepressant clomipramine may also be used
what is the mainstay treatment of PHAT?
Primary HIV associated thrombocytopenia; affects 40% of HIV pts, treat with zidovudine (which also reduces rate of opportunistic infections and kaposi's)
Evaluation of HIV pt after starting HAART
viral load should be measured at 4 weeks then 8-12 weeks after initiation. Then re-measure every 6-8 wks until viral load is undetectable (<50copies/ml). After that may evaluate every 3 months. Results in previously tx naive pt should be: 4wks-<5000 copies/ml, 8-16 wks-<500 copies/ml, 16-24 wks-<50copies/ml;
A true congenital diverticulum, small bulge in the small intestine, remnant of omphalomesenteric duct?
Meckel's Diverticulum," 2% of population, 2 feet from ileocecal valve, 2 inches in length, 2% are symptomatic, 2 types of common ectopic tissue (gastric and pancreatic), 2 yo is most common age, 2x more common in boys"; Presents as rectal bleeding, intestinal obstruction, volvulus, intussuseception. Dx w/ technetium 99m scan (meckel's scan). Tx surgically
Criteria for dx of major depression
at least five of the folowing in two week period (depressed mood, Sleep disorder, Interest deficit, Guilt, Energy deficit, Concentration deficit, Appeitite disorder, Psychomotor retardation or agitation, Suicidality ). "SIGECAPS"; 1st line is SSRI, psychotherapy is an adjunct
Treatment of grave's in the US is most commonly with? Some Pearls of wisdom for graves?
Radioactive iodine ablation; Some points: combine with corticosteroids if pt has ophtalmopathy (ablation w/o steroids can worsen opthalmopathy); Large retrosternal goiters contraindicates iodine ablation because post swelling can compromise airway
Tx of thyroid storm
beta blocker, a thionamide, glucocorticoticoids (decresae conversion of T4 to T3). Then 1 hr after thionamide, give iodine. If life threatening tx with PTU rather than methimazole (but methimazole has longer 1/2 life and less side effects, and pt should be transitioned to it prior to discharge)
Cough induced by forced expiration is characteristic of?
airway hyperactivity or asthma (or possibly COPD). also associated with physical activity and cold air.
What is a potential cause of b12 deficiency in pt with intestinal stasis?
bacterial overgrowth ( decreased bowel motility may be caused by anatomic abnormalities, PPI, systemic sclerosis). Gold standard dx test for bacterial overgrowth is jejunal aspirate.
Isolated elevation of serum creatinine may be caused by?
decreased tubular secretion of creatinine (induced by certain drugs, often cimetidine, probenecid, trimethoprim)
chronic acneiform condition characterized by vascular dilation in the central face?
Rosacea; most common in 30-60 yo, lighter skin; Other buzz words: facial erythema, telangiectasias, papules, pustules; Tx w/ topical metronidazole w/ or w/o oral antibiotics.
Frequent complications of rosacea
often ocular, including burning, foreign body sensation, blepharitis, keratitis, conjunctivitis, episcleritis, chalazion
Criteria for brain death?
Irreversible absence of cerebral and brainstem reflexes (pupillary, oculocephalic, oculovestibular, corneal, gag, sucking, swallowing, extensor posturing). Absence of resp drive off the vent for a duration long enough to produce hypercarbic drive (10-20mins usually for pCO2 of 50-60mmHg). Body temp below 34 c or 93.2 F. EEG isoelectric for 30 minutes at maximal gain. Absence of cerebral circulation by Doppler or MRA. At least 24 hrs of observation in adults with anoxic ischemic brain damage with a negative drug screen.
Pts treated with chronic corticosteroids for more than three months (or six months at <10mg/day) should receive what?
Vit D, calcium, baseline densitometry and repeat every year while on therapy.
Recommended duration of antidepressant medication?
for first episode, at least 6 months after resolution of depressive symptoms. Two or more episodes, chronically.
Newborn with irritability, drowsiness, poor feeding, abd distension, hypotonia. Also peripheral cyanosis, hypoglycemia, jaundice, apnea.
Neonatal polythycemia; Defined as HNH greater than 22g/dl or 65% from peripheral venous sample (NOTE peripheral venous H is usually 5-15% lower than capillary/heel sample); Tx w/ IV hydration and partial exchange transfusion.
Tinnitus, restlessness, nausea, vomiting, mild GI discomfort
Initial manifestations of salicylate intoxication. Progresses to depressed level of consciousness, fever, metabolic acidosis, hyperventilation (and resp alkalosis)
Pt in third trimester of pregnancy with pruritic lesions on scalp, anus, vulva and abdomen
Common, physiologic changes of pregnancy. Tx w/ topical steroids, antihistamines, oatmeal baths, and UVB.
Pregnancy associated dermatosis characterized by pruritic erythematous papules within the striae gravidarum
Papular urticarial papules and plaques of pregnancy (PUPPP). May also involve extremities
Urticarial plaques, papules, and vesicles surrounding umbilicus in pregnant pt
Herpes gestationis, usually 9 weeks gestation to 1 week postpartum (avg 21 weeks); NOTE: despite name is not viral, most likely autoimmune; tx w/ topical steroids and antihistamines (similar to other pregnancy related dermatoses)
Erythematous plaques with surrounding pustules
pustular psoriasis
small follicular pustules scattered widely over the trunk, appearing during the 2nd or 3rd trimester
prurutic folliculitis of pregnancy, resolves by 2-3 wks after delivery
purpura, petechiae, bleeding from nostrils/gums, plt count lower than 20,000. No other cause. First line tx, 2nd line tx.
Idiopathic Thrombocytopenic purpura. Steroids is 1st line, IVIG only if steroids fail NOTE: plasmapharesis is tx of choice for HUS and TTP
dorsal feet and hands edema, short webbed neck, cardiac murmur
turner syndrome (monosomy of x chromosome but may also be due to X mosaicism and Xp depletion)
First line tx for diabetic neuropathy
duloxetine (SNRI), pregabalin, tricyclic antidepressants. (also frequently used gabapentin, lamotrigine, carbamazepine)
Observer bias can be reduced by
blinding
Pt with mono presents with maculopapular rash.
Penicillin associated maculopaulor rash in up to 80% of pt with mono incorrectly treated with penicillin derivitives. Immune mediated and caused by IgG and IgM ab
3 week old baby presents with constipation and poor feeding followed by progressive hyptonia, weakness, and loss of deep tendon reflexes. diagnosis, treatment, prognosis?
Botulinism toxin, most freq between 2wk-6mo. Found in soil and canned foods. Tx with human derived botulinism anti toxin and supportive care. Last 1-3 mo and usually fully recover.
Appropriate management of shoulder dystocia
Tell mother not to push while baby is repositioned, if that fails then try McRoberts (two assistants grasp both mother's legs and flex thighs back against her abdomen)
Tx of ARDS
mechanical ventilation with low tidal volume (<6) and limits plateau pressure (<30)
well demarcated, non scarred, round patches of hair loss which may have "exclamation point" hairs
Alopecia areata, thought to be auto immune, associated with nail pitting
erythema, scaling "black dot" alopecia, pustules, boggy plaques, with hair loss
tinea capitis
Hair loss with irregularly shaped areas of hair loss containing hair of different lengths
trichotillomania, psychiatric impulse to pull hair
HIV pt with fever, CD4<200, non productive cough, progressive dyspnea and tachypnea. CXR shows diffuse bilateral ground glass alveolar infiltrates. Diagnosis, most sensitive diagnostic step, treatment?
Pneumocystis Jiroveci; Most sensitive diagnostic test is fiberoptic bronch w/ lavage; Treat with TMP-SMX, steroids if alveolar to arterial gradient is 35mmHg or more and or arterial oxygen tension of 70mm or less on RA
What does this EKG show. What is this patient at risk for
WPW, delta wave (above the blue bar), short PR interval (red bar), long QRS (geen bar). Risk for tachy arrhythmia. If symptomatic tx is catheter ablation (symptomatic WPW w/ tachyarrythmia can lead to sudden death)
Pattern of inheritance?
Mitochondrial. examples include leber hereditary optic neuropathy (BL optic atrophy at 15-30 yo), mitochondrial encephalopathies and myopathies
young pt presents with palpitations and severe headache. Diagnosis, diagnostic test, treatment
Pheochromocytoma, 24 hr metanephrine and free catecholamines, alpha blockade for 10-14 days then surgical excision
2 most common causes of massive colonic bleeding in elderly
diverticulosis and angiodysplasia (Note: associated with ESRD and aortic stenosis)
drugs that interfere with folate metabolism
trimethroprim, methotrexate, phenytoin
most effective treatment of folic acid deficient anemia
folinic acid (not folic acid). nice little trick question.
HAART therapy and pregnancy recommendations
Should be continued after first trimester. Zidovudine in particular is essential and reduces vertical transmission. Efavirnez and Delavirdine possibly have teratogenic effects and should be substituted.
elderly patient presents with shoulder and pelvic girdle pain? Diagnostic test and treatment
Polymyalgia rheumatica, ESR, steroids
red eye, decreased vision, seeing halos and lights, and severe headache and eye pain
angle closure glaucoma
red eye, copious purlulent discharge from one eye, no vision changes. Has erythema and yellow exudate. Tx
keratitis, likley bacterial. Treat with erythomycin (staph a., Strep p., moraxella, haemophilus influenzae,) unless patient is a contact wearer then use Cipro for pseudomonas coverage. Decreased risk of transmission after 24 hrs of abx therapy
Drugs that may exacerbate psoriasis
beta blockers, antimalarial drugs, NSAIDS, ACEi, lithium. (also bacterial and viral infection especially HIV can worsen infection)
electrolyte abn: hyperactive deep tendon reflexes, muscle cramps, and rarely convulsions
Hypocalcemia, may be associated with post surgery and extensive fluids (note hypomagnesemia may mimic hypocalcemia but is associated with alcoholism, prolonged NG suction or diarrhea and diuretic use)
electrolyte abn: nausea, vomiting, ECG changes, asystolie if severe
hyperkalemia. may be associated with severe burns, crush injuries, renal insufficiency.
