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303 Cards in this Set

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Echinocandins

anti-fungal medications that include:


caspofungin


micafungin


anidulafungin




Drug of choice for neutropenic fever not responding to Abx

Small bowel obstruction

Always think in a pt with abdominal pain post abd surgery




Best initial step in management --> Xray




Gold standard for dx --> CT with contrast

Times to perform LP

Fever




Photophobia




Neck stiffness




any other sign of CNS infection




DO NOT NEED TO DO FOR SEIZURE

Pituitary apoplexy

Sudden hemorrhage into the pituitary gland




can lead to hypotension due to loss of ACTH and cortisol --> endocrine emergency!




Immediately need to give stress dose glucocorticoid (eg hydrocortisone)

Acneiform

drug induced (eg steroids, testosterone, anti-epileptic, cyclosporin) induced acne




characterized by sudden onset of papules and pustules resembling acne lesions particularily on arms and trunk




rx with tretinoin cream

Miliaria

retention of sweat due to occlusion of eccrine sweat ducts and pores that lead to eruptions




most common on back bc of prolonged bedrest

Rx following initial variceal bleeding

50-80% of re-bleeding within 1 yr




rx with b-blockers, sclerotherapy, or banding




surg options follow medical rx

Testicular torsion

unilateral sudden onset of pain with tenderness and swelling



on PE, testicle is elevated compared to other testicle & it is erythematous



testicular cord may not be palpable



Wound dehiscence

suspect in pt with new onset serous d/c 7-10 post-laparotomy




diabetics have poor wound healing




pt may need to be brought back in OR to explore wound

Wernicke encephalopathy triad

In an etohic:




1) confusion




2) ataxia




3) oculomotor dysfunction




dx is purely on clinical information

w/u of epigastric pain

< 45 yr old:


give PPI and scope if Sxs do not improve


OR


H pylori stool Ag


OR


breath test and scope if positive



> 55 yr old:


upper endoscopy

Benzodiazepine withdrawal

Can be potentially fatal



Psychomotor agitation


Delirium


Autonomic instabillity


Seizures



Osgood-Sclatter dz

overuse injury




typically affects physically active adolescent boys with pain and swelling over the tibial tuberosity




caused by apophysitis (inflammation of the tibial tuberosity) and cartilage detachment




dx is made by hx & tibial tuberosity tenderness

Legg-Calve-Perthes dz

avascular necrosis of femoral head that is characterized by hip and knee pain, a limp, and decreased range of motion




affects boys 4-8 yrs old




rx with casting and surg

Osteosarcoma

most common bone tumor in children




occurs in metaphyses of long bones




p/w pain, swelling, and a palpable mass




XR shows a lytic lesion with "sunburst" pattern




rx is surg

Slipped capital femoral epiphysis (SCFE)

occurs in obese adolescent boys p/w knee, thigh, and limp




can find external hip rotation with hip flexion




XR findings include slippage of femoral epiphysis that can be compared to scoop of ice cream that has partially slipped from the cone




can also have a double density sign and a break in Klein's line on XR




Tx by internal fixation of epiphysis with screws and avoid weight bearing to protect from osteonecrosis (should do immediately)

Treatment of acute STEMI

Aspirin


Heparin


b-blocker


tPA IF within 12 hrs of Sxs

Treatment of acute NSTEMI/unstable angina

1) dual anti-plt therapy: aspirin & P2Y12 receptor blockers (eg clopidogrel, prasugrel, ticagrelor)


2) nitrates


3) b-blockers


4) statins


5) anti-coagulation: unfractionated heparin, LMWH, bivalirudin, or fondaparinux



in NSTEMI next step is NOT cardiac cath

Classic Sxs of Temporal arteritis

In a pt >60 yr old:



1) new onset headache


2) jaw claudication


3) elevated ESR




progressive vision loss can occur due to effect on ophthalmic artery




dx with bx of artery that will show mononuclear and giant multinucleated cells in the intima and media of the vessel




Also assoc with polymyalgia rheumatica --> limb girdle pain and stiffness

Epididymoorchitis

sexually transmitted dz most commonly caused by N gonorrhea & Chlamydia trachomatis




p/w scrotal pain and swelling with testicles and epididymis being enlarged and tender




Prehn's sign --> scrotal elevation may relieve some pain




u/s will show increased blood flow distinguishing btwn torsion or varicocele




rx with PO dox (for Chlamydia) & IM ceftriaxone (for gonorrhea)

Herpes simplex virus keratitis

suspect in pts with recurrent sxs of unilateral pain, redness, and photophobia with an epithelial staining defect




under slit-lamp biomicroscopy can show "dendritic pattern"

Dumping syndrome

surgical complication of treating peptic ulcer dz



surg is usually done if ulcer is bleeding, perforated, causing obstruction, or refractive to treatment



thought to be secondary to dumping hyperosmolar chyme into small intestine with the fluid shifts causing painful bowel distension



Tx with eating smaller meals with fewer carbs and more protein and fats

Preventing bacterial peritonitis

1 yr recurrence rate is as high as 70%




Give fluoroquinolone (eg levofloxacin) prophylactically

Tx for various types of headaches

temporal arteritis --> IV glucocorticoids



migraines --> sumatriptan



cluster headaches --> verapimil initially then oxygen therapy



acute glaucoma --> optho emergency, dx with intraocular pressure & tx with acetazolamide, topical beta blockers, mannitol, and pilocarpine

Risk factors for CAD

Most common --> HTN bc of the incidence




Most significant --> DM

Otitis media unresponsive to amox

switch Abx to:




cefdinir


ceftibuten


cefuroxime


cefpodoxime


amox-clavulanate


azithro

Dynamics of cardiac enzymes

CK-MB goes away by 3 days, whereas troponin is still elevated

CK-MB goes away by 3 days, whereas troponin is still elevated

SLE and pregnancy

pts with hx of anti-phospholipid Abs are given LMW heparin and aspirin during pregnancy




pts should also be screened for anti-Ro Abs bc of their association with congenital heart block

Abruptio placenta

separation of the placenta from the uterus leading to bleeding and possible fetal demise




most common in the setting of drug abuse (esp cocaine), smoking, or abdominal trauma




is very painful

Vasa previa

the blood vessels within the placenta or umbilical cord that are btwn the fetus and the internal cervical os



when ROM occurs, the umbilical cord may get severed resulting in fetal exsanguination

Placenta previa

placenta covers the internal cervical os



blood loss can be small amount or catastrophic



PAINLESS unlike abruptio placenta

HPV infected pap smear

sharply demarcated, large perinuclear vacuoles with alterations to the chromatin pattern




HPV type 6 and 11 are assoc with condyloma acuminata

Crohns and colon cancer

Colon ca risk isnt as high in crohn's vs UC



Risk increases in crohns when colon is involved and pt has been dx for >10 yrs



pts with colon involvement and having it for >10yrs should have yearly colonoscopy

Otitis externa

managed with topical Abx and steroids




Abx: polymyxin or neomycin or cipro or gentamicin or tobramycin or sulfisoxazole

Decompression sickness

aka the bends --> occurs when scuba divers ascend too fast such the body doesnt excrete nitrogen




Type I: less severe and leads to pain, fatigue, malaise, headache, anorexia, lymphatic and cutaneous manifestations --> tx with oxygenation and fluid intake




Type II: more severe and can affect the neurologic, CV, resp, and vestibular systems leading to shock --> tx with hyperbaric chamber

HIV and pregnancy

Babies are delivered via c-section unless viral load is <1,000 copies/ml

Prolactin

normally suppressed by dopamine released from hypothalamus



can be stimulated by TRH (which is increased in primary hypothyroid along with TSH)



someone with primary hypothyroid can mimic pituitary tumor and should be treated with levothyroxine

Anatomy of airway

Rt main stem bronchus has much steeper angle (closer to the trachea) than the left bronchus



nearly all upper airway aspirations of objects smaller than the airway will end up in that location

Inactivated/killed vs live/attenuated vaccines

Inactivated/killed (ok to give in pregnancy)


Hep A


Rabies


Polio


Influenza (Have both inactivated & live versions)



Live/attenuated (not recommended during pregnancy)


MMR


Varicella & zoster


Influenza (Have both inactivated & live versions)


Rotavirus


Yellow fever

Managment of non-hemorrhagic stroke

Pt should be minimally on aspirin




If on aspirin and has an event, then ADD dipyridamole OR SWITCH to clopidogrel




For cardiac you use aspirin + clopidogrel but for brain you use either aspirin or clopidogrel




