Exam things to note/review: Hypothyroid - can cause myopathy, see elevated CK -sxs: fatigue, weight loss, proximalmuscle weakness, may also see inc DTRs and a tremor (action tremor) Chronic hepatitis - to evaluate extent of damage need a liver bx Allergic rhinitis- see nasal eosinophillia, need to get a NASAL swab Marfan's see MR and MVP, also AR if threat of aortic dissection Hyper PTH- need to get a sestamibi scan Parkinsons- hypokinetic gait Mechanical ventilation! GO OVER IN DETAIL Hypoxemia- treat by increasing PEEP or by increasing FiO2 , measured through pO2 Note: Increasing FiO2 beyond 50-60% is contraindicated due to risk of O2 toxicity Tidal volume- inc would inc MV and peak inspiratory pressure (can worsen respiratory alkalosis) – judge by looking at pCO2 RR- judge adequacy by looking at the pCO2 (if low then ok) Respiratory quotient = CO2/O2 -used to wean ppl off ventilator and to determine if overfeeding (if over feeding with carbs then there is an increase in CO2) -if close to 1, then carbs are major nutrient oxidized- net lipogenesis occuring -0.8 protein -0.7 fatty acids Antiarrhythmic drugsWPW- Digoxin, verapamil and adenosine contraindicated bc they favor conduction across accessory pathway -should use procainamide, or cardiovert when they develop a rapid ventricular rhythm Class 1c – blocks Na channels Note: Flecainide – prolong QRS Flow volume loopsNormal- (insert image) fixed flat line Expiratory.nl shape but shortened Laryngeal edemaInspiratory.fixed flat line Membranous GN – can develop a renal vein thrombosis (abd pain.Obstructive lung dzInspiratory.g. fever.1 indicates a transudate) -Transudative process e.ascites albumin . portal hypertension Infxn with Echinococcus (dogs). instead surgical resection indicated + albendazole Succinylcholine – releases K therefore CONTRAINDICATED in ppl with hyperK Intracranial pressure: Cerebral blood flow – dysregulated in trauma and stroke -increased flow -increased cerebral vasodilation and elevated BP raises the ICP To lower ICP: Intervention Head elevation Sedation IV mannitol Hyperventilation Mechanism Increased venous outflow from head Decreased metabolic demand and control of HTN Extraction of free water out of brain tissue – osmotic diuresis CO2 washout. leading to cerebral vasoconstriction Gluconeogenesis.becomes pyruvate .serum albumin (if >1. hematuria) SAAG.substrates: -gluconeogenic AA (protein from muscle) -lactate (anaerobic metabolism) -glycerol 3-phosphate (from TAG in adipose) alanine (gluconeogenic AA) – via ALT.nl Expiratory – concave shaped Restrictive lung dzInspiratory – nl shape but shortened Expiratory.can develop hydatid cysts – unilocular lesion with egg shell calcifications -txt: DO NOT aspirate. sxs gastric outlet obstruction. seizures Hypertension of pregnancy – diagnosed AFTER 20wks -if before 20 wks must r/o Hyatidform mole (do an US to see if there is anormal gestational sac) Children.at risk for developing aortic aneurysms! Arterial Thrombosis. aureus MC. numerous eosinophils.slow. postprandial pain. hypotension.infants. colicky abdominal pain.MurmursHypertrophic cardiomyopathy. kids appear nontoxic. diminished pulses . and JVD -should STOP nitrates/nitroglycerin (bc they dec preload) and give fluids PE of R pulm artery – MCC thrombus from deep veins in LE (ileofemoral etc) Risk factors for respiratory distress: (inversely proportional to gesteational age) -male sex -c section w/out labor -perinatal asphyxia -maternal diabetes Protective factors for RDS: -prolonger ROM -maternal hypertension -intrauterine growth restriction NOTE difference btwn: Esophageal stricture – presenting symptom is dysphagia Pyloric stricture.dark brown discoloration of colon with lymph follicles shining through as pale patches (melanosis coli) RV infarct (in