Electrolyte abn: loss of deep tendon reflexes, flaccid quadriplegia, decreased respiration, and possibly apnea
hypermagnesemia
nausea, vomiting, anorexia, fatigue, confusion, visual disturbances, cardiac abnormalities. Drug toxicity
digoxin, may be exacerbated by verapamil (inhibits the renal tubular secretion of digoxin). Also quinidine and amiodarone may exacerbate digoxin.
concordant versus discordant
concordant: both observations are similar. Discordant: both observations are different. Strength is calculated C-D/C+D. 1.00 is perfect positive relationship, 0 means no relationship, -1 means perfect negative relationship
primoridal, primary, secondary, tertiary, quaternary prevention levels
primordial: prevention of risk factors; primary prevention: action before patient develops disease. 2ndary action which halts the progression of disease and prevents complications; tertiary: halt disease process beyond early stages, limit the impairments. Quaternary: health activities that mitigate or limit the consequences of unnecessary intervention by the health system
impaired vibratory sense and hyperreflexia with degeneration of dorsal and lateral spinal columns
Vit b12 deficiency.
symptomatic tachycardia in hyperthyroid patient can be rapidly managed with what?
beta blockers (propranolol or atenolol)
treatment of choice for aspiration pneumonia
clindamycin (gram positive cocci and anaerobe coverage)
patient is oliguric, hyperkalemic, and acidotic. What is the fluid choice?
D5%W with bicarb
indications for dialysis
intractable hyperkalemia (for boards must have already tried something), hypervolemia, acidosis, uremic symptoms
pt is in the hospital and presents with thrombocytopenia, w or w/o thrombosis, or >50% drop in platelet count after 4-10 days of admission. Treatment? Prevention?
HIT, Type I seen within days of heparin and is to a lesser degree(plt <100k). Type II is more serious immune mediated w/ ab against heparin-platelet factor 4 complex leading to plt activation, aggregation, clots (plt 30-60k). STOP BOTH WARFARIN AND HEPARIN, START direct thrombin inhibitor such as lepirudin(use w/ caution in renal pt) or argatroban (dose adjust in hepatic pt). To prevent HIT use LMWH instead of unfractionated heparin
hypertensive pt becomes confused agitated and has seizure after being on nitroprusside.
cyanide toxicity. Do not give more than 10ug/kg per minute for 10 mins or 2ug/kg for prolonged periods
pt has sudden onset of abdominal pain with extreme sensitivity to abd palpation. Dx? First test?
diagnosis is likely peritoniits, up right chest film to rule out pneumoperitenoum (if positive go straight to emergent laparotomy)
anion gap acidosis, increased osmolal gap, ketonemia, ketonuria, variable glucose levels
alcoholic ketoacidosis
hypertrophic pyloric stenosis phys exam characteristics and lab findings; best imaging modality. Associated with what two drugs?
palpable olive shaped mass in RUQ, peristaltic waves before vomiting. hypokalemia, hypochloermic, metabolic alkalosis. US or upper gastrointestinal contrast study; development of pyloric stenosis is associated with erythromycin and breastfeeding women using macrolides
most effective measure for primary prevention of stroke
Hypertension is the MOST effective (they will try to trick you, its not DM2 or smoking cessation although management of these two help as well)
urinary incontinence, cognitive decline, gait difficulty in elderly
"wet, wacky, wobbly" due to normal pressure hydrocephalus. Treat with ventriculoperitoneal shunting
initial diagnostic test in polycythemia? interpretation?
erythropoietin level; low EP level indicates polycythemia vera, high EP level indicates 2ndary cause such as chronic hypoxia or hormone producing neoplasm (typically renal cell carcinoma). on the boards consider sleep apnea if day time O2 sat is relatively normal
management of renal cell carcinoma
if confined within the renal capsule (stage I), partial nephrectomy; if it extends through the renal capsule but not beyond gerota's fascia (stage II), radical nephrectomy
on the boards what is the first test for pt you suspect gastroperesis in?
you must first rule out gastric outlet obstruction with either endoscopy or barium upper GI exam. Gastroperesis and gastric outlet obstruction present almost the same, but gastric outlet obstruction can mean serious cancer etc.
pt presents with new proximal muscle weakness and skin lesions.
Dermatomyositis. also may have gottrons sign (eczematous, erythematous, scaly lesions on the knuckles), heliotrope sign ( erythematous violacious rash on eyelids). Dermatomyositis in adults is usually related to malignancy (esp solid tumors, such as lung carcinoma)
cholecystectomy diet recommendations
no change in diet is required!
when should inguinal hernias be repaired in the pediatric age group?
"elective repair as early as possible"
presentation of superior sulcus tumor?
AKA pancoast's tumor, shoulder pain is most common initial presentation, may also have chest movement asymmetry, asymmetric LE deep tendon reflexes, and spinal cord compression in up to 25% of pts
low grade fever, lethargy, myalgias, followed by rash on ankles and wrists which spreads to palms, soles, and central body. Diagnosis? Treatment?
Rocky Mountain spotted fever, may progress to neurological signs, seizures, multiorgan failure, death; there is no good diagnostic test and treatment should be started before confirmatory tests; Treatment is doxycylcine
characteristics of cluster headaches (other than occurring in clusters); prevention therapy, acute treatment?
retroorbital pain, lacrimation, confjunctival injuction, rhinorrhea, sweating and pallor and sometimes horner's syndrome; preventive therapy with verapamil, acute treatment with 100% O2 and sumatriptan
best initial therapy for narcolepsy, then 2nd line?
scheduled naps, then try amphetamines such as methylphenidate
Standard tests for first prenatal visit.
blood type, antibody screen, Rh Type, CBC, rublla status, screening for syphilis, chlamydia, HIV, hep B surface antigen, UA, UC, pap smear
routinely measured on follow up prenatal visits (after the initial work up at first visit)
BP, Wt, uterine fundal ht, fetal heart tones, fetal presentation and activity, Urine glucose and protein
mild asymptomatic thrombocytopenia late in pregnancy
gestational thrombocytopenia (also must have no history of thrombocytopenia, no evidence of fetal thrombocytopenia, and spontaneous resolution after delivery)
hemolysis, elevated liver enzymes, low plt count during pregnancy
HELLP syndrome
thrombocytopenia w/ purpura, microangiopathic hemolytic anemia, acute renal insufficiency, neurological abnormalities, fever
TTP
pt with hypogonadism, low testosterone, gynecomastia (low testosterone to estrogen ratio). Diagnosis? high risk of?
Klinefelter's (47xxy), strongest risk factor for male breast cancer
back pain characterized by increased lumbar pain with extension, improvement with sitting or bending forward
lumbar spinal stenosis; MRI for diagnosis, unusual before 60s, therapy includes conservative or lumbar epidural. Final option is laminectomy
back pain that worsens with flexion
disc herniation
pt with C diff has return of symptoms after treatment with flagyl, what is next step?
bit of a trick question, you repeat a course of fagyl once more. Resistance in cdiff is very rare, and vanc should be tried after 2nd failure of flagyl
preferred steroid for antenatal corticosteroid therapy
betamethasone (sometimes dexamethasone)
pt reports subjective feeling of restlessness after starting antipsychotic. Diagnosis? treatment?
akathisia, add beta blocker
pt treated for DKA gets fever, facial swelling, maxillary pain and tenderness, nasal discharge, opthalmoplegia and HA. What is diagnosis? treatment?
mucormycosis, surgical debridment and IV amphotericin
if you are exposed to active TB, protocol?
immediate ppd, if negative repeat in 3 months.
contra-lateral spastic hemiplegia, contra-lateral vibratory proprioception loss, tongue deviation to the injured side. Where is the lesion
medial medulla
impaired sensory and motor function of CN V with limb ataxia, where is lesion?
lateral pons
ipsilateral limb ataxia, contralateral eye deviation, paralysis of the face, arm, leg, impairment of touch and position sense in some cases. Where is the lesion?
medial pons
ipsilateral horner syndrome, loss of pain and temp sensation to face, weakness of palate, pharynx, vocal cords, cerebellar ataxia, loss of pain and temp sens on contralateral side of body. Lesion?
lateral medulla
oculomotor paresis, CNIII disfunction, cerebellar ataxia, contralateral hemiplegia. Lesion?
central midbrain
common complication of pagets?
hearing loss, usually permanent
lesions of skin or mucous membrane that rapidly worsen and evolve into nodular patches marked by hemorrhage, ulceration, necrosis. Diagnosis? Treatment?
ecthyma gangrenosum, usually caused by pseudomonas aeruginosa bacteremia, IV abx (aminoclycoside ie tobra or amikacin and extend spectrum penicillin ie piperacillin or anti pseudomonal cephalosporin ie ceftazidime or cefepime); On the boards do not pick surgical debridement.
priaprism tx?
consrvative (ie ice pack), if that fails phenylephrine or epinephrine
treatment of high grade squamous intraepithelial cervical lesion
this include CIN II and III, treat with LEEP
treatment of ITP
corticosteroids and or IV IG
treatment of guillain barre
Plasmapheresis or IVIG
when do you fix cleft lip?
rule of 10, 10 lbs of weight gain, 10 weeks, hgb of 10
Fever, jaundice, right upper quadrant pain
charcot's triad or acute cholangitis, first step is BC and abx hydration and monitor vital signs. Then ERCP. Add
fever, jaundice, RUQ pain, hypotension, confusion
Reynold's pentad, sepsis due to cholangitis. 50% mortality rate
signs of phenytoin toxicity
first sign is nystagmus on far lateral gaze, then blurred vision, diplopia, ataxia, slurred speech, dizziness, drowsiness, lethargy, decreased mentation, eventually coma. Usual range is 10-20mcg/ml BUT CAN VARY FROM PT TO PT. ON THE BOARDS THEY WILL TRICK YOU BY GIVING A NORMAL RANGE BUT PRESENTATION IS OBVIOUS TOXICITY, if so reduce the dose of phenytoin
INR goal for AVR w/ bileaflet mechanical valve if the pt is in sinus, LA is normal size, and EF is normal
2-3
INR goal for pt with MVR with bileaflet mechanical valve or for pt with bileaflet mechanical aortic valve who have afib
3 or 2.5-3.5
INR goal for pt with mechanical prosthetic valve who suffer a systemic embolism despite anticoagulation
3 or 2.5-3.5 in combination with aspirin
when is CABG indicated
for pt with 3 vessel coronary artery disease or left main disease.
