new uworld incorrect

difficult conversations about prognosis should

express empathy using "wish and worry" framework

-avoid promoting false hope and offer constructive suggestions

in patients with peripheral artery disease "atherosclerosis of peripheral arteries" there is a risk of

thrombosis and acute on chronic limb ischemia which presents with mottling, coolness, prolonged capillary refill, paresis

simple renal cysts present as

thin, smooth, unilocular with no septae, asymptomatic require no follow up

->work up if features irregular walls, thickened septae, contrast enhanced, multilocular mass

as disease prevalence increases the NPV and PPV will

NPV decrease

PPV increase

AMS with COPD raise suspicion for

hypercapnic encephalopathy

->next step arterial blood gas due to prone CO2 retention

hypercapnia

excessive carbon dioxide in the blood

-presents with HA, somnolence, asterixis, profound CNS dysfunction

somatic symptom disorder involves

excessive anxiety and behaviors related to >1 symptom

-these pts have high health care use and undergo multiple tests with negative results

calcium stone reoccurrence from hypercalciuria tx with

increased fluid intake, dietary measures and if fails->add thiazide (increase renal Ca2+ absorption)

thiazide moa

increase calcium reabsorption at the level of the distal tubule and produce a relative hypovolemia that results in compensatory increase in sodium reabsorption

->decrease calcium urinary excretion!!!

-CALCIUM SPARING DIURETIC

cirrhosis of liver presentation

hypogonadism HPA dysfunction with elevated estradiol due to increased conversion from androgens

->ED, testicular atrophy, gynecomastia, low total T3/T4, weight loss

primary CNS lymphoma

AIDS defining malignancy associated with expression of EBV oncogenes

->MRI of brain shows solitary irregular nonhomogeneous ring enhancing mass

Progressive multifocal leukoencephalopathy (PML)

AIDs defining illness presents with confusion, lethargy, seizures

->brain imaging shows numerous Non enhancing lesions that do not cause mass effect

-reactivation of JC virus

EBV cancer associations

non Hodgkin lymphoma and primary CNS lymphoma

acute lymphoblastic leukemia(ALL) presents with

bruising, petechiae, bleeding due to impaired platelets production in bone marrow

-non tender lymphadenopathy and hepatosplenomegaly

hypospadias characterized by

ventrally displaced urethral opening and dorsal hooded foreskin

-failure of urethral folds to fuse

->needs urologic evaluation

open globe injury

laceration typically caused by small high velocity particles sent airborne

-may presents with peaked or teardrop pupil, asymmetric anterior chamber depth, loss of visual acuity, afferent pupillary response, reduced intraocular pressure

Sydenham chorea

a sequela of group A streptococcus(GAS) infection is the primary cause of chorea (abnormal, jerky movements that disappear during sleep) in children

-hypotonia and behavioral changes commonly seen

-work up: GAS testing with throat culture and Anti streptolysin O and Anti deoxyribonuclease(anti-DNAase) titers

->eval for RF with echo, ECG, inflamm markers

meconium ileus

inspissated stool causing obstruction at terminal ileum, strongly associated with CF

->fails to pass meconium within 24 hours, abd distention with or without perf, no stool in vault

->CF places pt at increased risk for chronic sinopulmonary disease

Meconium ileus is associated with which of the following disorders?

cystic fibrosis

Hirschsprung disease associated with

down syndrome

->increased rectal tone with squirt sign, stool in vault vs meconium ileus has no stool in vault

in clinical trials randomization is said to be successful when

a similarity of baseline characteristics of the patients in the treatment and placebo groups are seen

heat stroke

characterized by core temperature >104, with CNS dysfunction (ex: AMS), most commonly to those exposed in hot/humid environments while performing extreme activities

->complications include rhabdomyolysis, DIC, endo organ dysfunction

pts need to undergo pre0op CV risk assessments prior to noncardiac surgery ->6 risk predictors are

-high risk surgery(vascular, intrathoracic)

-ischemic heart disease

-hx of CHF

-hx of cerebrovascular disease9stroke or TIA)

-DM tx with insulin

-pre op Cr>2

low risk: 0-1 factor->no further eval

elevated risk >2 factors->further eval cardiac stress test

chronic osteomyelitis in setting of fracture can lead to

nonunion

->symptoms include intermittent pain and swelling and sinus tract formation

-must treat infection before fixing fracture or hardware will be infected!!!

