Professional Documents
Culture Documents
STUDY GUIDE
2014 EDITION
DOCTORS IN TRAINING*
STRUCTURED. FOCUSED. AWESOME.
B rian J enkins , MD
DISCLAIMER: THE AUTHO R DISCLAIMS ANY I.IAHIL ITY, LOSS, INJURY, O R DAMAGE INCURRED AS A CO NSEQ UENTS, DIRECTLY O R INDIRECTLY. O r THE USE A N D APPI iCAT ION O F AMY O F THE CO N TEN T A N D MATE RIAL CO NTAIN ED IN THIS TEXT. ALTHOUGH THE INFORMATION
IN THIS TEX I HAS BEEN CAREFULLY REVIEWED I OR CORRECTNESS. Wlf AUTHO R CA N N O T ACCEPT ANY RESPONSIBILITY FOR ANY ERRORS
O R OMISSIONS THAT MAY BE MADE. THE A U 1IIO R MAKES N O W ARRANT Y, EXPRESS ORTMPLIED. AS TO THE COMPLETENESS. CURRENCY
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N EU R O LO G Y
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P S Y C H IA T R Y
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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
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E N D O C R IN O L O G Y
1.
2.
3.
4.
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6.
7.
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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
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77
79
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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
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2.
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12.
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C A R D IO V A S C U L A R
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VI
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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
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2.
3.
4.
5.
6.
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9.
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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
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2.
3.
4.
5.
6.
7.
8.
9.
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12.
13.
183
184
185
187
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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.
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5.
6.
7.
8.
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12.
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14.
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
15-day plan
11
Approx. 4 hrs
17-day plan
10
21-day plan
Approx. 3 hrs
28-day plan
Approx. 2 hrs
34-day plan
*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
Introduction
1A
IB
1C
Neurology 2 - M eningitis
ID
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
2B
2C
2D
2E
2F
2G
2H
21
2J
2K
3A
3B
3C
3D
3E
3F
3G
3H
31
3J
3K
COURSE O R D E R
THAT YOU WATCH THE VIDEOS IN THE ORDER IN WHICH YOUR DASHBOARD PRESENTS THEM REGARDLESS OF
RECOMMENDED
COURSE ORDER
RECOMMENDED
Hi
4A
4B
4C
4D
4E
4F
4G
4H
41
4J
4K
5A
5B
5C
5D
Cardiovascular 2 - Atherosclerosis
Cardiovascular 3 - Hypercholesterolemia
Cardiovascular 4 - Stable Angina
5E
SF
5G
5H
SI
5J
5K
6A
6B
6C
6D
6E
Cardiovascular 14 - Antihypertensives
Cardiovascular 15 - Shock
6F
6G
6H
61
6J
6K
6L
7B
7C
7D
7E
7F
' 7G
IBM
71
7J
7K
7L
7M
8A
Gastroenterology 1 - GI Infections
8B
8C
8D
8E
8F
8G
8H
81
8J
9A
9B
9C
9D
9E
9F
9G
9H
91
9J
9K
Genitourinary 1 - Diuretics
9L
Research Studies
COURSE O RD ER
7A
RECOMMENDED
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
in
UK
Heme/Onc 10 - H IV Treatment
Heme/Onc 11 - Myeloma and Lymphoma
n il
:' r v ; v
:7
: i , v- : r
i:;V
14B
14C
14D
14E
14F
14G
Obstetrics 3
14H
141
14J
15C
mm
151
15J
15K
Pediatrics 1 - Development
Pediatrics 2 - Infancy to Adolescence
Pediatrics 3
15L
Pediatrics 4
Genetic Disorders
3 -5 M
Pediatrics 5
Preventive Medicine
vasai
N eurology
1
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
2.
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
2.
3.
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
Preferred medications:
1) ampicillin +
2) cefotaxime or gentamicin
1 month to 60
years of age
>60 years,
alcoholism, or
debilitating
comorbidities
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?
8.
9.
10.
11.
12.
!
I
CO
NEUROLOGY
Z
z
3 Question Warm-Up
1.
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.
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.
7.
8.
HEAD ACH E
HEADACHE
3 Question Warm-Up
1
2.
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
Migraine headache
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
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?
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.
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
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.
STROKE
3 Question Warm-Up
1.
2.
3.
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
6.
7.
8.
Lacunar arteries
Basilar artery
HEM ORRHAGE
HEMORRHAGE
3 Question Warm-Up
1.
2.
3.
[ 15]
6.
7.
8.
9.
SEIZURES
3 Question Warm-Up
1.