prune belly syndrome
renal, ureteral, urethral abnormalities in a neonate. Often seen with obstruction of upper urinary tract, underdeveloped abd musculuture leading to constipation and weak cough
first line treatment of gout
NSAIDS, NOT colchicine! due to possible toxicity should try NSAIDS first (and nsaids are effective in 90% of gout pts)
pylephlebitis is a rare complication of?
appendicitis (infectious thrombosis of portal veins, most of the time after rupture)
if you suspect gonococcal arthritis in a patient, what is the next step
culture the joint, rectum, urethra, and oral cavity (NOT JUST THE JOINT). Unique findings to gonococcal arthritis include tenosynovitis, pustular or transient vesiculo-pustular skin rash
elevated alk phos levels and unexplained pruritis in a woman is most likely? diagnostic test? Treatment
Primary biliary cirrhosis, also has progressive jaundice, steatorrhea, fatigue, hyperlipidemia, xanthomas, bone disease, hyperpigmentation and other autoimmune manifestations. Diagnostic test is anitmitochonddrial antibody. Treat with ursodeoxycholic acid and liver transplant
why should pilots wait 6 hours after taking viagra to fly?
adverse effect on blue green color vision
treatment of UTI in pregancny
amoxicillin, cephaleixin, or nitrofurantoin (TMP-SMX can effect folic acid metabolism, cipro can cause fetal arthropathy)
treatment of lead exposure in a child
level >10mg/dl just environmental/behavioral intervention. >44mg/dl start PO chelation therapy. > 70mg/dl admit to hospital and give IV chelation therapy. (note venous sampling is more accurate then capillary sampling, consider repeat if capillary is normal)
treatment of mono when airway obstruction appears imminent
corticosteroids
young patient presents with diabetes, osteoporosis, hypertension, hypokalemia. Screen for?
cushings with dexamethasone suppression test
acute dystonic reaction is characterized by? treated with?
can present as eyes rolling back of head, neck twisted to the side, can be due to typical antipsychotic medications (haloperidol), treat with diphenhydramine
maternal hyperglycemia can lead to what cardiac abnormality in neonate
hypertrophic cardiomyopathy and possibly CHF, corrects on its own
best imaging technique for small joint effusions?
ultrasound (ie a child with transient synovitis of the hip)
most common cause for rapidly spreading cellulitis and necrotising fasciitis
group a strep or strep pyogenes. Treat with clindamycin and debridement
CHADS2 score and interpretation
Afib risk management. Congestive heart failure, Hypertension, Age> 75, Diabetes, Stroke or TIA (worth 2 points). 0 is low risk and can be anticoagultaed with aspirin alone. 1 is moderate risk and can be given aspirin or warfarin. 2 or greater is high risk and should be given warfarin.
most common fracture while falling on outstretched hand?
Scaphoid fracture; has decreased range of motion in wrist, tenderness to palpation of the scaphoid w/in anatomic snuffbox, decreased grip strength; XR can be falsely negative and should be followed by MRI or CT. nondisplaced fracture is treated with thumb spica cast, while displaced is indication for ortho consult. CAN LEAD TO AVASCULAR NECROSIS
what is a colles fracture
occurs while falling on an outstretched hand, has the appearance of a dinner fork on lateral view of the wrist due to ulnar styloid separating from the rest of the bone.
Treatment of trichomonas
In non pregnant women either one dose of 2grams or 500mg BID for 7 days of metronidazole . In pregnant females the 2g sincle dose is preferred then stop breast feading for 12-24 hrs after
Treatment of psoriasis
for the face, low potency steroids (hydrocortisone 1%), for thick skin on extensor surfaces, high potency steroids (betamethasone .05% cream), for rash on >30% of the body use UVB light and possibly coal tar, and for systemic symptoms or pustular psoriasis use systemic steroids.
Treatment of type I DM during delivery or labor
normal insulin dose the night before surgery and insulin drip with D5 1/2 NS with 40 Meq kcl to keep sugar below 160
pt with celiac disease are at risk of developing?
intestinal lymphoma
What is breast milk jaundice? Treatment?
Factor in human milk increases enterohepatic circulation of bilirubin, uncongugated bili extends into third and later weeks of life. Treatment is interrupt breast feeding temporarily
What is breastfeeding failure jaundice? treatment?
feeding insufficiency resulting in decreased caloric intake, occurs first week of life. Promote support and successful breastfeeding.
Diagnosis and treatment of lyme disease
Elisa with confirmatory western blot (but can be falsely negative in 40% of cases). Treat with ORAL DOXYCYLCINE. If dissemenated w/ carditis or neuro symptoms use IV CEFTRIAXONE .
pt presents with "gritty burning sensation" of the eyes, dental carries, large nodule in the neck. Diagnosis? Test?
Sjogren's syndrome. "gritty burning sensation" is keratoconjunctivitis sicca 2ndary to abnormal teaer production of lacrimal glands. Also may present as prominent bulbar blood vessels and stringy discharge from eyes. Dental caries is a manifestation of xerostomia (decreased saliva production). Test with ANTI-RO/SSA or ANTI-LA/SSB. The large neck nodule could be a B-cell non hodgin's lymphoma (Sjogren's is due to poly-clonal B cell activation and infiltration of salivary glands)
if you suspect central hypothyroidism in a patient (low to normal TSH with low T4), what should you rule out first before treating?
rule out central adrenal insufficiency w/ cosyntropin stim test, as treating central hypothyroidism with concomitant adrenal insufficiency could cause adrenal crisis
Centor criteria to predict strep phyaryngitis
tonsillar exudates, tender anterior cervical lymphadenopathy, fever, absence of cough. Strep antigen testing is recommended if pt meets 2 criteria
isotretinoin side effect that can lead to pancreatitis
hypertriglyceridemia, seen in up to 25% of pts
Viral arthritis
RA like symptoms but after a recent viral illness and lasting LESS THAN 6 WEEKS
Screening protocol for gestational diabetes. BG recs for pregnant diabetic mothers?
50gm oral glucose then BG 1 hr later,if greater than 130-140 proceed to 100gm 3 hr test. Then check at 0,1,2,3 hrs, positive if BG> 95,180,155,140. BG should be less than 95 when fasting, and 120 postprandial!!!!!! Use NPH, regular or Lispro. AVOID GLARGINE as it is teratogenic in animal studies
What is bronchiolitis? treatment? diagnosis? complications?
infection (usually RSV) usually in young <2 yo, mild upper resp symtptoms, mild to moderate fever, wheezing. Liver and spleen may be palpable due to expansion of lungs. Usually self limiting but if hypoxic or poor feeding, hospitalize with isolation and try bronchodialators/humidified air. May confirm diagnosis with Rapid Detection of antigen in nasal secretions. 2ndary bacterial infection of middle ear and future asthma are most common complications.
most common complication after recent variceal bleeding?
infection such as SBP
Typical finding in pt w/ posterior communicating artery aneurysm?
CN III palsy
Typical finding in pt w/ posterior inferior cerebellar artery aneurysm?
ataxia and bulbar dysfucntion
Before applying physical restraints to a patient, you should always try what first?
low dose haloperidol
pt presents with erythematous scaling patches and plaques with indistinct margins on the scalp, central face, ears, chest , upper back, axilla and pubic area. What is diagnosis? what should you test this patient for?
Seborrheic dermatitis, common presentation of HIV
Before diagnosing dementia first rule out?
Vit B12 def and hypothyroidism
1st line treatment for alzheimers?
acetylcholinesterase inhibitors
In neurofribromatosis, acoustic neuroma's result from what cell line?
Schwann cells
Gingko biloba side effect
bleeding, anti-coagulation, especially with other prescription anticoagulants
RLS may be a symptom of? Treatment of RLS?
iron deficiency. If pt's iron is normal and RLS is sever treat with dopamine agonist such as pramipexole or ropinirole
how can you predict severity of acute pancreatitis?
APACHE II (Ranson criteria is old and requires 48 hrs of hospitalization) . Apache II includes: temp, MAP, HR, RR, Aa gradient, pH, Na, K, Cr, Hct, WBC, Glasgow, age, Chronic Dx
HIV prophylaxis?
All should receive Hep B vaccine, CD4< 200 warrants PCP prophylaxis w/ TMP/SMX, CD4<50 warrants MAC prophylaxis with azithromycin or clarirthromycin
What is schmidt's syndrome?
polyglandular autoimmune failure type II, characterized by addison's disease, Type I DM, and autoimmune thyroid disease
middle aged pt presents with shiny, discrete, intensely pruritic, polygonal shaped violaceous plaques and paupules on flexural surfaces with a whitish lacy pattern.
Lichen Planus, typically involves skin, nails, mucous membranes of mouth and genitals. Requires skin biopsy. Associated with HEP C
Treatment for PMS
Fluoxetine is first line, then try alprazolam. PMS is also associated with psychiatric disorders, mainly mood and anxiety disorders
first diagnostic test for chronic diarrhea?
stool microscopic examination
Diagnosis of celiac disease?
If probability is >5% (fam hx, iron def, steatorrhea, failure to thrive, DM type 1) go straight for biopsy. If probability <5% start with IgA EMA or tTG serum IgA level. small intestinal biopsy, findings include loss of normal villus architecture, mucosal flattening (villus blunting), lymphocytic infiltration
what is the most common cause of Fever of Unknown origin
connective tissue disorders (22%), infection (16%), malignancy (7%)
Safe treatment for a patient with Bipolar during pregnancy?
electroconvulsive therapy
abx known to decrease seizure threshold?
penicillins, cephalosporins, monobactams, carbapenems, fluoroquinolones
what is nelson's syndrome
pituitary enlargement and hyper pigmentation following bilateral adrenalectomy for cushing's disease. (caused by loss of feedback by the adrenal glucocorticoids following adrenalectomy). Tx w/ surgery or pit radiation
patients with suspected cerebral palsy should undergo?