the setting of an inferior wall MI) – see clear lungs. ataxia. LN is warm. cerebral edema. irritability.crescendo-decrescendo systolic murmur at LSB that does NOT radiate -associated with syncope Laxative abuse.vomiting. self-limiting Temporal arteritis. erythematous (can progress to induration and fluctuance) Erythema toxicum. encephalopathy. insidious onset. vomiting with early satiety Lead poisoning. progressive.acute unilateral lymphadenitis most likely BACTERIAL in origion -S. 2) is indcative of a n empyema!. impaired wound healing -develops in some ppl with TPN due to lack of Zinc in mixture Side effects of Abx-Acute renal failure – seen in Aminoglycosides (Amikacin) Digoxin can cause: Atrial tachycardia with AV block Trauma – apneic pts with suspected c spine fxs. perioral and periorbital pustules .LOW pH (<7.south-central and north-central US.works quickly and preduces preload -sometimes secondary to chronic HTN and LVF -due to diastolic dysfunction Parapneumonic effusions. can result in intrauterine death.alopecia. has a cutaneous manifestation (violaceous hue with sharp demarcated borders) Paroxysmal noctural dyspnea. Not great for adults (may increase CO2 retention) -Tracheostomy.presents as painful uterine contractions and dark red blood in vagina. contraindicated in apneic/hypopneic pts -Needle cricothyroidotomy. laying down) – bc widens canal Stroke – biggest RF is HTN! -smoking and DM also associated but not as strong! Blastomycosis.concerning for pul edema -give nitroglycerin to relieve dyspnea.good FIELD procedure in children.bc narrows canal -improved by flexion (sitting. associated with maternal hypertension Vasa previa. pulses diminished or absent in affected limb Lumbar spinal stenosis – vertebral degenserative disk dz .Arterial Embolus.exacerbated by extension (standing.presents as painless bright red vaginal bleeding Abruptio placenta.should perform orotracheal intubation -Nasotracheal intubation is a blind procedure that requires pt to be breathing. can result in painless bleeding but associated with rapid deterioration of fetal heart rate . indication for removal via thoracostomy -glucose <60 in pleural fluid also indicative for removal via tube thoracostomy Zinc deficiency.not a first option (prefer surgical cricoidotomy – then convert to tracheostomy) Ob-gyn: Placenta previa.pain is sudden!.fetal blood vessels cross lower part of placenta near fetus and internal cervical os. walking). at 28wks D/O of INCREASED Unconjugated bilirubin levels: 1. fasting etc. also see fever and malaise Measles.chronic granulomatous dz. Crigler-Najjar Type 1.also associated with renal disease. Usually precipated by stress. Chronic anticoagulation – Warfarin 3. Crigler-Najjar Type 2. Txt: IV pheniobarbital Parinaud’s syndrome.transferases is reduced.Multiple myeloma. affects peripheral nerves and skin.SAME presentation but pts with rubella are LESS sick DVT management steps: 1.. In US: Thyroid dysgenesis is the MCC of CONGENTIAL hypothyroidism GN after URI: ADULTS: IgA nephropathy CHILDREN: Post-streptococcal GN RhoGAM = anti-D gamma globulin -administer after abortion/traumatic event where fetal and maternal blood mixing occurs if mom has LOW titre <1:6 -administer for all moms Rh. Indirect levels can be 20-25 but can increase to 50. . Gilberts.paralysis of vertical gaze that may be associated with papillary disturbances and eyelid retraction (Collier’s sign) -causes an endocrine syndrome: interuppts the hypothalamic inhibitory pattern -caused by pinealoma or germinoma Leprosy. pyelonephritis. hyperuricemia. obstruction of distal and collecting tubules with paraproteins (Bence-Jones proteins) -Also see: hypercalcemia.Rubella.production of U-gly. Initial anticoagulation and clot stabilization – done with heparin of LMWH 