Dit 2014 Step 2 Ck-1

USMLE STEP 2 CK REVIEW
STUDY GUIDE
2014 EDITION
DOCTORS IN TRAINING*
STRUCTURED. FOCUSED. AWESOME.
B rian J enkins , MD
Doctors In Training.com: U SM LE Step 2 CK Review, 2014 edition
Author: Brian Jenkins, M D
Copyright 2014 D octors In Training.com , LLC

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N EU R O LO G Y
1.
2.
3.
4.
S.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Normal Neuro Function

Meningitis
O ther CNS Infections
Headache
T IA
Stroke
Hemorrhage
Seizures
Degenerative Disorders part 1
Degenerative Disorders part 2
Peripheral Disorders
Neoplasms and Sleep
Loss of Consciousness
Pedi Neuro
Ophthalmology part 1
Ophthalmology part 2
Audiovestibular Disorders
3
4
6
8
11
13
15
17
19
21
23
26
29
32
34
37
40
P S Y C H IA T R Y
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Depression
Antidepressants
O ther M ood Disorders
Anxiety Disorders
Psychotic Disorders
Personality Disorders
Substance Abuse part 1
Substance Abuse part 2
O ther Psych Disorders
Delirium and Dementia
Pedi Psych
45
47
51
53
55
59
61
62
64
66
68
E N D O C R IN O L O G Y
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Type 1 Diabetes
Type 2 Diabetes
Insulin Therapy
Acute Complications of Diabetes
Chronic Complications of Diabetes
Normal Thyroid Function and Hyperthyroidism
Hypothyroidism and Thyroid Cancer
Parathyroid Disorders
Pituitary Disorders
Cushing Syndrome and Hyperaldosteronism
O ther Adrenal Disorders
73
74
76
77
79
81
83
86
88
91
92
TABLE OF C O N T E N T S
TABLE OF CONTENTS
TABLE OF CO N TEN TS
TABLE OF CONTENTS
IV
E R , IC U , S U R G E R Y
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
95
98
100
102
105
108
111
113
116
121
122
123
C A R D IO V A S C U L A R
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
VI
Accidents and Injuries part 1

Accidents and Injuries part 2
Toxicology part 1
Toxicology part 2
Toxicology part 3
Cardiovascular Emergencies
Critical Care
Trauma part 1
Trauma part 2
Trauma part 3
Pre-Op and Post-Op Issues
Surgical Emergencies and Transplantation
Cardiology Basics
Atherosclerosis
Hypercholesterolemia
Stable Angina
Unstable Angina
Myocardial Infarction
Arrhythmias part 1
Arrhythmias part 2
H eart Failure
Valvular Diseases
Cardiomyopathies and Pericardial Disease
Myocardial Infections
Hypertension
Antihypertensives
Shock
Vascular Conditions
Vasculitis
Pedi Cardiology
127
128
129
130
132
134
135
137
138
140
142
144
145
147
148
150
152
154
PU LM O N O LO G Y
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
URI
Lower Respiratory Infections part 1
Lower Respiratory Infections part 2
ARDS and Asthma
C O PD
Neoplasms and Interstitial Lung Disease
Pulmonary Vascular Diseases
Pleural Diseases
Sleep Apnea and Pulmonary Surgical Concerns
Pedi Pulmonology part 1
Pedi Pulmonology part 2
159
161
163
165
167
169
171
173
174
176
179
TABLE OF CONTENTS
V II
G A STR O EN TER O LO G Y
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
V I II
Biostatistics
Research Studies
Abstracts and Advertisements
Ethics
211
214
216
220
G E N IT O U R IN A R Y
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
183
184
185
187
189
190
193
195
197
199
200
201
204
206
207
E P ID E M IO L O G Y A N D E T H IC S
1.
2.
3.
4.
IX
GI Infections
Viral Hepatitis
Oral and Esophageal Conditions
Gastric Conditions
Small Intestine part 1
Small Intestine part 2
Large Intestine part 1
Large Intestine part 2
Colorectal Cancer and G I Bleeding
Pancreatic Diseases
Biliary Diseases part 1
Biliary Diseases part 2
Alcoholic Liver Disease and Cirrhosis
O ther Hepatic Diseases
Pedi G I Disorders
Diuretics
Disorders of the Kidney part 1
Disorders of the Kidney part 2
Nephritic Syndromes
Nephrotic Syndromes
Renal Failure
Acid-Base Disorders
Hyponatremia
O ther Electrolyte Disorders
Bladder and Ureteral Disorders
M ale Reproduction part 1
M ale Reproduction part 2
Pedi Urology
225
226
229
231
232
234
236
239
242
244
245
248
251
H EM E/O N C
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Anemia part 1
Anemia part 2
Anemia part 3
Genetic Disorders of Hemoglobin
Leukocyte Disorders and Hypersensitivity
Thrombocytopenia
Coagulopathies and Hypercoagulable States
Hematologic Infections
H IV
H IV Treatment
Myeloma and Lymphoma
Leukemia
Pedi H em e/O nc
255
257
258
259
260
262
264
266
268
269
272
274
276
TABLE OF C O N T E N T S
TABLE OF CONTENTS
XI
M U SCU LO SK ELETA L
1.
2.
3.
4.
5.
6.
7.
Orthopedics part 1
Orthopedics part 2
Metabolic Bone Diseases
Infections, OA and Neoplasms
RA and Lupus
Other Rheumatologic Diseases
Pedi Ortho
281
284
286
288
290
292
295
D ER M A TO LO G Y
1.
2.
3.
4.
5.
6.
Infections part 1
Infections part 2
Infections part 3
Inflammatory Skin Conditions
Bullous Diseases and Neoplasms
Plastics, Pigmentation and H air Loss
301
304
308
311
316
318
G YN ECO LO G Y
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Menstrual Physiology
Menopause
Contraception
Amenorrhea
Menstrual Disorders part 1
Menstrual Disorders part 2
PCOS and Pelvic Prolapse
Gynecological Infections and STDs
Uterine and Cervical Neoplasms
Vaginal and Ovarian Neoplasms
Benign Breast Disorders
Breast Cancer
325
327
330
332
335
337
339
341
343
345
347
349
O B S T E T R IC S
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Normal Pregnancy Physiology

Prenatal Care
Medical Complications part 1
M aternal Drug Use
Congenital Infections
Obstetric Complications part 1
L& D: Assessment of Fetus
L& D: Labor
L&.D: Malpresentation and Cesarean Section
Postpartum Care
353
355
358
360
362
364
367
369
371
373
375
377
379
381
P E D IA T R IC S
1.
2.
3.
4.
5.
Development
Infancy to Adolescence
Infections and Immune Disorders
Genetic Disorders
Preventive Medicine
387
389
393
399
402
NOTES
COURSEVIEWING OPTIONS
The course consists of 169 instructional videos. Examples of 13, 15, 17, 21, 28, and 34 day plans
are provided below for maximum flexibility to meet your personal study needs.
No. of Videos/Day
Video Runtime/Day*
13-day plan
13
Approx. 4.5 hrs
15-day plan
11
Approx. 4 hrs
17-day plan
10
Approx. 3.5 hrs
21-day plan
Approx. 3 hrs
28-day plan
Approx. 2 hrs
34-day plan
Approx. 1.5 hrs
*Does not include study breaks or time spent annotating and answering questions.
l t h o u g h y o u h a v e t h e f l e x ib il it y t o v ie w t h e v id e o s in a n y o r d e r , w e s t r o n g l y r e c o m m e n d
HOW MANY VIDEOS YOU VIEW IN A DAY.
Introduction
1A
IB
Neurology 1 - Normal Neuro Function
1C
Neurology 2 - M eningitis
ID
Neurology 3 - O ther CNS Infections
IE
Neurology 4 - Headache
IF
1G
Neurology 5 - T IA
1H
Neurology 7 - Hemorrhage
Neurology 6 - Stroke
Neurology 8 - Seizures
ij
IK
Psychiatry 1 - Depression
Psychiatry 2 - Antidepressants
Psychiatry 3 - O ther M ood Disorders
2A
Psychiatry 4 - Anxiety Disorders
2B
Psychiatry 5 - Psychotic Disorders
2C
Neurology 9 - Degenerative Disorders part 1
2D
Neurology 10 - Degenerative Disorders part 2
2E
Neurology 11 - Peripheral Disorders
2F
Neurology 12 - Neoplasms and Sleep
2G
Neurology 13 - Loss o f Consciousness
2H
Neurology 14 - Pedi Neuro
21
Neurology 15 - Ophthalmology part 1
2J
2K
Neurology 16 - Ophthalmology part 2

Neurology 17 - Audiovestibular Disorders
3A
Psychiatry 6 - Personality Disorders
3B
Psychiatry 7 - Substance Abuse part 1
3C
Psychiatry 8 - Substance Abuse part 2
3D
Psychiatry 9 - O ther Psych Disorders
3E
Psychiatry 10 - Delirium and Dementia
3F
Psychiatry 11 - Pedi Psych
3G
Endocrinology 1 - Type 1 Diabetes
3H
Endocrinology 2 - Type 2 Diabetes
31
Endocrinology 3 - Insulin Therapy

Endocrinology 4 - Acute Complications o f Diabetes
3J
3K
Endocrinology 5 - Chronic Complications of Diabetes
COURSE O R D E R
THAT YOU WATCH THE VIDEOS IN THE ORDER IN WHICH YOUR DASHBOARD PRESENTS THEM REGARDLESS OF
RECOMMENDED
RECOMMENDED COURSE ORDER
COURSE ORDER
RECOMMENDED
Hi
4A
4B
Endocrinology 6 - Normal Thyroid Function and Hyperthyroidism

Endocrinology 7 - Hypothyroidism and Thyroid Cancer
4C
4D
4E
4F
4G
4H
41
4J
4K
5A
Endocrinology 8 - Parathyroid Disorders

Endocrinology 9 - Pituitary Disorders
Endocrinology 10 - Cushing Syndrome and Hyperaldosteronism
Endocrinology 11 - Other Adrenal Disorders
ER, ICU, Surgery 1 - Accidents and Injuries part 1
ER, ICU, Surgery 2 - Accidents and Injuries part 2
ER, ICU, Surgery 3 - Toxicology part 1
Cardiovascular 1 - Cardiology Basics
5B
5C
5D
Cardiovascular 2 - Atherosclerosis
Cardiovascular 3 - Hypercholesterolemia
Cardiovascular 4 - Stable Angina
5E
SF
5G
Cardiovascular 5 - Unstable Angina

Cardiovascular 6 - Myocardial Infarction
Cardiovascular 7 - Arrhythmias part 1
5H
Cardiovascular 8 - Arrhythmias part 2
SI
5J
ER, ICU, Surgery 6 - Cardiovascular Emergencies

Cardiovascular 9 - Heart Failure
5K
6A
6B
Cardiovascular 10 - Valvular Diseases

Cardiovascular 11 - Cardiomyopathies and Pericardial Disease-
6C
Cardiovascular 12 - Myocardial Infections

Cardiovascular 13 - Hypertension
6D
6E
Cardiovascular 14 - Antihypertensives
Cardiovascular 15 - Shock
6F
ER, ICU, Surgery 7 - Critical Care
6G
6H
Cardiovascular 16 - Vascular Conditions

Cardiovascular 17 - Vasculitis
61
Cardiovascular 18 - Pedi Cardiology

ER, ICU, Surgery 8 - Trauma part 1
6J
6K
6L

ER, ICU, Surgery 11 - Pre-O p and Post-Op Issues
7B
ER, ICU, Surgery 12 - Surgical Emergencies and Transplantation

Pulmonology 1 - U R I
7C
7D
7E
Pulmonology 2 - Lower Respiratory Infections part 1
7F
Pulmonology 4 - A R D S and Asthm a

Pulmonology 5 - C O PD
' 7G
IBM
Pulmonology 3 - Lower Respiratory Infections part 2
Pulmonology 6 - Neoplasms and Interstitial Lung Disease
71
Pulmonology 7 - Pulmonary Vascular Diseases
7J
7K
Pulmonology 8 - Pleural Diseases

Pulmonology 9 - Sleep Apnea & Pulmonary Surgical Concerns
7L
Pulmonology 10 - Pedi Pulmonology part 1
7M
Pulmonology 11 - Pedi Pulmonology part 2
8A
Gastroenterology 1 - GI Infections
8B
Gastroenterology 2 - Viral Hepatitis
8C
Gastroenterology 3 - O ral and Esophageal Conditions
8D
Gastroenterology 4 - Gastric Conditions
8E
Gastroenterology 5 - Small Intestine part 1
8F
Gastroenterology 6 - Small Intestine part 2
8G
Gastroenterology 7 - Large Intestine part 1
8H
Gastroenterology 8 - Large Intestine part 2
81
Gastroenterology 9 - Colorectal Cancer and G I Bleeding
8J
9A
Gastroenterology 10 - Pancreatic Diseases
9B
9C
Gastroenterology 12 - Biliary Diseases part 2

Gastroenterology 13 - Alcoholic Liver Disease and Cirrhosis
9D
Gastroenterology 14 - O ther Hepatic Diseases
9E
Gastroenterology 15 - Pedi G I Disorders
9F
Epidemiology and Ethics 1 - Biostatistics
9G
Epidemiology and Ethics 2
9H
Epidemiology and Ethics 3 - Abstracts and Advertisements
91
Epidemiology and Ethics 4 - Ethics
9J
9K
Genitourinary 1 - Diuretics
9L
Genitourinary 3 - Disorders of the Kidney part 2
Gastroenterology 11 - Biliary Diseases part 1
Research Studies
G enitourinary 2 - Disorders of the Kidney part 1
COURSE O RD ER
7A
RECOMMENDED

10A
10B
IOC
10D
10E
10F
10G
10H
101
10J
llA
11B
11C
11D
I IF
111
11G
Genitourinary 4 - Nephritic Syndromes

Genitourinary 5 - Nephrotic Syndromes
Genitourinary 6 - Renal Failure
Genitourinary 7 - Acid-Base Disorders
Genitourinary 8 - Hyponatremia
Genitourinary 9 - Other Electrolyte Disorders
Genitourinary 10 - Bladder and Ureteral Disorders
Genitourinary 11 - Male Reproduction part 1
Genitourinary 12 - Male Reproduction part 2
Genitourinary 13 - Pedi Urology
Heme/Onc
Heme/Onc
Heme/Onc
Heme/Onc
Heme/Onc
Heme/Onc
1 - Anemia part 1
2 - Anemia part 2
3 - Anemia part 3
4 - Genetic Disorders of Hemoglobin
5 - Leukocyte Disorders and Hypersensitivity
6 - Thrombocytopenia
HI
Heme/Onc 7 - Coagulopathies and HyperCoagulable States

Heme/Onc 8 - Hematologic Infections
Heme/Onc 9 - H IV
in
UK
Heme/Onc 10 - H IV Treatment
Heme/Onc 11 - Myeloma and Lymphoma
n il
11L Heme/Onc 12 - Leukemia

11M Heme/Onc 13 - Pedi Heme/Onc
12A Musculoskeletal 1 - Orthopedics part 1
12B Musculoskeletal 2 - Orthopedics part 2
12C Musculoskeletal 3 - Metabolic Bone Diseases
12D Musculoskeletal 4 - Infections, OA and Neoplasms
12E
Musculoskeletal 5 - RA and Lupus

12F Musculoskeletal 6 - O ther Rheumatologic Diseases
12G Musculoskeletal 7 - Pedi Ortho
12H Dermatology 1 - Infections part 1
121 Dermatology 2 - Infections part 2
12J Dermatology 3 - Infections part 3
12K Dermatology 4 - Inflammatory Skin Conditions

13A
13B
Dermatology 5 - Bullous Diseases and Neoplasms
:' r v ; v
:7
: i , v- : r
i:;V
Dermatology 6 - Plastics, Pigmentation and H air Loss

Gynecology 1 M enstrual Physiology
13D Gynecology 2 - Menopause
13E Gynecology 3 - Contraception
13F Gynecology 4 y Amenorrhea
13C
13G Gynecology 5 - M enstrual Disorders part 1

13H Gynecology 6 - M enstrual Disorders part 2
131 Gynecology 7 - PCO S and Pelvic Prolapse
13J Gynecology 8 - Gynecological Infections and STDs
14A Gynecology 9 - Uterine and Cervical Neoplasms
14B
Gynecology 10 - Vaginal and Ovarian Neoplasms
14C
Gynecology 11 - Benign Breast Disorders
14D
Gynecology 12 - Breast Cancer
14E
Obstetrics 1 - Normal Pregnancy Physiology
14F
Obstetrics 2 - Prenatal Care
14G
Obstetrics 3
14H
Obstetrics 4 - Medical Complications part 2
141
Obstetrics 5 - M aternal Drug Use
14J
Obstetrics 6 - Congenital Infections
15A Obstetrics 7 - Obstetric Complications part 1

15B
Obstetrics 8 - Obstetric Complications part 2
15C
Obstetrics 9 - Obstetric Complications part 3
15D Obstetrics 10 - Obstetric Complications part 4

15E Obstetrics 11 - L& D : Assessment of Fetus
1111 1SF Obstetrics 12 - L& D : Labor

15G
Obstetrics 13 - L& D : Malpresentation and Cesarean Section
1511 Obstetrics 14 - Postpartum Care
mm
151
15J
15K
Pediatrics 1 - Development
Pediatrics 2 - Infancy to Adolescence
Pediatrics 3
Infections and Immune Disorders
15L
Pediatrics 4
Genetic Disorders
3 -5 M
Pediatrics 5
Preventive Medicine
vasai
N eurology
1
N orm al N euro F unction
M en in g itis
O th e r C N S Infections
H eadache
T IA
Stroke
H em orrhage
Seizures
D egenerative D isorders p a rt 1
10 D egenerative D isorders p a rt 2
11 P eripheral D isorders
12 N eoplasm s and Sleep
13 Loss o f Consciousness
14 Pedi N euro
15 O p h th alm o lo g y p a rt 1
16 O p h th alm o lo g y p a rt 2
17 A udiovestibular D isorders
NORMAL NEURO FUNCTION
End of Session Quiz

1.
W h a t are the tw o m ost common locations o f aneurysms in the circle o f Willis?
2.
W h ic h spinal cord lesion matches each o f the following descriptions?

Fasciculations but also spastic paralysis
Impaired proprioception + pupils do not react to light
Bilateral loss of pain and temp below the lesion + hand weakness
Bilateral loss of vibration sense + spastic paralysis of legs then arms
Bilateral loss of pain/temp below lesion + bilateral spastic paralysis below lesion +
bilateral flaccid paralysis at the level of the lesion
3.
A lesion to which area o f the brain is responsible for each o f the following clinical
scenarios?
o Contralateral hemiballismus
Hemispatial neglect syndrome
Poor comprehension
Poor vocal expression
Personality changes
Agraphia and acalculia (inability to write, inability to do mathematical
calculations)
MENINGITIS
3 Question Warm-Up
1
W here does each o f the following spinal tracts decussate/cross over?

Dorsal columns
Lateral corticospinal tract
Spinothalamic tract
2.
W h a t cerebral artery infarct can cause aphasia?
3.
W hat are the characteristic features o f Brown-Sequard syndrome?
Bacterial Meningitis
4. W hat are the common organisms and empiric IV antibiotic choices for
bacterial meningitis based on the age of the patient?
Age Range
Organisms
Empiric Antibiotics
<1 month of age
Preferred medications:
1) ampicillin +
2) cefotaxime or gentamicin
1 month to 60
years of age
Adult dosing shown here:

1) cefotaxime or ceftriaxone
2) vancomycin
3) dexamethasone IV q6hrs x4d
(if over 6w of age)
>60 years,
alcoholism, or
debilitating
comorbidities
1) ampicillin (Listeria coverage)

2) cefotaxime or ceftriaxone
3) vancomycin
4) dexamethasone IV q6hrs x4d
5. W hat is the rational for dosing dexamethasone prior to or along with the first
dose of antibiotics for empiric treatment of bacterial meningitis?
Dexamethasone, when given with or prior to the first dose of antibiotic, reduces the risk
o f___________________________ inchildren with meningitis, especially in the cases
o f___________________________ .
In adults with bacterial meningitis, dexamethasone reduces both morbidity and mortality,
especially in the case o f _________________________ .
Viral Meningitis
6. W hat is the treatm ent for viral meningitis?
End of Session Quiz

7.
W h a t organism is responsible for bacterial meningitis given each o f the

following findings on C S F examination?
Gram-positive diplococci
Gram-negative diplococci
Small pleomorphic Gram-negative coccobacilli
Gram-positive rods and coccobacilli
8.
W h a t medication should be given to close contacts o f those w ith either

meningococcal or H ib (Haemophilus influenzae type B) meningitis?
9.
W h en should a C T scan be performed as a next step instead o f an L P in a

patient suspected o f having meningitis?
10.
You suspect an A ID S patient may have meningitis. W h a t fungal infection

should you be m ost concerned about?
11.
W h a t is the treatm ent for fungal meningitis?
12.
W h a t medications are used in combination in the treatm ent o f T B meningitis?
!
I
CO
NEUROLOGY
Acetaminophen for pain

IV fluids as needed
Empiric antibiotics until___________________________
If younger than 3 years, severely ill or immunocompromised, continue empiric antibiotics
until bacterial culture results confirm nonbacterial etiology
___________________ if suspicion of HSV or signs of encephalitis such as focal
neurologic findings
Discontinue if HSV PCR and cultures are negative or alternative diagnosis is made
Z
z
OTHER CNS INFECTIONS
3 Question Warm-Up
1.
W h a t is the most effective way to prevent bacterial meningitis in newborns?
2.
W h a t other drug should be given just before or along with the first dose of
antibiotics in a patient suspected o f having bacterial meningitis?
3.
W h a t is the most common location of a berry aneurysm?
W est Nile Virus

Birds are the reservoir, and mosquitoes are the vectors. Humans, horses and dogs are
incidental hosts
Sx: usually only headache, malaise, back pain, myalgia and anorexia for 3-6 days (flu
like)
Severe Sx in 1/150: meningitis +/- encephalitis including muscle weakness and flaccid
paralysis (via anterior horn involvement), alterations in consciousness, possibly death
D x:______________________________
Treatment:________________________
End of Session Quiz

5.
A patient is adm itted to the hospital w ith the presumptive diagnosis o f viral
meningitis. A n M R I o f the head shows lesions within the right temporal lobe.
W ith which pathogen is this pattern most consistent?
6.
W h a t are the features o f Reye syndrome?
7.
H o w should you treat a patient w ho has been bitten by an animal suspected o f

having rabies or by an animal th at cannot be observed for 10 days?
8.
A patient is brought into the E R w ith progressive muscle weakness, retained

sensation, headache, vomiting, neck pain and fever. C S F analysis shows
increased lymphocytes and norm al glucose and protein. W h a t life-threatening
complication can result i f this disease progresses?
HEAD ACH E
HEADACHE
3 Question Warm-Up
1
H ow do the symptoms o f encephalitis differ from those o f meningitis?
2.
Fill in the table o f C SF findings in cases o f meningitis caused by different types

o f pathogens.
Pressure
W BCs
Glucose
Protein
Healthy
Bacterial
Viral
TB/
fungal
3.
4.
W h a t other term should you remember when thinking about Reye syndrome?
W hat are the differences in the acute treatment of tension headaches, cluster
headaches and migraine headaches?
Type of Headache
Treatment
Tension headache
NSAIDs
Cluster headache
100% 0 2 (6+ L/m in on non-rebreather for 20+ min) and

sumatriptan or dihydroergotamine (D H E 45)
Migraine headache
Sumatriptan (or other triptan), dihydroergotamine (D H E

45), NSAIDs, and/or antiemetics (chlorpromazine,
prochlorperazine, metoclopramide) in varying combinations
based on severity, nature of symptoms and patients history
S. W hat agents can be used for prophylaxis of migraine headaches?

: verapamil (often first-line b/c safe and well tolerated)
propranolol, metoprolol (good choice if comorbid hypertension)
amitriptyline, nortriptyline (good choice if comorbid depression,
insomnia, pain syndrome)
------------------------------ : naproxen (good choice if menstrual migraine or comorbid
osteoarthritis or other pain that could benefit from NSAIDs)
------------------------------ : valproic acid (good if history of bipolar disorder), topiramate,
gabapentin
6. W hat headache symptoms would lead you to suspect a brain tum or as a cause
of a headache?
m
>
O
>
n
x
m
Pseudotumor Cerebri
7. W hat are the characteristic features of pseudotumor cerebri?
Young, obese woman
Headaches daily (worse in the morning), pulsatile, possible nausea/vomiting, possible
retroocular pain worsened by eye movement
O
Most worrisome sequela is vision loss
C T scan:___________________________
0 CSF pressure elevated ( ______________ in non-obese patient,______________ in obese
patient)
8. W hat treatm ent options are available for managing pseudotumor cerebri?
Confirm absence of other pathology with C T and M RI of the head (r/o central venous
thrombosis)
Discontinue any inciting agents (e.g.,_______________________________
)
___________________________ in obese patients
o ___________________________ - first line (start 250mg qid or 500mg bid > increase to
500mg qid to lOOOmg qid)
Invasive treatment options
- Serial lumbar punctures
- Optic nerve sheath decompression
Lumboperitoneal shunting (CSF shunt)
[9 )
NEUROLOGY
Mild headache which progressively worsens over days to weeks

New onset after age 50
_________ ; worsened by bending, lifting, cough or Valsalva maneuver (increased
intracranial pressure)
Associated seizures, confusion, altered mental status
Abnormal neurologic signs and symptoms (e.g., focal numbness or weakness)
Disturbs sleep or presents immediately upon awakening
Vomiting precedes headache
Known systemic illness (e.g., cancer, HIV, or collagen-vascular disorder)
What is the most likely cause of headache based on each of the following
descriptions?
Made worse by foods containing tyramine
Obese woman with papilledema
Jaw muscle pain when chewing
Periorbital pain with ptosis and miosis
Photophobia and/or phonophobia
Bilateral frontal/occipital pressure
Lacrimation and/or rhinorrhea
Elevated ESR
Worst headache of my life
Headache + extraocular muscle palsies
Scintillating scotomas prior to headache
Headache occurring either before or after
orgasm
Responsive to 100% oxygen supplementation
Frontal headache made worse by bending over
Trauma to the head > headache begins days
after the event, persists for over a week and
does not go away
E nd o f Session Quiz
10. W h a t is the pattern o f pain in a migraine? In a tension headache?
11. A 27-year-old m an comes to the clinic because o f a progressively worsening

headache. H e says that he never used to have headaches until this one. H e adds
that this one was easy to ignore at first but over the last few weeks has never let
up and is increasing in severity. W h a t should be next for this patient?
12. W h at would be the preferred antihypertensive in a patient w ith chronic

hypertension and recurrent migraines?
TIA
NEUROLOGY
3 Question Warm-Up
1.
A lesion to which area o f the brain is responsible for each o f the following
clinical scenarios?
Agraphia and acalculia
Hemispatial neglect syndrome
Personality changes
Coma
2.
M eningitis is diagnosed in a neonate. W h a t are the m ost likely organisms, and

w hat is the empiric treatment?
3.
W h a t should always be done prior to LP?
Transient ischemic attack (T IA )

4. W h at is the anticoagulant of choice in a patient with a history of stroke or T IA
given each of the following scenarios?
First TIA
TIA/stroke due to atrial fibrillation
TIA/stroke + coronary artery disease
Repeat TIA/stroke while on aspirin
Carotid artery disease

5. W h at are the classic signs and symptoms of carotid artery stenosis?
o
Transient ischemic attacks (TIAs)

Reversible ischemic neurologic deficits lasting up to 3 days
Amaurosis fugax (transient unilateral blindness)
Cerebrovascular accidents (CVAs)
o ______________________ are not caused by carotid artery stenosis
6. W h at are the surgical indications for carotid endarterectomy?

Symptomatic patients with narrowing o f______________________
Symptomatic men with narrowing o f______________________
Asymptomatic patients with narrowing of______________________ provided the fife
expectancy is > 5 years and the surgeon has a perioperative complication rate of < 3%
I [ 'I ]
W hat are the important nonsurgical treatments for carotid artery stenosis?
H TN control to < 140/90
Dyslipidemia control to LDL < 100 mg/dL, HD L > 35 mg/dL, triglycerides < 200 mg/dL
Lipid control with statins reduces stroke while other lipid-lowering drugs do not
Niacin reduces carotid artery mtima thickness
Al IA diet
DM control to fasting glucose < 126 mg/dL and H bA lC < 7%

Smoking avoidance, consider varenicline (Chantix)
Increased physical activity to at least 30-60 minutes 4 times weekly
Red wine consumption up to 2 drinks daily is beneficial. Avoidance of heavy drinking
Evaluation for CAD and PAD
________________ (if history of TIA/stroke while on aspirin use Aggrenox or
clopidogrel instead)
End o f Session Quiz

8.
List some major signs and symptoms o f a T IA .
9.
W h at anticoagulant would you give a patient who has just had his/her first TIA ?
I f the patient had another T IA while on ASA, what would you add?
10.
H ow long must a focal neurologic deficit last to qualify as a stroke?
STROKE
3 Question Warm-Up
1.
A child presents to the E R w ith mental status changes, hypoglycemia and

lesions suggestive o f chickenpox. W h a t is the most likely diagnosis?
2.
W h a t type o f headache causes unilateral, severe periorbital headache w ith

tearing?
3.
C S F analysis shows low glucose, elevated neutrophils and Gram-positive

diplococci. W h a t is the diagnosis?
4. W hat are the five main lacunar syndromes that may arise from a lacunar infarct?
Lacunar Syndrome
Description
Weakness of the face, arm and leg on one side of the
body + absent sensory or cortical signs (aphasia, neglect,
apraxia, hemianopsia)
(M ost common, about 50% of lacunar strokes)
Sensory defect (numbness) of the face, arm and leg on
one side of the body + absent motor or cortical signs
Ipsilateral weakness and limb ataxia out o f proportion

to the motor defect, possible gait deviation to the
affected side + absent cortical signs
Weakness and numbness of the face, arm and leg on
one side of the body + absent cortical signs
Facial weakness, dysarthria, dysphagia and slight

weakness and clumsiness o f one hand + absent sensory
or cortical signs
(Least common)

5.
In what timeframe must thrombolytic therapy be instituted in cases of ischemic

stroke?
6.
W h at is the principal cause o f a lacunar infarct?
7.
A patient with a D V T develops a stroke. W h a t study would most likely

identify the underlying etiology o f the stroke?
8.
W hat neurologic defects would be seen with an infarction o f the following

arteries?
Anterior cerebral artery
Middle cerebral artery
Posterior cerebral artery
Lacunar arteries
Basilar artery
HEM ORRHAGE
HEMORRHAGE
3 Question Warm-Up
1.
W h at are the four most common sequelae of meningitis in children?
2.
W h a t does a ring-enhancing brain lesion on C T in a patient w ith seizures

suggest?
3.
A 30-year-old w om an is in the office with a complaint o f facial pain. She

describes th at whenever her face is lightly touched she experiences incredible
electrical-like pain. W h a t is the first-line treatm ent for this condition?
4. W hat is the treatm ent for a subarachnoid hemorrhage?

Discontinue all anticoagulants and reverse any anticoagulation
Systolic blood pressure <
only if cognitive function is intact (adequate cerebral
perfusion pressure) until the aneurysm is clipped or coiled to prevent rebleeding. If the
cerebral perfusion pressure is not adequate, then lowering the BP will increase the risk of
infarction.
- _____________________________ preferred
A void_____________________________ which can increase intracranial pressure
___________________________(a CCB) to prevent vasospasm
Prevent physiologic derangements that may worsen brain injury
- Avoid hypoxia and hyperglycemia
Maintain a normal pH, euvolemia and normothermia
Phenytoin for seizure prophylaxis is controversial and generally avoided due to poorer
outcomes.
Ventriculostomy to monitor intracranial pressure in select patients
Surgical__________________________ into aneurysm
[ 15]
End of Session Quiz

5.
In which scenario is seizure prophylaxis with anticonvulsants recommended:

parenchymal hemorrhage or subarachnoid hemorrhage (SAH)?
6.
W h at are 3 feared complications o f parenchymal hemorrhage?
7.
W h at are the most common causes o f an epidural hematoma and a subdural

hematoma?
8.
I f you suspect a patient has an epidural or subdural hematoma, should you

perform a L P to confirm the diagnosis?
9.
W h a t is the treatment for subarachnoid hemorrhage?
SEIZURES
3 Question Warm-Up
1.
C om paring ischemic stroke, intracerebral hemorrhage and subarachnoid

hemorrhage, w hat are the different BP goals and BP medications?
BP goal
BP medications
Ischemic stroke
Intracerebral hemorrhage
Subarachnoid hemorrhage
2.
A 40-year-old m an presents w ith daily, unilateral retroorbital headaches

associated w ith rhinorrhea and lacrimation. W h a t is the diagnosis, and what
treatm ent w ill rapidly abort his headache?
3.
You suspect an A ID S patient may have meningitis. W h a t specific C SF

preparation should be ordered in addition to the usual C S F analysis, G ram stain
and culture?
4. W hich medications or medication withdrawals are known for causing seizures?
5.
W h at seizure medications are used for prevention of each of the following

types of recurrent seizures?
Seizure type
Initial treatment of choice
Grand mal (tonic-clonic)
valproate, carbamazepine, phenytoin, lamotrigine,

topiramate
Partial
> valproate, topiramate
Absence
Myoclonic
6.
W hich seizure medication matches each of the following descriptions?
Gingival hyperplasia
Drag of choice for absence seizures
Second choice for absence seizures
Drug of choice for trigeminal neuralgia
SEIZURES
7.
Which drugs are known for causing Stevens-Johnson syndrome?
8. Which drugs are known for inducing the cytochrome P450 system, thereby
speeding up the metabolism of other drugs such as O C P s and warfarin?

9.
W h at type o f seizure fits each description?

Focal sensory or motor deficit with NO loss of
consciousness
Focal sensory or motor deficit with impaired
consciousness (commonly localized to temporal
lobe on EEG)
Involves both hemispheres of brain with a pattern
of neuromuscular activation: tonic, clonic, tonicclonic, myoclonic, or atonic. Loss of consciousness
present with postictal period
Characterized by a brief (few seconds) impairment
of consciousness. No postictal period. Spike-andwave pattern on EEG.
10.
W h at are the most common causes o f seizures in children aged 2-10 years?
11.
W hat are the most common causes of seizures in young adults (18-35 years)?
12.
13.
14.
Although benzodiazepines are used to end a seizure in status epilepticus, what is

of more concern in the initial treatment?
W h a t is the drug o f choice for absence seizures?
A 45-year-old man is brought to the E R for new-onset status epilepticus. W h at

are some of the components o f the work-up to determine the cause o f epilepsy?
DEGENERATIVE DISORDERS PART I
3 Question Warm-Up
1.
W h a t two side effects should a physician be aware o f when using atypical

antipsychotics?
2.
W h a t are the signs and symptoms o f a T C A overdose? H ow is it managed?
3.
A patient is brought into the E R w ith headache, vomiting, neck pain and fever.
There is progressive muscle weakness, but sensation is intact. C S F analysis
shows normal glucose and protein, but the C SF lymphocyte count is high.
W h a t is the diagnosis?
4. W hat medications are used in the management of Parkinsonian symptoms?

Levodopa + carbidopa
______________________(MAO-B inhibitor) used in early disease and has
neuroprotective effects.
Dopamine agonists:
- ________________________(ergot compound)
Non-ergot D3 stimulators pramipexole, ropinirole, rotigotine (transdermal)
- Apomorphine (subQ) rescue therapy for sudden akinetic episodes
_____________________to potentiate levodopa: entacapone, tolcapone
_____________________for tremor: trihexyphenidyl, benztropine
________________ to increase dopamine release. Used as short-term monotherapy in
mild disease.
W hat are the characteristic features of amyotrophic lateral sclerosis (A LS,

Lou Gehrig disease)?
Weakness but with normal sensation
Initial presenting symptoms:
________________________ (80%) in hands, fingers, shoulder girdle, lower extremity
(foot drop) Oh pelvic girdle
( 20 %)
Upper motor neuron (UMN) signs and symptoms: movement stiffness, slowness and
incoordination; spasticity and hyperreflexia (spastic paralysis); slowed rapid alternating
movements; gait disorder
Bulbar UMN signs and symptoms: dysarthria; dysphagia; pseudobulbar affect with
inappropriate laughing, crying or yawning
Lower UMN signs and symptoms: weakness, gait disorder, reduced reflexes (flaccid
paralysis), muscle atrophy and fasciculations
Cognitive defects: frontotemporal executive dysfunction
Neuromuscular respiratory failure after months to years (average survival from time of
diagnosis is 3-5 years)
W hat are the C s of Huntington chorea?

CAG repeat disorder on chromosome Cuatro (4)
Caudate andputamen atrophy on MRI
Acetylcholine decrease
G A B A decrease
Cognitive decline (dementia)

Choreiform movements
Cuarenta (40) = age of onset

7.
W h a t medication is most commonly used to treat Parkinson disease?
8.
W h a t brain lesion is seen in patients w ith Parkinson disease?
9. W h a t will an electromyogram reveal in ALS?
10. W h a t medication is used to treat ALS?
11. W h a t is the life expectancy once a patient is diagnosed w ith ALS?
12. W h at drugs may be used to treat H untington disease?
DEGENERATIVE DISORDERS PART 2
3 Question Warm-Up
1.
W h a t is the pattern o f pain in a migraine? In a tension headache?
2,
W h a t is the treatm ent for nephrogenic diabetes insipidus caused by lithium

toxicity?
3.
A patient fell off a 20-foot-ladder and landed on his head. H is wife says
although he seemed dazed initially, he recovered quickly and seemed fine for
2 or 3 hours, before becoming confused, disoriented and somnolent. W h a t are
the diagnosis, the underlying injury and the treatment?
4. W h at are the usual components of a dementia work-up ?
5. W h at are the unique features of Lewy body dementia?
6. W hat are the unique features of frontotemporal dementia (Pick disease)?
DEGENERATIVE DISORDERS PART 2
End o f Session Q uiz

7.
A 66-year-old woman with forgetfulness and decreased bilateral parietal lobe

activity on P E T scan has what form o f dementia?
8.
W h a t medications are used in the treatment o f Alzheimer disease?
9.
How does one differentiate between vascular dementia and Alzheimer disease?
10.
W h at are two symptoms that should clue you in to the diagnosis o f multiple
sclerosis (MS)?
11.
W h at is the most sensitive test for multiple sclerosis?
12.
W h a t medication decreases the frequency o f relapses in patients w ith multiple

sclerosis?
13.
W h a t im portant neuronal tract is the first to be compressed and compromised

in the case o f syringomyelia?
PERIPHERAL DISORDERS
3 Question Warm-Up
1.
H ow do the features o f acute dystonia differ from tardive dyskinesia?
2.
W h ich medication is used more than any other in the treatm ent o f Parkinson
patients?
3.
W h a t is the maxim um am ount o f tim e a TLA. may last?
4. W hat is the classic presentation of Guillain-Barre syndrome (GBS)?

Symmetric muscle weakness that progresses over days to 4 weeks (usually 2 weeks)
Usually beginning in the distal legs but may begin in the arms or facial muscles in 10% of
cases
__________________________ requiring mechanical ventilation in ___________of
cases
__________________________ and/or oropharyngeal weakness in __________ which
may include bilateral facial muscle paralysis
Autonomic dysfunction in 70% - usually________________________
Absent or depressed deep tendon reflexes
Little if any change in sensation
No fever at the onset of symptoms
GBS may be preceded by:
Campylobacterjejuni diarrheal illness (about 20% of cases)
HIV infection
CM V infection
EBV infection
- Mycoplasma infection
- Other viral infections
Immunization (extremely rare)
5.
How is the diagnosis of Guillain-Barre syndrome made in a patient with

ascending muscle paralysis?
Characteristic clinical presentation
CSF analysis
(elevated protein and normal WBCs)
Electrodiagnostic studies: nerve conduction studies and electromyography (EMG) reveal
PERIPHERAL D ISO RDERS
6. W hat is the prognosis of a patient with Guillain-Barre syndrome?
7.
Spontaneous regression and complete recovery by 1 year in 80-90%

Relapse in 10%
Prolonged disease with delayed or incomplete recovery in 5-10%
Death despite ICU care in 5%
W hat is the treatment of Guillain-Barre syndrome?

Hospitalization for respiratory monitoring including vital capacity, BP monitoring, cardiac
monitoring (telemetry) and daily abdominal auscultation for ileus
Mechanical ventilation required in 30% of patients
ICU monitoring for autonomic dysfunction required in 20% of patients
Equally effective at shortening time to independent walking by iSQfb
Combining the two offers no additional benefit
_______________________ are NO T recommended in the treatment of GBS.

Previously the mainstay of therapy; new studies show absolutely no benefit.
8. W hat is required to make the diagnosis of Bells palsy?

Clinical diagnosis:
Diffuse involvement of the entire facial nerve >facial muscle paralysis (upper and lower)
Rule out Lyme disease b y _________________ : tick bite, heart block, arthritis, vertigo,
hearing loss
Rule out Otitis media b y__________________
Rule out stroke b y _______________________
Acute onset (1-2 days) >progressively worsening weakness for 3 weeks recovery within
6 months
Anything other than the above presentation requires imaging (CT and/or MRI) and
screening blood tests to rule out other pathology
| 2 4 ]
W hat is the treatm ent for Bells palsy?

Eye care to prevent corneal trauma
Artificial tears hourly while awake
Lubricating ointment qHS
Patch covering the eye at night
Glucocorticoids (e.g., prednisone 60mg daily x 1 week)
+/- Valacyclovir lOOOmg tid x 1 week (acyclovir provides no additional benefit over
glucocorticoids)
End of Session Quiz

10.
11.
12.
13.
W h a t test can help make the diagnosis o f myasthenia gravis?
H o w does Lam bert-Eaton syndrome differ from myasthenia gravis (M G ) on

history and physical exam?
W h a t are the treatm ent options for benign essential tremor?
A 35-year-old wom an presents w ith ptosis and diplopia that worsens throughout
the day. W h a t is the underlying problem?
14.
W h a t is a classic presentation o f Guillain-Barre syndrome?
15.
H ow do you treat Guillain-Barre syndrome?
16.
H o w can Bells palsy be easily differentiated from a motor cortex stroke?
NEOPLASMS AND SLEEP

s
'
. i -
v ... '
mw " m
" $
3 Question Warm-Up
1
W h a t two medications could be used for prophylaxis against meningococcal

meningitis?
2.
W h a t two classes o f medication could be used both to treat chronic

hypertension and also to prevent recurrent migraines?
3.
H ow do edrophonium, neostigmine and pyridostigmine work in the treatment

o f myasthenia gravis?
. W hat are the differences between nightmares and night terrors?

Nightmares - during REM sleep, patients that appear to wake up are actually awake
Night terrors - during non-REM sleep, patients that appear awake (and are frightened/
screaming, tachycardic and diaphoretic) are actually not fully awake, difficult to arouse
and usually fall right back to sleep after the episode
W hat is required to make the diagnosis of narcolepsy?

_______________________ (sudden loss of muscle tone) only occurs in narcolepsy and is
virtually diagnostic when present
Other causes of excessive daytime sleepiness are ruled out
Overnight polysomnogram (to r/o O SA and periodic limb movement disorder)
Rule out sedating medications as a cause
Multiple Sleep Latency Test - when given 4-5 opportunities to nap every 2 hours,
narcolepsy patients fall asleep in less than 8 minutes
W hat is the treatm ent for narcolepsy?
Avoidance of drugs that cause sleepiness

Scheduled naps (once or twice a day for 10-20 minutes)
Stimulants - _______________________ isfirst-line
Support group attendance
If cataplexy * venlafaxine, fluoxetine or atomoxetine
W hat medications are common in the treatm ent of insomnia? W hat makes
each one unique?
M elatonin
Non-addictive, O T C , vivid dreams, safe for < 3 months
Valerian
O T C herbal remedy, studies show no benefit
Antihistamines
(diphenhydramine,
doxylamine)
Commonly used by patients first-line, associated with

poor sleep quality, not for long-term use, anticholinergic
side effects (avoid in the elderly)
Trazodone
Antidepressant, decreases sleep latency, small risk of

priapism
TCA s
(amitriptyline,
doxepin)
Antidepressant, small risk of arrhythmias (obtain EKG

prior to use), anticholinergic side effects (avoid in the
elderly)
Benzodiazepines:
(temazepam,
lorazepam,
clonazepam,
diazepam,
chlordiazepoxide)
Addictive, short-term only (< 35 days)
Zolpidem
Zaleplon
Act at the benzo receptor, short-term only (< 35 days),

rebound insomnia when discontinued
Eszopiclone
May be used long-term
Ramelteon
Non-addictive because it works at melatonin receptors

instead of GABA/benzo receptors, avoid if hepatic
insufficiency, long-term studies are lacking
NEOPLASMS AND SLEEP
8. Restless Leg Syndrome

The sensation of unpleasant paresthesias that compels the patient to have voluntary,
spontaneous, continuous leg movements that temporarily relieve the sensations. The
discomfort worsens at rest, in the evening and/or during sleep. Sensation of spiders or
ants on/in Ket/calf muscles.
Usually a primary, idiopathic disorder
Secondary RLS can result from iron deficiency, end-stage renal disease, diabetic
neuropathy, Parkinson disease, pregnancy, rheumatic diseases (RA), varicose veins,
caffeine intake.
Treatment: pramipexole or ropinirole qHS (or levodopa/carbidopa), iron replacement,
avoidance of caffeine, clonazepam qHS, gabapentin, opioids

9.
W h a t is the next step once a brain tum or has been identified on C T or M R I of

the head?
10. W h a t are the important characteristics o f neurofibromatosis type 1?
11. W h at is the mechanism o f action o f the preferred medication in the treatment of

restless leg syndrome?
12. W h a t E E G waveforms correspond to the different stages o f sleep?

Awake
Awake, relaxed, drifting off to sleep
Stage N1
: Stage N2
Stage N3
REM
13. Benzodiazepines increase which stage o f sleep at the expense o f what other stages
o f sleep?
14. W h a t are the two most common primary brain tumors in adults? W h a t are the
3 most common primary brain tumors in children?
LOSS OF CONSCIOUSNESS
3 Question Warm-Up
1.
W h a t is the treatm ent o f acute dystonia and how does it differ from the
treatm ent o f tardive dyskinesia?
2.
W h a t E E G pattern is seen in cases o f absence seizures?
3.
W h a t are the m ost com m on prim ary sources o f metastases to the brain?
Syncope basics
Causes:
Reflex syncope
Vasovagal: associated with emotional stress, trauma, pain, sight o f blood, prolonged
standing
Situational: associated with micturition, defecation, coughing, G l stimulation
Carotid-sinus hypersensitivity: associated with head turning, shaving, tight collar

Cardiogenic: associated with exertion, palpitations, chest pain, SOB
Orthostatic
Cerebrovascular: associated with prolonged loss of consciousness, seizures, neurologic
deficits
No identifiable cause
Work-up basics:
Rule out orthostatic hypotension via tilt test on multiple occasions
Rule out seizure by history and physical
More likely seizure: history of seizure, prodrome of deja-vu postictal confusion, tongue
lacerations
More likely syncope: prodrome of lightheadedness or sweating, history of prolonged
standing
Nonspecific: brief limb jerking, urine incontinence
CBC, electrolytes, BUN/Cr, glucose

Assess volume status
Pulse oximetry and ECG
Evaluation of medications
In patients over 40 (without history of carotid disease or carotid bruits), rule out carotid
sinus hypersensitivity with carotid sinus massage while on telemetry monitor
Also consider:
Serial cardiac enzymes and ECGs x3
Especially if: > 45 years old, diabetes mellitus, smoker; prior myocardial infarction or
> 2-3 risk factors
Echocardiogram
Especially if: murmur exertional syncope or history of heart disease
Cardiac stress test

Bilateral carotid duplex
Especially if: > 65 years old, C A D , PVD or bruit
24-hour Holter monitor

Especially if: abnormal ECG, palpitations, heart disease or family history of sudden
death
C T head without contrast and EEG

Especially: if neurologic symptoms, new seizure, headache
W hat is the differential diagnosis for a patient presenting to the emergency room
for loss of consciousness?
A EIO U TIPS:
W hat should you think about for initial empiric therapy in a patient coming
into the emergency room with loss of consciousness?
W hy is thiamine given in a glucose infusion to alcoholics with hypoglycemia?

Glucose administration in the absence of thiamine can theoretically exacerbate damage
to the mammillary bodies and w orsen______________________________.
End of Session Quiz

8.
W h ich cause o f syncope is consistent w ith each o f these historical items or

physical exam findings?
W hile shaving
W hile singing in a choir concert
W ith a positive tilt test after taking
blood pressure medication
W ith prolonged loss o f consciousness
Preceded by palpitations
Type 1 diabetic interrupted while eating
9.
10.
11.
12.
13.
W h a t test is used to confirm orthostatic hypotension?
W h a t measurements indicate a positive tilt test?
In an intact brainstem, the patients eye should move in which direction w ith ice
water infusion into an ear canal?
W h a t are the elbows doing in decorticate posturing?
A patient is brought into the emergency room w ith loss o f consciousness. W h a t

should be administered before empiric glucose infusion?
PEDI NEURO
3 Question Warm-Up
1.
W hat drugs when combined with SSRIs are known for causing serotonin
syndrome?
2.
W hich commonly used antidepressant should be avoided in patients at risk for

seizure?
3.
A 60-year-old patient presents w ith an acute onset o f broken speech. W h at

type o f aphasia is this? W h a t lobe and vascular distribution have been affected?
W h at is the first step in the workup?
Arnold-Chiari Malformation
Downward displacement of the cerebellar tonsils and medulla through the foramen
magnum
Type I is the most common type and is often asymptomatic. Manifestations may include
headaches and/or cerebellar symptoms.
Type II (of IV severity) is usually accompanied by other neurologic anomalies.
W hat other neurologic anomalies are associated with an Arnold-Chiari

malformation?
W hat are some of the possible presenting features of cerebral palsy?

Spastic features - spastic paresis of any or all limbs, clonus present
Athetosis features - slow, writhing movements in distal muscles
Choreiform features - rapid, irregular, unpredictable contractions of muscles in face or
extremities
Dystonic features - uncontrollable jerking, writhing or posturing
Infants have persistence of primitive reflexes, involuntary grimacing, tendency to drool
and delayed psychomotor development.
Ataxia - difficulty coordinating purposeful movements
Atonic features - severe hypotonia present at birth with no future ability to stand or walk
Neonates may show signs of encephalopathy including lethargy, decreased spontaneous
movement, hypotonia and suppressed primitive reflexes.
Associated disorders: mental retardation, epilepsy, sensory impairment (speech, hearing, vision)
TJ
m
End of Session Quiz

7.
W h a t is the preferred treatm ent for febrile seizures?
8.
W hich element o f the quad/triple screen is abnormal in cases o f neural tube defect?
9.
W h a t neural tube defect matches each o f the following descriptions?

Incomplete closure of the dorsal vertebral
arches, often at the lumbosacral junction
Condition where the above defect is severe
enough for there to be herniation of the
meninges
A more severe defect in which the spinal
cord and meninges have herniated through
Failure o f closure o f the anterior portion of
the neural tube resulting in lack o f forebrain,
meninges and parts o f the skull
10.
W h a t is the definitive treatm ent for persistent hydrocephalus?
II.
Retinoblastoma can be detected from w hat part o f the physical exam?
12.
W h a t is the next step when a retinoblastoma is suspected on PE?
13.
W h a t does cerebral palsy look like in a neonate?
14.
W h a t medications are often used to treat spasticity in cerebral palsy?
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OPHTHALMOLOGY PART I
3 Question Warm-Up
]
W h a t vitamin supplement is recommended to all sexually active women of

childbearing age? W h a t developmental defect is this preventing?
2.
W h at is the diagnosis o f a patient who has periods o f mood disturbances while

psychotic as well as periods o f psychosis w ith normal affect?
3.
A n elderly patient presents to the E R w ith a headache and a dilated right pupil.
D uring the history, she reports that she fell at home 5 days ago. W h at is the
most likely diagnosis?
Describe what light reflexes will be seen in both eyes if the right optic nerve is
damaged prior to the pretectal nucleus (A K A afferent defect).
No constriction of either the left or right pupil when light is shone in the right eye
Both pupils constrict if the light is shone in the left eye
Describe what light reflexes will be seen in both eyes if the right oculomotor
nerve is damaged (A K A efferent defect).
Right pupil will not respond to light shone in either the right or left eye
Left pupil will constrict when a light is shone in either eye
W hat is amblyopia and what are the signs/symptoms?