Carotid endarterectomy is only for clot of 70-100%

Thrombolytics and chest pain

should administer within 12 hours of chest pain




if done within 2 hrs benefit is as much as 50%




if done within 12 hrs benefit is ~10%




should give thrombolytics within 30 mins of entering ED

Assessment of aortic dissection

can confirm dx with contrast chest CT




can also dx with transesophageal echo or conventional angiography

Six Ps of compartment syndrome

pallor




pain




paraesthesia




pulselessness (most ominous sign)




poikilothermia




paralysis




can lead to ARF bc of rhabdo secondary to muscle necrosis

Signs of pericarditis

pleuritic chest pain, leathery rub on systole and diastole, and newly enlarged heart




ST elevation in all leads




Tx with NSAIDS and if refractory tx with steroids

Abx for PID

Best initial therapy is cefoxitin or cefotetan AND dox



if anaphylactic reaction to penicillin --> clinda and gent

Nephrotic syndrome complications

assoc with increased chance of bacterial infections




mildy hypercoaguable state leading to thrombosis, DVT, and/or PE




pts are actually hypovolemic bc of 3rd spacing

Henoch-Schonlein Purpura

most common cause of vasculitis in children (mean age is 4-7)




IgA mediated vasculitis involving small blood vessels of skin, GI tract, kidneys, and joints




classic rash is palpable purpura concentrated on the buttocks and lower extremities but rarely on trunk




plt count has to be normal or elevated



Rocky Mountain spotted fever rash

maculopapular rash that begins on extremities and spreads inward to the trunk and includes the palms and soles




rash can become purpuric after several days

Erythema infectiosum (fifth disease)

caused by parvo B19 virus



p/w bright red raised erythema on the cheeks that has the appearance of a sunburn



can have fever, headache, and muscle asches



is only infectious BEFORE onset of rash

Zollinger-Ellison syndrome

normally, secretin inhibits gastrin secretion but with gastrinomas secretin actually stimulates secretion




if gastrin level is markedly elevated (>1,000) then this is sufficient to make dx




if gastrin level elevated (150-1000) then need to do secretin challenge test




after dx is made, then need to localize the tumor so need to perform imaging

Post thoracentesis pulmonary edema

after draining large volumes (>1 L), can have re-expansion pulmonary edema



risk depends on chronicity of the effusion, capillary permeability, and whether suction was used to drain effusion



bc of high mortality rates assoc with this, ppl tend to drain large volumes in stages or by slow gravity drainage

Chest pain secondary to ischemia

described as substernal and dull (or being punched)




positional pain is NOT ischemia




pain described as knife or point like pain, lasting a few seconds, sharp, or positional is NOT ischemia

Metformin and kidney function

contraindicated in pts with renal insufficiency bc it raises the possibility of metabolic lactic acidosis

Most common cause of epigastric discomfort

Non-ulcer dyspepsia (NUD) --> mid epigastric abdominal pain or fullness w/o a cause identified



2nd most common is GERD

Child abuse

any child not walking with a lower extremity fracture is a victim of child abuse until proven otherwise

EKG changes in hypothermia

hypothermia prolongs repolarization leading to upward deflection of S wave



Also see QT interval prolongation

Electrolyte abnormalities and EKG changes

hypokalemia --> diffuse broadening of T waves and prominent U waves




hyperkalemia --> peaked T waves




hypercalcemia --> QT interval shortening

Pruritic urticarial papules and plaques of pregnancy (PUPPP)

relatively common & normally occurs in 3rd trimester in primigravidas



typically develops on the abdomen with umbilical sparing



1-2mm erythematous papules which coalesce to form urticarial plaques



responds to steroids but usually resolves w/o treatment after pregnancy



can re-occur with future pregnancies

Pustular psoriasis of pregnancy

marked by acute, febrile onset with development of grouped erythematous plaques that are rimmed with small sterile pustules



hypocalcemia can develop leading to delirium, seizures, and tetany



Tx with high dose steroids



fetus is at higher risk for stillbirths and placental insufficiency

Risk factors for osteoporosis

advanced age


decreased gonadal function


Caucasian ethnicity


corticosteroid use


low Ca intake


poor physical activity

Rheumatoid arthritis

symmetrical joints of hands with elevated ESR, RF, anti-CCP, and CRP




most common extra-articular manifestation is nodules




pleural effusion with very low glucose is characteristic of RA

OCPs contraindications

migraine with aura



smoking in a patient >35yo



BP >160/>100

Contraindications for thrombolytics

Hemorrhagic stroke at any time in the past




BP >180/110




intracranial malignancy




aortic dissection




any major bleeding

Ectopic pregnancy management

Give low dose methotrexate IM if:


hemodynamically stable


b-HCG <5,000


mass <3-4cm with no fetal activity




repeat b-HCG 4 days then 1 week & if it doesnt decrease by more than 15% then give another dose of methotrexate (can give total of 3 doses)




if methotrexate doesnt reduce b-HCG --> surgical resection

Vitiligo

loss of melanocytes from the epidermis, mucous membranes, and other tissues




thyroid dz (hypo and hyper), DM, pernicious anemia, addison dz, multiglandular insufficiency syndrome, and alopecia areata are assoc with vitiligo




Tx with corticosteroids and phototherapy

Pacemaker and stress test

cannot do stress test when pacemaker is present

Relapsing polychondritis

recurrent inflammatory condition of the cartilage




aortic aneurysm maybe a complication




unique to RP is confinement to carilaginous organs such as ears and nose




tracheal narrowing is characteristic CXR finding




tx with high dose oral pred & IV steroids for acute airway obstruction

B12 deficiency

can lead to peripheral neuropathy

Linezolid side effects

bone marrow suppression --> thrombocytopenia

Cushings syndrome w/u

plasma cortisol at 8AM after 1mg dex the previous night or 24 hr urine cortisol -->




low dose dex suppression test, if no response --> plasma ACTH

Drug-induced vs spontaneous SLE

drug induced DOES NOT affect CNS or kidneys




nearly all cases of drug induced have anti-histone Abs




in both, first step is to look for ANA Abs




hydralizine, procainamide, minocycline, etanercept, & infliximab are common drugs that cause SLE

Febrile seizures

leads to generalized tonic clonic




occurs >24hrs after onset of fever & can last >15 mins

Ticlopidine side effects

ADP receptor inhibitor --> anti coagulant



assoc with neutropenia

Sjogren's syndrome & cancer

assoc with B-cell NHL (3-5%)

Sulfonylureas side effect

can lead to SIADH (hyponatremia with elevated urine Na and osmolality)



weight gain



hypoglycemia



eg chlorpropamide, glipizide, glyburide

Hydroxycholorquine side effect

reversible ocular or retinal toxicity

Post-strep glomerulonephritis

caused by group A beta-hemolytic streptococcus




Triad:


edema


hematuria


HTN




1st step in management, get anti-DNase B and/or ASO titers

Transected urethra

blood at urethral meatus with high riding prostate



need to do urethrogram immediately

Maternal alpha fetal protein

most common cause of abnormal finding --> incorrect preg dating so perform u/s




if correct date & abnormal --> offer amnio




if correct date & high --> neural tube defect?


& low --> Downs

Dipeptidyl Peptidase 4 inhibitors

eg Sitagliptin, saxagliptin, linagliptin




increase insulin levels and decrease glucagon levels by inhibiting destruction of GLP




function w/o increasing weight as opposed to sulfonylureas

Lead poisoning

<10 --> acceptable



10-14 --> repeat in 3 months



15-19 --> repeat in 2 months (>15 need to get health dept notified)



20-44 --> repeat in 1 week



45-70 --> chelation therapy with succimer



>70 --> tx with 2 chelators, dimercaprol & EDTA

Metformin & B12

leads to malabsorption of B12 in gut, resulting in macrocytosis and peripheral neuropathy

Waterhouse-Friderichsen syndrome

caused by Neisseria sepsis




can lead to b/l adrenal hemorrhages




need to check random cortisol level to make dx of adrenal insuff




tx with steroids

Metronidazole & breast feeding

appears in breast milk but do not know effects




as a result, recommend to pump and discard the milk for 24 hrs and then resume breastfeeding

Bacterial vaginosis

caused by Gardnerella vagianalis




d/c has fishy odor




KOH prep will produce foul smell (amine odor) & will see clue cells on microscopic evaluation




vaginal pH is elevated (>4.5)




not STI so treat with metro for the pt & dont need to tx the partner




in preg --> higher risk of preterm labor, PROM, spont abortion & tx with oral metro or clinda

