For the latest updated version of these notes, please visit: MAIN Divine Intervention Step 2CK Podcasts Notes - Read Only

Announcement from u/Coffee_Beast on June 06, 2021 

Hi Divine Intervention Podcast notes readers,

Please click here or use the link above to access the UPDATED podcast notes.

I have handed over the reins to u/Lukaszdadamczyk who will be managing the document at it’s new location! He has some great ideas for organizing this project moving forward, and I’m excited to see what he comes up with.

I want to thank everyone for their continued interest, support, and contributions! Ecstatic to see people benefiting from this. It all just started as an idea from u/saffronshawty to compile some podcast notes together, and with all of your contributions has turned into the mammoth 500+ pages. Full credit also goes out to Divine. Whose content at the back of his mind made this all possible. Thank you for leading the way.

I look forward to reading and upvoting all of your future Step 2 success stories posts on the subreddit in the near future :).

All the best,

u/Coffee_Beast  

For the latest updated version of these notes, please visit: MAIN Divine Intervention Step 2CK Podcasts Notes - Read Only

Common abbreviations you’ll find on the following pages:

#1 RF = number one risk factor

2/2 = secondary to

C/B or c/b = complicated by

C/I or c/i = contraindicaticated or contraindications

D/T = due to

Dx = diagnosis or diagnostic testing

HDS = hemodynamically stable

HDUS = hemodynamically unstable

MC = most common

MCC = most common cause

MCCOD = most common cause of death

MI = most important

MIPF = most important prognostic factor

MIRF = most important risk factor

MSC = most serious complication

ML = most likely

MLM = most likely mechanism

MLCP = most likely clinical presentation

NBS = next best step

NBSIM = next best step in management

POOP = pain out of proportion

Tx = treatment

 Table of Contents

Episode 17: Peds Diseases of The Pediatric Population Part 1.        7

Episode 19: Neurology Shelf review part 1        10

Episode 21: Comprehensive Pediatric 3rd Year Shelf Review        16

Ep 22 [OBGYN Shelf Review]        20

Episode 26: USMLE Radiology        37

Old Version - Episode 29: 3rd Year Medicine Shelf Review Part 1        38

Episode 30: Comprehensive Medicine Shelf Review Session 2.        52

Episode 31: Comprehensive Medicine Shelf Review. Session 3.        79

Episode 32: Comprehensive Medicine Shelf Review Session 4        115

Episode 36: Ophthalmology        140

Episode 37: Risk Factors        144

Episode 41: Antibiotic Guide        146

Episode 45: Neurology Clerkship Shelf Review Part 2        153

Episode 46: Neurology Clerkship Shelf Review Part 3        159

Episode 47: Neurology Clerkship Shelf Review Part 4        162

Episode 48: Neurology Clerkship Shelf Review Part 5        165

Episode 49: Neurology Clerkship Shelf Review Part 6        171

Episode 58: Neurology Clerkship Shelf Review Part 7        179

Episode 59: Neurology Clerkship Shelf Review Part        188

Episode 65: Ventilator Physiology for the USMLEs        195

Episode 94: Rapid Review, Series 1, Peds        196

Episode 95: Rapid Review, Series 2, Peds        198

Episode 97: “Most Important ”        200

Episode 100: The Clutch Micro        201

Episode 102: The “Clutch” cancer podcast (IN PROGRESS)        206

Episode 102: The “Clutch” cancer podcast (Version 2)        210

Episode 104: ACLS, Arrhythmias, and HY Cardiac Pharm        219

Episode 111: The “Clutch” Pharmacology Podcast Round 1        221

Episode 112: The “Clutch” Pharmacology Podcast Round 2        233

Episode 118: Confusing Breast Pathologies        248

Episode 119: Rapid Review Series 3 (IM)        248

Episode 120: Rapid Review Series 4 (IM/Peds)        250

Episode 121: Rapid Review Series 5 (IM/Peds)        252

Episode 123: Ethics I        254

Episode 125: Rapid Review Series 6 (IM)        256

Episode 126: Rapid Review Series 7 (IM)        258

Episode 127: Rapid Review, Series 8 OB/GYN        259

Episode 128: Rapid Review Series 9 (IM)        260

Ep 129: (Targeted Pulmonary Review)        262

Episode 130 : Rapid Review Series 10 (Peds)        270

Episode 131: Rapid Review Series 11 (OB, Psych, IM, Neuro)        273

Episode 132: Weird topics of Social Sciences        275

Episode 132: Weird topics of Social Sciences (Version 2)        279

Episode 134: Rapid Review Series 12 (IM / Cardiology)        286

Episode 135: The Clutch Electrolytes        288

Episode 137: Next Best Step In Management Series 1        293

Episode 138: The Clutch Genetic Disease        298

Episode 141: Rapid Review Series 13 (IM)        304

Episode 143: Biostats Review        308

Episode 145: Rapid Review, Series 14, Surgery        320

Episode 153: Rapid Review, Series 15, Surgery        321

Episode 156: Rapid Review, Series 16, OB/GYN        323

Episode 158: Rapid Review, Series 17, Surgery        324

Episode 159: Rapid Review Series 18 (IM)        325

Episode 161: The Clutch Antibody        327

Episode 163: Rapid Review, Series 19, Surgery (Abdomen)        330

Episode 164: The Clutch Toxicology Podcast (Drugs of abuse, overdose, withdrawal, toxidromes)        334

Episode 166: Rapid Review Series 20 (Psych)        339

Episode 167: Rapid Review Series 21 Cardio        341

Episode 169: Clutch Nephrotic/Nephritic Syndrome        344

Episode 169: Clutch Nephrotic/Nephritic Syndrome (Version 2)        345

Episode 173: The Clutch Immunodeficiency Diseases Podcast        348

Episode 174: Rapid Review Series 22 (IM)        352

Episode 175: Rapid Review Series 23 (Psych)        354

Episode 177: Rapid Review Series 24 (OGBYN)        357

Episode 180: Hematology        359

Episode 181: Comprehensive NBME Emergency Medicine Shelf Review Series 1        360

Episode 182: Comprehensive NBME Emergency Medicine Shelf Review Series 2        373

Episode 183: Comprehensive NBME Emergency Medicine Shelf Review Series 3        376

Episode 184: NBME weird        389

Episode 187: Rapid Review Series 25        394

Episode 189: Rapid Review Series 26        397

Episode 195: Rapid Review Series 27        401

Episode 196: Rapid Review Series 28        404

Episode 197: Bias in Biostatistics        406

Episode 198: Clutch Hypertensive Integrations.        408

Episode 199: Rapid Review Series 29        411

Episode 202: Rapid Review Series 30        414

Episode 203: Leukemia and Lymphoma        417

Episode 204: Military Part 1        419

Episode 206: Family Medicine Shelf Review Series 1        420

Episode 207: Geriatrics        425

Episode 207: Geriatrics (Version 2)        426

Episode 208: Transfusion Reactions        428

Episode 209: Family Medicine Shelf Review Series 2        430

Episode 210: Rapid Review Series 31        431

Episode 211: Rapid Review Series 32        433

Episode 212: Family Medicine Shelf Review Series 3 (GI)        436

Episode 213: Family Medicine Shelf Review Series 4 (GI)        439

Episode 214: Family Medicine Shelf Review Series 5 - GI        441

Episode 214: Family Medicine Shelf Review Series 5 - GI (Version 2)        445

Episode 215: Acetylcholine and The NBME        446

Episode 217: Family Medicine Shelf Review Series 6 - Pulm        449

Episode 217: Family Medicine Shelf Review Series 6 - Pulm (Version 2)        453

Episode 219: Rapid Review Series 34        454

Episode 220: Rapid Review Series 34        457

Episode 221: Trauma        461

Episode 223: NBME Peds Shelf Add-On: The HY Newborn        462

Episode 224: Genetic Diseases 2: Chromosomes        467

Episode 225: Rapid Review Series 35        472

Episode 226: Iron labs        474

Episode 227: Rapid Review Series 36 (OBGYN + Others)        475

Episode 228: CLEAN-SP 1 Palliative        477

Episode 230: CLEAN-SP 2 Quality/Safety        478

Episode 231: Military Part 2        479

Episode 232: Vasculitis        481

Episode 233: Shock        483

Episode 233: Shock (Version 2)        485

Episode 234: CLEAN-SP 2 Medication/Transition of Care        486

Episode 237: (HIV)        488

Episode 238: Rapid Review Series 37        490

Episode 239: OBGYN Risk Factors        492

Episode 240: Rapid Review Series 38 (Ortho and OBGYN)        493

Episode 242: Dermatology Part (1 of 3)        495

Episode 243: Water Soluble Vitamins        499

Ep 244: (Cardiac Valvular Disorders)        501

Ep 245: (Rapid Review Series 39)        506

Ep 246: (Derm Part 2 of 3)        508

Ep 247: (Rapid Review Series 40)        513

Ep 248: [New Free 120 Q1-10 (2020)]        516

Ep 249: (Blood Oxygen Content and the USMLEs)        519

Ep 250: [HY Vaccine]        522

Ep 251: [The HY Thyroid Podcast]        526

Ep 252 [Post Exposure Prophylaxis and the NBMEs]        530

Ep 253 [Starling Forces and The NBMEs]        532

Ep 255 [Legendary Step 2CK/3 Pharmacology]        533

Ep 256 [Rapid Review Series 41]        537

Ep 257 [Clutch Bilirubin Podcast]        539

Ep 258 [Rapid Review Series 42]        542

Ep 259 [Clutch Incontinence Podcast]        545

Ep 261 [USMLE Derm Part 3 of 3]        547

Ep 262 [Clutch TB]        550

Ep 263 [Clutch CNS Infection]        553

Ep 265 [Male Reproductive Pathologies and the USMLEs]        556

Ep 268 [Clean SP 4 - (Palliative Care 2)]        559

Ep 270 [Rapid Review Series 43]        562

----------------------------------------------------------------------------------------------------------------------------

Episode 17: Peds Diseases of The Pediatric Population Part 1.

GI PROBLEMS IN KIDDOS

• 7 yo Asian male w/ chronic watery diarrhea + stool positive for reducing sugars + positive hydrogen breath test → lactose intolerance = lactase deficiency

• Tx:

• Infant: soy-based formula
• Child: Avoid lactose

• 23 mo w/ bowed LE (vit D def) + diffuse blistering rash over patellae (dermatitis herpetiformis)  + diffuse muscle wasting + MCV 60L (iron deficiency), serum Ca+ 7.1L → celiac disease

• Dx:

•  tTG-IgA   *but IgA deficiency is common
• If IgA deficient → check gliadin Ab (IgG)
• Duodenal bx: flattening of microvilli, intraepithelial lymphocytes

• Tx:

• Avoid gluten
• Vitamins
• For dermatitis herpetiformis: dapsone

• Caution in G6PD deficiency

• IgA deficiency

• Anaphylactic transfusion reaction (type I hypersensitivity rxn)

• 8 mo drinks cow milk, causes bloody stool → milk protein allergy

• Outgrown by age 1
• Tx: formula with casein hydrolysate

• 5 yo kid w/ chronic constipation, immigrant from South America, rectal exam is accompanied by an explosive expulsion of poop → Hirschsprung's disease

• Failure of neural crest cell migration to distal colon
• Dx: distal colon biopsy w/ absence of Auerbach’s plexus
• Tx: resect affected bowel, end-to-end anastomosis
• Association: Down syndrome
• Mimic: Trypanosoma cruzi (Chagas) destroys enteric nervous system → megacolon

• 18 mo w/ recent URI, now with severe abdominal pain & bloody diapers + RLQ mass → intussusception

• Pressure necrosis of bowel if not corrected quickly
• Lead point for telescoping: Mecklel’s diverticulum, hyperplasia of Peyer’s patches in terminal ileum
• Dx:        

• US w/ target sign
• Air enema (diagnostic & therapeutic)

• Tx: surgery is air enema not effective
• If a kid gets septic after air enema? Think bowel perforation, do XR (see free air under diaphragm), give abx & straight to OR

• 4 yo with 12 hrs of severe abdominal pain and n/v + WBC 13k + US w/ echogenic material (likely fecolith) in the RLQ and fat stranding

• Dx: Appendicitis

• How to dx: US (Kid)

• PE findings (challenging / not always given in Peds population vignettes)

• McBurney’s point tenderness
• Psoas sign
• Obturator sign (pain with internal rotation of hip)
• Rovsing’s sign (palpation of LLQ → pain in RLQ)

• Tx: IVF, broad-spectrum abx (e.g. amp + gent + clinda/metro OR ceftriaxone + metro), lap appy
• Complications: abscess, perforation

GENETICS REVIEW

• Myotonic dystrophy → trinucleotide repeat disorder

• CTG repeat

• Fragile X Syndrome → trinucleotide repeat disorder

• CGG repeat

• Angelman → maternal deletion or paternal uniparental disomy (both chromosomes from dad)
• Prader-Willi Syndrome → paternal deletion or maternal uniparental disomy (both chromosomes from mom)
• Beckwith Wiedemann Syndrome → imprinting disorder of chromosome 11, can be caused by paternal uniparental disomy
• Trisomy 21 → maternal nondisjunction or unbalanced robertsonian translocation
• Mom passing a disease to all her kids → mitochondrial inheritance

• Ex: MELAS (Mitochondrial Encephalopathy, Lactic Acidosis, and Stroke-like episodes)
• Ex: MERRF (Myoclonic epilepsy with ragged red fibers)
• Ex: Leber's hereditary optic neuropathy & other optic neuropathies

CHROMOSOME DISORDERS

• Down’s syndrome = Trisomy 21

• Genetic pathophysiology?

• maternal nondisjunction (failure to separate in meiosis I or II)
• Robertsonian translocation (RT)

• Early onset neuro dz? Alzheimer dz (presenilin is on chromosome 21)
• Classic hematologic malignancy? ALL (TdT positive)

• “ALL fall Down”

• Considerations before beginning sports? Cervical XR to screen for atlanto-axial instability
• Hand findings? Single palmar crease
• Common cardiac defect? Endocardial cushion defects (endocardial cushion derived from neural crest)
• Common GI defects?

• Hirschprung’s
• duodenal atresia (bilious vomiting, double bubble)
• pyloric stenosis (first 8 weeks of life, non-bilious vomiting, olive-shaped mass, erythromycin exposure increases risk)

• Maternal quad screen findings

• High beta-hcg & inhibin A
• Low AFP & estriol
• “HIGH” → Hcg & inhibin are high

• How many chromosomes are found in a RT carrier (balanced RT)? 46
• How many chromosomes are found in a patient with Downs Syndrome from a RT (unbalanced RT)? 46

• Prominent occiput + overlapping digits + clenched fists + rocker bottom feet → Edward syndrome (trisomy 18)
• Microcephaly + cleft lip/palate + polydactyly + rocker bottom feet → Patau syndrome (trisomy 13)
• 5 yo M with a long face, large ears, and large testicles → Fragile X syndrome

• CGG repeat
• Inheritance? X-linked, trinucleotide repeat

• Genetic anticipation (worsens with each generation)

• Dx: FMR1 genetic testing
• Psych association: ADHD, Autism
• Neuro association: mild intellectual disability, seizures

• Most common cause of inherited ID in the US!

• Tall male + Gynecomastia + Infertility + no facial hair → Kleinfelter syndrome

• Karyotype? 47XXY

• Female with a low posterior hairline, webbed neck, congenital lymphedema or cystic hygroma, and short stature → Turner syndrome

• Karyotype? 45X
• Aortic pathologies? Bicuspid aortic valve → early AS, coarctation of the aorta → hypertension in arms & hypotension in legs
• Renal pathology? Horseshoe kidney
• How can the short stature be corrected? Give growth hormone
• How can the development of secondary sexual characteristics be promoted at puberty? Give estrogen
• What is the “kind” of hypogonadism associated with this disorder? hypergonadotropic hypogonadism (streak ovaries → no estrogen → no negative feedback → high LH/FSH)
• As an aside, what is the male equivalent (similar findings) of Turner’s syndrome? Noonan syndrome

• Is this disorder only present in males? NO!
• What is the mechanism of inheritance? AD
• Genetic mutation? PTPN11 mutation
• What is one good “cardiac clue” on exams to help with differentiating this counterpart from Turner’s syndrome? RVOT problems (e.g. pulmonic stenosis)

IMPRINTING DISORDERS

• Male with short stature, obesity, small testicles & penis, huge appetite → Prader-Willi syndrome

• Neonate: hypotonic, feeding difficulties, cryptorchidism
• Paternal chromosome is usually “on”, maternal chromosome is imprinted
• Deletion of paternal chromosome

• “Prader has no papa”

• Maternal uniparental disomy

• Female with ataxia, small face, uncontrollable laughter → Angelman syndrome

• Maternal chromosome is usually “on”, maternal chromosome is imprinted
• Deletion of maternal chromosome

• “M” in AngelMan for Mom

• Paternal uniparental disomy

VACTERL / CHARGE / CATCH-22 ASSOCIATIONS

• VACTERL association

• V = vertebral
• A = anal atresia
• C = cardiac defect
• TE = TE fistula (often with esophageal atresia)
• R = renal defect
• L = limb defect

• CHARGE association

• C = coloboma (keyhole defect in iris)
• H = heart defect
• A = atresia of the choanae (blue but pinks up when they cry)
• R = retardation
• G = GU anomalies
• E = ear anomalies

• CATCH-22 association? DiGeorge syndrome = velocardiofacial syndrome

• Failure of 3rd and 4rd pharyngeal pouches, derived from endoderm, to develop normally
• Cardiac abnormality (commonly interrupted aortic arch, truncus arteriosus and tetralogy of Fallot)
• Abnormal facies (e.g. micrognathia)
• Thymic aplasia (no thymic shadow on newborn CXR) → T cell deficit → viral & fungal deficits
• Cleft palate & cognitive deficits
• Hypoparathyroidism → hypocalcemia → seizure and/or QT prolongation
• 22q11 deletion

----------------------------------------------------------------------------------------------------------------------------

Episode 19: Neurology Shelf review part 1

• Brain tumor that causes loss of “vertical gaze” → pinealoma (causes Parinaud’s syndrome)

• Pathophys? Compression of superior colliculus, which is the vertical conjugate gaze center

• 13 mo child with history of hypopigmented macules + seizures. → tuberous sclerosis

• Hypopigmented macules = ash leaf spots
• Associated seizure syndrome? West syndrome (infantile spasms)

• EEG finding? Hypsarrhythmia
• Tx? ACTH or vigabatrin
  

• Most common primary brain tumor in kids → pilocytic astrocytoma

• Histology? Rosenthal fibers
• Marker? GFAP (glial cell marker)
  

• Medulloblastoma

• Location? Cerebellar vermis
• Histology? Homer-Wright rosettes
  

• Brain tumor presenting as hydrocephalus → ependymoma

• Histology? Perivascular pseudorosettes or ependymal rosettes
  

• Brain tumor causing visual problems in kid → craniopharyngiomas

• Derived from? Rathke’s pouch
• Imaging? Calcified suprasellar mass
• Complications?