Decreased vision due to a disruption in the normal development of vision usually from
strabismus, cataracts or refractive error prior to age 10
Possible presentations: esotropia (inward deviation), exotropia (outward deviation), diplopia
and/or refractive error not correctable with lenses
W hat is the most common cause of blindness in the following populations of

adults in the US?
Over age 55
Under age 55
Blacks of any age
Etiology
Type of Discharge
Bacterial
Purulent, copious, 24hrs a day
Viral
(adenovirus)
Watery, eyelid may be sealed

in am
May also have fever, URI,

LAD, pharyngitis
Allergic
Bilateral, watery eyelid may be

sealed in am
Pruritus, other allergy

symptoms
Other Features
OPHTHALM OLOGY PART I
8. W hat are the distinguishing features of bacterial, viral and allergic

conjunctivitis?
9. W hat is the m ost likely cause of conjunctivitis appearing in the first 24 hours of
life?
10. W hat causes of red eye most closely match each of the following statements?
May indicate a collagen-vascular disorder

Potential serious complication of corneal ulceration
Colored halos
Itching eye
Preauricular lymph node enlargement
Dry eyes
Shallow anterior chamber
11. W hat are the classic features that distinguish orbital cellulitis from periorbital
cellulitis?
12. W hat are the distinctions between a chalazion, a hordeolum and anterior
blepharitis? W h at is the treatm ent for each?
Description
Treatment
Chalazion
Inflammation of internal
Meibomian sebaceous
glands (eyelid swelling)
Usually self-limiting but can be

treated w ith surgical excision and/
or intralesional steroid injection
Hordeolum
(stye)
Infection of external
sebaceous glands of Zeiss or
M ol (tender, red swelling at
the lid margin)
H ot compress 3-4 times a day for

10-15 minutes
I f unresolved in 48 hours, then
I8cD
+/- Antibiotic ointment q3 hours
Anterior
blepharitis
Infection o f eyelids
and lashes secondary to
seborrhea (red, swollen
lid margins + dandruff on
lashes)
o W ash lid margins daily with

shampoo
Remove scales daily with cotton
ball
Antibiotic ointment qd to lid
margins
[ 35]
End of Session Quiz

13.
W h at would be the visual field defect for a lesion o f the optic tract?
14.
W h at are the symptoms o f H om er syndrome? W h a t is the classic cause?
15.
Does strabismus cause amblyopia or does amblyopia cause strabismus?
16.
O n morning O B /G Y N rounds, a very concerned new mother asks you about her
12-hour-old newborns red eyes. W h at is the likely reason for the babys red eyes?
17.
W h a t is the next step in the management o f a patient who has sustained a

chemical burn injury to the eye?
18.
W h a t is the easiest way to distinguish a hordeolum from a chalazion?
19.
W h a t im portant diseases are associated with uveitis?
OPHTHALMOLOGY PART 2
0
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1
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3 Question Warm-Up
1.
W h a t C S F findings would you see in a case o f subarachnoid hemorrhage?
2.
A young child has loss o f the red light reflex. W h a t is the diagnosis?
3.
W h a t is considered first-line pharmacotherapy for depression?
i3
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4. W h at is the classic presentation of a patient who has a cataract?

Painless progressive decrease in vision manifested by difficulty driving at night, reading
road signs or reading fine print
Usually bilateral, but often unilateral
Nearsightedness is often an early manifestation
Possible disabling glare in bright sunlight or from oncoming headlights (more likely with
steroid-induced cataracts)
5. W h at is the treatm ent for acute angle-dosure glaucoma?

Initial medications:
Pressure-lowering eye drop regimen: 1 drop each one minute apart of 0.5% timolol
(Timoptic), 1% apraclonidine (Iopidine) and 2% pilocarpine (Isopto Carpine)
Acetazolamide 250mg two tabs once
If refractory to above combination:
given IV once diagnosis confirmed by
ophthalmologist
Surgical intervention:
Laser peripheral iridotomy - tiny hole is made in the periphery of the iris so that aqueous
humor can flow into the anterior chamber
[ 37]
W hat is the treatment for a corneal abrasion?

Thorough eye exam with removal of any foreign body by irrigation
Topical antibiotics QID continued 3-5 days or until the eye is symptom free for 24 hours
(ointment > drops) - erythromycin, sulfacetamide, ciprofloxacin or ofloxacin
OTC lubricant (Refresh PM, Lacri-lube) as needed up to hourly
Pressure patching is optional for___________ , andis____________ if a foreign body is
present. There is no role for pirate patching.
Pain control with systemic opioids (e.g., Tylenol #3) or ophthalmic NSAIDs (e.g.,
diclofenac, ketorolac)
NEVER prescribe a topical anesthetic (OK to use during the initial exam) or topical
steroids!
24hr follow-up for contact lens abrasion, abrasion >3mm or abrasion with diminished
vision.
W hat disease would you suspect in a 35-year-old woman with new-onset rapid
loss of vision and pain when moving the eye? How would you treat this?
W hat eye abnormalities might be seen in a patient with vitamin A deficiency?

Night blindness or complete blindness
Xerophthalmia
Bitot spots (areas of abnormal squamous cell proliferation and keratinization of the
conjunctiva)
End of Session Quiz

9.
W h a t are some major clinical features o f acute angle-closure glaucoma?
10.
W h a t is the major exam finding in open-angle glaucoma?
11.
W h a t is the treatm ent for closed-angle glaucoma?
12.
W ith which disorders m ight you see a cherry-red spot on the macula?
13.
14.
W h a t is the treatm ent for macular degeneration (M D)? W h a t is the treatment

for retinal detachment (RD)?
W h a t is the differential diagnosis for dislocation o f the lens o f the eye?
AUDIOVESTIBULAR DISORDERS
3 Question Warm-Up
1.
W hat are the 5 main lacunar syndromes that may arise from a lacunar infarct?
2.
W h a t is the typical complaint o f a patient w ith retinal detachment?
3.
W h a t is the treatment o f choice o f mania w ith psychosis?
When is observation without antibiotics appropriate for a child with acute otitis
media?
According to 2013 AAP/AAFP guidelines, you may refrain from antibiotics and simply
observe if:
Age 6 months to 2 years + unilateral AOM without otorrhea + mild illness + appropriate
follow-up available + antibiotics can be started promptly if symptoms worsen
Age > 2 years + unilateral or bilateral AOM without otorrhea + mild illness + appropriate
follow-up available + antibiotics can be started promptly if symptoms worsen
In either case, the decision to observe without antibiotics should be made jointly between
provider and parent/caregiver(s)
Antibiotics should be started if improvement is not noted in 48-72 hours
W hat are the classic signs and symptoms of bullous myringitis?

Bullous myringitis is a bullous/vesicular inflammation of the tympanic membrane that
may occur in association with acute otitis media. It typically manifests as follows:
More painful than; usual acute otitis media
Otoscopy: large, reddish vesicles on the TM
W hat is the treatment for bullous myringitis?

____________________ is a common organism > treat with oral___________________
Topical analgesics
7.
W hat are the diagnostic features of mastoiditis?

Symptoms occur days-weeks after developing acute otitis media
Erythema, edema, tenderness behind the ear
External ear displaced
Diagnosis made from C T scan of the mastoid process
8. W h at are the distinguishing characteristics of acute labyrinthitis?

Acute onset of vertigo, nausea, vomiting and nystagmus
- Auditory function preserved = vestibular neuritis
Hearing loss + above symptoms = labyrinthitis
Single episode that lasts days to weeks (usually not longer than 2 weeks)
Preceded by a viral URI
Nystagmus: horizontal, suppressed with visual fixation and has a fast phase away from the
affected side
0 Abnormal head thrust test: W hen examiner rapidly turns the patients head to the affected
side, the patient is unable to maintain visual fixation
Gait instability, but preserved ambulation
Absence of focal neurologic defects
9. W h at is the treatm ent for acute labyrinthitis (vestibular neuritis)?

Typically subsides spontaneously within weeks
Corticosteroid taper shown to improve recovery
Symptomatic treatment only indicated for the first 48 hours of illness
E.g., scopolamine patch, meclizine, metodopramide or promethazine
Long-term recovery is theoretically delayed if used long-term
Vestibular rehabilitation exercises
M R I if > 60 years of age, headache, focal neuro signs, vascular risk factors or sustained
vertigo inconsistent with acute labyrinthitis (vestibular neuritis)
10. W h at is the m ost com m on cause of conductive hearing loss in adults? W hat is
the m ost com m on cause of sensorineural hearing loss in adults?
Conductive otosclerosis
Sensorineural presbycusis
11. Cholesteatom a:
Overgrowth of desquamated keratin debris within the middle ear space that may
eventually erode the ossicular chain and external auditory canal
Causes: negative middle ear pressure (chronic retraction pocket) from eustachian tube
dysfunction or direct growth of epithelium through a T M perforation
Commonly associated with chronic middle ear infection
PE: grayish-white pearly lesion behind or involving the TM , conductive hearing loss,
vertigo
Treatment: surgical removal usually involving tympanomastoidectomy and reconstruction
of the ossicular chain
AUDIOVESTIBULAR DISORDERS
12. W hat is the treatment for Ramsay Hunt syndrome?

Ramsay Hunt syndrome is herpes zoster oticus and is treated as follows:
Narcotic analgesia for pain relief
Oral steroids to decrease inflammation
Antiviral therapy with valacyclovir (highest efficacy), famciclovir or acyclovir
End of Session Quiz

13.
W hat are the important characteristics seen on otoscopic exam of a patient with
otitis media?
14.
W h at is the underlying cause o f benign paroxysmal positional vertigo (BPPV)?
15.
16.
Explain how the W eber test can help distinguish conductive hearing loss from
sensorineural hearing loss.
W hat are the major characteristics o f Menieres disease?
Psychiatry
1
D epression
A ntidepressants
O th e r M o o d D isorders
A n x iety D isorders
Psychotic D isorders
P ersonality D isorders
Substance A buse p a rt 1
Substance A buse p a rt 2
O th e r Psych D isorders
10 D eliriu m and D em entia

11 Pedi Psych
DEPRESSION
3 Question Warm-Up
1.
W h a t is the empiric treatm ent for a brain abscess?
2.
W h a t is the treatm ent for an epidural hematoma or subdural hematoma?
3.
W h a t is the typical pseudotumor cerebri patient?
4. A t what point does grief/bereavement become pathological?

G rief becomes pathological when any of the following are found:
Depression criteria met for at least 2 weeks after the first 2 months following the loss
Generalized feelings o f______________________________________________
O
Distressing feelings do not diminish in intensity by___________________
Inability to move on, trust others and reengage in life by___________________
5. W h at medical conditions can cause severe depression?
6,
W h at medications are known for causing symptoms of depression?

Sedatives: alcohol, benzos, antihistamines
Stimulant withdrawal
o _______________________ (antihypertensive often used for hypertension in pregnancy)
First-generation antipsychotics (such as haloperidol)
Anti-nausea drugs including metoclopramide and prochlorperazine
O
Insufficient thyroid replacement - hypothyroidism
o ________________________(used in viral hepatitis treatment)
DEPRESSION
7.
W h at are the sym ptom s of m ajor depression with atypical features? W h at

medications w ork well for this?
8. W hat is the first-line treatment for major depression with seasonal pattern?

9.
A 36-year-old male smoker says he has been thinking a lot about quitting,
and wants to talk to you about ways to go about it. A t what stage o f change in
overcoming his smoking habit is this man?
10.
W h a t neurotransmitter derangements are seen in patients with depression?
II.
List the symptoms o f depression using the mnemonic SIG E CAPS:
12. Diagnosis of major depressive disorder (MDD) requires five of the above
symptoms, including depressed mood or anhedonia, that must last how long?
ANTIDEPRESSANTS
3 Question Warm-Up
4.
1.
A patient presents w ith hyperphagia, hyperorality and hypersexuality. W h at is

the diagnosis, and w hat brain lesion causes this?
2.
W h a t are the m ost com m on causes o f seizures in young adults (18-35 years)?
3.
W h a t is the treatm ent for cluster headaches?
Categorize each of the following antidepressants:

nortriptyline, bupropion, mirtazapine,fluvoxamine, doxepin,phenelzine, fluoxetine,
imipramine, amitriptyline, milnacipran, sertraline, venlafaxine, paroxetine, tranylcypromine,
duloxetine, citalopram, trazodone, escitalopram, desvenlafaxine, nefazodone
SSRI -
TC A -
MAOI -
NDRI -
SNR.I -
Tetracyclic -
W h at are the sym ptom s of m ajor depression with atypical features? W h at

medications w ork well for this?
W hat is the first-line treatment for major depression with seasonal pattern?
End o f Session Q uiz

9.
A 36-year-old male smoker says he has been thinking a lot about quitting,
and wants to talk to you about ways to go about it. A t what stage o f change in
overcoming his smoking habit is this man?
10.
W h a t neurotransmitter derangements are seen in patients with depression?
11.
12. Diagnosis of major depressive disorder (MDD) requires five of the above
symptoms, including depressed mood or anhedonia, that must last how long?
ANTIDEPRESSANTS
S >
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3 Question Warm-Up
4.
1.
A patient presents w ith hyperphagia, hyperorality and hypersexuality. W h a t is

the diagnosis, and what brain lesion causes this?
2.
W h a t are the m ost common causes o f seizures in young adults (18-35 years)?
3.
Categorize each of the following antidepressants:

nortriptyline, bupropion, mirtazapine,fluvoxamine, doxepin, phenelzine, fluoxetine,
imipramine, amitriptyline, milnacipran, sertraline, venlafaxine, paroxetine, tranylcypromine,
duloxetine, citalopram, trazodone, escitalopram, desvenlafaxine, nefazodone
SSRI -
TCA -
M AOI -
N D RI -
SN RI -
Tetracyclic -
Atypical -
[ 47 ]
SSRIs
5. Which drugs should not be taken with SSR Is because of the risk of serotonin
syndrome?
6. W hat are the characteristic features of serotonin syndrome?
(anxiety, agitation, delirium, restlessness, disorientation)

o ' ___________________________(diaphoresis, tachycardia, hyperthermia, hypertension,
vomiting, diarrhea)
_____________________________ __ (tremor, muscle rigidity, myoclonus, hyperreflexia)
________________________ - slow, continuous, horizontal eye movements
Spontaneous or inducible clonus
Sabinski signs bilaterally
7. W hat is the treatment for serotonin syndrome?

Discontinue all serotonergic agents * symptoms usually resolve in 24 hours
Supportive care to normalize vital signs
Oxygen, IV fluids,icardiac monitoring
If medical treatment for tachycardia or hypertension is needed, use short-acting agents
(e.g., esmolol or nitroprusside)
Sedation with - _________________________

If temp > 41.1 C >sedation, paralysis and ET tube > mechanical cooling (e.g., ice,
cooling blankets, misting fans)
Paralysis should relieve the hyperthermia which is caused by muscle activity
There is no benefit in using antipyretics in this scenario
If agitation despite benzodiazepine >__________________________

After resolution of symptoms, assess need to resume serotonergic agent
8. W hat are the symptoms of serotonin withdrawal syndrome? W hich SSR Is are
well known for causing this when stopped abruptly?
SSRI discontinuation syndrome is characterized by dizziness, nausea, fatigue, muscle
aches, chills, anxiety and irritability that begins within days of abrupt discontinuation and
dissipates over 1-2 weeks.
Worst offenders:_____________ ____________________
TCAs
9.
W hat evaluation should take place prior to the initiation of T C A s in children?

Because TCA s can cause arrhythmias, the following should be performed:
Screen patients history for______________________________________________
0 Screen family history for sudden death prior to age 40, long Q T syndrome, arrhythmias
and hypertrophic cardiomyopathy
__________________________ prior to initiation and again when medication is
optimized
10. W hat are the symptoms of overdose with tricyclic antidepressants (TCA s)?
: tachycardia, hypotension, conduction abnormalities

__________________________ : sedation, obtundation, coma, seizures
________________
:
mydriasis, xerostomia, ileus, urinary retention
ABCs - Airway, Breathing, Circulation

Activated charcoal lg/kg up to 50kg (unless ileus is present)
Continuous cardiac monitoring for at least 6 hours * if no problems, then clear for psych
eval
Frequent neuro checks
o Lab/Studies: TC A level, Chem 7, EKG
AN TIDEPRESSAN TS
II. How is T C A overdose managed?
If ingestion < 2hrs ago * gastric lavage

If hypotension * IVF (LR or NS) * if ineffective, then norepinephrine
If QRS > 100 msec -trial__________________________ then infusion if effective
If seizures >_______
, barbiturates and/or propofol
(but n o t____________
. which is ineffective against toxin-induced seizures)
O ther Antidepressants
12. W hat food substances should be avoided when taking M AOIs in order to avoid
a tyram ine-induced hypertensive crisis?
Foods that are spoiled, pickled, aged, smoked, fermented or marinated contain
tyramine. The following foods should be avoided because of sufficient quantities of
tyramine to be problematic while on MAOIs:
Fermented cheeses (cream cheese and cottage cheese are OK)
Smoked or aged meats (sausage, bologna, pepperoni, salami, smoked or pickled fish)
Chianti, most beers and wines (especially over 120mL)
Soy sauce, shrimp paste, miso soup
Sauerkraut, avocados, ripe bananas, Fava beans
Brewers yeast and yeast extracts (yeast used in baking is OK)
13. In what group of patients is bupropion (W ellbutrin) contraindicated?

Because of an increased risk of lowering the seizure threshold, bupropion should be
avoided in patients with:
14. W h at are the indications for electroconvulsive therapy (E C T )?

Severe debilitating depression refractory to antidepressants
Psychotic depression
Severe suicidality
Depression with catatonic stupor
Depression with food refusal leading to nutritional compromise
Situations where a rapid antidepressant response is required (e.g., pregnancy)
Previous good response to EC T

Medical condition preventing the use of antidepressants (e.g., elderly patients)
Bipolar disorder/mania
Schizophrenia/psychosis (esp. catatonic)
[ 49]

15.
H ow long must a patient expect to take an SSRI before they see improvement
in their depression?
16.
In T C A overdose, what can be used to correct the prolonged QRS interval and
possible seizures?
17. W hich antidepressant matches the following statements?

SE: priapism
Lowers the seizure threshold and can be used for smoking cessation
Appetite stimulant that is likely to result in weight gain
Works well with SSRIs and increases REM sleep
" Can be used for bedwetting in children
18. W h at are the symptoms of serotonin syndrome?
OTHER MOOD DISORDERS
3 Question Warm-Up
1.
C T scan o f the head shows a crescent-shaped lesion. W h a t event most likely

caused this lesion?
2.
W h a t is the initial radiologic study in a patient w ith T IA /stroke symptoms?

W h a t radiologic studies need to be performed later to evaluate the underlying
cause o f the TIA /stroke?
3.
A 2-year-old develops lethargy, hypoglycemia and abnormal LFTs

approximately one week after being seen for a febrile U R I. W h a t is the most
likely diagnosis?
Bipolar Disorder
4.
How is depression managed in patients with bipolar disorder?

Mild depression >___________________________________
Moderate depression > add a second mood stabilizer (lamotrigine) or add an atypical
antipsychotic (olanzapine, quetiapine, risperidone)
Severe depression * consider________________
5. W h at are the potential side effects of lithium use in the treatm ent of bipolar
disorder?
CNS effects (depression, tremor, cognitive dulling)
o ________________________ _ (hyperthyroidism, hypothyroidism, euthyroid goiter)
o __________________________ (nausea, vomiting, diarrhea, metallic taste changes,
weight gain)
Nephrogenic diabetes insipidus (thirst, polydipsia, polyuria)
OTHER HOOD DISORDERS
6. W hat is the treatment for nephrogenic diabetes insipidus caused by lithium

toxicity?
Adjustment Disorder
7. W hat are the diagnostic criteria for adjustment disorder?
Clinically significant emotional or behavioral reaction causing marked distress or
impairment in social or occupational functioning
Symptoms develop in response to an identifiable psychosocial stressor (e.g., divorce, failure
at school, peer problems) other than bereavement
Symptoms begin within
of the stressor
Symptoms disappear within____________ of the disappearance of the stressor
If the stressor is chronic (e.g., ongoing parental conflict) then the disorder may last
longer than 6 months and is termed chronic
8. W hat is the difference between major depressive disorder and adjustment

disorder with depressed mood?

9.
W hat is the drug o f choice in the treatment o f bipolar disorder in a patient with
renal failure?
10. W h at is the most problematic congenital malformation associated with maternal

lithium use?
11. How long must hypomania symptoms or depressive symptoms be present to

diagnose cyclothymia?
ANXIETY DISORDERS
3 Question Warm-Up
1.
H ow does one differentiate between subarachnoid hemorrhage and a traumatic

lumbar puncture as a cause o f bloody cerebrospinal fluid?
2.
W h ich spinal tracts convey the following information?

Touch, vibration and pressure sensation
Voluntary motor command from motor cortex to body
Voluntary motor command from motor cortex to head/neck
Pain and temperature sensation
Important for postural adjustments and head movements
3.
A patient is recovering in the IC U after suffering a subdural hematoma that

occurred because o f a motor vehicle collision. The neurosurgery team performed
a craniotomy and drain placement to evaluate the clot. For the past few days the
drainage in the collection bulb was serous. Now, however, the drainage is thick
and yellow. A long w ith this, the patients neurological exam has deteriorated.
W h a t is the likely cause o f this clinical picture?
4. How is acute stress disorder different than post-traumatic stress disorder

(P TSD )?
5.
W hat are the treatm ent options for PTSD ?
Psychotherapy including behavioral (exposure) therapy and cognitive therapy

_______________ - first line
Other antidepressants - TCAs (imipramine, amitriptyline), MAOIs
Benzodiazepines should be avoided in PTSD due to lack of efficacy and potential for
abuse
a _______________ (carbamazepine or valproate) improve impulsive behavior, arousal and
flashbacks
o _______________ (prazosin) improves nightmares and sleep disturbance
Atypical antipsychotics if refractory to other therapies
End of Session Quiz

6.
How long must anxiety and worry symptoms be present to diagnose a patient
with generalized anxiety disorder?
7.
W h at are the treatment options for generalized anxiety disorder?
8.
How long must the symptoms o f P T S D be present to make the diagnosis?
9.
W h at are the treatment options for PTSD ?
PSYCHOTIC DISORDERS
3 Question Warm-Up
1.
W h a t complication may arise from perform ing L P in a patient w ith elevated

intracranial pressure?
2.
W h a t are the symptoms o f a basilar artery stroke?
3.
Bereavement and adjustment disorder share similar tim e tables in a patients

symptomatology. W h a t are the key differences between them?
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o
Schizophrenia
4. W h at are the diagnostic criteria for schizophrenia?
At least 2 o f the following during a 1-month period (including at least 1 of the first 3):
Delusions (irrational belief that cannot be changed by rational argument)
Hallucinations (most common type is auditory)
Disorganized speech (e.g., frequent derailment or incoherence)
Grossly disorganized or catatonic behavior
- Negative symptoms (e.g., flat affect, poverty of speech, lack of emotional reactivity)
Social/occupational dysfunction
Duration of at least 6 months
5. W h at is the difference between each of the following disorders?

Schizotypal personality
disorder
Schizophrenia
Schizoaffective
Schizoid personality
disorder
Schizophreniform
Brief psychotic disorder
[ 55]
D ISO RDERS
PSYCHOTIC
6.
W h at m ight you see on neuroim aging of a patient with schizophrenia?
7. W hat drugs are known to cause psychosis in patients?
Antipsychotic Medications
8. Categorize the following antipsychotics in the appropriate category as
neuroleptics (low- or high-potency) or atypical antipsychotics:
olanzapine, thioridazine, quetiapine, chlorpromaxine, haloperidol, fluphenazine, loxapine,
risperidone, thiothixene, trifluoperazine, clozapine, aripiprazole
Low-potency neuroleptics -
High-potency neuroleptics -
Atypical antipsychotics -
9. A patient previously diagnosed with schizophrenia arrives at the psych ER

with a severe neck spasm that forces his head to be maintained in an unusual
position. W hat is the treatment?
Acute dystonia (torticollis in this case) due to antipsychotics
R x :______________
10. W hat features characterize tardive dyskinesia that may develop from the use
of high-potency typical neuroleptics?
DISO RDERS
12. In what tim e frame would you expect to see Parkinsonian symptom side
effects in a patient taking antipsychotics?
PSYCHOTIC
11. W h a t is the treatm ent for tardive dyskinesia?
13. W hat is the treatm ent for Parkinsonian symptoms that have developed from
neuroleptic administration?
14. W h at are the signs and symptoms of neuroleptic malignant syndrome?

Mental status change initial symptom in most patients (agitated delirium with confusion
rather than psychosis)
Muscular rigidity +/- tremor
Hyperthermia greater than 38-40 C
Rhabdomyolysis appearing over 1-3 days
Autonomic instability - tachycardia, high/labile blood pressure, tachypnea, diaphoresis
15. W h at is the treatm ent for neuroleptic malignant syndrome?

Stop the offending medication
Supportive care in the ICU
- IVF
- Lower fever with cooling blankets, ice packs in the axilla, Tylenol
- Reduce hypertension with clonidine and/or nitroprusside ( cutaneous vasodilation can
facilitate cooling)
- D V T prevention with heparin or enoxaparin
- For agitation, use benzos (clonazepam, lorazepam)
o ______ prevents rigidity and hyperpyrexia by inhibiting
calcium release
Other possible therapies:________________________
[57]
End of Session Quiz

16.
Give examples o f negative symptoms of schizophrenia.
17. W hich neuroleptics are known for their extrapyramidal side effects?
18.
19.
20.
W h a t are the different treatments for acute dystonia, tardive dyskinesia and
neuroleptic malignant syndrome?
Acute dystonia
Tardive dyskinesia
Neuroleptic malignant syndrome
W h a t is the most common side effect o f olanzapine?
W h at is the drug category o f choice for the treatment o f the negative symptoms
o f schizophrenia?
PERSONALITY DISORDERS
3 Question Warm-Up
1.
A wom an who witnessed a murder is able to calmly describe every gory detail.
W h ich defense mechanism is she displaying?
2.
W h ich defense m echanism is a person displaying when she subconsciously

pushes memories o f past abuse out o f her conscious mind?
3.
A m other w ho is frustrated w ith her child yells at her husband. W h a t defense

mechanism is she displaying?
PERSONALITY DISORDERS
End of Session Quiz

4.
A 40-year-old woman comes to your office after becoming dissatisfied with

her former physician. She explains that her former physician was the most evil
creature with absolutely no redeeming qualities. She finishes her story and
remarks that she can tell you are so smart and will cure her of everything.
W hat personality disorder might this patient have?
5.
A 32-year-old woman tells you during one of her office visits that you are the best
doctor shes ever had but that your nurse is very disrespectful. O n a subsequent
visit, she threatens to change doctors because you do not feel a particular lab test
is necessary. Additionally, you notice several symmetrical cuts on her left forearm
which she attributes to cat scratches. W h at personality disorder does this person
have?
6.
A 55-year-old woman comes to your office wearing all black including a black
miniskirt and black feather boa. She is also wearing an excessive amount of
lipstick, and you notice her having conversations w ith many o f the other patients
in the waiting room. W h at personality disorder do you suspect in this patient?
7.
A person demands only the best and most educated doctor in town. W hat
personality disorder does this person have?
SUBSTANCE ABUSE PART I
3 Question Warm-Up
1.
W h a t is the m ost serious side effect o f clozapine?
2.
W h a t is T odds paralysis?
3.
W h a t is the first-line treatm ent for acute otitis media?
4. W hat treatm ents are effective in helping prevent relapse in recovering

alcoholics?
_________________________ is the tried-and-true best relapse prevention
O
O
o
Acamprosate (Campral) tid
End of Session Quiz

5.
W h a t are the components o f the C A G E questionnaire?
6.
In w hich vitamins are alcoholics typically deficient?
7.
W h a t is the m ost successful treatm ent for alcoholism?
8.
List the symptoms associated w ith the life-threatening condition delirium

tremens (D T).
9.
W h a t is the drug o f choice for alcohol withdrawal?
SUBSTANCE ABUSE PART 2
3 Question Warm-Up
1.
W hat medical conditions can cause severe depression?
2.
A 25-year-old man is seen in the E R w ith severe headache. H e tells you that the
headaches always occur at around the same time, and that the pain is localized
around the right eye. O n exam his pupils are unequal and his right eye is
tearing. W hile he waits for the C T scan o f the head, w hat treatment should he
receive?
3.
W h a t are the major symptoms o f H untington disease?
End of Session Quiz

4.
A 19-year-old slender woman presenting w ith recent weight loss is found to have
erythem a o f her turbinates and nasal septum. W h at is the cause o f her weight
loss?
5.
A patient is brought to the E R by police, restrained and exhibiting violent

behavior. W h a t O D is likely? W h a t is the Rx?
6.
W h a t features are unique to P C P intoxication that allow you to distinguish it

from LSD intoxication?
7.
W h a t drugs can be used in the case o f hypertension in a patient with cocaine or

amphetamine intoxication?
OTHER PSYCH DISORDERS
3 Question Warm-Up
1.
W h at is the treatment for benign paroxysmal positional vertigo (BPPV)?
2.
W hat disorder classically presents w ith the triad o f cognitive impairment,

urinary incontinence and abnormal gait?
3.
A patient with a history o f lithium use presents with copious amounts o f dilute
urine. W h at condition is this?
. Conversion Disorder
Sensory or motor neurological symptoms with no recognized neurological or medical cause
Motor symptoms:
Weakness/paralysis
0 Tremor
Dystonia/myoclonus
Gait disorder
Dysphagia
Dysphonia
Sensory symptoms:
Numbness/paresthesias
Blindness
Deafness
May or may not be related to specific psychological stressor
Som atic Symptom Disorder

One or more somatic symptoms that are distressing or significantly disruptive, e.g.:
Pain symptoms
Sexual symptoms (erectile dysfunction, decreased libido)
Neurological symptoms (motor or sensory deficits, gait disorder, tremor)
- Gastrointestinal symptoms (vomiting, diarrhea)
Symptoms may or may not be due to a recognized medical condition
Individual experiences disproportionate and persistent thoughts about the seriousness
of his/her symptoms, and/or a persistently high level of anxiety about his/her health or
symptoms.
Illness Anxiety Disorder

Preoccupation with having or acquiring a serious illness
High level of anxiety about health
Individual performs excessive health-related behaviors, such as repeatedly checking his/
her body for signs of illness
Somatic symptoms are not present
End of Session Quiz

7.
W h a t serum lab abnormalities may be seen in a patient with prolonged excessive

vomiting/purging?
8.
W h a t somatoform disorder matches each o f the following descriptions?

Patient w ith normal anatomy is convinced a part of
his/her anatomy is abnormal.
Unexplained loss o f sensory or motor function.
Normal exam/tests
Overwhelming worry about having a particular
disease, w ithout any signs/symptoms
Unexplained complaints in multiple organ systems
9.
10.
W h a t is a major difference between factitious disorder and malingering?
W h ich eating disorder can be treated effectively w ith SSRIs?
\ND DE
DELIRIUM AND DEMENTIA
3 Question Warm-Up
1.
Albuminocytologic dissociation (increased protein in the CSF, with only

modest increase in cell count) indicates what condition?
2.
A violent patient w ith vertical and/or horizontal nystagmus has been exposed to
what substance?
3.
Categorize each o f the following antidepressants:

duloxetine, nefazodone, bupropion, mirtazapine, desvenlafaxine,fluvoxamine,
doxepin,fluoxetine, imipramine, escitalopram, amitriptyline, phenelzine,
milnacipran, sertraline, venlafaxine, paroxetine, tranylcypromine, citalopram,
trazodone, nortriptyline
SSR1
TCA -
MAOI -
N D RI -
SN RI -
Tetracyclic -
Atypical -
End of Session Quiz

4.
W h a t are key features o f delirium that differentiates it from dementia?
5.
W h a t are the two most common causes o f dementia, and how do you
differentiate between them when m aking a diagnosis?
6.
A nurse pages you, saying that one o f your elderly patients has been sleeping
most o f the two days hes been on the unit, but is very agitated and aggressive
w ith the nurses while awake. She asks you to write for a benzodiazepine to
sedate the patient. W h a t do you propose instead and why?
7.
W h a t disease th a t causes dem entia is also associated w ith visual

hallucinations and frequent falls?
8.
W h a t disease that causes dementia is also associated w ith unpleasant behavioral

and personality changes?
PEDI PSYCH
PEDI PSYCH
3 Question Warm-Up
1.
After a minor car accident, a woman wears a neck brace and requests permanent
disability. W h a ts the most likely diagnosis?
2.
In which disease would you find atrophy o f the mammillary bodies?
3.
W h a t is the most common cause o f sensorineural hearing loss? W h at is the

most common cause o f conductive hearing loss?
Attention-Deficit Hyperactivity Disorder (A D H D )

4. W hat other medications can be used in the treatment of A D H D in children
who fail to respond to stimulants or atomoxetine?
5.
W hat are the common complications of A D H D stimulant medications, and

how are these complications managed?
Stimulants
Insomnia ~> address sleep hygiene, take meds earlier in the day, change to shorter duration
formulation, clonidine at night
0 Appetite suppression and weight loss administer meds after meals rather than before
Tics > usually transient, choose low-moderate dose methylphenidate which does not
worsen tics
Psychosis or mania >discontinue (no need to taper)
Decreased growth velocity -> reassure parents that adult height is not affected, drugholidays may help with catch-up growth
Atomoxetine
Increased risk of suicidality * close observation and usually discontinuation
Liver injury discontinue
[ 68 ] I
Tourette Syndrome
6. W hat therapeutic options are available for Tourette syndrome?
Counseling/psychotherapy for social adjustment and coping
If interfering with necessary functions of life > anti-dopamine agents: fluphenazine,
pimozide or tetrabenazine (which are all tolerated better than haloperidol in these patients)
If only focal motor or vocal tics Botox injections into affected muscles
If impulse control problems > clonidine or SSRIs
If refractory to medical management * consider deep brain stimulation of globus pallidus,
thalamus or other subcortical target (undergoing clinical trials)
Autism Spectrum Disorder

7.
W hat are some of the characteristic features of autism spectrum disorder?

Living in his own world
Symptoms evident prior to age 3
Lack of responsiveness to others, poor eye contact, absence of social smile
Impairments in communication, language delay, repetitive phrases
Peculiar repetitive, ritualistic habits (e.g., spinning around, hand flapping)
Fascination with specific, seemingly mundane objects (vacuum cleaners, sprinklers)
Usually below-normal intelligence
PEDI PSYCH
End of Session Quiz

8.
How is A D H D diagnosed?
9.
W hich childhood psychiatric disorder matches each of the following statements?

Females only. Loss of previously acquired
purposeful hand skills between 6-30 months
Impairments in social interactions,
communications, play. Repetitive behaviors
Characterized by hostility, annoyance,
vindictiveness, disobedience and resentfulness
Multiple motor and vocal tics
Impulsive and inattentive
10.
W hen treating a child suspected of having a learning disorder, what must first be
investigated?
E ndocrinology
1
Type 1 D iabetes
Type 2 D iabetes
Insulin Therapy
A cute C om plications o f D iabetes
C hronic C om plications o f D iabetes
D IA B E T E S
EV A LU A T IO N O F H Y P E R H Y P O T H Y R O ID IS M ) A N D
LESS CO M M O N PRO BLEM
LES, A
E V A R IO U S SYN D R O M
A D R E N A L IN SU FFIC IE N C Y
A N D A D R E N A L E X C E S S ),
N orm al Thyroid F unction and

H yperthyroidism
H ypothyroidism and Thyroid C ancer
Parathyroid D isorders
P itu itary D isorders
10 C ush in g Syndrom e and

H yperaldosteronism
11 O th e r A d ren al D isorders
ENDOCRINOLOGY
TYPE I DIABETES
3 Question Warm-Up
1.
W h a t is the treatm ent for neuroleptic m alignant syndrome?
2.
W h a t is the m ost common complication o f recurrent otitis media?
3.
W h a t is the treatm ent for delirium tremens (DTs)?
4. W hat anti-islet antibodies can be seen in patients with type I diabetes

mellitus?
Anti-insulin (IAA)
Anti-islet cell cytoplasm (ICA)
Anti-glutamic acid decarboxylase (GAD)
Anti-tyrosine phosphatase (IA-2)
End of Session Quiz

5.
W h a t lab test is used in diabetic patients to assess the adequacy o f glycemic control
over the last three months?
6.
W h a t is the leading cause o f death in diabetics?
7.
W h y m ust 3-blockers be used w ith caution in diabetics?
8.
W h a t can cause hypoglycemia in a non-diabetic patient?
TYPE 2 DIABETES
TYPE 2 DIABETES
3 Question Warm-Up
1.
W h at medications other than stimulants are used in the treatment o f A D H D ?
2.
W h a t are the three reasons for involuntary psychiatric hospitalization?
3.
W h a t is the psychiatric condition in which a person travels a long distance,

takes a new name and has no memory o f his prior life?
4. W hich of the oral agents used in the control of type 2 diabetes has the
following characteristics:
Lactic acidosis is a rare but worrisome side
effect
Most common side effect is hypoglycemia
Oldest and cheapest of the oral agents
Often used in combination with any of the
other oral agents
Also helps lower triglycerides and LDL
cholesterol levels
N ot safe in settings of C H F
Should not be used in patients with elevated
serum creatinine
Should not be used in patients with
inflammatory bowel disease
Hepatic serum transaminase levels should be
carefully monitored when using these agents
Not associated with weight gain, often used in
overweight diabetics
Metabolized by liver, excellent choice in
patients with renal disease
[ 74]
Primarily affects postprandial hyperglycemia,

taken with meals
5. W hat are the criteria for the diagnosis of metabolic syndrome?

Diagnosis based on any three of the following:
____________________ : Waist circumference > 40 in (102 cm) in men, or > 35 in (88 cm)
in women (IDF criteria is > 94 cm in men and > 80 cm in women)
___________________ > 150 mg/dl
____________________ < 40 mg/dl in men, or <50 mg/dl in women
____________________ > 130/85 mmHg
____________________ > 100 mg/dl (or 2-hour post oral glucose > 140 mg/dl)
H
-<
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m
ro
O
>
CD
m
H
m
on
End of Session Quiz

W h a t skin finding can be a sign o f having insulin resistance?
7.
W hich diabetic medications should be avoided in patients w ith heart failure?
8.
A type 2 diabetic has been well-controlled on a regimen o f metformin,

pioglitazone and glyburide, but now he is developing some episodes o f sweating,
tachycardia and confusion. These episodes resolve quickly if he eats something.
W hich o f his medications would be most likely to cause hypoglycemia?
9.
M atch the diabetes drug with its mechanism o f action:
ENDOCRINOLOGY
6.
Decreases G I absorption o f starch and

disaccharides
Stimulates insulin release
Decreases hepatic gluconeogenesis
Increases tissue glucose uptake and improves
insulin sensitivity
Mimics the action o f GLP-1: i glucagon, T
insulin, delays gastric emptying
Inhibits DPP-IV, leading to 1 glucagon, T
insulin, delays gastric emptying
I [75]
INSULIN THERAPY
INSULIN THERAPY
3 Question Warm-Up
1.
A n aphasic patient has difficulty producing words but understands everything

you say. W h a t type o f aphasia does he most likely have?
2.
W h a t would you see on physical exam o f a patient that has a cholesteatoma?
3.
W h a t antidepressant is preferred in the treatment of depression w ith comorbid

neuropathic pain?
End of Session Quiz

4.
W hich type o f insulin is used in continuous infusion insulin pumps and in

treatment o f DKA?
5.
W h at must be kept in m ind for a type 1 diabetic patient that plans to begin a
strenuous exercise program?
ACUTE COMPLICATIONS OF DIABETES
3 Question Warm-Up
1.
W h a t is the definitive treatm ent for an epidural or subdural hematoma?
2.
W h a t medication is used in the diagnosis o f symptomatic myasthenia gravis?
3.
W h a t are the m ost common causes o f seizures in children ages 2-10?
4. W hat are the common causes of DKA?

Usually due to excess glucagon, catecholamines or corticosteroids
Infection (pneumonia, gastroenteritis, UTI)
Medication reduction or omission
Severe medical illness (MI, CVA, trauma)
Undiagnosed DM
Dehydration
Alcohol or drug abuse
Corticosteroids
5. W hat are the necessary steps in the treatm ent of diabetic ketoacidosis?
ACUTE COM PLICATIONS OF DIABETES
End of Session Quiz

6.
W hat are the signs and symptoms of diabetic ketoacidosis?
7.
A 68-year-old type 2 diabetic ran out o f his metformin a week ago, and now
presents to the E R with 3 days o f severe polyuria, dry mouth and vomiting. H e is
lethargic, and seems to be an unreliable historian. His labs show Na+=144 m Eq/L,
K+=3.7 m Eq/L, Cl"=101 m Eq/L, H C 0 3 =18 m E q/L , and serum glucose=413
mg/dL. Based on this information, what is the most likely diagnosis, and what
two tests will help you confirm that diagnosis?
8.
W h a t is the work-up for the underlying cause o f DKA?
CHRONIC COMPLICATIONS OF DIABETES
3 Question Warm-Up
1.
W h a t medications are used in the treatm ent o f Tourette syndrome?
2.
W h a t is the cause o f muscle rigidity, fever and rhabdomyolysis in a

schizophrenic patient?
3.
W h ich antidiabetic agent is associated w ith lactic acidosis?
4. How do we diagnose diabetic gastroparesis?
5.
W hat are the treatm ent options for diabetic gastroparesis?
W hat are the routine health maintenance recommendations for diabetics?
Exercise: walking at least 2 hours a week reduces mortality by about 40%

Healthy diet
Daily finger stick blood glucose (FSBG) documented and brought to clinic visit
Physical exam every 3-6 months with attention to blood pressure (goal < 130/80),
weight loss, feet, waist circumference
HbAlC every 3 months if > 7.0, every 6 months if < 7.0
American Diabetic Association goal < 7.0
American Association of Clinical Endocrinologists goal < 6.5
Urine microalbumin every 3 months-1 year
24-hour urine for protein, C r and CrCI if UA protein > 100 or high serum C r
Consider annual 24-hour urine for protein, C r and CrCI
Lipid panel every year
Goal total cholesterol < 150
Goal LD L < 100 (< 70 if evidence of vessel disease): Use statins
Goal H D L > 40 (men), > 50 (women) (niacin may worsen insulin resistance)
Chem 8 and UA every year
Dilated eye exam (rule out retinopathy, glaucoma, cataracts) every year
Influenza vaccine every year
Pneumococcal vaccine
Consider daily ASA 81 mg, ACE inhibitor and statin
End of Session Quiz

7.
W hich class o f antihypertensive drugs will reduce proteinuria and slow/prevent

the progression o f diabetic nephropathy?
8.
W h a t is the treatment for proliferative diabetic retinopathy? W h a t is the

treatment for peripheral neuropathy?
9.
Besides retinopathy, what other common eye diseases are diabetics at an

increased risk o f developing?
10. H ow is diabetic gastroparesis diagnosed and treated?
NORMALTHYROID FUNCTION &HYPERTHYROIDISM
3 Question Warm-Up
1.
W h a t are the symptoms o f T C A overdose?
2.
D uring a yearly physical, a middle-aged m an jokes that he needs to buy some

reading glasses because he is having difficulty reading fine print. H e also notes
th at he has trouble driving at night and reading road signs. Though the patient
may have some presbyopia, for w hat else should you examine him?
3.
W h ich cranial nerve is responsible for each o f the following actions?

Eyelid opening
Taste from anterior 2/3 of tongue
Head turning
Tongue movement
Muscles of mastication
Balance
Monitoring carotid body and carotid sinus chemoreceptors and baroreceptors
AND HYPERTHYROIDISM
FUNCTION
NORMAL THYROID
End of Session Quiz

4.
W hat thyroid abnormalities would you expect to find during pregnancy?
5.
A patient has exophthalmos. W h at is the most likely cause?
6.
W hat is the treatment o f the most common cause o f hyperthyroidism?
7.
In which o f the following hyper thyroid diseases is radioactive iodine most likely
to result in hypothyroidism: Graves disease, toxic multinodular goiter, toxic
adenoma?
HYPOTHYROIDISM AND THYROID CANCER
3 Question Warm-Up
1.
W h a t serum lab abnormalities m ight you see in a patient with bacterial

meningitis?
2.
W h a t is the general treatm ent for DKA?
3.
W h a t disorder is present in a teenager w ith a history o f theft, vandalism and

violence toward family pets?
4. Thyroid Nodules
Incidence of palpable thyroid nodules (> 2cm) is about 4-5% of adults

About 1 out of 10 nodules is cancer
Death rate from thyroid cancer is about 1 out of 1 million
Higher chance that a nodule is cancer if:
- Child
Elderly
History of external radiation
Male
Family history of thyroid cancer
More likely malignant if sono/Doppler shows:
Irregular margins
Intranodal vascular pattern
- Microcalcifications
How do you manage a thyroid nodule?

Check TSH, free T4, thyroid ultrasound to measure size and assess for other nodules
If hyperthyroid -radionucleotide uptake scan
No role for radionudeotide uptake scan if euthyroid or hypothyroid!
Hot nodule treat as hyperthyroid
Cold nodule * FNA
AND THYROID
CA N CER
5.
HYPOTHYROIDISM
If hypothyroid -> replace thyroid replacement and monitor for decrease in nodule size
If nodule persists after thyroid replacement FNA
If euthyroid > FNA
6.
How should you follow up a FN A of a thyroid nodule?

Malignant > needs surgery
Benign -> repeat thyroid ultrasound every 6 months-1 year to make sure no increase in
size
If size increases * repeat FNA
0 Nondiagnostic > repeat FNA
Intermediate repeat thyroid ultrasound in 6 months
o Even if FNA is negative, you cannot completely rule out thyroid cancer. Explain to patient
that there is still about a 1% chance that this could be cancer and offer to let them choose
between ever 6 months ultrasound surveillance or removal of the nodule (partial vs. total
thyroidectomy).
[84] |
End of Session Quiz

7.
W h a t are the major differences between de Quervain thyroiditis and

H ashim oto thyroiditis?
-<
TJ
0
H
1
-<
73
O
o
>
8.
W h a t is the m ost common type o f thyroid cancer?
o
H
X
-<
73
q
o
n
>
z
n
9.
W h a t is the next step in the management o f a newly found thyroid nodule in a

patient w ith hyperthyroidism?
[ 85]
DISORDERS
PARATHYROID
3 Question Warm-Up
1.
A patient has exophthalmos, pretibial myxedema and decreased T S H . W h a t is

the diagnosis?
2.
W h a t are the most worrisome side effects o f the A D H D drug atomoxetine?
3.
W h a t important side effects are common to many o f the atypical antipsychotics?
4. W hat are the 2 most common causes of primary hyperparathyroidism? W hat

is the treatm ent for each?
The 2 most common causes are parathyroid adenoma and parathyroid hyperplasia. Treat
as follows:
Surgical parathyroidectomy if one of the following:
____________________________ > 1.0 mg/dL above the upper limit of normal

____________________________ reduced by 30%
____________________________ T-score < -2.5 at any site
Age < ----------------------------------------------
0 If adenoma and surgery indicated > removal of only the gland containing the adenoma
and biopsy of 1-3 other glands
If hyperplasia and surgery indicated > removal of 3 % glands and marking the remaining
half with a surgical clip (or forearm autotransplantation of the gland to remain in cases
where recurrence is likely such as M EN type I and Ila)
0 If surgery is not recommended or is refused:
Prevent worsening hypercalcemia by avoiding certain medications (________________
and____________________), volume depletion, prolonged bed rest or calcium
ingestion >IOOOmg/day
Adequate hydration (6-8 glasses of water daily) to avoid renal stones
Minimize bone resorption via _________________ , exercise, lOOOmg calcium daily
(except if calcitriol is elevated) and adequate vitamin D intake (400-600 lU/day)
Routine monitoring of serum calcium (q6m), serum creatinine (ql2m) and bone density
at the hip, L-spine and forearm (ql2m)
[86] |
W hat is the treatm ent for hyperparathyroidism due to chronic renal disease?
Hyperphosphatemia
Dietary restriction of phosphate (protein)
Oral phosphate binders taken with meals
- most commonly used (not calcium citrate which
increases aluminum absorption)
Sevelamer - nonabsorbable (does not cause hypercalcemia), can be taken with calcium
Lanthanum long-term side effects currently unknown
Aluminum hydroxide - now avoided because of gradual induction of aluminum toxicity
Renal Osteodystrophy
Lessen hyperphosphatemia via the above measures in order to lessen bone resorption
Calcitriol, other vitamin D analog or cinacalcet (a calcimimetic) to suppress P T H
secretion
End of Session Quiz

6.
H ow will vitamin D deficiency affect the levels o f Ca2+, P T H and phosphate?
7.
W h y m ight P T H be elevated in renal disease?
8.
W h a t happens to phosphate in patients with hyperparathyroidism caused by renal

disease?
9.
Com pare P T H , alkaline phosphatase, serum calcium and serum phosphate

levels in patients w ith the following diseases:
C a2+
Paget Disease
Osteomalacia/Rickets
Chronic renal failure
Osteoporosis
Osteopetrosis
Prim ary hyperparathyroidism
Hypoparathyroidism
Pseudohypoparathyroidism
Phos
Aik
Phos
PTH
PITUITARY DISORDERS
3 Question Warm-Up
1.
2.
A patient comes to clinic w ith the complaint o f hearing loss and vertigo. O n
examination o f the tympanic membrane you note a grayish-white pearly lesion
involving the T M . W h a t is the diagnosis?
3.
W h a t is the most likely cause o f galactorrhea, impotence (or menstrual

dysfunction) and decreased libido in a patient w ith a history o f schizophrenia?
Hyperprolactinemia
4. W hat are the symptoms of hyperprolactinemia?
Premenopausal female - hypogonadism * infertility, oligo/amenorrhea; rarely
galactorrhea
Postmenopausal female none since already hypogonadal; rarely galactorrhea
Male symptoms - hypogonadism (low testosterone) > decreased libido, impotence,
infertility (low sperm counts), gynecomastia, rarely galactorrhea
5. W hat is the treatm ent for a prolactinoma?

First step: Dopamine (DA) agonist ( _ _______________________ > bromocriptine or
pergolide)
If DA agonist ineffective * switch to a 2nd DA agonist
If DA agonists are ineffective -
____________________
If female with adenoma > 3cm and desire to become pregnant (during which time the DA
agonist is withheld)
transphenoidal surgery even if the DA agonist is effective
If large adenoma is surgically removed > radiation therapy after surgical debulking
Acrom egaly
6. W hat are the symptoms and signs of acromegaly? W hat tests can be used
to confirm the diagnosis?
The average tim e frame from onset to diagnosis is 12 years, and it presents
with the following symptoms:
Enlarged jaw (teeth spread apart); nose and frontal bones (coarse facial features); hands
and feet (increase in ring, glove, shoe size)
Soft tissue growth: voice deepens, macroglossia (teeth indentations in tongue), carpal
tunnel syndrome and other entrapment syndromes, hypertrophy of synovial tissue and
cartilage > arthropathy
Cardiovascular disease: H TN , LVH, diastolic dysfunction
Glucose intolerance in 50%, DM in 10%
Diagnostic testing:
Screen: measure serum levels of insulin-like growth factor 1 (IGF-1)
Confirm diagnosis with oral glucose suppression test (75g glucose >measure G H at
lh r and 2hr if G H concentration is >lng/mL = acromegaly)
If testing positive for acromegaly >pituitary M RI to eval for mass or empty sella
7.
W hat is the treatm ent for acromegaly?