->open bone biopsy is recommended for microbio assessment

->tx: surgical debridement of infected and necrotic bone

iron def anemia work up

GI blood loss m/c cause->endoscopy needed

->regardless of symptomatology work up with endoscopy do not need symptoms

still murmur

occurs in active, healthy children between 3-7 years old.

caused by vigorous expulsion of blood from left ventricle into aorta, increases with activity and diminishes when child is quiet.

->systolic vibratory murmur best heard of LLSB increasing in intensity when supine

carotid artery dissection or thrombus presents

with penetrating trauma (fall with object in mouth, neck manipulation)

->gradual onset hemiplegia, aphasia, neck pain, "thunderclap" HA

->can cause stroke which partial horner syndrome, unilateral HA and neck pain with cerebral ischemia

->dx: CT or MR angiography

hypertrophic cardiomyopathy physical exam shows

crescendo-decrescendo murmur that increases in intensity with decreased left ventricular blood volume, audible S4, brisk carotid pulses

->many patients have asymmetric hypertrophy of interventricular septum

aortic stenosis physical exam findings

crescendo-decrescendo murmur that decreases with Valsalva

-presents with S4, ejection click

-soft and delayed carotid pulses

secondary amyloidosis is a complication of a

chronic inflammatory condition (RA, psoriasis, IBD) resulting in extracellular tissue deposition of protein fibrils into tissues and organs

->pts develop multiorgan dysfunction (kidney, liver)

->tx; manage underlying disease

patients with burn injuries susceptible to

sepsis

->first sign acute enteral feeding intolerance

scleroderma renal crisis is characterized by

acute onset of HTN and AKI in patients with systemic sclerosis (thickened shiny skin)

->mainstay of treatment is ACE inhibitors which produce RAAs hyperactivity, improve renal function and normal BP

alcoholic cerebellar degeneration is

caused by damage to purkinje cells of cerebellar vermis

->manifests as slowly progressive onset of ambulation difficulties, wide based gait, postural instability, impaired truncal coordination (tandem gait) but limb coordination intact (finger to nose)

breast cyst management

Asymptomatic Simple

-Observe

Symptomatic (Tender) Simple

-FNA

--> Nonbloody or Bloody

->bloody needs biopsy

->nonbloddy and resolves no work up, if recurrent biopsy

Complex

-Biopsy

gastric cancer

common in those from eastern Asia/Europe, south america

->presents with progressive epigastric pain and weight loss

->iron def anemia

->metastasis to liver result in hepatomegaly, elevated transaminases, alkaline phosphatase

Primary spontaneous pneumothorax (PSP) treatment

small clinically stable pts->observe and supplemental oxygen

->occurs inpatients without hx of lung disease and is m/c in tall thin men in early 20s

Parkinson tremor

-basal ganglia dysfunction

->resting pill rolling tremor that asymmetrically affects the hands

-improves with involuntary actions(reaching for something), worsens when patients are distracted(doing math) and is not impacted by caffeine or alcohol

amiodarone adr

causes thyroid dysfunction due to iodine content and effect on thyroid metabolism->impairs synthesis of thyroid hormone and decreases conversion of T4->T3

-hepatocellular injury

a lesion impacting medulla can cause

motor weakness with UMN signs and lower CN dysfunction (CN12)

->tongue deviation

neurosyphilis

early manifestations are meningitis with ischemic stroke, uveitis, optic neuritis, hearing loss

->rash that is symmetric maculopapular involving extremities(palms, soles) and trunk

meningovascular syphilis presents with

subacute meningeal manifestations(HA, N/V, dizziness, neck stiffness) followed by signs of ischemic stroke