• Bitemporal hemianopsia (2/2 optic chiasm compression)
• Anterior pituitary hormone deficiencies (2/2 pituitary stalk/gland compression)
  

• MC cause of brain tumor in adults → metastasis

• Location? Grey-white junction
• Imaging? Multiple well-circumscribed lesions
  

• Most common primary brain tumor in adults → GBM

• Imaging? Butterfly-shaped mass that crosses corpus callosum + edema + central necrosis
• Marker? GFAP (glial cell marker)
• MC brain tumor excluding mets

• Bilateral acoustic neuromas

• Pathophys? Schwannoma of CN8
• Location? Cerebellopontine angle

• #1 MC tumor at cerebellopontine angle → acoustic neuroma
• #2 MC tumor at cerebellopontine angle → meningioma

• Tumor marker? S-100
• Associated syndrome? NF-2
  

• Brain tumor that presents as parasagittal mass along falx cerebri → meningioma

• Histology? Psammoma bodies (“laminated calcifications”)
  

• 2 yo child with abdominal mass that crosses midline + myoclonus + weird eye movements + calcified mass on imaging → neuroblastoma

• Alternate location: posterior mediastinum
• Associated syndrome?

• NF-1
• Beckwith-Weideman syndrome

• Neuroblastoma / Wilms tumor / hepatoblastoma
• Hemihypertrophy
• Macroglossia
• Enlarged abdominal organs
• Abdominal wall defects
• Hypoglycemic seizure in newborn

• Pathophys? hyperplasia of beta cells of pancreatic islets

• 2 yo child with abdominal mass that does not cross midline + no calcifications → Wilms tumor
• Frontal lobe tumor → oligodendroglioma

• Histology? fried egg appearance

• Brain tumor that produces EPO → hemangioma blastoma

• Associated syndrome? VHL syndrome
• Treat because they can cause a life-threatening hemorrhage!

• Recent viral illness + vertigo + tinnitus → labyrinthitis
• Feeling like room is spinning with positional changes + nystagmus with provocative maneuvers → BPPV (caused by otolith displacement)

• Diagnostic maneuver? Dix-Hallpike
• Tx? Epley / Semont maneuver

• Anesthesia over medial thigh + weak thigh adduction → obturator nerve injury

• Nerve roots? L2-L4
  

• Anesthesia over lateral thigh → lateral femoral cutaneous nerve injury

• 7 yo kid with ataxia + hypertrophic cardiomyopathy + LE hyporeflexia → Freidrich’s ataxia

• Pathohpys?

• GAA repeats → LOF mutation in frataxin gene (iron binding protein) → iron overload causes oxidative damage

• Destruction of dorsal columns of spinal cord → hyporeflexia
• Cerebellar destruction → ataxia

• Inheritance? AR

• Unlike other trinucleotide repeat disorders, which are AD

• Repeat? GAA
• MC cause of death? CHF 2/2 hypertrophic cardiomyopathy

• 35 yo F with a BMI of 35 with visual difficulty and severe intermittent headaches. She takes tetracycline for acne. → idiopathic intracranial hypertension (“pseudotumor cerebri”)

• Imaging/Procedure Mgmt:

• 1st step? Fundoscopic exam → shows papilledema
• 2nd step? Head CT → is normal
• 3rd step? LP → shows elevated OP

• Tx?

• Weight loss
• Acetazolamide (carbonic anhydrase inhibitor)
• Serial LPs
• VP shunt

• Tx for severe visual difficulties? optic nerve fenestration (relieves pressure)
• Triggers?

• Tetracyclines (i.e. female patient getting acne tx)
• Vit A derivatives

• Management of ischemic stroke (caused by blockage w/i blood vessel)

• Initial imaging? Non-contrast head CT to DDx ischemic stroke vs. hemorrhagic stroke b/c blood looks just like contrast ☺
• Next imaging? MRI
• Time window for tPA administration? 3-4.5 hrs

• Up to 6 hrs if you can inject tPA directly into involved vessel

• HY contraindications to TPA administration

• Bleeding disorder
• GI bleeding
• Recent brain surgery

• Blood pressure management?

• Permissive HTN (BP up to 220/120) in patients with ischemic strokes only in pt’s that cannot NOT get TPA

• Why? Increased BP keeps vessels perfused, which optimizes blood flow to ischemic penumbra of brain

• If getting tPA, BP < 185/110
• If hemorrhagic stroke with high BP, can lower BP with labetalol, nitroprusside, nicardipine

• 78 yo has 15 min episode of complete vision in one eye that has since resolved. → amaurosis fugax (TIA)

• Classic presentation? Painless loss of vision in one eye, “curtain coming down”
• Dx?

• Non-contrast head CT
• Brain MRI
• Echo (to look for origin of clot)
• Carotid US

• NBSIM? Probably carotid US on shelf exam
• Prevention of further episodes?

• Aspirin
• Aspirin + dipyridamole
• If aspirin contraindicated, clopidogrel

• Indications for carotid endo

• >70% stenosis
• Symptomatic

• #1 modifiable RF for a stroke? HTN

• 6 yo M with difficulty walking + uses arms to “walk up” his legs/thighs (Gower’s sign) + hypertrophy of calves bilaterally. → Duchenne muscular dystrophy

• Gene? DMD
• Mutated protein? Dystrophin (stabilizes sarcolemma to cytoskeleton)
• Inheritance? X-linked recessive
• Dx?         

• Increased creatine kinase levels
• Genetic testing for dystrophin gene mutation

• Tx?

• Steroids
• High-calorie nutrition

• MC cause of death? Respiratory failure or cardiac causes

• Muscular dystrophy + intelligence + life expectancy in the 50s → Becker muscular dystrophy

• Pathophys? Have some functional dystrophin
• Gene? DMD
• Mutated protein? Dystrophin
• Inheritance? X-linked recessive

• Ataxia + confusion + ophthalmoplegia → Wernicke encephalopathy

• Reversible
• Imaging? Hemorrhagic infarct of mamillary bodies
• Pathophys? Vitamin B1 deficiency
• Function of which enzyme affected? Transketolase in pentose phosphate pathway

• Decreased transketolase activity

• Tx? IV thiamine then glucose
• Note: “ophthalmoplegia” means eye problem; pt’s with Wernicke-Korsakoff can have any eye problem, e.g. nystagmus, lateral gaze palsy, etc.

• Complication of untreated Wernicke encephalopathy? Korsakoff syndrome

• Irreversible
• Sxs: ataxia + confusion + ophthalmoplegia + amnesia + confabulation 

• 40 yo F with diplopia or droopy eyelids worse at end of day + difficulty swallowing + weird speech → myasthenia gravis

• Pathophys? Antibodies to post-synaptic nicotinic ACh receptor
• Dx? anti-AChR or anti-MUSK Ab testing

• NOT edrophonium test/Tensilon test (no longer standard of care)

• Tx? AChE inhibitors (e.g. pyridostigmine)
• Associated malignancy finding? Thymoma (anterior mediastinal mass)
  

• NBSIM for patients with myasthenia gravis? CT chest to look for thymoma

• b/c removal of thymoma can resolve myasthenia gravis
  

• Smoker with proximal muscle weakness that improves with use → LEMS

• Pathophys? Antibodies to presynaptic voltage-gated Ca++ channel

• Lateral medullary syndrome (Wallenberg syndrome) causes dysphonia, dysphagia, and loss of gag reflex

• Blood vessel occluded? PICA occlusion
• Loss of pain and temperature on left face → L trigeminal nerve
• Loss of pain and temperature on right side of the body→ L spinothalamic tract

• Located in lateral brainstem
• Decussates at anterior white commissure → contralateral sxs

• Absent gag reflex, dysphonia, dysphagia → CN9/10

• Medulla

• Vertigo → CN8

• Pons/Medulla

• Ptosis and miosis on left (Horner’s) → L sympathetic tract to superior cervical ganglion        

• Located in lateral brainstem

• Medial medullary syndrome causes tongue deviation to ipsilateral side

• Blood vessel occluded? Anterior spinal artery occlusion
• Right sided paralysis → L corticospinal tract

• Runs through medial brainstem
• Decussates at level of medullary pyramids

• Tongue deviation to the left. → L CN12

• Tongue deviation to ipsilateral side

• A 35 yo African American female with 3-day history of eye pain. Funduscopic exam is notable for conjunctival erythema and miosis. CBC is notable for increased ACE levels and Ca2+ of 12.9. CXR with bilateral lymphadenopathy. What is the cause of her eye symptoms? → optic neuritis 2/2 sarcoidosis

• Exam finding? APD + pain with eye movements (this is optic neuritis!)
• Another condition a/w optic neuritis? Multiple sclerosis

• 35 yo F with tremors in her hands bilaterally that are worsened by stretching out her hand. Better with alcohol. → benign essential tremor

• Inheritance? AD
• Tx?

• Beta blocker (e.g. propranolol)
• Barbiturates (e.g. primidone)

• Mechanism? Increase duration of opening of chloride channels → hyperpolarization

-------------------------------------------------------------------------------------------------------------------------------

Episode 21: Comprehensive Pediatric 3rd Year Shelf Review

• CrouP treated with raCemiC ePinephrine
• Seizure disorders by age range

• Baby w/ hypsarrhythmia → West Syndrome (tuberous sclerosis)
• KId 2-6 yo → Lennox-Gastaut
• Teenager → JME

• Associations with eosinophils

• Erythema toxicum neonatorum
• Chlamydia pneumonia

• Empiric tx of neonatal sepsis per WHO? Ampicillin + gentamicin

• ID, low BW, microcephaly, high pitched cat like cry → cri-du-chat
• Obesity, infantile hypotonia, ID, small extremities, Cr 15 deletion → Prader-Willi
• Happy mood, ID, inappropriate laughter, ataxia, Cr 15 deletion (mom) → Angelman syndrome
• “Elfin facies”, short upward turned nose, long philtrum → Williams syndrome
• X-linked, CGG repeat, anticipation, long face, large ears, ID, macroorchidism → Fragile X
• Short palpebral fissures, thin upper lip, smooth philtrum, microcephaly, VSD → FAS
• Tricuspid valve displaced downward, RV hypoplasia → Ebstein’s anomaly (Li toxicity(
• Lateral neck mass that does not move with swallowing, derived from ectoderm → branchial cleft cyst
• Midline neck mass, moves with swallowing, may have ectopic thyroid tissue → thyroglossal duct cyst
• Hypopigmented macules identified with Wood’s lamp, shagreen patches, adenoma sebaceum (face), infantile spasms, subependymal nodules in brain, cardiac rhabdomyooma, renal angiomyolipoma → tuberous sclerosis

• Severe fasting hypoglycemia, lactic acidosis, hepatomegaly, gout, may have kidney sxs (since this also does gluconeogenesis), no muscle sxs, give cornstarch → Von Gierke disease (GSD type 1)

• Deficiency of? Glucose-6-phosphatase
• V for “very bad”
• Also remember the two L’s (liver only & lactic acidosis)

• Glycogen storage disease associated with heart failure and death at < 2 yo → Pompe disease (GSD type 2)

• Deficiency of? Lysosomal alpha-glucosidase = acid maltase
• P for “pump”

• Mild hypoglycemia, hepatomegaly, muscle sxs, no lactic acidosis → Cori disease (GSD 3)

• Deficiency of? Debranching enzyme
• C for “combined” (muscle & liver sxs)

• No lactic acidosis, muscle weakness, no hepatomegaly → McArdle’s dz (GSD type 5)

• Deficiency? glycogen phosphorylase (removes one glucose from the chain)
• M for “muscle”

• High-yield lymphadenopathy

• Anterior cervical → strep
• Posterior cervical → mono
• Posterior auricular & suboccipital → rubella
• Unilateral → Kawasacki

• Ostium primum defects associated with Down’s

• Ostium primum is down by the endocardial cushions so this makes sense

• Transposition of the great vessels associated with (pre-existing) maternal diabetes

• “Egg on a string” on CXR

• Truncus arteriosus associated with DiGeorge
• Tricuspid atresia

• Need ASD + VSD OR ASD + PDA
• LAD on EKG

• Tetralogy

• Squatting helps during Tet spells because it increases SVR (which decreases the R to L shunting)

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Ep 22 [OBGYN Shelf Review]

22 y/o G1P1 visits her obstetrician 1 week after delivering a 6 lb 4 oz boy. Delivery unremarkable. Apgars * and ( at 1 and 5 minutes. Plans to have her next baby when she graduates from graduate school 2 years from now. In addition to routin screening for post partum depression, what is the next best step in the management of this patient?

• Best answer is injectable bc you don’t want to give estrogen in this OCP-> this will cause difficulty breastfeeding. MOA’s- progestin only contraceptives- protect ag endometrial cancer, thicken cervical mucus. CI - If you have a malignancy that is progestin receptor + (lobular carcinoma in situ, invasive lobular carcinoma)- avoid progestin containing contraceptives. Side effect of injectables- can cause weight gain, reversible decrease in bone mineral density

Treat mastitis with dicloxacillin

Breast feeding = high prolactin state. Prolactin-> Shutting down HPG axis-> less production of “stuff” that causes breast cancer-> = decreased risk of breast cancer, decreased ovulation (destroying ovarian epithelium less)-> less risk of ovarian cancer. Helps to lose pregnancy weight.

Breast feeding contraindications

• If lady has active TB, HIV- do not breast feed

• Galactosemia- galactose 1 phosphate uridyl transferase deficiency - definite CI to breastfeeding

• Mastitis- NOT a breast feeding contraindication. She SHOULD breast feed bc this will help clear the infection

Q2

• 22 y/o female is tearful 3 days after delivery = post partum blues. Just reassure. Usually see in first 2 weeks of delivery.
• 22 y/o is brought to ED by husband 3 days after delivery. Sees a radio taped to her head, she claims she is receiving information from outer space about how sacrificing her baby will help solve world hunger. = postpartum psychosis. This is an indications for involuntary hospitalization, prescribe antipsychotics. High risk of infanticide if you do not involuntarily hospitalize her
• 22 year old female comes to 3 week post partum appt. She looks disheveled, and occasionally has thoughts of hurting the baby, which she feels remorseful about. She is breastfeeding, but no longer enjoys activities she loves before she got pregnant. She is accompanied by supportive husband. = post partum depression. See this more than 2 weeks after delivery, can see in immediate period after delivery as well.

Q3

4 days after c section of a 9 lb female, a 33 y/o G2P2002 complains of abdominal pain. Vitals are normal (BP-120/80, HR 99, Resp 19). She is febrile. She has diffuse lower abdominal tenderness and foul smelling lochia. C section was due to arrest in active pahse of labor. Most important risk factor in this presentation? = endometritis, biggest risk factor is c section (more so than maternal infection prior to delivery) - tx = clind + gent

• Do not confuse endometritis with chorioamnionitis. More important risk factor here is prolonged rupture of membranes. This will be a patient with fever during labor, fetal tachycardia, foul smelling lochia. Tx- amp + gent. Amp covers listeria. Give IV oxytocin to help deliver baby faster.
• Listeria- if you see a lady with a stillborn and abscesses all over the body, this may be granulomatosis infanticeptica = congenital listeriosis. Can kill the baby in utero.
• Rupture of membrane >18 hr- give GBS ppx

Diagnosing and dating pregnancy

• Check BhCG in urine or serum- serum shows up a week before the urine

• When is checking bhcg the NBSIM?

• Woman has ammenorrhea
• s/s ectopic pregnancy

• Date

• First day of LMP + 7 days, subtract 3 months, add 1 year

• GTPAL - G4P3104

• G = gravidity, how many times you have been pregnancy
• T = # of term pregnancies
• P= # preterm pregnancy
• A = # abortions
• L = # living children

Q4

Do you want to be a pregnant millionaire??