BP goal
BP medications
Ischemic stroke
Intracerebral hemorrhage
Subarachnoid hemorrhage
2.
3.
5.
Seizure type
Partial
> valproate, topiramate
Absence
Myoclonic
6.
Gingival hyperplasia
Drag of choice for absence seizures
Second choice for absence seizures
Drug of choice for trigeminal neuralgia
SEIZURES
7.
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?
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.
3 Question Warm-Up
1.
2.
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?
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)
8.
3 Question Warm-Up
1.
2,
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?
8.
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.
12.
13.
PERIPHERAL DISORDERS
3 Question Warm-Up
1.
2.
W h ich medication is used more than any other in the treatm ent o f Parkinson
patients?
3.
5.
7.
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 ]
11.
12.
13.
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.
15.
16.
'
. i -
v ... '
mw " m
" $
3 Question Warm-Up
1
2.
3.
W hat medications are common in the treatm ent of insomnia? W hat makes
each one unique?
M elatonin
Valerian
Antihistamines
(diphenhydramine,
doxylamine)
Trazodone
TCA s
(amitriptyline,
doxepin)
Benzodiazepines:
(temazepam,
lorazepam,
clonazepam,
diazepam,
chlordiazepoxide)
Zolpidem
Zaleplon
Eszopiclone
Ramelteon
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.
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
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
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
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?
9.
10.
11.
12.
13.
In an intact brainstem, the patients eye should move in which direction w ith ice
water infusion into an ear canal?
PEDI NEURO
3 Question Warm-Up
1.
W hat drugs when combined with SSRIs are known for causing serotonin
syndrome?
2.
3.
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.
TJ
m
8.
W hich element o f the quad/triple screen is abnormal in cases o f neural tube defect?
9.
10.
II.
12.
13.
14.
g
z
m
C
70
O
OPHTHALMOLOGY PART I
3 Question Warm-Up
]
2.
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
Etiology
Type of Discharge
Bacterial
Viral
(adenovirus)
Allergic
Other Features
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?
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)
Hordeolum
(stye)
Infection of external
sebaceous glands of Zeiss or
M ol (tender, red swelling at
the lid margin)
Anterior
blepharitis
Infection o f eyelids
and lashes secondary to
seborrhea (red, swollen
lid margins + dandruff on
lashes)
[ 35]
W h at would be the visual field defect for a lesion o f the optic tract?
14.
15.
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.
18.
19.
OPHTHALMOLOGY PART 2
0
"O
1
H
X
>
3 Question Warm-Up
1.
2.
A young child has loss o f the red light reflex. W h a t is the diagnosis?
3.
i3
O
i
o
o
-<
T3
>
73
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 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?
10.
11.
12.
W ith which disorders m ight you see a cherry-red spot on the macula?
13.
14.
AUDIOVESTIBULAR DISORDERS
3 Question Warm-Up
1.
W hat are the 5 main lacunar syndromes that may arise from a lacunar infarct?
2.
3.
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
7.
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
W hat are the important characteristics seen on otoscopic exam of a patient with
otitis media?
14.
15.
16.
Explain how the W eber test can help distinguish conductive hearing loss from
sensorineural hearing loss.
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
DEPRESSION
3 Question Warm-Up
1.
2.
3.
6,
DEPRESSION
7.
8. W hat is the first-line treatment for major depression with seasonal pattern?
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.
II.
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.
2.
W h a t are the m ost com m on causes o f seizures in young adults (18-35 years)?
3.
SSRI -
TC A -
MAOI -
NDRI -
SNR.I -
Tetracyclic -
W hat is the first-line treatment for major depression with seasonal pattern?
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.
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 >
I z
I
a
m
TJ
73
m
on
on
>
3 Question Warm-Up
4.
1.
2.
W h a t are the m ost common causes o f seizures in young adults (18-35 years)?
3.
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?
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.
10. W hat are the symptoms of overdose with tricyclic antidepressants (TCA s)?
AN TIDEPRESSAN TS
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)
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)
[ 49]
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?
3 Question Warm-Up
1.
2.
3.
Bipolar Disorder
4.
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)
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
W hat is the drug o f choice in the treatment o f bipolar disorder in a patient with
renal failure?
ANXIETY DISORDERS
3 Question Warm-Up
1.
2.
3.
5.
How long must anxiety and worry symptoms be present to diagnose a patient
with generalized anxiety disorder?
7.
8.
9.
PSYCHOTIC DISORDERS
3 Question Warm-Up
1.
2.
3.
n
x
O
H
n
g
on
o73
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
[ 55]
D ISO RDERS
PSYCHOTIC
6.