->m/c MCA affected, arteriography shows focal segmental arterial narrowing

->dx: LP with CSF analysis showing +VDRL

the most specific diagnostic test in osteomyelitis is

bone biopsy and culture

cyanide is a lethal toxin released in

house fires, mining, sodium nitroprusside

->features: reddish skin, lactic acidosis, elevated anion gap metabolic acidosis, HA, confusion, HTN, tahcycardia

->tx: hydroxocobalmin

methemoglobinemia

a blood disorder in which an abnormal amount of methemoglobin, a form of hemoglobin, is produced

-can also be due to exposure to oxidizing agents(dapsone, nitrates, topical/local anesthetics)

-pts cyanotic/dusky colored skin that does not resolve with supplemental oxygen

diaper dermititis-irritant

skin breakdown from exposure to stool/urine

-m/c type, confined to area in diaper

->erythematous papules, plaques that spare skin folds(vs candida does not spare)

-tx: topical barrier

atopic dermatitis can lead to

infectious complications(impetigo)

-consider when topical corticosteroids for flare is ineffective

->impetigo presents with golden crusts weeping, purulence, tx: topical mupirocin

anogenital warts(condyloma acuminata) in children

HPV infection(direct genital contact)

->due to sexual abuse, prenatal or perinatal, autoinoculation from other sites

-features: pink/flesh colored, verrucous papules and plaques, asymptomatic, pruritic friable lesions

-tx: self resolving, if symptomatic surgery or topical podophyllotoxin

diagnostics for idiopathic intracranial HTN

Lumbar puncture: elevated opening pressure, after looking for mass lesion

MRI/CT: for mass lesions and hydrocephalus

MR venography rule out thrombosis

->tx: acetazolamide

Rocky mountain spotted fever presents

in 3-4 days with nonspecific fever, HA, myalgia, arthralgia, macular and petechial rash on wrist/ankle->palms/soles->then spread centrally

-Labs: low platelets, hyponatremia, increased AST/ALT

tx: empiric doxycycline while awaiting serology

SCFE

commonly seen in obese adolescents

->dull hip pain, referred knee pain, altered gait, limited internal rotation of hip

-tx: surgical pinning

iliopsoas bursitis

inflammation in bursa posterior to iliopsoas muscle due to overuse or trauma

->pt have hip pain and limited ROM, with palpable click with manipulation of the hip present

anterior cord syndrome

loss of most function below the site of injury to the anterior portion of the spinal cord, usually due to trauma

->characterized by b/l motor function loss at and below level of the injury with diminished pain and temperature and crude touch sensation b/l that begins 1-2 levels below injury

->bilateral loss motor, pain, temp, crude touch

->proprioception, vibratory sensation and light touch unaffected

anticholinergics can cause

acute urinary retention by preventing detrusor muscle contraction and urinary sphincter relaxation

->tx with urinary catheterization and d/c medication

-ex: amitriptyline(TCA)

hyperventilation syndrome presents with

acute onset of deep breathing and/or tachypnea often with neurologic symptoms(tingling, numbness)

-nl lung exam

-similar to panic disorders but panic attacks characterized by intense fear that does not always have to include respiratory symptoms

tx: reassurance with breathing training

in children with HIV notice

immunocompromised at higher CD4 T cell counts

->PJP is often initial AID defining illness presenting at 3-6 months

-manifests as low grade fever, tachypnea, poor feeding, progressive dyspnea

->tx: TMP-SMX with corticosteroids if PaO2<70 or A-a >35

risk factors for osteoarthritis

advanced age

female

family hx

abnormal joint alignment

prior joint trauma or surgery

Secondary causes: infection, inflamm, bony deformities, neuromuscular weakness

ankylosing spondylitis complications

Osteoporosis/vertebral fractures

Aortic regurgitation(laterally displaced PMI due to compensatory hypertrophy)

Cauda equina syndrome

cocaine associated chest pain should be tx with

IV benzodiazepines (diazepam)

->then treat with aspirin, nitroglycerine, calcium channels blockers

CI: beta blockers

myasthenic crisis

an acute exacerbation of myasthenia gravis caused by inadequate amount of meds, infection fatigue or stress.