MRI brain
in pregnant females treat sympomatic UTI with?
cephalixin, amoxicillin, or nitrofurantoin (TMP/SMX is not advised in the first or third trimester, can displace bilirubin). (Note: cipro can cause tendon rupture in young children, tetracycline may cause dental staining and reduced bone growth). If UTI progresses to pyelo, treat with IV ceftriaxone, ampicilin, or gentamicin
first line for raynaud?
calcium antagonist, typically nifedpine or amlodipine
difference between acute stress disorder and PTSD?
acute stress disorder lasts at least 2 days max of 4 weeks and occurs w/in 4 weeks of event. PTSD last longer than 4 weeks and may last years
pt presents with proximal muscle weakness w/out neurological findings?
myopathy, diagnostic test to start with is EMG
Acute tx of MS? Long term tx? monitoring?
Acute with high dose steroids, long term with interferon or glatiramer acetate(both teratogenic). Repeat MRI 3 months after initial diagnosis. MS relapses are decreased during pregnancy but increase postpartum
MS prognositic indicators
good prognosis: onset early age, female sex, relapsing form, sensory symptoms as initial finding (specifically optic neuritis)
CXR shows possible TB lesion, next step?
Sputum studies, NOT PPD. PPD is not used for active TB. Also 3 negative sputum smears can be used to rule out infectivity
dx tool for parkinsons? treatment?
physical exam showing 2 of 3: tremor, bradykinesia, rigidity. Tx w/ dopamine agonist, such as pramipexole
Male presentation of Gonorrhea? Chlamydia? Treatment?
Gonorrhea: purulent discharge w/ multiple diplococci on gram stain. Treat w/ ceftriaxone. Chlamydia presents w/ out bacteria but has neutrophils in discharge. Treat with Azithromycin or doxycycline. If PCR is negative for both G/C or does not respond to azithromax/ceftriaxone consider trichomonas treated with metronidazole.
damage of the recurrent laryngeal nerve leads to?
unilateral vocal cord paralysis
Damage to facial nerve leads to?
can be damaged after it exits from the stylomastoid foramen and courses along the inferior portion of the year. It's marginal branch (supplies orbicularis oris muscle) is most commonly injured and results in asymmetric smile
damage to hypoglossal nerve may cause?
deviation of tongue to side of injury
CSF findings in cryptococcal meningitis
marked elevated opening pressure >200, low WBC count w/ mononuclear predominance, elevated protein and low glucose, positive india ink or cryptococcal antigen test. Treat with amphotericin B and flucytosine (in HIV pt fluconazole is used for maintenance therapy after an episode of cryptococcal meningitis)
CSF findings in bacterial meningitis
polymorphonuclear leukocytosis (>100), decreased glucose <40, increased protein > 45, increased opening pressure >180. Treat with ceftriaxone and vancomycin
CSF findings in viral meningitis
lymphocytic pleocytosis (25-500), normal to slightly elevated protein (20 to 80), normal glucose concentration, normal or mildly elevated open pressure (100 to 350) treat with acyclovir
6 month old presents with abd pain, current jelly stools, palpable mass in right abdomen, diagnosis? first test?
intussesception, US abd,
treatment of otitis externa?
IV abx w/ coverage for pseudomonas aeruginosa (ciprofloxacin, piperacillin/ticaracillin wth or with out aminoglycoside, 3rd gen cephalosporins). 6-8 weeks of total therapy (may switch to PO when stable)
Treatment of dysphagia in ALS?
PEG
seborrheic dermatitis
dandruff
management of thyroid nodule
if< 1cm followed up with US yearly; if > 1cm get TSH. IF TSH is normal then perform FNAC. IF TSH is suppressed get a radioactive nuclide scan to look for hot nodules
Screen for what before resecting medullary thyroid cancer?
pheochromocytoma. may have MEN2
gout crystals
negative birefringent needle shaped crystals
calcium pyrophosphate dihydrate deposition disease or pseudogout crystals
positive birefringent rhomboid crystals
calcium phosphate crystals
coin like particles, usually shoulder joint (milwaukee shoulder)
calcium oxalate crystals
bipyramidal variable birefringence, seen in endstage renal disease
hypercalcemia is associated with what physical findings
USUALLY NONE!!!! hypocalcemia on the other hand can have chvosteks (tap the face, get a twich) or trousseu's sign (BP cuff around arm for 3 mins, spasm), hyperpigmentation, seizures, muscle weakness, or hyptension
microhematuria and anemia in patient from Africa
schistosomiasis (rare in North America but one of the most common disease in the world), diagnose with urine microscopy
criteria for admitting anorexia
dehydration, electrolyte abnromalities, bradycardia, hypotension, orthostatism, acute food refusal, severe malnutrition (<75% of expected weight)
refeeding syndrome
develops in 2nd or 3rd week of nutrional therapy. characterized by edema, heart failure, eventually delirum and cardiac arrest. REPLACE PHOSPHATE and admit to ICU
Treatment for PID
IV cefoxitin and doxycylcine or cefraixone and doxycycline
major problem in finding cross matched blood in pts w/ a history of multiple transfusions is ?
alloantibodies
pt presents w/ acute chest pain after repetitive vomiting? Diagnostic test?
Boerhaave's syndrome or esophageal perforation. Most occur in distal esophagus. Pneumomediastinum, pleural effusion, and pneumothorax can be part of presentation. MEDIASTINITIS IS DEADLY in 40% if not diagnosed in 24 hrs. Initial diagnostic test is esophagogram.
what is condyloma acuminata?
manefestation of infection with HPV (usually 6 & 11). Papules range 1-2 cm, have smooth surface. Pt my deliver baby vaginally without any intervention.
when should IVC filter be considered
contraindication to therapetuic anticoagulation, pt who fail anticoagulation, pt who have experienced complication of anticoagulation, or pt with low cardiopulmonary reserve
Most common USMLE questioned causes of drug induced pancreatitis
1. Diuretics: furosemide, thiazide. 2. IBS: sulfasalazine, 5-ASA, 3. Patient on immunosuppressive agents: azathioprine, l_asparaginase. 4 pt with history of seizure or bipolar: valproic acid, 5. AIDS: didanosine, pentamidine. 6. Abx: metronidazole, tetracycline
Treatment of papillary thyroid cancer
near total tyhroidectomy, then radioactive iodine to destroy residual residual thyroid. Then total body scan to look for metastatic disease. Supprisive doses of levothyroxine may be used to suppress TSH below normal levels and further inhibit growth.
pt presents with suppressed TSH, normal T4 and T3 no symptoms, normal heart rate/ryhthm, and normal bone density. Diagnosis? Treatment?
subclinical tyhrotoxosis, usually caused by tx w/ levothyroxine, nodular thyroid disease, graves, thyroiditis (often cause is not found). No treatment necessary, just repeat TSH in 6-8 weeks.
criteria for ankylosing spondylitis? Management? Associated w/?
1. presence of low back pain and stiffness for more than three month duration that improves with exercise or activity. 2. Limitation of the range of motion of the lumbar spine 3. limitation of chest expansion relative to the normal values. First step is plain film of sacrio-iliac joint (can be used to monitor progression as well, 3 mo intervals). Extraarticular findings include acute anterior uveitis, aortic regurg, apical pulminary fibrosis, IgA nephropathy, restrictive lung disease
what is cilostazol
currently most effective conservative treatment of peripheral vascular disease. it is a phosphodiesterase inhibitor and inhibits platelet aggregation as well as a direct arterial vasodilator.
management of isolated anti HBc AB?
This has 3 possibilities: 1.) window period of acute infection 2) several years after recovery 3)after many years of chronic Hep B when HBsAg is undetectable. MANGEMENT Repeat hep B panel to rule out false positive, then measurement of anti HBc IgM and LFTs to determine acuity of infection (window period). If LFTs are elevated only then do you get HBV DNA.
treatment of tourette syndrome?
dopamine receptor blockers such as fluphenazine, pimozide, and tetrabenazine. May also add SSRI for the OCD, impulse problems, rage attacks common in these patients but not as direct treatment.
intraocular melanoma is best managed by?
surgical enucleation or radiotherapy
Best initial management for condyloma acuminata
genital warts, tricholoracetic acid application
Characterization and treatment of torsades?
rate of greater than 100, variotions in QRS, twisting of peaks. Mg is the treatment in STABLE pts. In UNSTABLE patients defibrillation is indicated
what should you suspect in patients with flash pulmonary edema, heart failure, and new mitral regurg?
Rupture of chordae tendinae. (don't confuse with papillary muscle rupture, which usually occurs in elderly w/ acute chest pain or as complication of MI)
Unilateral inability to extend the knee, loss of knee jerk reflex, sensory loss over the atnerior and medial aspects of the thigh, medial aspect of shin, and arch of foot. What nerve is damaged?
Femoral nerve
pain, weakness in leg adduction, and sensory loss over a small area in the medial thigh. What nerve is damaged?
obturator, usually from pelvic trauma or surgery
acute foot drop, weakness in dorsoflexion and eversion. May also have parashesias and or sensory loss over the dorsum of the foot and lateral shin. What nerve is damaged?
peroneal nerve
short PR interval (less than .12 sec), a delta wave at the beginning of the QRS, QRS duration of .12 sec or wider, non specific ST segments or T wave abnormalities.
WPW
Management of adnexal cyst in a pregnant woman
if the mass is larger than 5cm and persists beyond first trimester or shows no regression in subsequent visits, surgical intervention is indicated during the 2nd trimester. SHOULD NOT BE ALLOWED TO PROCEED TO 3rd with out removal because of complications.
alcoholic with large liver and LE edema comes in on more than one occasion with right sided pleural effusion even after repeat thoracentesis?
hepatic hydrothorax, treat with Na restriction and diuretics.
Light criteria
EXUDATE IF pleural fluid protein/serum protein >.5, or pleural LDH/Serum LDH>.6 or pleural fluid LDH greater than 2/3 upper limit of normal
pt is confused and has trouble wearing clothes, or struggles with attempting to get into a coat or pants. On exam she can not copy a simple picture. But she can speak clearly. Lesion?
non dominant parietal lobe lesion.
Pt has trouble performing simple math tasks, inability to name individual fingers, impaired writing, and right left confusion. Lesion?