Chlamydia

most common bacterial STI



p/w abd pain, intermenstrual vaginal bleeding, & acute PID



long term problems include pelvic adhesions and chronic pelvic pain



tx with either 1 dose of azithro or 7 day course of dox for both patient and partner

Trichomonas vaginitis

2nd most common STI




pear shaped flagellated protozoan




leads to frothy, green vaginal d/c w/ or w/o strawberry cervix




dx by seeing bugs on slide




tx with metro for both partner and patient

Tx of lyme

Early localized:


<8yo --> IV amox or IV ceftriaxone


>8yo --> PO dox, amox, or ceftriaxone



Late disease:


no neuro involvement --> PO dox or amox


neuro involvement --> IV ceftriaxone



in preg --> amox or cefuroxime

Brain death criteria

no spont movement




no response to painful stimuli




no seizure or decerebrate, decorticate, or dyskinetic movements




absence of central resp drive documented with an apnea test, a test that monitors the response of resp drive to the rising PaCO2

Wegener's granulomatosis

pauci immune vasculitis --> inflammation of the blood vessels with very little immune complex deposits in the active lesions




affects small & med sized arteries




ulcerating granulomas in upper and lower resp tract and cavitating pulm lesions are hallmarks of wegener's




nasal bx of lesion is diagnostic (if no nasal lesion --> lung or kidney bx)

Polymyalgia rheumatica

common in pts >50yo with mean onset of ~70yo




p/w aching and stiffness in the prox muscle groups & assoc with constitutional Sxs (malaise, fever, weight loss)




can be assoc with temporal arteritis




normally have normocytic anemia, elev ESR, elev ALK Phos




next step is to give steroids and temporal artery bx

Bronchiectasis

episodic symptoms of:




very high sputum


minimal physical findings, with clubbing rare


marked improvement to simply a cough btwn episodes




can find "parallel lines" or "tram-tracking" on CXR




most accurate test is high resolution CT scan

DM medication side effects

metformin - lactic acidosis, contraindicated in renal insufficiency



sulfonylureas - weight gain & SIADH



acarbose and miglitol - flatulance, GI distress, diarrhea



rosiglitazone & pioglitazone - CHF and MI

COMT inhibitors

eg tolcapone and entacapone




extend the duration of effect of levodopa by blocking its metabolism

Angiodysplasia

small vascular malformation of the gut


common cause of GI bleeding



assoc with ESRD, vWF dz, & aortic stenosis

Sjogren serologies

90-95% are ANA+




70% are RF+




50-65% are anti-Ro and anti-La +

Colon cancer screening

start at age 50-75



annual screening with high-sensitivity fecal occult blood testing (FOBT)



OR



sigmoidoscopy q5yrs with high sensitivity FOBT q3yrs



OR



colonoscopy q10yrs

Causes of seizures

hypernatremia and hyponatremia


hypocalcemia


hypomagnesemia


hypoxia


hypoglycemia


liver or renal failure


intracranial anatomic defect


cocaine


benzo or barbiturate w/d

Hyperkalemia and motor vehicle accident

after motor vehicle accident, can release large amt of K into blood (analogous to rhabdo)




can result in EKG abnormalities (peaked T-waves)




tx with calcium gluconate

Pill esophagitis

focal inflammatory lesion of distal esophagus



assoc with:


bisphosphonates (eg alendronate)


anti-inflammatory meds (eg aspirin)


dox


quinidine


clinda


potassium chloride pills

Rheumatoid factor

IgM Ab against Fc region of IgG




100% + in cryoglobulinemia




70-80% + in RA




70% + in Sjogren




30% + in SLE

Antipsychotics and Parkinsons

anti-psychotics lead to def of dopamine --> change to clozapine or quetiapine & give benztropine or trihexyphenidyl




PD drugs increase dopamine levels --> can lead to psychosis that should be treated with clozapine or quetiapine

Plummer Vinson syndrome

caused by iron def leading to a web in the prox esophagus due to fibrous/epithelial narrowing of a thin mucosal band




rare, but assoc with squamous cell carcinoma (barret's is adenocarcinoma)




Tx with iron supplementation, if doesnt improve then repair via endoscopic methods (eg bougie or pneumatic balloon)

Meniere's disease

distortion and distension of the membranous, endolymph-containing portions of the labyrinthine system




Tx with diuretics and H1 antagonists

Status epilepticus

order of drugs for treating seizures:




benzo (eg lorazepam) --> fosphenytoin --> phenobarbital --> midazolam/pentobarbital/thiopental/propofol




give fosphenytoin vs phenytoin bc if phenytoin given rapidly can lead to hypotension and AV block




earliest sign of phenytoin toxicity is nystagmus





Posterior urethral valves in a newborn

varying degrees of obstruction in the posterior urethra in males by cusps of tissue called valves




causes dilation of the bladder due to increased pressure which back ups to collecting systems of the kidney and can result in varying degrees of renal damage




dx with voiding cystourethrogram that will show a thickened and trabeculated bladder from muscular hypertrophy and dilated posterior urethra with narrowing




tx with surgery

Tx of carboxyhemoglobin

<10% --> administer 100% O2 for 3 hrs




10-15% --> admit and give 100% O2 for 24 hrs




>25% --> hyperbaric oxygen

USPTF recommendations for adults

all >18 yrs --> BP check at every visit




1st pap smear at age 21 regardless of when sexually active




21-29 yo a pap q3 yrs




30-65 yo q3 yrs OR pap + HPV co-testing q5 yrs

Magnesium sulfate side effect

give magnesium sulfate to any pregnant woman who has new onset hypertension to prevent seizures secondary to eclampsia



most common side effect is loss of deep tendon reflexes



can also lead to hypotension, complete heart block, muscle paralysis, resp paralysis, and possible cardiac arrest

Tx of OCD

SSRIs such as paroxetine, fluvoxamine, sertraline, citalopram, and fluoxetine

Anterior cerebral artery stroke

urinary incontinence




personality and psychiatric distrubance




unilateral leg weakness

Craniofacial zygomycosis

fungal infection that affects only immunocompromised ppl & diabetics




p/w fever, sinus pain, thin bloody nasal d/c, double vision w/reduced eye movement, & red or necrotic nasal turbinates




wet mount made from crushed tissue can show septated hypahe

Mallory Weiss tear

can inject epinephrine with persistent severe bleeding




if not actively bleeding, can just observe and supportive care




assoc with hiatal hernias

Essential tremors

isolated tremor that occurs at both rest and with exertion




has no rigidity assoc with it




tx with propranolol

Shy-Drager syndrome

variant of Parkinson that is characterized primiraliy by orthostasis and syncope




another name is multiple system atrophy

Initial tx for Parkinson's dz

mild to mod severe PD should be treated with dopamine agonist such as ropinirole, pramipexole, apomorphine, or bromocriptine





levodopa/carbidopa are second line bc long-term use can lead to destruction of substantia nigra & worsen sxs

ARDS criteria

acute onset



CXR appearance



PaO2/FiO2 <200



pulmonary cap wedge pressure <18 mm Hg -> most important distinguishing factor vs cardiogenic etiology

Sodium nitroprusside complication

can lead to cyanide toxicity



tx with sodium thiosulfate

Exercise stress tests

If patient is unable to exercise then:




Dipyridamole thallium stress test -> contraindicated in pts with asthma and/or reactive airway dz (eg COPD)




Dobutamine ECHO

Ankylosing spondylitis test

abnormal Schober test --> <5cm change in distance from top to bottom of lumbar spine on forward flexion



XR --> narrowing of sacroiliac joint



Assoc with restrictive lung dz so FVC, FEV1, and TLC decrease

Lowering serum glucose in DKA

want to decrease ~50-100mg/dL/hr




more aggressive decrease may lead to cerebral edema and herniation

Adrenal crisis

can be induced by pyelonephritis that leads to loss of glucocoritcoid and mineralocorticoid production



leads to:


hypotension


hypovolemia


hyponatremia


hyperkalemia


metabolic acidosis


hypoglycemia


eosinophila



tx with IV steroids then the underlying infection

Organophosphate toxicity

lacrimation


salivation


blurred vision


urinary incontinence


diarrhea


diaphoresis




severe changes include:


bradycardia, hypotension, respiratory paralysis, AMS




can have garlic-like odor on clothes




can test RBC cholinesterase activity to provide degree of toxicity




tx with atropine and pralidoxime

Interferon and ribavirin side effects

Interferon:


thrombocytopenia, neutropenia, depression, flu-like symptoms




Ribavirin:


hemolytic anemia




do not give ribavirin in pt with renal insufficiency

Psychiatric drug class side effects

SSRI: decreased libido




TCA: cardiac arrhythmia, decreased seizure threshold, orthostatic hypotension




MAOI: hypertensive crisis




Thioridazine: retinal pigmentation, prolonged QT




Clozapine: agranulocytosis




Olanzapine: increased weight gain, dyslipidemia, hyperglycemia

Metformin and contrast

should d/c metformin prior to any angiographic/radiologic procedure that uses contrast



contrast may lead to AKI & metformin can lead to lactic acidosis in pts with renal insufficiency