Transsphenoidal resection of pituitary adenoma or external beam radiation
If unable to resect adenoma >somatostatin analog (octreotide or lanreotide) inhibits
G H secretion
If somatostatin analog ineffective > cabergoline (dopamine agonist that inhibits GH
secretion)
Bromocriptine is less effective than cabergoline
If cabergoline ineffective > pegvisomant (GH receptor antagonist)
End of Session Quiz

8.
W hat is the most common presentation o f hyperprolactinemia?
9.
W hat drugs are known for causing elevated prolactin levels?
10.
W hat is the next step in the management o f a patient with hyperprolactinemia

not due to an obvious drug cause?
11.
W h at is the next step in the management o f a patient found to have an absent

pituitary on M R I (empty sella)?
12.
W h a t is the visual field deficit classically associated w ith prolactinoma?
13.
W h a t complications can result from acromegaly?
CUSHING SYNDROME AND HYPERALDOSTERONISM
c
GO
X
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73
3 Question Warm-Up
1.
W h a t is the m ost common pituitary tumor, and what is the treatment?
oz
m
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X
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2.
A 16-year-old woman has a left arm paralysis after her boyfriend dies in a car
crash. No medical cause is found. W h a t is the diagnosis?
73
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3.
A t w hat age do physicians begin to dose dexamethasone w ith (or prior to) the
first dose o f antibiotics in cases o f suspected bacterial meningitis?
Z
GO
End of Session Quiz

4.
O f D H E A , D H E A -S and testosterone, which is made only by the adrenals and is

a more specific marker for an androgen-producing adrenal tum or in a woman?
5.
W h a t are the electrolyte abnormalities found in hyperaldosteronism?
6.
W h a t is the most specific lab finding in making the diagnosis o f primary

hyperaldosteronism?
7.
A patient s work-up reveals a high plasma aldosterone concentration and low

plasma renin activity. W h a t is the diagnosis, and what medication could be used
to treat this condition until definitive treatment can be undertaken?
OTHER ADRENAL DISORDERS
3 Question Warm-Up
1.
W h at is the first-line treatment for moderate hypercalcemia?
2.
A 22-year-old man has 4 months o f social withdrawal, worsening grades,

decreased emotional expression, and concrete thinking. His speech is frequently
tangential and incoherent, and he sometimes says that the T V weatherman is
giving him instructions. W h at is the diagnosis?
3.
W h a t is the pattern o f vision loss in glaucoma vs. macular degeneration?
End of Session Quiz

4.
A patient w ith elevated blood pressure, palpitations, headache and excessive

perspiration is found to have elevated urine vanillylmandelic acid levels. W hat
effect would giving a 3-blocker have on this patient?
5.
W hat is the likely condition o f a female infant with virilization o f the genitalia and
hypotension?
6.
W h a t serum lab abnormality would you see in 17a-hydroxylase deficiency and

in 21a-hydroxylase deficiency?
7.
A patient w ith acromegaly is found to have elevated C a2+ on a blood draw

during a work-up o f his peptic ulcer. W h a t is the diagnosis o f this patient?
ER, ICU, Surgery

1
A ccidents and Injuries p art 1
A ccidents and Injuries p a rt 2
Toxicology p art 1
Toxicology p a rt 2
Toxicology p a rt 3
C ardiovascular Em ergencies
C ritical C are
T raum a p a rt 1
T raum a p a rt 2
10 T raum a p a rt 3
11 P re -O p and P o st-O p Issues
12 Surgical Em ergencies and
T ransplantation
ACCIDENTS AND INJURIES PART I
3 Question Warm-Up
1.
W h a t lab changes will be seen in a patient w ith hyperaldosteronemia?
2.
W h a t lab findings are diagnostic o f H ashim oto thyroiditis?
3.
W h a t are the 5 basic criteria for metabolic syndrome?
Burns
4. W hat are the differences between 1st, 2nd, 3rd and 4th degree burns?
Traditional
Classification
Depth
Classification
Involvement
1st degree
Superficial
Only the epidermis
Signs and Symptoms

Painful, erythema
Capillary refill intact
2nd degree
3rd degree
4th degree
Superficial
partial
thickness
Epidermis and
partial thickness of
the dermis
Deep partial
thickness
Epidermis and
partial thickness of
the dermis
Full thickness
Epidermis, entire
dermis and
possibly deeper
tissues
Additional
involvement of
muscle and bone
Painful, erythema
Capillary refill intact
Painful, blisters
W hite and/or charred
W hat complications can arise from electrical burns?

In electrical burns, internal damage may be worse than external damage
Complications may include:__________________ , ___________________ , bony
injuries, myoglobinuria, acidosis,___________________ and/or various neurologic
disturbances
W hat is unique to the management of electrical burn patients as compared to

heat burn patients?
____________________________ to prevent myoglobinuria, renal failure and acidosis

in the face of muscle necrosis
High index of suspicion for compartment syndrome
Obtain an EKG and monitor for dysrhythmias
W hat are the common life-threatening complications in a patient with

substantial burns?
End of Session Quiz

8. W h a t is the Parkland burn formula?
9.
A patient presents w ith 2nd degree burns covering the anterior surfaces o f both
arms. W h a t is the surface area o f the burn?
10. W h a t are the complications to watch for in a patient that has suffered an
electrical bum ?
11. A m ine worker is brought into the E R after an explosion occurred; examination
o f the burns, which is difficult secondary to pain at the site, reveals extension
into the dermis and blisters. To w hat degree is this burn classified?
12. W h a t pulm onary pathology should you be -watching for in a patient who had a
saltw ater near-drowning episode?
13. W here is an aspirated object such as a penny m ost likely to end up?
14. W h a t is the next step in the managem ent o f a patient th at has aspirated an
object th at cannot be dislodged, and is now having difficulty moving air and is
becoming hypoxic?
ACCIDENTS AND INJURIES PART 2
ACCIDENTS AND INJURIES PART 2
3 Question Warm-Up
1.
A 60-year-old obese patient presents with dirty, velvety patches on the back of
the neck. W h at is the diagnosis, and what is the initial workup?
2.
W hat is the appropriate treatment of hypertension in cases of pheochromocytoma?
3.
W h at is the classic presentation o f a patient w ith hyperprolactinemia?
Bites and Stings

4. W hat is the treatment for a black widow spider bite?
Mild skin reactions resolve in less than 12 hours without complications
Initially wash wound with soap and water
Ice to reduce inflammation
-
Analgesia as needed
Pressure and immobilization to slow the systemic spread of venom
24 hours observation for signs of systemic involvement
If systemic symptoms (AKA latrodectism manifesting with muscle spasms, abdominal
stiffness, altered mental status, autonomic stimulation):
-
formusclespasm
Analgesia with acetaminophen +/- opioids
Antivenin ideally within________________ of the bite
5. W hat is the treatment for a brown recluse spider bite?

If ulceration * wound care with dressing changes and debridement
If signs of infection, cellulitis, abscess > antibiotics (___________________________ )
Consider______________________________to possibly reduce the extent of local
necrosis due to leukocyte inhibitory properties (r/o G6PD deficiency prior to dapsone
use due to risk of hemolytic anemia)
W hat is the treatm ent for a dog or cat bite?

Clean surface with iodine, then copious pressure irrigation with normal saline. Use a soft
IV catheter to get deep into the wound
Should you suture the wound closed?
Puncture bites and dog bites to the_______________ should not be closed with
sutures
should be sutured due to low rate of infection
Higher likelihood of infection favors leaving wound open. Infection more likely in _____
bites than in dog bites
___________________ prophylaxis if the animal cannot be observed for 10 days or if the
animal is suspected to be rabid.
____________________ immunization if not received in the previous 5 years
0 If the victim is a child, then follow-up psychological assessment for__________________
is indicated as it occurs in more than 50% of these children.
W hat are the indications for a tetanus booster in an adult patient?

Td should be given to every adult every___________________
A Tdap booster is recommended once in place of the Td between ages 19-64 years
Td should also be given to patients with wounds as recommended below:
immunizations
Uncertain or < 3 prior

tetanus immunizations
Non tetanus-prone
wound, LE, clean 8c
minor
Td if > 10 years since last

dose
Td (D T if < 7 years old) -

complete series (3 total)
Tetanus-prone wound
(dirt, contamination,
puncture, crush injury)
Td if > 5 years since last

dose
Td (D T if < 7 years old) +

tetanus immune globulin
250 units IM at site other
than Td > complete series
> 3 prior tetanus
End of Session Quiz

8.
W h a t E K G abnormality is classic for patients w ith hypothermia?
9.
W h a t is the treatment for a black widow spider bite?
10.
A fter appropriate irrigation and cleansing, should a dog bite wound to the arm
be left open or sutured closed?
11.
W h a t is the treatm ent for a skin laceration on the dorsum o f the hand that
resulted from a closed fist hitting a victim s mouth?
TOXICOLOGY PART I
3 Question Warm-Up
1.
W h a t is the treatment for hyperparathyroidism due to parathyroid hyperplasia?
2.
W h at is the L D L goal in a patient with diabetes?
3.
W h a t method is used to calculate fluid repletion in burn patients?
W hat are the potential consequences of acetaminophen overdose?
Stage 1
30 min - 24 hrs
Nausea, vomiting, diaphoresis, pallor, lethargy and

malaise
Stage II
24-72 hours
o Elevated LFTs, PT and total bilirubin

0 RUQ_pain and tenderness
Stage III
72-96 hours
Peak LFT elevation

Jaundice, hepatic encephalopathy, bleeding, +/- acute
renal failure
Possible multisystem organ failure * death
Stage IV
4 days 2 wks
Recovery
W hat are the symptoms of anticholinergic toxicity? W hat is the antidote?
Hot as a hare (hyperpyrexia)

Dry as a bone (decreased secretions)
Red as a beet (cutaneous flushing)
Blind as a bat (cycloplegia and mydriasis)
Mad as a hatter (disorientation)
Bloated as a toad (constipation and urinary retention)
Tachycardia
Decreased or absent bowel sounds
Antidote -
W h a t are the signs and sym ptom s of cyanide ingestion?

Tachycardia, hypertension, flushing, tachypnea >obtundation >coma >death
(discernible to 60% of the population)

Late findings: bradycardia, hypotension, bradypnea, cyanosis, hepatic necrosis, renal
failure
Delayed-onset
sensitive to cyanide)
in survivors of severe poisoning (basal ganglia is
W hat is the treatm ent for cyanide poisoning?

Airway, Breathing, Circulation
High-flow oxygen regardless of pulse-ox readings
Mouth-to-mouth resuscitation is contraindicated here due to risk of provider exposure
If oral ingestion > 1 dose activated charcoal (50g in adults)
Sodium thiosulfate
Sulfur donor that facilitates the conversion of cyanide to thiocyanate which is renally
excreted
Hydroxocobalamin (a vitamin B12 precursor)
Directly binds cyanide to form cyanocobalamin which is less toxic and excreted in the
urine
Causes a reddish discoloration of the skin, mucous membranes and urine
Works well in conjunction with sodium thiosulfate
Generally preferred over nitrate-induced methemoglobinemia which can be lethal
Amyl nitrate and sodium nitrate
Induce methemoglobinemia which binds cyanide to form cyanomethemoglobin
Goal methemoglobin level is 20-30% (but this is lethal in children and anemic patients)
Contraindicated in patients with carboxyhemoglobinemia (usually from smoke
inhalation)
Methemoglobinemia can be reversed with methylene blue, but this should be avoided
in cyanide-poisoned patients because it will release free cyanide
- W orks well in conjunction with sodium thiosulfate
End of Session Quiz

8.
W h a t cardiac medications are safe to treat the tachycardia and hypertension

associated w ith cocaine overdose?
9.
W h a t is given to treat acetam inophen overdose? W h a t other uses does this

m edication have?
10. W h a t medications are used in cases o f cyanide poisoning?
TOXICOLOGY PART 2
3 Question Warm-Up
1.
A patient on haloperidol develops fever, muscle rigidity, confusion and

diaphoresis. W h a t is the drug o f choice in the treatment of this patient s
condition?
2.
W h a t kind o f tum or is the most common brain tumor?
3.
Lung cancer accompanied by muscle weakness is indicative o f what?
W hat are the classic features of digoxin toxicity?

Nonspecific symptoms: fatigue, blurred vision, change in color vision (e.g., yellow vision),
anorexia, nausea, vomiting, diarrhea, abdominal pain, headache, dizziness, confusion,
delirium
Characteristic EKG changes:
Prolonged PR interval, scooping of ST segments - seen at therapeutic levels
_____________________ - frequent vital sign abnormality
PVCs are most common findings on EKG
Atrial tachycardia with AV block (e.g., 4:1 or 6:1) less common
___________________indicates the severity of digoxin toxicity (which inhibits the
Na+-K"-ATPase)
Elevated serum digoxin levels
W hat is the treatment for digoxin toxicity?

Activated charcoal in repeated doses
_____ _____________ if one of the following is present:
Hemodynamic instability
Life-threatening arrhythmias or severe bradycardia (even if responsive to atropine)
Plasma potassium level > 5 mEq/L in an acute overdose
Plasma digoxin level > lOng/mL
Ingestion of > 10 mg of digoxin in adults or >4 mg in children
Presence of a digoxin-toxic rhythm in the setting of an elevated digoxin level
Treat hyperkalemia only if it is causing EKG disturbances and avoid_______________
which can worsen intracellular hyperkalemia in these particular patients
If bradycardia > __________________
ACLS medications as needed (except calcium)

NG tube gastric aspiration if ingestion of a large amount within the last 60 minutes (rare)
_____________________ to correct acidosis and limit penetration of toxic metabolites
into tissues (such as retina)
Inhibit the alcohol dehydrogenase enzyme with fomepizole or ethanol:
____________________ preferred drug
___________________ - if fomepizole is unavailable, dose to serum level of 100 mg/dL
Dialysis if________________________________________________________________
(e.g., vision changes or renal failure)
Folic acid, thiamine and pyridoxine supplementation to optimize elimination pathways
7. W hat are the characteristics of aspirin overdose?

_____________________ an important part of the patient history
0 Hyperthermia (as ASA uncouples mitochondrial oxidative phosphorylation)
0 _____________________ (from hyperventilation) >then mixed respiratory alkalosis
and metabolic acidosis with elevated anion gap
- Tachypnea results from A SA stimulation of the medullary respiratory center
- Acidosis results from accumulation of lactic acids and ketoacids
Nausea and vomiting, dehydration
Altered mental status
8. W hat is the treatm ent of a patient that has an elevated IN R from excessive
warfarin ingestion?
IN R <5 without bleeding. Options:
Skip next dose + lower routine dose
Lower routine dose only
Do nothing if minimal and identifiable inciting event
IN R 5-9 without bleeding. Options:
Skip next 1-2 doses > monitor IN R q I-2 days and resume dosing when IN R at desired
level + lower routine dose
Skip next dose + administer vitamin K (l-2.5mg orally) + lower routine dose
IN R >9
Hold dosing until IN R in therapeutic range + administer vitamin K5-I0m g PO once and
as needed subsequently + lower routine dose
IN R >20 >choose to treat as if serious bleeding or as IN R >9
Any serious bleeding
- Vitamin K lOmg slow IV + administer fresh frozen plasma (FFP*) + monitor IN R and
repeat FFP* dosing as needed + stop warfarin (individual clinical judgment must be
used in decision to restart)
* Prothrombin complex concentrate or recombinant human factor Vila can be used in
place of FFP
TOXICOLOGY PART 2
6. W hat is the treatm ent for methanol or ethylene glycol toxicity?
End of Session Quiz

9.
W h at are the antidotes to each o f the following toxins?

Aspirin
Acetaminophen
Opioids
Benzodiazepines
Tricyclic antidepressants
Atropine
Propranolol
Digoxin
Cyanide
Methemoglobin
Methanol
Isoniazid
Heparin
10.
A t w hat point in a patient with an elevated IN R due to warfarin would you

consider dosing vitam in K to reverse the warfarin?
TOXICOLOGY PART 3
3 Question Warm-Up
1.
W h a t is the m ost sensitive test for multiple sclerosis?
2.
W h a t type o f bite/sting can rarely cause acute pancreatitis?
3.
In which endocrine disorder m ight weight loss completely eliminate the need for
medication?
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4. A schizophrenic patient comes to the E R for ingestion of alkali plumbing liquid.

How is this patient managed?
- If respiratory distress > laryngoscopy > +/- tracheostomy
Emergency surgery if signs of perforation, mediastinitis or peritonitis.
D O N O T give an emetic such as_____________________ ,_a _____________________
(which will improve nothing, but may result in thermal injury), o r__________________
(which may lead to perforation or emesis of caustic material)
If asymptomatic and reliable history of low volume, accidental ingestion outpatient
follow-up only may be appropriate. Otherwise, manage as follows:
- Endoscopy (EGD) to look for severity of injury
- ICU care to manage life-threatening complications (mediastinitis, peritonitis, respiratory
distress, shock)
Esophageal dilations 3-6 weeks after injury if necessary for strictures
Surveillance EG D beginning 15-20 years after the ingestion at an interval of ql-3 years to
screen for esophageal squamous carcinoma
[ 105]
W hat are the signs and symptoms of organophosphate poisoning?

DUMBBELSS: Diarrhea, Urination, Miosis, Bronchospasm, Bradycardia, Emesis
and Excitation of skeletal muscle, Lacrimation, Sweating, Salivation and abdominal
cramping. (Think of extreme rest and digest, parasympathetic/cholinergic activity and
loss of fluids from multiple areas of the body.)
W hat sequelae would you expect to see in a toddler that ingested too much
iron when he found his mothers prenatal vitamins?
Gastrointestinal phase (30 min - 6 hours after ingestion)
Abdominal pain, vomiting; diarrhea (often btoody), hematemesis, melena, lethargy, shock
In cases of mild iron toxicity, this is usually the only phase present
If no Gl symptoms develop within____________ after ingestion, it is unlikely that iron
toxicity will occur (sinless the patipnt consumed enteric-coated iron)
Latent/stable phase (6 - 24 hours after ingestion)

Observation is required when patients have gone through the Gl phase in orderto
determine if the toxicity was mild then resotyed or if the patient simply entered into this
Latent phase
Shock and metabolic acidosis (6 72 hours after ingestion)
Widespread cellular dysfunction

Multisystem organ failure, Gl bleeding and/or perforation, pulmonary dysfunction,
coagulopathy, renal dysfunction and neurologic dysfunction can all occur in this phase
Outcomes are poor in this stage and therapies have little effect
Hepatotoxicity/hepatic necrosis (12 - 96 hours after ingestion)

__________________________ ( 2 - 8 weeks after ingestion)
Occurs from G l scarring classically at the gastric outlet
Vomiting is the pfesenting.symptom
W hat are the antidotes to the following toxins?

Arsenic
Copper
t-PA, streptokinase
W hat problems can arise from theophylline overdose?

Therapeutic range is 10-20mg/L. Every patient is unique and some may have mild SE at
ISmg/L. Even a level above 25mg/L is worrisome.
Main SE: seizures, hyperthermia, hypotension and__________________________
Seizure SE may occur at levels of 14-35mg/L. Seizure risk is more likely in older patients,
prior brain injury patients, patients with severe pulmonary disease and patients with
hypoalbuminemia.
End of Session Quiz

9.
W h a t is the treatment for lead poisoning in adults? W hat is the treatment in

children?
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-
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7>
10. W h a t is the next step in the management o f a patient that presents to the E R w ith
organophosphate poisoning?
11. W h a t classic toxic ingestion management options should not be chosen in patients
presenting w ith alkaline fluid ingestion?
12.
A C O P D patient comes to the E R w ith tachycardia and hypotension. D uring

the evaluation he begins to have seizures. W h a t is the most likely etiology?
13. W h a t are the antidotes to each o f the following toxins?

Arsenic
m
73
Anticholinesterases,
organophosphates
Carbon monoxide
Copper
on
C
C
Iron
Mercury
73
O
m
t-PA
I [ 107]
CARDIOVASCULAR EMERGENCIES
3 Question Warm-Up
1
A 52-year-old diabetic presents to the E R w ith classic anginal chest pain, and
you suspect an M I. W hile waiting for the EKG, what treatments do you
initiate immediately?
2.
W h a t are the antidotes for each o f the following types o f overdose?

Opioids
Heparin
Benzodiazepines
Barbiturates
(phenobarbital)
Carbon monoxide
3.
A patient presents w ith weakness, nausea, vomiting, weight loss and new
skin pigmentation. Labs show hyponatremia and hyperkalemia. W h a t is the
treatment?
W hat drugs are used in treating a stable, asymptomatic ventricular

tachycardia?
W hat is the treatm ent for supraventricular tachycardia (SVT)?

Attempt vagal maneuvers and carotid massage >adenosine ventricular rate-control
(calcium channel blocker or (3-blocker)
W hat is the initial treatm ent for new atrial fibrillation with rapid ventricular
rate of unknown duration?
Rate control with one or more of the following: ^-blockers, diltiazem or verapamil, or
digoxin
Anticoagulation with heparin (then later warfarin)
W hat is the treatm ent for pulseless electrical activity (P EA ) or asystole?
Evaluate and treat H causes

______ rapid volume resuscitation through multiple IV sites and/
or central line
______________________> correct via intubation, chest tube or oxygen
______________________> IV push 1-2 amps bicarb (commonly needed in a
prolonged code)
______________________ (common in a prolonged code" due to acidosis) CaCI2
IV push, bicarb, insulin/glucose
______________________ administer KCI
______________________ (always check a finger-sticki) > I amp D50 IV push
______________________ > warming
Evaluate and treat T causes
pericardiocentesis
needle decompression then chest tube
cardiac cath or thrombolytic
thrombolytic or thrombectomy
follow ATLS protocols
End of Session Quiz

8.
W hat is the maximum number of epinephrine doses that can be given when
treating cardiac arrest?
9.
In treating pulseless ventricular tachycardia, what drug could be given in place of

the first or second dose o f epinephrine?
10. W hat piece o f medical history should be obtained in deciding how to treat atrial
fibrillation?
11. W h a t is the ACLS protocol for ventricular fibrillation?
CRITICAL CARE
3 Question Warm-Up
1.
W h a t are the antidotes to the following toxins?

Antimuscarinic, anticholinergic
agents
Benzodiazepines
Tricyclic antidepressants
W arfarin
M ethanol, ethylene glycol (antifreeze)
Arsenic
2.
A n 18-year-old m an is found to have a systolic heart m urm ur heard at the apex

and left lower sternal border th at increases in intensity while standing after
squatting. W h a t diagnosis do you suspect?
3.
W h a t is the clinical definition o f hypertension?
CRITICAL CARE
End of Session Quiz

4.
W hich blood product is most appropriate in each of the following scenarios?

Severe anemia due to
autoimmune hemolytic anemia
Hemophilia
DIC
Shock due to trauma or
postpartum hemorrhage
To maintain blood pressure
during large volume paracentesis
Hemorrhage due to warfarin
overdose
Need for vWF-rich blood product
Thrombocytopenia
5.
W hich vasopressor matches each o f the following statements?

Theoretically causes renal
vasodilation
High doses optimize the a t
vasoconstriction
A D H analogue
Best choice for anaphylactic
shock
Best choice for septic shock
Best choice for cardiogenic shock
Causes vasoconstriction but with
bradycardia
6.
In a Swan-Ganz catheter (pulmonary artery catheter), o f what is the wedge

pressure a good estimate?
TRAUMA PART I
H
:30
>
C
3
>
5
H
3 Question Warm-Up
1.
W h a t is the classic E C G appearance in atrial flutter?
2.
W h a t side effects can arise from theophylline overdose?
3.
W h a t is the treatm ent for Kawasaki disease in the acute phase?
Traum a Assessm ent

4. W hat is the basic sequence of assessing a traum a patient?
Airway
- Obtain airway (ET tube or cricothyroid) if patient not moving air
(If patient is speaking then patient is moving air)
Breathing
- Start 0 2
- Pulse-ox
Bag ventilation if airway good, but still not breathing.
- Consider needle decompression and/or chest tube placement if auscultation is
consistent with pneumothorax.
Circulation
- Check pulse (carotid, femoral or other)
- Check vitals and rhythm on heart monitor > A CLS per protocol
Listen for heart sounds
- Make sure 2 large bore IVs or a central line has been started
- Start IVF
Control active bleeding
Disability
- Glasgow coma scale
- Neuro exam (limited)
- Fingerstick blood glucose
Exposure
Remove all clothes
DRE & Foley
- Cover with blanket to avoid hypothermia
[ 113]
TRAUMA PART I
Traum a Assessm ent cont

Secondary Survey
Reassess ABCs
DRE & Foley (no Foley if: mobile or high-riding prostate, or blood from urethral meatus)
N G T placement (as needed)
History (Allergies, Meds, Drugs, PMH/PSH, Last meal, Events of trauma)
Head-to-toe exam
Examine back for wounds or spinal injuries
Remove from backboard
X-rays - usually C-spine + C X R + AP pelvis
FAST scan (Focused Abdominal Sonography for Trauma)
C T scans (as needed)
Labs (CBC, Chem 14, EtOH, UDS, UA)
Other Management
Serious fracture management
0 Pelvic fracture: wrap bedsheet tightly around pelvis to stabilize
Femur fractures: closed reduction via manual traction, then stabilize with traction brace
Open fractures: remove any gross debris >NS pressure wash x5L > cover with Kerlex
Meds: antibiotics, analgesics, tetanus shot
Consults
Documentation and talk with family
Head Trauma
S. W hat is Cushings triad?
6. W hat are the classic physical findings in a basilar skull fracture?
7. W hat interventions can be used to lower intracranial pressure in a head injury

patient?
If patient needs intubation, pretreat with lidocaine to minimize ICP elevations
_______________
IV loadthenq6
hours.
q6hr serum______________ and______________ (dont rely on the Chem 7
calculated osmolarity)
Hold mannitol if Na > 152 mEq/L or osmolarity > 305 mOsm/L
Intubate and_____________until p C 0 2is 25-30 on ABG. Decreasing p C 0 2by 5-10
mmHg will lower ICP by 20-30 mmHg. This effect lasts less than a few hours and should
only be used as a temporary measure.
Other options: ventriculostomy, barbiturate coma, paralysis
Spinal Cord Traum a

8. W hat is the treatm ent for anterior spinal cord syndrome following a traumatic
injury?
Assess and manage Airway, Breathing and Circulation first. Keep spine stabilized.
If hypotension, aggressively bolus fluids, but hmit fluids once normotensive to avoid cord
swelling.
Immediate high-dose IV steroids (ideally 8 hours) - methylprednisolone 30 mg/kg initial
IV bolus then 5.4 mg/kg per hour for 23 hours
Controversial but still considered the standard of care at most hospitals
"A treatment option rather than treatment standard according to American Academy
of Neuro. Surgeons and American Academy of Emergency Medicine
Only used in non-penetrating cervical trauma without multi-system trauma
C T and M RI of the spinal cord
Once stabilized, decompression via closed reduction (halo headpiece and 5-15 lbs of
weight) or surgical intervention
End of Session Quiz

9.
A patient presents to the E R after being involved in a motor vehicle collision

(MVC). H e does not open his eyes or make any sounds, but he does withdraw
to painful stimuli. W h a t is his Glasgow coma score (GCS)? W h a t needs to be
done?
10. A nother M V C victim arrives to the ER. H e is able to carry on a conversation and
even comment on how nice one o f the nurses hair looks. H e is able to move all
o f his extremities on command, and he has significant periorbital ecchymosis and
surrounding superficial scrapes. W h a t is his GCS? W h a t radiological study does
he definitely need?
11. W h a t interventions are effective in the management o f elevated intracranial

pressure?
12. W hat are the symptoms of a basilar skull fracture?
TRAUMA PART 2
s?i
TRAUMA PART 2
3 Question Warm-Up
1
W h at heart disease fits each o f the following descriptions?

ST segment elevation in leads corresponding
to the perfusion of multiple arteries
Hypotension + distant heart sounds +
distended neck veins
Cardiac cath shows equal pressures in all
heart chambers
Chest pain that lessens when the patient
leans forward
2.
W h at is the next step in the evaluation o f a pulsatile abdominal mass and bruit?
3.
W h at is the treatment for ventricular fibrillation?
Neck Trauma
4. W hat are the different zones of the neck and structures contained in each
zone?
Zone
Landmarks
Structures Contained
Clavicle > cricoid cartilage
Great vessels, aortic arch, trachea,

esophagus, lung apices, cervical
spine, spinal cord and cervical nerve
roots
II
Cricoid cartilage angle of

the mandible
Carotid and vertebral arteries,

jugular veins, pharynx, larynx,
trachea, esophagus, cervical spine
and spinal cord
III
Angle of the mandible > base

of the skull
Salivary and parotid glands,

esophagus, trachea, cervical spine,
carotid arteries, jugular veins, major
cranial nerves
Chest Traum a
5. W hat C X R findings might indicate a ruptured thoracic aorta?
loss of aortic knob, pleural cap, deviation of the trachea
and esophagus to the right, and depression of the left main stem bronchus
6. W hat are the signs of tension pneumothorax? W hat is the treatment?
I
>
c
>
5
7>
H
I 10
Signs: absent breath sounds and hyperresonance to percussion (hollow sound) on the
affected side, distended neck veins, hypotension
Treatment:
- Immediate_____________________________
If delay in chest tube placement,_____________________________ on the affected
side (2nd or 3rd 1C space at midclavicular line or 5th 1C space at midaxillary line)
7.
W hat is a flail chest, and what is the classic presentation?

Flail chest is a free-floating portion of the chest wall that moves paradoxically to the rest
of the chest wall (inward motion with inspiration) and results from 3 or more sequential
rib fractures
Patients may have muscle splinting due to pain which may conceal the paradoxical motion
of the chest wall
Mechanism of injury is usually direct impact of the steering wheel or crush injury
8. W hat is the treatm ent for a flail chest?

Oxygen supplementation
Close monitoring for early signs of respiratory compromise
Placing an object (e.g., sandbag) to the affected region to stabilize the segment is no longer
done due to the consequence of restricting chest expansion
BiPAP by mask or endotracheal intubation with mechanical ventilation
(otherwise the patient may become hypoxic from limiting
breathing due to pain)
[117]
TRAUMA PART 2
Abdominal Trauma
9. W hat are the initial steps in the management of an abdominal stab wound
presenting to the ER?
If hypotensive >_________________________________________
Abdominal exam
Signs of peritonitis (peritoneal irritation)
____________________________________
Explore th e stab wound under local anesth< -.ia
If wound penetrates an terio r fa sc ia > O perate
If no penetration or unable to assess, admit for serial 24-hour exams > surgical
exploration if peritonitis, hemodynamic instability develop, Or positive on additional
testing (listed below)
NG tube - to decompress stomach and rule out blood in the stomach

Urinary catheter
Additional possible testing in the stable patient not already needing surgical
exploration:
Diagnostic Peritoneal Lavage (DPL) if indicated
Upright CXR - to identify hemo- or pneumothorax and/or intraperitoneal air
Diagnostic ultrasound to identify hemoperitoneum
Abdominal CT with contrast
Diagnostic laparoscopy
10. W hat are the next steps in the management of blunt abdominal traum a in a
patient with stable vital signs?
Airway, Breathing, Circulation (Primary Survey then Secondary Survey)
Establish IV access at two sites with large bore IVs
NG tube and Foley
O
Stat H&.H +/- Blood type and cross
11. W hat are the next steps in the management of a patient with blunt abdominal
traum a and unstable vital signs?
Primary and secondary survey
Assess for and manage pelvic fracture
FAST (Focused Assessment with Sonography for Trauma)
If blood in pelvis
' ________________ _____________________
If no blood in pelvis possible retroperitoneal hemorrhage

If FAST inconclusive
>
___________________
> _______________
If no blood in pelvis and angiography is normal, then

+/- admission
+ observation
12. W hat is the treatm ent for a retroperitoneal hematoma?

If penetrating injury or exsanguination into abdomen (bloody peritoneal aspirate)
If blunt trauma without blood in the abdomen >
Follow_______________
If hemodynamically unstable or falling H&H > ________________________________
Genitourinary and Pelvic Traum a

13. W hat is the immediate treatm ent for a patient with a pelvic fracture?
Primary and secondary survey including a thorough neurovascular examination
IV F luid+/-blood
Ultrasound (FAST) to assess for fluid in the pelvis > if no fluid in pelvis and patient is
hemodynamically unstable _____________________________________ to detect
bleeding missed by FAST
If blood detected _____________________________________
If hemodynamic instability but no blood detected > consider retroperitoneal
hemorrhage > _____________________________________
_______________________ until the external fixator is placed (a bedsheet twisted and tied
tighdy around the pelvis can be used if nothing else is available)
Assess for bladder and urethral injury with retrograde cystourethrogram
-
If extraperitoneal bladder rupture ^ _____________________________________
If intraperitoneal bladder rupture >______________________________________
End of Session Quiz

14. W h at is the next step in the evaluation o f the following patients?
Pelvic fracture + DPL shows blood in
the pelvis
Pelvic fracture + DPL shows urine in
the pelvis
Pelvic fracture + DPL shows nothing
+ hemodynamic instability
Blunt abdominal trauma + unstable
vital signs + FAST shows fluid in
pelvis
vital signs + FAST shows no fluid in
pelvis
vital signs + FAST inconclusive
Blunt abdominal trauma + stable vital
signs
Abdominal stab wound + hypotensive
or signs of peritonitis
15. W h at additional studies can be performed in the case o f a stable patient w ith an
abdominal stab wound that penetrated the peritoneum?
TRAUMA PART 3
3 Question Warm-Up
1.
W h a t type o f immunodeficiency increases the risk o f anaphylactic transfusion

reaction?
2.
W h a t would you find on physical exam o f a patient w ith pericardial effusion?
3.
A patient is in the hospital and begins to have atrial fibrillation w ith RVR (rapid
ventricular rate). This patient has had chronic atrial fib previously. W h a t study
has to be performed before the patient can be cardioverted?
4. W hat antibiotic prophylaxis should be provided for rape victims? W hat other
prophylactic measures should also be taken?
_______________________ 125mg IM (gonorrhea)
_______________________ lg PO o r________________________ lOOmg PO bid for 7
days (Chlamydia)
_______________________ 2g PO (Trichomonas)
Hepatitis B vaccine #1 of 3 (if not yet vaccinated) +/- Hep B immune globulin (not
standard of care)
_______________________ for 3-7 days with follow-up for further counseling.
Common prophylactic regimens:
Antiemetic (Promethazine) for nausea caused by H IV meds and pregnancy prophylaxis
Levonorgestrel (Plan B) 0.75mg PO repeat dose in 12 hours (alternatively, both doses
can be taken at once for improved compliance) (other options for emergency contraception
discussed in Gyn lecture)
End of Session Quiz

5.
W h a t should be done to evaluate an extremity trauma?
6.
Since bleeding between the fetus and m other is a concern in traum a, w hat
actions should be taken once the patient and the fetus are stabilized?
PRE-OP AND POST-OP ISSUES
3 Question Warm-Up
1.
W hich antidepressants are associated w ith hypertensive crisis? W h a t substance

can exacerbate this effect?
2.
W h a t EK G finding is associated w ith hypothermia?
3.
W h a t are the classical physical findings in cases o f endocarditis?
End of Session Quiz

4.
W hen is the greatest risk for a post-operative M I? W h at is recommended

perioperatively for patients with known CAD?
5.
W h at lab findings suggest hepatic disease during a pre-operative work-up?
6.
W hat interventions are helpful in optimizing lung function in the post-op period
in patients with preexisting lung disease?
7.
W h a t studies are ordered to evaluate the cause o f a fever in a post-op patient?
SURGICAL EMERGENCIES AND

TRANSPLANTATION
3 Question Warm-Up
1.
W h a t would you suspect in an E R patient with blood in the urethral meatus or

a high-riding prostate?
2.
W h a t are the tw o measures o f how severe the hypotension is in shock?
3.
W h a t causes a continuous machine-like heart murmur?
4. W h at is the typical E R lab work-up for a patient with acute abdominal pain?
5. W hat are the signs and symptoms of acute mesenteric ischemia?
Sudden onset of severe abdominal pain (periumbilical) that is_______________________

Vomiting and diarrhea
Condition that could cause emboli formation (e.g., atrial fibrillation)
Early exam: mosdy normal, abdominal distention, +/- occult blood on stool
Late exam (bowel infarction): abdominal distention, absent bowel sounds, peritoneal signs,
feculent odor to the breath
6. W hat is the treatm ent for acute mesenteric ischemia?

General care
Hemodynamic monitoring and support. Dobutamine or dopamine if necessary.
Broad-spectrum antibiotics
for diagnosis and treatment
Specific care
Heparin anticoagulation
- Papaverine infusion to decrease arterial vasospasm
If embolism embolectomy and resection of necrotic bowel second-look
laparotomy in 24-48 hours to remove additional necrotic bowel
If thrombus > thrombectomy and revascularization (e.g., supraceliac aortic graft to the
involved intestinal artery) > resection of necrotic bowel and second-look laparotomy
as needed aspirin daily after recovery
- Resection of necrotic bowel and bypass
SURGICAL EMERGENCIES AND TRANSPLANTATIO N
7. W hat are the classic signs/symptoms of chronic mesenteric ischemia?

AKA intestinal angina
Dull, crampy, postprandial epigastric pain within the first hour after eating, then
subsiding over 2 hours
Weight loss (due to food aversion to avoid postprandial pain)
Possibly nausea, vomiting and early satiety
Abdominal bruit (50%)
8. W hat are the treatment options for chronic mesenteric ischemia?

9.
W h at is seen on abdominal x-ray or C T scan that indicates a ruptured viscus?
10.
W h a t is the classic finding in the abdominal exam o f a patient w ith mesenteric

ischemia?
11.
W h a t is the usual lab panel ordered in a patient presenting to the E R with

generalized abdominal pain?
12.
W h a t is the type o f rejection th at is treatable w ith immunosuppressive

agents? W h a t is the m echanism o f this rejection? W ith in w hat tim e frame
may it show up?
C ardiovascular
1
C ardiology Basics
A therosclerosis
H ypercholesterolem ia
Stable A n g in a
U nstable A n g in a
M yocardial In farctio n
A rrh y th m ias p a rt 1
A rrh y th m ias p a rt 2
H e a rt Failure
10 V alvular D iseases
11 C ardiom yopathies and Pericardial
D isease
12 M yocardial Infections
13 H ypertension
14 A ntihypertensives
15 Shock
16 V ascular C onditions
17 Vasculitis
18 Pedi C ardiology
CARDIOLOGY BASICS
3 Question Warm-Up
1.
Categorize the following antipsychotics into the appropriate category as lowpotency neuroleptic, high-potency neuroleptic, or atypical antipsychotics.
olanzapine, thioridazine, quetiapine, chlorpromazine, haloperidol,fluphenazine, loxapine,
risperidone, thiothixene, trifluoperazine, dozapine, aripiprazole, paliperidone, droperidol
Low-potency neuroleptics '
High-potency neuroleptics Atypical antipsychotics
2.
W h a t overdose causes metabolic acidosis and retinal damage leading to

blindness?
3.
W h a t are the electrolyte abnormalities found in hyperaldosteronism?
End of Session Quiz

4.
W h ich coronary artery is the most common site o f occlusion?
5.
W h ich E C G leads correspond to occlusion o f the LA D ?
6.
In which phase o f the cardiac cycle do coronary arteries fill w ith blood?
7.
A n IC U patient has a B P o f 120/78. Calculate her m ean arterial pressure.
8.
W h a t is the electrophysiological reason that a Q R S complex would become

widened?
1EROSCLEROSIS
ATHEROSCLEROSIS
3 Question Warm-Up
1.
Otoscopy in a child presenting with acute onset o f ear pain reveals large reddish
vesicles on the T M . W h at is the diagnosis, typical organism and treatment?
2.
A burn patient presents with cherry-red flushed skin and coma. 0 2 saturation is
normal, but carboxyhemoglobin is elevated. W h at is the treatment?
3.
W h at mineralocorticoid medication is used in the treatment o f aldosterone

deficiencies such as adrenal insufficiency and 21-hydroxylase deficiency?
End of Session Quiz

4.
Your patient is undergoing a treadmill stress test. W h a t key EKG finding would
suggest myocardial ischemia during exercise?
5.
Stress testing is done as a screening test. I f angina or ischemia occurs with these
tests, what test should follow?
6.
Besides lowering LD L, what other effect do statins have that may contribute to
their ability to reduce the incidence of myocardial infarction?
HYPERCHOLESTEROLEMIA
3 Question Warm-Up
1.
A bipolar patient w ho is treated w ith a m ood stabilizer has concurrent

depression. W h a t should you use to treat his depression?
2.
W h a t are the differing presentations o f Alzheim er disease, Pick disease and

Lewy body dementia?
3.
W h a t are two key differences between somatization disorder and conversion

disorder?
End of Session Quiz

4.
W h ich lipid-lowering agent matches each o f the following descriptions?

SE: Facial flushing
SE: Elevated LFTs, myositis
SE: GI discomfort, bad taste
Best effect on H D L
Best effect on Triglycerides
Best effect on LDL/cholesterol
Binds C. difficile toxin
5.
W h a t are the recommendations for L D L levels in patients based on their C A D

risk?
6.
How can the flushing reaction o f niacin be prevented?
STABLE ANGINA
3 Question Warm-Up
1
Chvostek and Trousseau signs are associated w ith what metabolic abnormality?
2.
Cold water is flushed into a patients ear, and the fast phase o f the nystagmus is
toward the opposite side. W here is the lesion?
3.
A lesion to which area o f the brain is responsible for the following clinical
scenarios?
0 Contralateral hemiballismus
I Ilieumi in il neglect syndrome
Coma
Poor repetition
Poor comprehension
3 Poor vocal expression
4. W hat medications are used in the treatment of Prinzmetal angina?
5. W hat is the most likely cause of chest pain in each of the following scenarios?
ST segment elevation only during brief episodes of chest pain

Patient is able to point to localize the chest pain using one finger
Chest wall tenderness on palpation
Rapid onset sharp chest pain that radiates to the scapula
Rapid onset sharp pain in a 20-year-old and associated with dyspnea
Occurs after heavy meals and improved by antacids
Sharp pain lasting hours-days and is somewhat relieved by sitting forward
Pain made worse by deep breathing and/or motion
Chest pain in a dermatomal distribution
Most common cause of noncardiac chest pain
Acute onset dyspnea, tachycardia and confusion in a hospitalized patient
Pain began the day following an intensive new exercise program
Widened mediastinum on CXR
End of Session Quiz

6.
W h ich patients are more likely to have atypical angina (or no angina) during an
episode o f myocardial ischemia?
7.
H ow does nitroglycerin work acutely in a cardiac ischemic episode?
8.
W h y should relief o f chest pain with nitroglycerin administration not be used as a

diagnostic test for whether or not the chest pain is cardiac in nature?
UNSTABLE ANGINA
3 Question Warm-Up
1. W h a t would you suspect to be the cause o f hyperthyroidism in a patient
presenting with the symptoms o f hyperthyroidism in addition to the following
findings?
Extremely tender thyroid gland
Pretibial myxedema
Pride in recent weight loss, medical professional
0 Palpation of single thyroid nodule
Palpation of multiple thyroid nodules
Recent study using IV contrast dye (iodine)
Eye changes: proptosis, edema, injection
History of thyroidectomy or radioablation of thyroid
2.
W h a t is the difference between conduct disorder and oppositional defiant

disorder?
3.
W h a t is the difference between conduct disorder and antisocial personality

disorder?
Initial management of unstable angina

ABCs
MONA: IV Morphine (decreases stress and cardiac oxygen demand), Supplemental 0 2
(only if hypoxemia present), Nitroglycerin (decreases preload and BP), Aspirin
p-blocker (if no signs of heart failure) decreases blood pressure, contractility, heart rate
and oxygen consumption. Caution in patients with COPD, asthma or diabetic patients.
Statin (preferably before PCI)
Antiplatelet therapy to all patients (clopidogrel or ticagrelor). For very high risk patients
(recurrent ischemic discomfort, dynamic EKG changes or hemodynamic instability),
a GP Ilb/IIIa inhibitor (eptifibatide or tirofiban) may be added
Give anticoagulant therapy to all patients. Unfractionated heparin to all patients
undergoing PCI. Enoxaparin for patients not managed with PCI.
Potassium above 4 mEq/L and magnesium above 2 mg/dL
End of Session Quiz

5.
W h a t are the mechanisms o f action o f the following drugs?

Streptokinase
Aspirin
0 Clopidogrel
Abciximab
0 Tirofiban
0 Ticlopidine
T*
<
Lnoxapann
Eptifibatide
6.
W h a t is the benefit o f 3-blockers in patients w ith unstable angina?
7.
W h en should oxygen be used in a patient w ith suspect cardiac ischemia?
is !
MYOCARDIAL IN FARCTIO N
MYOCARDIAL INFARCTION
3 Question Warm-Up
1.
W h at is the treatment for opioid overdose?
2.
W hat is the classic presentation o f a patient w ith aspirin overdose?
3.
W h at is the first-line treatment for a growth hormone-secreting pituitary

adenoma?
End of Session Quiz

4.
W h a t medications should all post-M I patients receive as outpatients?
5.
W hich medication types have a proven reduction in mortality following M I?
6.
In what time frame do thrombolytics need to be given in an M I? H ow does this

differ from the time frame in which they need to be given for a stroke?
7.
W h at are specific labs ordered in patients suspected o f having an M I?
8.
W h at is the most common cause o f death in patients w ith an acute myocardial

infarction?
ARRHYTHMIAS PART I
3 Question Warm-Up
1.
W h a t is the antidote to each o f the fallowing toxins?

Salicylates
(3-blockers
Digoxin
Iron
Copper
t-PA, streptokinase
2.
A patient is found to have hypertension, m ild hypernatremia, hypokalemia and

metabolic alkalosis. W h a t is the m ost likely diagnosis?
3.
W h a t is the treatm ent far an M I due to a cocaine overdose?
ARRHYTHMIAS PART I
End of Session Quiz

4.
W hat type o f heart block is described by the following statements?

PR interval prolonged more than 0.2 sec
(5 small boxes)
No relationship between P waves and QRS
PR interval becomes progressively longer
until a beat is blocked
PR interval fixed, but with occasional
blocked beats
I 136]
5.
W hich heart blocks need a pacemaker?
6.
W hat is the drug o f choice in paroxysmal supraventricular tachycardia?
ARRHYTHMIAS PART 2
1>
yO
X
<
H
X
3 Question Warm-Up
1.
H o w does adjustment disorder w ith depressed m ood differ from major

depressive disorder?
2.
In acute labyrinthitis, patients will have symptoms o f vertigo, nystagmus and

nausea/vomiting. W h a t other im portant symptom will they have?
3.
Does strabismus cause amblyopia, or does amblyopia cause strabismus?
3
>
CO
"D
>
H
NJ
End of Session Quiz

4.
W h ich endocrine disorder can cause atrial fibrillation?
5.
W h ich antiarrhythm ic should be avoided in patients w ith preexisting lung

disease?
6.
W h a t is the treatm ent for sustained ventricular tachycardia?
>
7=>
a
in
C /l
c
73
HEART FAILURE
HEART FAILURE
3 Question Warm-Up
1
A lesion to which area o f the brain is responsible for each o f the following
clinical scenarios?
> Resting tremor
Intention tremor
Hyperorality, hypersexuality, disinhibited behavior
Personality changes
Agraphia, acalculia, finger agnosia
2.
W h at organism is known for causing infections in bum victims?
3.
W h a t is the treatment o f atrial fibrillation o f unknown duration?
4. W hat are Kerley B lines?

Thickening of the subplcural interstitium (interlobular septa) about 1cm in length and
1mm in thickness seen in the periphery of the lower lung zones on CXR resulting from
one of the following diseases:
Left ventricular failure, mitral valve disease
Lymphatic obstruction, lymphangitis carcinomatosis
Asbestosis, sarcoidosis
138 i j
End of Session Quiz

5.
W h a t is a normal range for the ejection fraction?
6.
W h a t E C G finding may indicate a very early stage o f heart failure?
7.
W h a t lab marker is used to help diagnosis acute exacerbations o f C H F ?
8.
W h a t medications are im portant in the outpatient treatm ent o f chronic C H F ?
9.
W h a t is the treatm ent for acute exacerbations o f C H F ?
VALVULAR DISEASES
3 Question Warm-Up
1.
In which patient populations are -trip tan drugs contraindicated?
2.
W hich drugs block transmission through the AY node?
3.
W h a t causes stones, bones, groans and psychiatric overtones?
W hich heart valves should blood be flowing through during systole?
W hat are the systolic heart murmurs?
W hat heart valves should blood be flowing through during diastole?
W h at are the diastolic heart m urm urs?
End of Session Quiz

8.
W h a t is the next step in the work-up o f a low-grade systolic m urm ur in an

otherwise healthy, asymptomatic patient?
9.
W h a t is the next step in the work-up o f a diastolic m urm ur in an otherwise

healthy, asymptomatic patient?
10. W h a t type o f heart m urm ur fits each o f the following descriptions?

Diastolic murmur heard best at left lower
sternum that increases w ith inspiration
Late diastolic murmur w ith an opening snap
(no change w ith inspiration)
Systolic murmur heard best in the second
right interspace, parasternal
Systolic murmur best heard in the second
left interspace, parasternal
Late systolic murmur best heard at the apex
Diastolic murmur with a widened pulse
pressure
Holosystolic m urm ur that is louder with
inspiration at the left lower sternum
Holosystolic murmur heard at the apex and
radiates to the axilla
CARDIOMYOPATHIES AND PERICARDIAL DISEASE
CARDIOMYOPATHIES AND PERICARDIAL DISEASE
3 Question Warm-Up
4.
W hat is the most common cause o f chest pain in a patient w ith sudden tearing
chest pain radiating to the back?
2.
Increased skin pigmentation is seen in patients with which kind o f adrenal

insufficiency?
3.
W h at are the classic symptoms o f Parkinson disease?
Kussmaul Sign vs. Pulsus Paradoxus
Kussmaul Sign
Pulsus Paradoxus
Event
JVD with inspiration
Decreased SBP by more than

10 mmHg with inspiration
Mechanism
Decreased capacity of RV
Decreased capacity of LV
Disease
Constrictive pericarditis >>

cardiac tamponade
Cardiac tamponade
pericarditis
End of Session Quiz

5.
W h a t is the classic appearance o f the heart on a C X R o f a patient w ith

pericardial effusion?
6.
W h a t is the treatm ent for cardiac tamponade?
7.
W h a t disease has signs o f heart failure + diabetes mellitus + elevated LFTs?
8.
In w hat scenarios m ight you see Kussmaul sign (increased JV D w ith

inspiration)?
MYOCARDIAL INFECTIONS
3 Question Warm-Up
1
W h at are the symptoms o f neuroleptic malignant syndrome?
2.
W h at is the treatment for neuroleptic malignant syndrome?
3.
A teenager whose father died at age 30 in a motor vehicle accident suddenly

collapses and dies while exercising. W h a t is the cause o f death?