Dominent parietal lobe
lesion of nondominant temporal lobe presents with?
visual disorders (homonymous upper gquadrantanopia), impaired perception of complex sounds
lesion of dominant temporal lobe presents with
homonymous upper quadrantanopia, impaired comprehension of written or spoken language.
management of young female with 2 uti's in 6 months or 3 in the last year
abx prophylaxis (diagnostic work up is usually negative or unrevealing)
bilateral breast englargement in 18-24 month old, no other features of precocious puberty, normal hormone profile for age.
benign premature thelarche, usually resolves
Workup of new diagnosis of turner's
echo, visual hearing assesment, renal ultrasound, TSH measurement. OTHER: Removal of streak gonads only if Y (mosaicism) chromosome is present. HRT when pt is about 14 yo
physical exam finding highly suggestive of testicular torsion?
absent cremasteric reflex
what is the risk of an offspring developing type 1 DM if parent's are type 1 DM?
3% if mother is type 1, 6% if the father is type 1.
how is hemophilia A passed on?
X-linked recessive (deficit in coagulation factor VIII)
most common cause of MI in SLE patients?
premature coronary atherosclerosis
anion gap formula
Na-(Cl+bicarb)
afebrile 2mo old child w/ staccato cough, history of concurrent conjunctivitis, auscultory and radiologic findings out of proportion to the healthy appearance. Diagnosis?
Chlamydia pneumonia, usually presents 2-19 weeks after delivery. WBC is usually normal but eosinophil count is elevated. (staccato cough is a short sudden burst of coughing)
contraindication to DTaP vaccine?
anaphylaxis or encephalopathy w/ receipt of DTaP. Temporary contraindications include severe illness. There are NO contraindications to Hib, polio, pneumonoccocal vaccines
How do you distinguish causes of ascites?
SAAG values: serum-ascites albumin gradient. SAAG>=1.1 differential include CHF, cirrhosis, alcoholic hepatitis. Low SAAG differential include peritoneal carcinomatosis, peritoneal tb, nephrotic syndrome, pancreatitis, serositis.
HIV exposure prophylaxis
2 nucleoside reverse transcriptase inhibitors for 4 weeks. ADD a protease inhibitor in cases where source pt has high viral load
what is amaurosis fugax?
sudden transient monocular blindness, marker of carotid artery atherosclerotic disease. Look for carotid bruit on exam
what is the preferred route for antenatal steroid therapy in preterm labor?
intramuscular (NOT IV, because IV can cause peaks and troughs in levels where as IM gives a slow steady release of steroids)
how do you preserve severed digits for transport?
rap in gauze soaked with saline, place in plastic bag, then place in container filled with mixed ice and saline or water. (NOT all ice, as all ice can cause frost bite)
who to screen for BRCA?
first degree releative with early age of breast cancer onset, multiple affected relatives, relatives w/ breast & ovarian cancer, or relatives w/ more than one primary cancer
what is Jarisch Herxheimer reaction?
acute febrile reaction usually w/in 24 hrs after initation of treatment for syphilis, no treatment available and cause is unknown
CML gene mutation?
translocation of chromosome 9 and 22 (philidelphia chromosome). bcr/abl fusion protein is diagnostic. Treat w/ tyrosine kinase inhibitor.
management of ASCUS?
HPV type/screen is preferred, may also repeat PAP in 6 months.
most important risk factor/predictor of adverse cardiovascular outcomes?
DM, it is a coronary heart disease equivalent. More adverse than hypertension or smoking.
Recommendation for colonoscopy follow up after finding adenomatous polyp?
hyperplastic polyps: 10 years
1 or 2 small (<1cm) tubular adenomas w/ no high grade dysplasia: 5 years
3 or more adenomas, high grade dysplasia, villous features, any adenoma 1cm or larger: 3 years
risk factors for candida endopthalmitis
central venous catheter, TPN, broad spectrum abx, prior abd surgery, neutropenia, steroid therapy, IV drug use. (Note treat w/ vitrectomy and systemic amphotericin B)
elevated PTH, hypercalcemia, and urinary calcium greater than 200mg/day, Diagnosis?
primary hyperparathyroidism. (Note: excretion of less than 100mg/day is likely familial hypocalcuric hypercaclemia, which can usually be monitored w/out intervention)
schizophrenic pt presents w/ immobility, mute, withdrawn, refusal to eat or drink. Dx? Tx?
catatonic type, treat w/ benzodiazpine (lorazepam) or ECT
appropriate protocol for switching from SSRI to MAOI or vise versa
monamine oxidase inhibitor (MAOI) and SSRI combined can cause fatal serotonin syndrome (hyperthermia, tachycardia, diaphoresis, agitation, muscle rigidity). You should taper off one, wait for a month, then start the other.
Pt presents with chest pain, bradycardia, and hypotension. Diagnosis of MI is suspected. Manegement?
sinus bradycardia is often (25%) a complication of inferior wall MI, usually transient and resolves on its own. May be treated w/ IV atropine sulfate
treatment of tb meningitis
pt present w/ malaise, HA, low great fever, progress to persistent HA, vomiting, cranial nerve involvement, confusion, seizures, coma and death. Tx w/ isoniazid, rifampin, pyrazinamide for 2 months. Followed by INH and rifampin. Children and infants shold be tx for 12 months . Adults for 7-10 months.(18-24 if drug resistant)
pt incidentally has PSA of 5, what is next step?
PSA>4 or abnormal digital rectal exam warrants transrectal US guided prostate biopsy. If PSA is elevated between 2.5-4 w/ normal exam, repeat PSA in weeks to months. (Note: PSA from 0-4 has positive predictive value (PPV) of cancer <10%, 4-10 has PPV of 25%, dramatic increase of PPV w/ PSA>10)
pts w/ downs are at increased risk for?
acute leukemia, alzheimers like dementia, autism, ADHD, depression, seizure disorder
treatment of community acquired pneumonia in children
<5yo usually s. pneumoniae, treat w/ amoxicillin. In older children may use azithromycin or doxycycline to cover for atypicals (mycoplasma, chlamydia)
treatment of SIADH
water restriction (w/ possible inclusion of salt administration). If this fails or water retention is severe, then use loop diuretics.
tx of supratherapeutic INR?
INR <5, hold warfarin; INR 5-9, add oral vit K; INR>9 increase dose vitamin K; If there is serious bleeding, IV vit k, FFP, factir VIIa, or prothrombin complex concentrate
pt presents w/ periodic involuntary eye closure that is often provoked by external stimuli (bright light, irritants). Diagnosis? Treatment?
blepharospasm, treat w/ botulinum toxin injections
child w/ scaling and slightly erythematous alopecia, wood lamp shows bright green fluorescence
microsporum canis infection
"dashboard injury" or injury from posterior directed force on the anterior aspect of proximal tibia with knee in flexed position. What is usually injured?
posterior cruciate ligament
pt w/ raynaud's and GERD presents w/ severe hypertension. What likely diagnosis? treatment?
Scleroderma, ace particularly captopril
when should cervical cancer screening start?
21 regardless of age of sexual activity. per new guidelines from 2009. (Note routine HPV testing is not indicated under 30yo)
pain, redness, variable visual loss and a contstricted irregular pupil. Diagnosis?
anterior uveitis or iritis. Confirmed by leukocytes in the anterior segment
triad of urethritis, uveitis, arthritis.
Reiter's syndrome
treatment of new hyperthyroidism in pregnancy
propylthiouracil (associated w/ liver failure) during first trimester then switch to methimazole (possible teratogen) in 2nd or 3rd trimester.
one FDA approved therapy for wrinkles, age spots?
tretinoin
rapidly progressive focal neurological deficits without evidence of increased intracranial pressure in HIV pt
progressive multifocal leukoencephalopathy (PML) caused by JC virus. Treat w/ HAART (there is no specific treatment for JC virus). W/out treatment most pt die w/in 3-6 months.
what is a desmoid tumor
slow growing and locally aggressive benign neoplasms w/ a high rate of local recurrence, even after surgical resection
EKG shows bradycardia w/ preservation of the PR interval, accompanied by periodic loss of QRS complexes. Dx? TX?
diagnosis is mobitz II second degree AV block, treat w/ cardiac pacemaker
tx of latent TB?
isoniazid for 9 months. In cases of isoniazid resistance, rifampin for 6 months in children and 4 months in adults
who should be treated for asymptomatic bacteruria?
pregnant, urologic intervention, hip arthoplasty.
Vent settings to treat ARDS
Low tital volumes (8ml/kg or less), PEEP around 9 cmH20, FiO2 below 60%
pt presents w/ asymmetry of the face when he frowns, puffs out his cheecks, and smiles. His right eye does not close completely. But there are no other neurological findings (stroke is not suspected). Diagnosis? Treatment?
Bells palsy, likely due to HSV. Treat eye with artificial tears and eye patch. Should resolve on its own in 3 weeks or less. If not then consider steroids and acyclovir (no evidence it improves outcome)
tetanus recommendations
Td booster for pt w/ dirty wounds who received booster >5 years ago and clean wounds w/ booster >10 years ago. TIG only for pt w/ dirty wound and unclear or incomplete immunization history.
Vent settings to treat ARDS
Low tital volumes (8ml/kg or less), PEEP around 9 cmH20, FiO2 below 60%
pt presents w/ asymmetry of the face when he frowns, puffs out his cheecks, and smiles. His right eye does not close completely. But there are no other neurological findings (stroke is not suspected). Diagnosis? Treatment?
Bells palsy, likely due to HSV. Treat eye with artificial tears and eye patch. Should resolve on its own in 3 weeks or less. If not then consider steroids and acyclovir (no evidence it improves outcome)
tetanus recommendations
Td booster for pt w/ dirty wounds who received booster >5 years ago and clean wounds w/ booster >10 years ago. TIG only for pt w/ dirty wound and unclear or incomplete immunization history.
pt w/ hematuria, proteinuria, and mild elevation of Cr has arthralgias, palpapble purpura, lymphadenopathy, hepatosplenomegaly and peripheral neuropathy. Also has hx of IV drug use. Diagnosis?
cryoglobulinemia, usually associated hepatitis C. test for cryoglobulin levels
lateral knee injury can result in what triad?