• blue/purple vagina = chadwick’s sign
• Blotchy pigmentation of the face = melasma
• Arterial BP in first 20 weeks- should go down bc of high levels of progesterone, a smooth muscle relaxant-> decrease in SVR. may get higher after first 20 weeks, but shouldnt get higher than before you were pregnant
• Plasma volume goes up. Think of birth as a bloody experience- the body prepared for this by boosting up moms plasma vol by 50%
• SVR- decreases bc progestin
• Oncotic pressure- decreases. Albumin goes down in the blood too
• CO- increases bc increased volume = increased preload

• Decreases when supine- uterus is compressing the IVC

• Nonreassuring fetal heart tone- tell mom to lay in LLD position

• RBC mass- goes up by 30%

• Hematocrit - a concentration measure. RBC mass is not increasing as much as plasma volume, so hematocrit is decreased- this is Physiologic anemia of pregnancy

• Coagulation factors- increase. You can think of this as mum is bound to bleed out a lot during birth, so lets make it easier to clot to prevent massive blood loss

• In general, every protein in the bloodstream increases during pregnancy, with the notable exception of Albumin

• Gastric motility- high levels of progestin-> smooth muscle relaxation-> decreased motility, increased gastric emptying time, GERD
• Acid base- see alkalosis. If mom is alkalotic relative to the fetus, it creates a gradient for the fetus to dump CO2 into mom’s circulation across the blood placental barrier.
• Tidal volume- increases
• Ureter size- consider progestin-> dilation. This could contribute to increased stasis  + increased UTI’s in pregnancy
• BUN/Cr- both decrease. If elevated, this is a concerning sign

• If blood volume is increasing, your hydrostatic pressure is increasing in the glomerulus
• GFR + cr clearance should go up

• Glucose and protein in the urine- increase. Transport maximum for glucose  in the PCT goes down in pregnancy. Very mild proteinuria is fine.
• Pituitary size- should double in size. If lady bleeds out a lot during delivery, hypoperfusion of pituitary can occur, = ischemic stroke of pituitary gland (sheehan’s syndrome). Presentation = failure to lactate after pregnancy
• Size of thyroid- increases. You need thyroid for proper fetal development

• Estrogen- increases synthesis of thyroxine binding globulin, so TBG goes up, and total thyroid hormone levels will go up, free thyroid levels are normal.

• BHcg - doubles every 2 days- increases until 10 weeks, then levels off/ tapers somewhat

Q5

32 y/o female 36 w gestation comes to ED because she hasn’t felt her baby move for 6 hours. Physical exam shows 37 cm from tip of pubis to top of uterus, no fetal heart tones detected on doppler u/s. Rest of exam is within normal limits. BP 105/78, HR 78, RR 16, mildly febrile. In addition to patient centered counseling and physician empathy, NBSIM? = induction of labor with IV oxytocin. Do not postpone delivery- retained fetal products can lead to DIC. NEVER do a c section- risk of surgery isnt worth it.

Q6

25 y/o primigravida at 10 weeks gestation presents for a first prenatal visit. Maternal exam and VS wnl. Maternal hgb is 11 g/dL. WBC = 6,000. Pap smear 5 months ago is unremarkable. Rubella titers WNL. HBV Surface antibody +,  surface antigen negative. Core antibody negative. HIV/syphillis/chlamydia all negative. NBSIM?. Urinalysis- screen for ax bacteriuria. Progestin effect causing ureter dilation and stasis-> increased risk UTI’s. Asx bacteruria can progress to pyelo if unnoticed. tx - normal non preg female- wouldnt treat asx bacteriuria unless it was complicated. In preg woman- tx with nitrofurantoin, amoxicillin, phosphomycin. If pyelo, give IV ceftriaxone. Pyelo can increase risk of preterm delivery- maintain this lady on nitrofurantoin for the rest of the preg. After treating, perform a test of cure.

• Do not give preg ladies excessive Vitamin A or live vaccines. Give folate.

Q7

What is the most appropriate time frame for the following interventions/prenatal tests

• rh d immune globulin in an rh negative female

• 28 w

• GBS swab

• 35-37 w

• Screen for gestational diabetes - 1 hour gtt, confirmatory is 3hr.

• 24-28 ish w
• Tx- diet, exercise, insulin is probably first line though
• ACOG- beginning to feel more comfortable using metformin and glyburide

• Chorionic villus sampling

• 10-13 w

• Screening u/s for neural tube defects

• 18-20

• Amniocentesis, quad screen

• After 15 w

• In the question stem, mom will be concerned about her baby’s risk of chromosomal problem etc- will give w of pregnancy in the q- use this to rule answers out.
• ***doing an invasive procedure that mixes mom and baby blood like this- give Rh d immunoglobulin!
• More info on prenatal testing

• Elevated AFp- think neural tube defect. Also see elevated acetylcholinesterase in the amniotic fluid. May also occur in abdominal wall defect, i.e. omphalocele/gastroschisis

• MCC- incorrect dating

• See increased level of inhibin A + bhcg, afp/estriol is decreased - think Downs. Arises from maternal nondisjunction, robertsonian translocation
• See decreased inhibin A, bhcg, AFP/estriol all low. Kid has rocker bottom feet, overlapping digits and toes.
• Quad screen is + -Get an u/s
• Lecithin : sphingomyelin is 2+, this is a sign of lung maturity.

If a lady has a history of 2nd trim painless preg loss, i.e. from cervical insufficiency- can place a cerclage. But, cerclage means CI to exercise

Gestational DM

• From human plactental lactogen- a diabetogenic hormone. Its job is to create hyperglycemia in mom so that she can shunt more energy to the fetus. GDM can cause macrosomia, polyhydramnios (AF >25)- (baby will have hyperglycemia, and will make more urine). When baby is delivered, no longer is exposed to hyperglycemia. Their pancreas will keep making insulin-> triggers hypoglycemia-> seizures. Also can have seizures from hypocalcemia
• Baby Cqx from GDM vs DMII mom

• Chronic DMII

• Kids have cardiac probs, i.e. hypertrophic Cm
• Fusion of legs (sirenomelia)
• Sacrum doesnt develop right= caudal regression syndrome
• Hypocalcemic seizures
• >4500g - recommend elective c section

Q8

Recommended weight gain from preg

• BMI underweight- gain 28-40 lb
• BMI 23- gain 25-35 lb
• BMI overweight- gain 15-25 lb
• BMI obese- 11- 20 lb

Q9

• 39 year old female with mood swings, amenorrhea for the past year. Has severe episodes of intense sweating and palpitations once or twice daily. Meds include levothyroxine, on physical, see skin hyperpigmentation. = premature ovarian failure

• Ovaries stop working-> estrogen goes down-> FSH/LH goes up because there is no negative feedback
• Tx menopause-

• dyspareunia- lubricant, vaginal estrogen to build back up vaginal epithelium.

• Vaginal estrogen is CI if  Hx of Estrogen responsive malignancy

• Osteoporosis (estrogen increases synthesis of osteoprotegrin- this binds up RANKL which decreases activation of osteoclasts.). Supplement Ca, VD, bisphosphonates (first line in osteoporosis), raloxifene (a SERM in the breast and uterus, agonist in bone!)

• Obesity is a protective factor for osteoporosis. Anorexics will have increased risk of osteoporosis.

• Obesity will also increase risk of osteoarthritis

• Severe menopausal sx- (use short course 6 months) HRT, used combined estrogen and progestin to have less problems.

• CI- If lady has estrogen responsive malignancy, hx of strokes, migraine with aura, hepatic adenoma

• 19 y/o female presents with intense anal pruritis. Physical exam reveals erythema of the vulvovaginal area. She recently completed a course of ciprofloxacin for lobar pneumonia.  She has a hx of DMI and pH of vaginal secretions of 4.3. KOH prep shows spores and structures resembling hyphae = candida

• Trich and gardnerella- pH >4.5.

• BV from gardnerella- see fishy smell, KOH shows clue cells. Take metronidazole, counsel not to take alcohol concurrently- dont want disulfiram effect from inhibition of acetaldehyde dehydrogenase
• Dont need to treat partner for candida or gardnerella
• Trich- treat partner as well to prevent recurrence. Tx with metro

• Punctate hemorrhages (strawberry cervix), frothy green foul smelling discharge

• Metro can treat GET GAP: Giardia, Entamoeba, Trich, Gardnerella, Anaerobes belows the diaphragm, Protozoal infections

• Risk factors for candida- immunosuppression, diabetes, recent antibiotic use
• Tx- antifungal cream, or oral fluconazole

Q10

34 y/o female at 10 weeks gestation is brought to ED by husband, who is concerned about her severe vomiting for the past week. Physical exam shows skin tenting, >20 mmHg change in BP from supine to standing position, weighs 131 lb (recorded in chart at 140 lb 3 months ago). Further testing would reveal- a hypokalemic hypochloremic metabolic alkalosis (hyperemesis gravidarum)    

• She is losing a lot of acid with vomiting, becomes hypochloremic. Losing acid = alkalotic. Volume down = RAAS activation-> principle cells ENAC transporter is working a lot-> excrete more K in the urine-> hypokalemia. If you increase activity of the proton ATPase pump, the a intercalated cells of the nephron, see alkalosis due to this as well because you are dumping more protons in the urine.
• She has lost more than 5% of her prepregnancy weight- this qualifies her for hyperemesis gravidarum.
• Tx - ondansetron, metochlopromide. Replace electrolytes, NBME likes thiamine

• Eat small frequent meals, take vitamin b6 and doxylamine

Q11

26 year old female presents to obstetrician for yearly check up. PMH hypertension controlled with captopril and LSM. vitals WNL. BMI 23. Mirena IUD implanted 18 months ago, wants it removed. Got married 3 months ago, plans to have kids. Pap smear 2 years ago. In addition to routine guidance, and recommendations and appropriate vitamin supplementation, NBSIM? = switch captopril to alphamethyldopa.

• pap smear- good bc its q3 years from 21-29 years
• Captopril- not good for pregnant woman, its a teratogen. So are ARBs
• Chronic hypertension- HTN before you are pregnancy
• Gestational hypertension- >140/>90 after 20 w pregnancy, no proteinuria

• Tx- “Hypertensive moms Love nifedipine”- Hydralazine, Methyldopa, Labetalol. Nifedipine

• Pre eclampsia- gestational hypertension + proteinuria

• Pathophys is unk- recognize phrases like endothelial dysfunction, formation of abnormal blood vessels
• Risk factors- most important = prior hx of preE

• PreE q/ severe features- they have some kind of end organ dysfunction, i.e. increasing BUN, Cr, LFTs, or BP is >160/>110

• Consider Mg at this pt for seizure prophylaxis.
• Check DTR’s- decreased is a telltale sign of Mg toxicity-> could lead to resp depression, CV collapse and die

• Rescue agent for Mg toxicity= calcium gluconate

• PreE w/ seizure= Eclampsia

• Tx- #1 mg. If mg doesnt work, give short acting benzo.
• Definitive treatment- delivery

• HELLP

• Hemolysis, elevated LFT, low platelets

Q12

Most common teratogen for each birth defect

• Hypoplasia of RV, downward displacement of tricuspid valve (atrialization of RV), mom is treated for bipolar.

• = epstein anomaly due to lithium toxicity
• Firstline med for mania in pregnancy is haloperidol

• Tooth discoloration

• Tetracyclines

• Cartilage damage

• Fluoroquinolones

• Stippling of epiphysis,  dont use this anticoagulant in a pregnant lady with DVT

• Warfarin

• Clear cell adenocarcinoma of the vagina

• DES (diethylsilbestrol)- assoc with t shaped uterus

• Renal probs in the fetus

• ACEi/ARBs

• Gray baby syndrome

• Chloramphenicol- because neonates have very low levels of UDP glucuronysyl transferase, can not metabolize the drug

• Kernicterus

• TMP-SMX

• Smooth philtrum, microcephaly,

• FAS

• IUGR, hypoplastic nails, microcephaly, cleft lip

• Phenytoin- fetal hydantoin syndrome

• Most dangerous anti epileptic/highest risk of neural tube defect

• Valproic acid

G13

21 y/o female comes to PCP with severe facial acne. LMP 1 w ago. Stable relationship with BF of 3 months, use condoms inconsistently. See open and closed comedones clustered around patient’s lower face. Trials of tetracycline, benzoyl perized, and combined OCP yielded no positive results. Smokes 2 cigarettes a day. Requests prescription of isotretinoin. Most likely CI to isotretinoin = unprotected sex control.

• Isotretinoin prescription requires 2 forms of birth control
• 35 y/o female that smokes/hx of migraine with auras, hx thromboembolic disease, hepatic adenoma- any of these- OCP with estrogen isnt a good option
• See jittery newborn that is inconsolable- think opioid withdrawal- give methadone, taper
• Cocaine use in pregnancy can cause abruptio placentae- painful third trimester bleeding

• Use acetaminophen in pregnancy- using cox inhibitors can trigger premature closure of the ductus arteriosus.  

G14

29 y/o G3P2 becomes unresponsive 15 min after delivering a 3900 g newborn. BP- 40/palpable, HR 40, RR 6, O2 sat 78%. See blood oozing from a venipuncture site = amniotic fluid embolism

Q15

Breast triggers

• 44 year old male treated for class 3 HF with gynecomastia

• Spironolactone- is an aldosterone receptor antagonist, but also has androgen receptor blocking activity

• 32 y/.o 4w postpartum has fever, breast tenderness, and erythema-

• Mastitis, tx with antistaph penicillins, i.e. dicloxacilin

• 22y/o with multiple mobile breast masses, become more painful and wax/wane in size with cycle

• = fibrocystic changes

• 23 y/o female with solitary, mobile, well defined nontender breast mass

•  fibroadenoma

• Bloody nipple discharge

• Intraductal papilloma

• 49 y/o female with large breast mass, core needle bx reveals structures of leaf like projections on histology        

• Phyllodes tumor

• BRCA mutation assoc with male breast cancer

• BRCA 2

• Most common location of breast cancers

• Upper outer quadrant

• Whats the receptor positivity most commonly found in LCIS

• ER/PR+

• Most common invasive breast cancer

• Invasive ductal carcinoma

• 55y/o female that presents with a breast mass, physical exam reveals peau d’orange

• Inflammatory breast cancer

• 55y/o presents with an eczematoid scaly appearing lesion around the nipple

• Paget’s disease of the breast

• Is there a difference in survival between lumpectomy + radiation or mastectomy for early stage breast cancer

• NO

• NBSIM in female with DCIS with + sentinel LN bx

• Do axillary LN dissection

• ER/PR + breast cancers tx

• Tx- SERMS, aromatase inhibitors (anastrozole)

• Treat Her2Neu+ malignancies

• Trastuzumab

• 45 y/o female with hx breast cancer tx had JVD, EF of 35%

• Due to trastuzumab. This is reversible
• If due to doxorubicin/daunorubicin- HF will be irreversible

• Preventable with iron chelator dexraroxane

• 55 y/o female with 10 year hx of lymphedema from axillary LN dissection has weight loss, purplish necrotic ulcerating mass on L arm

• Lymphangiosarcoma

• Breast cancer is floridly high yield- its very scenario based. The answers can vary from different sources. These answers are primarily from his best judgement from ACOG and online, but you should use your best research and email Divine questions

**core needle bx = excisional bx if the mass if small, well circumscribed

Q16A

• 45 y/o female has a palpable L breast mass she noticed when she took a shower 1 week ago.

• NBSIM = mammogram first.  Since she is older than 30, you do mammo first rather than u/s
• Diagnostic mammo is negative-> do a core needle biopsy

Q16B

• 25 y/o female with breast pain- LMP started 3 days ago. PE shows multiple mobile breast masses. NBSIM- reassure, schedule follow up for a few weeks

Q16C

• 25 y/o presents to yearly gyn appt with complaint of a palpable breast mass she noticed while taking a shower.

• See immobile, painless mass located close to the nipple. No FMH of breast cancer. NBSIM-get u/s
• See immobile, painless mass located upper outer quadrant of breast. U/S shows solid mass. NBSIM- get a core needle bx
• See immobile, painless mass located upper outer quadrant of breast. U/S shows cystic mass. NBSIM- get an FNA, send fluid for cytology, get a f/u u/s in a few weeks

• If FNA were bloody, send it for cytology and do a core needle bx
• If non bloody cyst recurs, get a core needle bx

Q16D

• American cancer society guidelines- screening mammos starting at 40 y/o annually. Divine says this is more reliable
• USPFTF guideline- start at 50, get q2y.
• Women with BRCA mutations get these mammos and also MRIs of the breast. Can do a prophylactic total abdominal hysterectomy and bilateral salpingo oophorectomy to prophylaxis ag breast, ovarian, and endometrial cancer.

Q17

33y/o G2P1 female presents to L&D at 34w gestation due to consistent uterine contractions. Last preg required classical c section due to severe obesity. As resident walks into the room, pt begins to complain of severe abdominal pain. Pelvic exam is notable for copious amounts of blood from vaginal canal. FHR shows HR of 33. Pt has hx cocaine use with current preg. ML Dx- uterine rupture

• NBSIM- crash c section
• Other common presentations of uterine rupture- palpating fetal parts in the abdomen, loss of fetal station
• Approach to third trimester bleeding

• Painless

• Placenta previa- low implantation of placenta
• Vasa previa- bb’s blood vessels overlie the cervical os

• Deliver baby soon, this is an obstetric emergency

• Painful

• Uterine rupture
• Abruptio placentae- see mom with cocaine use

Postpartum hemorrhage

• Definition according to ACOG- Blood loss >500mL after vaginal />1,000mL after c section
• Causes- “tone, tear, tissue, thrombin, topsy turvy”

• MCC- uterine atony

• Etio- Uterus is over worked in rapid labor, prolonged labor, uterus infection, gave too much tocolytics, multiple gestations, polyhydramnios, macrosomia
• NBSIM - uterine massage under u/s guidance

• IV oxytocin to contract it down

• Can also give methergin

•  (serotonin receptor agonist, like triptans- if a lady has a history of vasospastic angina or reynaud’s phenomenon, you should not give methergin)

• Can give Carboprost (Hemabate)

• Dont give to person with hx of asthma

• Can give dioprostone - PG2 analog

• Also Keeps PDA open
• Avoid it in women with profound hypotension

• B lynch sutures- “like suspenders on the uterus”

• Lacerations

• Risk factors - precipitous delivery, difficult delivery i.e. shoulder dystocia, operative vaginal delivery.
• Tx- surgery

• Retained placental tissue

• More common when a succenturiate lobe of placenta is present, with an invasive placenta (placenta accreta)
• Tx- d&c

• DIC
• Uterine inversion

• Causes- weak myometrium, pulled too hard on uterus

• Big risk factor- prior inversion

• Presentation- pulling out placenta, see a bluish bulge from the vagina
• Tx - replace uterus, give IV oxytocin to contract it back into place

• PPH treatments when all else fails

• Ligate uterine arteries, internal iliacs
• All else fails- hysterectomy

• Complications

• Sheehan’s syndrome vs apoplexy

• Apoplexy- think of it as a hemorrhagic stroke of the pituitary
• Sheehan’s- ischemic pituitary stroke

Menorrhagia

• PALM COEIN- Structural vs non structural causes of uterine bleeding (can cause IDA!)

