DEJAREVIEWTM

USMLEStep2CK

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DEJAREVIEWTM

USMLEStep2CK

SecondEdition

JohnH.Naheedy,MDFellow,PediatricRadiologyDepartmentofRadiology

Children’sHospitalBostonHarvardMedicalSchoolBoston,Massachusetts

DanielA.Orringer,MDChiefResident

DepartmentofNeurosurgeryUniversityofMichiganMedicalSchool

AnnArbor,Michigan

KhashayarMohebali,MDChiefResident,ClinicalInstructor

DivisionofPlasticandReconstructiveSurgeryDepartmentofSurgery

UniversityofCalifornia,SanFranciscoSanFrancisco,California

PeterF.Aziz,MDFellow-PediatricCardiologyDepartmentofPediatrics

Children’sHospitalofPhiladelphiaPhiladelphia,Pennsylvania

SusieLim,MDClinicalInstructor

ObstetricsandGynecologyKaiserPermanenteNorthwest

Portland,Oregon

Copyright©2010,2006byJohnH.Naheedy,DanielA.Orringer,KhashayarMohebali,PeterF.Aziz,andSusieLim.Allrights reserved.Except aspermittedunder theUnitedStatesCopyrightActof1976,nopartof thispublicationmaybereproducedordistributedinanyformorbyanymeans,orstoredinadatabaseorretrievalsystem,withoutthepriorwrittenpermissionofthepublisher.

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Tomyfamilyandfriends,fortheirloveandencouragement;andtomyparents,forbeinganexampleofeverythingIwanttobe.—John

ToMegan,thetrueauthorinthefamily.—Dan

Tomyparentsfordedicatingandsacrificingtheirlivestomakeminebetterandtomyfriendsfortheirinvaluableloyalty.—Khashi

Tomyfamily,forteachingmethattheloveofmedicinecanbegeneticallyinherited;andtothebunker,thesandtrapofmyclosestfriends,thanksfortheinspiration.

—Pete

ToMichael,OliverandSoë

—Susie

Contents

ContributorsReviewersPrefaceAcknowledgments

Chapter1INTERNALMEDICINECardiologyPulmonaryInfectiousDiseasesGastroenterologyRenal/GenitourinaryEndocrineHematology/OncologyRheumatology/MusculoskeletalDermatologyPreventativeMedicine,Ethics,andBiostatistics

Chapter2SURGERYTraumaGeneralSurgeryVascularSurgeryOrthopedicsAbdominalPainMaketheDiagnosis

Chapter3NEUROLOGYHeadacheSeizuresCerebralVasculatureIntracranialHemorrhageBrainTumorsCNSInfectionsCognitiveDisordersMovementDisordersAmyotrophicLateralSclerosis,MultipleSclerosis,andotherDemyelinatingDiseasesVertigoNeuromuscularDiseaseOphthalmologySyncopePeripheralNeuropathyLocalizetheLesionMaketheDiagnosis

CHAPTER4PSYCHIATRYMoodDisordersSuicideandViolencePsychoticDisordersAnxietyDisordersSomatoformDisordersEatingDisordersSubstanceAbuseChildhoodDisorders

PersonalityDisordersMiscellaneousPsychiatricDisordersPsychopharmacologyMaketheDiagnosis

Chapter5OBSTETRICSANDGYNECOLOGYObstetricsAntepartumIntrapartumPostpartumGynecologyGynecologyOncologyReproductiveEndocrinologyUrogynecologyMaketheDiagnosis

Chapter6PEDIATRICSGeneticDefectsCongenitalHeartDiseaseDevelopmentImmunodefiencySyndromesChildAbuseNeonatologyInfectiousDiseaseNephrologyGastroenterologyEndocrinologyHematologyPulmonologyOncologyRheumatologyNeurologyMiscellaneousMaketheDiagnosis

Chapter7EMERGENCYMEDICINETraumaToxicologyEnvironmentalEmergenciesMaketheDiagnosis

AppendixABBREVIATIONS

Index

Contributors

KarlaFredricks,MDResidentDepartmentofPediatricsChildren’sHospitalofPhiladelphiaPhiladelphia,PennsylvaniaChapter:Pediatrics

EmilyY.Fukuchi,MDResidentDepartmentofObstetricsandGynecologyUniversityofCalifornia,SanFranciscoSanFrancisco,CaliforniaChapters:InternalMedicine,Surgery

KarenA.Kinnaman,MDUniversityofMichiganMedicalSchoolAnnArbor,MichiganClassof2009Chapter:EmergencyMedicine

VijayPottathil,MDResidentDepartmentofInternalMedicineUniversityofIowaIowaCity,IowaChapter:InternalMedicine

JaysonSack,MDResidentDepartmentofNeurosurgeryUniversityofSouthFloridaTampa,FloridaChapters:Neurology,Psychiatry

MiguelTrujillo,MDResidentDepartmentofObstetricsandGynecologyOregonHealthandScienceUniversityPortland,OregonChapter:ObstetricsandGynecology