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 -
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
13. W hat is the treatm ent for Parkinsonian symptoms that have developed from
neuroleptic administration?
[57]
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 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.
3.
PERSONALITY DISORDERS
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?
3 Question Warm-Up
1.
2.
W h a t is T odds paralysis?
3.
6.
7.
8.
9.
3 Question Warm-Up
1.
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.
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.
6.
7.
3 Question Warm-Up
1.
2.
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
8.
9.
10.
\ND DE
3 Question Warm-Up
1.
2.
A violent patient w ith vertical and/or horizontal nystagmus has been exposed to
what substance?
3.
TCA -
MAOI -
N D RI -
SN RI -
Tetracyclic -
Atypical -
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.
8.
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.
3.
5.
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)
PEDI PSYCH
How is A D H D diagnosed?
9.
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
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 ),
Parathyroid D isorders
ENDOCRINOLOGY
TYPE I DIABETES
3 Question Warm-Up
1.
2.
3.
Anti-insulin (IAA)
Anti-islet cell cytoplasm (ICA)
Anti-glutamic acid decarboxylase (GAD)
Anti-tyrosine phosphatase (IA-2)
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.
7.
8.
TYPE 2 DIABETES
TYPE 2 DIABETES
3 Question Warm-Up
1.
2.
3.
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]
H
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m
H
m
on
7.
8.
9.
ENDOCRINOLOGY
6.
I [75]
INSULIN THERAPY
INSULIN THERAPY
3 Question Warm-Up
1.
2.
3.
5.
W h at must be kept in m ind for a type 1 diabetic patient that plans to begin a
strenuous exercise program?
3 Question Warm-Up
1.
2.
3.
5. W hat are the necessary steps in the treatm ent 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.
3 Question Warm-Up
1.
2.
3.
5.
8.
9.
3 Question Warm-Up
1.
2.
3.
AND HYPERTHYROIDISM
FUNCTION
NORMAL THYROID
5.
6.
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?
3 Question Warm-Up
1.
2.
3.
4. Thyroid Nodules
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.
[84] |
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0
H
1
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o
>
8.
o
H
X
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73
q
o
n
>
z
n
9.
[ 85]
DISORDERS
PARATHYROID
3 Question Warm-Up
1.
2.
3.
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
7.
8.
9.
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.
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
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.
9.
10.
11.
12.
13.
c
GO
X
o
GO
-<
o
73
3 Question Warm-Up
1.
oz
m
a
X
-<
-o
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
>
i
D
O
7>
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
5.
6.
7.
3 Question Warm-Up
1.
2.
3.
5.
W hat is the likely condition o f a female infant with virilization o f the genitalia and
hypotension?
6.
7.
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
3 Question Warm-Up
1.
2.
3.
Burns
4. W hat are the differences between 1st, 2nd, 3rd and 4th degree burns?
Traditional
Classification
Depth
Classification
Involvement
1st degree
Superficial
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
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?
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.
3.
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
immunizations
Non tetanus-prone
wound, LE, clean 8c
minor
Tetanus-prone wound
(dirt, contamination,
puncture, crush injury)
9.
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.
2.
3.
Stage 1
30 min - 24 hrs
Stage II
24-72 hours
Stage III
72-96 hours
Stage IV
4 days 2 wks
Recovery
Antidote -
9.
TOXICOLOGY PART 2
3 Question Warm-Up
1.
2.
3.
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
10.
TOXICOLOGY PART 3
3 Question Warm-Up
1.
2.
3.
In which endocrine disorder m ight weight loss completely eliminate the need for
medication?
O
X
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o*
o
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[ 105]
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)
o
-
o
CD
-<
>
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.
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.
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 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 maximum number of epinephrine doses that can be given when
treating cardiac arrest?
9.
10. W hat piece o f medical history should be obtained in deciding how to treat atrial
fibrillation?
CRITICAL CARE
3 Question Warm-Up
1.
2.
3.
CRITICAL CARE
5.
6.
TRAUMA PART I
H
:30
>
C
3
>
5
H
3 Question Warm-Up
1.
2.
3.
[ 113]
TRAUMA PART I
Head Trauma
S. W hat is Cushings triad?
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?
TRAUMA PART 2
s?i
TRAUMA PART 2
3 Question Warm-Up
1
2.
W h at is the next step in the evaluation o f a pulsatile abdominal mass and bruit?
3.
Neck Trauma
4. W hat are the different zones of the neck and structures contained in each
zone?
Zone
Landmarks
Structures Contained
II
III
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
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.
[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?