2. Treatment of DVT-related complications – compression stockings etc. amyloid deposition Childhood exanthems. Txt: liver transplant 3.rash starts at face and spreads downwards.milder autosomal recessive form. 2. Caused by mycobacterium leprae -dx: skin bx will see acid-fast bacilli Osgood-schlatter dz: associated with traction apophysitis -worsened by sports -reproducible by extending knee against resistance . only see levlevated unconjugated indirect bilirubin levels. also see posterior cervical and occipital LN.severe jaundice and neuro impairment iat birth. urinary urgency. pallor of optic disk Syphilis. Hb. personal or family h/o -TB -Toxoplasmosis serology -Hb electrophoresis (high risk ethnic background.very rare to have sxs -can get painless hematuria as MC sx Retinal detachment.painless papule that becomes ulcerated ulcer (can be found on vulva). PIP. boxcar segmentation of blood in retinal veins. MCV <80) -Lead levels Sickle cell trait (HbS). pelvic pain (dysparunia). frequency. symmetric -affects MCP. wrist and ankle joints Pregnancy tests for all pts: -Cervical cytology -Rhesus type and Ab screen -Hct.submucosal petechiae or ulcerations . also see bilateral inguinal lymphadenopathy Note: Differentiate from chancroid and HSV – bc they both have painful ulcers Interstitial cystitis. MCV -Rubella immunity -Varicella immunity -Urine Cx -Syphilis testing -Hep B Ag -Chlamydia testing -HIV test -Influenza vaccine during flu season -Offer genetic screening for CF and Downs Syndrome At risk pregnant pts: -Thyroid fxn ONLY if sxs.Sickle cell anemia – peripheral smear: reticulocytes and sickle cells Viral arthritis – seen in adults that work with kids -due to Parvovirus B19 -acute onset -polyarticular.photopsia (flashes of light) and floaters (spots in visual field) described as “curtain coming down over my eyes” Central retinal artery occlusion – sudden painless loss of vision in one eye -cherry red fovea. chronic condition -Cystoscopy. suspect in elderly with rapidly progressive dementia. trimethoprim). rifampicin.drugs that cause: antibiotics (PCN.MC in MALES. can give Morphine if symptomatic treatment does not work Valproic acid. high pitched cry. captopril NOTE: association between seborrheic dermatitis and parkinsons and HIV SE of PTU.causes neural tube defects.see the presence of sxs BEFORE age 3 Fetal Defects: Neonatal abstinence syndrome. tremors. hyperactive Moro reflexes. vomiting -Txt: symptomatic. may cause cardiac anomalies. diuretics. poor feeding. cephalosporins. myoclonus (+ extensor plantar response) -EEG periodic sharp waves -Bx: spongiform changes Condition Urine Chlorid e (mEq/L ) High (>20) Very low Very Plasma renin Plasma aldosteron e Elevated Elevated Elevated Seru mK Seru m Bicar b High High High Serum Na Diuretic use Vomiting Bartter/Gitelman Elevate d Elevate d Elevate Low Low Low Low/norma l Low/norma l Normal .Childhood disintegrative d/o. -Due to premature androgen secretion from the adrenal glands AIN. withdrawl not as severe as opiates Premature adrenarche. dysmophic facies (cleft lip. narrow bifrontal diameter) Cocaine.occurs neonates that have been exposed to opiates (heroin) in utero -Sxs: occurs within 48hrs after birth – see diarrhea.agranulocytosis (most serious SE).isolated appearance of axillary hair before age 6. period of normal development for at least 2 yrs followed by a loss of previously acquired skills Autism. excessive sucking.jitteriness. tachypnea. NSAIDs. MC SE is allergic reaction CJD. seizures. TB.milder form of Bartter due to defect in distal convoluted tubule Amniocentesis – best performed btwn 16-18 wks gestation after triple screen abnormal CVS.find pneumatosis intestinalis on KUB. histolytica (will see flask shaped inclusion bodies) Watery diarrhea – Cryptosporidium