Reviewers

JessicaBury,MPHMedicalStudentMayoClinicalCollegeofMedicineClassof2010

TinaNguyen,MDResident,EmergencyMedicineHarborUCLAMedicalCenterUniversityofCaliforniaLosAngelesSUNYUpstateMedicalUniversityClassof2008

Preface

DéjàReview™USMLEStep2CKhasbeenscrutinizedandeditedtoproduceasecondeditionthatisevenhigheryieldandeasiertousethanthefirst.Outstandingmedicalstudents,whohaverecentlytakenStep2,revisedtheoriginaltexttoensurethematerial covered herein is complete and current. The authors, nowwith a combined 30 years of experience in themedicalfield,havealsoeditedthemanuscripttoemphasizetheclinicalrelevanceofthecoreconceptscoveredinStep2.WeareconfidentthatoureffortshaveproducedoneofthemostusefulguidesforStep2reviewavailabletoday.

Step2oftheUnitedStatesMedicalLicensingExamination(USMLE)teststheseniormedicalstudent’sabilitytoapplythebasicprinciplesofclinicalmedicine.However,beforeyoucanapplythoseprinciples,youmustbeabletorapidlyrecallacorebodyofessentialfacts.ThisiswhytheDéjàReviewseriesisthemostefficient,well-organized,portable,andaboveall,high-yieldresourcetopreparestudentsfortheUSMLE.AsrecentgraduateswhohavetakenStep2,weareconfidentthatwehavecompiledanovelreviewguidethatpromotesrapidrecallofalloftheessentialfactsnecessaryforsuccessonthisexamination.Wealsorealizethatasolidfoundationintheseprincipleswillallowyoutomakeasmoothtransitionintoyourresidency.

ORGANIZATION

All concepts are presented in a question and answer format that covers the key facts on hundreds of common anduncommondiseases.Thematerial isdividedintochapterscoveringthesixmajordivisionsofclinicalmedicine: internalmedicine,surgery,neuroscience,psychiatry,OB/GYN,andpediatrics.Wehavealsoincludedabriefemergencymedicinechapterthataddressestopicsnotcoveredunderemergentconditionsineachoftheotherchapters.

Thisquestionandanswerformathasseveralimportantadvantages:

•Itprovidesarapid,straightforwardwayforyoutoassessyourstrengthsandweaknesses.

•Itallowsyoutoefficientlyreviewandcommittomemoryalargebodyofinformation.

•Itwillprepareyouforgetting“pimped”byresidentsandattendingsonthewards.

•Itoffersyouabreakfromtedious,convolutedmultiple-choicequestions.

•Theclinicalvignetteswillexposeyou to theprototypicpresentationofdiseasesclassically testedon theUSMLEStep2.

•Itservesasaquick,last-minutereviewofhigh-yieldfacts.

Thecompact,condenseddesignof thebook isconducive tostudyingon thego,especiallyduringanydowntimeon thewards.

HOWTOUSETHISBOOK

Remember,thistextisnotintendedtoreplacetextbooks,coursepacks,orlectures.Itis,however,intendedtoserveasasupplementtoyourstudiesduringthethirdandfourthyearsofmedicalschool.ThistexthasbeensampledandrefinedbyanumberofmedicalstudentswhofoundittobeanessentialpartoftheirpreparationfortheUSMLEshelfexaminations,inaddition toStep2 itself.Werecommendhaving the textspiralbound tomake itmoreportableandeasier touse.Beginusing this book early in your third year by carrying itwith youduringyour clinical clerkships.Youmay cover up the

answerswiththeincludedbookmarkandquizyourselforevenyourclassmates.Foragreaterchallenge,trycoveringupthequestions!

Howeveryouchoosetostudy,wehopeyoufindthisresourcehelpfulduringyourpreparationfortheUSMLEStep2andthroughoutyourclinicalrotations.Bestofluck!

JohnH.Naheedy,MDDanielA.Orringer,MD

KhashayarMohebali,MDPeterF.Aziz,MD

SusieLim,MD

Acknowledgments

Theauthorswouldliketothankthefollowingindividualsfortheirinvaluablecontributionstothistextandtheireffortsinmakingthisausefulresourceforstudents:

DeborahA.Bartholomew,MDClinicalAssociateProfessorDepartmentofObstetricsandGynecologyOhioStateUniversityMedicalCenterColumbus,Ohio

PeterMuscarellaII,MDAssistantProfessor,ClinicalDepartmentofSurgeryOhioStateUniversityMedicalCenterColumbus,Ohio

EmileEl-Shammaa,MDAssistantProfessor,ClinicalDepartmentofEmergencyMedicineDepartmentofPediatricsColumbia,OhioOhioStateUniversityMedicalCenterColumbus,Ohio

TheauthorswouldliketorecognizethefacultyandstaffattheOhioStateUniversityCollegeofMedicinefortheirendlesscommitmenttoeducation.WithoutthewisdomandencouragementofmentorslikethelateJohnM.Stang,MD,thisprojectwouldnothavebeenpossible.Wewouldalsoliketothankthestudentswhousedthistextinpreparationfortheirboardsandprovidedfeedbackessentialtooptimizingthistext.Finally,specialthankstoourmanagingeditorKirstenFunkforherdedicationandpatience.