Airway, Breathing, Circulation
If hypotensive >_________________________________________
Abdominal exam
Signs of peritonitis (peritoneal irritation)
____________________________________
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)
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
>
___________________
> _______________
+ observation
TRAUMA PART 3
3 Question Warm-Up
1.
2.
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)
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?
3 Question Warm-Up
1.
2.
3.
5.
6.
W hat interventions are helpful in optimizing lung function in the post-op period
in patients with preexisting lung disease?
7.
2.
3.
4. W h at is the typical E R lab work-up for a patient with acute abdominal pain?
10.
11.
12.
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.
3.
5.
6.
In which phase o f the cardiac cycle do coronary arteries fill w ith blood?
7.
8.
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.
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.
2.
3.
5.
6.
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
5. W hat is the most likely cause of chest pain in each of the following scenarios?
W h ich patients are more likely to have atypical angina (or no angina) during an
episode o f myocardial ischemia?
7.
8.
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.
3.
6.
7.
is !
MYOCARDIAL IN FARCTIO N
MYOCARDIAL INFARCTION
3 Question Warm-Up
1.
2.
3.
5.
6.
7.
8.
ARRHYTHMIAS PART I
3 Question Warm-Up
1.
2.
3.
ARRHYTHMIAS PART I
I 136]
5.
6.
ARRHYTHMIAS PART 2
1>
yO
X
<
H
X
3 Question Warm-Up
1.
2.
3.
3
>
CO
"D
>
H
NJ
5.
6.
>
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.
3.
138 i j
6.
7.
8.
9.
VALVULAR DISEASES
3 Question Warm-Up
1.
2.
3.
9.
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.
3.
Kussmaul Sign
Pulsus Paradoxus
Event
Mechanism
Decreased capacity of RV
Decreased capacity of LV
Disease
Cardiac tamponade
pericarditis
6.
7.
8.
MYOCARDIAL INFECTIONS
3 Question Warm-Up
1
2.
3.
5.
6.
7.
8.
HYPERTENSION
3 Question Warm-Up
1.
2.
3.
7.
8.
9.
ANTIHYPERTENSIVES
3 Question Warm-Up
1.
2.
3.
5.
SH O C K
SHOCK
3 Question Warm-Up
1.
2.
3.
Shock
4.
[ A8 ] |
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
Hypoperfusion and resultant tissue ischemia are the concern in shock patients.
W h a t is the chemical marker o f this?
6.
7.
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.
3.
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
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
8.
9.
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.
2.
3.
W hat two cardiovascular diseases are the biggest risk factors for C H F?
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.
PEDI CARD IO LO G Y
PEDI CARDIOLOGY
3 Question Warm-Up
1.
Serum
Phos
Aik
Phos
PTH
Paget Disease
Osteomalacia/rickets
Chronic renal failure
Osteoporosis
Osteopetrosis
Primary
hyperparathyroidism
Hypoparathyroidism
Pseudohypoparathyroidism
2.
3.
PEDI CA RD IO LO G Y
W hat are the unique structures o f the fetal circulation that close after birth?
7.
8.
Pulmonology
1
URI
L ow er R espiratory Infections p a rt 2
A R D S and A sth m a
COPD
P leural Diseases
7?
PULMONOLOGY
URi
3 Question Warm-Up
1.
2.
3.
Treatm ent
Needle aspiration or I& D
Pain meds + antibiotics
- Amoxicillin/clavulanate
Clindamycin
[ 159]
URI
6.
7.
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.
3.
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
lm 4m
4m 4y
5 y -1 5 y
Streptococcus pneumoniae
Mycoplasma pneumoniae
Chlamydophila pneumoniae
O ther viruses*
+/- cefotaxime
1. Amoxicillin + clarithromycin
2. Azithromycin
3. Amoxicillin + doxycycline
W hat infectious agent is the cause of pneumonia based on the following lab
test:
9.
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.
2.
3.
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)
[ 163]
5mm
A :
o
10mm
15mm
7.
, 4
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?
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
I 166 |
7.
8.
COPD
3 Question Warm-Up
1.
2.
3.
4. C O P D Staging
G O LD
G O LD
G O LD
G O LD
I234-
FEV,
FEV,
FEV,
FEV,
5. C O P D Management
Bronchiectasis
6. W hat are the possible etiologies for bronchiectasis?
8.
9.
3 Question Warm-Up
1.
2.
3.
4.
t-
t V
[ 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.
8.
9.
PULMONARYVASCULAR DISEASES
3 Question Warm-Up
1.
2.
3.
"O
c
r~
3
O
z
>
-<
JS
oo
n
c
r~
>
70
O
CO
m
>
[ 171 ]
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.