etc -MAC only involves small bowel Carpal tunnel synd in pregnancy – due to estrogen med buildup of ground substance which causes interstitial edema in hands and face.defective Na and Cl resorption in thick ascending loop of Henle -presents as polyuria.syndrome Primary hyperadolsteronis m Renin-secreting tumor Factitious diarrhea high (>40) Very high (>40) Very high (>40) Very low (<10) d Low Elevate d Elevate d Elevated Elevated Elevated Low Low Low High High High Elevated Elevated Low/norma l Bartter’s syndrome. histoplasmosis .best between 10-12wks in women with KNOWN genetic diseases for the purposes of aborting the fetus After Rubella vaccine – wait for 1 month for conception! No cases of congential rubella from vaccine reported Erythema nodosum associated with: strep infxn. polydipsia and mental retardtion in early life Gitelmans synd.give cyclophosphamide and steroids HIV pts: BLOODY diarrhea – CMV colitis (MC cause) -other causes E. sarcoidosis. also gastric retention first sx Chagas = protozoal disease! Goodpastures – emergency plasmapheresis is imperative to prevent kidney damage Wegners. can result in carpal tunnel . IBD Necrotizing enterocolitis. see hypertension.pancytopenia with anomalies: hyperpig on trunk. Sub-Saharan Africa – prophylaxis with mefloquine Plasmodium vivax/ovale. CBC shows normocytic or macrocytic anemia with reticulocytopenia Fanconi’s anemia.usually a rxn to abdominal surgery but also due to paralysis -see gas filled loops of small and large intestines Note: in SBO. hypogonadism. skeletal anomalies Malaria.pure RBC anemia.polyarticular and symmetric arthritis -can have a +Rf and +ANA Paralytic ileus.prophylaxis with Chloroquine -Resistant areas: INDIA. muscle weakness and numbness -high aldosterone/renin ratio Ototoxic drugs: -Loop diuretics (furosemide) -Aminoglycoside abx -cyclophosphamide -ASA (more of a tinnitus) AI conditions associated with vitiligo: -Pernicious anemia -Autoimmune thyroid dz (Grave’s chronic autoimmune thyroiditis) -T1DM -Primary adrenal insufficiency -hypopituitarism -alopecia arreata Intraventricular hemorrhage associated with PREMATURITY Aplastic anemia – see bone marrow hypocellularity and fatty infilteration Diamond-Blackfan anemia.-txt: neutral position wrist splint first then if that fails can give local/oral CCS Viral arthritis. Early life. short status.see pallor and poor feeding.bowl DISTAL to obstruction is NOT distended Primary hyperaldosteronism. upper limb abnormalities.Plasmodium falciparum.prophylax/treat with Primaquine -liver manifestations Resting tremor – problem with basal ganglia! Not the same as essential tremor! = intention tremor Syncope + confusion afterwards = seizure! (complex partial or generalized seiqures) . neck intertriginous areas. danaproid Coarctation of aorta – MC to get elevated BP in R arm Atherosclerosis of upper extremities. hallucinations. hexagonal crystals on UA Vertebral osteomyelitis – best test to dx is an MRI of spine If suspect cord compression/spinal stenosis – first step is to give CCS THEN get and MRI Pneumomediastinum – seen in esophageal perforation.MC in L subclavian a. -used in txt of essential tremor (BBlockers also used) Note: if suspect anemia of chronic dz.class C interferes with folate metabolism (should be used in last trimester only) In HIT: -STOP heparin -can’t use LMWH! Cross reacts with heparin Abs -Alternate treatments include: DIT (leupirudin. Specific phobia – treated with BBlockers . proteinura. arthlarlias. poorly solube. hepatosplenomegaly -seen with underlying Hep C infections Cystine stones – hard.cause probs with bone and tooth development -Fluroquinolones – cause arthropathies -TMP-SMX. otherwise suspect Fe def or thalassemia Thyrotoxicosis – hyperdynamic state causes secondary hypertension Drugs