• structural        

• Polyps
• Adenomyosis

• Symmetric, painful, soft

• Leiomyomas = fibroids

• Presents as asymmetric nodularity of the uterus. Usually painless, firm.
• Can be palpable on physical exam, can detect on a transvaginal u/s
• Tx- OCp to regulate the HPG axis, NSAIDS if painful
• If this lady wants to get pregnant in the future, perform a myomectomy. If she is postmenopausal, can perform a hysterectomy

• Before surgery, you can give continuous Leuprolide to shrink the tumors- they are estrogen responsive

• Can give tranexamic acid - helps to bleed less

• Malignancy and hyperplasia

• Non structural

• Ccoagulopathy
• Ovulatory dysfunction (PCOS)
• Endometrial causes
• Iatrogenic
• Not yet defined

• Other alphabet soup

• Metrorhagia- bleeding between periods

• Think of a metro bus coming more often

• Polymenorrhea- bleeding occurs <21 days apart
• Oligomennorhea- bleeding occurs > 35 days apart
• Hypomennorhea- regularly times menses with very light flow
• Menometrorrhagia- heavy bleeding at irregularly timed intervals

• Life threatening hemorrhage

• Type and cross, 2 large bore IVs, IVF, transfuse as needed
• IV estrogen is first line
• Consult OBGYN

Q18

27 y/o G0P0. annual gyn exam. no abnormal pap smears. Over the past decade, she has had irregular periods. Married for past 3 years. Unprotected intercourse every other day, has not become pregnant. Physical shows male pattern hair growth around chin, no evidence of clitoromegaly. BMI 35. BP 150/102. Requests referral to dermatologist for long standing hyperpigmentation under breast and axilla since 6 months ago = PCOS

• Dx PCOS is clinical. Need 2/3 criteria- 1. Polycystic ovaries on u/s 2. Evidence of hyperandrogenism (hirsut). 3. Need objective sign of anovulation/ can also see insulin resistance, LH:FSH ratio elevated- not required for sx, but supportive.
• r/o other causes of hyperandrogenism
• Tx

• Clomiphene- an ER partial agonist.-> shut down estrogen negative feedback->  This can increase GnRH-> encourage ovulation and fertility
• OCP

• regulates HPG axis
• Estrogen can increase synthesis of Sex hormone binding globulin (SHBG)-> binds testosterone!-> decrease testosterone levels, decreasing hirsut sx!!

• Spironolactone

• Helps with hyperandrogenism
• Helps with hirsut- inhibits 5a reductase (testosterone-> DHT) in the skin

• Metformin + LSM for insulin resistance

• Longstanding PCOS complications

• Metabolic syndrome antecedents (stroke, MI)
• Infertility (this is the most common cause of infertility due to ovulatory factors)
• Endometrial hyperplasia/cancer

• If you see a 39 y/o lady with abnormal bleeding and 5 y history of PCOS- think about getting an endometrial bx!!

Postmenopausal bleeding from the vagina- think of endometrial cancer. NBSIM - endometrial biopsy.

Q19

32 presents to L&D at 37 weeks gestation with consistent moderately painful uterine contractions. Pregnancy is complicated by hx diabetes. FHR normal. Offered elective c section due to macrosomia, but she insisted on having a natural birth. During second stage of labor, baby’s anterior shoulder is stuck under the pubic symphysis, the baby is successfully delivered after repeated traction on the shoulder and arm, and maternal maneuvers i.e. hip flexion. This increases risk of injury to = C5-C6 roots of the brachial plexus (erb duchenne palsy)

• Waiters tip deformity- kids hand is pronated, elbow extended, wrist is flexed

• Dont confuse with klumpke’s palsy- this is C8-T1

• Shoulder dystocia- is an obstetric emergency (fetal hypoxia)
• Manuevers

• Apply suprapubic pressure
• Mcrobert’s maneuver = flex hips
• Mom on all fours
• Zavanelli maneuver if all else fails- push the child back into the uterus and do a c section

FHR tracings

• HR

• Normal- 110-160
• <110 = fetal bradycardia
• >160 = fetal tachycardia

• Accelerations

• Rise in HR of 15 BPM for at least 15 seconds
• 2 of these in a 20 min period = positive NonStress Test -> expectantly manage

• Absence of this-> proceed to Biophysical Profile

• 5 components- NST, amniotic fluid index (5-25), breathing, movement, tone. Each is 2 points.

• Score of around 4- bad sign, thinking about delivery of some sort

• Variability

• The squiggles- should be present

• Abnormal tracings- refer to vodcast

• Early decel- not normal, but its benign. Gradual decrease and increase of FHR, in phase with maternal contraction. Caused by head compression. Reassuring tracing
• Variable decel- is a more abrupt change of FHR. caused by umbilical cord compression. Non reassuring tracing, may want to deliver
• Late decel- gradual downslope and increase of FHR that is out of phase with maternal contractions- caused by Uteroplacental insufficiency

• NBSIM- increase perfusion of placenta-> mom in LLB position

• Deliver soon

• If you think a FHR tracing is abnormal, first determine if it is an abrupt change or not (is most likely variable). If it is gradual, ask if it is in phase with maternal contraction. In phase = early decel, not in phase = late decel
• Sinusoidal wave = fetal anemia

• May want to do PUBS to check for anemia, can also transfuse with PUBS1

• VEAL CHOP

Q24

15 y/o primigravida complains of severe morning sickness and vagina bleeding. Vomiting for hourse every day, has lost 15 lb since LMP 8 weeks ago. Is taking benadryl to help with the nausea. BP is 140/98, RR is 18, HR is 103. TVUS reveals central heterogenous mass in the uterus. Having a solid hyperechoic area interspersed with a multitude of cystic areas. BHcg is positive. NBSIM = suction curretage (molar pregnancy/hydatidiform mole)

• solid hyperechoic area interspersed with a multitude of cystic areas = snowstorm appearance
• Partial mole

• 2 sperm fertilize 1 egg (triploid). Has some fetal tissue. Less Bhcg than complete moles. Could theoretically progress to choriocarcinoma, but lesser risk than complete mole.

• Complete mole

• 2 sperm fertilize an empty egg, or 1 sperm fertilizes an empty egg and duplicates its genetic material. diploid
• No fetal tissue. Produces a lot more bhcg. Much more likely to progress to choriocarcinoma.

• Moles- See size-dates discrepancy, hyperemesis gravidarum.

• Hyperemesis gravidarum is due to BHcg!
• Patient should be on birth control for 6 month- want to see Bhcg go to 0 to ensure no recurrence.

Psammomma bodies- can be described as laminating calcficications

• Assoc with papillary thyroid cancer, meningioma (assoc with neurofibromatosis, around falx cerebri), serous cystadenoma/carcinoma

Q25

2 months after a suction curretage, the patient begins to have vaginal bleeding, SOB, and very high bhcg-NBSIM = CXR. this is choriocarcinoma. Most common area of mets = lungs, then brain

• Tx- methotrexate- dihydrofolate reductase inhibitor.

• Side effect- severe bone marrow suppression- add leucovorin, a folinic acid analog
• f/u- birth control for 1 year so that we can detect recurrence

• Choriocarcinoma can present as hyperthyroidism bc BHcg and TSH share a common alpha subunit, along with FSH/LH. TSH will be low, thyroid hormone levels will be high

Q26

29 y/o G2P1 female presents for first prenatal visit at 10w gestation. RhD negative. Anti immune globulin is negative. NBSIM- give RhD immune globulin at 28 w

• If pt was instead having a + RhD immune globulin titer- NBSIM = check Rh- status

• If dad is RhD negative, baby can not be Rh +, nothing to worry about.
• If dad is RhD pos/unk

• Check for fetal anemia by checking doppler u/s of middle cerebral artery of the fetus- baby is hypoxic, and tries to combat this by increasing cardiac output. if you have increased flow in the middle cerebral artery, you should be worried about fetal anemia.

• Can do PUBS and transfuse

Q27

35 y/o female with hx of 4 c sections presents with painless vaginal bleeding at 32 w gestation. NBSIM- u/s first. If you did a vaginal exam first, you are at risk of worsening the bleeding.

• Placental previa- is likely in the setting of many c sections bc of the increased amounts of scar tissue- this is the #1 RF

• If you detected it at 30/31 weeks- do NOT need to proceed to delivery now bc placental location can change!

• Pelvic rest (stop having sex), give steroids, Mg if <32w to protect ag cerebral palsy (neuroprotection)

• If you detected it at 36 ish weeks, plan a c section. Dont want vaginal delivery with possible life threatening bleeding.

Q28

37 y/o G2P1 with prior hx c sections has severe bleeding after the second stage of labor, ultimately requiring a hysterectomy. Intraop evaluation of the uterus reveals an

• adherence of the placenta to the myometrium = accreta

• Invasion of the placenta in the myometrium = increta
• Invasion of bladder = percreta

23 y/o G2P1 rushed to the OR after FHR revealed multiple persistent late decels, her pregnancy has been uncomplicated. The OBGYN resident noticed severe vaginal bleeding after membranes were ruptured = vasa previa. Do crash c section.

Q29

• 32y/o G2P1 at 34 w gestation is the only survivor of an MVA. she is brought to the ED. she complains of abdominal pain. Trans abdominal u/s is unremarkable. Pelvic exam reveals blood emanating from the cervical OS. hx poorly controlled BPs, heavy cocaine use. Last OBGYN visit was at 10 w gestation = abruptio placentae. Do an emergency c section
• 25 y/o G2P1 at 38 w gestation has been on L&D for the past 24 hours after her water broke. Microscopic eval of vaginal fluid has a ferning pattern. Pt has no uterine contractions. =  Premature rupture of membranes and prolonged ROM. give oxytocin to help mum along.
• More alphabet soup

• Normal ROM- first contractions, then ROM, then see positive ferning on microscopy of vaginal fuid or confirm w nitrazine
• PROM- premature rupture of membranes- membrane ruptures before contractions start
• PPROM - preterm premature ROM- <37w preg.
• PPPROM - prolonged preterm premature ROM. PPROM when the water has been broken for an >24h , (text book definitions differ on exact amount of hours).

• Give mom ampicillin or penicillin for the prolonged rupture of membranes to prevent GBS
• <34 weeks give dexamethasone to promote fetal lung maturity
• <32 weeks give Mg to decrease risk of fetal cerebral palsy

• Fibronectin test “in two weeks baby will come”, good negative predictive value for preterm labor
• Cant delay preterm labor for more than 24-48 hrs. Give mom steroids, Mg, tocolyse w terbutaline (b2 agonist) cAMP  goes up in smooth muscle causing relaxation bcof inhibiting myosin light chain kinase

• Mg is NOT a preferred tocolytic
• No indomethacin after 32 weeks

• Bacterial Vaginosis, multiple pregnancies, and prior hx of preterm labor all increases risk of preterm labor  

• Also having a bicornuate uterus bc paramesonephric ducts didnt fuse

Q30

hypoplastic fetal lungs + amniotic fluid index <2cm + facial, skin, and limb defects =

Potter Sequence arises secondary to  bilateral renal agenesis leading to oligohydramnios

Oligohydramnios can also be described as a newborn with fullness in suprapubic area, think posterior urethral valves

Polyhydramnios: anencephaly, neural tube defect, mom didnt take enough folate, maternal diabetes, duodenal atresia, esophageal atresia (think VACTERL)

Maternal Diabetes: If baby is hyperglycemic, filters more sugar at the level of glomerulus leads to fetal polyuria leads to polyhydramnios

Duodenal Atresia: double bubble, hx of down syndrome

Q31

Mom’s size>date + Quad screen high AFP and B-hcg+ splitting of embryo on day 10 after fertilization + 2 babies are born, one anemic and SGA other baby is polycythemic, volume overloaded and has signs of heart failure=

Twin Twin Transfusion. Monochorionic, diamniotic. Know these on Ultrasound

Earlier split of embryo (days 0-4) dichorionic diamniotic,  day (4-8)  monochronic diamniotic (MD), day 9-12 monochorionic, monoamniotic, day 13+ conjoined twins monochorionic, monoamniotic.

Q32

 22yo lower abdominal pain and vaginal bleeding. LMP 7 weeks ago, PMHx of PID. smokes a pack of cigs a day. ---> ectopic pregnancy

Risk Factors: PID: scarred fallopian tubes. Smoking: decreased motility of fimbriae of oviduct Hx of tubal ligation: not 100% effective. Prior Hx of ectopic

Most common location of an ectopic is in ampulla of fallopian tube

If hemodynamically unstable w ectopic→ proceed to surgery

If hemodynamically stable and beta-hcg is <5000 → give methotrexate AVOID if bad kidneys or liver in mom

Hemodynamically stable, you suspect an ectopic pregnancy,  beta hcg + (<1500) → may not see a gestational sac on ultrasound. You should recheck in two days. If beta hcg has doubled (or more) in those two days that is a good sign for an intrauterine pregnancy (get an U/S) to confirm

If beta hcg >1500 but you dont see a gestational sac, this is diagnostic of an ectopic pregnancy.

Q33 Spontaneous Abortion

Vaginal bleeding, closed os, viable fetus on ultrasound: threatened abortion

Vaginal bleeding, closed cervical os, no viable fetus on u/s: missed abortion

Vaginal bleeding, open cervical os, intact gestational sac on u/s: inevitable abortion

Vaginal bleeding, open cervical os, some products of conception visible on u/s: incomplete abortion

Vaginal bleeding, open/dilated cervical os, no products of conception visible on u/s; complete abortion

<20 weeks, perform a D&C, can also use uterotonic like oxytocin

ethics : be supportive and empathetic, but need to get the baby out SOON

Septic abortion: give broad spectrum antibiotics, perform urgent D&C

>20weeks its called Intrauterine Fetal Demise. In general, dont perform a D&C on these, perform a dilation and evacuation. NO C Section

 painless, 2nd trimester losses from cervical insufficiency-->think about placing a cerclage

        Contraindication to exercise

        Classic Hx: previous LEEP procedure

Q34 What is the most likely bug?

1. Chorioretinitis, hydrocephalus, intracranial calcifications, cat litter, give folate inhibitors (pyrimethamine/sulfadiazine) = Toxoplasmosis (if mom has infection in pregnancy, give spiramycin)
2. Slapped cheek rash, arthritis in adults, anemia +/- fetal hydrops → Parvovirus B19 (single stranded DNA virus, slapped cheek rash) infects erythroid precursor cells
3. Fetus born with scarred skin, hypoplastic limbs, life threatening pneumonia, mom had a generalized, vesicular, blistering rash in different stages of healing during pregnancy → Herpes 3 VZV (potentially give acyclovir)
4. Mom consumes deli meats/soft cheeses, stillborn fetus, abscesses in hear, liver, spleen, give ampicillin→ Listeria (granulomatosis infantiseptica)
5. Cataracts, deafness, machine like murmur in a newborn w blueberry muffin rash → Rubella
6. Periventricular calcifications in the fetus, sensorineural hearing loss with jaundice, hepatosplenomegaly → CMV
7. Prevent infection by a scheduled C section, give AZT during intrapartum period → HIV
8. Give acyclovir prophylaxis starting at 36 weeks if infection with → HSV.

1. Visible herpes lesions on vagina→ C section
2. No visible lesions → vaginal delivery

9. Sloughed skin of hands and feet, nasal secretions in neonate, later in life kid has a prominent forehead, collapsed nasal bridge, Hutchison teeth, and anterior tibial bowing →  Syphilis. Snuffles in newborn* wear gloves when touching snuffles.

1. If mom has syphilis in pregnancy but is penicillin allergic… give PENICILLIN. De-sensitize mom.

10. Cause of a notable infection in first 28 days of life → GBS (S. agalactiae)

Q35

1. 67yo female presents with a 1yr history of anogenital pruritus, exam reveals large, ivory white patches on the vulva with extension to the perineum. What is the next best step in management?