4.
W hat are the common viruses th at cause myocarditis?
5.
W h at are the major Jones criteria o f acute rheumatic fever?
6.
W h a t are the H A C E K bacteria?
7.
Describe the following peripheral signs o f endocarditis:

Janeway lesions
0 Osier node
Roth spots
0 Splinter hemorrhages
8.
W h a t is the best study to visualize a vegetation on a heart valve?
HYPERTENSION
3 Question Warm-Up
1.
W h a t causes hypocalcemia, high phosphorus and low P T H ?
2.
W h a t is the classic EK G finding in pericarditis?
3.
W h a t commonly causes heart failure in young patients?
4. W hat blood pressures define prehypertension? How should prehypertension

be managed?
Prehypertension = SBP_______________ or D B P _______________
If the patients SBP is >130 or DBP >80 and has diabetes, chronic kidney disease,
end-organ damage or cardiovascular disease, then medical management with an
antihypertensive is indicated
If none of the above comorbidities, then non-pharmacologic management with weight
reduction, sodium restriction, increased physical activity and avoidance of excess alcohol
5. W hat tests can be used to diagnose renal artery stenosis?

______________________________of renal arteries - most frequently used screening test
______________________________of renal arteries with IV contrast
______________________________- time-consuming (2 hours) and requires well-trained
operator
______________________________- gold standard, but invasive
End of Session Quiz

6.
H ow many consecutive abnormally high readings are needed before prescribing

BP medications?
7.
W h a t intervention is most effective at reducing blood pressure?
8.
W h a t is the most common cause o f secondary H T N ?
9.
W h at is the most likely cause o f secondary hypertension given the following

findings?
High BP in U E but
low BP in LE
Proteinuria
Hypokalemia
Tachycardia, diarrhea,
heat intolerance
Hyperkalemia
Episodic sweating,
tachycardia
ANTIHYPERTENSIVES
3 Question Warm-Up
1.
W h a t lab marker is used to help diagnose acute exacerbations o f C H F?
2.
W h a t is the work-up for the underlying cause o f DK A ?
3.
W h a t are the H causes o f PEA ?
End of Session Quiz

4.
W h ich antihypertensive class is first line in patients w ith the following

problems?
Diabetes
H eart failure (multiple)
BPH
Left ventricular hypertrophy
Hyperthyroidism
Osteoporosis
Benign essential tremor
Post-menopausal woman
Migraines
5.
W h ich antihypertensive drugs fit the following side effects?

First dose orthostatic hypotension
Hypertrichosis
D ry mouth, sedation, severe rebound H T N
Bradycardia, impotence, asthma exacerbation
Reflex tachycardia
Cough
Avoid in patients w ith sulfa allergy
Angioedema
Development of drug-induced lupus
Cyanide toxicity
SH O C K
SHOCK
3 Question Warm-Up
1.
W h at is the most common cause o f Cushing syndrome?
2.
W h a t is the Parkland burn formula?
3.
W h at is Becks triad for cardiac tamponade?
Shock
4.
[ A8 ] |
Know the different types of shock and how they present:

Cause of
shock:
M AP
SV R
HR
PCW P
(left atrial
pressure)
PCW P
after fluid
challenge
Hypovolemic
(often due to
hemorrhage)
Low
High
High
Low
Unchanged
or high
Fluids
Cardiogenic
Low
High
Variable
High
Very high
Dobutamine or
dopamine
Extracardiac
obstruction
(tension PTX,
massive
hemothorax)
Low
High
High
Low or
normal
Unchanged
or increased
Chest tube
Extracardiac
obstruction
(cardiac
tamponade)
Low
High
High
High
High or very
high
Pericardiocentesis
Neurogenic
Low
Low
Low
Low or
normal
High
IVF, pressors,
Atropine for HR
Septic
Low
Low
High
Low or
normal
High
Fluids, Abx, NE
Anaphylactic
Low
Low
High
Low
High
Epinephrine
Treatm ent
End of Session Quiz

5.
Hypoperfusion and resultant tissue ischemia are the concern in shock patients.
W h a t is the chemical marker o f this?
6.
W h a t complications can arise from the use o f vasopressors such as

norepinephrine in treating shock?
7.
W h a t is the underlying mechanism o f each o f the following types o f shock?

Cardiogenic
Extracardiogenic
Hypovolemic
Anaphylactic
Neurogenic
Septic
VASCULAR C O N D IT IO N S
VASCULAR CONDITIONS
3 Question Warm-Up
1.
W h at are the two most common adverse effects o f statin use, and what labs
would reveal these effects?
2.
W h a t type o f shock causes a decreased cardiac output, decreased P C W P and

decreased peripheral vascular resistance?
3.
W hich blood pressure medications should be avoided in patients with ischemic

stroke or subarachnoid hemorrhage because o f the increase in intracranial
pressure associated w ith them?
Aortic Conditions
4. W hat are the indications for the repair of an abdominal aortic aneurysm
(A A A ) in order to prevent future rupture?
Diameter greater than________ in men o r_________ in women
Increase in diameter by more than
in a _________ month interval
(should be receiving abdominal ultrasound every 6 months)
Symptomatic (e.g., tenderness, pain in abdomen or back)
Arterial Conditions
5. W hat are the components of conservative medical management of peripheral
artery disease (PAD)?
Smoking cessation
Glucose and BP control
Daily exercise to increase collateral flow
Cilostazol (Pletal)
Improve flow to LE and decrease claudication
More effective than pentoxifylline (Trental)
Contraindicated if any heart failure due to increased mortality
Daily aspirin or clopidogrel to reduce cardiovascular events

Statin therapy to reduce cardiovascular events and increase pain-free walking distance
I 150]
Venous Conditions
6. W hat options are available to treat varicose veins?
Weight reduction, avoidance of prolonged standing, leg elevation
Compression stockings
Sclerotherapy (injection of a substance directly into the vein that causes injury and
thrombosis)
Thermal ablation (laser therapy)
Surgery involving ligation of the long saphenous vein or short saphenous vein
End of Session Quiz

7.
A patient comes to the E R following a motor vehicle collision, and C X R

reveals widening o f the mediastinum. W h a t imaging study would confirm your
diagnosis?
8.
W h a t study should be ordered for a patient suspected o f having an A A A

(abdominal aortic aneurysm)?
9.
W h o should be screened for an abdominal aortic aneurysm?
10.
W h a t is the next step in the m anagem ent o f a patient w ith a D V T that has a
high likelihood o f falling?
VASCULITIS
3 Question Warm-Up
1.
W h a t are the preferred vessels in the placement o f a Swan-Ganz catheter?
2.
A n EK G shows complete independence o f P waves and QRS complexes. W hat

is the next step in the management?
3.
W hat two cardiovascular diseases are the biggest risk factors for C H F?
Thromboangiitis Obliterans (Buerger Disease)

Vasculitis of small- and medium-sized peripheral arteries and veins
Affects young male smokers (30s-40s)
Clinical presentation:
Intermittent claudication
Superficial nodular phlebitis
Raynaud phenomenon
Gangrene, atifoSfftputation of the digits
Treatment: smoking cessation
W hat are the diagnostic criteria for Kawasaki disease (mucocutaneous lymph
node syndrome)?
Fever (>40C or 104F) lasting at least five days in addition to 4 of the following 5
symptoms (CRASH):
- _______________________ (bilateral, non-exudative, painless)
- _______________________ on the trunk
- _______________________ of the cervical lymph nodes
- _______________________ and diffuse erythema of mucous membranes
- _______________________ have edema with induration, erythema or desquamation
Coronary artery aneurysms can occur within weeks of the illness onset, but are not
included in the diagnostic criteria.
How is Kawasaki disease treated?

IVIG (ideally within the first 10 days of illness)
0 High-dose aspirin, continued until 48 hours after fever resolution; followed by low-dose
aspirin until inflammatory markers (platelets, ESR) return to normal (usually 6 weeks)
Steroids are not indicated and are of no proven benefit.
Echocardiogram in the acute phase and 6-8 weeks later
End of Session Quiz

7.
W h ich type o f vasculitis fits each o f the following descriptions?

Weak pulses in upper extremities
Necrotizing immune complex inflammation of visceral/renal vessels
Young male smokers
Young Asian women
? Young asthmatics
Infants and young children; involves coronary arteries
Most common vasculitis
Associated with hepatitis B infection
Occlusion of ophthalmic artery can lead to blindness
Unilateral headache, jaw claudication
PEDI CARD IO LO G Y
PEDI CARDIOLOGY
3 Question Warm-Up
1.
Compare P T H , alkaline phosphatase, serum calcium and serum phosphate

Serum
C a2+
Serum
Phos
Aik
Phos
PTH
Paget Disease
Osteomalacia/rickets
Osteoporosis
Osteopetrosis
Primary
hyperparathyroidism
Hypoparathyroidism
2.
W h a t autoimmune complication occurs 2-4 weeks after an M I?
3.
W h a t type o f psychotherapy is used to treat phobias, obsessive-compulsive

disorder and panic disorder?
W hat is an Ebstein anomaly?

Associated with maternal______________________ use
________________
aredisplacedintorightventricle,hypoplasticright
ventricle, tricuspid regurgitation or stenosis
Patent foramen ovale with a right-to-left shunt (80%)
Dilated right atrium leads to an increased risk of:
- Supraventricular tachycardia (SVT)
Wolff-Parkinson-White syndrome (W PW )
Physical exam:
- W idely split S2
- Tricuspid regurgitation
Treatment:
- PGE
Digoxin
Diuresis
Propranolol for SVT
A 6-week-old infant presents to the pediatric emergency room for irritability

and is found to have signs of left-sided heart failure. An EK G is interpreted as
left-sided myocardial infarction. W hat is the m ost likely diagnosis?
PEDI CA RD IO LO G Y
End of Session Quiz

6.
W hat are the unique structures o f the fetal circulation that close after birth?
7.
W h a t medication is used to close a PDA?
8.
W hat are the abnormalities associated w ith tetralogy o f Fallot?
Pulmonology
1
URI
Low er R espiratory Infections p a rt 1
L ow er R espiratory Infections p a rt 2
A R D S and A sth m a
COPD
N eoplasm s and In terstitial L u n g Disease
P u lm o n ary Vascular Diseases
P leural Diseases
Sleep A pnea and P u lm o n ary Surgical

C oncerns
10 Pedi P ulm onology p a rt 1

11 Pedi P ulm onology p a rt 2
7?
PULMONOLOGY
URi
3 Question Warm-Up
1.
2.
W h a t is the treatm ent for iron overdose?
3.
W h a t does a fall in systolic BP o f > 10 m m H g w ith inspiration indicate?
4. W hat are the diagnostic features of a peritonsillar abscess? W hat is the

treatment?
Infection between the tonsil and pharyngeal constrictors caused by Strep, pyogenes, Staph.
aureus and/or Bacteroides spp.
Severe sore throat, fever, muffled hot potato voice
Classic diagnostic feature is obvious abscess on the tonsil or deflection of the uvula to the
opposite side
Other signs and symptoms include trismus (lockjaw) and drooling
Treatm ent
Needle aspiration or I& D
Pain meds + antibiotics
- Amoxicillin/clavulanate
Clindamycin
[ 159]
URI
End of Session Quiz

5.
W h at is a normal A-a gradient? W h a t causes a high A-a gradient?
6.
W hat are the feared complications o f streptococcal pharyngitis?
7.
W hat are the signs o f peritonsillar abscess?
LOWER RESPIRATORY INFECTIONS PART I
3 Question Warm-Up
1.
Short systolic m urm ur at the cardiac apex that decreases w ith squatting, is
sometimes associated w ith a benign chest pain, and lasts only a few seconds:
2.
In w hich etiology o f restrictive cardiomyopathy is the pathology reversible w ith

phlebotomy?
3.
Com pare the vasodilating effects o f the following:

Nitroglycerine
Dihydropyridine CCBs
Hydralazine
Nitroprusside
4. W hat are the most common causes of pneumonia and empiric antibiotics used
for children in the age ranges of newborn, I -4 months, 4 months-4 years, and
5-15 years?
Age
Causes
Empiric Treatment
Newborn
Group B streptococcus (GBS)

Escherichia coli
Listeria monocytogenes
Chlamydia trachomatis
Ampicillin and gentamicin

+/- vancomycin (if M RSA is a
concern)
Erythromycin (Chlamydia
trachomatis)
lm 4m
Respiratory syncytial virus (RSV)

Chlamydia trachomatis
Parainfluenza
Bordetella
Streptococcus pneumoniae
Staphylococcus aureus
4m 4y
RSV or other viruses*

Haemophilus influenzae
Mycoplasma pneumoniae
Staphylococcus aureus
5 y -1 5 y
Mycoplasma pneumoniae
Chlamydophila pneumoniae
O ther viruses*
+/- cefotaxime
1. Amoxicillin + clarithromycin
2. Azithromycin
3. Amoxicillin + doxycycline
* O ther viruses include rhinovirus, influenza, parainfluenza, adenovirus, coronavirus
W hat are the indications for pneumococcal vaccination in adults?

65 years old or older
Serious long-term health problem such as heart disease, sickle cell disease, alcoholism,
leaks of cerebrospinal fluid, lung disease, diabetes or cirrhosis
Resistance to infection is lowered due to Hodgkin disease; multiple myeloma; cancer
treatment with x-rays or drugs; treatment with long-term steroids; bone marrow or organ
transplant; kidney failure; HIV/AIDS; lymphoma, leukemia or other cancers; nephrotic
syndrome; damaged spleen or no spleen
Cigarette smokers between the ages of 19 and 54
W hat antibiotics can be used in the treatment of Pseudomonas pneumonia?

An antipseudomonal 3-lactam (piperacillin-tazobactam, cefepime, imipenem,
meropenem, aztreonam) must be added to one of the following for at least 2 weeks for
adequate coverage:
Antipseudomonal quinolone (ciprofloxacin or levofloxacin)
Aminoglycoside (tobramycin, gentamicin or amikacin) + azithromycin
Aminoglycoside (tobramycin, gentamicin or amikacin) + antipseudomonal quinolone
W hat infectious agent is the cause of pneumonia based on the following lab
test:
Gram (+) cocci in clusters

Gram (+) cocci in pairs
Gram (-) rods in 80-year-olds
Gram (+) cocci in neonate
Gram (-) rods in neonate

8.
W h at is the empiric treatment for pneumonia in a 2-month-old? In a 2-year-old?
9.
W hat organism is associated with the following:

Associated with atypical pneumonia in young adults
Associated with atypical pneumonia in the
elderly and very young
Most common pneumonia in children (infant to
5 years old)
Most common cause of pneumonia in neonates
10. A hospital has multiple admissions o f elderly patients presenting with atypical
pneumonia. All were present at the grand re-opening o f an old bingo
establishment that has an indoor waterfall. W h at is the likely causative organism?
11. Cystic fibrosis patients are at risk for acquiring pneumonia from which organism?
3 Question Warm-Up
1.
W h a t is the reversal agent for heparin?
2.
W h ich class o f antihypertensives is contraindicated in the following patients?

COPD
Bilateral renal artery stenosis
0 Pregnancy
0 Advanced renal failure
Gout
3.
W h a t is the most common cause o f hypertension in young women?
LOWER RESPIRATORY INFECTIONS PART 2
LOWER RESPIRATORY INFECTIONS PART 2
4. W hat x-ray and lab findings would lead you to highly suspect P C P as a cause of
respiratory distress?
CXR: diffuse, bilateral, interstitial infiltrates (most common finding)
CD4 usually <__________
level usually > 220 (and a rising LD H despite appropriate treatment portends a
poor prognosis)
5. W hat is the treatm ent for PCP?

21 days of antibiotics. Choices include:
- TM P-SM X (IV or PO)
Pentamidine (IV)
- Primaquine (PO) + clindamycin (IV or PO)
[ 163]
End of Session Quiz

6.
Fill in the table of criteria used to determine when a P P D is considered positive:

Induration
5mm
C onsidered Positive in th ese Situations
A :
o
10mm
15mm
7.
, 4
W hich infectious agents fit the following descriptions?

Common cause of pneumonia in immunocompromised patients
Most common cause of atypical/walking pneumonia
Pneumonia associated with currant jelly sputum
Can cause an interstitial pneumonia in bird handlers
4 Often the cause of pneumonia in a patient with a history of exposure to bats and
bat droppings
? Often the cause of pneumonia in a patient who has recendy visited southern
California, New Mexico or West Texas
Common causative agent for pneumonia in alcoholics

Associated with pneumonia acquired from air conditioners
Most common cause of pneumonia in children 1 year old or younger
Most Common cause of pneumonia in the neonate (birth-28d)
Most common cause of pneumonia in young adults (including college students,
military recruits and prison inmates)
Common cause of pneumonia in patients with other health problems

Most common cause of viral pneumonia
Causes woolsorters disease (a life-threatening pneumonia)
Common pneumonia in ventilator patients and those with cystic fibrosis
ARDS AND ASTHMA
3 Question Warm-Up
1. A South Am erican im m igrant has cardiomegaly and achalasia. W h a t is the
organism likely responsible for this patients disease?
2. D uring a surgical procedure, the anesthesiologist notices that the patients

temperature has climbed quickly and her muscles are rigid. Recognizing this
feared complication, the doctor should administer which medicine?
3. W h a t is the next step in the evaluation o f penetrating injuries to the different

zones o f the neck?
4. W hat treatm ents are available when managing a patient with Acute
Respiratory Distress Syndrome (ARDS)?
Treat the underlying disease and provide supportive care in the ICU
Mechanical ventilation with low tidal volumes (to minimize injury) and adequate PEEP
(to recruit collapsed alveoli)
Conservative fluid management to reduce pulmonary edema. Goal CVP 4-6 H 20 .
(Furosemide and albumin may also be helpful to prevent pulmonary edema)
Prone positioning improves oxygenation but does not improve survival
Minimize oxygen consumption by preventing fever (anti-pyretics), minimizing anxiety
and pain (sedative and analgesics), and limiting respiratory muscle use (paralytics),
particularly in cases of asynchrony of the ventilator and patients efforts
Transfuse blood only if Hgb drops below 7 g/dL as transfusion may T risk of death in
ARDS patients
5. W hat methods of providing oxygen to a patient can be used in order to deliver

a specified percentage of F i0 2?
Nasal canula
Face mask
Non-rebreather
CPAP
Mechanical vent
* 24-40% F i0 2 (F i0 2 increases 3% for every 1 L/min up to 6 L/min)

> 50-60% F i0 2
* 60-95% F i0 2
- 80% F i0 2
up to 100% F i0 2
ARDS AND ASTHMA
I 166 |
End of Session Quiz

6.
In a patient with pulmonary edema, how can pulmonary capillary wedge

pressure (PC W P) distinguish A R D S from cardiogenic edema?
7.
W h at are the diagnostic characteristics o f Acute Respiratory Distress Syndrome

(ARDS)?
8.
W h a t defines mild persistent asthma? W h a t is the outpatient management?
COPD
3 Question Warm-Up
1.
W h a t heart sounds are considered benign when there is no evidence o f disease?
2.
A young wom an presents w ith amenorrhea, bradycardia and abnormal body

image. vVhat is the diagnosis?
3.
A patient presents w ith a history o f interm ittent tachycardia, w ild fluctuations in

blood pressure, headache, diaphoresis and panic attacks. W h a t is the diagnosis?
4. C O P D Staging
G O LD
G O LD
G O LD
G O LD
I234-
FEV,
FEV,
FEV,
FEV,
> 80% predicted (mild)

50-80% (moderate)
30-50% (severe)
< 30% (very severe)
5. C O P D Management
Category A (G O LD I or 2 with mild or infrequent symptoms) - short-acting

bronchodilator (albuterol, atrovent)
Category B (G O LD I or 2 with moderate to severe symptoms) - above + long-acting
bronchodilator (j32-agonist or anticholinergic (tiotropium, ipitropium))
Category C (G O LD 3 or 4 with mild or infrequent symptoms) - above + inhaled
steroids
Category D (G O LD 3 and 4 with moderate to severe symptoms) - above +/theophylline + home 0 2 if pulse-ox < 88%, +/- phosphodiesterase-4 inhibitor
(roflumilast)
Bronchiectasis
6. W hat are the possible etiologies for bronchiectasis?
Unknown etiology in 50% of patients

Cystic fibrosis
Immunodeficiency
Dyskinetic cilia: Kartagener syndrome (dextrocardia, sinusitis, bronchiectasis), autosomal
dominant polycystic kidney disease (ADPKD)
Pulmonary infections (TB, fungal or lung abscess)
Obstruction (e.g., foreign body aspiration, tumor, lymph nodes)
Other etiologies: Young syndrome, foreign body aspiration, rheumatoid arthritis, Sjogren
syndrome, allergic bronchopulmonary aspergillosis, cigarette smoking
End of Session Quiz

7.
W h a t is the hallmark pulmonary function test finding in C O PD ?
8.
A patient has an FEVj at 55% o f predicted and has frequent episodes o f

shortness o f breath when walking on level ground. W h a t medications would be
appropriate for this patient?
9.
A t what point do patients with chronic C O P D qualify for home 0 2?
3 Question Warm-Up
1.
W h a t are the H causes o f PEA?
2.
W h a t are the T causes o f PEA ?
W ssm iS & m l& Q ti *
3.
4.
t-
t V
NEOPLASMS AND INTERSTITIAL LUNG DISEASE
W h a t is the treatm ent for endocarditis?
How is idiopathic pulmonary fibrosis diagnosed?

CXR possible findings normal in 10%, reticular pattern, nodular pattern or honeycomb
lung (poor prognosis)
High-resolution C T scan greater diagnostic accuracy than plain films
Serum markers including SP-A, SP-B, MCP-1 and KL-6
Pulmonary function testing (PFTs) reveal restrictive lung disease with decreased TLC,
FRC and RV
Lung biopsy is required to make the definitive diagnosis and determine the stage of disease
[ 169]
E n d o f Session Q uiz
5.
6.
W hat is the next step in the work-up o f a patient with a solitary pulmonary
nodule?
W hich type of lung cancer is associated with each of the following paraneoplastic
syndromes?
s ? Elevated ACT 11 > glucocorticoid excess > Cushing syndrome
Elevated PTH-related peptide >hypercalcemia
Elevated AD H SIADIT hyponatremia
> Antibodies to presynaptic Ca2*channels >Lambert-Eaton syndrome
7.
W h at is the initial treatment o f a localized non-small cell lung cancer?
8.
W h a t are the classic radiological findings in idiopathic pulm onary fibrosis

(IPF)?
9.
W h a t is the treatment for idiopathic pulmonary fibrosis (IPF)?
10. W h ich type o f pneumoconiosis matches each o f the following descriptions?

Progressive fibrosis
Increased risk of TB
Associated with working with electronics; causes
increased cancer risk
M alignant mesothelioma and bronchogenic
carcinoma
PULMONARYVASCULAR DISEASES
3 Question Warm-Up
1.
W h a t heart defect is associated w ith each o f the following disorders?

Chromosome 22qll deletion
Down syndrome
Congenital rubella
Turner syndrome
Marfan syndrome
2.
W h a t is the treatm ent o f cardiogenic shock?
3.
W h a t is the next step in the m anagement o f a positive PPD ?
"O
c
r~
3
O
z
>
-<
JS
oo
n
c
r~
>
70
O
CO
m
>
4. W hat studies are helpful in the diagnosis of pulmonary embolism?

ABG respiratory alkalosis due to hyperventilation but low P 0 2 due to hypoxia
D-dimer a normal d-dimer makes PE much less likely and an elevated d-dimer is
nonspecific
0 U/S of LE veins to rule out DVT - presence of DVT makes PE more likely, absence of
DVT doesnt tell you anything
CXR usually normal but may have atelectasis, pleural effusion or Hamptons hump
(wedge-shaped opacification at the distal lung fields)
EKG changes - most commonly sinus tachycardia +/- nonspecific ST and T wave
changes, and very rarely the classic S1Q3T3 (wide S in lead I, large Q_and inverted T in
lead III)
V/Q_scan useful and accurate only in confirming low or high clinical probability
C T scan with contrast (AKA: C T PE protocol, or C T pulmonary angiography) - most
commonly used method to diagnose or rule out a PE, but not 100% accurate
Pulmonary angiogram the gold standard, but more invasive and rarely performed
5. Vasodilators used in pulmonary hypertension
Prostanoids epoprostenol, treprostinil, iloprost

Endothelin receptor antagonists - bosentan, ambrisentan
Cyclic G M P phosphodiesterase inhibitors sildenafil
CCB nifedipine
[ 171 ]
End of Session Quiz

6.
W h at is a classic sign o f P E on CXR?
7.
W h a t is the next step in the diagnosis o f a patient that you suspect has
pulmonary H T N because o f his symptoms o f JV D , loud S2, dyspnea and
fatigue?
8.
A former smoker with chronic C O P D and chronic C H F presents w ith acute

shortness o f breath and hypoxemia. W h a t C X R findings m ight suggest
pulmonary edema as the cause o f his dyspnea?
9.
W h a t imaging studies are most helpful in diagnosing a PE?
10.
W h a t is the primary drug category used to treat pulmonary H T N ?
PLEURAL DISEASES
3 Question Warm-Up
1.
W h a t are the indications for surgical repair o f an abdominal aortic aneurysm?
2.
W h a t is the next step in the management o f a child w ith severe asthma

exacerbation and persistently low oxygen saturation despite medication?
3.
W h a t is the next step once a brain tum or has been identified on C T or M R I o f

the head?
End of Session Quiz

4.
W h a t study can help you determine whether pleural effusion is loculated or freeflowing in the thorax?
5.
A patient presents to the E R in respiratory distress following a M V C . C X R

shows pleural effusion. W h a t is the next step in the management o f this patient?
6.
W h a t might cause a transudative pleural effusion?
7.
W hat size pneumothorax requires a chest tube placement?
SLEEP APNEA AND PULMONARY SURGICAL CO N CERN S
SLEEP APNEA AND PULMONARY SURGICAL CONCERNS
3 Question Warm-Up
1.
W h a t are the W s o f post-op fever?
2.
W hich type o f lung cancer is associated w ith hypercalcemia?
3,
A patient presents to the E R after an M V C with hypertension, bradycardia and

abnormal respirations. After ABCs, w hat is the next step in the management?
4. W hat is the treatm ent for obstructive sleep apnea (OSA)?

_____________________ if overweight or obese
Avoidance o f____________ and other CNS depressants or sedatives
____________________ at night first-line but poor compliance
Oral appliance to protrude the mandible forward or prevent posterior tongue displacement
- Not as effective as CPAP
If excessive daytime sleepiness despite therapies > modafinil qAM
Surgical options:
Tonsillectomy & adenoidectomy - especially in children or if hypertrophied
Us pa r pharyngopla ' (UPPP) - most common, surgery in adults for O SA
Gemoglossus advancement
Maxillaryernandibular advancement
[. I /d ] !
W hat are the components of rapid sequence intubation?

Rapid sequence intubation requires an acutely unstable patient needing an airway
rapidly + rapid-acting sedative and paralytic to create optimal intubating conditions
enabling rapid control of the airway.
Preparation
Pre-oxygenation
Pretreatment
(toblunt
ICP elevations)
Fentanyl (to blunt the pain response and BP elevations)
_____________________ (to decrease airway secretions and prevent bradycardia in
children during intubation)
Paralysis with induction
Rapid induction agents: etomidate, ketamine, midazolam or propofol
Rapid paralytics: succinylcholine, rocuronium
Protection and Positioning (including______________ pressure to help prevent
aspiration)
Placement of E T tube
Post-intubation management - secure E T tube, CXR, set ventilator
End of Session Quiz

6.
W h a t medication is used prior to intubation in head injury patients?
7.
W h a t substances should be avoided in patients w ith obstructive sleep apnea?
PEDI PULMONOLOGY PART I
3 Question Warm-Up
1.
W h at is the usual time frame for stopping warfarin prior to surgery?
2.
W h at are the indications for operating on an abdominal aortic aneurysm?
3.
W hen might subclinical mitral stenosis from rheumatic heart disease become
clinically apparent?
Croup
4. W hat are the classic signs and symptoms of croup?
Inflammation of larynx, trachea and/or bronchi >____________________, respiratory
distress, upper airway obstruction w ith____________________
0 Symptoms are worse at night
0 75% caused by parainfluenza viruses
0 6% incidence annually in children under 6 years old
Common cause of hospitalization in children younger than 4 years old (esp. in fall/winter
months)
Course: 12-72 hours of mild fever and coryza > hoarseness and barking cough peak
resp distress at 24-48 hours * resolution in 1 week
5. W hat is the treatment for croup? W hat are the indications for hospitalization?
ER Treatment
Change ambient temperature
Humidified oxygen mask
Dexamethasone 0.6mg/kg IM or PO once. Prednisolone may be administered for several
days because of shorter half-life.
____________________ ql-2 hours
0 Admission criteria: progressive stridor or stridor at rest, no improvement 5 hours after
steroids, hypoxia/cyanosis, resp distress, unclear diagnosis
Home treatment: cool mist humidifier (esp. at night) (commonly used, but no proven
benefit)
6. W hat are the characteristic features of epiglottitis?

Acute-onset fever, severe sore throat, dysphagia, drooling and toxic appearance
Progression to airway obstruction with inspiratory distress, muffled speech (hot potato
voice) and cyanosis
Tripoding (arms back, trunk leaning forward, neck hyperextended and chin thrust
forward) in an attempt to maximize airway diameter
CBC: leukocytosis with bandemia
Lateral neck X-ray: thumb sign (enlarged epiglottis)
Visualization of the swollen epiglottis in young children simply by depressing the tongue
with a tongue blade
Anxiety and increased respiratory effort with this portion of the exam may cause
cardiopulmonary arrest and should be performed cautiously and only if prepared to
intubate
Direct or indirect laryngoscopy may be needed in older children to confirm the diagnosis:
cherry-red, swollen epiglottis
PEDI PULMONOLOGY PART I
Epiglottitis
7. W h at is the treatm ent for epiglottitis?

Minimize the childs anxiety during the interview
Intubation or tracheostomy as soon as possible upon making the diagnosis
Nasotracheal intubation with an ET tube 0.5-1 mm smaller than what would normally
be used is ideal in these patients
- Average duration is 2-3 days
Culture and sensitivity from blood and epiglottis surface
Empiric IV antibiotics
(Oxacillin, nafcillin, cefazolin, clindamycin or vancomycin) + (ceftriaxone or cefotaxime)
Duration 7-14 days
( 177 ]
Bronchiolitis
8. W hat is the classic presentation of RSV bronchiolitis?
Starts with 1-3 days of mild URI symptoms: rhinorrhea, mild cough and mild fever +/otitis media
Cough with prolonged expiration, expiratory wheezing, crackles and hyperresonance on
percussion
Possible respiratory distress with nasal flaring, tachypnea, retractions, grunting
Possible apnea in infants (indication for mechanical ventilation)
Complete resolution usually takes one month
9. W hat is the treatment for RSV bronchiolitis?

Supportive care such as 0 2 and IVF as needed.
Albuterol nebs o r____________________. If good results seen with either race Epi or
albuterol, then continue, otherwise Stop treatment. Some studies showed a benefit of
albuterol or epinephrine neb in infants under 12 months
are N O T effective in bronchiolitis (NEJM 2007;357:331)

____________________ use in children is controversial, expensive, and generally is not
used
Hospitalize if:
Toxic appearing, poor feeding, lethargy, dehydration
Respiratory distress (nasal flaring, intercostal retractions or cyanosis)
Hypoxemia (< 929 on room air)
Apnea
Parent is Unable to care for the child at home
End of Session Quiz

10.
W h at is the treatment for epiglottitis?
11.
W h at is the treatment for croup?
12. W h at is the treatment for RSV bronchiolitis?
PEDI PULMONOLOGY PART 2
!
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3 Question Warm-Up
1.
W h a t medication combination is used in the treatment o f T B meningitis?
2.
W h a t is the preferred diagnostic test for a pulm onary embolism?
3.
W h a t are the indications for surgical parathyroidectomy for a parathyroid

adenoma?
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Respiratory Distress Syndrome of the Newborn

4.
How is the lecithin:sphingomyeiin (L:S) ratio used in determining fetal lung

maturity?
As the lungs mature a t __________ weeks, the amount of lecithin produced increases
while sphingomyelin remains constant.
A L:S ratio o f__________ obtained by amniocentesis indicates fetal lung maturity
If the ratio is 1.5-1.9,50% of these infants will develop respiratory distress syndrome
(RDS)
A ratio o f__________predicts a 75% chance of RDS development
(Samples containing blood or meconium should be discarded due to unpredictable
variations. In these cases a phosphatidylglycerol (PG) measurement is most reliable.)
5. W h at chest X -ra y characteristics distinguish neonatal respiratory distress

syndrome from transient tachypnea of the newborn?
RDS low lung volumes, diffuse_______________ appearance w ith_______________
T T N - increased lung volumes with flattening of the diaphragms, prominent vascular
markings from the hilum (sunburst pattern), fluid streaking in interlobular fissures, +/pleural effusions
6. W hat is the treatm ent for neonatal respiratory distress syndrome?

________________administration (from porcine or bovine source)
Continuous positive airway pressure (CPAP) or intubation and mechanical ventilation
- CPAP is preferred in larger babies (> I500g), or if active, breathing spontaneously and
not in respiratory failure
- Mechanical ventilation if respiratory failure
[ 179]
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PEDI PULMONOLOGY PART 2
Cystic Fibrosis
7. How is cystic fibrosis diagnosed?
Sweat chloride test: sweat chloride concentration >___________ on two or more
occasions
Performed by a lab familiar with the test
Considered the gold standard to diagnosing CF
Genetic testing for___________ gene mutations
Identifies about 90% of CF cases
Nasal transepithelial chloride secretion: measures abnormalities in ion transport across the
nasal epithelium
8. W hat are the general strategies for treating the pulmonary component of
cystic fibrosis?
9.
p 2 agonist (albuterol, salmeterol, formoterol)

DNase I (dornase alfa) to decrease sputum viscosity
Hypertonic saline for chronic cough
Physiotherapy (such as aerobic exercise) for increased mucus clearance
Azithromycin used liberally prn when lung function decreases in order to slow the decline
in lung function and treat any Pseudomonas aeruginosa
W hat are the general strategies for managing the GI component of cystic
fibrosis?
End of Session Quiz

10. W h at is the typical C X R appearance o f newborn respiratory distress syndrome?
11. Shortly after birth, a child has stridor, wheezing, and shortness of breath despite
medical therapies. W h a t is likely to be causing this patient s symptoms?
12. W h a t are the general strategies for treating the pulmonary component o f cystic
fibrosis?
G astroenterology
1 G I Infections
V iral H epatitis
O ral and Esophageal C onditions
G astric C onditions
Sm all In testin e p a rt 1
GASTROENTEROLOGY
6 Sm all In testin e p a rt 2
7 L arge In testin e p a rt 1
8 L arge In testin e p a rt 2
9
C olorectal C ancer and G I Bleeding
10 Pancreatic D iseases
HRH
I life r
B ll
11 B iliary D iseases p a rt 1
A R M l
12 B iliary D iseases p a rt 2
8 1
M B B
13 A lcoholic Liver D isease and C irrhosis

1 i1
14 O th e r H epatic D iseases
15 P edi G I D isorders
W
B ^ M
ISiIlgipS S iS i si
Gl INFECTIONS
..............
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3 Question Warm-Up
W h a t are the characteristic features o f a patient presenting with pericarditis?
2.
W h a t is an acceptable urine output in a trauma patient?
3.
W h a t are some o f the causes o f an exudative pleural effusion?
GASTROENTEROLOGY
1.

4.
5.
W h a t infectious agent most likely corresponds to each o f the following

statements?
Food poisoning as a result of mayonnaise sitting out too long
Rice-water stools
Diarrhea transmitted from pet feces
Food poisoning resulting from reheated rice (Chinese food)
Most common cause of travelers diarrhea
0
Diarrhea after a course of antibiotics

Diarrhea + recent ingestion of water from a stream
Mild intestinal infection that can become neurocysticercosis
Food poisoning from undercooked hamburger
Diarrhea from seafood
Bloody diarrhea from poultry

Diarrhea + pink eye
Bloody diarrhea liver abscess
Diarrhea in an AIDS patient
Dehydrated child with greenish diarrhea in winter months
W h a t is the treatment for each o f the following diarrheal illnesses?

Entamoeba histolytica
Giardia lamblia
Salmonella
Shigella
Campylobacter
[ 183]
VIRAL HEPATITIS
VIRAL HEPATITIS
3 Question Warm-Up
1
W h at blood pressure range is considered prehypertension?
2.
A patient presents w ith chronic sinusitis, hemoptysis and hematuria. W h at is

the treatment?
3.
You are examining a patient and discover a cherry red spot on the macula.
W h a t is the differential diagnosis?
End of Session Quiz

4.
W hich hepatitis virus confers a high risk o f chronic hepatitis?
5.
W hich hepatitis vims confers an increased risk o f hepatocellular carcinoma?
6.
W h at type of current or past hepatitis B exposure is present in each o f the

following scenarios?
7.
Hep BsAg
Hep BsAb
Hep BcAb
Negative
Negative
Positive (IgM)
Positive
Negative
Positive (IgG)
Negative
Positive
Negative
Negative
Positive
Positive (IgG)
W h at is the treatment for Hepatitis C vims infection?
ORALAND ESOPHAGEAL CONDITIONS
3 Question Warm-Up
1.
Cafe-au-lait spots are characteristic o f what diagnosis?
2.
A 50-year-old m an with a 25-pack-year history o f smoking presents with

his second bout o f pneumoni a in the last 6 months. C X R reveals a lobar
consolidation in the same location as the previous pneumonia. Besides treating
his pneumonia, what is the next step in the management o f this patient?
3.
W h a ts the underlying cause o f neonatal respiratory distress syndrome?
4. W hat anatomical structures in the G l tract are evaluated by the following

radiologic studies?
Barium swallow
Gastric emptying study
Small bowel follow through (SBFT)
Barium enema
5. W hat surgical term m atches each of the following descriptions?

Surgical connection of the stomach to the
skin of the abdominal wall for feeding
Surgical connection of the ileum to the
skin of the abdominal wall
Surgical connection of the colon to the
skin of the abdominal wall
Visualization of the peritoneal cavity
using a laparoscope
Surgical incision into the abdominal
cavity
W h at is the difference between M allory-W eiss and Boerhaave syndrome?
End of Session Quiz

7.
W h a t is the next step after H&JP in the work-up o f a patient com plaining o f
dysphagia?
8.
H ow does the treatm ent for diffuse esophageal spasm differ from th at of
achalasia?
9.
Name the esophageal disorder that matches each o f the following descriptions:
Chest pain; uncoordinated
contractions; corkscrew pattern on
barium swallow
Inability to relax the LES; birds beak
on barium swallow
Bad breath; regurgitation of food eaten
days ago
10. W here are the following types o f esophageal diverticula located?

Zenker diverticulum
Traction diverticulum
Epiphrenic diverticulum
11.
12.
Besides the sensation o f heart burn, what is another common symptom of

G ER D ?
W h a t is Barrett esophagus, and why is it important?
GASTRIC CONDITIONS
3 Question Warm-Up
1.
W h a t imaging study is used to diagnose a DVT?
2.
A patient who visited the Southwest U.S. presents with fever, malaise, cough and
night sweats. W h a t is the diagnosis and treatment?
3.
W h a t diarrheal illness is associated with picnics/mayonnaise?
End of Session Quiz

4.
How do the symptoms o f gastric ulcer differ from the symptoms o f duodenal
ulcer, based on the timing o f pain and the effect o f eating upon the severity of
pain?
Gastric Ulcer
Duodenal Ulcer
Timing of pain
Effect of eating
5.
W h at is the most effective treatment o f a duodenal ulcer not due to Z E

syndrome?
6.
W hat is the treatment for gastric cancer?
7.
A female patient has a known duodenal ulcer that has been refractory to highdose PPI therapy. W hat two tests may diagnose her disease?
SMALL INTESTINE PART I
3 Question Warm-Up
1.
W h a t radiographic study is used to diagnose injury to the urethra?
2.
W h a t are the side effects o f corticosteroids?
3.
W h a t type o f oral infection has branching rods when examined microscopically?
End of Session Quiz

4.
W h a t is the m ost likely cause o f malabsorption in a patient w ith a (+) Sudan

stain in the stool sample and a norm al D-xylose test?
5.
W h a t is the treatm ent for W hipple disease?
6.
W h ich tumors can cause secretory diarrhea?
7.
W h a t is the most common cause o f adult chronic diarrhea?
SMALL INTESTINE PART 2
3 Question Warm-Up
1.
Hypoxemia + pulmonary edema + normal pulmonary capillary wedge pressure.

W hat is the diagnosis?
2.
W hat are the two most common foodbome bacterial G l tract infections in the
U.S.?
3.
W hat are the symptoms o f a basilar skull fracture?
Irritable Bowel Syndrome (IBS)

4. W hat are the ROME II Diagnostic Criteria for IBS?
At least 12 weeks of abdominal discomfort or pain in the preceding year associated with
one of the following:
Relief with defecation
Change in____________________of stool
Change in____________________of stool
Characteristic of IBS:
Change in stool form or frequency (> 3 daily or < 3 weekly)
Straining
Urgency
Feeling of incomplete passage
Bloating/distention
- Mucus
Not characteristic of IBS:
Anorexia
- Weight loss
Malnutrition
Progressively worsening pain
Pain that prevents sleep
5. W hat are the two main types of IBS? W hat are the treatments for the two
types of IBS?
Diarrhea-predominant
Tricyclic antidepressants (desipramine) or SSRIs (ifT C A s not well tolerated)
If woman with severe disease, alosetron (Lotronex)
Loperamide (Imodium) as needed
0 Constipation-predominant
Fiber-bulking agents with adequate hydration
Inflammatory Bowel Disease (IB D )

6. W hat treatm ents are available for managing Crohns disease?
____________________________ or mercaptopurine > methotrexate
____________________________ (e.g., infliximab, adalimumab)
__________________________ _+/- antibiotics for acute exacerbations
Bowel Obstruction
7.
W hat are the most common causes of small bowel obstruction?
A _______________________ from previous surgeries (about 75% of cases)

B __________________________ (second most common cause)
C __________________________ (most commonly metastatic colorectal cancer)
Other less common causes:
- Volvulus, intussusception, Crohn's disease, gallstone ileus, bezoar, bowel wall hematoma
from trauma, inflammatory stricture, congenital malformation, radiation enteritis
8. W hat are the classic signs and symptoms of a small bowel obstruction (SBO)?
W hat radiographic findings help you confirm the diagnosis?
Signs and symptoms: abdominal pain/tenderness; N/V; +/- recent flatus/small BM;
______________________ bowel sounds; (also common is history of previous abdominal
surgery leading to adhesions)
Diagnosis:_______________________of small bowel proximal to the obstruction seen on
plain film abdominal series or C T scan of the abdomen
9. W hat is the treatm ent for a small bowel obstruction?
NPO, IV fluids, monitor electrolytes, Foley catheter to monitor urine output

Nasogastric tube (NG tube) to low intermittent wall suction (LIWS)
Hospital observation with frequent reassessments +/- repeat C T scans
Avoid pain medication if possible which may interfere with identification of disease
worsening
Surgery (laparotomy and lysis of adhesions) if:
No improvement in 12-24 hours
Complete SBO
Suspected, impending, or ongoing strangulation
10. W h at is the m ost common benign small bowel tumor?
11. W h a t is the m ost com m on m alignant sm all bowel tumor?

192 I
End of Session Quiz

12.
W hich form o f IB D causes perianal fissures and fistulas?
13.
W h a t serum lab findings might help distinguish Crohns from UC?
14.
W hat is the most common cause o f large bowel obstruction?
15.
W hat is the treatment for Crohns disease?
16.
W hich signs and symptoms are and which are not associated with IBS?
LARGE INTESTINE PART I
3 Question Warm-Up
1.
W h a t is the drug o f choice for trigeminal neuralgia?
2.
W h a t is the initial treatment for a child presenting with an acute asthma attack?
3.
A normalizing P C 0 2 in a patient having an asthma exacerbation may indicate

what problem?
Appendicitis
4. W hat radiological studies can be used to diagnose appendicitis?
C T scan with oral contrast

C T scan with rectal contrast +/- IV contrast
C T scan without contrast
Plain radiograph
Ultrasound
5. W hat is the specific treatm ent for appendicitis?

N PO and IVF
Pain control:
Morphine or meperidine PCA
Antibiotic administration for mild to moderate inpatient:
- Ampicillin/sulbactam (Unasyn)
Piperacillin/tazobactam (Zosyn)
- Ticarcillin/davulanate (Timentin)
Levofloxacin + metronidazole
Ciproflqxacin + metronidazole
Antibiotic administration for severe ICU patient:
- Ampicillin + levofloxacin + metronidazole
Imipenem/cilastatin (Primaxin)
Meropenem
If presentation within 24-72 hours of symptom onset
- Surgical removal of appendix by laparoscopy or open appendectomy
If symptoms present for more than 5 days and pain specifically in RLQ_
- Antibiotics, IVF, bowel rest then interval appendectomy about 8 weeks later
If abscess on C T scan
- Percutaneous drainage (interventional radiology)
LARGE INTESTINE PART I
Ileus
6. W hat is the classic presentation of gallstone ileus?
Classically presents as an episodic subacute obstruction in an elderly woman with vague,
recurrent abdominal pain and vomiting that recurs as the stone repeatedly lodges and
dislodges
Average time from symptom onset to hospitalization 5 days
Volvulus
7. W hat is the treatment for sigmoid volvulus?
Sigmoidoscopy or colonoscopy for decompression
If gangrenous or sigmoid/colonoscopy is unsuccessful > laparoscopic resection of the
affected colon and colostomy
Once corrected, the recurrence in 40-60% of patients can be prevented with one of the
following:
Mesosigmoidopexy
Resection with primary anastomosis
Hartmanns procedure (proximal colostomy + stapling but not removal of the distal
segment)
End of Session Quiz

8.
W h a t is the classic characteristic o f acute mesenteric ischemia?
9.
In a wom an w ith history and labs suggestive o f acute appendicitis, w hat

additional lab should be done first before surgery?
10. W h a t m ight you see on C T scan o f the abdom en in a patient suspected

o f having ischemic colitis?
11. W h a t is the classic tim e frame in which post-op ileus resolves in the
different parts o f the gut?
Small bowel
Stomach
Colon
LARGE INTESTINE PART 2
>
73
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3 Question Warm-Up
1.
A patient has dyspnea, hilar lymphadenopathy on chest x-ray, with hypercalcemia.

2.
W h a t characteristics favor carcinoma in an isolated pulmonary nodule?
3.
W h a t is the treatment for normal pressure hydrocephalus? W h a t is the treatment

for pseudotumor cerebri?
O
>
70
Diverticulitis
4. W hen is inpatient admission for diverticulitis treatm ent indicated?
Elderly
Immunocompromise
Significant comorbidities
High fever with significant leukocytosis
Unable to tolerate oral intake
5. W hat are the steps in the inpatient management of diverticulitis?

IV fluids
Broad-spectrum empiric antibiotics
o If
*_________________ >emergency exploration through midline incision
6. A 65-year-old woman that presented to the emergency room with severe

abdominal pain is found to have leukocytosis and an abscess in the region of
the sigmoid colon. W hat is the most likely predisposing lesion, and what is the
next step in management?
Diverticulosis >________________________ * _________________________
CT-guided or US-guided percutaneous drainage
IV antibiotics
[ 195 j
LARGE INTESTINE PART 2
Carcinoid Tum or
7. W hat are the classic features of carcinoid syndrome?
Be FDR
Bronchospasm (10-20%)
Flushing (85%)
Diarrhea (80%)
Right-sided valvular disease/murmurs
8. W hat is the treatment for carcinoid syndrome?

________________________ analog such as octreotide
Other drugs that can be used for symptom relief:
Cyproheptadine for diarrhea and/or anorexia
Albuterol and/or theophylline for asthma symptoms
Codeine and/or cholestyramine for diarrhea
If symptoms are refractory to octreotide ______________________ combined with
octreotide
Surgical resection in certain circumstances of isolated tumors
Valvular surgery for symptomatic carcinoid heart disease
End of Session Quiz

9.
W h a t are risk factors for diverticulosis?
10.
W h a t is the treatm ent for mild diverticulitis?
11.
W h a t is the treatm ent for diverticulitis w ith abscess formation?
12.
W h a t is the next step in the management of a patient younger than 50 with

minimal bright red blood per rectum (e.g., only seen on the toilet paper after
wiping)?
13.
W h a t is the most likely cause o f acute pain and swelling o f the midline
sacrococcygeal skin and subcutaneous tissues?
COLORECTAL CANCER AND Gl BLEEDING
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3 Question Warm-Up
1.
W h a t type o f immunodeficiency increases the risk o f anaphylactic transfusion

reaction?
2.
Patients w ith silicosis are at higher risk for what type o f infection?
3.
A patient presents with a sudden onset o f severe, diffuse abdominal pain (AX R
reveals free air under the diaphragm). W h a t is the next step in management?
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Colorectal Cancer
4. W hat are the current colon cancer screening recommendations for normal risk
patients?
For the average risk patient, the following screening should start at age 50:
Fecal occult blood test___________with stool guaiac (samples from three consecutive
stools is ideal)
)
Colonoscopy q _________ (or flex sig with double-contrast barium enema q
C T Colonography is not currently used for screening because it does not have adequate
sensitivity and specificity.
Screening should stop when a patients life expectancy is less than 5 years (or at age 75,
whichever comes first).
G l Bleeding
5. W h at are the next steps in the management of a patient that presents to the
E R with massive lower G l bleeding?
Assess and Stabilize
H 8tP
Continuous monitor of vital signs
Obtain IV access with 2 large bore IVs (18-gauge in both arms) or central line
Volume resuscitation with NS or LR as needed
Type and cross 2U PRBC
Lab: CBC, coags, (guaiac stool if necessary to confirm blood)
Treat and Determine cause
N G T lavage to rule out massive upper G l bleed
If colonoscopy is nondiagnostic and not feasible (e.g., too much active bleeding may
obscure visualization) and bleeding persists >radionucleotide scan and/or angiogram
[ 197]
COLORECTAL CANCER AND Gl BLEEDING
End of Session Quiz

6.
W h a t gene is responsible for familial adenomatous polyposis (FAP)?
7.
A patient in the E R has just thrown up his second basin full o f blood. H e is
drunk and tachycardia W h a t is the next step in managing this patient?
8.
W h at are common etiologies o f upper G I bleeds?
9.
W h a t are the most common causes o f lower G I bleeds?
10.
11.
H ow is volume status assessed in a patient with a G I bleed?
A 35-year-old m an tells you that his father had colon cancer at age 49. W hen
should this m ans first colonoscopy be scheduled?
PANCREATIC DISEASES
3 Question Warm-Up
1.
W h a ts the difference between Mallory-Weiss and Boerhaave tears?
2.
W h a t medications should be given to a patient with muscle spasms, abdominal

stiffness, altered mental status and tachycardia due to a spider bite?
3.
W h a t are the H A C E K bacteria?
End of Session Quiz

4.
W h a t are the Ranson criteria for determ ining the prognosis o f patients with
acute pancreatitis?
O n admission
^ 48 hrs
5.
W h a t is the treatm ent for chronic pancreatitis?
6.
W h a t are the m ost com m on causes o f acute pancreatitis in the U nited States?
7.
W h a t procedure is performed to treat an isolated cancerous tum or in the head o f

the pancreas?
BILIARY DISEASES PART I
3 Question Warm-Up
1.
A t what point do patients with chronic C O P D qualify for home 0 2?
2.
A patient presents with amenorrhea and bitemporal hemianopsia. W hat is the

most likely diagnosis?
3.
W hich lung cancer is associated with SIADH?
. W hat is a HI D A scan (A K A cholescintigraphy)?