Diabetes screening

age >45, especially obese


family hx


hyperlipidemia


vascular dz


HTN

MMR and varicella vaccines

both are live attenuated vaccines



should not give prior to age 1



after first shot, should get booster btwn age 4 and 6



HepA should also be given at age 1

Fitz-Hugh-Curtis syndrome

complication of PID



salpingitis that spreads to cause more peritonitis affecting anterior surface of liver resulting in localized fibrosis and scarring



tx underlying chlamydial/gonococcal infections but with adhesions, surgery maybe required

Carotid stenosis

indications for endarterectomy are TIA/symptomatic stroke AND >70-99% stenosis




carotid angioplasty and stenting is done in those who cannot undergo surgery or who recur after endarterectomy




if pt has stroke and <70% stenosis, just tx with aspirin. if stroke reoccurs, can change to clopidogrel

Acarbose side effect

alpha-glucosidase inhibitors that block absorption of glucose in brush border of small intestine




diarrhea


abdominal pain


cramping


gas

Octreotide

synthetic somatostatin analog




used in acute management of variceal bleeding

Thrombolytics use in stroke

must use within 3 hrs of Sxs but get CT first to make sure there is no hemorrhage



older stroke pt should get ECHO, carotid duplex, telemetry, & MRI



should do neuro checks q1 hr for first 24hrs



giving anti-plt or anticoagulants are contraindicated within first 24 hrs

Hepatopulmonary syndrome

combination of liver dz, increased A-a gradient, and intrapulmonary vascular dilatations




platypnea- dyspnea caused by upright position and relieved by lying down




orthodeoxia- desaturation on assuming an upright position




dx via either:


contrast-enhanced ECHO


technetium-99m-labeled macroaggregated albumin scanning


pulm arteriography

Refeeding syndrome

severe malnutrition decreases metabolic rate of cells and lack of dietary phosphate leads to whole body phosphate depletion




when refeeding is initiated, there is a spike in insulin with glucose rapidly taken up by cells leading to glycolysis and usage of phosphate




this leads to hypophosphatemia that can cause lethargy, muscle weakness, resp failure, and rhabdo

TCA overdose

dry mouth


blurred vision


constipation


sinus tachy


memory dysfunction


urinary retention

Fetal fibronectin

fibronectin is glycoprotein found in amniotic fluid, parts of placental tissue, and thought to act as trophoblastic glue




test predicts likelihood of delivery in the next 14 days




should only be performed with gestational age of 22-34 and have intact membranes

Risk factors for ectopic pregnancy

high risk factors:


previous ectopic


previous tubal surg


tubal pathology


congenital anomolies


current IUD use




mod risk factors:


infertility


previous cervicitis


hx of PID and multiple sex partners


smoking




low risk factors:


previous abd & pelvic surg


vaginal douching


age

Different types of shock

cardiogenic:


low CO, high PAWP, and high SVR




hypovolemic shock:


low CO, low PAWP, and high SVR




neurogenic shock:


nl-low CO, nl-high PAWP, low SVR




septic shock:


variable CO, nl-high PAWP, low SVR




extracardiac obstructive shock:


low CO, nl-high PAWP, high SVR

Varicocele

abnormal dilation of the spermatic veins within the scrotum




can be assoc with infertility & testicular atrophy




on PE find bag or worms & u/s shows dilated veins that distend on Valsalva --> usually appears on left & if on right, should get CT of abdomen to look for IVC obstruction




Asymptomatic pts just need f/u




surg required if:


varicoceles are b/l


causing sxs


decreased testicular volume or infertility

Adolescent pregnancies

increased risk of:




perinatal mortality


preterm delivery


premature & low birth weight

Flexible bronchoscopy

primary diagnostic tool to evaluate pts with persistent or nonresolving pneumonia or pulm infiltrates




best diagnostic tool for endobronchial obstructive lesions but next step in management for these cases should be CT

Histrionic personality disorder

pattern of excessive emotionality & attention seeking behavior since early adulthood




inappropriate sexually seductive or provocative behavior




shallow, shifting, dramatic emotions

Borderline personality disorder

exhibit attention-seeking, manipulative behavior, & rapidly shifting emotions



Self-injurious & suicidal behavior



intense anger



chronic feelings of emptiness



identity disturbance



use defense mechanism of splitting (ppl are all bad or all good)

Onychomycosis

fungal infection of toenails caused by Trichophyton rubrum




thick, brittle, discolored nails




dx with KOH, PAS stain




tx with terbinafine or itraconazole

Hypertonic saline

used in severe & symptomatic hyponatremia (Na <115)




do not want to raise Na >12mEq/L in first 24 hrs

Complications of infective endocarditis

cardiac:


valvular insufficiency


perivalvular abcess


conduction abnormalities


mycotic aneurysm




neurologic:


embolic stroke


cerebral hemorrhage


brain abscess


acute encephalopathy




renal:


renal infarction


GN


drug induced acute interstitial nephritis from therapy




musculoskeletal:


vertebral osteomyelitis


septic arthritis


msk abcess

Subchorionic hematoma

bleeding btwn endometrium & gestational sac



appears as crescent shaped hypoechoic regions adjacent to gestational sac



increased risk of experiencing spontaneous abortion



next step is repeat u/s in 1 week

Multiple sclerosis

nearly 50% develop optic neuritis, which typically p/w monocular visual loss accompanied by eye pain




can develop transverse myelitis resulting in upper motor neuron signs & sensory loss below the level of spinal involvement




best test for dx is MRI that reveals ovoid-shaped periventricular white matter lesions




tx of acute flair is with steroids




long term tx is with b-interferon or glatiramer can decrease freq of exacerbations & reduce development of brain lesions

Symptomatic management of common MS findings

depression --> SSRI




spasticity --> PT & stretching, massage therapy, baclofen




fatigue --> sleep hygiene, regular exercise, amantadine, stimulants




neuropathic pain --> gabapentin or duloxetine




urinary incontinence --> timid voiding, fluid restriction, anticholinergics

Abs that cause C diff

fluoroquinolones




enhanced spectrum penicillins




cephalosporins




clindamycin

Tx of squamous cell carcinoma

first line is surgical excision




second line for low risk is cryotherapy, electrosurgery, or radiation therapy

Adult polycystic kidney disease extra-renal manifestations

hepatic, pancreatic, splenic, & pulm cysts




cerebral aneurysms




aortic aneurysms




colonic diverticula




mitral valve prolapse




inguinal and abd hernia

Actinic keratosis

pre-malignant condition caused by excessive sunlight exposure


small, rough, erythematous, and keratotic papules that are often easier to feel than they are to see


leads to increased risk of squamous cell carcinoma


individual lesions can be r...

pre-malignant condition caused by excessive sunlight exposure




small, rough, erythematous, and keratotic papules that are often easier to feel than they are to see




leads to increased risk of squamous cell carcinoma




individual lesions can be removed via liquid nitrogen cryosurgery or surgical excision but if numerous --> tx with 5-FU, topical diclofenac, imiquimod

Likelihood ratio

Positive LR = sens / (1-spec)




Negative LR = (1-sens) / spec




prob of given test result occurring in a pt with a disorder compared to the prob of the same result occurring in a pt w/o the disorder




not dependent on disease prevalence as PPV and NPV are

Verification bias

when study uses gold standard testing in order to confirm a positive or negative result of preliminary testing




this can over- or underestimate the sensitivity or specificity

Thyroid lymphoma

p/w rapid increase in size that causes difficulty in breathing




can be palpable on exam




assoc with Hashimoto's thyroiditis (high TSH, low T4) --> Hashimoto's is also assoc with anti-peroxidase Ab




dx via large-bore needle bx

Drug caused pancreatitis

thiazides, furosemide




sulfasalazine, 5-ASA




azathioprine, L-asparaginase




valproic acid




didanosine, pentamidine




metro, tetracycline

C diff colitis algorithm

Tx of C diff recurrence



Bronchopulmonary aspergillosis

hypersensitivity to Aspergillus in pts with asthma




p/w recurrent episodes of fever, malaise, cough, with brownish mucoid expectorian, wheezing, & sxs of bronchial obstruction