Get a biopsy. Most likely lichen sclerosus, but could be cancer. Treat lichen sclerosus with a steroid like clobetasol

2. 60yoF presents with a large adnexal mass that is resected. A pathological specimen reveals psammoma bodies (lamellated calcifications ) → serous cystadenocarcinoma
3. 39yoF 1 yr hx of severe adnexal pain for several days during her menstrual cycle, diagnostic laparoscopy revels what appears to be walled off “dark brown” material → endometrioma (chocolate cyst)
4. 15yoF presents to the ED with severe, sudden onset abdominal pain, a large mass was palpated in the abdomen by her OBGYN 2 yrs earlier, resection biopsy reveals teeth and hair → dermoid cyst. Teratomas present as anterior mediastinal masses contrast with neural tumors like a neuroblastoma that tends to present in the posterior mediastinum
5. 10yoF is being evaluated for precocious puberty. u/s reveals an ovarian mass (may present with Call Exner bodies) → granulosa cell tumor tumor marker is estrogen
6. 10yoF is being evaluated for virilization, ovarian mass on u/s, testosterone is 10x the upper limit of  normal→  leydig cell tumor
7. Early menarche, nulliparity, and late menopause (increase or decrease) the risk of ovarian cancer? More cycles,increases risk of ovarian cancer.
8. Tumor markers  for yolk sac tumors? AFP (and hepatocellular carcinoma)

1. Choriocarcinoma? Beta hcg
2. Granulosa cell? Estrogen

Q36

44yoF schedules an appt with her Gyn 3 months after her annual checkup. She has felt irritable and moody for the past 9 weeks and often has to change her nightgown as a result of severe night sweats. Physical exam is notable for mild pretibial edema. Vitals are notable for mild tachypnea. The patient is in a good relationship with her husband of 20 years. She has regular, 30 day menstrual cycles although she has recorded no flow for the past two cycles. What is the next best step in management?

Measure serum beta hcg. She may be pregnant!!

Male and Female Sexual Development

Male, XY, Y chromosome has sex determining region, results in formation of testes. Testes contain two cells, one of which is the  Leydig cell that produces Testosterone. Testosterone can be converted to DHT by 5 alpha reductase. DHT virilizing the external genitalia. Testosterone is a “survival factor” for the Wolffian Duct. Testosterone thus promotes differentiation of epididymis, vas deferens and seminal vesicles. The second kind of cell in the testes is the Sertoli cell that produces MIH, mullerian inhibiting hormone. Recall mullerian duct is NOT a precursor to ovaries, mullerian duct will eventually form the uterus, upper ⅓ of vagina, and fallopian tubes. Sertoli cells also produce inhibin which acts as a negative feedback mechanism on the anterior pituitary decreasing the release of FSH.

Q37 Primary Amenorrhea- 13yo no secondary sex characterisitics or 16yo with secondary sexual characteristics with no menses

• 20yoF has breasts and a uterus. All levels of hormones are normal → imperforate hymen (some kind of obstruction
• 20yoF model or hardcore athlete has breasts and a uterus. What would be true of her hormone levels?   All low hypogonadotropic hypogonadism
• 20yoF breasts, no uterus, testosterone levels are high. → Androgen Insensitivity Syndrome
• 20yF, breasts, no uterus, karyotype reveals 46 XX →  mullerian agenesis. MRKH
• 20yoF, no breasts, has a uterus, cant smell→ kallman syndrome hypogonadotropic hypogonadism as well
• 20yoF, 3’ 5” tall, low posterior hairline, widely spaced nipples, high blood pressure in arms, low blood pressure in legs, no breasts, has a uterus→ turner syndrome. No breasts bc low estrogen (bc of streak ovaries)
• 20yoF, uterus, no breasts, visual field defects → hyperprolactinemia or craniopharyngioma

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Episode 26: USMLE Radiology

Slides

-   Bamboo Spine: Ankylosing spondylitis: HLA-B27 Pos + assoc with sacroiliitis

-   Apple core lesion: Colon cancer 55 yo M with heme stools with Hb of 6.9

o   IDA in pt > 50 - colonoscopy

-   Bird’s beak : Achalasia – dysphagia to solids and liquids

-   Boot heart: TOF – child born with hypocalcemic seizures. Assoc with down syndrome and Digeorge

-   Sunburst/ Codman’s triangle : osteosarcoma  child with white reflex at birth (assoc with Rb)

-   Sail sign in anterior mediastinum in newborn : thymic shadow (absent in SCID , Digeorge)

-   Steeple sign = croup (stridor). Subglottic stenosis. Parainfluenza.

-   Thumb sign = epiglottitis. Supraglottic stenosis. H flu type B. next step: intubate

-   String sign = Crohn’s. Terminal ileum impacted.  B12 def/ megaloblastic anemia.

-   Target sign: Intussusception Red currant jelly stools in kid. Avoid rotavirus vaccine.

o   Currant jelly sputum in alcoholic = klebsiella

-   Target sign (2): Pyloric stenosis: nonbilious vomiting in newborn taking erythromycin

-   Coin lesion: lung malignancy. 12-200 pack year smoking history

-   Leather Water bottle stomach: Linctus plastic – diffuse gastric cancer. Assoc with h. pylori and with E-cadherin mutations.

o   13-50 Ib weight loss in a 6 month period

o   Histo – signet ring cells

-   Water bottle heart: pericardial effusion.  Can cause cardiac tamponade (becks triad), electrical alternans/ low voltage ekg.

-   Coffee bean = sigmoid volvulus. Severe abd pain and constipation

-   Onion skin :  Ewing sarcoma (11;22) 12 yo with 2 mo hx of fevers and leg pain.  Tx w/ dactinomycin

-   Double bubble: Duodenal atresia. This child has a history of Tri 21 + Bilious vomiting

o   Bilious = (stenosis distal sphincter of oddi)

o   Other HY t21 assoc: VSD, atlantoaxial instability (get lateral neck xray before sports), Alzheimer’s, Hirschsprung

-   Blueberry/ Berry sign: Berry aneurysm: Nasty headache in a patient with a hx of ADPKD. Most common location AComm > Pcomm.

-   Grape sign: Hydatidiform mole: severe hyperemesis gravidarum. Increased B-hcg → hyperemesis

-   Snowstorm appearance: Hydatidiform mole or molar pregnancy

-   Batwing: in pt with hx of CF: pulm edema

-   Butterfly: GBM: Severe headache over the past 6 mo. Type IV astrocytoma crossing corpus callosum. Central. necrosis and edema Tumor marker: GFAP.

-   Lead pipe colon: Ulcerative colitis: hint: also has a hx of Primary Sclerosing Cholangitis. Loss of haustral markings

-   Box heart: Ebstein’s anomaly (+mom took lithium when she was pregnant for BPD). Buzzword atrialization of right ventricle

-   Corkscrew esoph: diffuse esophageal spasm. Chest pain relief with nitroglycerin. Tx with nitrates or CCB. Intermittent dysphagia to solids and liquids

-   Egg on a string: TotGV: single s2. Newborn with cyanosis.

-   Honeycomb lung: IPF: 65 y/o M with 6 mo history of exercise intolerance: DLCo Dec.

o   Reticular opacities, ground glass opacities and honeycombing

-   Whirlpool spin: midgut volvulus. 3 month old with bilious vomiting.

-   3 sign: COTA. EG: Pt has history of turner’s syndrome. High BP in arms and no pulse in legs.

-   Snowman sign: TAPVR. Pulm veins drain into RA. newborn with cyanosis.

-   Signet Ring sign in lung: bronchiectasis. (pt may have hx of cystic fibrosis or ciliary dyskinesia)

-   Rachitic Rosary: Rickets> elevated PTH low CA and low Phosphate. Vitamin D def (secondary hyperparathyroidism)

-   Pencil and cup deformity: psoriatic arthritis. Seronegative spondyloarthropathies.

-   Ladder of GI tract: SBO can also be in LBO but classic for SBO

-   White out lung: ARDS . ICU pt on vent. Noncardiogenic pulm edema so PCWP <18. Tx with low TV and high PEEP

-   Ground glass opacities in the lung in preemie: Neonatal respiratory distress syndrome. Premie with Lecithin/sphingomyelin = 1

-   Bowel in thoracic cavity: congenital diaphragmatic hernia. Scaffold abdomen. Newborn with severe resp distress at birth. Kid will have lung hypoplasia.

-   NGT curling in upper thorax: esoph atresia with TE Fistula . MC is H type. Assoc with VACTERL. KNOW VACTERL and CHARGE.

-   Interstitial infiltrates in pt with CD4<200: PCP Give IV Bactrim, if not a choice possibly pentamidine.

o   Know criteria for steroids: Aa gradient> 35 or O2 <92% or PaO2 < 70 to avoid hypoxic respiratory failure

 Cross checked: Yes

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Old Version - Episode 29: 3rd Year Medicine Shelf Review Part 1

• Opening snap with diastolic rumble at left 4th interspace. Tall jugular venous A waves → tricuspid stenosis

• A wave represents atrial contraction.

• Contraction against increased resistance → taller A waves

• How can we increase the intensity of this murmur? Increase preload

• Leg raise
• IVF
• Inspiration

• How can we decrease the intensity of the murmur? Increase afterload

• Less flow across stenotic valve

• Elevated AST/ALT, blistering lesions on the dorsum of the hands, severe hirsutism. → porphyria cutanea tarda

• Deficiency enzyme? UROD (uroporphyrinogen decarboxylase)
• Tx? Phlebotomy

• Hypoglycemia, hypoglycemic sxs, resolution with glucose administration → Whipple’s triad

• Tumor? insulinoma

• Differentiating 3 big causes of hypoglycemia based on labs

• Insulin high + C peptide high + neg secretagogue screen → insulinoma
• Insulin high + C peptide low + neg secretagogue screen → exogenous insulin
• Insulin high + C peptide high + pos secretagogue screen → sulfonylureas

• The acute treatment of hypoglycemia

• juice/sugary drink
• glucagon injection (quickest way to acutely raise BG)

• Skin finding associated with glucagonoma → necrolytic migratory erythema

• Name the bug associated with the diarrhea

• Pork consumption → Yersinia enterocolitica
• Undercooked shellfish → Vibrio parahaemolyticus or Vibrio vulnificus

• Which has poor prognosis in pt with liver dz? Vibrio vulnificus

• Severe rice-water stools in a developing country → Vibrio cholera

• Tx? Oral rehydration solution + doxy

• Bloody diarrhea with a super small inoculum → Shigella
• Bloody diarrhea after consuming eggs/poultry → Salmonella enteritidis
• Watery diarrhea 2 hrs after consuming potato salad → Staph aureus
• Bloody diarrhea with low plts/unconjugated hyperbilirubinemia/elevated creatinine → E. coli O157:H7 or Shigella
• Diarrhea upon return to the US from Mexico → ETEC
• Foul smelling watery diarrhea after recent treatment for an anaerobic bacterial pneumonia → C. diff

• Prevention? Hand-washing
• Tx?

• 1st line: Oral vancomycin or fidaxomicin
• Metronidazole is no longer first-line
• Last resort: fecal transplant

• Crampy abdominal pain after consumption of home canned veggies → botulism
• Bloody diarrhea with ascending paralysis in a puppy owner → GBS 2/2 Campylobacter jejuni
• Watery diarrhea after eating fried rice at a Chinese restaurant → Bacillus cereus

• Empiric tx of diarrhea (if exam is making you pick abx)? Fluoroquinolones

• Alternative? Macrolides

• Prussian blue staining of a bone marrow smear reveals basophilic inclusions around the nucleus in a 75 yo M that lives in a home built in the 1930s. → lead poisoning

• Histology? Ringed sideroblasts
• Lab findings?

• Ferritin? High
• TIBC? Low

• Tx?

• Succimer = Dimercaptosuccinic acid (DMSA)
• EDTA
• Dimercaprol = British anti-Lewisite (BAL)

• Vit tx for sideroblastic anemia? B6

• ALAS (rate-limiting enzyme) uses B6 as a cofactor

• CXR showing diffuse, bilateral, ground glass infiltrates in a febrile patient taking high dose immunosuppressants. → PCP pneumonia

• Dx? BAL
• Relevant stain? Silver stain
• Elevated marker from pulmonary fluid? LDH
• Ppx? TMP-SMX for CD4 < 200

• Alternatives? Aerosolized pentamidine, dapsone, atovaquone

• Tx? TMP-SMX

• Steroid criteria?

• O2 Sat < 92% = PaO2 < 70
• A-a gradient > 35

• Flank pain with gross hematuria → nephrolithiasis

• MC cause of kidney stones
• Envelope shaped → calcium oxalate (X in oxalate like the paper folds of an envelope)

• Causes?

• Ethylene glycol
• Crohn’s → increased reabsorption oxalate

• Coffin shaped → struvite (magnesium-ammonium-phosphate)

• Bug? Proteus

• Urease-positive so makes urine alkaline → precipitates stones

• Hexagonal → cysteine (“SIXtine”)

• Cause? Cystinuria

• Pathophys? Defective transporter → cannot reabsorb the "COLA" amino acids (cysteine, ornithine, lysine, and arginine) in the PCT
• Tx? Acetazolamide

• Mechanism? Alkalinizes the urine & solubilizes the stones (cystine stones are acidic)

• Radiolucent → uric acid stones (U in radiolucent for U in uric acid)
• Dx? CT

• In pregnant woman? US

• Tx? Fluids + tamsulosin (alpha-1 blocker)

• For large stone? ESWL (extracorporeal shock wave lithotripsy)
• For giant struvite stone? Nephrostomy tube to drain tube + surgery

• 24 yo M presents with a painless, palpable bony mass on the left knee. Knee X ray reveals a contiguous mushroom shaped mass. → osteochondroma

• Contrast with osteosarcoma

• Tends to show up in kids on NBMEs

• Contrast with osteoid osteoma

• Pain in legs at night, relieved with NSAIDs

• 66 yo F is found unconscious at home by her daughter in December. PE is notable for a cherry red appearance of the skin. → carbonic monoxide poisoning

• Classic presentation? HA + AMS + cherry rid lips
• Associations? Winter, space heaters, garage suicide
• Pathophys?

• Occupies spots on Hgb & has 200x affinity
• Leftward shift of oxyhemoglobin dissociation curve → prevents Hgb from releasing O2

• NBS dx? Carboxyhemoglobin level
• Tx? Hyperbaric O2

• Mechanism? Reduces the half-life of CO binding to Hgb

• Neuroimaging finding? Hyperintense lesions in the globus pallidus

• Elevated creatinine 24 hrs after getting a CT scan. → contrast nephropathy

• Prevention? Hydration + N-acetylcysteine
• Other uses of N-acetylcysteine:

• Acetaminophen overdose
• Inhaled for CF patient (breaks disulfide bonds)
• Hemorrhagic cystitis 2/2 cyclophosphamide BUT mesna is first-line

• Virus that causes hemorrhagic cystitis? adenovirus
• Bug in pt from Egypt? Schistosoma haematobium

• Skin fibrosis after getting a brain MRI → nephrogenic systemic fibrosis

• Exposure? Gadolinium

• What DM medication that should be held before getting a CT scan? Metformin

• Why? Risk of lactic acidosis with renal dysfunction (which could happen after contrast exposure)

• A common lower extremity side effect associated with hydralazine and Ca channel blockers. → peripheral edema

• Pathophys? Dilation of precapillary arteriole
• Tx? ACE-I

• Mechanism? Dilation of post-capillary venule to decrease capillary hydrostatic pressure

• HIV patient with a 3 day history of fever presents with targetoid skin lesions, lip/mouth ulcerations, and visual impairment. PE is notable for skin sloughing (8% BSA). Nikolsky sign is +ve. He was placed on Allopurinol 10 days ago for chronic gout. → SJS

• What if there is > 30% BSA involvement → TEN
• NBS? STOP the drug

• 30 yo F presents with 3 day hx of polydipsia and polyuria. Blood glucose is 650 mg/dl, Bicarb is 21, pH is 7.35. → HHNS (Hyperglycaemic hyperosmolar non-ketotic syndrome)

• Contrast with DKA? Requires low pH & ketosis
• Why no ketosis in pts with T2DM? They still make insulin (they have insulin resistance) which inhibits glucagon and thus prevents DKA
• Tx? Fluids + insulin
• Na balance? Hyperosmolar hyponatremia

• Na correction: add 1.6 for every extra 100 of glucose
• E.g. glucose of 900 → add 1.6*8 = 12.8

• K balance?

• Serum K+ high
• Total body K+ low

• The patient becomes altered/comatose with rapid treatment. What happened? Cerebral edema 2/2 rapid lowering of glucose

• 49 yo F presents with wheezing and flushing. PE is +ve for murmurs consistent with tricuspid regurgitation and pulmonic stenosis. → carcinoid syndrome

• Mnemonic “Be FDR” = bronchospasm + flushing + diarrhea + R-sided heart lesions
• Mnemonic “TIPS” = tricuspid insufficiency + pulmonary stenosis
• Why R-sided heart lesions? Lungs metabolize serotonin
• If carcinoid is localized to the GI tract (e.g. appendix), there are no sxs because the liver metabolizes serotonin. When it’s metastatic to the liver, then the pt will start to have sxs
• Dx? urine 5-HIAA (metabolite of serotonin)

• If positive 5-HIAA, abdominal CT scan

• If no tumor found on CT → octreotide scintigraphy

• Tx? Can use octreotide to reduce sxs
• Vit deficiency? Niacin (B3) → pellagra

• Presentation? Diarrhea, dermatitis, dementia, death
• Pathophys? Tryptophan can be used to make serotonin and niacin. A carcinoid diverts all tryptophan to the production of serotonin, causing a niacin deficiency.

• Tumor of the thyroid that could present with diarrhea? Medullary thyroid cancer (calcitonin causes diarrhea)

• 61 yo M presents with exertional dyspnea. CBC is notable for a Hct of 27%. What is the next best step in management? Colonoscopy to r/u colon cancer

• Iron studies?

• Ferritin low
• TIBC high
• Transferrin sat low

• When is transfusion indicated?