Technetium-labeled hepatic iminodiacetic acid (HIDA) given IV >taken up by
hepatocytes > excreted into bile >visualization of gallbladder
Inability to visualize the gallbladder with this test indicates cystic duct obstruction usually
from acute cholecystitis or an obstructing stone
End of Session Quiz

5.
W h a t type o f patient is at high risk o f acalculous cholecystitis?
6.
W h a t are C harcots triad and Reynold s pentad?
7.
H ow does the interventional component o f treatm ent o f cholecystitis differ

from that o f cholangitis?
Cholecystitis
Cholangitis
BILIARY DISEASES PART 2
>
75
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3 Question Warm-Up
1.
A patient who recently received a bone marrow transplant develops a rash, nausea
and vomiting, and is having continued bleeding from her gums after brushing her
teeth. W h a t should be suspected in this patient?
2.
A patient presents w ith dysphagia, and the barium swallow shows a corkscrew
pattern o f the esophagus. W h a t is the diagnosis?
3.
A patient presents w ith dysphagia, and the barium swallow shows a birds beak
sign in the distal esophagus. W h a t is the diagnosis?
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Prim ary Biliary Cirrhosis

4. W hat physical exam and lab findings would lead you to suspect prim ary biliary
cirrhosis as a diagnosis?
Usually women (95% of patients) between ages 30-65
___________________________ are the most common presenting symptoms
Excessive daytime somnolence
Pruritus often starts during pregnancy but is not relieved postpartum
Patients are often initially referred to a dermatologist for pruritus and excoriations are
common
Skin changes: hyperpigmentation due to melanin deposition (25-50%), xerosis (70%),
dermatographism (57%)
Xanthelasma (10%) (cholesterol-filled plaques on the medial aspects of the eyelids
bilaterally) and/or xanthoma (5%)
Hepatomegaly that progressively worsens +/- splenomegaly
Malabsorption and steatorrhea from less bile acid secretion
Cirrhosis, jaundice, ascites, edema, portal hypertension occur in late stage disease
Labs: elevated alk phos and GGT, elevated serum direct and indirect bilirubin (but not in
early disease), elevated cholesterol
Elevated serum ___________________________ (>95% of patients) - the hallmark
finding of PBC
Elevated ____________________ (70%)
Associated conditions: other autoimmune disorders (e.g., thyroiditis/hypothyroid (20%),
sicca syndrome, scleroderma, Sjogren, arthritis, Raynaud), osteoporosis, osteomalacia
I [201 ]
BILIARY DISEASES PART 2
5. W hat is the treatment for primary biliary cirrhosis?

Ursodeoxycholic acid (UDCA) - delays disease progression and enhances survival
The only approved therapy for PBC
If UDCA not sufficient, may add colchicine +/- methotrexate
If pruritus, cholestyramine
Prevention of metabolic bone disease:
Calcium 1,500 mg/d + at least 800 IU of vitamin D daily
Supplement vitamins A and D as needed based on annual serum levels of these
vitamins
Evaluation with bone D X A scan at the L-spine and hip
If low bone density, bisphosphonates
If esophageal varices, 3-blocker +/- band ligation +/- surgical intervention (splenorenal
shunt or TIPS)
If iron deficiency anemia, oral iron replacement
If fatigue, modafinil (not well studied)
Dietary changes:
If steatorrhea, reduce dietary fat
If weight loss, supplement medium-chain triglycerides which do not need bile for
absorption
If pancreatic insufficiency, pancreatic enzyme replacement
Treat hypothyroidism as needed
If painful or debilitating xanthomas on palms or soles, large-volume plasmapheresis ql-2
weeks to normalize serum cholesterol
Definitive treatment is liver transplantation
Prim ary Sclerosing Cholangitis

6. W hat are some of the possible etiologies of secondary sclerosing cholangitis?
Intraductal biliary stones

Surgical trauma or blunt abdominal trauma to the biliary tree
Drugs (IV chemotherapy)
Recurrent pancreatitis
Autoimmune pancreatitis
AIDS cholangiopathy
End of Session Quiz

7.
W h a t distinguishes prim ary biliary cirrhosis from prim ary sclerosing

cholangitis?
8.
W h a t is the treatm ent for prim ary biliary cirrhosis?
9.
W h a t name is associated w ith each o f the following findings, and with what
diseases are they associated?
Description
Deep palpation of RUQ_>
arrest o f inspiration due to pain
C harcots triad (fever, jaundice,
RUQ_pain), hypotension, altered
mental status
RLQ_pain on passive extension
of the hip
RLQ_pain on passive internal
rotation of the flexed hip
LUCLpain and referred left
shoulder pain
Ecchymosis of the skin overlying
the flank
Ecchymosis o f the skin overlying
the periumbilical area
Sign
Disease
LIVER DISEASE AND CIRRHO SIS
ALCOHOLIC LIVER DISEASE AND CIRRHOSIS
1.
W hat is the most common cause o f travelers diarrhea?
ALCOHOLIC
2.
W hat is the initial treatment of a localized non-small cell lung cancer?
3.
W hat is the medical treatment for ulcerative colitis?
3 Question Warm-Up
4.
N A SH : Nonalcoholic Steatohepatitis
0
0
Most common causes: obesity, DM, hyperlipidemia, insulin resistance

Due to insulin resistance at the liver -> excess lipid accumulation in the liver
Can progress to cirrhosis, lead to hepatocellular carcinoma, worsen Hep C progression
Suspect if chronically elevated ALTs
Diagnosis
Liver US, C T scan or MRJ can make the diagnosis
Magnetic resonance spectroscopy (MRS) is the gold standard
Liver biopsy can also make the diagnosis. It is the only manner to identify those at risk
for disease progression
Treatment
Avoidance of all alcohol
- Weight loss - most likely beneficial, but no proven benefit
- Control any diabetes aggressively to keep HbAlc < 7.0
T Z D s (pioglitazone) - improves LFTs and possible histology improvement
Metformin shows improvement in animal studies
5. W hat are the signs and symptoms of Budd-Chiari syndrome?

Budd-Chiari syndrome is the thrombosis and occlusion of the hepatic vein or the
intrahepatic/suprahepatic portion of the inferior vena cava, and presents with the
following symptoms:
_________________________ (84%)
_________________________ (76%)
Jaundice
Acute presentation: acute RUQpain and hepatomegaly, and rapid development of jaundice
and ascites
Subacute or chronic presentation: gradual development of ascites, LE edema, cirrhosis and
portal hypertension over a few months
Eventual development of liver failure and hepatic encephalopathy
1
6. W h a t is the S A A G ?
Serum-ascites albumin gradient = [serum albumin] [ascites albumin]
SAAG a l j . indicates portal hypertension (low albumin in the ascites):
Cirrhosis
Alcoholic hepatitis
- Heart failure/constrictive pericarditis
- Massive hepatic metastases
Budd-Chiari syndrome
SAAG <1.1 means the ascites is not due to portal hypertension (high albumin in the
ascites, or low serum albumin):
High albumin in the ascites
Peritoneal carcinomatosis
Peritoneal tuberculosis
Pancreatitis
- Serositis
Low serum albumin
Nephrotic syndrome
O
O
x
O
n
73
>
o
n
73
73
X
7. W hat is the treatm ent for spontaneous bacterial peritonitis (SBP)?

______________________ (2g IV q8 hours), ceftriaxone or other third-generation
cephalosporin for at least 5 days to cover for gut bacteria (E. coli, Klebsiella and
Enterococcus), Staph, and Strep.
______________________ dosed IV (1.5g/kg at diagnosis then lg/kg on day 3) maintains
plasma volume >preserves renal function reduces renal impairment and mortality
End of Session Quiz

8.
W h a t is the treatm ent for hepatic encephalopathy?
9.
W h a t antibiotics can be used to treat spontaneous bacterial peritonitis (SBP)?
10.
W h a t two diuretics are used in conjunction for the treatm ent o f ascites/portal
hypertension?
11. W hat are the symptoms o f Budd-Chiari syndrome?
[205 ]
OTHER HEPATIC DISEASES
3 Question Warm-Up
1.
A patient with lung disease is found to have anti-glomerular basement membrane

antibodies. W hat is the treatment?
2.
W h at are the components o f the medical management of peripheral artery

disease?
3.
W h at anatomic locations are options for immediate needle decompression of a

tension pneumothorax?
Hepatic Adenoma
Most often in women ages 20-44 (OCP years)
Risk Factors: OCP use, anabolic steroids, (glycogen storage disease types I and III)
Sx: RUQ_pain, but usually there are no symptoms because it is often an incidental finding
on imaging
Malignant transformation in 10% of patients
Rx: discontinue the OCP, serial imaging and AFP, +/- resection (esp. if > 5cm)
End of Session Quiz

5.
W h a t is the most widely used screening test for hemochromatosis?
6.
W h a t copper-related lab value would you order in a patient suspected o f having

W ilson disease?
7.
W hat is the treatment for hemochromatosis?
PEDI GI DISORDERS
U
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o
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3 Question Warm-Up
A 40-year-old black woman is found to have non-caseating granulomas o f the
lung and hypercalcemia. W h a t is the diagnosis?
2.
A 25-year-old m an presents w ith pain and watery diarrhea after meals. Exam
shows fistulas between the bowel and skin, and nodular lesions on his tibias.
3.
W h en is rifampin prophylaxis indicated in the case o f bacterial meningitis?
GASTROENTEROLOGY
1.
Neonatal Jaundice
4. W hat are the various causes of neonatal jaundice?
5.
Physiologic jaundice (50% of newborns)- starts day 2-3,peaks at

<10mg/dL on day 3-5
Exaggerated physiologic jaundice (AKA breastfeeding jaundice)
- occursin 1st week of
life, peaks at 12-15mg/dL, due to dehydration > make sure baby has more than 10 feeds/
day
Breast milk jaundice- starts days 4-14 (usually after 1st week) due to substances in breast
milk. May continue for weeks to months while breastfeeding. Improvement with the
substitution of formula for 48-72 hours is diagnostic.
Immune Related
- A BO incompatibility
Rh (or other antigen) incompatibility (erythroblastosis fetalis)
Trauma, cephalohematoma, bruising
Infection/sepsis (look for other signs of infection such as fever, lethargy and poor feeding)
Polycythemia
Hereditary disease
- G6PD deficiency (more common in black, African, Asian, Mediterranean, and MiddleEastern men)
Hereditary spherocytosis
- Dubin-Johnson (direct/conjugated bili elevation)
- Rotor syndrome (direct/conjugated bili elevation)
- Byler disease (direct/conjugated bili elevation)
Biliary atresia - may present after 2 weeks of age with jaundice and pale stools. Direct bili
is more than 20% of the total bili which is usually elevated to 6-12mg/dL. Early referral to
Pedi GI for diagnosis (US + biliary nuclear imaging +/- biopsy) is important since surgical
repair prior to 2 months of age is essential in preventing biliary cirrhosis.
W h at antibiotic is contraindicated in neonates with hyperbilirubinemia and

why?
[207]
PEDI Gl DISORDERS
6. W hat characteristics might help you identify newborn jaundice as pathological?
Any jaundice in 1st 24 hours

Rise in total bili by more than 0.5mg/dL/hr
Rise in total bili more than 5mg/dL/day
Direct (conjugated) bili greater than 20% of the total bili or > 1.5mg/dL
Total bili higher than 13mg/dL in term neonates
Jaundice appearing after 2-3 weeks of age
Failure to Thrive
7. W hat are the criteria for failure to thrive in a child younger than 2 years of
age?
Weight < 3rd or 5th percentile for gestation corrected age on > 1 occasion
(make sure to use special growth chart for Down syndrome and Turner syndrome
patients)
Weight < 80% of ideal weight for age

Weight crosses 2 major percentiles downward on a standardized growth chart over time
Weight for length ratio < 10th percentile
Rate of daily weight gain less than that expected for age
End of Session Quiz

8.
W h a t is the most common type o f T E fistula?
9.
W h a t is the classic presenting scenario for necrotizing enterocolitis?
10. Fill in the chart for unconjugated hyperbilirubinemia/jaundice o f the newborn.
Physiologic
Age
T. bili level
Cause
Treatment
Exaggerated
physiologic /
Breastfeeding
Breast milk
Epidemiology and Ethics

1
Biostatistics
R esearch Studies
A bstracts and A dvertisem ents
E thics
BIOSTATISTICS
H
CO
H
CO
3 Question Warm-Up
1.
W h a t is the most common foodborne bacterial G I tract infection in developed

countries?
2.
W h a t is the treatment for a rectal fistula?
3.
In what disease would you see a H am ptons hump on x-ray?
EPIDEMIOLOGY AND ETHICS
4. W hat are the definitions of the following epidemiological terms?

Rate
Definition
B irth rate
Live births/1000 population
Fertility rate
Live births/1000 population o f women aged 15-45 years
D eath rate
Deaths/1000 population
Neonatal mortality rate
Neonatal deaths (first 28 days of life)/1000 live births
Perinatal m ortality rate
Neonatal deaths + stillbirths/1000 total births
Infant m ortality rate
Deaths (from 0-1 year old)/1000 live births
M aternal m ortality rate
M aternal pregnancy-related deaths (deaths while

pregnant or in the first 42 days after delivery)/100,000
live births
[211 ]
S D iis u v is o ia
5.
In a population of sexually active people, 20% have H PV infection. In a population

of people who are not sexually active, only 5% have H PV infection. W hat is the
attributable risk of sexual activity to HPV?
6. Absolute Risk Reduction (ARR)

Conceptually similar to calculation of attributable risk, but the exposure is some
intervention designed to decrease the likelihood of a particular disease
ARR = (risk of disease in unexposed population) - (risk of disease in exposed population)
<= ARR = C/(C+D) - A/(A+B)
7.
Num ber Needed to Treat (N N T )
8.
N N T = 1/absolute risk reduction

Number of patients you would need to treat in order to save/affect one life
Important number to help determine if a drug should be used or is cost effective
Example: If out o f20,000 pts that received tPA during a STEMI, 100 were saved by the
tPA, then the N N T is 200. In other words, you would need to treat 200 patients in order
to save/affect 1 life.
How do you calculate confidence intervals?

Confidence is a range of values in which the examiner can be (90%, 95%, 99%) confident
that the value obtained from the study truly reflects reality
The confidence interval range = mean +/- (Z x SEM)
If a 90% confidence interval is desired, then use Z = 1.645
A s the % confidence interval increases, so does the range on either side of the mean
If the confidence interval range for odds ratio or relative risk crosses one, this indicates
there may be no association between the risk and the disease.
If the confidence interval range for a study of two treatment groups crosses zero, this
indicates there may be no actual difference between two treatments.
[212]
End of Session Quiz

9.
W h a t is the equation for odds ratio? W h a t is the equation for relative risk?
10.
W h e n is the odds ratio a good approximation o f relative risk?
11.
W h a t does it m ean when the relative risk is equal to one?
12.
W h a t is most im portant in a screening test? In a confirmatory test?
13.
W h a t equations represent sensitivity, specificity, positive and negative predictive

value using antibodies to X to detect disease X?
Autoimmune Disease X
Present
Absent
800
200
100
1400
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Assum ing a norm al bell-shaped distribution, w hat percentage o f the study

population falls w ithin 1 standard deviation, 2 standard deviations and 3
standard deviations o f the mean?
RESEARCH STUDIES
3 Question Warm-Up
1.
W hich antihypertensive class is first-line in patients with the following

conditions?
No comorbidities
Diabetes
* Heart failure (multiple)
BPH
Left ventricular hypertrophy
Hyperthyroid
o Osteoporosis
Benign essential tremor
Post-menopausal female
Migraines
2.
W hat are four signs and symptoms o f streptococcal pharyngitis?
3.
W hat are the usual imaging studies in a trauma series?
po
CO
End of Session Quiz

4.
Fill in the blank for the study design that matches its characteristics.
Study Design
Characteristics
Identifies T W O groups: diseased group and healthy
group. Retrospectively compares them. Weakened
by recall and selection biases.
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D
m
co
Seeks to estimate disease prevalence and exposure across

a population
Examines a collection of studies on a given subject
Prospective blinded study involving placebos,

existing therapies and experimental interventions
Examines a collection o f cases to seek insight into

the disease o f interest. Useful in rare diseases.
5.
M atch the type o f bias w ith its description.
Bias
Description
Memory errors produce incorrect data
Subject awareness of being studied alters their answers
and behavior from normal
Certain medical studies attract subjects with
particular medical histories rather than general
population
Studies that show a difference are preferably
published and then later included in meta-analysis
rather than studies that support the null hypothesis
Screening tests designed to detect asymptomatic
disease may miss rapidly-progressive disease
because the interval between successive screenings
only detects slowly-progressive ones
Screening test may allow earlier diagnosis of disease
but does not translate into actual length of survival
EPIDEMIOLOGY AND ETHICS
Focuses on O N E group with a shared exposure or

disease and either prospectively or retrospectively
compares them
ABSTRACTS AND ADVERTISEM ENTS
ABSTRACTS AND ADVERTISEMENTS
3 Question Warm-Up
1.
W hat is the treatment for Guillain-Barre syndrome?
2.
W hat is the cause of chest pain in a young patient that has angina at rest with ST
segment elevation but normal cardiac enzymes?
3.
W hat infection can cause diarrhea and pseudoappendicitis?
The Effects o f Rosiglitazone on Mild CHF in Type 2 Diabetics

OBJECTIVE:
This study investigated the effects of rosiglitazone on left ventricular ejection
fraction (LVEF) in subjects with type 2 diabetes and N Y H A functional class I to II
congestive heart failure (CHF).
M ETHODS:
Design: Double-blind randomized placebo-controlled trial
Follow-up period: 26 weeks
Patients: 224 patients with both type 2 diabetes and N Y H A functional class I to II
CHF. At baseline, both groups had similar H gbA lc (treatment group 7.7 +/- 0.4%,
placebo group 7.6 +/-0.7%) and LVEF (treatment group 36.2 +/- 5.2%, placebo group
36.6 +/- 6.8%). Exclusion criteria included treatment with a thiazolidinedione
within 6 months prior to enrollment in the study, hospitalization for any cause
within 1 year prior to enrollment, and concurrent insulin therapy.
Intervention: Patients were randomized to receive 26 weeks of treatment with either
rosiglitazone (4 to 8 mg daily, n = 109) or placebo (n = 115) in addition to their
existing therapy for diabetes and CHF. Treatment was titrated to achieve target
fasting plasma glucose <126 mg/dL, and C H F medications were adjusted as needed.
Outcomes measured: Changes in H gbAlc and LVEF, new or worsening edema that
required medical intervention, and increases in C H F medication.
RESULTS:
After 26 weeks of treatment, glycemic control was significantly better in the
treatment group (mean difference in HgbA lc -0.58%, p <0.001). The LVEF was
similar in both groups after 26 weeks of treatment (mean difference 1.36%, p = 0.11).
The treatment group had a significantly higher incidence of new or worsening edema
(treatment n = 26 [23.8%]; placebo n = 9 [7.8%]; p = 0.005), as well as more increases
in C H F medication (treatment n = 31 [28.4%], placebo n = 17 [14.8%]; p = 0.036). A
similar proportion of patients from each group withdrew from the study because of
adverse events.
CONCLUSIONS:
After 26 weeks of treatment, rosiglitazone did not affect LVEF in patients with
N Y H A functional class I to II C H F and type 2 diabetes. There were more edemarelated events with rosiglitazone, although on the whole these did not cause subjects
to withdraw from the study.
A 73-year-old man with N Y H A class I heart failure and poorly-controlled type

2 diabetes presents for routine follow-up. He is currently taking metformin for
his diabetes, and furosemide, carvedilol and ramipril for his C H F . His H gb A lc
is 8.4%, and you recommend starting rosiglitazone to help get his H g b A lc to
goal. A fter 6 months on rosiglitazone, his H g b A lc has improved to 7.2. Based
on the abstract, is this better or worse than the average improvement in A le
seen in the study?
Eight months after starting rosiglitazone, your patient is hospitalized for

an acute exacerbation of C H F . Based on the abstract, what percentage of
patients in the treatm ent group required hospitalization for C H F?
Based on these study results, what is the relative risk of having an acute
exacerbation of edema due to rosiglitazone?
Superior ACE Inhibition... Superior Outcomes
gTM
rO
Lowers systolic blood pressure more than any other ACE inhibitor
Proven reductions in post-MI mortality
Fewer adverse effects
(prilapril)
Powerful BP Reduction
Reduced All-Cause Mortality

Following STEMI at 1 Year **
-Superace
-Placebo
DBP
SBP
Superace
Usinoprit
Months Post-STEMI
Placebo
** Mortality in 287 hospitalized patients randomized to either

Prilapril or placebo following STEMI, plus standard post-MI therapy.
Superior Side Effects Profile

Hypotension
Cough
Hyperkalemia
Renal insufficiency
Angioedema
Seizures
Rectal bleeding
Gigantism
Superace
Ramipril
Placebo
8.4%
3.6%
4.0%
1.6%
0.6%
0.3%
0.2%
0.5%
11%
9.6%
5.4%
1.8%
0.8%
0%
0%
0%
0.6%
1.2%
0.3%
0.7%
0%
0.2%
0.1%
0.1%
Flexible Dosing Options

Once- or twice-daily dosing
Scored tablets: 2.5mg, 5mg, lOmg, 20mg, and 40mg
Safety Information
Prilapril is indicated for the treatment of
hypertension, and to reduce the risk of death
following myocardial infarction.
Prilapril should not be used in patients with a
history of sensitivity to ACE Inhibitors, or
history of angioedema.
Prilapril is pregnancy risk category D. Based
on human data, ACE Inhibitors can cause
injury and death to the developing fetus
when used in the second and third trimesters.
ACE Inhibitors should be discontinued as soon
as possible once pregnancy is detected.______
MGM Therapeutics 2012
7. A 45-year-old woman is currently taking a combination of lisin o p ril-H C TZ for

essential hypertension. She has seen T V com m ercials for Superace, and she
is interested in knowing more about the superior outcomes that the tagline
promises. If she switched to prilapril, what superior outcomes might you
expect to see?
8. Your next patient, a 57-year-old man with type 2 diabetes, has mild diabetic
nephropathy. His baseline BP is 128/94. Is Superace a better choice for him
than lisinopril?
9. You are going over the discharge instructions with a 72-year-old woman
admitted for an acute STEM I, treated with P T C A and stenting of the LA D .
You have explained the need for her to be on aspirin, dopidogrel, metoprolol,
atorvastatin and prilapril. How long must she take prilapril in order to see any
real m ortality benefit?
10. W hich of the advertisem ents claims is best supported by the data presented?
Lowers systolic blood pressure more than any other ACE inhibitor
Proven reductions in post-MI mortality
Fewer adverse effects
ETHICS
ETHICS
3 Question Warm-Up
1.
A smoker has rapid onset JV D , facial swelling and altered mental status. W hat
is the treatment?
2.
A 24-year-old woman comes to the clinic for a check-up and is found to have
markedly elevated BP. She is at a recommended body weight, follows a good
diet, exercises and does not smoke or use birth control. W h at might be the
cause o f her H T N ? W h at might be seen on radiological imaging?
3.
W hich oral hypoglycemic medicine should not be given when a patient is to

have a radiologic procedure in which he will need IV contrast?
4. The mother of an adolescent boy wants you to ask her son (your patient) if he
is gay. How do you proceed?
Medical Malpractice
S. W hat are the 4 elements of a malpractice claim?
___________________________ : A legal obligation to conform to a reasonable standard
of care
___________________________ : Failure to conform to the standard of care
0 ___________________________ : Injury or harm to the plaintiff
___________________________ : The breach of duty is determined to be the cause of the
injury or harm
6. W hat are the 2 ways that the standard of care can be established in a
malpractice case?
A surgical sponge is left behind in a patients abdomen following a laparotomy.

The hospital, surgeon, scrub nurse and circulating nurses are all named in the
subsequent malpractice suit. The surgeon claims that the scrub nurse (not the
surgeon) is responsible for making sure that the sponge count was correct. Why
does this argument not free the surgeon from legal liability?
End of Session Quiz

8.
W h a t should you do in the case o f a childs parents refusing a clearly life-saving

treatm ent for their child in an emergency situation?
9.
Under what circumstances are you allowed to break confidentiality with a patient?
10. A cancer patient is emergently intubated in the E R after a motor vehicle

accident. The patients family brings you a D N R signed by the patient stating
th at she does not wish to be intubated. W h a t do you do next?
11. W here in the U S is euthanasia legal?
12. A patient has a living will that states he does not w ant to be placed on a
ventilator. H is wife tells you to place him on the ventilator for one week and
then remove it if he is not improving. W h a t should you do in this scenario?
13. W h y can a heavily intoxicated patient refusing medical intervention be treated

temporarily against his will?
G enitourinary
1
D iuretics
D isorders o f the K idney p a rt 1
D isorders o f the K idney p a rt 2
N ep h ritic Syndrom es
N ephrotic Syndrom es
R enal Failure
A cid-B ase D isorders
H yponatrem ia
O th e r E lectrolyte D isorders
10 B ladder and U reteral D isorders

11 M ale R eproduction p a rt 1
12 M ale R eproduction p a rt 2
13 Pedi U rology
DIURETICS
73
m
nGO
3 Question Warm-Up
1.
W h a t is the treatm ent for acromegaly?
2.
A patient w ith cirrhosis presents to the E R to have his recurrent ascites drained.
Analysis o f the ascites fluid reveals an absolute neutrophil count >250 cells/mm3.
3.
W h a t are the protein and L D H criteria for an exudative pleural effusion?
End of Session Quiz

W h a t type o f diuretic is each o f the following drugs?
Triamterene
Acetazolamide
Hydrochlorothiazide
Bumetanide
Spironolactone
Ethacrynic acid
Mannitol
Metolazone
Chlorthalidone
o Furosemide
Amiloride
Torsemide
5.
W h ich diuretic (or diuretic class) would be most useful in each o f the following
situations?
Acute pulmonary edema
Idiopathic hypercalciuria (causing calcium stones)
Glaucoma
Mild to moderate C H F with expanded ECV
o In conjunction with loop or thiazide diuretics to retain K
o Edema associated with nephrotic syndrome
Increased intracranial pressure
Mild to moderate hypertension
Hypercalcemia
Altitude sickness
Hyperaldosteronism
GENITOURINARY
4.
DISORDERS OF THE KIDNEY PART I
[226]
DISORDERS OFTHE KIDNEY PART I
3 Question Warm-Up
1.
W h at infectious agent is most likely responsible for each o f the following

diarrheal illnesses?
Diarrhea in an AIDS patient
Diarrhea after a course of antibiotics
Diarrhea from seafood
Rice-water stools
Mild intestinal infection that can become neurocysticercosis
0 Diarrhea + pink eye
Food poisoning resulting from reheated rice (Chinese food)
2.
A 6-week-old presents with non-bilious projectile emesis. W h at is the first step

in the management?
3.
W h a t is the most likely cause o f active lower G I bleeding in patients over 40?
Nephrolithiasis
4. W hat is the general treatm ent for calcium nephrolithiasis?
W hat to expect:
If <4mm diameter, will pass spontaneously (average 8-12 days)
0 5-7mm stones are 60% likely to pass. 8-9mm stones are about 50% likely to pass
If >10mm diameter, unlikely to pass spontaneously (<25% chance)
If in proximal ureter > about 50% likely to pass. If in UVJ >about 80% likely to pass
Expectant management:
Strain urine with strainer >bring any stones to lab for analysis
Drink 3L of fluid daily (also drink during night)
Flomax (tamsulosin) 0.4mg qd x 4 weeks facilitates stone passage (relaxes smooth muscle)
Nifedipine 30mg qd x 4 weeks may be of some benefit
Pain medications: NSAIDs (diclofenac 50mg PO bid-tid pm pain), Vicodin 7.5/500 1-2
q4-6 hours pm breakthrough pain (not to exceed 8/24 hours)
Cipro ER lOOOmg qd xl4days if signs of U T I without pyelonephritis or urosepsis
Repeat C T stone protocol in 4 weeks to ensure all fragments have passed F/U in clinic
after C T
Hospitalization by urology required if:
Clinical complete obstruction (regardless of hydronephrosis on C T scan)
Unable to tolerate PO intake despite nausea meds
Intractable pain not able to be relieved with PO meds
Acutely elevated BUN or creatinine, or anuria
Fever, pyelonephritis or urosepsis
Solitary kidney
* Admit for IVF, IV pain meds (Toradol), IV antibiotics (typically Zosyn until C&S returns)
and surgical intervention (usually uteroscopy with lithotripsy and possible stent)
Surgical treatment:
10-20% of all kidney stones require surgical removal
Required if: unable to pass stone after 4-6 weeks, complete urinary obstruction, persistent
infection, impairment of renal function
Extracorporeal Shock Wave Lithotripsy (ESWL) for stones in renal pelvis or upper ureter
Ureter stones ureterorenoscopy with possible lithotripsy and possible stent placement
Staghorn calculi >percutaneous nephrostolithotomy (PNL)
DISORDERS OF THE KIDNEY PART
End of Session Quiz

5.
W h at bacteria typically cause pyelonephritis?
6.
W h at are the dietary recommendations in the treatment o f nephrolithiasis?
7.
W h at is the treatment for uric acid renal stones?
8.
W h a t size calcium renal stone has a 50% likelihood o f passing without surgical
intervention?
DISORDERS OFTHE KIDNEY PART 2
3 Question Warm-Up
1.
W h a t tum or marker is used in colon cancer patients?
2.
A lung cancer patient is re-adm itted to the hospital for dyspnea. H e is found to
have re-accumulation o f his pleural effusion. W h a t do you expect the pleuralto-serum protein and L D H ratios from the thoracentesis to be? W h a t do you
expect the pleural fluid protein content to be?
3.
W h a t is the next step in the managem ent o f a patient that comes to the E R
w ith severe abdominal pain and A X R shows free air in the abdomen?
4. W hat are the steps in evaluating hematuria?

Thorough physical exam, UA, CBC, Chem 8, PSA (men over 40)
- UA in women with hematuria should be via straight cath, or after perineum is cleansed
and a tampon is placed in the vagina
C T scan abdomen/pelvis stone protocol (no contrast) to rule out renal stone
If C T stone protocol reveals no stones, then C T abdomen/pelvis with contrast and postC T plain film KUB (equivalent to I VP) to view any radiopaque stones
If low suspicion of disease, consider treatment for U TI and F/U UA in 3-5 days
I f smoker, over age 50, cyclophosphamide use, FHx of urinary tract cancer, or suspicion
for cancer >send urine for cytology and perform cystoscopy
I f work-up reveals no pathology, consider IgA nephropathy or thin basement membrane
disease. Routinely (q6m) repeat UA and urine cytology, and consider F/U with renal
sonogram and cystoscopy in 1 year
End of Session Quiz

5.
W h a t are 5 etiologies of temporary hematuria?
6.
W h at renal pathology can result from uncorrected severe benign prostatic

hypertrophy?
7.
W h a t cardiac abnormalities are associated w ith A D PK D ?
8.
W h a t is the biggest risk factor for renal cell carcinoma?
9.
A patient involved in a motor vehicle accident has a crushed thigh. Your

resident advises you to make sure to give the patient enough IV fluids to
m aintain a high urine output o f 100-200ml/hr. W h y did she advise this?
10.
W h a t is the most common cause o f interstitial nephropathy/nephritis?
11.
A 58-year-old male smoker presents with flank pain, weight loss, hematuria and
polycythemia. W h a t is the next step in the management?
NEPHRITIC SYNDROMES
3 Question Warm-Up
1.
P FT s show decreased F E V /F V C ratio. W h a t is the diagnosis?
2.
W h a t ethical problem exists when a doctor refers a patient for an M R I at a

facility he owns?
3.
W h a t are the m ost com m on causes o f acute pancreatitis?
End of Session Quiz

4.
W h ich renal pathology would you suspect most in a patient w ith each o f the
following findings?
IF: granular pattern of immune complex deposition; LM: hypercellular glomeruli
IF: linear pattern of IgG deposition
Anti-GBM antibodies, hematuria, hemoptysis
Nephritis, deafness, cataracts
LM: crescent formation in the glomeruli
Palpable purpura on back of arms and legs, abdominal pain, IgA nephropathy
Positive ANCA
o Anti-dsDNA antibodies
NEPHROTIC SYNDROMES
3 Question Warm-Up
1.
You have a well-controlled D M II patient who needs a C T scan with IV

contrast. W h a t medication is this patient likely on that must be temporarily
held?
2. W hich type o f esophageal cancer is most prevalent in the United States?
3.
A C O P D patient comes into the E R w ith tachycardia and hypotension.

D uring the evaluation, he begins to have seizures. W h a t is the most likely
etiology?
Amyloidosis
Abnormal amyloid proteins being deposited in tissues (kidney, heart, liver, brain)
In patients with systemic amyloidosis, the kidney is the most commonly involved organ.
Commonly presents with nephrotic-range proteinuria
Renal biopsy shows expansion of the mesangial matrix due to deposition of amyloid in
the mesangium
Apple-green birefringence using Congo red stain under polarized light
In which diseases are the following urinary casts commonly seen?

0
Hyaline casts
Red cell casts
White cell casts
Epithelial cell casts
Granular casts
End of Session Quiz

6.
W h a t are the defining features o f nephrotic syndrome?
7.
Glom erular histology reveals multiple mesangial nodules. This lesion is

indicative o f w hat disease?
8.
W h ich renal pathology would you suspect most in a patient w ith each o f the
following findings?
Most common nephrotic syndrome in children
Most common nephrotic syndrome in adults
EM: loss of epithelial foot processes
Nephrotic syndrome associated with hepatitis B
Nephrotic syndrome associated with H IV
EM: subendothelial humps and tram-track appearance
LM: segmental sclerosis and hyalinosis
EM: spike and dome pattern of the basement membrane
Most common nephrotic syndrome in African American males
Apple-green birefringence with Congo red stain under polarized light
RENAL FAILURE
RENAL FAILURE
3 Question Warm-Up
1.
W h at is the ACLS treatment for asystole?
2.
A patient is found to have fever, rash, elevated creatinine, and eosinophilia.

W h at is the diagnosis?
3.
Does a cohort study identify incidence or prevalence?
4. Treatment for Chronic Kidney Disease:

Stop smoking!
B P aggressive control to goal <130/80 (JN C-7). Most need >3 medications
- ACE-I or ARB
p-blockers - to reduce C A D risk
Diuretic
Dihydropyridine CCB
Clonidine patch
Minoxidil in refractory cases
D M aggressive control to H g b A lC goal of <6.5% with insulin and oral agents (usually not
metformin)
Lipid aggressive control with statins to goal L D L <100 (but <70 is better)
Statins have been shown to reduce sepsis risk by 63% in patients on hemodialysis
(JAMA 2007;297:I455)
Anemia aggressive control to goal Hgb 11-12
For every decrease in Hgb of 0.5 g/dL, increase risk of LVH by 32% (> increase C A D
and CV D risk)
Usually requires iron and erythropoietin
Vitamin D replacement
Phosphate binders (Phos-Lo)
D aily A S A 81mg to reduce endothelial injury C A D risk
End of Session Quiz

5.
In prerenal-acute renal failure (ARF), what is the value for the fractional
excretion o f sodium (FENa)? For the BUN:Creatinine ratio?
6.
W h ich test is used for screening diabetic patients for kidney damage?
7.
W h a t blood pressure medications are renal protective and preferred in the

treatm ent o f H T N in patients w ith chronic kidney disease (CKD)?
8.
W h a t medications are necessary in patients w ith end stage renal disease?
9.
W h a t is the m ost com m on cause o f death in dialysis patients?
ACID-BASE DISORDERS
ACID-BASE DISORDERS
3 Question Warm-Up
1.
W hich antihypertensive drug fits each o f the following side effects?

0 First dose orthostatic hypotension
0 Hypertrichosis
0 Dry mouth, sedation, severe rebound H TN
Bradycardia, impotence, asthma exacerbation
0 Reflex tachycardia
Cough
Avoid in patients with sulfa allergy
Angioedema
Development of drug-induced lupus
Cyanide toxicity
2.
W hen can a physician refuse to continue treating a patient on the grounds of

futility?
3.
W h a t is the next step in the diagnosis o f cholecystitis when the ultrasound is

equivocal?
4. W hat are the normal values on an arterial blood gas (ABG)?
Normal Gas Values
Normal Ranges
pH = 7.35-7.45
pH = 7.35-7.45
P C 0 2 = 35-45
P C 0 2 = 35-45 mmHg
P 0 2 > 90 (45 x 2 = 90)
P 0 2 = 75-105 mmHg
H C 0 3- = 22 (45/2 = 22.5)
H C 0 3" = 22-28 m Eq/L
W hat acid-base disorder would cause the following lab values?
pH
hco3
Pc o 2
7.40
23
40
7.50
35
42
7.33
13
28
7.42
32
64
7.24
19
38
7.24
24
54
7.50
22
22
7.58
36
30
7.47
14
22
7.46
35
53
7.39
12
22
7.34
31
62
7.10
15
50
Type of Acid-Base Disorder
W h at is the differential diagnosis for metabolic acidosis with a normal anion gap?
How can serum potassium be useful in narrowing the differential diagnosis?
Low serum potassium: renal tubular acidosis types I and II, diarrhea, Fanconi syndrome
High serum potassium: Addison disease, renal tubular acidosis type IV, hyperalimentation
ACID-BASE DISORDERS
End of Session Quiz

7.
W h at are the distinguishing characteristics o f each type o f renal tubular acidosis

(RTA)?
Type Defect
Urine pH
Serum K+
Serum H C 0 3'
Type I - Distal
Type II - Proximal
Type IV - Hypoaldosterone
8.
W h at is the treatment for each type o f renal tubular acidosis?
Type I RTA
Type II RTA
Type IV RTA
9.
Name common causes o f each o f the following acid-base disturbances:
Metabolic alkalosis
Respiratory alkalosis
Respiratory acidosis
Anion gap metabolic acidosis
Non-gap metabolic acidosis
HYPONATREMIA
3 Question Warm-Up
1.
W h a t is the treatm ent for febrile seizures?
2.
A patient is found to have a honeycomb pattern on C T scan o f the chest. W h at

is the diagnosis and treatment?
3.
A 45-year-old obese wom an w ith pruritus, clay-colored stools and dark urine
has an elevated alkaline phosphatase and elevated bilirubin. W h a t is the most
likely cause?
4. W hat is pseudohyponatremia? How is this different from hyponatremia from

hyperosmolality?
W hen the serum volume is expanded by a substance such as lipid or protein (e.g., multiple
myeloma), the amount of sodium per volume of serum may decrease even though
the amount of sodium per unit of water in serum is appropriate. This is referred to as
pseudohyponatremia.
This is different than hyponatremia due to hyperosmolality from elevated glucose or
mannitol administration. In the case of hyperosmolality, the increase in serum osmols
pulls water out of cells, thereby diluting serum sodium. Here the plasma sodium level
is expected to fall by 1.6 mEq/L for every increase of 100 mg/dL of plasma glucose
(which increases to 2.4 m Eq/L per 100 after glucose levels exceed 400 mg/dL). Use
this calculation to determine how much you can expect the sodium to rise as the plasma
glucose begins to fall with treatment and water is consequently shifted back into cells.
5. W hat urine sodium and urine osmolality would you expect to see with the
following causes of euvolemic hyponatremia?
Cause
SIA D H
Psychogenic polydipsia
Thiazides
Hypothyroidism
Urine Na+
Urine osmolality
W hat is the differential diagnosis for hypovolemic hyponatremia based on

urine sodium levels?
Urine sodium <10 m Eq/L: Extrarenal losses
Gl losses (vomiting, diarrhea, NG tube)
Fluid sequestration (peritonitis, pancreatitis)
Insensible loss (sweating, extensive burns)
Urine sodium >20 mEq/L: Renal losses
Diuretics (thiazides)
Salt-losing renal disease
Partial urinary tract obstruction
Adrenal insufficiency (inadequate mineralocorticoid, Addison)
W hat is the differential diagnosis for hypervolemic hyponatremia based on

urine sodium levels?
W hat condition may result from the rapid correction of hyponatremia? W hat
are the manifestations?
Central pontine myelinolysis (osmotic demyelination)
Occurs when sodium is corrected by more than 12-20 mEq/L over 24 hours or is
overcorrected to above 140
0 Symptoms are irreversible and typically delayed 2-6 days after the correction of
hyponatremia
Dysarthria, dysphagia
Paraparesis or quadriparesis
Behavioral disturbances
Lethargy and coma
0 Head C T or M RI 4 weeks after the event reveals areas of demyelination
W hat are the different etiologies of the syndrome of inappropriate antidiuretic

hormone (SIAD H )?
CNS disease: head trauma, brain tumor, stroke, CNS infection, pituitary surgery
Pulmonary disease: pneumonia, tumor (small cell)
0 Drugs: NSAIDs, antidepressants, antipsychotics, antineoplastic agents, carbamazepine,
ecstasy, vasopressin, DDAVP
Other: HIV/AIDS, major abdominal or thoracic surgery
End of Session Quiz

10. W h a t is the consequence o f correcting hyponatremia too rapidly? H ow rapidly
can it safely be corrected?
11. W h a t volume status would you expect to find in a patient w ith hyponatremia
due to the following causes?
0 Thiazide diuretics
SIADH
Cirrhosis
Addison disease
Hypothyroidism
o Renal failure
Psychogenic polydipsia
12. W h a t are the most common causes o f S IA D H ?
OTHER ELECTROLYTE DISORDERS
3 Question Warm-Up
1.
A 24-year-old woman comes to the clinic for a check-up and is found to have
markedly elevated BP. She is at a recommended body weight, follows a good
diet, exercises, and does not smoke or use birth control. W h a t might be the
cause o f her H T N ? W h a t might be seen on radiological imaging?
2.
W h at is the tum or marker most useful in the diagnosis o f pancreatic cancer?
3.
In which form o f IB D would you see a lead pipe appearance on barium

enema?
K+ shifts
K* shift out of cells > Hyperkalemia
Low insulin
3 -blockers
Acidosis
Digoxin
Cell lysis (e.g. leukemia)
K+ shift into cells Hypokalemia

Insulin
3-agonists
Alkalosis
Cell creation/proliferation
W hat is the emergency treatment for hyperkalemia?
Repeat K* level to ensure not lab error/lysis

Stat EKG to identify any EKG changes such as peaked T waves
Ca2*gluconate 1-2 amps (or CaCl2 1 amp) to protect myocardium
D50 1 amp IV followed immediately by 10 units R insulin IV (drives K* into cells > 4-6
hour effect)
N aH C 03(drives K* into cells in exchange for H*)
Albuterol nebulizer (drives K* into cells)
Kayexalate PO/PR (exchanges Na for K* in the gut >excretion of K* >24-hour effect)
Consider IV Lasix to increase K* wasting in urine. May also use dialysis.
Replace magnesium if it is less than 2.0 mg/dL
Determine cause of hyperkalemia and treat
End of Session Quiz

6.
W h a t is the consequence o f correcting hypernatremia too rapidly? H ow rapidly

can it safely be corrected?
7.
W h a t is the next step in the m anagement o f a patient w ith peaked X waves on

E K G due to hyperkalemia?
8.
W h a t m edications can be used to rapidly correct hyperkalem ia by shifting

potassium into cells?
9.
W h a t is the treatm ent for nephrogenic diabetes insipidus?
10.
W h a t medications are known for causing hyperkalemia? Hypokalemia?
11.
W h ich electrolyte abnormality causes Q T prolongation on EKG? W hich

electrolyte abnormality causes Q T shortening?
BLADDER AND URETERAL DISORDERS
BLADDER AND URETERAL DISORDERS
3 Question Warm-Up
1.
W h at biostatistical calculation looks at individuals w ith and without a disease

and determines the likelihood o f exposure to a risk factor?
2.
W h a t is the empiric treatment for pneumonia in a 2-month-old? In a 2-yearold?
3.
W hich R TA is associated with abnormal H C 0 3' and rickets?
4. W hat are the treatment options for urge incontinence?

Anticholinergics (oxybutynin, tolterodine, fesoterodine, trospium, solifenacin, darifenacin)
0 Imipramine
Duloxetine (off-label in the US, approved in Europe)
End of Session Quiz

5.
W h a t are common antibiotics used to treat uncomplicated cystitis?
6.
W h a t are risk factors for developing bladder cancer?
7.
A 72-year-old smoker presents w ith painless gross hematuria. W h a t study

should you order to confirm the diagnosis o f bladder cancer?
8.
W h at are the three main types o f urinary incontinence?
9.
W h a t diagnostic tests will confirm the diagnosis o f overflow incontinence?
10. W hat is the first step in treating bladder outlet obstruction?
MALE REPRODUCTION PART I
3 Question Warm-Up
1.
W h a t are Ransons criteria in determ ining the prognosis in patients w ith acute
pancreatitis?
2.
W h a t diagnostic test differentiates central diabetes insipidus from nephrogenic

diabetes insipidus?
3.
A patient is unable to inspire completely due to pain during palpation o f the

R U Q i W h a t is this sign? W h a t is the diagnosis?
Benign Prostatic Hyperplasia (B P H )

4.
How is B P H diagnosed?
Clinical diagnosis based on symptomatic scoring system
Rule out other pathologies that may cause similar symptoms using history and the
following tests:
- Digital rectal exam to detect malignancy
- Urinalysis - to detect hematuria indicating infection, calculi or prostatitis
- Serum creatinine - to detect possible renal or prerenal disease
Other useful but optional tests: serum PSA, postvoid residual, maximum urinary flow rate
W hat is the treatment for BPH?

Alternative Medicine
Isoflavones as found in soy decrease the growth of hyperplastic prostate tissue in
histoculture. Trinovin at 40-80mg/d may help relieve symptoms.
Saw palmetto is as effective as finasteride (Proscar) (Urology 2001; 58:71-6), has fewer SE,
and decreases prostate size without changing PSA values (JAMA 1998; 280:1604-9).
Medical Intervention
Nonselective O^-blockers
Doxazosin (Cardura), prazosin (Minipress) and terazosin (Hytrin)
Decrease prostate smooth muscle tone > immediate improvement in urine flow
SE: dizziness, postural hypotension, fatigue, asthenia. To reduce SE, dose qHS and
titrate dose upward slowly over time (weekly)
Tamsulosin (Flomax) (selective a iA-blocker) - fewer SE than nonselectives, has no
antihypertensive effects, costs a bit more
5Q-reductase inhibitors: finasteride (Proscar), dutasteride (Avodart)
Slowly reduces dihydrotestosterone levels > 20% decrease in prostate volume over
3-6 months
May work best in those with a palpably enlarged prostate
Best to use in combination with an a-blocker
Decreases PSA levels by about 50% when using PSA to screen for prostate cancer,
double the value to attain the actual number.
SE: decreased libido, ejaculatory disorder; impotence
Surgical Intervention
Indications for surgery: failure of medical therapy, refractory urinary retention, inability to
express urine without a catheter, recurrent infection, persistent hematuria, bladder stones
or renal insufficiency
TU RP transurethral resection of the prostate. Most common surgery for BPH.
Symptomatic improvement in 88%. SE include excessive bleeding (1%), retrograde
ejaculation (70%), impotence (14%), partial incontinence (6%), total incontinence (1%)
Open prostatectomy symptomatic improvement in 98%, but is invasive and associated
with more morbidity than TURP. Usually reserved for those with extremely large prostate
or structural problems (protrusion into bladder, large bladder stone, urethral diverticulum).
Other interventions: transurethral incision of the prostate (TUIP), transurethral
microwave thermotherapy (TUMT), transurethral vaporization of the prostate (TUVP),
transurethral electrovaporization of the prostate (TVP), transurethral needle ablation of
the prostate (TUNA)
W hat is the next step in the management of a 65-year-old man that presents
to the ER with inability to urinate and painful bladder distention?
Decompression of bladder with 14-18 French Foley catheter (may downsize to 10-12
French if necessary)
If h/o BPH, may require a cath with a firm Coude tip to power through the narrowed
urethra
If unable to pass urethral cath, then__________________
(usuallyunderUS
guidance)
If unable to pass urethral cath and no one trained in suprapubic cath placement will be
available for hours, then____________________________________
Prostate Cancer
7.
A 60-year-old man presents to the clinic for a well-male exam. On digital

rectal examination, a hard nodule is palpated on the prostate. Lab work-up
shows an elevated PSA . W hat is the next step in the management of this
patient?
End of Session Quiz

8.
W h a t is the treatm ent for urethritis in men?
9.
W h a t are classic symptoms o f benign prostatic hyperplasia (BPH)?
10.
11.
N am e the tw o classes o f prescription medications used to treat B PH .
In a patient suspected o f having prostate cancer, w hat m ight an elevated alkaline

phosphatase indicate?
PART 2
MALE REPRODUCTION PART 2
MALE REPRODUCTION
3 Question Warm-Up
1.
W hat is the classic (but rare) EK G finding in pulmonary embolism?
2.
W h a t is the most common EK G finding in pulmonary embolism?
3.
I f pancreatitis is due to gallstone obstruction o f pancreatic duct, what should be

done after the pancreatitis has passed?
Testicular Torsion
4.
How can testicular torsion be differentiated from epididymitis?
Torsion
Epididymitis
Onset
Acute, abrupt and often

associated with a physical
activity
Subacute and may be associated

with STDs and/or anal
intercourse
Infection
No signs of infection
Possible signs of STD (urethral

discharge, fever, dysuria,
erythema)
Visual changes
Testicle may be raised

and horizontal
Testicle in normal position and

lie
Cremasteric reflex
Absent
Present
Ultrasound
Compromised blood flow
Normal blood flow
Support
5. W hat is the difference between the treatment of testicular torsion vs.

epididymitis?
Torsion
Surgical detorsion with bilateral orchiopexy within 6 hours
Epididymitis
Under 35yo = GC/Chlamydia > ceftriaxone IM then doxycydine xIO days
Over 35yo or h/o anal intercourse = Enterobacteriaceae > fluoroquinolone x 10-14
days
[248]
Male Infertility
6.
W h a t are the characte ristic features of a varicocele?

Dilation of pampiniform plexus in the scrotum (testicular mass)
Dull, aching scrotal pain usually on the left (left-sided varicoceles are 10 times more
common than right-sided)
Right-sided varicocele may point to a _____________________
Testicular atrophy on the affected side
Infertility is common varicoceles are present in 25% of infertile men vs. only 11% of
fertile men.
Color Doppler ultrasound shows retrograde flow to the scrotum
Impotence
7. W h at are the proper steps in the evaluation of a patient presenting with
erectile dysfunction?
History:
- Onset and duration
Symptoms of depression (SIG E CAPS)
Medication and drug use
Psychological stressors and interpersonal conflict
If dysfunction is situational (e.g., only with one particular partner)
Presence of nocturnal or early-morning erections (absent if organic cause, present if
psychogenic)
Physical exam components:
Anal tone (neuro dysfunction)
- Lower extremity sensation (neuro dysfunction)
Cremasteric reflex (neuro dysfunction)
Femoral and peripheral pulses (vasculogenic cause)
- Penis (Peyronie disease)
- Testes (hypogonadism)
- Secondary sexual characteristics (hypogonadism)
Visual fields (pituitary tumor)
- Gynecomastia (prolactinoma)
Serum lab tests: total testosterone, prolactin, TSH, +/- PSA
If vasculogenic >cardiac stress test to assess for cardiac endothelial damage as well
8. W h at medications are known for causing erectile dysfunction?
Most antidepressants, especially SSRIs

Spironolactone
Sympathetic blockers: clonidine, guanethidine, methyldopa
Thiazide diuretics, ^-blockers
Ketoconazole
Cimetidine (but not ranitidine or famotidine)
Antipsychotics
PART 2
MALE REPRODUCTION
9.
W h at are the available treatm ents for a patient with erectile dysfunction?
First-line: Phosphodiesterase inhibitors: sildenafil (Viagra), vardenafil (Levitra), tadalafil
(Cialis)
Second-line:
Penile self-injectable drugs: papaverine, phentolamine, alprostadil
Vacuum and constriction devices
Third-line: Penile prosthesis implantation
Other: Androgen replacement if hypogonadal
End of Session Quiz
[ 250] I
10.
W h a t is the treatment for epididymitis?
11.
W h at is the most common germ cell tum or o f the testis?
12.
W h a t lab work is included in the work-up for erectile dysfunction?
PEDI UROLOGY
1 "O
m
-
50
o1
o
o
3 Question Warm-Up
1.
W h ich type o f vasculitis fits the following descriptions?