CXR b/l upper lobe parencymal infiltrates




best screening test --> skin prick test for aspergillus --> if positive, then serum IgE & aspergillus serologies




tx with oral steroids & itraconazole

Intussusception



Lithium and drug interactions

lithium toxicity includes:


confusion


ataxia


neuromuscular excitability




lithium levels can be affected by thiazides, ACEI, & NSAIDS, SSRI

Heart sounds



Fahr's syndrome

effect of long-standing pseudohypothyroid




hypocalcemia with hyperphoshatemia leads to b/l cataracts & calcification of basal ganglia

Low Ca



Porphyria cutanea tarda

def of uroporphyrinogen decarboxylase --> enzyme involved in heme synthesis




can p/w painless blisters, hypertrichosis, & hyperpigmentation




assoc with Hep C infection & can be triggered by certain substances (eg etoh, estrogen)




dx with urinary uroporphyrins




tx with phlebotomy or hydroxychloroquine or if with Hep C --> IFN-a

Glucagonoma

rare pancreatic tumor




characteristic rash of "necrolytic migratory erythema" assoc with mild diabetes




when dx normally have mets to liver




also secrete VIP, calcitonin, or GLP1




dx with measuring glucagon levels




tx with surgery

Superior vena cava syndrome

usually secondary to lung malignancy (most likely bronchogenic carcinoma)



p/w dyspena, persistent cough, facial fullness and neck pain, & progresses into hoarseness, dysphagia, chest pain, & syncope



can find dilated veins of arms & neck



best way to dx is CT with contrast



Tx of kidney stones

if pt has urosepsis, ARF, or complete obstruction --> urology consult for surg




<10mm --> hydration, pain control, a-blockers, strain urine




>10mm --> urology consult for surg

Clinical features of melanoma (ABCDEs)

Asymmetry


Border irregularities


Color variegation


Diameter >6mm


Evolving - lesions change in size, shape, or color

HIV lipodystrophy

fat deposition on the back of neck & abdomen with thin extremities & face --> Cushingoid pattern




pts also develop insulin resistance




tx with statins and if triglycerides >500 tx with fibrates (eg gemfibrozil)

Carpal tunnel risk factors

Obesity/DM




hypothyroid




RA




ESRD




pregnancy




TYPING IS NOT ASSOCIATED BUT CAN WORSEN

W/u of palpable breast mass



Bone anti-resorptive agents

eg bisphosphonates & raloxifene




use in post-menopausal woman <65 with high risk of osteoporesis/bone fracture:




<58kg


chronic steroid use


smoking


malabsorptive dz


fam hx or personal hx of hip fracture

Opioid withdrawal

GI --> N/V, diarrhea, cramping




CV --> tachy, HTN, & diaphoresis




Psych --> insomnia, yawning, dysphoric mood




General --> myalgias, arthralgias, lacrimation, rhinorrhea, piloerection, mydriasis




tx with opioid agonist (eg methadone or buprenorphine) OR non-opioid (eg clonidine or benzo)

Tinea capitis

"ringworm of the scalp"




patches of scaling, slightly erythematous alopecia with cervical adenopathy




dx clinically but can also do KOH exam of epilated hair stubs or fungal cx




tx with oral griseofulvin or oral terbinafine

Ethylene glycol toxicity

rapid and deep breathing




N/V




slurred speech




ataxia




nystagmus




lethargy




bad toxicity can lead to confusion, flank pain, renal failure, pulm edema, AMS, & coma




first line tx is fomepizole & second line is etoh

Scombroid poisoning

ingesstion of improperly stored seafood




p/w flushing, throbbing headache, palpitations, abd cramps, diarrhea, & oral burning




occurs within 10-30 mins of ingesting fish

Herbal supplements & drug reactions

Licorice --> stomach ulcers


inhibits conversion of cortisol to cortisone & can aggravate HTN




Saw palmetto --> BPH


increased bleeding risk




St John's wort --> depression


HTN crisis & interacts with many drugs (SSRI, OCP, digoxin, anticoagulants)




Garlic preparations --> hypercholesterolemia


bleeding risk




Fish oil supplementation --> refractory hypertriglyceridemia




Ginkgo --> memory


can interact with aspirin or warfarin leading to spont bleeding




Kava --> anxiety & insomnia


use with etoh, benzos, & other sedatives can potentiate their effect & cause drowsiness or disorientation. Also leads to severe liver damage




Black cohosh --> PMS & menopausal sxs


can cause hypotension & bleeding risk




Horse chestnut --> used in venous insuff or chronic venous stasis


can cause bleeding in pts on aspirin or warfarin

Asymptomatic left sided heart failure

pts with decreased EF who are asymptomatic --> tx with ACEI

Different types of dementia

Pick's dz


slowly progressive frontal lobe dementia affecting speech, executive functioning, mood, & disinhibition



Lewy body dementia


affect cortex & brainstem & p/w gradually progressive dementia assoc with visual hallucinations & parkinsonism motor features leading to falls



Vascular dementia


diffuse white matter dementia & seen in pts with multiple strokes & presents acutely



Wernicke's encephalopathy


mental impairment, ophthalmoplegia, horizontal nystagmus, & ataxia



Huntington dz


slowly progressive characterized by chorea & behavioral disturbances

Rashes associated with dermatomyositis

Gottron's papules --> erythematous papules overlying the metacarpal and interphalangeal joints




Heliotrope rash --> violaceous eruption on the upper eyelids (& in rare cases of lower eyelid) with itching & swelling




this is assoc with proximal muscle weakness




first step is serology --> ANA+ (80% of pts)

MELD score

determines prognosis and liver transplant listing for chronic liver failure




depends on bilirubin, INR, creatinine so these 3 characteristics are the most important predictive factors for prognosis in liver failure

Emergency contraception

most effective is Cu IUD but contraindicated in active pelvic infection or cervicitis

most effective oral is Ulipristal

most effective is Cu IUD but contraindicated in active pelvic infection or cervicitis



most effective oral is Ulipristal



always do b-HCG before giving



Sexual assault ppx meds

HIV --> 3 drug regimen (eg tenofovir-emtricitabine with raltegravir)




Hep B --> Hep B vaccine +/- Hep B Ig




Chlamydia --> azithro




Gonorrhea --> ceftriaxone




Trichomonas vaginalis --> metro

Acute chest syndrome

new pulm infiltrate with 1 or more of:


incr work of breathing, cough, tachypnea, wheezing


temp >38.5 (101.3)


hypoxemia


chest pain




tx with ceftriaxone + azithro & IV fluids & pain control

Premenstrual syndrome

occur in the second half of the menstrual cycle & resolve after menses




depression, anxiety, irritiability, bloating, & breast tenderness




Premenstrual dysphoric d/o is severe form with anger & irritability




up to 80% can develop primary psychiatric, mood, or anxiety d/o




tx with SSRIs & if one doesnt work try another (eg fluoxetine --> citalopram), if no desire to get pregnant, can also try OCPs

Management of cat & dog bites



Metoclopramide drug side effects

metoclopramide is a dopamine (D2) blocker used as an anti-emetic




can lead to extrapyramidal sxs such as akathisia, dystonia, & parkinsonian-like sxs




should use ondansetron (serotonin receptor antagonists) or aprepitant instead

VSD vs ASD murmur

VSD with left-right-shunting --> holosystolic murmur




ASD with left-right-shunting --> wide and fixed splitting of S2




TOF has VSD along with RV outflow obstruction, overriding aorta, & RV hypertrophy

Sodium-glucose cotransporter 2 (SGLT2) inhibitors

inhibits glucose reabsorption at the level of the


prox renal tubule so reduces serum glucose via inducing glucosuria




common side effect is vulvovaginal candidiasis, polyuria, & increased UTIs

Mentzer index

MCV / RBC count




helps distinguish btwn iron def & thalessemia




>13 --> iron def




<13 --> thalassemia

Black box for atypical antipsychotics

elderly pts with dementia-related psychosis, treated with antipsychotics are at an increased risk of death




risk of death is primarily via CV events or infectious causes




but still can be considered with risk/benefit ratio

Management of back pain



Hypokalemia and SBO

hypokalemia can lead to paralytic ileus



loop diuretics (eg furosemide) can lead to both hypokalemia & hyponatremia



tx SBO with oral or parenteral K+

Gestational DM w/u

done at 24-28 weeks gestation




50g oral glucose & measure glucose 1 hr after:


<140 --> no further testing




>140 --> do 100g oral glucose & test each hr for 3 hrs


fasting should be <105


1 hr should be <190


2 hr should be <165


3 hr should be <145




if 2 or more times are abnormal --> dx with gestational DM




tx gestational DM with dietary modification & if that doesnt work start insulin or oral agents (eg metformin or glyburide)




two most common fetal complications are macrosomia & shoulder dystocia




can also cause cardiomyopathy/CHF (hypertrophic interventricular septum leading to ventricular outflow obstruction) in fetus

Anatomic location of digit arteries, nerves, veins, & tendons

run on sides:


arteries


nerves


veins




runs on anterior surface (palmar surface):


tendons

Catatonia syndrome

assoc with severe psychiatric illnesses that results in marked psychomotor disturbance



can range from stupor to marked agitation



first line tx is benzos (eg lorazepam), if this doesnt work can do ECT

Neuroleptic malignant syndrome

assoc with antipsychotic meds




muscle rigidity


fever


autonomic instability


delirium


elevated CK




tx with dantrolene sodium for muscle rigidity, benzo for agitation, & can consider bromocriptine or amantidine to reverse dopaime blockade

Ddx for vaginitis



Isotretinoin toxicity

used for nodulocystic acne




side effects include:


metabolic effects (hypoglycemia & hypertrig --> can lead to acute pancreatitis)


hepatotoxicity


mucocutaneous reactions


hematologic abnormalities


ocular toxicity


known teratogen & woman of child bearing age need 2 negative preg tests & use 2 methods of contraception 1 month before, during & after tx

Tx of clavicle fractures



Reactive arthritis



Metastatic bone lesions

osteoblastic: detect with radionucleotide bone scan followed by Xray


prostate


small cell lung


Hodgkin lymphoma



osteolytic: detect with Xray or PET


MM


non-small cell lung


non-Hodgkins



osteoblastic or osteolytic:


breast

Oropharyngeal lesions in kids

anterior oral mucosa:


aphthous stomatitis (canker sore) --> no fever


herpes gingivostomatitis (HSV type 1)--> with fever




posterior oropharynx:


herpangina (caused by coxsackie group A)--> with fever




tonsillar exudates:


group A pharyngitis --> anterior cervical LAD


infectious mono --> diffuse LAD w/ +/- HSM

Calcium channel blocker side effect

peripheral edema particularly with amlodipine & nifedipine



when given with ACEI, can reduce CCB assoc peripheral edema

Rotator cuff tendonitis

p/w lateral shoulder or deltoid pain aggravated by reaching or lifting the arms up




frozen shoulder is seen in rotator cuff tendonitis & pain is accompanied by stiffness & decreased ROM in abduction & external rotation




rotator cuff tear is likely if there is accompanying weakness or loss of strength during external rotation or abduction of shoulder

Tx of bacterial conjunctivitis

erythromycin ointment


OR


sulfa drops


OR


polymyxin/trimethoprim drops




for contact lens wearers --> fluoroquinolone bc of pseudomonas coverage

Meckel's diverticulum

p/w painless hematochezia




rule of 2s:


2% prevalence


2:1 male:female ratio


2% are symptomatic at age 2


located within 2 feet of ileocecal valve




dx with technetium-99M scan




tx with surgery for symptomatic pts

PPx for neonatal GBS

do rectovaginal cx at 35-37 weeks




tx with penicillin if:


had prior birth to affected infant


GBS bacteriuria or GBS UTI at any point in pregnancy


GBS+ within 5 weeks of labor




unknown GBS status AND 1 of following:


<37 weeks gestation


intrapartum fever


ROM for >18hrs

Diffuse esophageal spasm

p/w dysphagia to solids & liquids usually w/o weight loss




manometric studies demonstrate high amplitude peristalic contractions




difference btwn this & achalasia is lower sphincter has normal relaxation response




tx with PPIs, antispasmodics (eg nitroglycerin, CCB, hydralazine), dietary modulation, & psychiatric counseling

Achalasia

pt complains of "food stuck in chest" and also has difficulty with liquids



p/w dysphagia to solids & liquids with weight loss



manometric studies show lower esophageal sphincter does not relax (has high tone)



Initial test --> barium swallow



Best test --> manometry



path shows muscle hypertrophy, inner circular muscle with absence or degeneration of ganglia in Auerbach's plexus



esophagogram can show dilated esophagus like a bird's beak



can be caused by T cruzi



tx with ballon dilation of narrowed esophagus or surgical myotomy

Zenker's diverticulum

p/w dysphagia to solids with description of food gets stuck but many are totally asymptomatic




d/o of prox esophagus generally seen in woman




dx via barium swallow




tx with surgery





Scleroderma and esophagus

loss of distal peristalsis due to complete atrophy of esophageal smooth muscle & fibrosis (this is opposite of achalasia)




lower esophageal sphincter becomes incompetent with time that can lead to reflux esophagitis & a stricture




progressive & difficult to treat

Antibodies and diseases

ant-dsDNA --> SLE & can be used to follow dz activity



anti-centromere --> CREST variant of scleroderma



anti-Scl70 (topoisomerase) --> systemic scleroderma



anti-Smith --> SLE but less sensitive than dsDNA



anti-Ro/La --> assoc with heart block in neonatal SLE but is more sensitive for Sjogren's



anti-Jo1 --> dermatomyositis & polymyositis



anti-mitochondrial --> primary biliary cholangitis

Tx of syphilis



Jarisch-Herxheimer reaction

occurs after tx for syphilis & subsequent spirochetal lysis




p/w fever, malaise, chills, headaches, & myalgias




no way to prevent

Tx UTI in pregnancy

TMP-SMX affects folic acid metabolism




Cipro causes fetal arthropathy




tx with either amox, cephalexin, or nitrofurantoin

Molluscum contagiosum

small skin colored papules with indented centers  accompanied by pruritus & surrounding dermatitis

caused by poxvirus

children most commonly affected but also immunocompromised (adult pt with it --> think HIV)

usually self-limited

transmissi...

small skin colored papules with indented centers accompanied by pruritus & surrounding dermatitis




caused by poxvirus




children most commonly affected but also immunocompromised (adult pt with it --> think HIV)




usually self-limited




transmission via skin to skin contact (can be transmitted sexually)

Meconium ileus

characterized by distal intestinal obstruction, wherein the terminal ileum is dilated and filled with thick, tar-like, inspissated meconium




pathognomic for CF




dx with abd XR

Metastatic brain tumor

in order of freq (most common to lesser): lung, breast, unknown, melanoma, colon cancer



next step is MRI with contrast



presence of multiple, well-circumscribed lesions & relatively large amt of vasogenic edema as compared to size of lesion favors mets



Tx with whole brain radiotherapy

Acute rheumatic fever


Ddx for neuromuscular weakness



Botulinum

toxin released by C botulinum




botulinum toxin inhibits release of Ach into the synaptic cleft in both autonomic & somatic nervous systems




p/w acute bulbar and descending limb weakness with absent reflexes & autonomic dysfunction




similar to MG but MG does not have autonomic dysfunction & reflexes are normal

Labyrinthitis

p/w vertigo, tinnitus, nausea, & loss of balance




normally caused by viral illness (eg influenza)




usually self limiting

Hep B vaccine serology

Vaccine is against HBs so IgG against Hbs could be from vaccine



anti-HBc IgM is serology that will be + during window period of acute HBV infection when HbsAg goes down

Anti-histamine drugs

H1 blocker --> hydroxyzine




H2 blocker --> ranitidine




2nd generation --> loratadine & cetrizine

Rabies ppx



Salicylate toxicity

tinnitus


restlessness


N/V


mild GI discomfort


metabolic acidosis


ARF


hepatotoxicity




tx with gastric lavage, activated charcoal, & alkalinization of the urine

Cutaneous cryptococcosis

seen in immunocompromised ppl




disseminated cryptococcosis usually affects CNS (meningitis or encephalitis) but skin is also common non-neuronal site




skin lesions are usually multiple, discrete, red-colored papules of varying size with slight central umbilication resembling Molluscum contagiosum




dx with bx of lesion that will show granulomatous inflammatory reaction with multtinucleated giant cells, histiocytes, lymphocytes, neutrophils, & plasma cells with numerous yeast-like organisms




once dx is made, need to do CXR, blood & CSF cx

Levothyroxine absorption

should take on empty stomach bc many meds can affect absorption of drug




Ca and Fe tabs are 2 things that cause impaired absorption




levothyroxine should be started slowly in pts with CAD bc can increase myocardial O2 demand