ok in Pregnancy for UTI: -Nitrofurantoin -Amoxicillin -Amox-clavulanate -Cephalexin Contraindicated in preg: -Tetracyclines. argatroban).Mixed cryoglobulinemia – palpable purpura. Boerhaave synd -NOT seen in Mallory-Weiss tears (bc incomplete) Primidone SE: colicky abd pain. radioopaque.check ESR to make sure inflammation is occurring. confusion. dizziness. headaches. hematuria. pain to palpation near knee joint. chorioretinitis. IgG. sinopulm infxns. sinopulmonary infxns Infxns of respiratory. microcephaly.Congential toxoplasmosis.hydrocephalus. see neutropenia. Onset of recurrent bacterial infxns in first 5 yrs of life 2. can weight bear afterwards Immunodeficiency Bruton’s agammaglobulinemia (XLA) Sxs 1.immediate swelling. IgM. Less than 2% CD19+ B cells in peripheral circulation Low levels of IgM. Absent isohemagglutinins or poor response to vaccines 4. IgG. B cell number normal High levels of IgM with def in IgA. cerebral calfications. opportunistic infections (PCP). Serum IgG. IgA. GI and urogenital tract Seen in ppl with normal level of IgG yet still develop recurrent pulm infxns Common variable immunodeficiency Hyper IgM syndrome (HIM) IgA def Selective IgG subclass deficiences Lung findings Consolidation Pleural effusion Pneumothorax Interstitial lung disease Bronchial breath sounds increased during EXPIRATION Egophony Crackles Dullness to percurssion Decreased breath sounds Egophony sometimes heard at fluid level Hyperreasonant Decreased breath sounds Vesicular breath sounds Resonant on percussion Fine crackles at end of inspiration . inability to weight bear on knee Meniscal tear. hepatosplenomegaly NE induced vasospasm – can cause ischemia and necrosis of distal fingers/toes -dusky appearance! -can also occur in intestines (resulting in mesenteric ischemia) or kidney (renal failure) ACL tear. IgA values that are decreased 3. should give all contacts erythromycin for 14d (despite vaccination) -transmitted via respiratory droplets Pulm embolismCXR: Westermark’s sign: dilatation of pulm artery proximal to clot and collapse of vessels distal to the clot Hampton’s hump: Pulm infiltrates corresponding to areas of pulmonary infarction EKG: MC finding. and chest wall abnormalities -most have decreased FRC except Ankylosing spondylitis (FRC increased bc chest wall fixed in an inspiratory position) Rotator cuff tendonitis – improved by injecting joint with steroids N-acetylcysteine. sinus tachycardia .highly contagious despite immunization.Mucous plugging Emphysema No breath sounds at portion Lungs hyper-reasonant to percussion bilaterally Vesicular breath sounds Fine crackles at end of inspiration Hashimoto’s thyroiditis – susceptible to develop lymphoma of thyroid Note: Bacilus cereus – also produces a preformed toxin – found in rice and starch based foods Restrictive lung disease.as long as given within 8hrs of ingestion will work equally well (therefore can wait to get a liver level of Acetaminophen before giving antidote for toxicity Bronchiectasis. alveolar edema.large cells that appear to have clear halos around then because cancer cells become retracted from adjacent keratinocytes -usually due to an underlying adenocarcinoma SBO. pleural fibrosis.partial obstructions (still passing gas) – can be observed -full obstructions – ER laparotomy Pertussis. neuromuscular disease.nonpurulent expectorant Paget’s disease of breast.FEV1/FVC>80% Causes: interstitial lung disease.mucopurulent expectorant. can also get clubbing of digits Chronic bronchitis. somnolence.secondary syphilis. respond to PCN Vulvar cancer. confusion. LOW haptoglobin) Dubin-Johnson synd. soreness and vaginal discharge Klumpke paralysis.associated with hyperoxaluria (due to fat malabsorption) Sickle cell.vulvar lesions. fleshy lesion on labia majora