9.
10.
PLEURAL DISEASES
3 Question Warm-Up
1.
2.
3.
W h a t study can help you determine whether pleural effusion is loculated or freeflowing in the thorax?
5.
6.
7.
3 Question Warm-Up
1.
2.
3,
[. I /d ] !
7.
3 Question Warm-Up
1.
2.
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)
Epiglottitis
( 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
11.
!
1 TmJ
i
U
C
r~
3 Question Warm-Up
1.
2.
3.
o
z
o
1
o
o
-<
TJ
>
73
_1
N>
[ 179]
"U
c
r~
2
o
z
o
l~
o
o
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.
W hat are the general strategies for managing the GI component of cystic
fibrosis?
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
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
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
W
B ^ M
ISiIlgipS S iS i si
Gl INFECTIONS
..............
I n
m
<">
H
o
zoo
3 Question Warm-Up
W h a t are the characteristic features o f a patient presenting with pericarditis?
2.
3.
GASTROENTEROLOGY
1.
5.
VIRAL HEPATITIS
VIRAL HEPATITIS
3 Question Warm-Up
1
2.
3.
You are examining a patient and discover a cherry red spot on the macula.
W h a t is the differential diagnosis?
5.
6.
7.
Hep BsAg
Hep BsAb
Hep BcAb
Negative
Negative
Positive (IgM)
Positive
Negative
Positive (IgG)
Negative
Positive
Negative
Negative
Positive
Positive (IgG)
3 Question Warm-Up
1.
2.
3.
Barium swallow
Gastric emptying study
Small bowel follow through (SBFT)
Barium enema
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
11.
12.
GASTRIC CONDITIONS
3 Question Warm-Up
1.
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.
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.
6.
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?
3 Question Warm-Up
1.
2.
3.
5.
6.
7.
3 Question Warm-Up
1.
2.
W hat are the two most common foodbome bacterial G l tract infections in the
U.S.?
3.
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
Bowel Obstruction
7.
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
13.
14.
15.
16.
W hich signs and symptoms are and which are not associated with IBS?
3 Question Warm-Up
1.
2.
W h a t is the initial treatment for a child presenting with an acute asthma attack?
3.
Appendicitis
4. W hat radiological studies can be used to diagnose appendicitis?
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)
9.
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
>
73
CD
Z
H
m
3 Question Warm-Up
1.
2.
3.
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
[ 195 j
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
10.
11.
12.
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?
O
r~
O
50
m
5>
r~
3 Question Warm-Up
1.
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?
n>
z
n
m
>
U
(D
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]
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.
9.
10.
11.
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.
2.
3.
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.
6.
W h a t are the m ost com m on causes o f acute pancreatitis in the U nited States?
7.
3 Question Warm-Up
1.
2.
3.
6.
7.
>
75
-<
GO
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?
>
7>
I [201 ]
8.
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
1.
ALCOHOLIC
2.
3.
3 Question Warm-Up
4.
N A SH : Nonalcoholic Steatohepatitis
0
0
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
9.
10.
W h a t two diuretics are used in conjunction for the treatm ent o f ascites/portal
hypertension?
[205 ]
3 Question Warm-Up
1.
2.
3.
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)
6.
7.
PEDI GI DISORDERS
U
m
O
g
(>
-rr.
r,
_ _
o
a
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.
W h a t is the diagnosis?
3.
GASTROENTEROLOGY
1.
Neonatal Jaundice
4. W hat are the various causes of neonatal jaundice?
5.
[207]
PEDI Gl DISORDERS
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)
9.
Physiologic
Age
T. bili level
Cause
Treatment
Exaggerated
physiologic /
Breastfeeding
Breast milk
Biostatistics
R esearch Studies
E thics
BIOSTATISTICS
H
CO
H
CO
3 Question Warm-Up
1.
2.
3.
Definition
B irth rate
Fertility rate
D eath rate
Deaths/1000 population
[211 ]
S D iis u v is o ia
5.
7.
8.
[212]
W h a t is the equation for odds ratio? W h a t is the equation for relative risk?
10.
11.
12.
13.
Autoimmune Disease X
Present
Absent
800
200
100
1400
+-
X
+o-*
CO
<y
~o
Cl .
_Q
+-J
+
a2
<
14.
<D
CO
(U
n
<
RESEARCH STUDIES
3 Question Warm-Up
1.
2.
3.
po
CO
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.
m
>
7>
n
x
co
I
C
D
m
co
5.
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
3 Question Warm-Up
1.
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.