Weak pulses in upper extremities
Necrotizing granulomas of lung and necrotizing glomerulonephritis
Necrotizing immune complex inflammation of visceral/renal vessels
Young male smokers
Young Asian women
Young asthmatics
2.
W h a t is the treatm ent for superior vena cava syndrome?
3.
W h a t tw o disorders should come to m ind when a neonate has meconium ileus?
4. W hat is the classic presentation of the most common renal tum or in children?
W ilm s tumor:
Most common age:__________________
Palpable flank mass (most common presenting symptom)
Abdominal pain (30%)
Hematuria (12-25%)
Hypertension (
Possibly multiple other associated congenital anomalies, including WAGR syndrome
- Wilms tumor
Aniridia
- GU abnormalities
- Retardation (mental)
PEDI UROLOGY
5. A t what age should nocturnal enuresis be treated? W hat are the treatment
options?
Enuresis cannot be diagnosed until 5 years of age (chronological and developmental)
Treatment is usually delayed until the child is at least 7 years of age
First-line: behavioral interventions:
Start toilet training if not yet attempted
Motivational therapy (e.g., star charts)
Restrict fluids before bed (with a compensatory increase in daytime fluids)
Nighttime chaperone to the toilet or scheduled wakening to void using alarm clock
Enuresis alarm (pad with alarm device) in bed for classic conditioning. This is most
effective long-term therapy
Second-line: pharmacologic interventions:
High likelihood of recurrence upon discontinuation
Imipramine for short term (up to 6 weeks)
Desmopressin (DDAVP) orally
Indomethacin suppository
End of Session Quiz
[252 ]
6.
W h a t is the most common physical finding/presenting symptom o f a child with

a W ilm s tumor?
7.
A 4-year-old boy is diagnosed w ith a U T I. W h a t study should be performed

next?
8.
W h a t are the recommended therapies for nocturnal enuresis?
9.
A male newborn has a distended palpable bladder and oliguria. W h a t is the

most common cause o f congenital urethral obstruction?
H eme/O nc
1
A nem ia p a rt 1
A nem ia p a rt 2
A nem ia p a rt 3
G enetic D isorders o f H em oglobin
L eukocyte D isorders & H ypersensitivity
T hrom bocytopenia
C oagulopathies and
H ypercoagulable States
H em atologic Infections
H IV
10 H IV T reatm en t
11 M yelom a and Lym phom a
12 L eukem ia
13 Pedi H em e /O n c
ANEMIA PART I
ANEMIA PART I
3 Question Warm-Up
1.
W h ich is more ethically unfavorable in a D N R patient: withdrawing lifesustaining care or withholding care?
2.
A 25-year-old m an is diagnosed w ith a solitary testicular mass by ultrasound.

W h a t is the next step in the management?
3.
W h a t are the classic findings o f Henoch-Schonlein purpura (HSP)?
4. W hat are the characteristic findings of hereditary spherocytosis?

Jaundice and gallstones
o
M C H C (mean corpuscular
Anemia with reticulocytosis and
hemoglobin concentration)
Higher incidence of pseudohyperkalemia as RBCs lyse after blood draw and intracellular
potassium leaks
Peripheral smear reveals _______________________
Positive osmotic fragility test
5. W h at is the treatm ent for hereditary spherocytosis?

Folic acid lm g daily
Red blood cell transfusions in cases of extreme anemia
o
____________ in moderate to severe disease
[255]
End of Session Quiz

6.
Increased body temperature, acidosis and exercise shift the hemoglobin-oxygen

dissociation curve in which direction? W h at effect does this have on oxygen
delivery to the tissues?
7.
W h a t is the cause o f anem ia th at develops after taking a sulfa drug?
8. W h a t lab markers suggest anemia due to hemolysis?
9.
In hemolytic anemia, why is the serum haptoglobin level decreased? W h y is

the serum lactate dehydrogenase (L D H ) increased?
ANEMIA PART 2
3 Question Warm-Up
1.
W h a t is the treatm ent for each o f the following diarrheal illnesses?

0 Entamoeba histolytica
Giardia lamblia
Salmonella
Shigella
Campylobacter
2.
W h a t is the treatm ent for m ild persistent asthma?
3.
W h a t is C harcots triad in cases o f cholangitis?
End of Session Quiz

4.
Com pare the serum iron, ferritin, and transferrin levels in iron deficiency
anemia to those in anemia o f chronic disease.
5.
A n elderly m an is in the office for evaluation o f fatigue and exertional shortness

o f breath. H e is fit for his age, but he says that he isnt able to be as active
recently. H e has no fever or symptoms suggesting infection. O n exam, his
conjunctivae are pale and a stool guaiac is positive. U ntil proven otherwise, this
patient should be considered as having w hat disease?
6.
W h a t would you see on a blood smear o f a patient w ith anemia due to lead
poisoning?
ANEMIA PART 3
3 Question Warm-Up
1.
A patient presents w ith hypertension, depression and kidney stones. W h a t is the

most likely underlying diagnosis?
2.
A n E G D with biopsy in a 65-year-old m an reveals gastric cancer. W h a t is the

next step in the management?
3.
W h a t are the signs and symptoms o f pyelonephritis?
End of Session Quiz

4.
W hich RBC disorder is associated w ith each o f the following findings:

Schistocytes (fragmented RBCs)
Acanthocyte (spur cell)
Bite cell
Basophilic stippling of RBCs
0 Peripheral neuropathy + ringed sideroblasts in bone marrow
Hypersegmented neutrophils
Heinz bodies (denatured Hgb in RBC)
5.
Given each o f the following presentations, provide the type o f anemia and
whether it is macro-, norm o- or microcytic:
Presentation
Anemia type
MCV
Mental status change, neuropathy,

constipation
Heavy menses, strict vegetarian,
ice pica
Dark urine, jaundice,
hepatosplenomegaly
Alcoholic, malnourished
6.
W h a t virus can cause aplastic anemia as well as erythem a infectiosum (fifth

disease)?
GENETIC DISORDERS OF HEMOGLOBIN
3 Question Warm-Up
1.
W h a t test is used to rule out urethral injury?
2.
A 19-year-old m an presents w ith a palpable flank mass and hematuria, and

renal ultrasound shows bilateral enlarged kidneys w ith cysts. W h a t brain
anomaly is associated w ith this condition?
3.
W h ich lipid-lowering agent matches each o f the following descriptions?

SE: Facial flushing
SE: Elevated LFTs, myositis
SE: G l discomfort, bad taste
Best effect on H D L
Best effect on triglycerides
Best effect on LDL/cholesterol
Binds C. diff. toxin
End of Session Quiz

4.
W h ich type o f thalassemia is m ost commonly associated w ith patients o f

M editerranean descent? W ith patients o f African or Asian descent?
5.
W h a t complication occurs in 10% o f patients w ith sideroblastic anemia?
6.
W h ich organism may be responsible for osteomyelitis in a sickle cell patient?
7.
W h ich vaccines are particularly im portant in children w ith sickle cell disease?
8. W hat medication is used in the long-term management of sickle cell anemia?
LEUKOCYTE DISORDERS AND HYPERSENSITIVITY
3 Question Warm-Up
1.
W h at drugs are known for causing elevated prolactin levels?
2.
W hat substances are known to cause hemolysis in patients with G 6PD

deficiency?
3.
W h at would you expect with eosinophilic casts found in the urine?
W hat is the differential diagnosis for serum eosinophilia?

D NAAACP
Drugs (NSAIDs, penicillins/cephalosporins)
Neoplasm
Allergies, asthma (Churg-Strauss), allergic bronchopulmonary aspergillosis
Adrenal insufficiency (Addison disease)
Acute interstitial nephritis
Collagen vascular disease (PAN, dermatomyositis)
Parasites (such as Strongyloides, and Ascaris * Loeffler eosinophilic pneumonitis)
(Other causes: HIV, hyper-IgE syndrome, hypereosinophilic syndrome,
coccidioidomycosis and numerous other potential causes)
W h a t is the treatm ent for anaphylaxis?
End of Session Quiz

6.
W h a t is the next step in the management o f a patient w ith febrile neutropenia

due to chemotherapy?
7.
W h ich type o f infection will cause an eosinophilia?
8.
W h ich immunoglobulin class is associated w ith eosinophilia?
9.
Goodpasture glomerulonephritis results from autoantibodies targeting the

glomerular basement membrane (GBM). W hich hypersensitivity reaction is
this, and how can it be treated?
10.
A patient presents w ith red marks on her ear lobes and left wrist, and is
ulti mately diagnosed w ith nickel allergy. W h a t type o f hypersensitivity reaction
is this?
11.
W h a t is the m ost im portant medication in the treatm ent o f anaphylaxis?
THROMBOCYTOPENIA
3 Question Warm-Up
1.
A 45-year-old man presents with acute-onset flank pain and hematuria. W hat
is the most likely etiology?
2.
W h a t is the most likely cause o f aortic stenosis in a 50-year-old patient?
3.
W hich type o f bias is introduced when screening detects a disease earlier and
thus lengthens the time from diagnosis to death?
W hat drugs are known for causing thrombocytopenia?
Heparin (H IT = heparin-induced thrombocytopenia), abtiximab (GP Ilb/IIIa inhibitor)

Carbamazepine, phenytoin, valproate
Cimetidine
Acyclovir, rifampin
Sulfonamides (e.g., sulfasalazine, TMP-SMX)
Procainamide, quinidine
Quinine, gold compounds
End of Session Quiz

5.
W h a t is the mechanism o f action o f each o f the following drugs?

0 Streptokinase
Aspirin
Clopidogrel
Abciximab
Tirofiban
Ticlopidine
Enoxaparin
Eptifibitide
6.
W h a t is the classic pentad for throm botic thrombocytopenic purpura
7.
W h a t lab test is used to monitor warfarin? Heparin? L M W H ?
COAGULOPATHIES AND HYPERCOAGULABLE STATES
COAGULOPATHIES AND HYPERCOAGULABLE STATES
3 Question Warm-Up
1.
You suspect your patient has gastric cancer. D uring the physical exam you
palpate in two places for enlarged lymph nodes associated with this disease.
W here will you palpate, and what are the names o f these enlarged nodes?
2.
A 2-year-old boy presents with painless rectal bleeding. W h a t diagnosis do you

suspect, and what study would you order to confirm the diagnosis?
3.
A patient tells you she does not want to know the result o f her recent lung
biopsy, but the family is begging you to tell them. To whom do you tell the
results?
4. W hat is the treatment for the most common inherited bleeding disorder?
von Willebrand factor deficiency treatments:
________________________(which increases vW F secretion) is first-line for acute
bleeding
Cryoprecipitate or Factor VIII concentrates for severe or refractory bleeding
0 ________________________for menorrhagia
Avoid________________________ and other platelet inhibitors
5. W hat are the most common causes of DIC?
W h a t are the inherited diseases of hypercoagulation?
------------------------------Antithrombin deficiency
Protein C deficiency
Protein S deficiency
most common (40-50%)
Prothrombin gene mutation (prothrombin G20210A)

Hyperhomocysteinemia (M TH FR gene mutation)
Rarer disorders: dysfibrinogenemia, plasminogen deficiency
End of Session Quiz

7.
W h a t lab changes would you see in each o f the following diseases?
Disorder
Platelet
Count
Bleeding
Time
PT
PT T
H U S o rT T P
Hemophilia A or B
von W illebrand disease
D IC
W arfarin use
End stage liver disease
Aspirin use
8.
W h a t is the treatm ent for von W illebrand disease?
9.
W h a t are th e m ost com m on causes o f D IC?
10.
W h a t is th e m ost com m on m utation th a t predisposes to venous throm bosis

in w hite patients?
HEMATOLOGIC INFECTIONS
HEMATOLOGIC INFECTIONS
3 Question Warm-Up
1.
A post-op patient has poor urine output, a BUN o f 85, creatinine o f 3, and clear
lungs. W h a t is the next step in the management o f this patient?
2.
W h at infection causes aplastic crisis in sickle cell patients?
3.
A patient presents w ith glomerulonephritis plus bilateral sensorineural deafness.

4. W hat is the treatment for infectious mononucleosis?
0
0
There is no antiviral medication available for mononucleosis (acyclovir is of no benefit)

NSAIDs or acetaminophen for fever, sore throat, malaise
Encourage rest and plenty of fluids
Return to sport (risk of splenic rupture):
May return gradually to noncontact sports 3 weeks after symptom onset

May return gradually to contact sports 4 weeks after symptom onset
Steroids only helpful if impending airway compromise due to enlarged tonsils or if
life-threatening sequelae develop (e.g., fulminant liver failure, hemolytic anemia,
thrombocytopenia)
2661
End of Session Quiz

5.
A 63-year-old obese wom an w ith uncontrolled diabetes undergoes an

emergency laparotomy to repair a perforated duodenal ulcer. A fter her surgical
procedure, she is taken to the IC U intubated and on a ventilator, w ith both an
arterial line and a right subclavian central line. Post-op H gb is 12 g/dL. The
surgical IC U resident is tasked w ith her continued care. As o f now, the patient s
blood pressure is 106/58 m m H g w ith a heart rate in the 140s. H er temperature
is 96.5F. W h a t treatm ent is necessary for this patient at this point?
6.
W h a t are the criteria for the diagnosis o f SIRS?
7.
A m an returns from a safari in Africa and now has periodic fevers, chills,
diaphoresis, muscle aches and fatigue. H ow could this m an have avoided this
illness?
HIV
HIV
3 Question Warm-Up
1.
W hat is the classic (but rare) EK G finding in pulmonary embolism?
2.
A post-op patient w ith significant pain presents with hyponatremia and normal
volume status. W h a t is the diagnosis?
3.
W h a t is the treatment for mild unconjugated hyperbilirubinemia in a neonate?

Severe unconjugated hyperbilirubinemia in a neonate?
End of Session Quiz

4.
A n HIV-positive patient is seen in the E R w ith shortness o f breath. H e reports

that over the past few weeks it has become increasingly difficult to breathe
when exerting himself. H e has a cough, fever, and you notice white plaques
on the tongue and visualized pharynx. H e also admits to having pain with
swallowing. You fear this patients disease has advanced, so you order a C D 4
count. W h a t do you expect the C D 4 count to be?
5.
A 39-year-old male H IV patient receives a head C T for headache and

new-onset confusion and slurring o f words. The imaging reveals
ring-enhancing lesions. W h a t infection is suspected in this person?
W h a t lab test would support the diagnosis?
6.
W h a t is the rate o f transmission o f H IV through a needle stick incident? W hat

drugs should be given in case there is appreciable risk o f transmission o f H IV in
this setting?
HIV TREATMENT
3 Question Warm-Up
1.
W h a t is the tum or marker for each o f the following?

Hepatocellular carcinoma
Colon cancer
0 Gastric cancer
Pancreatic cancer
0 Ovarian cancer
2.
A patient w ith sickle cell disease presents w ith pain in the right tibia, and
investigation reveals osteomyelitis. W h a t is the most likely causative organism?
3.
W h a t does an odds ratio estimate in the case o f a disease w ith low prevalence?
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End of Session Quiz

5.
A 25-year-old m an is diagnosed with H IV and m ust begin a H A A R T

regimen. W h a t classes o f drugs should his regimen include initially?
6.
W h ich antiretroviral class matches each o f the following statements?

SE: lactic acidosis
SE: GI intolerance
SE: rash
SE: hyperglycemia, diabetes mellitus, and lipid abnormalities
7.
W h ich antiretroviral matches each o f the following statements?

SE: bone marrow suppression with megaloblastic anemia
SE: potentially fatal hypersensitivity reaction
SE: neurophychiatric symptoms (depression and vivid nightmares)
SE: hyberbilirubinemia, jaundice
SE: teratogenic, should not be given to women of childbearing age off of
contraceptives
SE: inhibits cytochrome P450, used to boost other drugs
MYELOMA AND LYMPHOMA
MYELOMAAND LYMPHOMA
3 Question Warm-Up
1.
W hat is the most common cause o f aortic stenosis in a 70-year-old patient?
2.
W hich of the following are elevated in DIC: fibrin split products, D-dimer,
fibrinogen, platelets, and hematocrit?
3.
W hich type of renal tubular acidosis (RTA) is associated with abnormal H +

secretion and nephrolithiasis?
Polycythemia Vera
4. W hat is the classic presentation of polycythemia vera?
Most signs and symptoms are related to hyperviscosity causing vascular sludging.
Average age of onset 50-60 years (but children and young adults can be affected as well)
Visual disturbances blurred vision, amaurosis fugax, scintillating scotoma, ophthalmic
migraine
____________________(15%) - stroke, M I or angina, claudication, DVT or PE, BuddChiari syndrome, superficial thrombophlebitis
Erythromelalgia _______________________________ with erythema, pallor or
cyanosis
____________________(especially after a warm bath)
O
O
Elevated H & H and red cell mass, basophilia, leukocytosis (40%), thrombocytosis (60%)
5. W hat is the treatment for polycythemia vera?

Phlebotomy to keep hematocrit below 45% in men, 42% in women
Induces a desirable iron deficiency anemia > do not supplement iron!
A dd___________________ if at high risk for thrombosis (over age 70, prior thrombosis,
platelets >1,500,000, or presence of cardiovascular risk factors)
___________________ every day to help prevent thrombosis (MI, CVA, PE, DVT)
If refractory pruritus or refractory erythrocytosis >___________________
If symptomatic hyperuricemia allopurinol 300mg every day
[ 272 ]
End of Session Quiz

6.
A 66-year-old woman fractures her hip after falling from standing.

Radiographs reveal punched out lesions in the vertebrae, hips and femurs.
The patient says th at she has had increasing back pain, weakness and fatigue,
but she has attributed all o f that to aging. Labs show anemia, hypercalcemia,
and increased B U N and creatinine. W h a t studies would help to make the
diagnosis, and what would you expect to see?
7.
A 21-year-old male patient presents w ith recent weight loss, pruritus and night
sweats. Physical exam reveals hepatosplenomegaly and a nontender cervical
lymphadenopathy. W h a t do you immediately suspect?
8.
W h ich blood cell pathology matches each o f the following high-yield

descriptions?
Associated w ith Epstein-Barr virus
(in Africa)
Reed-Sternberg cells, cervical
lymphadenopathy, night sweats
Bence-Jones proteins, osteolytic
lesions, high calcium
Translocation 14;18
M ost common lymphoma in the US
Translocation 8;14
M ost common form of Hodgkin
lymphoma
Starry-sky pattern due to
phagocytosis o f apoptotic tumor
cells
H igh hematocrit/hemoglobin,
pruritus (especially after hot bath
or shower), burning pain in hands
or feet
LEUKEMIA
LEUKEMIA
3 Question Warm-Up
i 274 |
1.
A n elderly man is seen in the E R w ith a chief complaint o f headache. Further

questioning reveals that since the weather has turned cold and he had to begin
using his kerosine heater, he has felt fatigued and a little nauseated along with
the headache. O n physical exam, the mans lips seem remarkably red. W h at do
you expect the pulse ox to show? H ow will you treat this man?
2.
A 3-year-old girl presents w ith an abdom inal mass, hem aturia and
hypertension. W h a t is the m ost likely diagnosis?
3.
A recent C uban im m igrant with symptoms o f malabsorption is found to also

have megaloblastic anemia. W h a t is the disease and treatment?
End of Session Quiz

4.
W h a t type o f leukemia matches each o f the following descriptions?

Most common neoplasm in children (peak age 3-4 years)
Most common leukemia in adults (average age of onset SO years)
Philadelphia chromosome is almost always seen
Smudge cells on peripheral smear
Peripheral blasts are PAS (+) and TdT (+)
Peripheral blasts are PAS (-), myeloperoxidase (+) and have Auer rods
Pancytopenia in a Down syndrome patient
Associated with translocation 9;22
W hite cells with hair-like projections
5.
W h a t medication is associated w ith remission in 95% o f patients w ith CM L?
6.
The peripheral smear o f an asymptomatic patient reveals macrocytosis and

hypogranular granulocytes w ith bilobed nuclei. W h a t is the diagnosis?
PEDI HEME/ONC
PEDI HEME/ONC
3 Question Warm-Up
1.
W hat is the definition of maternal mortality?
2.
W hich type of lung cancer is associated with each of the following paraneoplastic
syndromes?
3.
[ 276 ]
Elevated ACTH glucocorticoid excess > Cushing syndrome

Elevated PTH-related peptide >hypercalcemia
Elevated ADH * SIADH > hyponatremia
Antibodies to presynaptic Ca2* channels > Lambert-Eaton syndrome
W hat disease causes glomerulonephritis with deafness?
4.
A 5-year-old boy is brought in w ith a swollen leg. The child has not had any
recent traum a according to the parents, and the physical exam confirms that.
However, the swollen area is actually a mass that seems embedded within the
vastus medialis o f the right thigh. W h a t is the next step in the management?
5.
W h a t is the m ost common adrenal tum or in children? W h a t lab studies can be

used to diagnose this?
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6.
A 4-year-old girl is brought into the county clinic w ith an upper respiratory
infection (U R I). The m other reports th at this child seems to get sick more
often th an her friends kids o f the same age. Physical exam is remarkable for
dangling thum bs, short stature, and hypopigmentation o f some skin areas.
Labs reveal a pancytopenia. W h a t is the likely diagnosis?
7.
A 3-m onth-old child is brought to the office w ith difficulty breathing, fatigue
and pallor. H e has a heart m urm ur and abnormal thumbs. Labs are as follows:
Hgb
4 g/dL
H ct
12%
W BC
8,000 per pL
Platelets
300,000 per pL
M CV
99 fL
PEDI HEM E/ONC
End of Session Quiz
W h a t is the diagnosis? W h a t would you expect the level o f erythropoietin to be?
[ 277]
Musculoskeletal
1
O rthop ed ics p a rt 1
O rthop ed ics p a rt 2
M etabolic Bone Diseases
Infections, O A and Neoplasm s
R A and Lupus
O th e r R heum atologic Diseases
Pedi O rth o
ORTHOPEDICS PART I
3 Question Warm-Up
1.
A n elderly woman w ith a history o f cholelithiasis presents w ith a 5-day history

o f vague intermittent abdominal pain and vomiting. W h a t diagnosis do you
immediately suspect?
2.
A 60-year-old w om an leaks urine w hen laughing or coughing. W h a t are

her nonsurgical options?
3.
W h a t is the late, life-threatening complication o f chronic myelogenous

leukemia (CM L)?
Dislocations
4.
How does an anterior shoulder dislocation present differently than a posterior

shoulder dislocation?
A rm position
Neurovascular
compromise
Anterior Shoulder
Dislocation
Posterior Shoulder
Dislocation
External rotation and slight

abduction
Internal rotation and

adduction
Unable to externally rotate
artery and nerve
Unusual
at risk
Classic
scenario
Blow to abducted, externally

rotated, extended arm (blocking a
basketball shot)
Blow to anterior shoulder

and
electrocution
Physical exam
Prominent acromion (if thin

patient) and loss of shoulder
roundness
Posterior prominence and

anterior shoulder is flat
ORTHOPEDICS PART
Fractures
5. W hat nerve is damaged when a patient presents with each of the following
symptoms?
Claw hand
Ape hand
Wrist drop
Scapular winging
Unable to wipe bottom
Loss of forearm pronation

Cannot abduct or adduct fingers
Loss of shoulder abduction
Weak external rotation of arm
Loss of elbow flexion and forearm supination
Loss of wrist extension

Trouble initiating shoulder abduction
Unable to abduct arm beyond 10 degrees
Unable to raise arm above horizontal
6. W hat nerve is most at risk of injury with the following types of injury?
Fracture of the shaft of the humerus

Fracture of the surgical neck of the humerus
Supracondylar humerus fracture
Fracture of the medial epicondyle
Anterior shoulder dislocation
Injury to the carpal tunnel
End of Session Quiz

7.
8.
W h a t are the classic symptoms o f carpal tunnel syndrome?
1
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W h a t is the difference between a M onteggia fracture and a Galeazzi fracture?
r~
9.
W h a t complications should you look for w ith the following types o f

fracture/injury?
Fall on outstretched arm > snuffbox tenderness
A nterior shoulder dislocation
Fracture of the 5th metacarpal neck
Humerus fracture
H ip fracture
Femur fracture
Tibial fracture
Pelvic fracture
I [ 283 ]
ORTHOPEDICS PART 2
3 Question Warm-Up
1.
W hat infections are classically associated with cold agglutinins?
2.
W hat is the most likely cause o f secondary hypertension given the following
findings?
Hypertension measured in the arms but low BP in the LE
Proteinuria
Hypokalemia
Tachycardia, diarrhea, heat intolerance
Hyperkalemia
Episodic sweating, tachycardia
3.
W hat is the cause o f erythroblastosis fetalis?
W hat type of knee injury matches each of the following statements?
Most commonly injured knee ligament

Positive Lachman test
Positive McMurray test aids in diagnosis
Common dashboard knee injury in an MVA
W hat are the characteristic features of com partm ent syndrome?
Earliest sign: pain in excess of what is expected and occurs even with passive motion
6 Ps:________________________________________________________
Measured compartment pressures > _____________ mmHg
Most common compartments: volar compartment of forearm, anterior compartment of leg
Most commonly due to fractures (supracondylar humerus, both-bone forearm, proximal tibia)
End of Session Quiz

6.
H ow is com partm ent syndrome diagnosed?
7.
W h a t is the treatm ent for com partment syndrome?
0
TO
H
1
o~o
m
u
n
CO
"0
>
TO
W h a t is the cause o f low back pain given the following hints at presentation?
Pain increases with passive straight leg raise
Pain lessens with flexion at the hips (e.g., bending over shopping cart)
Elderly, weight loss, pain constant but worse when supine
Acute urinary retention
Pain made worse by walking and standing (AKA pseudoclaudication)
o Loss of foot dorsiflexion and pain on crossed straight leg raise
Pain limited to the paraspinal region
[ 285 ]
METABOLIC BONE DISEASES
[286 ] I
METABOLIC BONE DISEASES
3 Question Warm-Up
1.
A 4-week-old child presents with non-bilious vomiting despite changing from

milk-based formula to soy-based formula. W h a t is the most likely etiology?
2.
W hich type o f vasculitis fits the following descriptions?

Infants and young children; involved coronary arteries
Most common vasculitis
Associated with hepatitis B infection
Occlusion of ophthalmic artery can lead to blindness
Perforation of nasal septum
Unilateral headache, jaw claudication
3.
W h a t are the four main causes o f microcytic anemia?
f ill
End of Session Quiz

4.
W h a t medications are used in the treatment o f acute gout? Pseudogout?
5.
Com pare P T H , alkaline phosphatase, serum calcium and serum phosphate

Serum
C a 2+
Serum
Phos
A ik
Phos
PTH
Paget Disease
Osteomalacia/rickets
Osteoporosis
Osteopetrosis
Primary
hyperparathyroidism
Hypoparathyroidism
6.
W h ich disease matches each o f the following descriptions?

Knee x-ray reveals calcification of the menisci
Needle-shaped, negatively birefringent crystals
Child with low-trauma fractures
Narrowing of the marrow cavity results in low H & H
55-year-old woman that trips and sustains a distal radius fracture
7.
A 6-year-old girl is brought to the childrens E R for suspected broken bone

in the forearm after the child fell while running around the backyard. The
parents tell you th at this is the patients third fracture. The patient doesnt seem
to respond to questioning, to w hich the parents inform you that she is hard
o f hearing. W ith this clue, you check the patients eyes to help confirm your
diagnosis. W h a t are you looking for? I f this diagnosis is correct, how can it be
treated?
8.
A 60-year-old m an is in the clinic for a checkup. H e is a new patient and you

notice th at his legs are bowed out. H e also is bent forward w ith kyphosis and is
hard o f hearing. H e has no complaints besides his favorite hat not seeming to
fit anymore. H e claims that it feels smaller. W h a t imaging is most sensitive to
diagnose this process?
INFECTIO NS, OA AND NEOPLASMS
INFECTIONS, OA AND NEOPLASMS
3 Question Warm-Up
1.
W h at are the signs suggesting radial nerve damage with a humeral fracture?
2.
A patient presents to the clinic for follow-up and is found to have a blood
pressure o f 150/85. You note in the chart that during his last visit one month
ago, his blood pressure was 145/90. W h at is the next step in the management
o f this patient?
3. W h a t is the most common testicular cancer?
4. W hat is the classic presentation and clinical course of Lyme disease?

Early localized disease 80% of patients, usually within 1 month
Erythema chronicum migrans - bulls eye rash with central clearing that expands over
days to weeks
+/- constitutional symptoms (fatigue, headache, myalgias, arthralgias,...)
0 Early disseminated disease - weeks to months after the tick bite, may include any of the
following:
Meningitis (lymphocytic)
Unilateral or bilateral cranial nerve palsies (esp. of the facial nerve > "bilateral Bells
palsy)
Radiculopathy
Peripheral neuropathy
- Carditis (AV heart block, myopericarditis)
Late Lyme disease - months to years after infection onset
Arthritis (esp. knee)
Subacute encephalitis
5. W hat is the treatment for Lyme disease? W hat is the treatment for Rocky
Mountain Spotted Fever?
Early Lyme disease treatment options (14-21 days):
___________________________________ lOOmg PO bid (preferred agent, can be
dosed over only 14 days, avoid in pregnancy)
Amoxicillin 500mg PO tid
Cefuroxime 500mg PO bid
Late Lyme disease (carditis, encephalitis, arthritis) >usually Ceftriaxone 2g IV q24
hours x 14-28 days
0 Rocky Mountain Spotted Fever treatment options:
Doxycycline lOOmg PO bid x7 days
Chloramphenicol 50mg/kg daily divided in four doses in pregnant patients
End of Session Quiz

6.
In cases o f an unhelpful x-ray and unavailable M R I, w hat 3 studies can be used

to make the diagnosis o f osteomyelitis?
m
n
H
O
z
o>
>
7.
W h a t is the treatm ent for Lyme disease? For Rocky M ountain Spotted Fever?
8.
W h a t is the empiric treatm ent for septic arthritis?
9.
W h a t are the m ost common causes o f bony metastasis?
10.
W h a t is the classic radiological appearance o f osteosarcoma? O f Ewing

sarcoma?
11.
A patient presents w ith bone tenderness, and is found to have elevated W B C

count, CRP, and ESR. W h a t is the most likely diagnosis?
12.
W h a t is the m ost common organism in osteomyelitis overall? W h a t organism

should also be kept in m ind for sickle cell patients? W h a t organism should also
be kept in m ind for IV drug users?
z
a
z
m
o
[ 289 ]
RAAND LUPUS
3 Question Warm-Up
1.
W hich glomerular disease would you suspect most in a patient with the
following findings?
Most common nephrotic syndrome in children
Most common nephrotic syndrome in adults
Kimmelstiel-Wilson lesions (nodular glomerulosclerosis)
LM: crescent formation in the glomeruli
o LM: segmental sclerosis and hyalinosis
Anti-GBM antibodies, hematuria, hemoptysis
Nephrotic syndrome associated with hepatitis B
Nephrotic syndrome associated with HIV
2.
Positive p-A N C A is associated with what conditions?
3.
A husband asks that his wife (your patient) not be told about her recentlydiscovered lung cancer. W h a t should you do?
W hat are the diagnostic criteria for rheumatoid arthritis?

(Arthritis Rheum 2010; 62:2569)
Synovitis in at least 1 joint, not better explained by another disease, plus a total score of
> 6/10 (add score of categories A-D below):
A. Joint involement
2-10 large joints = I point
1-3 small joints (with or without large joints) = 2 points
4-10 small joints (with or without large joints) = 3 points
>10 joints (at least I small joint) = 5 points
B. Serology
Low positive RF or ACPA = 2 points
High positive RF or ACPA = 3 points
C. Abnormal CRP or ESR = 1 point
D. Duration of symptoms > 6 weeks = 1 point
W hat medications are considered first-line treatments for rheumatoid

arthritis?
Disease-modifying anti-rheumatic drugs (DMARDs)
O
Sulfasalazine
O
_______________ inhibitors
- Etanercept
Adalimumab
Golimumab
Certolizumab
Infliximab
Leflunomide
Anakinra
Steroids or N SAID s (ibuprofen 800mg qid, naproxen 500mg bid, celecoxib lOOmg bid)
are only used as adjuncts
End of Session Quiz

6.
W h a t disease should you include in your differential with arthropathy o f the

following joints?
D IP and PIP
PIP and M CP (but not DIP)
7.
W h a t factors tend to elicit joint pain and stiffness in RA? W h a t factors tend to
relieve pain/stiffness? H ow does this differ from the pattern seen in OA?
8.
W h a t disease is associated w ith each o f the following serologic markers?
Marker
Disease
Anti-histone antibodies
Rheumatoid factor
A nti-dsD N A antibodies
Anti-Sm antibodies
HLA -D R4
9.
W hat are the 4 skin findings that are diagnostic criteria for SLE?
OTHER RHEUMATOLOGIC DISEASES
3 Question Warm-Up
1.
W h at lab changes would you see in the following diseases?
Disorder
Platelet
Count
Bleeding
Time
PT
PTT
HUS or T T P
Hemophilia A or B
von Willebrand disease
DIC
Warfarin use
End stage liver disease
Aspirin use
2.
W h a t type o f acute renal failure would you suspect in a patient w ith FE N a

<1%?
3.
B oth folate deficiency and vitamin B., deficiency can result in a megaloblastic
anemia. H ow can they be differentiated clinically?
W hat is the classic presentation of dermatomyositis?

Rash features
Heliotropic (periorbital) red-purple rash
Shawl sign rash involving the shoulders, upper chest and back that is worsened by UV
light exposure
Gottrons papules - papular rash with scales on the dorsum of the hands at the bony
prominences (may be mistaken for psoriasis)
Erythroderma of the malar region and forehead
Mechanics hands - roughened, cracking skin on the tips and lateral aspects of the
fingers
Polymyositis features
Symmetric proximal muscle weakness
Myalgias and muscle tenderness in 25-50% of patients
W hat is the treatm ent for fibromyalgia?

Non-pharmacological treatment options
Reassurance - that it is a real illness that is benign, not life-threatening, and not deforming
Walking, strength training, and stretching daily (Archives of Internal Medicine
2007;167:2192)
Relaxation techniques
Stress reduction programs
Encourage journaling and emotional writing of past traumatic experiences.
Sleep appropriately address any sleep hygiene issues
Address any other psychiatric disorders: depression, anxiety, PTSD
Pharmacological treatment options
Elavil (amitriptyline) or nortriptyline 25-50mg qHS > improvement in 25-45% of
patients
Tylenol 650mg + Ultram 75mg QID > 50% pain reduction
Pregabalin (Lyrica) (FDA-approved for fibromyalgia June 2007)
Duloxetine (Cymbalta) (FDA-approved for fibromyalgia June 2008)
Fluoxetine 20-80mg qAM (+/- Elavil qHS)
Milnacipran (FDA-approved for fibromyalgia Jan 2009)
6.
73
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o
O
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o
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m
>
How is the diagnosis of C R E S T scleroderm a (A K A limited cutaneous systemic

sclerosis) made?
The diagnosis is primarily clinical, but lab studies can support the clinical diagnosis.
Calcinosis cutis - subQcalcifications often in the fingers, not always present
Raynaud phenomenon - cyanotic vasoconstriction especially in the fingers
Esophageal dysmotility due to lower esophageal sphincter sclerosis >reflux, dysphagia
Sclerodactyly skin fibrosis especially at the fingers, hands and face
Telangiectasias on the Up, hand or face; not always present
Labs: anti-Scl-70, anti-RNA, anti-Ul RNP, anti-centromere (Lab work can support the
diagnosis, but cannot rule out scleroderma.)
I [ 293 ]
OTHER RHEUMATOLOGIC DISEASES
End of Session Quiz

7.
A 65-year-old African American woman is evaluated for weakness. H ie patient

has been an active person but now has weakness in her lower extremities. O n
exam, both are equally weak. She also has a rash on the chest. W hat labs would
be helpful to order initially?
8.
A 67-year-old woman complains of pain in her extremities, especially in the

shoulders and hips. It is hard for her to even get out of bed. ESR is markedly
elevated. W hat is the treatment?
9.
W hat serious disease must you look out for in patients with polymyalgia
rheumatica?
10. W hich rheumatologic disease matches each o f the following descriptions?

Proximal muscle weakness and facial rash
Pain and stiffness in the hips and shoulders
o Muscle pain and tenderness in multiple distinct locations
Man in his 20s with low back pain that improves with exercise
0 Jaw claudication and pain with standing from a chair
Pencil-in-cup deformities of the DIP and PIP joints
Bamboo spine on x-ray
Arthritis + oral ulcers + proteinuria
11. W h a t are the seronegative H LA -B27 spondyloarthropathies?
O
73
HI
X
3 Question Warm-Up
1.
W h a t are the four potassium-sparing diuretics?
2.
Low urine specific gravity in the presence o f high serum osmolality. W h a t is

the diagnosis?
3.
W h a t is the diagnostic test for hereditary spherocytosis?
4. W hich infants should be screened for developmental dysplasia of the hip?

Obtain hip sonogram at 6 weeks if:
5. W hat is the treatm ent for slipped capital femoral epiphysis?

Bedrest
Avoid weight bearing, crutches and/or wheelchair until surgically repaired
Prompt surgical pinning of the head of the femur
If acute/unstable > admit to hospital for surgical treatment
If chronic/stable urgent outpatient evaluation
Closed reduction of acute slips prior to pinning is controversial
6. W hat is the recommendation for the amount of vitamin D supplementation

for infants?
All children (including breastfed infants) should receive vitamin D supplementation of
400 IU daily starting th e __________________________________
[295]
MUSCULOSKELETAL
PEDI ORTHO
PEDI ORTHO
7.
W hat is the treatment for juvenile idiopathic arthritis?

NSAIDs are the drugs of choice
If unresponsive to a trial of two different NSAIDs over at least six weeks, then
second-line is____________________ o r____________________
8. W hat are the characteristic features for Osgood-Schlatter disease?

Most common symptom is_____________________________ that increases over time
and is worsened by quadriceps contraction (running, jumping)
Signs at th e_____________________________ may include soft tissue swelling,
a palpable bony mass and/or pain upon quadriceps flexion
9. W hat is the treatment for Osgood-Schlatter disease?

Can continue sports despite pain
Rehabilitation:
Stretching the hamstrings and quadriceps
Strengthening the quadriceps
Osgood-Schlatter pad - protective pad over the tibial tuberosity
Ice to the affected area after activities
NSAIDs for pain
Knee immobilizers are contraindicated
10. W hat is the treatm ent for a clavicle fracture in a newborn?

No treatment needed (not necessary to immobilize by pinning the shirt)
Evaluate for brachial plexus injury
11. W hat is the treatm ent for a mid-third clavicle fracture?

Figure-of-eight strap and/or arm sling until fracture site and range of motion are painless
(usually 4-8 weeks)
Follow-up in 1-2 weeks, then every 2-3 weeks until asymptomatic (adults: usually 6-12
weeks, children: 3-6 weeks)
Repeat x-ray at 6 weeks and upon clinical healing
Orthopedic consult if nonunion after 12 weeks
Rehabilitation:
Elbow range of motion (ROM) exercises starting day I
Shoulder ROM exercises after immobilization
12* W hat is the treatment for nursemaids elbow?

D
O
73
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X
13. W hat is the treatm ent for Legg-Calve-Perthes disease?

0 Non-weight bearing on the affected side for an extended period of time
0 If limited femoral head involvement and full RO M :
Observation
0 If extensive femoral head involvement or limited RO M :

Bracing
Hip abduction with a Petrie cast
Osteotomy
14. W hat is the classic presentation of childhood spondylolisthesis?

0 Anterior slip of a vertebra resulting in a palpable step-off on physical exam (usually L5 over
S I)
0 Subacute back pain exacerbated by hyperextension of the spine

0 Knee-flexed, hip-flexed gait in cases where the sacrum becomes relatively more vertical
and hip extension is impaired
0 Possible neurological dysfunction including urinary incontinence (very rare)
[297]
MUSCULOSKELETAL
Reduce by gently flexing and.

the arm with one hand while
supporting the elbow and applying gentle pressure to the radial head with the other hand
Give the child a popsicle that they can eat only by using the recently reduced arm to
encourage movement and confirm successful treatment
No need to immobilize
PEDI ORTHO
End of Session Quiz

15.
16.
W hat is the treatment for developmental dysplasia o f the hip in children younger
than 6 months o f age?
W hat is the treatment for slipped capital femoral epiphysis?
17. W hat is the treatment for Osgood-Schlatter disease?
18. W h at disease is responsible for a painful limp in a child in each of the following
scenarios?
Scenario/Finding
X-ray reveals femoral head sclerosis
X-ray reveals ice cream scoop (femoral head)
falling off of cone (femur)
Obese, male adolescent with dull hip pain
and inability to bear weight
Acute onset of tibial pain, fever, malaise,
elevated ESR, no joint pain
Acute onset of knee pain, fever, elevated
ESR, leukocytosis
7-year-old with growth delay and inner thigh
pain
13-year-old boy with pain and swelling at the
tibial tuberosity
19. W h a t is the treatment o f nursemaid s elbow?
D isease
D ermatology
1
Infections p a rt 1
Infections p a rt 2
Infections p a rt 3
Inflam m atory Skin C onditions
Bullous D iseases and N eoplasm s
Plastics, P igm entation and H a ir Loss
INFECTIONS PART I
3 Question Warm-Up
1.
W h ich vaccines should not be given to an HIV-positive patient?
2.
W h a t is the treatm ent for T T P ?
3.
C om pare the serum iron, ferritin and transferrin levels in iron deficiency (IDA)
to anemia o f chronic disease (AOCD).
Serum iron
Ferritin
Transferrin
ID A
AOCD
4.
Com plete the table:
Definition
Examples
Flat spot less than 1 cm

(non-palpable, just visible)
Freckles, tattoos
Flat spot > 1 cm
Port-wine stain
Solid, elevated lesion < 1 cm

(palpable)
W art, acne, lichen

planus
Same as papule but > 1 cm

and flat-topped
Psoriasis
Palpable, solid lesion > 1 cm

and not flat-topped
Small lipoma,
erythema nodosum
Elevated, circumscribed
lesion < 5 mm containing
clear fluid (small blister)
Chickenpox, genital
herpes
Same as vesicle but > 5 mm

(large blister)
Contact dermatitis,
pemphigus
Itchy, transiently edematous

area
Allergic reaction
Term
n
H
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!>
INFECTIONS PART I
5.
Describe the proper treatment for skin abscesses.

Incision and drainage (I&D) if overt clinical abscess or proven by sono or CT
If at risk for endocarditis, then antimicrobial prophylaxis prior to l&D (e.g., vancomycin
or TMP-SMX)
Culture in aerobic and anaerobic tubes. Ideally anaerobic sample is obtained via needle
aspiration to avoid air exposure
Surgery consult for I&D in OR when abscess is particularly large or in a sensitive area
No antibiotic therapy needed if < 5cm and low-risk patient
Antibiotics for 10-14 days for presumed community-acquired MRSA
Bactrim DS + rifampin
Clindamycin (may have inducible resistance) + rifampin
Minocycline (or doxycycline) + rifampin
Linezolid ($$$)
6. W hat are some of the distinguishing characteristics of necrotizing fasciitis?
Unexplained, excruciating pain in the absence of or beyond areas of cellulitis

Erythema with blister and bullae formation and possible crepitus
Diabetes patient with foot cellulitis and signs of systemic toxicity
Perineal cellulitis with abrupt onset and rapid spread (Fournier gangrene)
7. W hat is the general treatment for necrotizing fasciitis?

Immediate, extensive surgical debridement
Antibiotics:
General empiric polymicrobial coverage - imipenem (or meropenem) +/- vancomycin
If Streptococci penicillin G +/- clindamycin
If Clostridia - penicillin G + clindamycin
Treatment for shock if it arises (IV fluids, dopamine)
8. W hat are the distinguishing characteristics of gangrene?

Wet gangrene - bruised, swollen, blistered with pus
Dry gangrene
Early signs - ache, cold, pallor
Late signs bluish-black, dry, hard, shriveled tissue
Gas gangrene
Early signs - pain and swelling around an injury site (often surgical incision)
Classic signs initially pale, then dark purplish-red, tense, tender, with soft-tissue crepitus
Signs of systemic toxicity - tachycardia, low-grade fever; diaphoresis +/- shock and
multisystem organ failure
9.
W hat is the treatm ent for a limb with dry gangrene?

Autoamputation over time
Angiography to evaluate the extent and location of peripheral artery disease > distal
bypass of stenotic areas >if circulation improves and healing is adequate, then
amputation of the affected region
10. W hat is the treatm ent for a wet gangrene infection?
[ 302 ] |
Emergency debridement or guillotine amputation of the infected portion of the foot, then
revision to a below or above the knee amputation 72 hours later
Antibiotics are indicated if cellulitis or gas gangrene is present
End of Session Quiz

11. A patient is admitted to the IC U for fluid resuscitation and monitoring following
trauma with significant blood loss. A central line that was inserted into the
right groin emergently in the E R has been in place for a few days, and now the
surrounding skin is red and warm. Also, the patients temperature is rising, and the
W B C count is elevated. W h at is the likely cause?
12. A 44-year-old African-American woman is in the office for evaluation o f an area

o f inflammation in her left axilla. She said that initially the area was simply itchy,
but has now become painful. O n exam, the area has about six papules and nodules
that are erythematous, indurated and warm. The skin is fluctuant, and drainage is
noted at some o f the lesions. H ow will this patient need to be treated?
13. W h a t are the characteristic features o f necrotizing fasciitis?
14. W h a t is the treatm ent for dry gangrene? W h a t is the treatment for wet
gangrene?
15. A 66-year-old m an w ith longstanding, poorly-controlled diabetes arrives at

the E R complaining o f a horrid smell coming from his left foot. H e denies
pain, b u t admits to having lost the feeling in his feet a long tim e ago from the
diabetes. O n exam, there is an open wound between the 1st and 2nd toe on the
left foot. Pus drains from the w ound and some crepitus is felt in the area. The
odor is atrocious. The patient is tachycardic and feverish. W h a t treatm ent does
he need?
16. A 7-year-old boy is brought to the county clinic w ith a rash. The m other denies
th at the child has acted ill. The exam is unremarkable besides perioral honeycrusted lesions and regional lymphadenopathy. W h a t can be used to treat this
patient?
INFECTIONS PART 2
3 Question Warm-Up
1.
W hich glomerular disease would you suspect most in a patient w ith the
following findings?
IF: granular pattern of immune complex deposition; LM: hypercellular glomeruli
IF: linear pattern of immune complex deposition
EM: loss of epithelial foot processes
EM: subendothelial humps and tram-track appearance
o Nephritis, deafness, cataracts
Purpura on the back of the arms and legs, abdominal pain, IgA nephropathy
Anti-dsDNA antibodies
2.
A patient presents to the E R with a very painful, irreducible inguinal mass.

W h a t is the next step in the management o f this patient?
3.
W h at cause o f aplastic anemia is associated with thum b abnormalities, diffuse

hypo- or hyperpigmentation, cafe-au-lait spots and short stature?
Acne Vulgaris
4.
W hich acne medication is known for causing photosensitivity?
5. W hat should you know about oral isotretinoin (Accutane) in the treatment of
acne?
Usually try 2-3 other therapies prior to using this therapy

Check |3-hCG, CBC, lipids and LFTs regularly
25% develop increase in triglycerides (> 800 > risk of pancreatitis)
For dry skin - moisturizing soap, lotions, Chapstick, Polysporin to nares PRN, eye drops
PRN
Screen for depression and suicidal ideation each visit
Never use with tetracycline >combined risk of pseudotumor cerebri
OCPs should be prescribed to women patients due to high risk of teratogenic side effects
Rosacea
6- W hat is the classic presentation of rosacea?
Middle-aged patient
Facial erythema with telangiectasias starting at the nose and cheeks
Recurrent facial flushing provoked by various stimuli including hot/spicy foods, alcohol,
temperature extremes, emotional reactions
Inflammatory papules, pustules, cysts and/or nodules similar in appearance to acne but
without comedones
Ocular blepharitis, conjunctivitis and/or keratitis
Rhinophyma (sebaceous gland hyperplasia of the nose)
7.
W hat are the treatm ent options for rosacea?

Topical Treatment:
Sulfacetamide 10% + sulfur 5% lotion/gel
Metronidazole gel or cream
Rhinophyma may require laser therapy
Systemic Treatment:
Tetracycline
Doxycycline or minocycline
Isotretinoin (Accutane) for severe refractory cases
Varicella
8. W h at are the clinical features of varicella chicken pox?
Prodrome of malaise, fever, pharyngitis, headache and myalgia for 24 hours prior to rash
onset
Pruritic evolving rash: red macules >teardrop vesicles > rupture and crusting over
Vesicular rash starts on the face and trunk then spreads to extremities
Rash appears in successive crops of vesicles over 2-4 days
Most all lesions are fully crusted by 6 days
Skin bacterial superinfections may occur (S. pyogenes)

Adults may also develop pneumonia and/or encephalitis
9.
W h at treatm ents are available for children with chicken pox (varicella)?
Antihistamines for pruritus
Cut fingernails closely to avoid excoriations leading to bacterial superinfections
Acetaminophen for fever
No need for acyclovir in otherwise healthy children younger than 12 (AAP
recommendation) because although it has been shown to decrease duration by 1 day and
decrease the number of lesions, it does not reduce complications
Acyclovir for the following groups: older than 12 years of age, household contacts, history
of chronic cutaneous or cardiopulmonary disorders, those taking intermittent oral or
inhaled steroids, those taking chronic salicylates
[305]
INFECTIONS PART 2
10. W hat is the treatment for an uncomplicated varicella zoster outbreak in an

elderly patient?
Antiviral therapy if uncomplicated zoster presenting within 72 hours of clinical symptoms
Valacyclovir
Famciclovir
Acyclovir - high dosing frequency but low cost
Analgesia with opioids
Corticosteroids (prednisone tapered over 7 days) only if severe symptoms and no
contraindications. Usually the high risk of side effects outweighs the only modest benefits.
II. W hat medications are used in the treatment of postherpetic neuralgia?
[ 306 ]
End of Session Quiz

12. A 15-year-old girl is brought to the dermatologist for treatment o f her acne. W hat
is the causative organism in acne?
13. W h a t medication options are available for the treatment o f acne vulgaris?
15. A 41-year-old wom an w ith rosacea is seen in the clinic. It is a mild case, for which
avoidance o f the triggers o f facial flushing would be an initial therapy. W h at are
some examples o f things to avoid?
16. W h a t is the treatm ent for rosacea?
17. W h a t is the tim e frame in the treatm ent o f varicella?
18. A 25-year-old m an is in the office for cold sores. O n exam, he has a collection
o f 3 small vesicles at the vermillion border. H e says that they are painful. This
is the second tim e he has had these. H e says he knew he was about to get them
because he could feel a tingly sensation at that location a few days before the
lesions appeared. W h a t studies m ight be helpful to diagnose this disease?
19. A n elderly w om an presents w ith a rash on her right flank. She says that the
rash appeared a few days ago and followed a recent cataract surgery. The rash
is causing her terrible pain. O n exam, the rash extends from the spine past
the m id-axillary line in a dermatomal distribution. The rash is composed of
grouped erythematous vesicles. W h a t can be used to treat this woman?
DERMATOLOGY
14. W h a t side effects can arise from the use o f oral isotretinoin?
NFECTIONS PART 3
INFECTIONS PART 3
3 Question Warm-Up
1.
In what condition would you see Auer rods?
2.
In what circumstances should confidentiality not be protected?
3.
W hat x-ray finding is indicative o f croup? W h a t x-ray finding is indicative o f

epiglottitis?
W arts
4. W hich H PV types cause skin warts? W hich cause genital warts?
5. W hat are the different treatment options for condyloma acuminata (genital
warts)?
Spontaneous regression of small asymptomatic warts within 3 months occurs about 25% of
the time
0 Podophyllotoxin (self-administered) (for vulvar lesions in non-pregnant women)
0 Podophyllin (for vulvar lesions in non-pregnant women)
Trichloroacetic acid (TCA) often the first-line treatment
0 Imiquimod (self-administered) (for vulvar lesions in non-pregnant women) - induces
interferon-mediated antiviral response
Cryoablation with liquid nitrogen
Funga! Infections
6. W hat are the treatment options for tinea versicolor?
t 308 j
Topical OTC antifungal for 2 weeks (terbinafine (Lamisil), clotrimazole (Lotrimin))

Selenium sulfide (foam, solution, shampoo) qd-bid daily to affected areas for 1 week >
then ql-3 weeks for prophylaxis
Ketoconazole 2% shampoo daily for 3 days
Oral antifungal for extensive disease: ketoconazole, fluconazole, itraconazole
7.
W h at is the treatm ent for onychomycosis?