Afebrile pneumonia syndrome

caused by C trachomatis, U urealyticum, Mycoplasma, CMV, RSV, Parainfluenza, Adenovirus, & Pneumocystis



young children p/w cough, tachypnea, irritability, & poor feeding



staccato cough --> C trachomatous --> look for conjuctivitis



can see eosinophilia

Aspiration pneumonia vs pneumonitis

pneumonia: commonly polymicrobial with gram +, gram -, & anaerobes


occurs 1-5 days after aspiration event


CXR will show infiltrate


tx with clinda & b-lactam




pneumonitis: chemical injury leading to inflammation of parenchyma secondary to gastric content --> Mendelson's syndrome


occurs 2-5 hrs after aspiration event


tx is supportive

Thiamine deficiency triad

encephalopathy


oculomotor dysfunction


ataxia




seen in alcoholics




no change in MCV like in B12 def

Ankylosing spondylitis extraarticular assocs

anterior uveitis


aortic regurg


IgA nephropathy


apical pulm fibrosis


restrictive lung dz

4 T's in HIT

thrombocytopenia


timing --> 5-10 days after starting heparin


thrombosis


oTher causes




stop heparin & give direct thrombin inhibitor (eg argatroban or bivalirudin)

CF pneumonia

most commonly secondary to S aureus & Pseudomonas aeruginosa with Pseudomonas becoming more common as the pt ages



other pathogens include H influenza, Burkholderia cepacia, & gram - rods

Abx that cover Pseudomonas

cefepime or ceftazidime


amikacin (aminoglycoside)


imipenem or meropenem


piperacillin-tazobactam


aztreonam


colistin


cipro




think pseudomonas in CF pt & for malignant otitis externa

Diphtheria toxin

can lead to myocarditis, neuritis, & rarely, nephritis




tx with diphtheria antitoxin --> it is generated in horse serum so run risk of anaphylaxis --> administer with epi

Boerhaave's syndrome

p/w chest pain, dyspnea, epigastric pain, & shoulder pain after repeated episodes of vomiting leading to esophageal perforation



perforation normally occurs in distal third of esophagus


75% of cases will develop pulm effusion on left side



after few hours, can also lead to mediastinitis, which requires urgent management



best initial test is esophagogram w/water soluble contrast


Pressure ulcers

Stage 1- nonblanchable erythema of intact skin



stage 2- superficial ulcers causing a partial thickned loss of the epidermis, dermis, or both



stage 3- deeper ulcers causing a full thickness loss with damage to subq tissue that may extend to, but not through, any underlying fascia



stage 4- very deep ulcers causing full thickness loss with extensive tissue destruction that may damage adjacent muscle bone

Serotonin syndrome triad

AMS


autonomic dysfunction


neuromuscular hyperactivity (hyperreflexia, myoclonus, ocular clonus, tremor, etc)




normally occurs secondary to drug interactions (eg SSRIs + MAOI (eg phenelzine))




tx with d/c serotonergic drugs, supportive measuers, & sedation with benzos




in very severe cases, can think of serotonin antagonist (eg cyproheptadine)



Breast cancer screening



Condyloma acuminata

caused by HPV 6 & 11 described as flesh colored hyperkeratotic papules




if pt gets during pregnancy, can still deliver vaginally with only reason to do c-sect is when one suspects the lesion may start bleeding

Subclinical hypothyroid

mildly elevated TSH with normal free T4 & no sxs




does not need tx UNLESS:


presence of anti-peroxidase Abs


abnormal lipid profile


sxs of hypothyroid


ovulatory & menstrual dysfunction

Chronic methotrexate and anemia

leads to macrocytic anemia bc of inhibition of DHFR leading to folic acid deficiency



TMP & phenytoin also affect folate metabolism


tx with folinic acid (leucovorin) NOT folic acid

Scabies

caused by Sarcoptes scabiei




p/w intensely pruritic rash (often worse at night) in the flexor surfaces of wrist, lateral surfaces of fingers, & finger webs




see excoriations with small, crusted, red papules scattered around the region, often with linear burrows




delayed type IV hypersensitivity




dx with skin scrapings from lesions revealing mites, ova, and feces under light microscope




tx with topical 5% permethrin cream or oral ivermectin

Cyclosporin side effect

increases serum uric acid levels --> can lead to gout




if cyclosporin is being given for renal transplant, tx gout with intra-articular glucocorticoid injection & NOT NSAIDs bc of contraindication of affecting kidney function along with cyclosporin

Erythromycin side effect

assoc with pyloric stenosis

Abx assoc with seizures

penicillins


cephalosporins


monobactams


carbapenems


fluoroquinolones

Caloric intake

30kcal/kg/day with 1g/kg of protein




can consider 15kcal/kg/day in pts with severe malnutrition to prevent refeeding syndrome




if possible, always prefer enteral feeds over parenteral

Hypothyroid & hyperlipidemia

>85% of pts with hypothyroid also have elevated LDL




can also have concamitant elevation of trigly




tx of hypothyroid may improve hyperchol in pts with TSH >10

INH side effects

most common side effect is hepatotoxicity




normally occurs within the first 2 months of tx & range from mild hepatotoxicity to hepatitis




should get baseline LFTs prior to starting INH




pts are usually asx & have self limited transaminitis & can cont tx with close monitoring




d/c if ALT or AST are >5x above normal limit OR >3 with sxs




if not given with vit B6 (pyridoxine), can cause ataxia, peripheral neuropathy, & paresthesias

Aortic stenosis findings

soft single S2




delayed and diminished carotid pulse --> parvus and tardus




loud & late-peaking systolic murmur




best heard at right upper sternal border




normal split S2 r/o aortic stenosis

Restless Leg Syndrome

maybe caused by Fe def so need to do iron studies




tx with dopamine agonists (eg pramipexole or ropinirole)

Contraindications for breast feeding



Herpes gestationis

believed to be an autoimmune condition & not thought to be caused by viral infection




occurs during 2nd, 3rd, or postpartum periods




normally starts as pruritis & then develops into a rash localized around the umbilicus




characterized by papules, urticarial plaques, & vesicles




different from PUPPP bc PUPPP spares the umbilical region




tx with topical corticosteroids & if severe use systemic steroids

Hemochromatosis & arthropathy

can p/w arthropathy in someone in 50s-60s




will find calcium pyrophosphate dihydrate (CPPD) crystals aka pseudogout --> positive birefringent rhomboid crystals




usually affects 2nd & 3rd MCP joints but can also affect knees, ankles, & shoulders




assoc with morning stiffness that lasts <30 mins




hemochromatosis can also p/w liver dysfunction, central hypogonadism, DM, & skin pigmentation ("bronze DM")




next step is Fe studies

Knee ligament injuries

ACL --> hyperextension of knee & hear a popping noise


can dx with knee flexed at 20 degrees, 1 hand on prox tibia, & other hand stabilizes femur (Lachman's test)




PCL --> posteriorly directed force is placed on anterior aspect of prox tibia with knee flexed (car accident with knee hitting dashboard)




MCL & LCL --> line of force strikes from the side of the joint




Medial menscus --> occur after twisting injury with 1 foot fixed to the ground & can also hear popping like in ACL

Stages of labor

Stage 1:


latent --> 0-6cm dilation


active --> 6-10cm cervical dilation


arrest of labor in active phase if >4 hrs despite adequate contractions OR >6 hrs with inadequate contractions




Stage 2 --> 10cm dilation to delivery




Stage 3 --> delivery of baby to expulsion of placenta

Tx of pulmonary arterial hypertension

after dx is made via ECHO, should do vasoreactivity test that looks at pulm arterial pressure response to vasodilator --> if there is good response, then tx with CCB




if no response --> tx with endothelin receptor antagonist (eg bosentan) OR phosphodiesterase-5 inhibitor (eg sildenafil) OR prostanoid medication (eg epoprostenol)