MAM, Medial meniscal injury, anterior cruciate ligament tear, medial cruciate ligament injury
treatment of aortic stenosis
once symptomatic, replacement (NOT balloon valvulutomy)
asthmatic previously well controlled presents with recurrent fever, malaise, cough w/ brownish mucoid sputum, wheezing, and bronchial obstruction. Diagnosis? First test?
allergic bronchopulmonary aspergillosis, skin prick for aspergillus then IgE level for confirmation. Treat with oral prednisone
side effect of diltiazam
peripheral edema is a well known side effect of calcium antagonist therapy
imaging is recommended in which UTI pts?
1. child under 5 w/ febrile UTI
2. Male of any age w/ first UTI
3. Females under 3 w first UTI
4. Child w/ UTI that does not respond to abx
5. Child w/ recurrent UTI
young girl presents w/ jerking movements of the face, hands, feet. Hypotonic state, positive pronator sign, sudden changes in pitch and volume
Sydenham's Chorea, usually seen 1-8 months after rheumatic fever
bacteremic pt presents w/ new LBBB, which valve is involved?
most likely aortic, due to its close proximity to ventricular conduction system.
what is autoimmune metaplastic atrophic gastritis
type of gastritis leads to pernicious anemia. immune response to oxynitc cells and intrinsic factor. 3 main components include glandular atrophy, intestinal metaplasia, inflammation. Atrophy affects mainly gastric body and fundus
recommended emergency contraception?
levonorgestrel, maximal efficacy in first 12 hrs and good w/in 48 hrs. May work up to 120 hrs
best treatment for obstructing promximal ureteral stone w/ infection and hemodynamic instability?
percutaneous nephrostomy. (retrosurgical procedures such as stent placement may push infected material into urinary tract, shock wave lithotripsy is proper choice for uncomplicated proximal stones)
most senstive for detection of CREST variant scleroderma?
anti centromere antibodies
most sensitive auto-immune serologic test for primary biliary cirrhosis?
anti mitochondrial antibodies
most sensitive auto immune serologic test for Sjogrens
anto-ro/SSA
Most specific auto immune serologic test for SLE
anti dsDNA (titers may also be used to follow disease)
treatment of SLE
can always use steroids. HYDROXYCHLORQUINE for mild disease including arthralgis, serositis, cutaneous symptoms. CYCLOPHOSPHAMIDE is reserved for pt w/ lupus nephritis, CNS involvement, vasculitis. METHOTREXATE for significant organ involvement w/ incomplete response to above or prednisone.
treatment for metoclopramide induced dystonia
diphenhydramine
anterior knee pain that is provoked by climbing stairs or prolonged sitting
patello-femoral pain syndrome
first line for childhood absence seizures
ethosuximide (valproate is reserved for pts with absence seizures who also have other types, phenobarbital and phenytoin are effective against generalized tonic clonic but can make absence seizures worse)
evaluation of hyperthyroidism in pregnancy requires what blood tests?
TSH, T4, AND FREE T4! TBG are increased during pregnancy leading to naturally higher T3 and T4. So free T4 must be ordered as well.
gestational transient thyrotoxosis
mildly increased FREE T4, slightly decreased TSH at the end of the first trimester.
treatment of primary pulmonary hypertension
first receive vasoreactivity test. If response is favorable during test start calcium channel bloocker, otherwise start prostanoid medication such as epoprostenol, endothelin receptor antagonist such as bosentan, or a phosphodiesterase 5 inhibitor like sildenafil
criteria for febrile seizures
<6 yo, no hx of afebrile seizures, temp > 38c, no evidence of CNS infection/inflammation, no metabolic disturbances.
hypopigmented spots, family hx of bilateral deafness.
NF-2, autosomal dominant. Deafness is due to bilateral acoustic neuroma.
Hyperpigmented sports, family hx of unilateral deafness
NF-1
congenital hypopigmented maculae (ash leaf spots), glial proliferation, and several organ hamartomas/cysts
tuberous sclerosis
facial port wine stain and leptomeningeal angiomatosis
sturge weber syndrome
multiple telangiectasias and vascular lesions of the CNS
osler rendu weber syndrome
management of htn in pregnancy
hydralazine or labetalol for acute management. Methyldopa in mild to moderate hypertension. (ofcourse this does not apply to eclampsia, for that give Mg, which is also the best tx for eclampitc seizures, and deliver)
pt w/ tachypnea, shallow breathing, anterior chest bruises and peripheral cyanosis. Dx?
Flail chest, usually result of double rib fractures. Present in 10-20% of trauma admissions
when to treat subclinical hypothyroidism
1. antithyroid antibodies, 2. an abnormal lipid profile. 3. symptoms 4. ovulary and menstral dysfuction
what is phentolamine
alpha antagonist used for cocaine related hypertension. (also good for pheocromocytoma)
pt w/ hashimoto's thyroiditis presents with rapid enlargement of thyroid gland. Consider?
thyroid lymphoma
best imaging for urethral diverticula
transvaginal ultrasound or MRI. If this inconclusive then gold standard is voiding urethroscopy.
when should undescended testes be evaluated for intervention
6 months
simple and least toxic treatment of bleeding in renal dysfunction?
desmopressin
does diagnosis of latent TB and refusal of treatment prevent work in a hospital?
no, someone can not be refused employment for latent TB (only active TB), but refusal of treatment should be documented
management of breast mass in women under 30
ultrasound, then core needle biopsy if a solid mass is present w/ atypical features
best test to confirm vasovagal syncope
upright tilt table test
drugs that cause lupus like syndrome
hydralazine, procainamide, penicillamine, isoniazid, minocycline, diltiazem, methyldopa, chlorpromazine, interferon alpha
licorice side effect
hypertension
imaging modality of osteonecrosis of femoral head?
MRI (tx w/ core decompression for stage 1 or 2, hip replacement for stage 4)
Contraindications to combined oral contraceptive pills
hx of thromboembolic event, liver disease, hx of estrogen dependent tumor, pregnancy, undiagnosed abn uterine bleeding, heavy smoking in pt >35. Relative contraindications include poorly controlled htn, anticonvuslant therapy, migraines (w/ aura or focal symptoms is considered absolute contraindication)
keratocanthoma
common on the cheek, low grade malignancy that resembles squamous cell carcinoma. Solitary, firm, round, skin colored or reddish plaque that develops into nodule with a central keratin plug
pt w/ chronic hypoparathyroidism and low serum calcium and high urinary calcium. Treat w/?
thiazide diuretic
gross hematuria after acute upper respiratory infection is common presentation of?
IgA nephropathy, no definitive treatment (poststrep glomerulonephritis follows strep throat infection w/ gap of 10 days and compliment levels are decreased)
long standing hypocalcemia with hyperphosphatemia w/ elevated PTH level
most likely pseudohypoparathyroidism (resistance of PTH on target tissue)
absence of peristaltic waves in the lower 2/3 of esophagus and a significant decrease in lower esophageal sphincter tone are characteristic of?
scleroderma
signicant decrease or absence of peristaltic waves and increased LES tone?
achalasia
what is reiter's syndrome, diagnosis, treatment
OR reactive arthritis: conjunctivitis, urethritis, spondyloarthropathy. Common preceding infections include chlamydia. Strong association with HLAB27 (BUT DO NOT ORDER THIS, SPINE XRAY IS FIRST TEST)treat w/ antibiotics for acute infection, excercise for mobility, and disease modifying agents such as sulfasalizine and MTX
most common causes of otitis media
strep pneumo (35%), haemophilus influ (25%), moraxella catarrhalis (15%). most of the h. flu strains are non type-able. Tx w/ amoxicillin, if this fails IT IS STILL ONE OF THE ABOVE organsims (just possibly resistant). Change to amoxicillin/clavulanate, TMP-SMX, clarithromycin, or 2nd gen oral cephalosporin
Subacute lymphocytic thyroiditis
mild diffuse painless enlargement of the gland, less than 2 months duration. Associated w/ amiodarone, interferon alfa, interleukin 2. THIS IS USUALLY TRANSIENT and may change to hypothyrodism. Do not treat w/ PTU, manage symptoms with a beta blocker
Single most important risk factor for prognosis of COPD?
Age and FEV1 are most important, after adjusting for age FEV1 is most important. (airway responsiveness, current smoker, decreased exercise capacity, decreased BMI, airway bacterial load and HIV status are all prognostic but not as important as FEV1)
most common cause of erysipelas
specific form of cellulitis, usually in lower extremities but may be in face. RED, PAINFUL, EDEMATOUS, ELEVATED, SHARP DEMARCATION AND BORDERS. also usually abrupt onset, systemic symptoms (fever, chills, malaise)
gold standard imaging of nephrolithiasis
non contrast helical CT is gold standard, followed by intravenous pyleogram. US is preferred in pregnant women only (or when radiation or contrast is contraindicated)
Pregnancy risk category C
1) studies in animals have shown an adverse effect but no studies have been done on pregnant women. 2) no studies have been done on animals or pregnant women
pregnancy risk category A
GOOD
Pregnancy risk category D
Acceptable despite the high risk
Pregnancy risk category X
VERY BAD
universal complication of lumbosacral myelomenginocele
bladder dysfunction (followed by lower GI tract dysfucntion and fractures of the lower extremities)
treatment of choice for onchymyocosis
terbinafine or itraconazole
initial manage of testicular mass.
US, then if suggestive of cancer proceed to CT of abd and pelvis, chest xr, tumor markers (AFP, HCG). finally radical inguinal orchiectomy is the definitive procedure for histological diagnosis
pt w/ hx of depression presents w/ hypotension, anticholinergic effecs, CNS manifestions, cardiac arrhythmia. Diagnosis? Treatment?