->characterized by severe respiratory muscle weakness->respiratory failure

->tx: intubations, plasmapheresis, IVIG

m/c cause of nonreactive stress test

quiet fetal sleep cycle, no accelerations

-can last as long as 40 minutes, extend to ensure fetal activity outside of sleep is captures

congenital fetal heart block on NST

fetal bradycardia (<110/min)

symmetric polyarticular arthritis with brief self limited course->

viral arthritis due m/c to parvo

-think with exposure to children

guillian barre syndrome is a

acute or subacute ascending flaccid paralysis

->CSF shows elevated protein level with normal cell count

->tx: IVIG, plasmapheresis

craniopharyngiomas are

benign suprasellar tumors that present with visual defects, HA, symptoms of pituitary hormonal deficiencies (mass effect, decreased libido due to hypogonadism)

-commonly occur in children age 5-14, with second peak in adults 50-75

generalized anxiety disorder characterized by

hx of feeling easily overwhelmed by anxiety and multiple worries accompanied by physical nonspecific symptoms

-commonly have perinatal GAD->tx: psychotherapy

acute vertebral compression fracture

caused by twisting, lifting, other minimal trauma and presents with back pain and vertebral point tenderness

->typically occurs in patients with osteoporosis and other conditions with decreased bone mineral density

-dx: plain x-ray of spine

complication of miliary Tb

primary adrenal insufficiency

-hypovolemia, hyponatremia, hyperkalemia

-combines with pulmonary airspace disease with lymphadenopathy prior residence in Tb endemic region

-infectious/tuberculosis adrenalitis is the second m/c caused or adrenal insufficiency

idiopathic intracranial HTN (pseudotumor cerebri)

m/c in obese women of childbearing age or are pregnant

->presents with headaches, pulsatile tinnitus, papilledema

-dx: MRI of brain followed by LP

initial treatment of choice in patients with persistent tachyarrhythmia causing hemodynamic instability is

immediate synchronized cardioversion

ex: A-fib with RVR

in patients with ventricular fibrillation of pulseless v-tachy treatment is

defibrillation

breast pain that is cyclical, b/l, diffuse->tx

reassurance and symptom management (supportive bra, NSAIDs)

inhibitor development

occurs in severe hemophilia patients with factor 8 deficiency

-consider in a patient bleeding refractory to replacement therapy or with increased bleeding frequency

suspect PE in any patients who presents with

sudden onset SOB and pleuritic CP

->commonly see tachycardia, hypoxemia, low grade fever, JVD

chemical pneumonitis:

look for patient who went under conscious sedation

-inhalation of gastric acid leads to direct chemical injury of bronchial and alveolar epithelial cells

-sudden onset within minutes to hour

-abrupt onset dyspnea, cough, hypoxemia

->tx: resolves spontaneously

effect modification

results when an extraneous variable(modifier) changes the direction or strength of an association between a risk factor and a disease

-a modifier is associated with the disease but not the RF

-distinguished from confounding by stratified analysis, will show significant difference in each strata while confounding will not

Chiari I malformation is characterized by

inferior displacement of cerebellar tonsils through the foramen magnum

->commonly associated with syringomyelia(cyst in spinal cord)

-occipital HA exacerbated by activity and Valsalva

complication of celiac disease

vit D deficiency->osteoporosis

-bone pain, muscle weakness, impaired ambulation

principles of prescribing in elderly

limit the number of prescribers

consider time to benefit for each drug

tailor regimen to patients goals and life expectency

myasthenia gravis presentation

fluctuating and fatigable proximal muscle weakness, worsens with activity, improves with rest

-ocular(diplopia, ptosis)

-bulbar(dysphagia, dysarthria)