Based on these study results, what is the relative risk of having an acute
exacerbation of edema due to rosiglitazone?
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
-Superace
-Placebo
DBP
SBP
Superace
Usinoprit
Months Post-STEMI
Placebo
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%
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
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.
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?
9.
Under what circumstances are you allowed to break confidentiality with a patient?
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?
G enitourinary
1
D iuretics
N ep h ritic Syndrom es
N ephrotic Syndrom es
R enal Failure
H yponatrem ia
O th e r E lectrolyte D isorders
DIURETICS
73
m
nGO
3 Question Warm-Up
1.
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.
W h a t is the diagnosis?
3.
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.
[226]
3 Question Warm-Up
1.
2.
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)
6.
7.
8.
W h a t size calcium renal stone has a 50% likelihood o f passing without surgical
intervention?
3 Question Warm-Up
1.
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?
6.
7.
8.
9.
10.
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.
2.
3.
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.
3.
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
Hyaline casts
Red cell casts
White cell casts
Epithelial cell casts
Granular casts
7.
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.
2.
3.
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.
8.
9.
ACID-BASE DISORDERS
ACID-BASE DISORDERS
3 Question Warm-Up
1.
2.
3.
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 = 75-105 mmHg
H C 0 3- = 22 (45/2 = 22.5)
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
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
Type Defect
Urine pH
Serum K+
Serum H C 0 3'
Type I - Distal
Type II - Proximal
Type IV - Hypoaldosterone
8.
Type I RTA
Type II RTA
Type IV RTA
9.
Metabolic alkalosis
Respiratory alkalosis
Respiratory acidosis
HYPONATREMIA
3 Question Warm-Up
1.
2.
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?
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 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
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 ?
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.
3.
K+ shifts
K* shift out of cells > Hyperkalemia
Low insulin
3 -blockers
Acidosis
Digoxin
Cell lysis (e.g. leukemia)
7.
8.
9.
10.
11.
3 Question Warm-Up
1.
2.
3.
6.
7.
8.
9.
3 Question Warm-Up
1.
W h a t are Ransons criteria in determ ining the prognosis in patients w ith acute
pancreatitis?
2.
3.
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 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.
9.
10.
11.
PART 2
MALE REPRODUCTION
3 Question Warm-Up
1.
2.
3.
Testicular Torsion
4.
Torsion
Epididymitis
Onset
Infection
No signs of infection
Visual changes
Cremasteric reflex
Absent
Present
Ultrasound
Support
[248]
Male Infertility
6.
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
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
[ 250] I
10.
11.
12.
PEDI UROLOGY
1 "O
m
-
50
o1
o
o
3 Question Warm-Up
1.
2.
3.
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
[252 ]
6.
7.
8.
9.
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
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.
3.
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
[255]
7.
9.
ANEMIA PART 2
3 Question Warm-Up
1.
2.
3.
Com pare the serum iron, ferritin, and transferrin levels in iron deficiency
anemia to those in anemia o f chronic disease.
5.
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.
2.
3.
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
6.
3 Question Warm-Up
1.
2.
3.
5.
6.
7.
W h ich vaccines are particularly im portant in children w ith sickle cell disease?
3 Question Warm-Up
1.
2.
3.
7.
8.
9.
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.
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.
3.
W hich type o f bias is introduced when screening detects a disease earlier and
thus lengthens the time from diagnosis to death?
6.
7.
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.
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
------------------------------Antithrombin deficiency
Protein C deficiency
Protein S deficiency
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.
9.
10.
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.
3.
0
0
2661
6.
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.
2.
A post-op patient w ith significant pain presents with hyponatremia and normal
volume status. W h a t is the diagnosis?
3.
5.
6.
HIV TREATMENT
3 Question Warm-Up
1.
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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MYELOMAAND LYMPHOMA
3 Question Warm-Up
1.
2.
W hich of the following are elevated in DIC: fibrin split products, D-dimer,
fibrinogen, platelets, and hematocrit?
3.
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%)
[ 272 ]
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.
LEUKEMIA
LEUKEMIA
3 Question Warm-Up
i 274 |
1.
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.
5.
6.
PEDI HEME/ONC
PEDI HEME/ONC
3 Question Warm-Up
1.
2.
W hich type of lung cancer is associated with each of the following paraneoplastic
syndromes?
3.
[ 276 ]
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.
'.'.5a
A- ,
K jg
t j .
",
A 1
V '.
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
[ 277]
Musculoskeletal
1
O rthop ed ics p a rt 1
O rthop ed ics p a rt 2
R A and Lupus
Pedi O rth o
ORTHOPEDICS PART I
3 Question Warm-Up
1.