• Hgb < 7

• What would your diagnosis be if the patient had a similar presentation and difficulty swallowing? Plummer–Vinson syndrome

• Triad = IDA + esophageal webs + atrophic glossitis (smooth red tongue)

• 29 yo F with a recent trip to India (ate local foods). Returned 2 weeks ago and initially had fevers for 1 week. Now presents with severe abdominal pain and distension. PE is notable for salmon colored circular lesions on the trunk. → Typhoid fever

• Bug? Salmonella typhi
• Tx? FQ

• Septic arthritis

• MC bug? Staph aureus
• Bug in sickle cell pt? Salmonella
• Bug in a young F with purpuric skin lesions? NG
• NBS? Arthrocentesis

• WBC count in joint fluid? >50k

• Tx? Joint washout + abx

• Tx for gonococcal arthritis? Ceftriaxone + doxy/azithro

• CT vs NG tx difference

• CT: just give azithro or doxy
• NG: ceftriaxone + azithro/doxy

• Treat empirically for Chlamydia

• Subconjunctival hemorrhage in a patient with nasty coughing episodes OR pt with post-tussive vomiting → pertussis

• Tx? Macrolide
• Ppx for close contacts? Macrolide
• Lab findings? Elevated lymphocytes

• NBSM for pt that recently started Ramipril for the treatment of HTN who has a cough? Switch to ARB

• Prolonged PR interval w/o dropped beats → 1st degree

• Tx? nothing!

• Progressive PR prolongation then dropped → 2nd degree Mobitz I/Wenckebach

• “Longer longer longer drop → Wenckebach”

• Fixed PR prolongation + dropped beats → 2nd degree Mobitz II
• P-P interval constant, R-R interval constant, no relation between P waves & QRS → 3rd degree
• Who gets a pacemaker?

• 2nd degree Mobitz II
• 3rd degree

• Acute management in decompensated pt? Transcutaneous or transvenous pacing + atropine
• Contraindicated medications?

• Beta blocker
• CCB (diltiazem/verapamil)
• Digoxin (has muscarinic agonist activity)

• Reduced EF in a patient with coarse facial features and enlarging fingers. → acromegaly

• Dx?

• 1st step: check IGF-1
• 2nd step: glucose suppression test

• Normal: glucoses causes suppression of GH release
• Failure to suppress → acromegaly

• 3rd step: MRI

• Tx? Transsphenoidal surgery

• Differs from prolactinoma (usually managed medically)
• Tx prior to surgery?

• Octreotide
• dopamine agonist (bromocriptine/cabergoline)
• Pegvisomant (GH receptor antagonist)

• MC cause of death? HF

• Dysphagia to solids and liquids in a patient with thick/thin blood smears (Giemsa) revealing what appears to be motile parasites. → Achalasia 2/2 Chagas

• Bugs? Trypanosoma cruzi
• Dx?

• Mnemonic “BME”
• 1st step: Barium swallow
• 2nd step: manometry
• 3rd step: endoscopy

• Imaging? bird’s beak sign
• Tx?

• Dihydropyridine CCB
• Botox injection
• Balloon dilation

• Adverse outcome? Esophageal rupture

• Heller myotomy (cut LES muscles)

• Manifestations of T. cruzi

• Achalasia → megaesophagus
• Dilated cardiomyopathy
• Destruction of myenteric plexus → megacolon

• Reduced MCV in a patient with a long history of untreated rheumatoid arthritis. → anemia of chronic disease

• Iron studies

• Ferritin high
• TIBC low
• Transferrin sat low (iron locked away in macrophages)

• Pathophys? Hepcidin → ron sequestration by bone marrow macrophages & reduced iron export by enterocytes

• 25 yo M with nasal packing presents with a BP of 65/40, elevated Cr, respiratory distress, T of 104, and marginally elevated troponins. → Toxic shock syndrome

• Pathophys? Superantigen production →
• Bugs? Staph aureus + Strep pyogenes
• Tx? Fluids (+/- pressors) + abx

• Sequelae of CKD

• Acid-base anomalies? Metabolic acidosis 2/2 H+ retention

• Recall there’s a H+ pump in the alpha-intercalated cell

• Electrolyte anomalies?

• Hyperkalemia

• Pathophys? Kidneys not excreting K+ (normally happens via ROMK channel)

• Hypocalcemia

• Pathophys? Low 1-alpha hydroxylase → cannot make active Vit D → can’t absorb Ca+ and phos from the gut

• Hyperphosphatemia

• Pathophys? Hypocalcemia → 2ary hyper-PTH → BUT can’t excrete phos because the kidneys aren’t working
• Contrast with liver disease

• Can’t make calcidiol → 2ary hyperparathyroidism → hypercalcemia & hypophosphatemia (kidneys functional)

• Hematologic anomalies?

• Hgb low

• Pathophys? Kidneys not producing erythropoietin

• Manifestations of uremia

• Pericarditis
• Platelet dysfunction

• Tx? desmopressin

• AMS

• Tx

• Hyperphosphatemia → phosphate binders (sevelamer)
• Hypocalcemia → calcitriol

• NOT calcidiol, because they can’t convert calcidiol to calcitriol

• How is kidney function preserved in diabetic nephropathy? ACE-I
• Indications for dialysis

• A = acidosis
• E = electrolyte problems
• I = ingestion
• O = overload (fluid)
• U = uremia

• Rb gene mutations, Paget’s disease, and Teriparatide (PTH analog) administration increase risk of what primary bone malignancy? Osteosarcoma

• Associated radiological features?

• Codman’s triangle
• Sunburst pattern

• Asthma step-up treatment

• Albuterol
• ICS
• LABA (e.g. salmeterol)
• Oral steroids
  

• Asthma + nasal polyps → Aspirin Exacerbated Respiratory Disease

• 3 things to think about with nasal polyps?

• AERD
• Wegener’s = GPA
• CF

• Pathophys?

• Arachidonic acid → prostaglandins (COX) + leukotrienes (LOX)
• Aspirin blocks COX, which causes flux down LOX pathway

• Tx?

• Leukotriene receptor (CYSLTR1) blockers

• E.g. montelukast

• Lox inhibitors

• E.g. zileuton

• AE? Hepatotoxic

• Regular narrow-complex tachycardia → SVT

• Tx asymptomatic pt?

• Acute

• Vagal maneuvers
• Adenosine

• Chronic

• Beta blocker
• Verapamil/diltiazem

• Tx HDUS pt? Synchronized cardioversion

• Indications for unsynchronized cardioversion (defibrillation)

• V fib
• Pulseless V tach

• MC EKG finding in a patient having a pulmonary embolus? Sinus tachycardia

• 18 yo F presents with scaly, erythematous upper extremity lesions. She has a long history of allergic rhinitis. → atopic dermatitis/eczema

• CBC finding? Elevated eosinophils
• Tx? Topical steroids
• What if these lesions also had umbilicated vesicles → eczema herpeticum

• Pathophys? HSV superinfection
• Tx? Acyclovir

• A patient presents with the classic “stones, bones, groans, and psychic overtones”. PE is notable for skin tenting. What is the FIRST step in management? Fluids!

• Bisphosphonates

• Indications?

• Osteoporosis

• T-score cutoff? -2.5

• Hypercalcemia of malignancy
• Paget’s disease
• Ppx if on oral steroids for >3 months

• AE?

• Esophageal irritation

• Prevention? Sit up for 30 minutes after taking pill

• Osteonecrosis of the jaw

• H. Pylori infection

• Dx?

• Urea breath test
• Stool antigen
• EGD with biopsy

• Tx?

• Triple therapy = clarithromycin + amox + PPI
• Quad therapy = metronidazole + bismuth + tetracycline + PPI (“MBTP”)

• RF for PUD?

• H. pylori
• Chronic NSAID

• Alpha vs Beta Thalassemias

• Mutation in 1 alpha gene → clinically silent
• Mutation in 2 alpha genes → alpha thalassemia trait, asymptomatic
• Mutation in 3 alpha genes → Hb H disease

• Hgb H = tetramers of beta
• Presentation? At birth

• Why? There are alpha chains in HbF

• Mutation in 4 alpha genes → Hb Barts

• Hgb Barts = tetramers of gamma

• Mutation in 1 beta gene → beta thalassemia minor

• Electrophoresis findings? Elevated HbA2

• HbA2 = alpha2-delta2

• Mutation in 2 beta genes → beta thalassemia

• Electrophoresis findings? Elevated HbA2 + HbF
• Presentation? After 6 months

• Why? Persistence of HbF until ~6 months

• Blood smear finding in thalassemias? Target cells

• Classic CBC findings in hemolytic anemias

• Low haptoglobin
• Indirect bilirubinemia

• Classic “gallbladder” pathology present in patients with hemolytic anemias → pigmented gallstones
• These patients are at risk of aplastic crises with what bug? Parvovirus B19
• Do thalassemias present as a microcytic, normocytic, or macrocytic anemia? Microcytic with normal RDW

• Contrast with IDA (high RDW)

• 23 yo M who recently returned from Tucson presents with a 2 week history of fever, ankle/knee pain, chest pain, and a painful, erythematous pretibial lesion → coccidiomyocosis

• Geographic association? Southwest US
• Derm finding? Erythema nodosum
• Microscopy finding? Spherules
• Tx? itraconazole

• Periorbital edema, hematuria, and HTN in a patient with a recent history of cellulitis. BUN and Cr are elevated. → Post-infectious GN

• Pathophys? Nephritic syndrome
• Ab? Anti-streptolysin-O and anti-DNase B
• Type of HSR? 3
• Complications of…

• Strep pharyngitis

• Rheumatic fever - abx decrease risk
• PIGN - abx have NO EFFECT on risk

• Strep skin infection

• Only PIGN

• 11:22 translocation, X-Ray imaging reveals an “onion skin like” periosteal reaction, bone biopsy with histology reveals small, round, blue cells. → Ewing’s sarcoma

• Tx? Actinomycin D

• Parapneumonic effusion (PNE) = pleural effusion in the setting of pneumonia

• What is your diagnosis? V-tach

• How would you describe the rhythm? Regular, wide-complex
• Tx pulseless V tach → defibrillate
• Tx V tach w/ pulse but HDUS → synchronized cardioversion
• T V tach w/ pulse HDS → amiodarone

• What is the MC cause of death in the immediate period following an MI? V fib

• Tx V fib → defibrillation = unsynchronized cardioversion

• Oral mucosal ulcerations + +ve Nikolsky sign (flaccid skin blisters) in a 45 yo M. → pemphigus vulgaris

• Pathophys? Autoantibodies against desmosomes (against desmoglein 1/3)
• Type HSR? 2
• Dx? skin bx w/ immunofluorescence → intraepidermal immunofluorescence (net-like pattern)

• Contrast with bullous pemphigoid, which will have a linear pattern

• Tx? Oral steroids

• Lab differentiation between primary and secondary hyperaldosteronism

• Conn syndrome = primary hyperaldosteronism

• Aldosterone high
• Renin low
• Plasma aldosterone:renin ratio >20

• Secondary hyperaldosteronism

• E.g. young F with abdominal bruits OR resistant HTN + AV nicking → fibromuscular dysplasia
• E.g. old man with abdominal bruits → renal artery stenosis
• Aldosterone high
• Renin high

• Dx for Conn syndrome? Plasma aldosterone:renin ratio
• Tx for Conn syndrome? Aldosterone antagonists (e.g. spironolactone, eplerenone)

• Young F with abdominal pain relieved with defecation → IBS

• Rome Criteria

• Recurrent abdominal pain associated with 2 of the 3

• Related to defecation
• Change in stool form
• Change in BM frequency

• Are there lab abnormalities? NO
• IBS Classification

• IBS-C → give stool softener
• IBS-D → give antidiarrheal (e.g. loperamide)

• Cold vs Warm Agglutinins

• Cold agglutinins → IgM

• Bug? Mycoplasma
• Tx? Cytotoxic drug (cyclosporine, azathioprine etc)

• Warm agglutinins → IgG

• Tx? Splenectomy

• Why? IgG opsonized things, splenic macrophages clear antibody-bound RBCs

• LDH, Bilirubin, and Haptoglobin levels in hemolytic anemia.

• LDH up
• Indirect bilirubin up
• Haptoglobin down

• 32 yo Egyptian immigrant presents with a 2 week history of abdominal pain, hepatosplenomegaly, and hematuria. He swam in The Nile 2 months ago. → schistosomiasis

• Bug? Schistosoma haematobium
• Transmission? Direct contact with water
• CBC finding? Elevated eosinophils
• Associated malignancy? Squamous cell carcinoma of bladder
• Tx? Praziquantel

• Synpharyngitic glomerulonephritis → IgA nephropathy

• Presentation? 2-6 days after URI
• Contrast with PIGN, which occurs 2-6 weeks after URI
• Lab findings? Low complement
• Tx? steroids
• Urine microscopy findings? RBC casts
• Urine protein? <3.5 g/24 hrs

• 70 yo M with leg pain that is worsened by a back held in extension (but better when held in flexion). → spinal stenosis

• Dx? MRI spine
• Tx? PT + pain control

• If refractory, decompressive laminectomy

• Opening snap with a diastolic rumble heard best in the 4th intercostal space in the midclavicular line. → mitral stenosis

• #1 RF? Rheumatic fever
• Dx? Echo
• Tx? Valve replacement
• MC arrhythmia in pts with MS? A fib

• No oral mucosal lesions + Pruritus + Tense blisters w/ negative Nikolsky sign →

• Pathophys? Autoantibodies against hemidesmosome
• Dx? Skin bx w/ immunofluorescence → linear subepidermal pattern
  Tx? Topical steroids

• 69 yo M with fever, leukocytosis, and LLQ pain → diverticulitis

• Pathophys? Inflammation of diverticula
• Dx? CT abdomen
• Contraindicated study? colonoscopy
• Tx?

• Cipro (GNRs) + metronidazole (anaerobes)
• Metronidazole + amox + gentamicin

• What abx choice should you NOT choose on exams? Pip-tazo (too broad)
• What if this patient presents weeks later with recurrent UTIs with urinalysis revealing air and fecal material → colovesical fistula

----------------------------------------------------------------------------------------------------------------------------- 

Episode 30: Comprehensive Medicine Shelf Review Session 2.

• Primary adrenal insufficiency = problem at level of adrenal glands

• Causes? Addison’s disease
• Pathophys? Autoimmune destruction of the adrenal glands
• Associated with hyperpigmentation

• POMC is precursor to both ACTH and MSH
• PAI → lack of negative feedback → high ACTH

• Lab findings?

• ACTH high
• Aldosterone low

• Destruction of zona glomerulosa

• Renin high

• Hypotension → RAAS activation

• Electrolytes

• Na+ low, K+ high

• CBC

• Eosinophils high

• Pathophys? Glucocorticoids → eosinophil apoptosis. Lack of glucocorticoids cause eosinophilia.

• Dx? Cosyntropin testing → no rise in cortisol

• Adrenal glands aren’t working, so no response to ACTH.

• Tx? prednisone/hydrocortisone/dexamethasone + fludrocortisone (mineralocorticoid)

• Stress-dose steroids for surgery, serious illness, etc.

• Secondary adrenal insufficiency = problem at level of pituitary, reduced ACTH release

• Causes?

• MC is prolonged steroid use → ACTH suppression
• Sheehan’s syndrome (infarction of pituitary)
• Pituitary tumors (ACTH-producing tumor)

• Lab findings?

• ACTH low

• Anterior pituitary is being inhibited

• Aldosterone normal

• Zona glomerulosa under control of RAAS system

• Renin normal
• Electrolytes

• Na+ & K+ unaffected (Aldosterone levels are normal)

• CBC

• Neutrophilia due to demargination (if pt was recently taking steroids)

• Dx? Cosyntropin testing → rise in cortisol

• Adrenal gland is functional

• Tx? Glucocorticoids

• Do not need to replace mineralocorticoids since adrenals are functional and aldosterone is under RAAS control
• Stress-dose steroids for surgery, serious illness, etc.

• AI with a history of nuchal rigidity and purpuric skin lesions → Waterhouse-Friedrichson syndrome

• Pathophys? AI 2/2 hemorrhagic infarction of the adrenal glands in the context of Neisseria meningitidis infection

• Adrenal synthesis enzymes

• If the enzyme starts with 1 → HTN (high mineralocorticoids)
• If the second # is 1 → virilization (high androgens)
• E.g. 11-beta hydroxylase deficiency → HTN & virilization
• E.g. 21 hydroxylase deficiency → virilization only
• E.g. 17-alpha hydroxylase deficiency → HTN only

• B12 deficiency

• Where does B12 come from? Animal products
• Physiology

• R factor in saliva binds to B12 and protects it from acidity in the stomach. R factor-B12 travels to the duodenum.
• Parietal cells produce intrinsic factor, which travels to the duodenum.
• Pancreatic enzymes cleave B12 from R factor and B12 then binds IF.        
• B12-IF complex is reabsorbed in the terminal ileum

• Reabsorption where? Terminal ileum
• Causes of B12 deficiency

• Extreme vegan
• Pernicious anemia
• Pancreatic enzyme deficiency

• Can’t cleave B12 from R factor

• Crohn’s

• Affects terminal ileum

• Lab markers

• Homocysteine HIGH
• MMA HIGH

• Presentation?