First confirm diagnosis by sending a nail clipping for pathologic diagnosis.
Onychomycosis is only responsible for 50-60% of abnormal appearing nails
Terbinafine (Lamisil) and itraconazole (Sporanox) have cure rates of only 60-70%
Strongly consider pretreatment LFTs and mid-treatment LFTs
Terbinafine
- Fingernails (6 weeks)
- Toenails (12 weeks)
(Off-label dosing: 250mg qd x7d every 2-3m x lyr may have better efficacy)
Itraconazole
Fingernails 200mg PO qd x8 weeks, or 400mg qd for I week each month for 2 months
Toenails 200mg PO qd xl 2 weeks, or 400mg qd for I week each month for 3 months
Fluconazole (Diflucan) 150mg once weekly x24 weeks (consider for those with
complicated med regimens) (efficacy not as good as Lamisil or Sporanox; cure only about
32%)
Reassure patient that oral agents will continue to work after stopping use. It may take a
few months to see complete resolution
Ciclopirox Nail Lacquer (Penlac) x48 weeks has complete cure rate of only 7% which
means 1 in 15 patients will have a favorable outcome
Lice and Crabs

8. W h at is the treatm ent for pediculosis capitis and pediculosis pubis?
Pediculosis capitis (lice) wash scalp normally then towel dry >saturate scalp with
permethrin cream (OTC Nix 1%) or pyrethrin (OTC Rid) for 10 minutes then rinse >
repeat in 1 week due to resistance (CDC rec.)
Malathion lotion 0.5% (Rx) may be used instead of permethrin
Lindane is not used due to potential neurotoxicity and widespread resistance
Ivermectin can be used in resistant cases (not FDA approved). 200 mcg/kg PO x l,
repeated in 2 weeks
If younger than 2 years, then wet combing with conditioner or olive oil rather than
insecticides performed q3-4 days for weeks
- Children may return to school after the first treatment session (wet combing or
insecticide)
Pediculosis pubis (crabs) permethrin 1% cream (OTC Nix 1%) or pyrethrin (OTC
Rid) for 10 minutes then rinse repeat in 1 week
- Malathion or ivermectin can be used as alternatives (see above)
- Sexual partners need to be treated at the same time
- Bedding and clothing should be machine washed and dried in a hot dryer, dry cleaned,
or bagged for a min of 72 hours
INFECTIONS PART 3
End of Session Quiz

9.
W hat is the appearance o f molluscum contagiosum?
10. A n obese, 42-year-old diabetic woman complains o f a pruritic rash underneath

her breasts. Exam reveals an erythematous, patchy rash underneath large,
pendulous breasts. W h at diagnostic study would be helpful, and what would be
seen?
11. W h a t medication is preferred in the treatment of scabies?
12. A 22-year-old Asian patient comes to your office. She is concerned because she
notices small areas of hypopigmentation on her back. She says these areas are
more noticeable in the summer. W h a t is the organism that is likely causing her
skin condition?
[310] I
3 Question Warm-Up
1.
W h a t is the treatm ent for W hipple disease?
2.
W h a t complications can arise from electrical burns?
3.
W h a t are the differing presentations o f Alzheim er disease, Pick disease and

Lew y body dementia?
INFLAMMATORY SKIN CO N D ITIO N S
INFLAMMATORY SKIN CONDITIONS
Erythem a Multiforme
4. W hat are the characteristic features of erythem a multiforme (EM)?
Skin lesion with target appearance (dull red center, a pale zone and a darker outer ring)
Lesions can take many different shapes (multiforme)
Lesions develop over 10+ days: macule >papule >vesicles/bullae in the center of the
papule
Common sites: hands/forearms, soles/feet, face, elbows and knees, penis and vulva
Severe form (EM major) always involves the mucus membranes >can become SJS/TEN
5. W h at is the treatm ent for erythem a multiforme?
Stop any inciting medication

Symptomatic treatment with antipruritics
If severe > systemic glucocorticoids (although no proven effectiveness)
I f patient also has history of HSY > antiviral such as acyclovir or valacyclovir
Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

6. W h at is the distinction between Stevens-Johnson syndrome (SJS) and toxic
epidermal necrolysis (TE N )?
SJS is the less severe form of T E N . In SJS, skin sloughing (epidermal detachment)
is limited to less than 10% body surface area. In T E N , at least 30% of the skin is
detaching. There is overlap between the two at 10-30% skin involvement.
[ 311 ]
Seborrheic Dermatitis
7. W hat is the treatment for infantile seborrheic dermatitis (A K A cradle cap)?
Selenium sulfide (Selsun Blue) shampoo twice a week until resolved
Massaging olive oil into the scalp and leaving for 15 minutes can help remove scale when
washing
+/- Hydrocortisone 1% cream bid to affected area
8. How does seborrheic dermatitis manifest in adults?

Erythema, scaling, and white flaking in areas of sebaceous glands including eyebrows,
nasolabial folds, face, external ear, scalp, upper trunk, and body folds (axilla, groin)
9. W hat diseases are associated with an increased incidence of seborrheic

dermatitis?
Parkinson, HIV, psoriasis, immunocompromised patients (e.g., transplant patients)
Exacerbations are common in emotional stress and hospitalizations
0 Severe intractable seborrheic dermatitis may point to H IV infection
Atopic Dermatitis
10. W hat are the available treatments for atopic dermatitis (A K A eczema)?
Switching to a moisturizing soap (Dove, Aveeno) and adding an O TC emollient may be
all that is needed for maintenance and mild cases
Hydration/Emollients: Cetaphil, Eucerin, Lubriderm, Aveeno, Aquaphor (or generic
equivalents)
High-water/low-oil lotions will worsen xerosis and eczema, and high-oil creams and
ointments will reduce xerosis
Calcineurin inhibitors: tacrolimus (Protopic) or pimecrolimus (Elidel)
Topical steroids
Antibiotics for open lesions (cover Staph, aureus and Strep, spp.)
Antihistamines
Leukotriene inhibitors (Singulair) theoretical efficacy supported by weak studies
UV light therapy
0 Systemic steroids (l-2mg/kg/day in children, then taper) only in severe cases and only for
short duration
For very severe cases, consider methotrexate, cyclosporin, azathioprine (Imuran)
11. W hat are the possible side effects of the calcineurin inhibitors (Elidel cream or
Protopic ointment) in the treatment of atopic dermatitis?
Do not cause systemic side effects or skin atrophy like topical steroids. Safe on face/eyelids
Try to avoid in children younger than 2 years due to higher rates of URIs. However, most
dermatologists have no problems using these in those under 2 years, because the alternative
of using topical steroids would probably have more side effects
Preliminary studies suggest possible slight increase in risk of lymphoma. Therefore, keep
duration as short as possible
12. W h at drugs are used in the treatm ent of psoriasis?
Topical steroids (NEVER give oral steroids to someone with psoriasis)

Calcipotriene (vitamin D3 analog that inhibits epidermal cell proliferation)
Tazarotene (Tazorac) (topical retinoid >normalizes keratinocyte proliferation)
Coal tar (suppresses DNA synthesis)
Anthralin
SaUcyhc acid (keratolytic used to remove excess scale)
UV therapy - for patients with more than 10% (refer to a Dermatologist)
Soriatane (acitretin)
Kenalog (triamcinolone) injections into dermis
Enbrel (etanerept): Anti-TNF agent approved for use in mod-severe psoriasis
Other agents: oral retinoids, methotrexate, cyclosporine
INFLAMMATORY SKIN C O N D IT IO N S
Psoriasis
Pityriasis Rosea
13. W hat is the treatm ent for pityriasis rosea?
This is a self-limiting disease of 4-6 weeks, and no treatment is necessary. Sunlight is
helpful.
If significant itching, may use a moderate-potency topical steroid
If extensive disease or severe itching, phototherapy
Possibly beneficial, but unproven:
Erythromycin 250mg four times daily x 14 days
Acyclovir 800mg five times daily x 7 days
Lichen Planus
14. W h at are the characteristic features of lichen planus?
Skin involvement - pruritic, purple, polygonal papules and plaques that are shiny and flat,
and commonly occur on the flexor surface of the extremities (e.g., wrist)
Wickham striae is a white, lace-like pattern on the surface of the papules/plaques
Mucus membrane involvement - Wickhams striae in the lateral buccal mucosa and
possibly erosive lesions that may become infected with Candida
Genital involvement usually limited to violaceous papules on the glans penis in men and
vulva of women
15. W h at infections are associated with an increased likelihood of lichen planus?
16. W h at is the treatm ent for lichen planus?

Corticosteroids of medium to high potency - topical or intralesional (oral if topical
unsuccessful)
Acitretin (an oral retinoid)
I [313]
Decubitus Ulcers
17. W hat are the different stages of decubitus ulcers?
Stage I
Pressure-related alteration in intact skin such as change in color,

consistency, sensation or temperature
Stage II
Superficial ulcer, abrasion or shallow crater
Stage III
Full thickness skin loss with damage to the subQ_tissues; deep crater
Stage IV
Extensive destruction or necrosis; damage to muscle, bone or

supporting structures
18. W hat are the treatments for the different stages of sacral decubitus ulcers?
Address nutrition
Insure adequate protein & calorie intake
Possibly helpful: daily MVI, zinc sulfate, vitamin C, arginaid (with L-arginine)
Relieve the pressure:
Turn q2 hours (30 angle on side) or advise patient to have frequent small changes in
position
- Appropriate, soft mattress
Elevate heels above bed surface with pillow placed lengthwise and curled at the end, or
use heel protectors (which usually dont work)
Stage I as above +/- application of a protective dressing such as Xenaderm
Stage II routine wound care and hydrocolloid dressing (avoid wet-to-dry dressings)
Stage III or IV wound care with debridement and hydrocolloid dressing
Stasis Dermatitis
19. W hat is the characteristic appearance of stasis dermatitis?
Eczematous dermatitis with inflammatory papules, scaly and crusted erosions, increased
pigmentation, stippling with recent and old hemorrhages, and possible ulceration
20. W hat is the treatment for stasis dermatitis?

Compressive dressings or stockings with at least 20-30mmHg of pressure (usually 3040mmHg)
Elevation of the legs above the heart whenever possible, but for at least 30 min 3-4 times a
day
Topical steroids
Consider horse chestnut seed extract
Aspirin 300-325mg/day (may accelerate the healing of venous ulcers)
End of Session Quiz

21.
A patient presents w ith erythem a multiforme. W hich medications are the most
common offenders?
TI
r~
>
Z
o7 3
-<
C/l
A
22.
W h a t are the distinctions between erythema multiforme, Stevens-Johnson

syndrome, and toxic epidermal necrolysis
(TEN )?
icrolvsis (TI
23.
W h a t is the classic presentation o f pityriasis rosea? W h a t is the treatment?
24.
W h a t is the classic presentation o f erythem a nodosum?
25.
W h a t are the treatm ent options for psoriasis?
26.
W h a t is the classic presentation o f lichen planus?
z
o
o
z
g
H
o
z
BULLOUS DISEASES AND NEOPLASMS
BULLOUS DISEASES AND NEOPLASMS
3 Question Warm-Up
1.
W h a t findings do the following signs describe, and with what diseases are they
associated?
Deep palpation ofRUQ_> arrest of inspiration due to pain
Charcots triad (fever, jaundice, RUQ_pain), hypotension, altered mental status
R LQpain on passive extension of the hip
RLQ_pain on passive internal rotation of the flexed hip
LUQpain and referred left shoulder pain
Ecchymosis of the skin overlying the flank
Ecchymosis of the skin overlying the periumbilical area
2.
W h a t is the treatment for RSV bronchiolitis?
3.
W h a t is Becks triad?
Bullous Diseases
4. W hat are the distinctive features of pemphigus vulgaris and bullous
pemphigoid?
Pemphigus vulgaris
Bullous pemphigoid
Bullae appearance
Flaccid; easy to rupture

(positive Nikolsky)
Tense, hard; difficult to

rupture
Presence of oral lesions
Almost always
Rare (10-35%)
Histologic location of
antibodies
Epidermis
Dermal-epidermal junction
(Basement membrane)
Type of antibody
Anti-desmosome
Anti-hemidesmosome
5. W hat is the treatm ent and prognosis for pemphigus vulgaris?
Steroids - high-dose systemic

Azathioprine or cyclophosphamide can be used as a steroid-reducing adjuvant
Treat wounds as burns
Antibiotics if infection is present
Dermatologist referral and possible life-long suppressive therapy
Prognosis fatal if left untreated, mortality of 5% even with treatment
6. W hat is the treatm ent and prognosis for bullous pemphigoid?

Topical steroids (e.g., clobetasol cream) have now been shown to be more effective
(decreased mortality and less complications) than oral steroids for bullous pemphigoid
If topical steroids are not possible (high cost, difficult to apply, mucus membranes involved)
> oral steroids (e.g., prednisolone)
Melanoma
7.
W hich type of melanoma matches each of the following descriptions?
Most common type of melanoma

Non-pigmented melanoma
Dark papule on the legs or trunk that bleeds with minor trauma
Occurs on palms, soles, or beneath nail plate in patients with dark skin
Dark lesion larger than 6mm with irregular, asymmetric borders
End of Session Quiz

8.
W h a t is the classic appearance o f porphyria cutanea tarda?
9.
From the presentation, how m ight pemphigus vulgaris be distinguishable from

bullous pemphigoid?
10.
W h a t do the antibodies target in bullous pemphigoid and pemphigus vulgaris?
11.
W h a t is the m ost im portant prognostic indicator in cases o f melanoma?
12.
W h a t is the classic appearance o f basal cell carcinoma?
13. W hat is the classic appearance of squamous cell cancer?
AND HAIR LOSS
PLASTICS, PIGMENTATION AND HAIR LOSS
PLASTICS, PIGMENTATION
3 Question Warm-Up
1.
W h at is the next step in the management o f testicular torsion confirmed with

an ultrasound?
2.
W h a t are the causes o f hypovolemic hyponatremia?
3.
Fever + rash + elevated creatinine + eosinophilia. W h a t is the diagnosis?
Pigmentation Disorders
4. W hat are the treatment options for melasma?
Hydroquinone
Azelaic acid (cream)
Flucinolone + hydroquinone + tretinoin
Prevention by minimizing sunlight exposure and by using an opaque sunblock (titanium
dioxide or zinc oxide)
5. W hat are the characteristic features of vitiligo?

Sharply demarcated patches of complete depigmentation (due to loss of melanocytes)
Borders are hyperpigmented
More common at acral areas and around body orifices
Skin is of normal texture (which excludes morphea and lichen sclerosis)
Associated with thyroid disease in 30% of patients (especially women)
Most common at ages 20-30
6. W hat comorbidities are associated with vitiligo?

Autoimmune disorders: Graves disease, autoimmune thyroiditis, pernicious anemia,
type 1 DM , primary adrenal insufficiency, hypopituitarism, alopecia areata,
autoimmune hepatitis
7.
W hat is the treatm ent for vitiligo?

Sunscreen to minimize tanning of normal skin which would increase the contrast
Dyes and make-up to camouflage depigmented areas
Corticosteroids if < 10% of skin affected
If > 12 years, class III or IV > e.g., fluticasone propionate ointment or mometasone
cream q-day for 4-6 months
If < 12 years, class V > e.g., fluticasone propionate cream ordesonide 0.05% cream
daily for 4 months
Tacrolimus or pimecrolimus (calcineurin inhibitors)
- Do not cause skin atrophy like steroids
Psoralens (topical or oral) + UV light (PUVA or UV-B) by dermatologist for extensive
disease
Surgical mini-grafting an option when medical therapy fails
Depigmentation of normal skin to match regions of vitiligo using hydroquinone is a last
resort
8. W hat treatm ent options are available for treating acanthosis nigricans?
Treat the underlying disorder which may require weight loss, discontinuation of
an offending agent (e.g., glucocorticoids, OCPs), or identification and removal of a
malignancy.
Lightening agents may be used, which often include Retin-A (tretinoin) and topical
steroids.
Fish oil oral supplementation may also be used
Red Vascular Skin Lesions

9.
W hat type of hemangioma does each of the following statements describe?
Purple-red lesion on face that does not regress with age

Infant with bright-red lesion that regresses over months-years
Benign, small red papule that appears on skin with age
Bright red papule with radiating blanching vessels
Blue, compressible mass that does not regress
Red-pink nodule on a child that is often confused with melanoma
10. W hat is the treatm ent for an uncomplicated infantile hemangioma? W hen are
infantile hemangiomas worrisome?
Since most uncomplicated infantile hemangiomas (AKA strawberry hemangioma)
gradually resolve within the first two years of life (or at least 10% resolution each year),
observation is usually the best treatment
They are worrisome and require additional treatment (such as systemic steroids) if
periorbital, in an airway, or associated with high-output heart failure
PLASTICS, PIGMENTATION AND HAIR LOSS
Hair Loss
11. W hat are the clinical features of alopecia areata?
Asymptomatic, inflammatory, non-scarring areas of complete hair loss

May be precipitated by stress
Regrowth after 1st attack in 30% by 6 months, in 50% by 1 year, in 80% by 5 years
10-30% will not re-grow hair, 5% progress to total hair loss
Obtain syphilis screen, CBC, BMP, ESR, TSH, ANA (to rule out pernicious anemia,
chronic active hepatitis, thyroid disease, SLE, Addison)
Rule out trichotillomania (pulling out ones hair) look for broken hair shafts of different
lengths, consider shaving a small patch and observe over a few weeks for growth
12. W hat is the treatm ent for alopecia areata?

Fluocinolone oil and/or shampoo qd
Intralesional steroid injection - most common therapy for limited involvement,
triamcinolone injected into entire patch q4-8 weeks, can be used in girls past age 7-9 and
boys past age 10-12
Minoxidil topical, works within 12 weeks, not best choice for children
Anthralin cream - commonly used in children, growth within 2-3 months
Squaric acid dibutylester (SADBE) or diphenylcyclopropenone (DPCP) rubbed into scalp
creates an allergic response resulting in hair growth, both about 60% effective in children,
may be best non-injection choice for children
Topical steroids are ineffective due to poor scalp penetration. Oral steroids work well, but
alopecia returns once stopped.
13. W hat is the name given to diffuse stress-related hair loss? W hat is the
treatment?
14. W hat is the treatm ent for androgenic alopecia?

If signs of androgen excess in women, check serum testosterone, DHEA and prolactin
Men > finasteride +/- minoxidil.
Women >minoxidil +/- spironolactone.
Finasteride (Propecia) lm g qd
Dose is lmg qd for hair loss (Proscar 5mg qd is used for BPH)
Not used in women. Shouldn't even be touched by premenopausal women. Not
effective in postmenopausal women.
Minoxidil (Rogaine) 5% solution
Can be used in both men and women. May use with finasteride or spironolactone.
5% works better than 2%
ImL bid to dry/involved scalp bid for at least 4 months. Results will be seen by 12
months. Use indefinitely. Discontinuation will result in a return to baseline.
SE: hypertrichosis (3%), pruritus, dermatitis, scaling
Spironolactone 100-200mg PO qd
15. W h a t dermatologic condition matches each o f the following statements?

Associated with obesity, diabetes or malignancy (especially if over 50)
Pigmented plaques that appear to be stuck onto the skin
Black, velvety plaques on flexor surfaces and intertriginous areas
Rough lesions on sun-exposed skin that are easier to feel than see
Circular rash with central clearing on the trunk or arms
AND
HAIR LOSS
16. A 31-year-old wom an has patches o f hypopigmentation on her skin.

Considering the associated comorbidities w ith this condition, what endocrine
test m ight you order initially?
PLASTICS, PIGMENTATION
End of Session Quiz
17. W h a t type o f hemangioma does each o f the following statements describe?

Purple-red lesion on face that does not regress with age
Infant with bright-red lesion that regresses over months-years
Benign, small red papule that appears on skin with age
Bright red papule with radiating blanching vessels
Blue, compressible mass that does not regress
Red-pink nodule on a child that is often confused with melanoma
18. W h a t treatm ent is indicated for a newborn w ith an uncomplicated strawberry
hemangiom a on the face?
[321 ]
G ynecology
1
M en stru al Physiology
M enopause
C ontraception
A m enorrhea
M e n stru al D isorders p a rt 1
M e n stru al D isorders p a rt 2
P C O S and Pelvic Prolapse
G ynecological Infections and S T D s
U terine and C ervical N eoplasm s
10 V aginal and O v arian N eoplasm s

11 B enign B reast D isorders
12 B reast C ancer
MENSTRUAL PHYSIOLOGY
3 Question Warm-Up
1.
Anticentromere antibodies are associated w ith w hat condition?
2.
W h a t blistering skin disease has a positive Nikolsky sign?
3.
W h ich blood cell pathology matches each o f the following high-yield

descriptions?
Associated w ith Epstein-Barr virus (in
Africa)
Reed-Sternberg cell, cervical
lymphadenopathy, night sweats
Bence-Jones proteins, osteolytic lesions, high
calcium
Translocation 14;18
M ost common lymphoma in the US
Translocation 8;14
Translocation 9;22
M ost common form of Hodgkin lymphoma
Starry-sky pattern due to phagocytosis of
apoptotic tum or cells
H igh hematocrit/hemoglobin, pruritus
(especially after hot bath or shower), burning
pain in hands or feet
End of Session Quiz

4.
W h at is the mean age o f menarche in the US?
S.
W h at is the definition o f precocious puberty?
6.
W h a t lab findings distinguish true precocious puberty from pseudoprecocious

puberty?
7.
W h a t are some o f the causes o f pseudoprecocious puberty?
8.
W h a t is the treatment for central precocious puberty?
9.
W hich phase o f the menstrual cycle is fixed at 14 days, regardless o f cycle

length?
10.
F SH triggers the release o f which hormone from the follicle?
MENOPAUSE
3 Question Warm-Up
1.
W h a t nam e is given to diffuse stress-related hair loss? W h at is the treatment?
2.
W h a t are the classic features that distinguish orbital cellulitis from periorbital
cellulitis?
3.
W h a t is the classic (but rare) E K G finding in pulm onary embolism?
Menopause
4.
How is menopause diagnosed?

12 months of amenorrhea in a woman over 45 is diagnostic and requires no additional
work-up
A woman over age 45 with irregular menses (oligomenorrhea) and menopausal symptoms
(hot flashes, mood changes, sleep disturbances) can be assumed to be going through
perimenopause
Seram FSH levels increase in the perimenopausal period and after menopause, but this is
of little diagnostic value beyond obtaining a menstrual history and history of symptoms
If younger than 45, other etiologies for oligo/amenorrhea must be excluded (TSH, serum
hCG, prolactin, FSH)
MENOPAUSE
Hormone Replacement Therapy (H R T )

5. W hat are the pros and cons of hormone replacement therapy for menopause?
PROS
Control of menopausal symptoms (hot flashes, vaginal dryness/atrophy, urinary
incontinence, emotional lability)
Reduced risk of_________________________________
Reduced risk of colorectal cancer
CO N S
Not indicated for the prevention of chronic disease, stroke, heart disease and osteoporosis
(USPSTF)
HRT doubles risk of:
Invasive breast cancer (+8 per 10,000) but not noninvasive breast cancer
Endometrial cancer
Venous thromboembolism (+8 PEs per 10,000)
Increases risk of stroke by up to 32-41% (+8 per 10,000)
Increases risk of heart disease by 29% (+7 per 10,000)
However, if taken at ages 50-59, H R T results in less coronary calcification on C T scan
(NEJM 2007;356:2591). This may or may not correlate with less risk of heart disease in
women taking H R T during ages 50-59
Increases risk of biliary disease and need for biliary surgery
6. W hat non-hormonal options can be used in the treatment of menopausal hot

flashes?
Desvenlafaxine only non-hormonal drug FDA-approved for hot flashes. Also works as
an antidepressant
Venlafaxine good choice if any depression, anxiety, fatigue or isolation. Good first-line
drug
Clonidine - good choice if BP control is also needed. SE of dry mouth, constipation and
drowsiness
Gabapentin - about 50% reduction seen in a small trial. Good choice if insomnia, restless
leg syndrome, seizure d/o, neuropathy, chronic pain
Time about 30-50% of women have symptom improvement within a few months, and
most have resolution within 4-5 years
Placebo - placebo effect is about 20-25% effective in reducing hot flashes
[ 328
7.
Prem ature menopause is defined as menopause before what age?
8.
W h a t is required for a diagnosis o f menopause?
9.
As periods become less frequent during perimenopause, what hormonal changes

are occurring?
10.
MENOPAUSE
End of Session Quiz
W h a t are the side effects o f estrogen? Progesterone?
[ 329]
CONTRACEPTION
3 Question Warm-Up
1.
In which patients is bupropion contraindicated?
2.
W h at is the treatment for serotonin syndrome?
3.
A middle-aged man presents for knee pain, and x-ray reveals bilateral
calcifications o f the articular cartilage. W h a t is the treatment?
W hat are the absolute contraindications to the use of oral contraceptive pills
(OCPs)?
Pregnancy (although accidental use in early pregnancy is not associated with congenital
anomalies)
History of thromboembolism (DVT, PE) or inherited thrombophilia
History of estrogen-dependent tumor (endometrial or breast carcinoma)
Cerebrovascular disease (history of stroke) or CAD
Poorly-controlled hypertension
O
Hepatic disease/neoplasm (adenoma, cancer, hepatitis, cirrhosis)
Abnormal vaginal bleeding of unknown etiology
___________________________________, neurologic symptoms or vascular involvement
(increased risk of stroke)
W hat are the advantages and disadvantages of combination oral

contraceptives?
Advantages
D isadvantages
Reliable (< 3% failure rate)

Reduce risk of endometrial
and
Decreased incidence of
ectopic pregnancy
Menses more predictable,
lighter, less painful
Daily dosing
Do not protect against STDs
Breakthrough bleeding
Estrogen SE: bloating, breast tenderness,
nausea, headaches
Progesterone SE: depression, acne,
hypertension
Increased risk of DVT
Elevated triglycerides
W hat type of liver pathology is associated with O C P use?

Reversible cholestasis
O
Benign liver tumor which may undergo malignant transformation
Incidence is 3-4 per I00K long-term users vs. 0.1 per I00K in the general population
Development typically requires high-dose estrogen for > 5 years
Budd-Chiari syndrome from hepatic vein thrombosis or IVC thrombosis
Veno-occlusive disease of the terminal hepatic venules and hepatic sinusoids (similar to
Budd-Chiari)
Hepatocellular carcinoma
Resulting cirrhosis, portal hypertension or liver failure from one of the above
W h at medications are well known for reducing the effectiveness of

combination oral contraceptive pills through changes in liver metabolism?
Antibiotics:_____________________________ (griseofulvin to a lesser degree)
Antiepileptics (e.g., phenobarbital, phenytoin, carbamazepine, topiramate, oxcarbazepine,
primidone)
Other: St. Johns wort
W h at are the contraindications to IU D placement?

Current vaginal or cervical infection
Known pregnancy or desire for pregnancy in the near future
Severe uterine distortion (bicornuate uterus, cervical stenosis, fibroids distorting the
uterine cavity)
Uterine bleeding that has not yet been worked up
Copper allergy or Wilson disease >avoid copper IUD
Breast cancer avoid progesterone IUD
End of Session Quiz

9.
W h a t are 4 different options for emergency contraception?
10. W h a t are the mechanisms o f action o f OCPs?
11. O C P use decreases the incidence of what type of cancer?
AM ENORRHEA
AMENORRHEA
3 Question Warm-Up
[332
1.
A 25-year-old woman is seen in the clinic w ith complaints o f fatigue and

chronic joint pain. Physical exam and routine labs reveal a malar rash, mildly
elevated temperature and anemia. It is unclear whether this womans anemia
is caused by autoimmune hemolytic anemia or from her recent menstruation.
W h a t test can distinguish between possible autoimmune-mediated hemolytic
anemia versus other causes o f anemia, including non-immune mediated
hemolytic anemia?
2.
A study shows that taking 325mg o f aspirin a day has no effect on ischemic
cardiac events. W h a t type o f error is this?
3.
W h a t labs should be ordered to identify the pathogen in a patient w ith an acute

diarrheal illness?
W hat are the first steps in the work-up of a woman with prim ary amenorrhea?
Thorough history and physical exam

Congenital defects identified: imperforate hymen, transverse vaginal septum, vaginal
agenesis
If signs of hyperandrogenism > serum testosterone and________________________
to assess for an androgen-secreting tumor
If galactorrhea > serum ___________________________ and thyrotropin to assess
for prolactinoma
Pelvic sonogram if uterus does not appear to be present or is difficult to assess

If uterus absent *
and serum___________________
Androgen insensitivity syndrome (46,XY; elevated testosterone)
Abnormal mullerian development (46,X X ; normal female testosterone levels)
If uterus present >
and serum___________________
If p-hCG high > pregnancy
If FSH high > karyotype for Turner syndrome (45,X O )
If FSH low > cranial MRI for hypothalamic or pituitary disease
If FSH normal serum prolactin and thyrotropin
A 15-year-old girl comes in for evaluation of prim ary amenorrhea. On physical

exam , a bluish bulge is evident where the vaginal orifice should be. W hat is the
diagnosis?
W h at are the first steps in the work-up of a woman with secondary

amenorrhea?
Serum [3-hCG to rule out pregnancy
Thorough history and physical exam
Serum prolactin (rule out hyperprolactinemia), serum TSH (rule out thyroid disease),
serum FSH (rule out ovarian failure)
If signs of hyperandrogenism > serum DHEAS and total testosterone
If all of the above are normal or history of dilation and curettage (D&.C) >
progestin withdrawal test (rule out Asherman syndrome)
End of Session Quiz

7.
A woman presents with prim ary amenorrhea, absent secondary sexual

characteristics, and anosmia. W h at is the diagnosis?
8.
W h at is the definition o f premature ovarian failure?
9.
W h a t is the most common cause o f secondary amenorrhea?
10.
W h a t is the initial step in the management o f a woman presenting with

secondary amenorrhea and new galactorrhea when the [3-hCG is negative?
11.
W h at are the basic components o f a work-up for secondary amenorrhea?
MENSTRUAL DISORDERS PART I
3 Question Warm-Up
1.
A young child presents w ith thigh muscle weakness, a waddling gait, and
pronounced calf muscles. W h a t is the diagnosis?
2.
A female neonate who was born in breech position is found to have asymmetric
inguinal and gluteal skin folds on her newborn exam. W h a t is the diagnosis
and treatment?
3.
H ow is benign paroxysmal positional vertigo (BPPV) diagnosed? H ow is it

treated?
4. W hat are the characteristic features of endometriosis?

Pelvic pain (most severe during menses, 2-7 days prior to menses and possibly at ovulation)
3 Ds: dysmenorrhea, deep dyspareunia and dyschezia (painfiil defecation during menses)
Difficulties with fertility
Physical findings:
Localized tenderness in the cul-de-sac or uterosacral ligaments (esp. at the time of menses)
Palpable, tender nodules in the cul-de-sac, uterosacral ligaments or rectovaginal septum
Pain with uterine movement
Tender, enlarged adnexal masses
Adhesions causing a fixed or retroverted uterus
5. W h at are the treatm ent options for treating endometriosis?

Expectant management if minimal symptoms or perimenopausal
Pain control with NSAIDs
Hormonal therapies:
- Combined O CPs dosed continuously - common first-line option with prn NSAIDs
GnRH agonist (nafarelin, leuprolide or goserelin) for 6-12 months - induces a medical
menopause, used in patients with moderate-severe pain, side effects can be managed
by "add-back hormones
- Progestin (PO, IM, IU) - usually 2nd- or 3rd-line because of breakthrough bleeding and
other SE, including depression and weight gain
Danazol for 6 months induces a medical menopause but no add-back" therapy
available, usually a 3rd- or 4th-line option
Aromatase inhibitors (anastrozole or letrozole) used with GnRH agonist or OCP,
otherwise follicular cysts develop
Surgical intervention
Laparoscopic surgery to confirm diagnosis and ablate ectopic endometrial tissue and
lyse adhesions
Hysterectomy with bilateral salpingo-oophorectomy (TAH/BSO), lysis of adhesions
(LO A) and removal of endometrial implants
MENSTRUAL DISORDERS PART I
6. W hat is the first-line treatment for a young, infertile woman with obvious signs
and symptoms of endometriosis?
End of Session Quiz

7.
W h a t is the treatment o f choice for primary dysmenorrhea?
8.
W h a t medications are effective in the treatment o f PM S and PM D D ?
9.
W h a t is the first-line treatment for endometriosis?
10.
W h a t is the most common cause o f female infertility?
11.
W h a t are the 3 D s o f the presentation o f endometriosis?
MENSTRUAL DISORDERS PART 2
3 Question Warm-Up
1.
W h a t do an elevated ery th ro p o ietin level, elevated hem atocrit and norm al

O a satu ratio n suggest?
2.
A n ew born is found to have a congenital h e a rt disease th a t causes early

cyanosis. W h a t m edication does this new born need?
3.
W h a t is th e difference betw een a M onteggia fracture and a G aleazzi

fracture?
4. W hat is the m ost likely cause of abnormal uterine bleeding (A U B ) in each of

the following patients?
M ost common cause of abnormal uterine
bleeding
Positive |3-hCG + intrauterine pregnancy
+ closed os
Enlarged uterus + menometrorrhagia for
months
Bleeding associated w ith severe menstrual
pelvic pain
M enorrhagia + perimenopausal
AUB started w ith menarche
Positive |3~hCG + severe pain + no fetus in
uterus on US
M etrorrhagia especially after intercourse +
no pain + normal-sized uterus
Depression + constipation + AUB
MENSTRUAL DISORDERS PART 2
[ 338 ]
End of Session Quiz

5.
W h a t is the most common cause o f irregular, heavy uterine bleeding?
6.
W hen is an endometrial biopsy a necessary part o f the work-up for abnormal

uterine bleeding?
7.
W h a t is the most common clotting disorder that can cause menorrhagia? W h a t

lab values are abnormal?
PCOS AND PELVIC PROLAPSE
3 Question Warm-Up
1.
A hospitalized patient is suspected o f having an infection. W h a t should be done

before empiric antibiotics are started?
2.
W h a t intracranial abnormality is associated w ith A D PK D ?
3.
Diming a routine exam, a 70-year-old m an is found to have new-onset iron

deficiency anemia. W h a t should you suspect and investigate further?
4. W h at are the features of pelvic prolapse?

Types
- Cystocele - Prolapse of bladder into vagina
- Rectocele - Prolapse of rectum into vagina
Enterocele Prolapse of small bowel into vagina (usually following hysterectomy)
- Uterine prolapse Prolapse of uterus into vagina
Historical clues: Pelvic pressure or heaviness, obvious protrusion of tissue out of the
vagina, feels like Im sitting on an egg
Treatment
- Mild pelvic floor exercises and/or physical therapy with behavior modification (e.g.,
timed voiding)
- Moderate pessary
Severe > surgical correction
PCOS AND PELVIC PROLAPSE
End of Session Quiz

5.
W h at is the most common cause o f hirsutism in the US? W hat lab findings are
used to make the diagnosis?
6.
For which type o f cancer are women with P C O S at an increased risk and why?
7.
W h at medications are used in the treatment o f PCOS?
GYNECOLOGICAL INFECTIONS AND STDS
3 Question Warm-Up
1.
W h e n can lactational amenorrhea be relied upon as an effective method o f

contraception?
2.
W h a t is the treatm ent for acute angle-closure glaucoma?
3.
W h a t rash is classically described as dew drops on rose petals?
4. W hat are the diagnostic features of pelvic inflammatory disease (PID)?
or adnexal tenderness
Leukocytosis on CBC
New/unusual purulent cervical or vaginal discharge
W BCs on wet prep of vaginal secretions
Temp > 101 F
Elevated ESR or CRP
Imaging may reveal:
Thickened or fluid-filled fallopian tubes
- +/- fluid in the pelvic cul-de-sac
G YN ECO LO GICAL INFECTIONS AND STDS
[ 342 ] I
End of Session Quiz

5.
W h at are the distinguishing features o f bacterial vaginosis, Candida vaginitis

and Trichomonas infection?
6.
W h a t is the treatment for gonorrhea? Chlamydia?
7.
A sexually-active woman presents with the classic symptoms o f cystitis. Gram

stain of the urine shows no organisms. W h a t organism do you suspect is the
cause o f this patients symptoms?
8.
W h a t medications can be used in the treatment o f syphilis?
UTERINE AND CERVICAL NEOPLASMS
c
H
m
70
zm
>
,? Question Warm-Up
1.
W h a t is the antidote to each o f the following toxins?

Anticholinesterases, organophosphates
M ercury
Carbon monoxide
o
n
m
30
<
n
>
o
03
z
cn
Heparin
Isoniazid
2.
W h a t is the laboratory work-up for abnormal uterine bleeding?
3.
A patient presents w ith a painless, pruritic papule w ith regional

lymphadenopathy th at evolves over 7-10 days into a necrotic ulcer w ith a black
eschar. W h a t is the diagnosis and treatment?
4. W h at are the current recommendations for Pap screening in patients with no

history of abnormal Pap?
0 Initiate screening at age_________________
0 Frequency of Pap smears:
Every 3 years for ages 2 1-29
Patients 30+ may continue Pap smear every 3 years, or may opt for Pap smear + HPV
testing every 5 years (preferred by some professional organizations)
Women in higher risk groups may need more frequent testing
0 Screening may be stopped at age 65 if adequate normal Paps
0 If hysterectomy for benign disease, there is no need to screen for cervical cancer
-
[343]
UTERINE AND CERVICAL NEOPLASMS
[ 344 ]
End of Session Quiz

5.
W h a t are the indications for an endometrial biopsy?
6.
W h a t is the next step in the management o f a C IN 2 cervical lesion identified

on biopsy in a woman who has completed fertility?
7.
W h at is the next step in the management of an ASCUS Pap smear with

positive H P V test?
8.
W h at is the next step in the management o f an AGUS Pap smear?
VAGINAL AND OVARIAN NEOPLASMS
3 Question Warm-Up
1.
W h a t is the differential diagnosis for eosinophilia?
2.
A 60 year old male smoker is found to have a varicocele that does not empty
w hen the patient is recumbent. W h a t should you be suspicious o f in this
patient?
3.
W h a t acid-base disorder would cause the following lab values?

pH
hco
pco2
7.30
12
26
7.25
18
37
7.23
24
55
D iso rd e r
4. W h at are the general treatm ent strategies for squamous cell cancer of the
vagina?
Stage
T re atm en t
Stage I less than 2cm

Stage I greater than 2cm
Stage II, III, and IV
5.
Lichen Sclerosis
Chronic inflammatory condition of the anogenital region, most commonly affecting
postmenopausal women
Classic late findings - ivory or porcelain-white macules and plaques with pruritus
Treatment - Low threshold for punch biopsy to r/o SCC; steroids (clobetasol) or
pimecrolimus
End of Session Quiz

6.
W h a t are the symptoms o f ovarian cancer?
7.
W h a t are the risk factors for ovarian cancer?
8.
W h a t serum marker may be elevated in cases o f ovarian cancer?
9.
W h a t ultrasound findings are consistent w ith benign ovarian tumors? W ith

malignant ovarian tumors?
10.
W h a t type o f ovarian tum or is associated with psammoma bodies? Estrogen

excess? Androgen secretion?
BENIGN BREAST DISORDERS
3 Question Warm-Up
1.
W h a t is the complication o f gonorrhea or chlamydia that infects the capsule of

the liver?
2.
W h a t type o f heart m urm ur fits each o f the following descriptions?

Diastolic murmur heard best in left lower sternum that increases with inspiration
Late diastolic murmur with an opening snap (no change with inspiration)
Systolic murmur heard best in the second right interspace
Systolic murmur heard best in the second left interspace
Late systolic murmur heard best at the apex
Diastolic murmur with a widened pulse pressure
Holosystolic murmur that is louder with inspiration at the left lower sternum
Holosystolic murmur heard at the apex and radiates to the axilla
3.
W h a t is the first-line treatm ent for pediculosis capitis and pediculosis pubis?
4. W h at is the differential diagnosis of gynecomastia?

Puberty (resolves spontaneously in 6m to 2yrs)
Drugs: spironolactone, marijuana (THC), chronic alcohol use, cimetidine, ketoconazole,
estrogens, digoxin
Herbal agents: tea tree oil, lavender oil
Cirrhosis
Hypogonadism (e.g., Klinefelter, hyperprolactinemia)
Testicular germ cell tumor
Hyperthyroidism
Hemodialysis patients
BREAST DISORDERS
BENIGN
End of Session Quiz

5.
W hich type o f breast disease matches each o f the following descriptions?

Most common tumor in teen and young women
Most common mass in patients 35-50
Often presents with serous or bloody nipple discharge
6.
W h at drugs are notable for causing gynecomastia?
BREAST CANCER
3 Question Warm-Up
1.
A n 8-year-old child was in a motor vehicle accident and now requires an

emergency blood transfusion. H er parents are not present, but the child states she
is a Jehovahs Witness. W h a t do you do?
2.
A 50-year-old female smoker presents w ith hematuria. W h a t do you suspect?
3.
W h a t statistical calculation looks at true positives and divides them by the number
o f patients w ith the disease?
End of Session Quiz

4.
W h a t is the m ost common breast cancer? W h a t is the most common site for
breast cancer?
5.
W h a t findings are suspicious on a mammogram?
6.
W h a t is the treatm ent for ductal carcinoma in situ o f the breast?
7.
O nce you have ruled out invasive cancer, w hat is the management o f LCIS?
W h y is drug therapy so effective?
O bstetrics
1
N orm al P regnancy Physiology
P renatal C are
M edical C om plications p a rt 1
M edical C om plications p a rt 2
M a tern al D ru g Use
C ongen ital Infections
O bstetric C om plications p a rt 1
O bstetric C om plications p art 2
O bstetric C om plications p a rt 3
10 O bstetric C om plications p a rt 4
11 L & D : A ssessm ent o f Fetus
12 L&JD: L abor
13 L & D : M alpresentation and
C esarean Section
14 P o stp artu m C are
NORMAL PREGNANCY PHYSIOLOGY
3 Question Warm-Up
1.
W h a t is the difference between the following disorders?

Schizotypal personality disorder
Schizophrenia
Schizoaffective
Schizoid personality disorder
Schizophreniform
Brief psychotic disorder
2.
W h a t term describes heavy bleeding during and between menstrual periods?
3.
W h a t is the m ost common type o f tracheoesophageal fistula?
4. W hat change is responsible for physiologic anemia of pregnancy? A t what

gestational age is it most apparent? W hen should anemia in pregnancy be
treated with oral iron?
This greater increase in plasma volume as compared to red cell mass is most apparent
during the second trimester
Treat anemia in pregnancy with iron replacement when hemoglobin falls below______
g/dL in the first or third trimesters, or when less than
g/dL in the second
trimester
NORMAL PREGNANCY PHYSIOLOGY
End of Session Quiz

5.
Between what weeks gestation is a fetus most susceptible to teratogens and why?
6.
W h at effect does pregnancy have on blood pH?
7.
H ow do the following parameters change during pregnancy?
8.
TSH
Blood pressure
Cardiac output
Ventilation
W h a t hormone contributes to glucose intolerance often seen in pregnancy?
PRENATAL CARE
3 Question Warm-Up
1.
W h a t is the most sensitive and specific lab test for the diagnosis o f chronic
pancreatitis?
2.
W h a t is the classic presentation o f poststreptococcal glomerulonephritis?
3.
W h a t would be the concern in a sickle cell patient that contracts erythema

infectiosum (fifth disease)?
4. W h at is Goodells sign? W hat is Chadw icks sign? W hat is Hegars sign?

Goodells sign softening and cyanosis of the
at 6 weeks gestation
Chadwicks sign - bluish discoloration of the _

congestion at 8-12 weeks gestation
. due to vascular
Hegars sign - softening of th e ___
at 6 weeks gestation
5.
How do |3-hCG levels change during early pregnancy?
6.
How many additional calories are needed on a daily basis during pregnancy and
breastfeeding?
During pregnancy, an additional 340 kcal/day is needed in the second trimester and 452
kcal/day is needed in the third trimester
During breastfeeding, an additional 500 kcal/day is required to breastfeed, but since fat
stores developed during pregnancy begin to be mobilized, only an additional dietary 330
kcal/day is needed
7.
W h at dose of folic acid is recommended to mothers for the prevention of

neural tube defects?
o _____________________ folic acid daily is recommended to all women of childbearing
years (CDC rec.) to reduce neural tube defects by 57%
Higher doses of folic acid daily reduce the risk of neural tube defects even more
If previous child with neural tube defect, recommended folic acid intake starting the
month prior to pregnancy is 4 mg daily (AAP, ACOG)
PRENATAL CARE
8. W here would you expect to find the fundus of the uterus on physical exam
throughout pregnancy?
12 weeks 16 weeks
20 weeks 20-36 weeks -
9. W hat are the indications for percutaneous umbilical blood sampling (PUBS)?
In most cases fetal amniocentesis is sufficient and safer than PUBS. PUBS (AKA
cordocentesis) is preferred only for confirmation o f_________________________
.
with possible___________________________________ .
10. In pregnancy, which vaccines are currently indicated, and which are
contraindicated?
Vaccines indicated in pregnancy
________________ qlO years (OK in pregnancy. Dose TDaP in 2nd or 3rd trimester.)
________________ annually (OK in pregnancy.)
________________ , _________________ , and_________________ if indicated (OK
in pregnancy)
Vaccines contraindicated in pregnancy
O
o
o
o
Postpartum or post-abortion vaccines

If rubella non-immune (titer < 10), then rubella vaccine prior to discharge
If no h/o tetanus vaccine in last 10 years, then administer TD aP vaccine prior to discharge
If no evidence of varicella immunity (h/o chickenpox/shingles, h/o vaccine, or serologic
confirmation), then varicella vaccine prior to discharge. 2nd dose 4-8 weeks after the first
End of Session Quiz

11. W h a t additional supplements should be given to complete vegetarians during
pregnancy?
12.
13.
W h a t supplements should be given to women on anticonvulsants during

pregnancy?
W h a t disorders can increased nuchal translucency indicate?
14. Q uad screen shows decreased A FP, decreased unconjugated estriol, elevated
inhibin A and elevated j3-hCG. W h a t diagnosis do you suspect?
MEDICAL COMPLICATIONS PART I
MEDICAL COMPLICATIONS PART I
3 Question Warm-Up
1.
W h at is the differential diagnosis for the dislocation of the lens o f the eye?
2. W h a t type o f infection causes honey-crusted lesions usually around the nose or

mouth?
3. W h a t is the most common cause o f morbidity and mortality in patients w ith

SLE?
4. A 30-year-old woman with hypertension is currently on an A C E inhibitor,

but has just discovered that she is pregnant. Knowing that A C E inhibitors
are teratogens, you decide to switch her to a different medication for her
hypertension. W hat medications are commonly used in the management of
chronic hypertension in pregnancy?
End of Session Quiz

5.
A pregnant woman at 24 weeks gestation has a random glucose o f 130. W h a t is

the next step in her management?
6.
W h a t is the drug o f choice for gestational diabetes? W h a t other drugs are safe
for use in pregnancy for gestational diabetes?
7.
W h a t fetal cardiac defect is most associated with pre-pregnancy diabetes?
8.
W h a t diagnosis would you suspect in a pregnant patient w ith hypertension prior

to 20 weeks gestational age?
9.
For how long is magnesium sulfate continued after delivery in preeclampsia? In

eclampsia?
10.
W h a t are the features o f H E L L P syndrome?
MEDICAL COMPLICATIONS PARI
MEDICAL COMPLICATIONS PART 2
3 Question Warm-Up
1.
W h a t is the next step in the evaluation o f each o f the following patients?

Pelvic fracture + DPL shows blood in the pelvis
Pelvic fracture + DPL shows urine in the pelvis
Pelvic fracture + DPL shows nothing +
hemodynamic instability
Blunt abdominal trauma + unstable vital signs +
FAST shows fluid in pelvis
FAST shows no fluid in pelvis
FAST inconclusive
Blunt abdominal trauma + stable vital signs
Abdominal stab wound + hypotensive or signs
of peritonitis
4.
2.
W h a t antibiotic combinations are used in the outpatient treatment o f

diverticulitis?
3.
W h a t is the next step in the management o f a woman w ith uncomplicated

cystitis?
How is hyperemesis gravidarum distinguished from normal morning sickness?

0 Weight loss exceeding_______ %of pre-pregnancy body weight and detection of ketonuria
due to starvation are usual markers used to distinguish hyperemesis gravidarum from
morning sickness.
5. W hat work-up should be performed in a patient with hyperemesis gravidarum?

Weight, orthostatic blood pressures
Serum_________________________ , serum electrolytes and urine ketones
(Expected, non-worrisome lab abnormalities associated with vomiting: elevated AST and
ALT (but each < 1000), elevated amylase and lipase (but each < 5x normal), and elevated
bilirubin (but < 4 mg/dL))
Ultrasound to detect gestational trophoblastic disease (molar pregnancy) and multiple
gestations
W h a t are the treatm ent options for nausea in pregnancy?

Conservative O TC nausea/vomiting control: Vitamin__________ 25mg tid, Ginger
250mg tid, Unisom (___________________
)I2.5mg bid(A),acupressure
Prescription nausea/vomiting control: promethazine (C), ondansetron (B) or granisetron
(B), metoclopramide (B)
If dehydrated, IV fluids in ER or as inpatient (daily Chem 7, Mg, Phos)
If vomiting for more than 3 weeks, multivitamins + thiamine lOOmg IV daily for 2-3 days
If refractory to above and losing weight, then NG tube feeds (parenteral nutrition only as a
last resort)
End of Session Quiz

7.
W h a t is the treatm ent for D V T in pregnancy and how long is it continued?

W h a t drug do you N O T give during pregnancy?
8.
W h a t dipstick finding is considered diagnostic o f a U T I?
9.
W h a t is the first-line treatm ent for hyperemesis gravidarum?
MATERNAL DRUG USE
3 Question Warm-Up
1.
W h a t lab is often elevated in patients with an upper G I bleed?
2.
A 30-year-old female African immigrant presents with hematuria. W h a t do

you suspect in this patient?
3.
A young woman thrown from a horse presents w ith low back pain, urinary
retention, saddle anesthesia and decreased rectal tone. W h a t is the treatment for
her condition?
W hat adverse effects can be seen with maternal marijuana use during
pregnancy?
At least six joints per week >small head circumferences in children at all ages (Ottawa
study)
No association between prematurity or congenital anomalies
Increases risk of using alcohol and cigarettes during pregnancy, which are both harmful to
the fetus
Small studies show problems later in life including increased incidence of psychiatric
problems (ADHD, depression and substance abuse) and increased incidence of certain
cancers (non-lymphoblastic leukemia, rhabdomyosarcoma and astrocytoma)
W hat adverse effects can be seen with maternal A C E inhibitor or A R B use?