TCA overdose. TCAs inhibit fast sodium channels, leading to QRS prolonagation and reentrant arrhthmias (ventricular tachy, vfib, torsades). SODIUM BICARB is the most effective agent. LIDOCAINE is the antiarrhythmic drug of choice
work up of musculoskeletal back pain
manage conservatively w/ pain control and physical therapy unless there are findings suggest infection, tumor, or neurological compromise. If pain continues for longer than 6 weeks, order ESR/CRP. Longer than 12 weeks, order MRI. (NOTE this is for ms type back pain with no focal neurological findings)
Absolute contraindications to excercise during pregnancy?
significant cardiac or pulmonary disease, cervical incompetence, multiple gestation, placental abruption, placenta previa, premature labor, ruptured fetal membranes, preeclampsia
pruritic papules and vesicles that appear mainly on elbos, knees, buttocks, posterior neck, scalp. Associated w/ gluten sensitive enteropathy.
dermatitis herptiformis
pruritic honey colored macules, vesicles, bullae on the face and other exposed parts
impetigo, staph a or group a strep
what is porphyria cutanea tarda
painless blisters, hypertrichosis, and hyperpigmentation. Often associated with Hep C infection and can be triggered by certain substances (ethanol, estrogens), which should be discontinued if suspected
what is presbycusis
hearing loss w/ normal aging
lactose intolerance is diagnosed via?
lactos breath hydrogen test. Fast for 8 hrs, then consume lactose containing beverage. (lactose is fermented by colonic bactera to form fatty acids and hydrogen gas)
HIV pt presents w/ hemiparesis, disturbance of speech, vision and gait changes. MRI finds multiple demyelinating non enhancing lesions w/ no mass effect
progressive multifocal leukoencephalopathy (PML). No treatment, caused by JC virus. (Note: toxo, cns lymphoma, and brain abscess can all occur in HIV but produce ring enhancing lesions and mass effect on MRI)
most effective treatment for prostatitis?
ciprofloxacin or levofloxacin. TMP-SMX is second line. requires tx for 6-12 weeks.
most commonly involved muscles in myasthenia gravis?
ocular and bulbar muscles. Classic presentation is musclar weakness throughout the day that improves w/ rest
pt elevates hands above head for one minute and has pain
another test for carpal tunnel (Phalen's HYPERFLEXION is the classic test. Tinel's sign is tapping the median nerve). Treat w/ night time splinting first, then try injected steroids. Surgical decompression should only be used if symptoms continue for >6 months
treatment of asthma exacerbation
first Oxygen, then short acting bronchodilaters, finally SYSTEMIC steroids
triad of periodic vertigo, unilateral hearing loss and tinnitus
meniere's disease
positive valgus test
MCL (vaLgus is moving feet Laterally)
pain and laxity w/ anterior drawer or lachman maneuver
ACL tear, usually after non contact deceleration, a cutting movement, or hyper extension. May have popping sound
knee injury w/ little pain or alteration in range of motion but the posterior drawer test is positive
posterior cruciate ligament injury, uncommon. occurs from posteriorly directed force on flexed knee (dashboard being struck by anterior of flexed knee in MVA) or from hyperextension
positive varus test
usually lateral collateral ligament injury. Also have pain along lateral joint line.
sulfonylurea overdose treatment
first line is dextrose. Then if pt is persistently hypoglycemic try octreotide (somatostatin analog decreases insulin production)
sicca syndrome
dry mouth (xerostomia) and dry eyes (keratoconjunctivitis sicca). Perform schirmer test (secretory test), and autoantibody screen (ro, la, rf, ana)
psuedomonas aeruginosa antibiotics
Cefepime and ceftazidime (ant-pseudo cephalosporins), amikacin (aminoglycoside). Then the carbapenems, certain fluroquinolones (levofloxacin), piperacillin-tazobactam, aztreonam, colistin
recommended calcium intake for different age groups
9-18 years old: 1300 mg
19-50 year old: 1000 mg
51 and older: 1200 mg
HIV med side effects, indinavir
crystal induced nephropathy
HIV med side effect, didanosine
pancreatitis
HIV med side effects, abacavir
hypersensitivity syndrome
HIV med side effects, any of the NRTIs
lactic acidosis
HIV med side effects, any of the NNRTIs
steven's johnson syndrome
HIV med side effects, nevirapine
liver failure
treatment of acute variceal bleeding
consertative with octreotide and beta blockers if pt is stable, then try endoscopic intervention if this fails or pt is unstable, repeat this again if necessary. If two endoscopic attempts fail then proceed to TIPS
pt presents w/ shortness of breath worse in supine position but does not have heart failure
consider diaphragmatic paralysis. May have paradoxical abdominal wall retraction during inspiration when the patient is lying supine. Sniff test using fluoroscopy can confirm diagnosis. (note: should trigger work up of other neurological findings i.e. lower extremity muscle atrophy and tongue fasciluations along with diaphragmatic paralysis suggest ALS.)
infant w/ barking cough and stridor. Diagnosis, treatment
Croup, viral infection. Treat w/ corticosteroids, cool mist, nebulized racemic epinephrine
most appropriate initial test in pt w/ long standing allergic rhinitis that does not respond to over counter meds
nasal cytology. This test is not specific but will rule in or rule out infection versus allergic (eosinophillia will be present)
serious organophosphate poisoning should be treated w/
atropine (reverses muscarinic receptor effects), pralidoxime (cholinesterase activator)
hashimoto's thyroiditis is associated w/ what antibody test
anti TPO (antimicrosomal)
majority of pts w/ primary hypothyroidism also have?
85% of pts w/ hypothyroidism have HYPERLIPIDEMIA
metformin contraindications
CHF, alcoholism, renal failure
pioglitazone contraindications
pioglitazone is an insulin sensitizer (TZD), contraindications are class III/IV CHF
less well known complication of endometriosis
intestinal obstruction
loss of pupillary reaction, vertical gaze paralysis, loss of optokinetic nystagmus, ataxia. Diagnosis?
pineal tumor (parinaud's syndrome). some are germinomas and may secrete HCG
craniopharyngeomas are classically associated w/ ?
diabetes insipidus and a deficiency of one or more anterior pituitary hormones
standard parenteral feeding composition
30 kcal/kg/day and 1g/kg/day of protein
what is prophylaxis for stress ulcers in ICU pts?
recommended for pts w/ coagulopathy, hx of GI bleeding in last year, mechanical vent for more than 48 hrs, or two of the following (sepsis, icu admission longer than 1 week, occult gi bleeding longer than 6 days, glucocorticoid therapy). Proton pump inhibitor is the agent of choice for PO, H2 receptor antagonist for IV.
initial test for penumothorax
upright chest xr (posteroanterior view)
subchorionic hematoma
bleeding between endometrium and gestational sac in pregnant women. Appear on US as crescent shaped hypoechoic regions adjacent to gestational sac and are most commonly identified source of 1st trimester bleeding. No treatment, follow up ultrasound 1 week later. Does have increased spontaneous abortion risk
elevated calcitonin levels in pt w/ medullary thyroid cancer following total thyroidectomy indicate?
metastatic disease. CT scan of the neck and chest is the inital step. NOTE: medullary thyroid cancer does not take up iodine, so iodine scan is NOT helpful.
what do sickle cell, HbS-HbC disorder, beta thalassemia all have in common?
they affect the beta chain of hemoglobin (they rarely present early in life because predominant hemoblogin in newboards is HbF (alpha2/gamma2)
Platelet transfusion protocols
should only be tranfused if under 50k with severe bleeding or 10k. Measure platelets 10-60 mins after completion. Each unit of platelet transfused should cause an immediate post transfusion rice by 5k. (Note; if platelets don't demonstrate normal rise at 1 hr, likely alloimmuniaztion. If they rise at 1 hr appropriately but fall again the next day then consider something like DIC)
Hypercalcemia in a new quadraplegic pt is most likely due to
immobilization. Increased bone resorption and simultaneous decrease formation. Unknown mechanism
abx choice for dog/cat bites
amoxicllin/clavulanate
carpel tunnel is associated w/ following conditions
diabetes, hypothyroidism, ESRD/dialysis
MEN1
THREE Ps! hyperParatyhroid, gastrinoma (pancreatic tumor) and pituitary tumor. Usually require removal of parathyroid glands
treatment of T1a N0 M0 glottis squamous cell carcinoma
T1a designates a lesion confined to one vocal cord, treat w/ radiation therapy, laser excision, partial vocal cordectomy (for T3 you use chemo then radiation, if this doesn't work then resort to partial or total laryngectomy)
treatment of symptomatic uterine prolapse?
hysterectomy
cat scratch disease, complications, treatment.
due to bartonella henselae, may lead to supparation of lymph nodes ( most common complication), also neuroretinitis, encephalopathy, fever of unknown origin, hepatosplenomegaly). Treat with azithromycin
child presents w/ fever, lymphadenopathy of posterior cervical and suboccipital nodes, maculopapular rash that erupts on the face and spreads caudally
rubella
pt presents w/ cough, conjunctivitis, coryza. Then progress to fever and photophobia.on exam has blue white spots on buccal mucosa. Next day has maculopapular rash on the face that spreads to to trunk and extremities
rubeola or measles. Remember 3 c's Cough, Conjunctivitis, Coryza (another word for rhinitis). Blue white spots are also called koplik spots
pt has a very high fever that resolves rapidly, then eruption of rosy non pruritic rash on the trunk that spreads to extremities
roseola
pt has fever, myalgias, ha, petechial rash. Rash started on distal extremities (palms, soles), then spread to trunk
rocky mountain spotted fever
most common complication of variocele
venous drainage of testes involves pampinoform plexus, which keeps the temp below normal body temperature. Dilation of the plexus (veriocele) results in an increased temp of scrotal sac and testicular atrophy. Left sided is more common because the left spermatic vein enters the left renal vein at a 90 degree angle (NOTE: pts who have bilateral varicoele, RIGHT variocele or variocele that does not disappear in the supine position showed be worked up for inferior vena cava obstruction with CT of abd)
nipple discharge concerning for cancer has what characteristics
unilateral, spontaneous (not only expressed with pressure), and guaiac positive. (in contrast pts w/ endocrine or medication induced tend to have bilateral discharge). All unilateral discharge should be followed up with mammogram
current guidelines for DM2 diagnosis
HbA1c >6.5
OR at least an 8 hr fasting bg of over 126,
OR classic symptoms along w/ random glucose >200
OR two hr plasma glucose >200 during a 75g OGTT
which pts with new GERD require upper GI scope?
any alarm symptoms (weight loss, anemia, early satiety, dysphagia), and any pt over 45. other wise starting with urea breath test or H pylori ab may be appropriate.
management of AKI in SLE pt
MUST GET A RENAL BIOPSY! especially in pt w/ less severe mild proteinuria or hematira or when presentation is nephrotic w/ bland urinary sediments. Thereapy is directed at type. Type I and II require no treatment, type III and IV require immunosuppresion. Type V requires treatment when proliferative lesions are superimposed. IV methylprednisone is best choice followed by cyclophosphamide if that fails. Monitor w/ complement or anti dsDNA levels
excercise induced amenorrhea can also be associated w/
leads to decrese in the pulsatile secretion of LH, which leads to a decline in estrogen production. This can cause osteopenia, osteoporosis, breast and vaginal atrophy, mild hypercholesterolemia, and infertility.
treatment of otitis externa
clean ear w/ a cerumen wire loop or cotton swab (or hydrogen peroxide if tympanic membrane is visualized and there is no debris), THEN topical antibiotics
treatment of intestinal parasitosis
albendazole or mebendazole
treatment of gastrectomy dumping syndrome?
high protein low carb diet w/ small frequent meals.
bone marrow transplant pt presents w/ cough, chest pain, HA, nasal bleeding, fever. What should be considered?
invasive aspergillosis
Pt presents w/ altered mental status, hallucinations, hypertension, tachychardia, and multidirectional nystagmus. Diagnosis? treatment?