• Megaloblastic anemia
• Subacute combined degeneration (of dorsal columns + lateral corticospinal tract)
• Peripheral neuropathy

• Dx of pernicious anemia? anti-IF Ab

• Folate deficiency

• Where does folate come from? Leafy things
• Causes of folate deficiency

• Poor diet (e.g. alcoholics, elderly)
• Phenytoin

• Lab markers

• Homocysteine HIGH
• MMA normal

• Presentation? Megaloblastic anemia

• Prophylaxis in HIV+ patients

• CD4 < 200 → PCP

• TMP-SMX, inhaled pentamidine, dapsone, atovaquone

• CD4 < 100 → Toxo

• TMP-SMX

• CD4 < 50 → MAC

• Azithromycin

• If live in endemic area, CD4 < 250 → Coccidioides Immitis

• E.g. Arizona, Nevada, Texas, California
• Itraconazole

• If live in endemic area, CD4 < 150 → Histoplasma Capsulatum

• E.g. Kentucky, Ohio, Missouri
• Itraconazole

• Diabetes insipidus

• Dx? Water deprivation test

• Measure serum osmolality & urine osmolality
• Deprive pt of water
• Remeasure serum osmolality & urine osmolality

• If urine osmolality doesn’t go up → suspect DI

• Central DI → deficiency of ADH

• Pathophys? Supraoptic nucleus not making enough ADH
• Dx? Give desmopressin → urine osmolality increases significantly

• Nephrogenic DI → kidneys are not responding to ADH

• Dx? Give desmopressin → urine osmolality doesn’t change much
• Tx? Hydrochlorothiazide

• Unless 2/2 lithium, use amiloride or triametere

• Causes?

• Lithium
• SSRIs
• Carbamazepine
• Demeclocycline

• Tx of normovolemic hypernatremia? D5W to correct free water deficit

• Divine says NS, but most other resources I found said correct free water deficit

• Tx of hypovolemic hypernatremia? Give NS first until normal volume, then give D5W
• Consequence of correcting hypernatremia too rapidly? Cerebral edema

• Osteoarthritis

• Presentation? Old person with joint pain that gets worse throughout the day
• RF? obesity
• Imaging findings?

• Joint space narrowing
• Subchondral sclerosis
• Subchondral cysts
• Osteophytes

• Arthrocentesis findings? <2000 cells
• Tx?

• 1st line acetaminophen
• 2nd line NSAID (e.g. naproxen)
• 3rd line joint replacement surgery

• Returned from a business conference 1 week ago + Fever + Nonproductive cough + Abdominal pain + Hyponatremia → Legionella

• Dx? Urine antigen
• Tx? FQ or macrolide

• MaCroLide mnemonic = Mycoplasma, Chlamydia, Legionella

• What are the common causes of atypical PNA? Mycoplasma, Legionella, Chlamydia

• MC cause? Mycoplasma
• CXR findings? Interstitial infiltrates
• HY associations

• C. Psittaci → birds
• C. Burnetii → cows, goats, sheet
• Mycoplasma → college student w/ walking pneumonia

• Midsystolic click heard best at the apex. → mitral valve prolapse

• “Stenosnap & Proclick”
• RF? Connective tissue disease

• Marfarn
• Ehlers-Danlos
• ADPKD

• Classic demographic? Young woman
• Pathophys? Myxomatous degeneration
• Exam maneuvers

• Anything that increase amount of blood in LV → murmur softer

• Increase preload
• Increase afterload

• Anything that decreases amount of blood in LV → murmur louder

• Dx? Echo

• Scaly, itchy skin with yellowish crusting in the winter. → seborrheic dermatitis

• Tx? Topical antifungals

• e.g. ketoconazole or selenium sulfide shampoo

• Classic disease distribution?

• Hair → e.g. cradle cap
• Eyebrows

• Episodic HTN + HA → pheochromocytoma

• Genetic disease associations

• MEN2A
• MEN2B
• VHL
• NF-1

• Pathophys? Catecholamine-secreting tumor
• Location?

• Adrenal medulla
• Posterior mediastinum
• Organ of Zuckerkandl (chromaffin cells along the aorta)

• Dx?

• 1st step: urine metanephrines

• If elevated → CT abdomen

• If nothing found on CT → MIBG scan

• Tx? Alpha blocker (e.g. phenoxybenzamine, phenotaline) THEN beta blocker

• Most common cause of a LGIB in the elderly → diverticulosis

• Dx? Colonoscopy or barium enema

• Recall that you acutely do a CT scan for diverticulitis, then 6 weeks later colonoscopy to r/o cancer

• Ppx? Eat fiber

• Megaloblastic anemias

• Blood smear findings?

• Hypersegmented neutrophils
• MCV > 100

• Classic patient demographic with folate deficiency?

• Alcoholics
• Elderly person with poor nutrition

• Folate synthesis inhibitors

• Pt with molar pregnancy → methotrexate

• Pulmonary issue? Pulmonary fibrosis

• HIV+ pt with ring-enhancing lesions → pyrimethamine-sulfadiazine

• Pyrimethamine inhibits DHFR

• AIDS pt on ppx for toxo → TMP-SMX

• TMP inhibits DHFR

• Use of leucovorin? Rescue bone marrow in setting of methotrexate toxicity

• Mechanism? Folinic acid analog

• CMV presentations

• Esophagitis → linear ulcers
• Colitis → post-transplant pt
• Retinitis → HIV pt with CD4 < 50
• Congenital CMV → periventricular calcifications + hearing loss

• calcifications elsewhere → toxo

• Histology? Owl’s eye intranuclear inclusions
• 
• Tx? Gancicyclovir

• Resistance? UL97 kinase mutation
• Tx for resistance? foscarnet

• CD4 < 200 + severe peripheral edema + frothy urine. → FSGS in HIV pt

• Variant classic in HIV+ pts? Collapsing variant
• Tx? Steroids + cyclophosphamide + ACE-I

• Indinavir AE? Kidney stones
• triad of fever, rash, and eosinophiluria → acute interstitial nephritis

• Drugs cause? Penicillins
• Tx? Stop the drug!

• Can add steroids if severe

• Vitamin D metabolism

• Liver converts Vit D to calcidiol (25OH-Vit D). Calcidiol goes to kidney. Alpha-1 hydroxylase converts calcidiol to calcitriol (1,25-OH Vit D).
• Common causes of Vitamin D deficiency

• CKD → 1-alpha hydroxyalse deficiency
• Liver disease → can’t make calcidiol
• CF → malabsorption
• Crohn’s → malabsorption

• Osteomalacia vs Rickets

• Osteomalacia in adults
• Rickets in kids

• Tx? Calcium + vit D
• Lab findings?

• Ca++ low
• Phos low

• Low in liver disease
• High in kidney disease (kidneys can’t get rid of phos)

• PTH high (2ary hyperpara)
• Alk phos

• Aspiration pneumonia

• RF?

• Alcoholism
• Dementia
• Neuromuscular problems (e.g. MG, ALS)

• Bugs?

• Anaerobes

• Bacteroides
• FUsobacterium
• Peptostreptococcus

• Klebsiella → currant jelly sputum

• Tx? Clindamycin

• CURB-65 criteria

• Purpose? Who to admit
• Cutoff? 2+ → hospitalize
• C = confusion
• U = uremia (BUN > 20)
• R = RR > 30
• B = BP < 90/60
• Age > 65

• Drugs commonly used in PNA treatment

• Ceftriaxone
• Levofloxacin
• Macrolides - great for atypical PNA

• Pharmacological management of pulmonary arterial HTN

• Endothelin antagonists

• Bosentan
• ambrisentan

• PDE-5 inhibitors

• Sildenafil
• Tadalafil

• Prostacyclin analogs

• Iloprost
• Epoprostenol
• Treprostinil

• Causes?

• Young female → idiopathic PAH

• Mutation? BMPR2

• 55 yo F presents with a 5 week history of a rash on her forehead. PE reveals scaly macules with a sandpaper texture. → actinic keratosis

• RF? Sun exposure
• Tx? Topical 5-FU
• Possible dangerous sequelae? Squamous cell carcinoma
• Most likely disease sequelae? Resolution

• Hypercalcemia

• Presentation? bones, stones, groans, psychic overtones
• Tx?

• 1st step: NS
• Hypercalcemia of malignancy → bisphosphonates

• EKG finding? Shortened QT

• Periumbilical pain that migrates to the right lower quadrant. → appendicitis

• PE findings?

• McBurney’s point tenderness
• Psoas sign
• Obturator sign (pain with internal rotation of hip)
• Rovsing’s sign (palpation of LLQ → pain in RLQ)

• Dx? CT scan

• Pregnant → US
• Kid → US

• Tx? Surgery

• Classic drug and viral causes of aplastic anemia.

• Drugs?

• Carbamazepine
• Chloramphenicol

• Viral? Parvovirus B19 (single stranded DNA virus)

• Fanconi anemia

• Pathophys? Problems with DNA repair
• Fanconi anemia vs Fanconi syndrome

• Fanconi anemia → cytopenias + thumb anomalies + short stature + cafe-au-lait spots
• Fanconi syndrome → type 2 RTA (proximal)

• CD4 count of 94 + MRI revealing ring enhancing lesions in the cortex → toxoplasmosis

• Tx? Pyrimethamine-sulfadiazine

• Rescue agent for pt who becomes leukopenic with treatment? leucovorin

• Who should get steroids? Increased ICP

• For PCP pneumonia:

• O2 sat < 92
• PaO2 < 70
• A-a gradient > 35

• Ppx? TMP-SMX for CD4 < 100
• Congenital toxo

• Hydrocephalus
• Chorioretinitis
• Intracranial calcifications

• Classic methods of transmission? handling cat litter

• Lupus nephritis

• Associated autoantibody? anti-dsDNA
• Classic “immunologic” description? “Full house” pattern
• Tx? Steroids + cyclophosphamide

• Osteoporosis

• Screening population? women > 65
• Screening modality? DEXA scan
• Dx? T-score < -2.5
• RF?

• Postmenopauseal
• Low BMI
• Smoking
• Alcohol

• Preventive strategies?

• Weight bearing exercise
• Smoking cessation
• Reduce alcohol consumption

• Tx?

• 1st line: bisphosphonates + Ca/Vit D supplementation
• Raloxifene (SERM)

• Agonist in bone
• Antagonist in breast

• Classic locations of osteoporotic fractures

• Vertebral compression fracture
• Hip fracture

• Name the PNA

• Red currant jelly sputum. → Klebsiella
• Rust colored sputum. → Strep pneumo
• PNA in an alcoholic. → Klebsiella
• Post viral PNA with a cavitary CXR lesion. → Staph aureus
• PNA in a patient that has chronically been on a ventilator. → Pseudomonas
• MC cause of CAP. → Strep pneumo

• Pharmacological management of MRSA.

• Vanc
• Clinda
• Linezolid
• Ceftaroline (5th gen cephalosporin)
• Tigecycline

• Pharmacological management of Pseudomonas.

• Ceftazidime (only 3rd gen cephalosporin)
• Cefepime (4th gen cephalosporin)
• Pip-tazo
• FQ
• Carbapenems
• Aztreonam
• Aminoglycosides

• JVD and exercise intolerance in a patient with a recent history of an URI. → dilated cardiomyopathy 2/2 viral myocarditis

• MC cause? Coxsackie B
• Drug causes?

• Clozapine
• Anthracyclines

• Prevention? Dexrazoxane (iron chelator)

• Trastuzumab

• Classic cause in a patient with recent history of travel to S. America? Chagas

• Potential sequelae?

• Achalasia
• Dilated cardiomyopathy
• Megacolon (2/2 degeneration of myenteric plexus)

• Massive skin sloughing (45% BSA) in a patient that was recently started on a gout medication? TEN

• Dx?

• <10% BSA → SJS
• >30% BSA → TEN

• Tx? STOP the drug

• IVF
• Topical abx to prevention infection

• Tetany and a prolonged QT interval in a patient with recent surgical treatment of follicular thyroid carcinoma. → hypocalcemia due to removal of parathyroids
• Recurrent viral infections + QT prolongation + tetany → DiGeorge syndrome

• Pathophys? Failure of development of 3rd/4th pharyngeal pouches

• Trousseau and Chvostek signs.

• Trousseau → inflation of BP cuff causes carpopedal spasm
• Chvostek → taping on cheek causes facial muscle spasm

• Hypocalcemia that is refractory to repletion → consider hypomagnesemia
• Electrolyte/drug causes of prolonged QT intervals

• Electrolytes?

• Hypocalcemia
• Hypomagnesemia
• Hypokalemia

• Drugs?

• Macrolides
• FQ
• Haloperidol
• Ondensatron
• Methadone

• Hypoalbuminemia and Ca balance

• Hypoalbumenia → decrease in total body Ca++, no change in ionized Ca++
• Drop of 1 in albumin → add 0.8 to Ca++

• Abdominal pain radiating to the back → acute pancreatitis

• Causes?

• #1 = Gallstones
• #2 = Alcohol
• Hypertriglyceridemia
• Scorpion sting
• Handlebar injuries

• Lab markers?

• Lipase - most sensitive
• Amylase

• Physical exam signs in pancreatitis.

• Cullen’s sign = periumbilical ecchymosis
• Grey Turner sign = flank ecchymosis

• Tx? NPO + IVF + pain control

• Meperidine is a good agent because it doesn’t cause sphincter of Oddi spasms

• Management of gallstone pancreatitis

• Dx? US then ERCP
• Tx? DELAYED cholecystectomy

• What if the patient becomes severely hypoxic with a CXR revealing a “white out” lung? ARDS

• PCWP? <18 mmHg

• 20 yo M with red urine in the morning + hepatic vein thrombosis + CBC findings of hemolytic anemia. → paroxysmal nocturnal hemoglobinuria

• Pathophys? Defect in GPI anchors, which attach CD55 and CD59 to cell (they prevent complement from destroying RBC)

• Sleep → hypoventilation → mild respiratory acidosis → activation of complement cascade

• Gene mutation? PIGA
• Dx? Flow cytometry
• Tx? Eculizumab (terminal complement inhibitor)

• Vaccine required? Neisseria meningitidis

• Chronic diarrhea and malabsorption in a HIV+ patient + detection of acid fast oocysts in stool. → cryptosporidium parvum

• Acid-fast organisms

• Cryptosporidium
• TB
• MAC
• Nocardia

• Dx? Stool O&P
• Tx? Nitazoxanide
• Route of transmission? Contaminated water

• Muddy brown casts on urinalysis in a patient with recent CT contrast administration (or Gentamicin administration for a life threatening gram -ve infection) → ATN

• Woman with morning joint stiffness > 1 hr → RA.

• Ab?

• RF (IgM against IgG)
• anti-CCP - more specific

• HLA? DR4
• Pathophys? IgM constant region activates complement → inflammation → formation of pannus (hypertrophied synovium) → damage to cartilage and bone
• Caplan syndrome = RA + pneumoconiosis
• Felty syndrome = RA + neutropenia + splenomegaly (“RANS”)
• Classic hand/finger findings/distribution? MCP & PIP joints of hands (DIP joints spared)
• Imaging findings?

• Symmetric joint space narrowing

• Tx? Methotrexate (DMARDs)

• If no response → TNF alpha inhibitor (e.g. infliximab)

• Required testing prior to starting methotrexate?

• PFTs

• Required testing prior to starting infliximab?

• TB
• Hep B/Hep C

• Differentiating Strep pharyngitis from Infectious Mononucleosis

• LND distribution

• Anterior cervical → Strep
• Posterior cervical → Mono

• Disease onset

• Acute → Strep
• Over weeks → Mono

• Organ involvement

• Splenomegaly → Mono

• Pt with sore throat takes amoxicillin and gets rash → mono

• NOT allergic rxn!

• CENTOR criteria

• C = absence of Cough
• E = tonsillar Exudates
• N = nodes/anterior cervical lymphadenopathy
• T = temp (fever)
• OR

• <15 → +1
• >=45 → -1

• Using CENTOR score

• 0/1 → don’t test, don’t treat
• 2/3 → rapid antigen test

• Positive → treat
• Negative → throat culture

• 4/5 → treat empirically

• Tx of Strep pharyngitis?

• Amoxillcin
• If PCN allergic → azithromycin

• Potential sequelae of Strep pharyngitis

• RF - preventable with abx
• PSGN

• Endocarditis

• MC cause of endocarditis? IVDU

• Bug? Staph aureus
• Valve? tricuspid

• Prosthetic valve endocarditis

• Bug? Staph epidermidis

• Endocarditis after dental procedure? Viridans group streptococci

• Strep viridans, Strep mitis, Strep mutans, Strep sanguineous

• Patient with malar rash and echo showing vegetations on both sides of the mitral valve → Libman-Sacks endocarditis
• Presentation? Fever + night sweats + new murmur

• Splinter hemorrhages
• Roth spots (retinal hemorrhages)
• Painless Janeway lesions + painful Osler nodes (immune phenomenon)

• Dx?

• 1st step: blood cultures
• TEE

• Tx? Abx that include Staph aureus coverage (e.g. vancomycin) for WEEKS
• Bugs implicated in culture negative endocarditis

• HACEK

• H = haemophilus
• A = actinobacillus
• C = cardiobacterium
• E = eikenella
• K = kingella

• Coxiella burnetii

• Blood cultures in a patient with endocarditis reveal S. Bovis (or S. Gallolyticus bacteremia). NBS? Colonoscopy
• Who needs antibiotic prophylaxis?

• Hx endocarditis
• Prosthetic valve
• Unrepaired cyanotic congenital dz
• Heart transplant with valve dysfunction

• Erythematous salmon colored patch with silvery scale on the elbows and knees. → psoriasis

• Tx? Topical steroids
• If this patient presents with joint pain (especially in the fingers)? Psoriatic arthritis

• Imaging? Pencil-and-cup deformity
• Tx? NSAIDs

• T of 104 + tachycardia + new onset Afib in a patient with a history of Graves disease. → thyroid storm

• Lab findings?