_________(+/- renal failure) > oligohydramnios intrauterine
growth restriction (IUGR), limb contractures,_______________________________,
lack of skull ossification (> craniofacial deformation), in utero death
W hat doses of radiation are considered safe in pregnancy?

Less than 0.05 Gy (5 rads) over the pregnancy - no evidence of any harm to the fetus
Risk of fetal malformations increases after 0.10 Gy (10 rads)
Examples of fetal radiation exposure in maternal imaging: IVP (up to 0.9 rads), barium
enema (up to 1.6 rads), abdominal C T (about 0.25 rads)
(1 Gray = 100 rads)
7.
Identify the following teratogens based on the defects:

Phocomelia
Deafness
Spina bifida, hypospadias
Cardiac (Ebstein) anomalies
Craniofacial defects, IU G R, CNS malformation,
stillbirth
Fingernail hypoplasia, craniofacial defects
Central nervous system, craniofacial, ear and
cardiovascular defects
Goiter, cretinism
Cerebral infarcts, intellectual disability
Clear cell vaginal cancer, adenosis, cervical
incompetence
8.
W h a t are the m ain fetal complications o f tobacco use in pregnancy?
9.
H o w are migraines treated in pregnancy and why?
USE
Yellow or brown teeth
MATERNAL DRUG
End of Session Quiz
CONGENITAL INFECTIONS
3 Question Warm-Up
1.
W h a t is the definitive cure for preeclampsia?
2.
W h a t is the treatment for macular degeneration? W h a t is the treatment for

retinal detachment?
3.
W h a t are the characteristic findings in tertiary syphilis?
W hat are the signs and symptoms seen in a newborn exposed to rubella virus
in utero (congenital rubella)?
Findings at birth: IUGR, radiolucent bone disease, hepatosplenomegaly,
thrombocytopenia, purpuric skin lesions (blueberry muffin rash), hyperbilirubinemia
Sensorineural deafness
Cataracts, glaucoma
Cardiac malformations:_________________________________
Neurologic sequelae: intellectual disability, meningoencephalitis, behavior disorders
W hat are the features of congenital syphilis?

Early manifestations (first 5 weeks of life)
Hepatosplenomegaly, elevated LFTs
Hemolytic anemia, jaundice
Rash followed by desquamation of hands and feet
Snuffles (blood-tinged nasal secretions)
Radiographic changes at birth: metaphyseal dystrophy and periosteitis
Late manifestations (if left untreated in the first 3 months of life)
Hutchinson teeth (notching or blunting of the upper incisors)
Saddle nose deformity
Frontal bossing
Saber shins (anterior bowing of the tibia)
90% are asymptomatic at birth >15% of these go on to develop progressive hearing loss
(usually unilateral)
Symptoms at birth: small for gestational age, hepatosplenomegaly, petechiae/purpura,
jaundice
Neuro: microcephaly, seizures, intracranial calcifications, feeding difficulties, hydrocephaly
Ophtho: chorioretinitis, optic atrophy, central vision loss
Thrombocytopenia, hemolytic anemia
7. W hat congenital defects are associated with new varicella infection during
pregnancy?
Skin dermatomal scarring
Chorioretinitis, cataracts, microphthalmos, nystagmus, Horner syndrome

Microcephaly, cortical atrophy, intellectual disability
Hypoplasia of the hands and feet
Low birth weight
Early death
8. W hat congenital defects are associated with maternal zoster reactivation?
9.
W hen should you provide intrapartum antibiotic prophylaxis for Group B Strep
(GBS)?
GBS detected on vaginal-rectal screening culture a t_________________ weeks

GBS bacteriuria during the current pregnancy
History of early-onset GBS in a previous infant
Intrapartum fever (> 38C or 100.4F), preterm labor (< 37 weeks gestation) or prolonged
rupture of membranes (>18 hrs) if previous screening was not done
10. W hat antibiotics can be used for intrapartum prophylaxis for Group B Strep
(GBS)?
_________________ 5 million units IV, then 2.5 million units IV q4 hours or

_________________ 2g IV, then lg IV q4 hours
If penicillin allergic (h/o rash only), cefazolin 2g IV then lg q8 hours
If penicillin allergic (h/o airway compromise), then GBS culture with antibiotic sensitivity
testing + one of the following: vancomycin lg IV ql2 hours (or if sensitivity is known,
use clindamycin 900mg IV q8 hours or erythromycin 500mg IV q6 hours instead of
vancomycin)
CONGENITAL IN FE C T IO N S
W hat congenital defects are associated with in utero CM V infection?
CONGENITAL INFECTIONS
End of Session Quiz

11. W hat are the indications for Group B Strep prophylaxis?
12. W h a t congenital infection is a leading cause o f preventable blindness?
13. W hich congenital infection is associated with each o f the following defects?
? Initially asymptomatic, but later develops a unilateral hearing loss
o Hydrocephalus, intracranial calcifications, chorioretinitis
Rash, deafness, cataracts
Hearing loss, chorioretinitis, intracranial calcifications
PDA or pulmonary artery stenosis
<* Anemia, blood-tinged nasal secretions, hepatosplenomegaly
Temporal lobe encephalitis
14. W h a t measures are im portant in preventing vertical transmission o f H IV ?
15. W h a t advice should you give a mother w ith H IV about breastfeeding her
infant?
1.
W h a t are the causes o f fever in the post-op period?
2.
W h a t medication is given for seizure prophylaxis in severe preeclampsia?
3.
W h a t is the m ost com m on cause o f bloody nipple discharge?
COM PLICATIONS PART I
3 Question Warm-Up
OBSTETRIC
OBSTETRIC COMPLICATIONS PART I
4. W hen can m ethotrexate be used in the treatm ent of ectopic pregnancy rather
than surgical removal?
M ethotrexate can usually be used successfully if the following criteria are met:
Hemodynamically stable
Reliably compliant with post-treatment monitoring
Pretreatment serum hCG < 5,000 mlU/mL
Tubal size less than 3cm and no fetal cardiac activity on US
No contraindications to methotrexate (breastfeeding, immunodeficiency, renal
insufficiency, etc.)
[ 367 ]
E n d o f Session Q uiz
5. W hat are some risk factors for ectopic pregnancy?
6.
W hen is it appropriate to treat an ectopic pregnancy medically vs. surgically?
7.
W h a t are the differences in presentation between the following different types

o f spontaneous abortion (SAB): threatened, inevitable, missed, completed, and
incomplete?
IU P on sono + yag bleeding prior to 20 wks
+ closed internal cervical os
Nonviable IU P on sono + open cervical os +
no tissue passed
Nonviable IU P (fetal demise) that has not
passed (lack of uterine activity)
Open cervical os + tissue at or beyond
cervical os. Some, but not all, of the POC
have passed
All PO C have been passed
8.
W h a t is the m ost common cause o f first trimester spontaneous abortions?
9.
W h a t is the presentation and management for inevitable abortion?
10.
Up to w hat gestational age can a dilation and evacuation be used in the

management o f intrauterine fetal demise? A fter this time?
OBSTETRIC COMPLICATIONS PART 2
3 Question Warm-Up
1.
W h ich congenital infection m ight present w ith a blueberry muffin rash?
2.
A child has flesh-colored, umbilicated lesions to the face. W h a t are these

lesions, and where do they appear in adults?
3.
W h ich childhood psychiatric disorder matches each o f the following

statements?
Females only, loss o f previously acquired language
and motor skills
Impairments in social interactions,
communications, play; repetitive behaviors
Impairm ent in social interaction (but not
avoidance), no language delay
Stereotyped hand movements
Ignoring the basic rights o f others
Characterized by hostility, annoyance,
vindictiveness, disobedience and resentfulness
Multiple motor and vocal tics
Impulsive and inattentive
7-year-old that avoids going to school to stay home
with parent
4. W hat tests are used to confirm rupture of membranes?

Pooling of amniotic fluid in vaginal vault visible on sterile speculum exam
o ___________________________ _____ : turns blue in the alkaline amniotic fluid
(normally urine and vaginal secretions are acidic)
o ___________________________ ______ : electrolyte-rich amniotic fluid dried on a glass
microscope slide crystallizes in a fern-leaf pattern
Oligohydramnios confirmed by ultrasound can also be useful

5.
W h a t is the most frequent initial ultrasound finding for IUGR?
H ow would gastroesophageal atresia affect the amount o f amniotic fluid?
7.
W h a t might cause oligohydramnios in the 2nd trimester? 3rd?
8.
By what mechanism do N SA ID s decrease amniotic fluid volume?
9.
W h a t is the definition o f PRO M ?
10.
W hen should you suspect chorioamnionitis in a patient w ith PROM ?
11.
In general, w hat are the A F I findings for oligohydramnios and polyhydramnios?
3 Question Warm-Up
1.
W h a t are the diagnostic criteria (Jones criteria) for rheumatic fever?
2.
W h a t therapies are used in treating polycystic ovarian syndrome?
3.
W h a t imaging study is preferred for imaging soft tissue in joint injuries, such as
ligamentous tears? W h a t about bone?
4. W hat drugs can be used as tocolytics?

Vasodilator: tachycardia, H A , flushing,
+/- hypotension
M ost commonly used 3-agonist for labor
inhibition
Contraindicated in cardiac disease and poorly
controlled DM
SE: maternal/fetal tachycardia
Risk of magnesium toxicity
Contraindicated in myasthenia gravis
Possible premature closure of ductus arteriosus if
given for more than 48 hours
0 Decreases amniotic fluid production >
oligohydramnios
W hat are the signs and symptoms of magnesium toxicity? W hat is the reversa
agent?
O
o
Reversal asrent is
compromise.
(9.6-12 msr/dD
(12-18 mg/dL)
(24-30 mg/dL)
la; IV over 5-10 min for situations of cardiorespiratory
End of Session Quiz

6. W hat are the risk factors for placenta previa?
7.
W h a t is the management o f a woman in labor who has a complete placenta

previa?
8.
W h a t are the risk factors for placental abruption?
O
CD
EE
n
n
o
3 Question Warm-Up
1.
W h a t is the treatm ent for epididymitis?
2.
W h a t medications are used in the treatm ent o f W egeners granulomatosis?
3.
A patient has signs o f peritonitis 6 hours after sustaining blunt traum a to a fully
distended bladder, and you are suspicious o f a rupture o f the bladder. W h at
portion o f the bladder m ust have been injured to allow for a chemical peritonitis
to develop?
n
>
H
o
z
on
5
73
Gestational Trophoblastic Disease

4. W hat is the treatm ent for metastatic choriocarcinoma?
0 ______________________ to eradicate any drug-resistant local disease and shorten the
course of chemotherapy
Chemotherapy
Single agent for stage I and II .
. or dactinomycin
Combination for stage ll-IV - (EMA/CO) etoposide + methotrexate + dactinomycin,
then cyclophosphamide + vincristine
If future fertility is desired chemotherapy alone, then hysterectomy only if
chemotherapy is ineffective
Infertility
5. W hat are the first steps in the work-up of an infertile couple?
____________ collected after 48-72 hours of abstinence (30-40% of infertility is due to the
males sperm)
Evaluation for anovulatory cycles (20%)
Careful menstrual history
Basal body temperature monitoring - rise in progesterone (2 days after LH surge)
corresponding to I day after ovulation
Home urinary ovulation test (detects LH surge in urine I day prior to ovulation), then
postovulation serum progesterone level ( > 5 ng/mL indicates ovulation)
+/- Endometrial biopsy on day 26 of cycle
_______________ to r/o anatomic disorder (30%). Performed after menses cessation, but
prior to ovulation.
+/- Postcoital test: Performed 1-3 days prior to ovulation, 2-12 hours after intercourse.
[ 373]
W hat are some of the different anatomic causes of infertility in women?

Scarring of fallopian tubes most commonly from prior STD
O
Adhesions from prior surgery or pelvic inflammation (STD, appendicitis, IBD)
Tumor, fibroids (leiomyomata)
Traumatic disruption of normal anatomy
Congenital anomalies such as septate uterus
End of Session Quiz

7.
W h at is typically included in an infertility work-up?
8.
A 19-year-old G2P1 presents at 9 weeks gestation. She is vomiting all day every
day and has lost 7% o f her body weight. O n ultrasound, no gestational sac is
found, but rather, there is a snow storm appearance to the uterine contents.
W h a t is the management o f this patient?
9.
This same patient is lost to follow-up, only to present back to clinic 8 months
later complaining o f vaginal bleeding and hemoptysis. H er uterus is enlarged,
but on ultrasound, there is no gestational sac. Rather, there is a uterine mass
w ith a mix o f hemorrhagic and necrotic areas w ith parametrial invasion. W h a t
is her prognosis?
L&D: ASSESSMENT OF FETUS
3 Question Warm-Up
1.
W h ich antibiotics should be avoided during pregnancy due to potential

teratogenic effects?
2.
W h a t laparoscopic findings can be seen in endometriosis?
3.
W h y is thiam ine given in a glucose infusion to alcoholics w ith hypoglycemia?
4. Abnorm al fetal heart rates

* Sensitivity is only about 85% and specificity is poor >many infants with
nonreassuring F H R are in good condition.
Fetal tachycardia FH R > 160bpm for > 10 minutes
Fetal bradycardia - FH R < llObpm for > 10 minutes
Sinusoidal baseline 120-160 bpm with oscillating amplitude of 5-15 bpm, often due to
fetal anemia
Loss of variability poor short-term or long-term variability, due to fetal sleep, CNS
depression, or fetal acidosis; normal variability ranges from 6-25 bpm
Early decels begin with uterine contraction, due to pressure on the fetal head
Variable decels - begin before, during, or after uterine contractions (variable onset), rapid
fall in F H R often below lOObpm and rapid return to baseline, due to cord compression
Late decels begin after the uterine contraction, maximal after peak of contraction, and
return to baseline after contraction complete; due to uteroplacental insufficiency / fetal
hypoxia
5. W hat is the differential diagnosis for fetal tachycardia?

o
0 Fetal anemia
Fetal tachyarrhythmias (HR > 200)
Maternal thyrotoxicosis
Drugs or medications (_
Fetal hypoxia
Fetal immaturity
., atropine)
6. W h at type of fetal surveillance strategy is typical for high-risk pregnancies?
7.
W h a t is considered a norm al, reactive non-stress test?
L&D: ASSESSMENT OF FETUS
8. What are the first steps in the management of non-reassuring fetal heart tones
during labor?
Place maternal 0 2 + t urn off Pitocin (remove cervidil)

+ turn mom to left side
Correct hyperstimulation if needed w ith
0.25mg SubQ_
Correct any maternal hypotension (often associated with epidural). IVF bolus if needed
SVE and place FSE (check for cord prolapse)
Consider need for intervention such as amnioinfusion or C-section

9.
M atch the following statements to the type o f deceleration with which they
belong:
A check mark-shaped fetal heart
tracing
Onset either before, during, or
after uterine contraction
Consistent dips in fetal heart tones
when uterine contractions begin
Occur after uterine contraction has
begun
Unpredictable changes in fetal
heart tone tracing
10. W h a t is the usual physical cause o f each o f these types o f decelerations?

Early
Variable
Late
11. W h a t would be some contraindications to fetal scalp electrode placement?
i 376 |
L&D: LABOR
3 Question Warm-Up
1.
A patient comes to the E R s/p M VA with a suspected tib/fib fracture. The

patient s lower leg is pale, the dorsalis pedis pulse is absent, and the patient has
pain w ith passive motion o f the leg. W h a t is the treatment?
2.
Undescended testes put a patient at higher risk for what condition?
3.
A n African-American teenager presents to the E R w ith right hip pain and a

hematocrit o f 25%. W h a t is the most likely diagnosis?
Stages of Labor
4.
W hat defines prolonged active phase of labor?

Nulliparous <_______________ cm/hour dilation
Multiparous <
cm/hour dilation
5. W hat type of contraction pattern is typically necessary for cervical dilation to

occur?
6. W hat are the 3 Ps that must be assessed in the event of labor dystocia?
__________________ - contraction strength, duration, and frequency
__________________ - fetal weight; fetal lie, presentation, and position
__________________ - adequacy of pelvis in shape and diameter
7. W hat is the definition of arrest of descent? In general, how is it managed?

Arrest of descent occurs when stage 2 of labor lasts > 2 hours in multips and > 3 hours
in primips (with epidural)
Management
Reassess the 3 Ps
Placement of IUPC to better assess Power (> 200 MVU/lOmin)
Augmentation with oxytocin to augment Power
C-section if power, passenger and passage are unable to be further augmented
Induction of Labor
8. W hat is the definition of uterine hyperstimuiation (tachysystole)? W hat
adrenergic agonist is particularly helpful in reversing uterine hyperstimuiation?
Uterine hyperstimuiation is defined by one of the following:
> 5 contractions over 10 minutes, averaged over a 30-minute window
A single contraction > 2 minutes in duration
Terbutaline 0.25mg sub-q is often used as a tocolytic to stop uterine contractions

9.
W h a t is the definition o f arrest o f descent?
10.
One hour into the active stage o f labor, a fetus heart tones become
nonreassuring. W h a t actions are taken immediately?
11.
In addition to the actions taken above, w hat else would you do to manage
uterine hyperstimuiation?
12.
W h a t is the role o f fetal pulse oximetry in labor and delivery?
L&D: MALPRESENTATION AND CESAREAN SECTION
3 Question Warm-Up
1.
W h a t are the symptoms o f a lacunar stroke?
2.
W h a t are the classic symptoms o f placenta previa?
3.
W h a t is the next step in the evaluation o f a patient w ith two consecutive Pap
smears w ith atypical squamous cells o f undeterm ined significance (ASCUS)?
4. W hat are the management options in the case of a breech presentation?

Spontaneous version often occurs (25% of the time after 36 weeks)
C-section at time of labor is currently the standard of care when cephalic version is
unsuccessful, due to a decrease in neonatal morbidity and mortality
_____________________ should be offered to all women with breech pregnancy when near
term (after__________ weeks) (ACOG). Success rate is 35-75%
Vaginal delivery only if there is no time for a C-section
Deliver the feet and legs
- Deliver the body (no traction above the pelvis) and rotate
- When scapula visible, sweep posterior arm
Sweep anterior arm
- Rotate head to O A position
Flex head for delivery by applying fingers to nose/maxillary prominences and applying
maternal suprapubic pressure.
5.
H ow should a breech presentation be managed after 36 weeks gestation?
6.
W h at are some indications for cesarean section?
7.
About what potential events must patients considering VBAC be counseled?
L&D: MALPRESENTATION
AND CESAREAN SECTIO N
End of Session Quiz
[ 380 ]
POSTPARTUM CARE
3 Question Warm-Up
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y
( " 'V '
1.
H ow old would a child have to be before diagnosis o f a nocturnal enuresis could

be made?
2.
A 19-year-old college student comes to the student clinic for evaluation o f recent
fatigue and sore throat. She says that she has never gotten so tired w ith sore
throats in the past, but this one has wiped her out. She does not remember
having any sick contacts. O n exam, she has posterior cervical lymphadenopathy,
fever, and an easily palpable spleen. W h a t test might confirm the diagnosis?
W h a t do an elevated erythropoietin level, elevated hematocrit and normal 0 2

saturation suggest?
Breastfeeding
4. W hat are some of the contraindications to breastfeeding?
Hepatitis B and C are present in breast milk, but no transmission has ever been reported.
Educate patients of this, and let them make the choice.
Need to use medications contraindicated in breastfeeding such as________________ ,
chloramphenicol, topiramate, antineoplastic agents o r________________ .
Use of illicit drugs
Infantile galactosemia
OK in breastfeeding:
- __________________ (must also monitor levels in the newborn)
- __________________ (does not pass into breast milk)
- __________________ (passes into breast milk but appears to be relatively safe)
(passes into breast milk and generally recommended to limit
consumption to I glass a day)
I [381 ]
POSTPARTUM CAR
5. W hat is the treatment for mastitis in a postpartum woman?

Continue nursing and/or pumping breast milk
Rest and ibuprofen
Antibiotic choices for 10-14 days: dicloxacillin cephalexin, amoxicillin-clavulanate (if
no response to other agents in 24-48 hours), TMP-SMX (for presumed MRSA), add
metronidazole 500mg PO tid (if odor suspicious of anaerobes)
Incision and drainage
6.
How is a clogged milk duct (galactocele) distinguished from mastitis?
7. W hat type of oral contraceptive can be given to lactating women?
8. W hat is the treatment for a woman who does not wish to breastfeed
postpartum?
Postpartum Bleeding
9. W hat are the risk factors for uterine atony?
Uterine overdistention: multiple gestations, polyhydramnios, macrosomia
Exhausted myometrium: prolonged labor, oxytocin stimulation
Decreased ability to generate contractions: chorioamnionitis, use of Mag sulfate (e.g., in
preeclampsia), general anesthesia, uterine fibroids
Prior history: multiparity, prior history of postpartum hemorrhage
10. W hat are the treatment options for uterine atony/postpartum hemorrhage?
o
__________________________ 10 units IM xl (or IV)

Methergine (methylergonovine) 0.2mg IM (ergot agent that is contraindicated if HTN)
Hemabate (PGF2 ) 0.25mg IM or intrauterine (contraindicated if asthma)
Surgical options: uterine artery ligation, internal iliac artery ligation, selective arterial
embolization or hysterectomy
Dilation and curettage (D&.C) if there is retained placenta
Tamponade
[ 382
Postpartum Endometritis
II.
W hat are the characteristic features of postpartum endometritis?

0 Incidence < 3% after vaginal delivery, but increased risk with c/s, prolonged ROM,
multiple cervical checks, manual placental removal, internal monitors (IUPC)
Fever on postpartum day 1-7 (temp > 100.4F twice or > 101F)
O
Absence of other potential fever etiologies (especially UTI)
May also have: foul lochia, chills, lower abdominal pain
Leukocytosis with a left shift
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12. W hat is the treatm ent for postpartum endometritis?

0 Antibiotic options:
_____________________________+/- ampicillin 2g IV q6 hour
Ceftriaxone + clindamycin
- Ampicillin-sulbactam (Unasyn) + doxycydine
Cefoxitin + doxycydine
Continue antibiotics until afebrile for 24-48 hours
No need for PO antibiotics after IV antibiotics unless blood culture is positive, in which
case 7 days of oral antibiotics are given (e.g. clindamycin)
End of Session Quiz

13. A postpartum wom an presents w ith pain and tenderness o f the breast that is
limited to only one region. There is no redness or warm th. W h a t is the most
likely diagnosis?
14. W h e n can O C P s be initiated in postpartum patients who do not intend to

breastfeed?
15. W ith in the immediate postpartum period, a patient develops sudden-onset

hypoxia, cardiogenic shock and D IC . W h a t etiology is at the top o f your
differential?
16. A patient loses more than 500 cc o f blood postpartum and now has anemia.
Attem pts at breastfeeding have been unsuccessful, as it appears she is unable to
generate any milk. W h a t diagnosis do you suspect?
[ 383 ]
Pediatrics
1
D evelopm ent
Infancy to Adolescence
Infections and Im m une D isorders
G enetic D isorders
Preventive M edicine
DEVELOPMENT
3 Question Warm-Up
1.
W h a t is the next step in the evaluation o f penetrating injuries to the

different zones o f the neck?
2.
W h a t are the cardinal movements o f labor?
3.
A n IV drug user has JV D and a holosystolic m urm ur at the left sternal border.
W h a t is the diagnosis? O r w hat is the treatment?
4. C a r Seats
<2 years: Rear-facing car seat unless they outgrow the weight or height limit for their car
seat. Preferably in the middle of the back seat
2-4 years: Forward-facing car seat with a harness for as long as possible up to the highest
weight or height allowed for their car seat
4-12 years: Continue with forward-facing car seat until weight or height limit reached
for car seat. Then switch to belt-positioning booster seat until the vehicle seat belt fits
properly. Typically when they have reached 4 feet 9 inches in height and are between 8-12
years of age.
Older children: Always use lap and shoulder seat belts. All children younger than 13
should be in the rear seats of the vehicle
End of Session Quiz

5.
W hen do children first exhibit separation anxiety? W hen is gender identity

typically formed?
6.
H ow would you expect weight to increase in the first 2 years o f fife?
7.
W h e n can children begin to eat solid foods? W h en can children drink

cows milk?
8.
H ow many total doses o f the D T aP vaccine should a 6-year-old have received?
9.
A t w hat age is the m eningococcal vaccine indicated?
INFANCYTO ADOLESCENCE
3 Question Warm-Up
1.
W h a t m edications and interventions are used in the treatm ent o f cerebral

palsy to alleviate contractures and improve function?
2.
A 15-year-old pregnant girl requires hospitalization for preeclampsia.

Should her parents be inform ed?
3.
W h a t is the treatm ent for m astitis in a patient th a t is breast feeding?
Neonates
4.
How many calories are present in an ounce of breast milk? How many calories
are present in an ounce of formula?
5. W hat are the caloric needs for an infant younger than 6 months?
6. W hat work-up should be performed on a newborn with a single umbilical

artery?
Occurs in about 0.5% of births and 20-30% of these infants have major structural
anomalies
___________________________as 7% will have clinically significant (but asymptomatic)
renal anomalies
7.
W hat are the m ost com m on problems that arise in premature infants?
, hypoglycemia, persistent PDA, infection/sepsis,

retinopathy of prematurity, intraventricular hemorrhage, necrotizing enterocolitis
8. W hat is the difference between caput succedaneum and cephalohematoma?

Caput - diffuse swelling or edema of the scalp,____________________ , resolves within
a few days
Cephalohematoma - subperiosteal hemorrhage,
, resolves in weeks
to months
INFANCY TO AD O LESCEN CE
9. W hat is the next step in the management of a newborn female with bloody
vaginal discharge in the first week of life?
10. Benign Skin Findings in the Newborn
Cutis marmorata -
of the skin. Non-concerning.
Erythema toxicum neonatorum - 2-3mm yellow pustule with red base (similar appearance
to white head) arising in first 24-72 hours, microscopic examination of the pustular
contents (not necessary for diagnosis) reveals numerous________________________ ,
usually gone by 3 weeks, tell parents to leave alone
Harlequin color change - intense reddening of gravity-dependent side and blanching of the
nondependent side with a line of demarcation between the two, lasts a few sec-min, affects
10% of newborns (more common in newborns), most common in first few days of life, may
be due to immaturity of autonomic innervation to skin vessels. Completely benign and will
resolve in days to 3 weeks.
Macular stains (stork bites) - permanent vascular malformations most commonly
occurring on the nape of the neck, but also upper eyelids and middle of forehead. Benign
bu t______________________.
Milia (miliaria) - due to accumulation of sweat beneath eccrine sweat ducts that are
obstructed by keratin at the stratum corneum, usually develops in 1st week after birth,
associated with excess warmth (incubator, excess clothes, fever). No treatment is needed,
except possibly to reduce sweating with loose clothing and cool baths.
Mongolian spot - bluish discoloration over buttocks and base of spine, probably present on
at least one of the parents. Benign and will usually fade in 1-2 years.
___________________________ to avoid later confusion with bruises.
Neonatal acne (acne neonatorum) - seen in 20% of infants, due to maternal hormone
stimulation of sebaceous glands, usual age of onset is 3 weeks old. There is no increased
risk of acne in adolescence. Mild lesions should be left alone and will resolve in 4 months.
Severe inflammation can be managed with benzoyl peroxide or topical retinoids.
Infantile acne - different than neonatal acne, onset usually at 3-4 months of age, yellow
papules around nose and cheeks, usually clears by age 1, but may persist until age 3.
Severe inflammation can be managed with benzoyl peroxide or topical retinoids.
Transient neonatal pustular melanosis - superficial pustules overlying hyperpigmented
macules. Tell parents to leave alone.
II.
W hat medications can be used to treat thrush in an infant?
12. W hat are the risk factors for Sudden Infant Death Syndrome (SIDS)?
Usually occurs a t_________________ old
0 Usually occurs while infant is sleeping
Maternal risk factors: low SES, age < 20, drugs/cigarettes during pregnancy, late or no
prenatal care
INFANCY TO A D O LESCEN CE
Infancy
Infant risk factors: low birth weight, male, premature, prior sibling with SIDS, prone sleep
position, sleeping on a soft surface, overheating
Preventive measures:
13. W hen would you expect the anterior fontanelle to close in a child? W hat
would you suspect if it did not close in the expected time frame?
Closed in 1% by age 3 months, 38% by 12 months, and 96% by 24 months
I f delayed, consider:__________________, achondroplasia,__________________,
congenital hypothyroidism and increased intracranial pressure
If closure < 3 months, carefully monitor head circumference for craniosynostosis
(premature closure of cranial sutures)
Craniotabes (soft occipital bone, like ping-pong ball) from 3-12 months is highly
suspicious for rickets
14. W hat are the signs of severe dehydration in a child?

M ILD
M O D ER A TE
SEVERE
Older child (3%)

30m l/kg
Older child (6%)

60m l/kg
Older child (9%)

90m l/kg
Infant (5%) 50m l/

kg
Infant (10%)
lOOml/kg
Infant (15%) 150ml/

kg
Skin turgor
Normal
Tenting
none
MM
M oist
Dry
Parched/cracked
Tears
Present
Reduced
none
Fontanelle
Flat
Soft
Sunken
CNS
Consolable
Irritable
Lethargic
HR
Normal
M ild increase
Increased
Cap refill
< 2 sec
About 2 sec
> 3 sec
Urine out
Normal
Decreased
Anuric
[391
INFANCY TO AD O LESCEN CE
Adolescence
15. W hat mnemonic can you use for the questions you should ask during an annual
adolescent exam?
SHADESSS:
End of Session Quiz

16.
H ow many kilocalories are in an ounce o f breast milk? Formula?
17. W h a t is the #1 killer o f adolescents and why?
18. W h at newborn skin finding matches each o f the following descriptions?

2-3mm yellow pustule with red base (similar
appearance to white head) arising in first 24-72
hrs, microscopic examination of the pustular
contents (not necessary for diagnosis) reveals
numerous eosinophils, usually gone by 3 wks
Spider-webbing/marbling of the skin
Intense reddening of gravity-dependent side

and blanching of the nondependent side with a
line of demarcation between the two, lasts a few
sec-min
Due to accumulation of sweat beneath eccrine
sweat ducts that are obstructed by keratin at the
stratum corneum
3 Question Warm-Up
1* W h ic h vasopressor m atches each o f the following statements?
Theoretically causes renal vasodilation
High doses optimize the CXl vasoconstriction
A D H analogue
Best choice for anaphylactic shock
Best choice for septic shock
0 Best choice for cardiogenic shock
Causes vasoconstriction, but with bradycardia
2.
W h a t m edication is given to accelerate fetal lung m aturity, for how long is it

given, and at w h at gestation is it no longer necessary?
3.
A pediatric p atien t presents w ith red currant jelly stools. W h a t is the

diagnosis?
INFECTIONS AND IMMUNE D ISO RDERS
INFECTIONS AND IMMUNE DISORDERS
Pediatric Rash
4. W h at are the clinical features of measles infection (rubeola)?
Prodrome for 2-3 days: fever, malaise, anorexia and 3 Cs (cough, coryza, conjunctivitis)
__________________ on buccal mucosa after 1-2 days (white-gray spots with a red base)
>occur 48 hours prior to rash. Pathognomonic for measles
Rash five days after prodrome onset: erythematous, maculopapular starting at the head
then spreading to the feet >lasts 4-5 days >resolves from head down
5. W hat is the treatm ent for measles?

Supportive therapy (antipyretics, fluids)
Monitoring and treating bacterial superinfections such as pneumonia or otitis media
O
100,000 IU PO xl in 6 -to 12-month-olds, 200,000 IU PO xl if olderthan 12 months
W H O recommends vitamin A to all children with measles in areas where vitamin A
deficiency is prevalent and measles mortality exceeds \%
- A A P recommends vitamin A given as above to children 6 months - 12 years
hospitalized for measles or its complications, or if immunodeficient or high likelihood of
vitamin A deficiency (ophthalmologic evidence, intestinal malabsorption, malnutrition or
recent immigration from an area with high measles mortality)
is not yet well studied and not currently standard of care for
measles, despite that it harms measles virus in vitro
-
I [ 393 ]
6. W hat are the classic features of rubella virus (German measles)?
Low grade fever, lymphadenopathy and rash

Prodromal malaise, fever, anorexia for 1-5 days prior to rash
Lymphadenopathy __________________________________________________
Erythematous, tender, maculopapular rash that starts at the___________________ , then
generalizes
Rash persists 5 days and does not darken as does the rash of measles
Fever is mild and generally only on day 1, in contrast to measles
Polyarthritis may be seen for up to a month in women and adolescents
7. W hat are the characteristic features of Coxsackie hand, foot, and mouth
disease?
Constitutional fever and anorexia
________________________ on the buccal mucosa and tongue
Small, tender, maculopapular/vesicular rash on th e_________________________and
sometimes buttocks
Duration is typically 3-5 days without complications
8. W hat are the signs and symptoms of scarlet fever caused by Strep, pyogenes?
Rash that is coarse (sandpaper-like), erythematous and blanching (sunburn-like)

Rash starts on the trunk then generalizes, but________________________
Rash is most prominent in skin creases of axilla and groin (Pastias lines/sign)
________________________ , beefy-red pharynx, cervical LAD
Fever/chills
Later desquamation of hands and feet (additional DDx Kawasaki disease, toxic shock
syndrome, acrodynia of mercury poisoning)
Positive throat culture or rapid strep test
9.
W hat are the characteristic symptoms of roseola infantum (HHV-6)?

Sudden, high fever (exceeding 102 F) for 3-4 days
Child has no other signs of infection and often acts/plays normally
Rash that appears when fever dissipates and starts on the trunk then spreads over entire
body and lasts 24 hours
0 Other common findings: erythematous papules on soft palate and uvula, mild cervical
LAD, edematous eyelids, bulging anterior fontanelle in infants
0 Commonly misdiagnosed as acute otitis media and subsequent antibiotic allergy!
10. W hat is the treatment for roseola infantum?
11. W hat is the differential diagnosis for cervical lymphadenitis in a child?

0 If acute and bilateral > usually viral
URIs: Rhinovirus, Adenovirus, Influenza, group A Strep
Mono: EBV, CMV, Mycoplasma
- Other viruses: HIV, HSV
If acute and unilateral >usually bacterial {Staph, aureus, group A Strep > anaerobes,
GBS)
If chronic and unilateral:
Bartonella henselae > cat scratch fever
Toxoplasmosis
TB scrofula
- Actinomyces israelii sinuses drain pus
Noninfectious causes (much less common): Kawasaki disease, Hodgkin lymphoma
INFECTIONS AND IMMUNE DISO RDERS
O ther Pediatric Infections
12. W hat is P FA P A syndrome?

Benign 4-5 day syndrome consisting of Periodic Fever, Aphthous ulcers, Pharyngitis, and
Adenitis
Occurs monthly (q28 days)
Exclusion criteria include neutropenia, cough, coryza, diarrhea, severe abdominal pain,
rash, arthritis and neuro defects
Usually affects preschool-aged children (2- to 5-year-olds)
0 Benign, self-limiting disease
Treatments
Glucocorticoids relieve symptoms in a matter of hours
Cimetidine may be used for prevention of episodes, but is of questionable efficacy
Average duration of recurring symptoms is 4.5 years
13. W hat are the classic symptoms of pertussis?

Incubation 7-10 days
Catarrhal stage (7-10 days): mild URI symptoms
Paroxysmal stage (_____________________): paroxysms of cough with inspiratory whoop
that is worse at night and often with post-tussive emesis and exhaustion
Often confused with acute bronchitis
0 Convalescent stage (2-3 weeks): waning of symptoms
14. W hat is the treatm ent for pertussis?

Antibiotic choices:___________________ (5 days), erythromycin (14 days), clarithromycin
(7 days), TM P-SM X (14 days)
Prophylaxis for close contacts (full course of one of the above antibiotics)
Isolation from school/day care until 5 days of antibiotics have been completed, or three
weeks after the onset of symptoms in untreated patients
Hospital admission (with isolation) indications for children with pertussis:
Respiratory distress
Pneumonia
Inability to feed
Cyanosis or apnea (with or without coughing)
- Seizures
395
15. W hat additional work-up, if any, is needed in a child diagnosed with a UTI?
Renal and Bladder Ultrasound (RBUS)
Child < 2 years with febrile UTI
Child any age with recurrent febrile UTIs
Child any age with family history of urologic disease, poor growth or hypertension
Child with UTI that does not respond to antibiotics
Voiding Cystourethrogram (VCUG)
Child any age with > 2 febrile UTIs
Child any age with first febrile UTI and family history of urologic disease, poor growth or
hypertension
Immunodeficiencies
16. Bruton Agammaglobulinemia
X-linked (Boys)
B cell deficiency >defective tyrosine kinase gene >low levels of all immunoglobulins
Recurrent bacterial infections after 6 months
No B cells on peripheral smear
17. Thym ic Aplasia (DiGeorge Syndrome)

3rd and 4th pouches fail to develop >
No thymus >no mature T cells
No parathyroids > no PTH > low Ca2+ tetany
Congenital defects in heart / great vessels
Recurrent viral, fungal, protozoal infections
0 90% have a chrom 22qll deletion
18. Severe Combined Immunodeficiency (S C ID )

Defect in early stem cell differentiation
Can be caused by at least 7 different gene defects (e.g., adenosine deaminase deficiency)
Presentation Triad
1) Severe re c u rre n t infections
- Chronic mucocutaneous candidiasis

- Fatal or recurrent RSV, VZV, HSV, Measles, Influenza, Parainfluenza
- Pneumocysticjirovetii pneumonia (PCP)
2)
C hronic diarrhea
3)
Failure to thrive
No thymic shadow on newborn CXR

DO NO T GIVE LIVE VACCINES
19. Chronic Mucocutaneous Candidiasis

T cell dysfunction v. C. albicans
Rx: antifungals (ketoconazole, fluconazole)
96
Wiskott
Aldrich
Immunodeficiency
Thrombocytopenia and purpura
Eczema
Recurrent pyogenic infections
21. Ataxia-Telangiectasia
IgA deficiency
Cerebellar ataxia and poor smooth pursuit of moving target with eyes
Telangiectasias of face > 5yo
[ Cancer risk: lymphoma 8c acute leukemias
Radiation sensitivity (try to avoid x-rays)
+/- 'j'AFP in children > 8m
Average age of death = 25 years
INFECTIONS AND IMMUNE D ISO RDERS
20. W iskott-Aldrich Syndrome
22. Selective Immunoglobulin Deficiencies

IgA deficiency is most common
- Most appear healthy
- Sinus and lung infections
1/600 European descent
- Associated with atopy, asthma
Possible anaphylaxis to blood transfusions and blood products
23. Chronic Granulomatous Disease (C G D )

Lack of NA D PH oxidase activity * impotent phagocytes
Susceptible to organisms with catalase {S. aureus, E. coli, Klebsiella spp., Aspergillus spp.,
Candida spp.)
Dx:
- Classic test is a negative nitroblue tetrazolium test (no yellow to blue-black oxidation)
More commonly diagnosed by flow cytometry
Prophylactic TM P-SM X
IFN-y also helpful
24. Chediak-Higashi Disease

Defective LYST gene (lysosomal transport)
Defective phagocyte lysosome giant cytoplasmic granules in PMNs are diagnostic
Presentation Triad:
1) Partial albinism
2) Recurrent respiratory tract and skin infections
3) Neurologic disorders
[ 397]
25. Hyperimmunoglobulin E Syndrome (Job Syndrome)

Deficient IFN-y * impaired neutrophil chemotaxis
High levels oflgE and eosinophils
Presentation Triad:
1) Eczema
2) Recurrent cold Staph, aureus abscesses (think of biblical job with boils)
3) Coarse facial features: broad nose, prominent forehead (frontal bossing''), deep
set eyes and "doughy skin
Also common to have retained primary teeth resulting in 2 rows of teeth
26. Leukocyte Adhesion Deficiency Syndrome

Abnormal integrins >inability of phagocytes to exit circulation
Delayed separation of umbilical cord
End of Session Quiz

27.
W h a t are the 3 Cs o f the prodrome o f rubeola?
28.
W h a t are some causes o f desquamation o f the hands and the feet?
29.
W hich viral infection is characterized by sudden high fevers for 3-4 days but is
otherwise asymptomatic? A rash will often appear when the fever dissipates.
30. W hich immunodeficiency matches each o f the following descriptions?

Congenital heart defect + low calcium
+ recurrent infections
Chronic mucocutaneous candidiasis +
chronic diarrhea + failure to thrive
Negative nitroblue tetrazolium test
Poor smooth pursuit of eyes + elevated
A FP after 8 months
Partial albinism + recurrent URIs +
neurological disorders
31. W hen do infections typically begin in children w ith immune disorders?
|398|
1.
W h a t is cradle cap and w hat is the treatm ent?
2.
W h a t is the cause o f bilious emesis in a new born w ith in hours after the first
feeding?
3.
W h a t are the tw o m ost com m on prim ary brain tum ors in adults? W h a t are
th e 3 m ost com m on prim ary brain tum ors in children?
DISO RDERS
3 Question Warm-Up
GENETIC
GENETIC DISORDERS
4. W hat is the most com m on malformation of the head and neck?
5. W hat features are characteristic of fetal alcohol syndrome?

Facial features: short palpebral fissures, thin upper lip, smooth philtrum, flattened midface
Deficient brain growth: structural brain abnormalities, < 10th percentile for head
circumference, abnormal neuro exam, variable intellectual disability
Growth retardation: < 10th percentile for height and weight, failure to thrive despite
adequate intake, disproportional low weight to height
6. W h at congenital defect is associated with lithium use during pregnancy?

Ebstein anomaly:
Tricuspid leaflets are displaced into right ventricle, hypoplastic right ventricle, tricuspid
regurg or stenosis
80% have a patent foramen ovale with a R > L shunt
Dilated right atrium >increased risk of SVT and W P W
Physical exam: widely split S2, tricuspid regurgitation
7.
W h at are the differences in presentation between a branchial cleft cyst and a

thyroglossal duct cyst?
[ 399 ]
GENETIC DISORDERS
8. W hat are the common possible presenting features of tuberous sclerosis?
9.
Distinctive brown, fibrous plaque on the forehead seen in infancy

Ash leaf spots (hypopigmented macules) - most easily identified with Woods lamp
Shagreen patch (leathery cutaneous thickening usually on the lower trunk)
Facial angiofibromas (AKA adenoma sebaceum)
Seizures
Intellectual disability
Subependymal nodules
W hich glycogen storage disease matches each of the following statements?

Lactic acidosis, hyperlipidemia,
hyperuricemia (gout)
Diaphragm weakness respiratory failure
Increased glycogen in liver, severe fasting
hypoglycemia
Hepatomegaly, hypoglycemia, hyperlipidemia
(normal kidneys, lactate, and uric acid)
Painful muscle cramps, myoglobinuria with
strenuous exercise
Severe hepatosplenomegaly, enlarged kidneys
100]
End of Session Quiz

10. I f a female child is in the 80th percentile for height and the 25th percentile
for head circum ference, w hat chrom osom al abnorm ality should you suspect?
11. W h a t genetic disorder matches each o f the following descriptions?

Cleft lip/palate, life expectancy < 1 yr,
polydactyly
High-pitched, cat-like cry
Elfin facial features, cardiac defects
Tall, thin man w ith gynecomastia and
testicular atrophy
Obesity and overeating
M icrognathia, life expectancy < 1 yr, rockerbottom feet
Happy mood, inappropriate laughter, ataxic
gait
Large ears, ID , macroorchidism
M R , simian crease, G I and cardiac defects
Short stature, infertility, coarctation o f aorta
12. A child presents w ith short palpebral fissures, a thin upper lip, smooth philtrum
and a flattened midface. H e is below the 10th percentile for height and weight,
and his IQjis 65. W h a t is the cause o f his abnormalities? W h a t could have been
done to prevent them?
13. W h ich glycogen storage disease matches each o f the following statements?
Lactic acidosis, hyperlipidemia, hyperuricemia
(gout)
Diaphragm weakness respiratory failure
Increased glycogen in liver, severe fasting
hypoglycemia
Hepatomegaly, hypoglycemia, hyperlipidemia
(normal kidneys, lactate, and uric acid)
Painful muscle cramps, myoglobinuria with
strenuous exercise
Severe hepatosplenomegaly, enlarged kidneys
PREVENTIVE MEDICINE
3 Question Warm-Up
1.
H ow can the flushing reaction o f niacin be prevented?
2.
W h a t supplements should be given to wom en on anticonvulsants during

pregnancy?
3.
W h a t findings would you expect to see in a post-term pregnancy beyond 42

weeks gestation?
W hat is the U S P S T F recommendation for hypertension screening?
W hat is the U S P S T F recommendation for cholesterol screening in patients

without C A D risk factors?
W hat specific interventions are helpful in smoking cessation?

Counseling to quit at every encounter
- Ask, assess, advise, assist, and arrange
Set a precise quit date while in clinic > instruct patient to throw away all smoking
paraphernalia including ash trays and lighters
Offer American Cancer Society Quitline: I-800-ACS-2345
Offer prescription therapies to help them quit, especially varenidine (see below)
Nicotine replacement doubles the quit rate
Much higher efficacy when used with bupropion (see below)
Patch: start 21mg > I4mg (start here in light smokers) 7mg. Titrate over 10 weeks.
Gum: chew until soft, then park it between cheek and gum for nicotine absorption
Others: inhaler, nasal spray, lozenge
Prescription therapies to help them quit
Varenidine (Chantix) 30% I year success rate (12 week therapy), 44% I year success
rate (24 week therapy) (JAMA 296:64,2006) SE: nausea, suicidal thoughts, bizarre
dreams
Bupropion (Zyban or Wellbutrin) Instruct pts to quit after I week. More effective if
used with nicotine replacement. SE: dry mouth, weight loss. Contraindications: seizure
d/o, pregnancy, already on 3 or more psychiatric meds, bulimia
Preventive Medicine for Ages 50-65

History and Counseling:
Ask and assist with smoking and alcohol use
Remind about exercise, high fiber (30-35g/day), sunscreen (SPF 15+), seat belts and highrisk behaviors
Ask about depression, assault/abuse, advance directive/will
Dental exam/cleaning q6 months-1 year
Donation of blood and bone marrow (< 60 years old)
Physical:
PE with BP check, BMI, skin cancer screen ql year
Snellen eye exam ql year
M eds/Interventions:
Daily MVI, calcium 1200mg/d and vitamin D >600 IU/d
Flu shot ql year
Tetanus-diphtheria booster (Td or Tdap) qlO years. Use Tdap instead of Td if no h/o
Tdap.
Assess for varicella immunity by h/o chickenpox/shingles, h/o vaccine, or serology >
vaccinate if nonimmune
Zostavax once after age 60 regardless of shingles history
Consider ASA 81mg QD (to help prevent M I, stroke, colon CA)
Proven benefit if 10 year Ml risk is > 10%, or annual Ml risk is > 1%
- Women who take A SA had a 25% decrease in deaths from all causes (Arch Intern Med
2007; 167:562)
Lab/Studies:
FOBT q l year
Colonoscopy qlO years or Flex sig/BE q3-5 years
TSH q5 years
Lipid Panel q5 years
Consider glaucoma screening ql-5 years (esp. Blacks)
Consider EKG q5 years
Consider regular Chem 14, UA, and CBC (ql-5 years)
Offer H IV test
PREVENTIVE M EDICINE
7.
Vitamin Supplementation
8. W hich vitamin deficiencies match each of the following descriptions?
Increased RBC fragility

Dermatitis, cheilosis, glossitis
Peripheral neuropathy, angular cheilosis, glossitis
Hemorrhagic disease
Neural tube defects
Dermatitis, diarrhea, dementia
Megaloblastic anemia
Pernicious anemia
Bitots spots, keratomalacia, xerophthalmia
Osteomalacia
Rickets
I [403 ]
Which vitamins match each of the following statements?
Can be used to treat acne and psoriasis

Involved in the hydroxylation of prolyl residues
Requires intrinsic factor for absorption
Deficiency may result from kidney disease
Given prophylactically to newborns
Can be used to elevate H D L and lower LDL
Deficiency can be caused by isoniazid use
Cobalt is found within this vitamin
End of Session Quiz

10. H ow often should a normotensive patient get their blood pressure checked?
11. W h en should you start screening for high cholesterol in otherwise healthy
patients?
12. W h ich medication for sm oking cessation carries a black box w arning about
its side effect o f suicidality?
13. W h a t sm oking cessation m ethod doubles the quit rate?
14. W h a t symptoms o f vitam in deficiencies do you get if you havent had

enough folate? A? D? E? B3?
15. W h a t vitam in can be used to treat psoriasis?
16. W h a t vitam in can be used to prevent deficiency in isoniazid?
17. W h a t vitam in can be used to elevate H D L and lower LD L?

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USMLE STEP 2 CK REVIEW

Doctors In Training.com: U SM LE Step 2 CK Review, 2014 edition

Author: Brian Jenkins, M D

Copyright 2014 D octors In Training.com , LLC

Doctors In Training.com , LLC

Normal Neuro Function

Accidents and Injuries part 1

Normal Pregnancy Physiology

Approx. 4.5 hrs

Approx. 3.5 hrs

Approx. 1.5 hrs

HOW MANY VIDEOS YOU VIEW IN A DAY.

Neurology 1 - Normal Neuro Function

Neurology 3 - O ther CNS Infections

Psychiatry 4 - Anxiety Disorders

Psychiatry 5 - Psychotic Disorders

Neurology 9 - Degenerative Disorders part 1

Neurology 10 - Degenerative Disorders part 2

Neurology 11 - Peripheral Disorders

Neurology 12 - Neoplasms and Sleep

Neurology 13 - Loss o f Consciousness

Neurology 14 - Pedi Neuro

Neurology 15 - Ophthalmology part 1

Neurology 16 - Ophthalmology part 2

Psychiatry 6 - Personality Disorders

Psychiatry 7 - Substance Abuse part 1

Psychiatry 8 - Substance Abuse part 2

Psychiatry 9 - O ther Psych Disorders

Psychiatry 10 - Delirium and Dementia

Psychiatry 11 - Pedi Psych

Endocrinology 1 - Type 1 Diabetes

Endocrinology 2 - Type 2 Diabetes

Endocrinology 3 - Insulin Therapy

Endocrinology 5 - Chronic Complications of Diabetes

RECOMMENDED COURSE ORDER

RECOMMENDED COURSE ORDER

Endocrinology 6 - Normal Thyroid Function and Hyperthyroidism

Endocrinology 8 - Parathyroid Disorders

Cardiovascular 5 - Unstable Angina

Cardiovascular 8 - Arrhythmias part 2

ER, ICU, Surgery 6 - Cardiovascular Emergencies

Cardiovascular 10 - Valvular Diseases

Cardiovascular 12 - Myocardial Infections

ER, ICU, Surgery 7 - Critical Care

Cardiovascular 16 - Vascular Conditions

Cardiovascular 18 - Pedi Cardiology

ER, ICU, Surgery 9 - Trauma part 2

ER, ICU, Surgery 11 - Pre-O p and Post-Op Issues

ER, ICU, Surgery 12 - Surgical Emergencies and Transplantation

Pulmonology 2 - Lower Respiratory Infections part 1

Pulmonology 4 - A R D S and Asthm a

Pulmonology 3 - Lower Respiratory Infections part 2

Pulmonology 6 - Neoplasms and Interstitial Lung Disease

Pulmonology 7 - Pulmonary Vascular Diseases

Pulmonology 8 - Pleural Diseases

Pulmonology 10 - Pedi Pulmonology part 1

Pulmonology 11 - Pedi Pulmonology part 2

Gastroenterology 2 - Viral Hepatitis

Gastroenterology 3 - O ral and Esophageal Conditions

Gastroenterology 4 - Gastric Conditions

Gastroenterology 5 - Small Intestine part 1

Gastroenterology 6 - Small Intestine part 2

Gastroenterology 7 - Large Intestine part 1