PCP intoxication, treat w/ quiet environment and or benzo
treatment of ethylene glycoal and methanol intoxication?
fomepizole infusion is first line, ethanol is 2nd line. Do not give together.
treatment of metastatic prostate cancer
first use flutamide (antiandrogen) to block testosterone surge, then start LHRH agonist such as leuprolide
antibiotics notorious for causing cdiff?
CLINDAMYCIN has the highest probability of causing cdiff followed by ampicillin, amoxicillin, cephalosporins
treatment of lead poisoning?
lead >70, dimercaprol and EDTA. Moderate (45-7), IV EDTA or oral DMSA. <45 DMSA or d penicillamine
thyrotoxicosis presents with low or high radioactive iodine uptake?
LOW, as seen in sub-acute thyroiditis, painless thyroiditis, postpartum thyroiditis, surreptitious thyroid hormone administration, and iodine induced thyroiditis
cholesterol screening guidelines in children
children with a family hx of cholesterol greater than 240 or premature CAD should be screened. If family member>240, order random cholesterol at 2 years old. If child is <170 repeat in five years, if >200 order FLP (if family member has hx of premature CAD order FLP directly)
most common cause of 2ndary hypertension
renal parenchymal disease (NOT RENAL STENOSIS)
pt has iron deficiency and vit D deficiency without any apparent malabsorption symptoms
consider celiac disease
slow progressive frontal lobe dementia characterized by speech abnormalities, impaired executive functioning, irritable mood, hyper oral behavior and disinihbition.
Pick's disease, imaging reveal the classic finding of prominent symmetric atrophy of the frontal and or temporal lobes
pt presents w/ varying cognitive function and alertness, persistent visual hallucinations and some motor features of Parkinsons (rigidity, intention tremor) falls are common
lewy body dementia
what is scombroid poisoning
10-30 mins after ingesting fish, self limited. Presents w/ flushing, throbbing headache, palpitations, abd cramps, diarrhea, oral burning
medications for schizophrenia and poor compliance
long acting medications: haloperidol deconate, risperidone, fluphenazine
child with presumed otitis media has pain behind his ear
inflammation and possible pus in mastoid air cells
treatment for chronic RA failing over counter meds
methotrexate, if that fails may switch to or add anti-cytokine drug (be aware of opportunistic infection)
major cause of respiratory muscle weakness and can lead to failure of being able to wean a patient off the respirator
hypophosphatemia, usually caused by glucose infusions
Alternative treatment for squamous cell carcinoma if pt refuses surgery
Radiation therapy
treatment of significant scrotal trauma
surgical exploration
female pregnant w/ twins delivers one but the 2nd does not deliver, management?
place electronic fetal monitoring and use ultrasound to monitor 2nd fetus. If in no distress may continue w/ vaginal but use oxytocin
management of toxic megacolin
presents w/ toxic appearnce, distended tympanic abd, usually hx of UC. image with abd xr. Treat with steroids
in pt w/ thyroid cancer, after resection and radioactive iodine therapy how do you dose the levotyhroxine?
should be dosed to a goal TSH of .1 to .3 (normal TS is .35-5)
pt w/ hypothyroidism considering oral contraceptive pills, management?
TSH levels checked 12wk after COCP started. levothyroxine usually has to be increased. (hormones increase TBG leading to less free T4)
pt presnts w/ unilateral headache, miosis, ptosis, anhidroisis should be worked up for?
this is horner's syndrome which is carotid dissection until proven otherwise. MRA is the initial diagnostic test
when should an elective abortion be performed?
pts w/ cyanotic congenital heart disease (ie eisenmenger syndrome)
most common complication of transurethral resection procedure of prostate?
retrograde ejaculation (occurs in 70%)
increased Cr after starting ACEi in a renal transplant pt is indicative of?
renal artery stenosis
recommendations for diet in child with diarrhea (not requiring admission)
fluids low in sugar and normal age appropriate diet w/ minimal sugar and fat
side effect of thiazolidinedione medications
(ie pioglitazone) fluid retention via PPAR-y agonist on the renal collecting tubule (Na resorbtion). Usually in pts w/ underlying CHF
treatment of lightening strike
pt can present w/ fixed dilated pupils, asystole. Do not stop resuscitation because dilated pupils may be transient autonomic dysfunction. Also give epi for asystole.
best assessment of immune status in HIV pts
CD4 count is good marker for current status. Viral load is a good marker of disease activity or the potential for future damage "the damage that is about to occur"
before using peritoneal dialysis in adult polycystic kidney disease, must rule out?
diverticulosis with colonoscopy
treatment of asymptomatic porcelain gallbladder
cholecystectomy due to high risk of gallbladder carcinoma
egg containing vaccines
influenza and yellow fvever
treatment of prolactinomas
dopaminergic receptor agonist (ie bromocriptine) . DO NOT PICK transphenoidal resection (this is reserved for pituitary adenomas)
early signs of compartment syndrome
pain out of proportion, persistent deep pain, parashesias. Phys exam shows tightness of the area, weakness, pain w/ passive stretching. (no pulses is a late finding)
best study method for investigating infectious disease outbreaks
case control (question infected pts, and question non infected or controls, then compare the two)
carotid endarterectomy should be considered in pts w/ stenosis greater than?
70%
treatment of pituitary adenomas
transphenoidal resection
most common causes of viral meningitis in pediatric population
enterovirus and arbovirus (easter equine, western equine, st louis encephalitis, colarodo tick fever, califorinia encephalitis) think rural, summer, animal exposure
sarcoid pt w/ hilar adenopathy and erythema nodosum, treatment?
this clinical picture (hilar adenopathy and erythema nodosum) is actually a favorable varient of sarcoid and has a high rate of spontaneous remission. DO NOT TREAT unless pt has symptoms, abnormal PFTs or progressive disease (standard sarcoid treatment is steroids)
chemo-prophylaxis for contact w/ neiserria meningitidis in adults
rifampin for 2 days, or if pt can't tolerate rifampin (ie pt is on oral contraceptives and can not take rifampin) 2nd line is ciprofloxacin
Pt w/ TPN suddenly develops hyperglycemia
suspect sepsis
Open wounds that should not be closed
animal bites on the hand or puncture wounds anywhere on the body (due to infection). Face wounds may be closed.
what is superior sagittal sinus thrombosis, treatment?
associated w/ trauma, infection, hypercoagulation, vasculitis, nephrotic syndrome, sever dehydration and pregnancy. Hx shows HA, hemiparesis, papilledema, seizure. Treat w/ heparin EVEN IF AREA OF INFARCTION OR HEMORRHAGE IS SEEN ON CT
PT w/ mild diabetes presents w/ erythematous scaly rash w/ clearing from center. The boarders appear slightly elevated and crusty. Also complains of lethargy, weight loss, diarrhea, abd cramps and occasional flushing. Diagnosis
Rash is called necrolytic migratory erythema. Diagnosis is glucagonoma. Symptoms are due to VIP, calcitonin, GLP1 Treat w/ surgery
rotator cuff tear presenst w/
pain w/ abduction and external rotation
acromiclavicular pain or glenohumral joint osteoarthritis and bicep tendinitis presents w/
anterior shoulder pain
posterior should pain is usually
referrred pain from cervical spine (least common shoulder pain)
when should you be concerned about transmission of vaccine associated VZV
post vaccination rash
evaluation of pt receiving cardiotoxic chemo
radionuclide ventriculography or MUGA scan
mainstay treatment of chronic constipation
fiber, hydration, and bulk laxatives (psyllium or methylcellulose). Note: milk of magnesia is contraindicated in renal failure, docusate is not very effective, castor oil can cause electrolyte abnormalities, bisacodyl can lead to hypokalemia
treatment of lobular carcinoma in situ (breast mass)
non malignant lesion but should be removed w/ excesional biopsy due to future malignancy potential
best tool to evaluate patients w/ persistent or nonresolving pneumonia or pulmonary infiltrates
flexible bronch, HRCT is another option but does not provide confirmatory information
diagnosis of carbon monoxide poisoning?
co-oximetry
acute pericarditis as related to MI
occurs 1-4 days after MI (DRESSLER'S ON THE OTHER HAND OCCURS WK TO MONTHS AFTER MI OR CARDIAC SURGERY), worse w/ position changes, deep inspiration, pericardial friction rub and EKG showing tachy, diffuse ST sigment elevations, PR depression
Delayed puberty in boys
does not have testicular enlargement by 14, or if testicles are 2.5 cm or less in diameter. or delay in development 5 year or more from the onset of genitalia enlargement
what percentage of pt w/ familial adenomatous polyposis will develop colon cancer by 45?
95%, tx w/ prophylactic colectomy, also upper GI scope at diagnosis