2.
3.
Dislocations
4.
A rm position
Neurovascular
compromise
Anterior Shoulder
Dislocation
Posterior Shoulder
Dislocation
Unusual
at risk
Classic
scenario
Physical exam
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
6. W hat nerve is most at risk of injury with the following types of injury?
8.
1
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I [ 283 ]
ORTHOPEDICS PART 2
3 Question Warm-Up
1.
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.
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)
7.
0
TO
H
1
o~o
m
u
n
CO
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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 ]
[286 ] I
3 Question Warm-Up
1.
2.
3.
f ill
5.
Serum
C a 2+
Serum
Phos
A ik
Phos
PTH
Paget Disease
Osteomalacia/rickets
Chronic renal failure
Osteoporosis
Osteopetrosis
Primary
hyperparathyroidism
Hypoparathyroidism
Pseudohypoparathyroidism
6.
7.
8.
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?
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
m
n
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7.
W h a t is the treatm ent for Lyme disease? For Rocky M ountain Spotted Fever?
8.
9.
10.
11.
12.
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.
3.
A husband asks that his wife (your patient) not be told about her recentlydiscovered lung cancer. W h a t should you do?
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.
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?
3 Question Warm-Up
1.
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.
3.
B oth folate deficiency and vitamin B., deficiency can result in a megaloblastic
anemia. H ow can they be differentiated clinically?
6.
73
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m
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I [ 293 ]
8.
9.
W hat serious disease must you look out for in patients with polymyalgia
rheumatica?
O
73
HI
X
3 Question Warm-Up
1.
2.
3.
[295]
MUSCULOSKELETAL
PEDI ORTHO
PEDI ORTHO
7.
[297]
MUSCULOSKELETAL
PEDI ORTHO
16.
W hat is the treatment for developmental dysplasia o f the hip in children younger
than 6 months o f age?
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
D isease
D ermatology
1
Infections p a rt 1
Infections p a rt 2
Infections p a rt 3
INFECTIONS PART I
3 Question Warm-Up
1.
2.
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.
Definition
Examples
Freckles, tattoos
Port-wine stain
Psoriasis
Small lipoma,
erythema nodosum
Elevated, circumscribed
lesion < 5 mm containing
clear fluid (small blister)
Chickenpox, genital
herpes
Contact dermatitis,
pemphigus
Allergic reaction
Term
n
H
O
z
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INFECTIONS PART I
5.
9.
[ 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
14. W h a t is the treatm ent for dry gangrene? W h a t is the treatment for wet
gangrene?
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.
3.
Acne Vulgaris
4.
5. W hat should you know about oral isotretinoin (Accutane) in the treatment of
acne?
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.
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
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
[ 306 ]
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?
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.
2.
3.
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
7.
INFECTIONS PART 3
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.
2.
3.
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
[ 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
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
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
I [313]
Decubitus Ulcers
17. W hat are the different stages of decubitus ulcers?
Stage I
Stage II
Stage III
Full thickness skin loss with damage to the subQ_tissues; deep crater
Stage IV
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
A patient presents w ith erythem a multiforme. W hich medications are the most
common offenders?
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22.
23.
24.
25.
26.
z
o
o
z
g
H
o
z
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.
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
Almost always
Rare (10-35%)
Histologic location of
antibodies
Epidermis
Dermal-epidermal junction
(Basement membrane)
Type of antibody
Anti-desmosome
Anti-hemidesmosome
Melanoma
7.
9.
10.
11.
12.
PLASTICS, PIGMENTATION
3 Question Warm-Up
1.
2.
3.
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)
7.
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
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
Hair Loss
11. W hat are the clinical features of alopecia areata?
13. W hat is the name given to diffuse stress-related hair loss? W hat is the
treatment?
AND
HAIR LOSS
PLASTICS, PIGMENTATION
[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
MENSTRUAL PHYSIOLOGY
3 Question Warm-Up
1.
2.
3.
S.
6.
7.
8.
9.
10.
MENOPAUSE
3 Question Warm-Up
1.
2.
W h a t are the classic features that distinguish orbital cellulitis from periorbital
cellulitis?
3.
Menopause
4.
MENOPAUSE
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
[ 328
7.
8.
9.
10.
MENOPAUSE
[ 329]
CONTRACEPTION
3 Question Warm-Up
1.
2.
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)
D isadvantages
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
AM ENORRHEA
AMENORRHEA
3 Question Warm-Up
[332
1.
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 hat are the first steps in the work-up of a woman with prim ary amenorrhea?