-respiratory(myasethnic crisis)

tx: Acetylcholinesterase inhibitors(pyridostigmine), thymectomy

ARP (attributable risk percent)=

(RR-1)/RR x 100

rectus abdominis diastasis

not a true hernia, not palpable while supine

pericardial effusion

accumulation of fluid in the pericardial cavity

->can be purulent from hematogenous or direct intrathoracic spread (staph)

-fevers, chills, CP

EKG: tachycardia, diffuse ST segment elevation, low voltage QRS complex

CXR: enlarged cardiac silhouette and clear lung fields

->dx via ECHO: pericardial effusion

but if purulent pericardiocentesis needed for dx and tx

hydrocephalus

suspect in young child or infant with rapidly enlarging head circumference crossing multiple growth percentiles

->signs of increased ICP see once anterior fontanelle closes, irritable, developmental delay, HTN/bradycardia, papilledema

patellofemoral pain syndrome

common cause of anterior knee pain in young women, seen in runners from chronic overuse or malalignment

-pain provoked by maneuvers that involve contraction of quadriceps with the knee in flexion

-tx: activity modification, NSAIDs, strengthening and stretching exercises(quads)

tuberous sclerosis

autosomal dominant

-ash leaf spots, periungual fibromas, shagreen patch, seizures, cardiac rhabdomyomas, renal angiomyolipoma's

vitreous hemorrhage

Sudden loss of vision with floaters, usually secondary to diabetic retinopathy

->hazy vision, red hue, vision loss, floaters with a decreased or absent red reflex

predictors of severe acute pancreatitis includes

SIRS criteria with elevated bun and hematocrit with intravascular volume depletion

->patients have increased risk of morbidity and mortality

=acute pancreatitis with organ failure persistent over 48 hours

unilateral lower extremity edema with hx of recurrent cellulitis->

chronic lymphedema

-since chronic now non pitting edema with firm thickened skin

pulmonary edema causes

hypoxemia due to R->L intrapulmonary shunting, an extreme V/Q mismatch

-when the edema is diffuse, alveolar ventilation is zero throughout much of the lungs and hypoxemia does not correct with supplemental O2

-with V/Q mismatch->increased A-a gradient

increased A-a gradient in

diffusion limitations, V/Q mismatch, large intrapulmonary shunt, large dead space ventilation

renal colic secondary to nephrolithiasis in preg will present as

presents with abdominal pain, flank tenderness, hematuria, irregular uterine contractions

dx: US

disseminated gonococcal infection presents as

purulent monoarthritic or triad of tenosynovitis, dermatitis, migratory polyarthralgia

CGD

recurrent cutaneous and pulmonary infections with catalase positive organisms(staph, Serratia)

-abnormal oxidative burst is consistent with diagnosis

-prophylaxis: TMP-SMX, itraconazole

posterior hip dislocation:

commonly occurs in head on MVA

-leg appears shortened and IR, hip held in flexion and adduction

m/c than anterior

-also in SCFE

tibial stress fractures

Overuse injuries that seem like shin splints except that the pain is in a specific location. (point tenderness)

-common in athletes or others who increase activity level

antiphospholipid antibody syndrome should be suspect

patients with still birth and multiple prior pregnancy loss

-stillbirth from uteroplacental artery thrombosis which leads to uteroplacental insufficiency and asymmetric growth restriction

ulnar injury at elbow presents as

numbness in medial hand, decreased grip strength, weaker wrist flexion

->if at wrist just numbness and paresthesia

ventilator associated pneumonia

suspect when intubated patient develops new pulmonary infiltrates on chest x-ray, worsened respiratory status(increased oxygen requirement), clinical signs of infection

hypokalemic, hypochloremic metabolic alkalosis

in patients with NG suctioning, vomiting, loop or thiazide diuretic use

->tx: saline to correct alkalosis

medication induced hyperkalemia with

ACE/ARBs

NSAID

amiloride, spirinolactone

heparin

TMP

cyclosporine

digoxin

succinylcholine