• TSH low
• T3/T4 high

• Tx?

• 1st step: propranolol
• 2nd step: PTU
• Then:

• Prednisone
• Potassium iodide (Lugul’s solution)

• Wolff-Chaikoff effect → large amounts of iodine inhibit thyroid hormone synthesis

• Biopsy revealing tennis racket shaped structures in cells of immune origin. → Langerhans cell histiocytosis

• Electron microscopy? Birbeck granules (tennis rackets)
• Marker? S100

• Small bowel obstruction in a HIV patient with purple macules on the face, arms, and lower extremities. → Kaposi’s sarcoma

• Bug? HHV8
• Tx? HAART
• Pathophys of vascular lesions? Overexpression of VEGF

• Fever + rash + eosinophiluria 10 days after a patient started an antistaphylococcal penicillin. → acute interstitial nephritis

• Tx? STOP drug + steroids

• SLE

• SOAP BRAIN MD

• S = serositis
• O = oral ulcers
• A = arthritis
• P = photosensitivity
• B = blood disorders (cytopenias)
• R = renal
• A = ANA/anti-dsDNA
• I = immunologic
• N = neurologic findings
• M = malar rash
• D = discoid rash

• Type 2 vs 3 HSRs in lupus

• Type 2 → cytopenias
• Type 3 → all other manifestations

• Lupus Ab?

• ANA
• anti-dsDNA
• anti-Smith

• Lupus nephritis → full house pattern on IF
• Antiphospholipid antibody syndrome → recurrent pregnancy losses

• Pathophys? Thrombosis of the uteroplacental arteries.

• MC cause of death in lupus patients?

• What I’ve read recently: CV disease
• Per Divine:

• Treated → infection
• Untreated → renal dz

• Also 40x risk MI

• Endocarditis in lupus pt? Libman-Sacks endocarditis
• Neonatal 3rd degree heart block → neonatal lupus

• Maternal autoimmune dz?

• Sjogren’s
• SLE

• Ab?        

• anti-SSA/anti-Ro
• anti-SSB/anti-La

• Tx?

• Steroids
• Cyclophosphamide
• Hydroxychloroquine → good for skin lesions

• Pulmonary abscesses

• Bugs?

• Staph
• Anaerobes
• Klebsiella

• RF?

• Alcoholism
• Elderly
• Post-viral pneumonia

• MC location of aspiration pneumonia? Superior segment of RLL

• Chest pain worsened by deep inspiration and relieved by sitting up in a patient with a recent MI or elevated creatinine or URI or RA/SLE. → pericarditis

• EKG findings? Diffuse ST elevations + PR depression
• PE finding? Friction rub (“scratchy sound on auscultation”)
• A few days after MI → fibrinous pericarditis
• Weeks after MI → Dressler’s
• Tx? NSAIDS

• Consider adding on colchicine

• Cardiac tamponade

• Beck’s triad = hypotension + JVD + muffled heart sounds
• EKG findings? Electrical alternans
• Type of shock? Obstructive cardiogenic (Amboss)

• CO low
• SVR high
• PCWP high

• Tx? Pericardiocentesis

• Pearly lesion with telangiectasias on the ear in a farmer. → BCC

• MC type skin cancer
• Location? Upper lip
• Dx? Biopsy
• Tx? Mohs surgery

• Cold intolerance in a 35 yo white F → hypothyroidism

• MC cause? Hashimoto’s
• Histology? lymphoid follicles w/ active germinal centers
• Lab findings?

• TSH high
• T3/T4 low

• Ab?

• anti-TPO
• Anti-thyroglobulin

• HLA? DR3/DR5
• Tx? Levothyroxine
• Future complication? thyroid lymphoma

• Massive hematemesis in a patient with a history of chronic liver disease. → ruptured varices

• Pathophys? L gastric vein has anastomosis with azygos veins. Increased portal pressure → backward flow from L gastric veins to azygous vein (which empties into SVC).
• Acute tx? IVF + octreotide + ceftriaxone/cipro + EGD w/ ligation

• Do NOT give a beta blocker for acute tx

• Ppx? Beta blocker + spironolactone
• Other manifestations of elevated portal pressures

• Caput medusa
• Internal hemorrhoids

• Tx for cirrhotic coagulopathies? FFP

• If uremia → give desmopressin

• Hemophilia A

• Pathophys? deficiency of factor 8
• Inheritance? XLR
• Coag labs?

• Bleeding time normal
• PTT HIGH
• PT normal

• Hemophilia B

• Pathophys? deficiency of factor 9
• Inheritance? XLR
• Coag labs?

• Bleeding time normal
• PTT HIGH
• PT normal

• Hemophilia C

• Pathophys? deficiency of factor 11
• Inheritance? AR
• Coag labs?

• Bleeding time normal
• PTT HIGH
• PT normal

• Bernard Soulier Syndrome

• Pathophys? Deficiency of GpIb
• Coag labs?

• Bleeding time HIGH
• PTT normal
• PT normal

• Glanzmann Thrombasthenia

• Pathophys? Deficiency of GpIIbIIIa
• Coag labs?

• Bleeding time HIGH
• PTT normal
• PT normal

• Von Willebrand’s disease

• Pathophys? Deficiency of vWF
• Inheritance? AD
• Coag labs?

• Bleeding time HIGH
• PTT HIGH

• vWF is a protecting group for factor 8

• PT normal

• ITP

• Pathophys? Ab against GpIIbIIIa
• Classic pt? Pt with SLE
• Tx?

• Observation
• Steroids
• IVIG
• Splenectomy

• TTP

• Pathophys? Deficiency in ADAMTS13 enzyme → cannot cleave vWF multimers → activation of platelets → thrombosis → thrombocytopenia
• Presentation? microangiopathic hemolytic anemia + thrombocytopenia + renal failure + fever + neurologic problems
• Tx? Plasma exchange transfusion

• HUS

• Bugs? Shigella or E. coli O157:H7
• Presentation? microangiopathic hemolytic anemia + thrombocytopenia + renal failure

• Platelet deficiency vs coagulation factor bleeds

• Platelet deficiency → mucosal bleeds, petechiae, heavy menses
• Coag factor deficiency bleeds → hemarthrosis

• Why do patients with CKD have a coagulopathy? Uremia → platelet dysfunction

• Tx? desmopressin

• Exercising caution with transfusion in patients with Bernard Soulier syndrome

• Do NOT give transfusion that includes platelets
• They can have an anaphylactic rxn to GpIb (since they don’t have GpIb)

• Oropharyngeal candidiasis.

• RF?

• HIV
• Chronic ICS use
• TNF inhibitor

• Micro finding? Germ tubes at 37C
• Tx oral candidiasis? Nystatin swish-and-swallow
• Tx invasive candidiasis? Amphotericin B

• Prevention of Amphotericin B toxicity? Liposomal formulation

• Pleural effusions

• Light’s criteria (must meet all 3 to be considered transudative!)

• LDH < 2/3 ULN
• Pleural LDH/serum LDH < 0.6
• Pleural protein/serum protein < 0.5

• Causes of transudative effusion

• CHF
• Cirrhosis
• Nephrotic syndrome

• Causes of exudative effusion

• Malignancy
• Parapneumonic effusion
• TB

• Unique cause of both transudative & exudative effusions? PE
• Classic PE findings?

• Decreased breath sounds
• Dullness to percussion
• Decreased tactile fremitus

• Tx? Chest tube

• Chylothorax = lymph in the pleural space

• Pathophys? Obstruction of thoracic duct or injury to the thoracic duct
• Pleural fluid findings? High TG

• Holosystolic murmur heard best at the apex with radiation to the axilla in a patient with a recent MI. → mitral regurg 2/2 papillary muscle rupture

• Dx? Echo
• Why widely split S2? Aortic valve is closing earlier (LV is emptying into both aorta & LA)
• Maneuvers that increase intensity

• Increase preload (putting  more blood in that can be regurgitated)
• Increase afterload

• Decubitus ulcers

• RF?

• Elderly
• Paraplegic
• Fecal/urinary incontinence
• Poor nutrition

• Staging

• Stage 1 = non-blanchable erythema

• Tx? Repositioning q2hrs

• Stage 2 = loss of epidermis + partial loss of dermis

• Tx? Occlusive dressing

• Stage 3 = involves entire dermis, extending to subQ fat

• Does NOT extend past fascia
• Tx? Surgical debridement

• Stage 4 = muscle/tendon/bose exposed

• Tx? Surgical debridement

• General tx strategies? Repositioning + good nutritional support
• Marjolin’s ulcer = non-healing wound that is actually squamous cell carcinoma

• T1DM

• Pathophys? Autoimmune destruction of pancreas
• Ab?

• anti-GAD 65 (glutamic acid decarboxylase)
• anti-IA2 (islet tyrosine phosphatase 2)
• Islet cell autoantibodies
• Insulin autoantibodies

• Dx?

• A1c > 6.5% (twice)
• Fasting BG >= 126 (twice)
• Oral glucose tolerance test >= 200 (twice)
• Sxs of DM + random glucose > 200

• Tx? Long-acting insulin + mealtime insulin

• Long-acting

• Glargine
• Detemir

• Rapid-acting

• Lispro
• Aspart
• Glulisine

• 3 HY complications

• Nephropathy
• Retinopathy & cataracts
• Neuropathy

• Chronic DM care

• A1c q3 months
• Foot exam annually
• Eye exam annually
• Microalbumin:Cr ratio annually

• Nephroprotection in DM? ACE-I

• GI bleed algorithm

• 1st step: ABCs + 2 large-bore IVs + IVFs
• 2nd step: NG lavage

• Clear fluid → go deeper
• Blood → UGIB → upper endoscopy
• Bilious fluid → have ruled out UGIB → proceed to colonoscopy

• See source → intervene as needed
• See nothing →

• CT angiography for large bleed
• Tagged RBC scan for smaller bleed

• Antiplatelet Pharmacology

• Aspirin

• Mechanism? Irreversibly inhibits COX-1 and COX-2

• Clopidogrel/ticlopidine = P2Y12 (ADP receptor) blockers

• Mechanism? Inhibit platelet activation

• Abciximab/eptifibatide/tirofiban = GpIIbIIIa receptor blockers

• Mechanism? Inhibit platelet aggregation

• Ristocetin cofactor assay

• Issues with adhesion step → abnormal result
• Abnormal ristocetin cofactor assays:

• Von Willebrand disease
• Bernard Soulier disease

• Normal ristocetin cofactor assay:

• Glanzmann Thrombasthenia

• Von Willebrand disease effects on PTT? Increased

• Pathophys? vWF is a protecting group for Factor 8.

• Treatment of VWD? Desmopressin

• Mechanism? Increases release of vWF from Weibel-Palade bodies of endothelial cells

• HSV1 vs HSV2.

• Oral herpes → HSV1
• Genital herpes → HSV2
• Dx? PCR (most up-to-date)

• Tzanck smear (outdated, not very sensitive, nonspecific) → intranuclear inclusions

• Brain area affected by HSV encephalitis? Temporal lobes
• CSF findings in HSV encephalitis? RBCs
• Tx herpes encephalitis? Acyclovir

• AE? Crystal nephropathy

• Can’t see, can’t pee, can’t climb a tree. → reactive arthritis

• HLA? B27
• Classic bug? Chlamydia
• Tx? steroids

• Need abx? Only if ongoing infection

• Can’t see, can’t pee, can’t hear a bee → Alport syndrome

• Inheritance? X-linked dominant

• Tx of NG & CT

• NG → treat empirically for both → ceftriaxone + azithro/doxy
• CT → azithro/doxy

• Tx anaphylactic shock? epinephrine

• Melanomas

• ABCDE

• A = asymmetry
• B = irregular borders
• C = color variation
• D = diameter > 6 mm
• E = evolving

• Dx? Full-thickness biopsy

• Excisional for small lesions
• Punch for larger lesions

• Most important prognostic factor → Breslow depth

• DM pharmacology

• Lactic acidosis → metformin
• Decreases hepatic gluconeogenesis → metformin
• Hold before CT w/ contrast → metformin
• Weight gain → sulfonylureas & TZDs (-glitizones)
• Diarrhea → acarbose & migliton

• Inhibits disaccharidases (can’t reabsorb disaccharides)

• Recurrent UTIs → SGLT-2 inhibitors
• Weight loss → GLP-1 agonists (e.g. liraglutide, exenatide) & DPP4 inhibitors (-gliptins)
• Contraindicated in pt with HF → TZDs

• PPAR-gamma receptor found in kidney → water retention

• Contraindication in pt with MTC → GLP-1 agonists
• Biggest risk of hypoglycemia? Sulfonylureas

• RF esophageal adenocarcinoma

• Barrett’s esophagus

• RF esophageal squamous cell carcinoma

• Smoking
• Drinking
• Achalasia

• Location esophageal adenocarcinoma? Lower 1/3
• Location esophageal squamous cell carcinoma? Upper 2/3
• MC US? Adenocarcinoma
• MC worldwide? Squamous cell carcinoma
• Presentation? Dysphagia to solids → dysphagia to liquids
• Dx? EGD
• Staging? CT scan or esophageal US

• Factor V Leiden

• Pathophys? Resistance to protein C
• Dx? Activated Protein C resistance assay

• Patient needs super large doses of heparin to record any changes in PTT → AT-III deficiency

• Recall that heparin is a AT-III activator

• 35 yo with a hypercoagulable disorder that does not correct with mixing studies. → antiphospholipid antibody disorder
• Anaphylaxis in a patient with a long history of Hemophilia A → Ab against factor 8 that cause type 1 HSR with transfusion
• Hx of hemophilia, diagnosed 5 years ago. Before you would give them factor 8 concentrate and PTT would normalize. Now they’re requirizing larger doses of factor 8 to normalize PTT. → inhibitor formation (antibodies against clotting factors)
• Skin necrosis with Warfarin → protein C/S deficiency
• Prothrombin G20210 mutation → overproduction of factor II

• Rash in dermatomal distribution → VZV infection

• Contraindications to VZV vaccination?

• Pregnant woman
• Kid < 1 year
• Severe immunosuppression (e.g. HIV with CD4 < 200)

• Tx? Acyclovir

• If resistant, foscarnet

• Tzanck smear findings? Intranuclear inclusions

• Shingles vaccination guidelines? Adults over 60

• #1 cause of ESRD in the US → DM nephropathy

• Histology? Kimmelsteil-Wilson nodules

• #2 cause of ESRD in the US → hypertensive nephropathy
• Pt with BP 240/150. How fast should you lower BP? 25% in first 24 hrs
• Drugs for hypertensive emergencies?

• Nicardipine
• Clevidipine
• Nitroprusside

• AE? Cyanide poisoning

• Tx? Amyl nitrate + thiosulfate OR hydroxycobalamin

• Labelol

• Renal protective medications in patients with DKD or hypertensive nephropathy? ACE-I

• Anemia + Cranial Nerve deficits + Thick bones + Carbonic Anhydrase 2 deficiency + Increased TRAP + Increased Alkaline Phosphatase. → osteopetrosis

• Pathophys? Carbonic anhydrase is defective → osteoclasts cannot produce acid to resorb bone
• Tx? IFN-gamma

• Osteoclasts are a specialized macrophage
• IFN-gamma is an activator of macrophages

• Clinical diagnostic criteria for Chronic Bronchitis

• Diagnostic criteria?

• 2 years
• 3 months/year of chronic cough

• PFT findings

• FEV1 low
• FEV1/FVC ratio low
• RV high
• TLC high

• Which PFT market can differentiate CB from emphysema? DLCO

• DLCO normal → CB
• DLCO low → emphysema

• Tx acute exacerbation? Abx + bronchodilators + corticosteroids (“ABCs”)
• Prevention? Stop smoking!

• Afib

• #1 RF? Mitral stenosis

• #1 RF MS? Rheumatic fever

• MC arrhythmia in hyperthyroidism → Afib
• MC site of ectopic foci in Afib → pulmonary veins
• EKG findings? “Irregularly irregular” + no P eaves
• Location of emboli formation? LA appendage
• Who should be cardioverted back to sinus rhythm?

• New onset (<48 hrs) Afib
• Anticoagulated for 3 weeks + TEE negative for clot
• Afib that’s refractory to medical therapy
• Afib & HDUS

• Q on T phenomenon? Depolarization during T wave (repolarization) can cause QT prolongation → Torsades → death

• Prevention? SYNCHRONIZED cardioversion

• Tx?

• Rate control

• Beta blockers
• ND-CCB (e.g. verapamil, diltiazem)

• Rhythmic control

• Amiodarone

• Reducing stroke risk in Afib? Anticoagulation for CHA2DS2VASc score >= 2
• Anticoagulation options

• Valvular cause (e.g. MS) → warfarin
• Any other cause → warfarin or NOAC

• Reversal of AC

• Warfarin → Vit K, four-factor PCC
• Heparin → protamine sulfate
• Dabigatran → idarucizumab

• Crusty, scaly, ulcerating lesion with heaped up borders → squamous cell carcinoma

• Classic location? Lower lip
• Precursor lesion? Actinic keratosis
• What if it arises in a scar or chronic wound? Marjolin ulcer

• Hypothermia + hypercapnia + non pitting edema + hyponatremia + HR of 35 + hypotension in a patient with a history of papillary thyroid cancer → myxedema coma

• Tx? Levothyroxine + steroids
• Lab findings?

• TSH high
• T3/T4 low
• LDL high

• Acute onset “dermatologic” breakout in a patient with a recent history of weight loss and epigastric pain. → Leser–Trélat sign associated with visceral malignancy

• Lymph node associations

• Supraclavicular → Virchow’s node
• Periumbilical → Sister Mary Joseph