Primary biliary cirrhosis

chronic & progressive liver dz that is autoimmune




90% are F




find destruction of small & mid-sized bile ducts with progressive fibrosis




p/w with progressive jaundice, pruritis, steatorrhea, hyperlipidemia, with an elevated ALK Phos




also assoc with bone dz (osteomalacia & osteoporosis)




dx with anti-mitochondrial Abs (high sens & specificity)




tx with ursodeoxycholic acid but only curative tx is liver transplant

Hidradenitis suppurative

aka acne inversa




inflammatory dz characterized by occlusion of skin follicles most commonly affecting intertriginous areas (eg axilla, inguinal, genital)




mild cases can be tx with topical antibiotics (eg clinda)




mod cases with scar formation req oral antibiotics (tetracyclines)




severe cases with diffuse involvement may require TNF-a inhibitors (eg infliximab) & surgical excision

APACHE II scoring system

predicts severity of acute pancreatitis using 12 physiologic variables




score >8 predicts severe dz & should undergo CT scan at 72 hrs to assess pancreatic necrosis

Ecthyma gangrenosum

assoc with lesion of the skin or mucous membrane that rapidly worsens into nodular patches marked by hemorrhage, ulceration, & necrosis




normally caused by Pseudomonas (gram - rod) in immunocompromised person




tx with 2 IV Abx (aminoglycoside (eg tobramycin, amikacin) + extended spectrum penicillin (eg piperacillin) OR cephalosporin (eg ceftazidime, cefepime)

Neonatal sepsis



Urethral diverticula

3 Ds:


Dribbling


Dysuria


Dyspareunia




can be congenital or acquired with maternal birth trauma being common cause of acquired




next step is either u/s or MRI



Trastuzumab side effect

anti-HER2 monoclonal




reversible cardiotoxicity affect LVEF that could lead to clinical heart failure




cardiotoxicity is even worse when combined with anthracycline (eg doxorubicin) & cyclophosphamide




usually EF goes back to baseline after d/c

Amiodarone side effect

long-term use can lead to:




thyroid dysfunction


hepatotoxicity


cardiac bradyarrhythmias


interstitial pneumonitis


neuro sxs (ataxia, peripheral neuropathy)


blue-gray skin discoloration


visual disturbances

Relative risk vs attributable risk

RR = risk of exposed / risk of unexposed




AR = (risk of exposed - risk in unexposed) / risk of exposed = (RR-1) / RR




Population AR percent (PARP) = (risk in total population -risk in unexposed) / risk in total population

Tx of peripheral arterial dz



Guidelines for management of CHF



Prenatal testing

first visit:


T&S


CBC


Rubella status


Screening for syphilis, chlamydia, & HIV


HepB sAg


UA & cx


Pap




routine subsequent visits:


BP


weight


uterine fundal height


fetal heart tones


fetal presentation & activity


urine glucose & protein

Meningococcal meningitis ppx

household members


roommates or intimate contacts


child care center workers


airline travelers seated next to an affected person for >8 hrs




tx with rifampin (600mg twice daily for 2 days) OR cipro (500mg single dose) OR ceftriaxone (250mg single dose)




do not give rifampin to someone taking OCPs

Postpartum endometritis

polymicrobial infection of the decidua characterized by fever, uterine tenderness, foul smelling vaginal d/c, & leukocytosis




most sig risk factor is c-section




tx with clinda & gent




do not give metro for breast feeding mother

Dengue fever

viral infection spread by Aedes mosquito

can lead to circulatory failure

viral infection spread by Aedes mosquito




can lead to circulatory failure

Diabetic neuropathy management

strict glycemic control is best thing



for pain:


duloxetine (SNRI)


pregabalin


tricyclic antidepressant


gabapentin


lamotrigine


carbamazepine

OCPs & hypothyroid

can lead to increase in total T4 BUT decrease in free T4




pts with hypothyroid will require higher dose of levothyroxine




TSH should be checked q3 months in pt with hypothyroid

Gerstmann syndrome

damage to dominant parietal lobe




difficulty performing simple arithmetic, inability to name individual fingers, impaired writing, right/left confusion

Epidural abscess triad

fever


focal spinal tenderness/back pain


neurological dysfunction




Next step includes urgent MRI, blood cx, inflammatory markers, CT-guided aspiration & cx, & abx

Papillary muscle rupture vs chordae tendineae rupture

both can lead to acute onset of MR (systolic decresendo murmur)




papillary muscle rupture --> occurs 2-7 days after an MI




chordae tendineae rupture --> multiple causes including mitral valve prolapse (think Marfan or Ehlers-Danlos), infective endocarditis, rheumatic disease

Congenital adrenal hyperplasia

Steroid synthesis



Ramsay Hunt syndrome triad

1) ear pain


2) vesicles in external auditory canal


3) ipsilateral facial paralysis




aka herpes zoster oticus




caused by reactivation of varicella zoster virus

Smoking cessation meds

1) varenicline - partial agonist of nicotinic ACh receptor


avoid in pts with unstable psychiatric issues (eg depression/suicidal ideation)




2) Bupropion - norepinephrine-dopamine reuptake inhibitor


also functions as anti-depressant w/o weight gain or sexual dysfunction


but increases risk of seizures

Schizoaffective disorder



Nelson's syndrome

following b/l adrenalectomy for Cushing's dz:


pituitary enlargement


hyperpigmentation


visual field defect




tumors are fast growing & should be tx with surgery (transsphenoidal) and/or pituitary radiation

Cocaine and HTN & cardiac spasms

tx with benzos, phentolamine (alpha blocker), and/or nitroprusside




phentolamine is also used in pheo

Helminth infection causing diarrhea

Ascaris lumbricoides --> roundworm



Trichuris trichiura --> whipworm




Necator americanus/Ancylostoma duodenale --> hookworm




will find eosinophilia on CBC




tx all with albendazole or mebendazole

Heberden nodule vs Bouchard's nodule

Heberden --> distal interphalangeal joint




Bouchard --> prox interphalangeal joint (be seen in RA)




both are seen in osteoarthritis

Kappa statistic

quantative measure of inter-rater reliability




also referred to as inter-rater concordance




-1 is perfect disagreement & 1 is perfect agreement

External vs internal validity

external validity - refers to generalizability of the study




internal validity - refers to whether the study is actually measuring/observing what they are intending (major worry is confounding factors)

Bicuspid aortic valve



Exogenous thyroid hormone intake

Will see:


TSH - very low


T4 - normal/high


RAUI - low


thyroglobulin - low



first step when you suspect is get 24 hr RAUI



exogenous intake is only scenario you get both thyroglobulin & RAUI to be low

Intertrigo

most commonly caused by Candida albicans

affects intertriginous areas (areas with folds like inguinal, genital, axillary, perineal, etc)

obese, diabetics, tight clothing, all predispose

eryhtematous plaques and erosions with satellite papules c...

most commonly caused by Candida albicans




affects intertriginous areas (areas with folds like inguinal, genital, axillary, perineal, etc)




obese, diabetics, tight clothing, all predispose




eryhtematous plaques and erosions with satellite papules can be seen

Whipple's triad

1) sxs of hypoglycemia


2) low blood glucose


3) sx resolution after giving glucose



these pts should be suspected of taking hypoglycemic agents when C-peptide is normal or high (if they took exogenous insulin, C-peptide would be low)

Viral encephalitis/meningitis

peds:


arbovirus or enteroviruses (eastern equine encephalitis, western equine encephalitis, St. louis encephalitis, etc)


zoonotic transmission so occur in rural areas




adults:


most common cause is HSV




Immunocompromised:


CMV

Birth trauma to head

Autoimmune metaplastic atrophic gastritis

gastritis that is assoc with pernicious anemia




autoimmune reaction against oxyntic cells & intrinsic factor (hence assoc with pernicious anemia)




affects mainly gastric body and fundus leading to:


1) glandular atrophy


2) intestinal metaplasia


3) inflammation

Juvenile myoclonic seizures

usually affects young adolescents




p/w myoclonic jerks in the upper extremities




progression leads to tonic-clonic seizures




50% can have psychiatric d/o like anxiety d/o




EEG shows bilateral polyspike and slow discharge




tx with valproic acid

Erythema multiforme

targetoid lesions distributed symmetrically on arms

assoc with herpes simplex virus infection, cancer, & collagen vascular dz

targetoid lesions distributed symmetrically on arms




assoc with herpes simplex virus infection, cancer, & collagen vascular dz

EKG Leads

II, III, and aVF --> inferior wall (RCA)


V1 --> septum (LAD)


V2, V3, V4 --> anterior part of heart (LAD)


V5, V6 --> lateral wall (Circumflex/LAD)