8.
9.
10.
11.
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.
6. W hat is the first-line treatment for a young, infertile woman with obvious signs
and symptoms of endometriosis?
8.
9.
10.
11.
3 Question Warm-Up
1.
2.
3.
[ 338 ]
6.
7.
3 Question Warm-Up
1.
2.
3.
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.
3 Question Warm-Up
1.
2.
3.
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
[ 342 ] I
6.
7.
8.
c
H
m
70
zm
>
,? Question Warm-Up
1.
o
n
m
30
<
n
>
o
03
z
cn
Heparin
Isoniazid
2.
3.
[343]
[ 344 ]
6.
7.
8.
3 Question Warm-Up
1.
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.
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
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
7.
8.
9.
10.
3 Question Warm-Up
1.
2.
3.
W h a t is the first-line treatm ent for pediculosis capitis and pediculosis pubis?
BREAST DISORDERS
BENIGN
6.
BREAST CANCER
3 Question Warm-Up
1.
2.
3.
W h a t statistical calculation looks at true positives and divides them by the number
o f patients w ith the disease?
W h a t is the m ost common breast cancer? W h a t is the most common site for
breast cancer?
5.
6.
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
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
O bstetric C om plications p a rt 1
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
3 Question Warm-Up
1.
2.
3.
Between what weeks gestation is a fetus most susceptible to teratogens and why?
6.
7.
8.
TSH
Blood pressure
Cardiac output
Ventilation
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.
3.
at 6 weeks gestation
. due to vascular
at 6 weeks gestation
5.
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.
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
12.
13.
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?
3 Question Warm-Up
1.
W h at is the differential diagnosis for the dislocation of the lens o f the eye?
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.
8.
9.
10.
3 Question Warm-Up
1.
4.
2.
3.
8.
9.
3 Question Warm-Up
1.
2.
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)
7.
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.
9.
USE
MATERNAL DRUG
CONGENITAL INFECTIONS
3 Question Warm-Up
1.
2.
3.
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
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
9.
W hen should you provide intrapartum antibiotic prophylaxis for Group B Strep
(GBS)?
10. W hat antibiotics can be used for intrapartum prophylaxis for Group B Strep
(GBS)?
CONGENITAL IN FE C T IO N S
CONGENITAL INFECTIONS
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
15. W h a t advice should you give a mother w ith H IV about breastfeeding her
infant?
1.
2.
3.
3 Question Warm-Up
OBSTETRIC
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.
7.
8.
9.
10.
3 Question Warm-Up
1.
2.
3.
7.
8.
9.
10.
11.
3 Question Warm-Up
1.
2.
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?
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
7.
8.
O
CD
EE
n
n
o
3 Question Warm-Up
1.
2.
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
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]
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?
3 Question Warm-Up
1.
2.
3.
0 Fetal anemia
Fetal tachyarrhythmias (HR > 200)
Maternal thyrotoxicosis
Drugs or medications (_
Fetal hypoxia
Fetal immaturity
., atropine)
7.
8. What are the first steps in the management of non-reassuring fetal heart tones
during labor?
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
i 376 |
L&D: LABOR
3 Question Warm-Up
1.
2.
3.
Stages of Labor
4.
cm/hour dilation
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
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
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.
3 Question Warm-Up
1.
2.
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)?
5.
6.
7.
L&D: MALPRESENTATION
[ 380 ]
POSTPARTUM CARE
3 Question Warm-Up
~o
ooo
H
"o
>
H
C
2
i >
y
1.
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?
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
6.
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
[ 382
Postpartum Endometritis
II.
"O
O
oo
H
~T3
>
73
H
C
n
>
TO
m
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
G enetic D isorders
Preventive M edicine
DEVELOPMENT
3 Question Warm-Up
1.
2.
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
6.
7.
8.
9.
INFANCYTO ADOLESCENCE
3 Question Warm-Up
1.
2.
3.
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?
7.
W hat are the m ost com m on problems that arise in premature infants?
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 -
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.
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
M O D ER A TE
SEVERE
Infant (10%)
lOOml/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:
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.
3.
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
is not yet well studied and not currently standard of care for
measles, despite that it harms measles virus in vitro
-
I [ 393 ]
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?
9.
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
C hronic diarrhea
3)
Failure to thrive
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
[ 397]
28.
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.
|398|
1.
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
7.
[ 399 ]
GENETIC DISORDERS
9.
100]
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.
2.
3.
PREVENTIVE M EDICINE
7.
Vitamin Supplementation
8. W hich vitamin deficiencies match each of the following descriptions?
I [403 ]
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?