Lichen sclerosus. high LDH. hyperkeratotic.paralysis of hand – due to injury of 7th and 8th cervical n.hemolytic anemia (reticulocytosis.SE: hallucinations. wrinkled skin over labia.HPV. see pruitus. application of trichloroacetic acid/podophyllin leads to resolution of lesions Other vulvar lesions: Condyloma lata.white. pruitic Vulvar lichen planus.increased risk of vertebral fractures due to decreased bone mineral density Chronic Hep C associated with extra hepatic complications: -cryoglobulinemia -b-cell lymphomas -plasmacytomas -AI dz like Sjogren’s and thyroiditis -Lichen planus -Porphyria cutanea tarda -Idiopathic thrombocytopenic purpura Crohn’s dz. thin. -Note: can also see ipsilateral Horner syndrome due to miosis and ptosis Note: for ppl that do not want to undergo cholescystecomy can give ursodeoxycholic acid – bile salt which decreases cholesterol content of bile by reducing hepatic secretion and intestinal resorption of cholesterol Levidopa/carbidopa.SE: livedo reticularis and ankle edema Ankylosing spondylitis.middle aged women.singular.pink. high bilirubin.conjugated chronic hyperbilirubinemia (not associated with hemolysis) -see dark pigment in liver -benign therefore no treatment needed Henoch-Schonlein Purpura. teardrop shaped growths. see flat velvety lesions. erosive/papulosquamous in appearance. dyskinesia Amantadine.IgA mediated vasculitis of small vessels . and 1st thoracic n. routine eye exams needed STROKE – think about TIME frame! -if within 3-5hrs of sx onset. slows disease progression and relieves symptoms Spondylolisthesis.-abdominal pain. before administer get CT to r/o hemorrhagic stroke -if >5hrs.spike of either IgG or IgA PBC.increased risk of endometrial Ca Waldenstrom’s Macroglobulinemia. liver sz. if renal impairment.repeated inhalation of inciting Ag leading to alveolar inflammation -txt: remove exposure Raloxifene.plasma cell neoplasm -production of excessive amts of IgM Ab in blood (causes thickening of blood) -IgM spike! -inc spleen size.txt with ursodeoxycholic acid. SE: increased risk of venous thromboembolism. and LN -tendency of bleed/bruise easily -night sweats -headache and dizziness -various visual probs (retinal vein engorgement) -pain and numbness in extremities due to demyelinating sensorimotor neuropathy Multiple myeloma.association between antiphospholipid Abs and fetal loss after 10 wks gestation -most likely due to thrombus formation in placenta Childhood strokes – think SICKLE CELL ANEMIA Hypersensitivity pneumonitis.look at BUN and Cr BEFORE starting Li. increase hot flashes and leg cramps Tamoxifen. renal disease -may follow URI SLE. rash. forward slip of vertebrae (usually L5 over S1) -chronic back pain in KIDS Hydroxychloroquine – used for txt of SLE -SE: damage to eye (retinopathy).palpable step off of lumbosacral area. give ASA PUD.SERM.MC complication hemorrhage Bipolar d/o. start on Valproic acid instead . give tPA (fibrinolytics). arthralgias. soles. palms.macular.confirm dx with muscle biopsy Stable angina.<10% BSA involved (less severe than TEN) Erythema multiforme minor.Toxic epidermal necrolysis.associated with stiffness in Cervical spine (C1-C2 instability and subaxial subluxation) .mucocutaneous exfoliative disease ->30% of BSA involved Steven’s Johnsons. popular. bullous or purpura.hypoxia due to increased alveolar-arterial oxygen gradient Cushings.see HYPOKALEMIA Trastuzumab (Herceptin). then use nitrates Pneumonia. occur in extensor surfaces.FIRST use BBlocker or CCB.monoclonal Ab used in HER2 + breast cancers -SE: can cause cardio toxicity in conjunction with chemo -must get baseline Echo before starting treatment TB txt: use INH + pyridoxine for 9mo Rheumatoid arthritis. and mucous membranes Duchennes.
Report "Step 2- Notes on Questions From USMLE World"