CHAPTER1InternalMedicine

CARDIOLOGY

Hypertension

Whatpercentageofhypertensivepatientshaveessentialhypertension(HTN)?90%-95%

Namethecauseofsecondary(2°)HTNinthefollowingclinicalscenarios:HTNupperextremities;decreasedornormalbloodpressure(BP)inlowerextremitiesCoarctationoftheaortaHTNaccompaniedbyproteinuriainanondiabeticpatientGlomerulardiseaseHTNinapatientwithahistoryof(h/o)renalandhepaticcystsPolycystickidneydiseaseSuddenworseningofHTNinanelderlymalewithcoronaryarterydisease(CAD)andperipheralvascular

disease(PVD)RenalarterystenosisEpisodicHTN,weightloss,headache,anddiaphoresisPheochromocytomaElevatedsystolicHTNwithoutdiastolicHTNHyperthyroidism40-year-old(y/o)femalewithah/o20yearsoforalcontraceptivepills(OCP)useDrug-induced(OCP)HTNHTNinapatientwithhypokalemicmetabolicalkalosisConnsyndrome/hyperaldosteronismHTNinanoverweightpatientwithbuffalohump,moonfacies,hirsutism,andabdominalstriaeCushingsyndrome

Whatisthedifferencebetweenhypertensiveurgencyandhypertensiveemergency?Inhypertensiveurgencytherearenosignsofend-organdamageduetoHTN.Inhypertensiveemergencythereare

signsoforgandamage(papilledema,renalfailure,heartfailure,stroke).

Whatisthetreatmentofhypertensiveurgency?OralBPmedication(labetalol,captopril,clonidine)

Whatarethethreepreferredagentsforthetreatmentofhypertensiveemergency?1.IVnitroprusside

2.Nitroglycerine3.Hydralazine

Whatisthepreferredtreatmentforhypertensioninpregnancy?Hydralazineandclonidineormethyldopa

Foreachofthefollowingconditions,selectthebestantihypertensiveagent(s):

NocomorbiditiesDiureticsorβ-blockersIsolatedsystolicHTNThiazidediureticsAnginapectorisβ-Blockers,calciumchannelblockersDiabetesAngiotensin-convertingenzymeinhibitors(ACEi)orangiotensinreceptorblocker(ARB),β-blockersHyperlipidemiaACEi,calciumchannelblockersCongestiveheartfailure(CHF)Diuretics,ACEiH/omyocardialinfarction(MI)β-blockers,ACEiChronicrenalfailureDiuretics,calciumchannelblockersAsthma,chronicobstructivepulmonarydisease(COPD)Diuretics,calciumchannelblockersBenignprostatichyperplasia(BPH)α1-selectiveantagonist(terazosin)PheochromocytomaPhenoxybenzamine(α1α2-antagonist),phentolamine(α1-blocker)Hypertrophicobstructivecardiomyopathyβ-blockersHyperthyroidismβ-blockersAnxietyβ-blockersSupraventriculartachycardia(SVT)β-blockersMigraineheadachesβ-blockers,calciumchannelblockersModeratebradycardiaβ-blockerswithintrinsicsympathomimeticactivity:pindololandacebutololOsteoporosisThiazidediuretics(reabsorbsCa2+)

Foreachofthefollowingconditions,listtheantihypertensiveagent(s)thatshouldbeusedwithcaution:CHFVerapamil,α-blockersAsthma,COPDβ-blockersDiabetesβ-blockers,thiazidesRenalarterystenosis,renalfailureACEinhibitors

Hypercholesterolemia

Whatgeneticdiseaseshouldbesuspectedinapatientwithxanthomas,xanthelasmas,andlipemiaretinalis?Familialhypercholesterolemia

State the recommended therapeutic intervention or further workup (w/u) for patients with the following lipid

values:Totalcholesterol200Retestin5yearsTotalcholesterol>200TreatbasedonlipidfractionsLow-densitylipoprotein(LDL)>190Beginlipid-loweringtherapy(goal160)LDL>160inapatientwithtwoormorecoronaryriskfactorsBeginlipid-loweringtherapy(goal130)LDL>130inapatientwithCADordiabetesmellitus(DM)Beginlipid-loweringtherapy(goal100)LDL>100inapatientwithapreviousMIBeginlipid-loweringtherapyTriglycerides(TGs)>200BeginTG-loweringtherapy

For each of the following drugs, provide: (1) the mechanism of action (MOA), (2) indication(s) (IND), and (3)significantsideeffectsanduniquetoxicity(TOX)(ifany):

CholestyramineMOA:bile-acid-bindingresinIND:adjuvanttherapyforpatientswithfamilialhypercholesterolemiaTOX:constipation,gastrointestinal(GI)discomfort,mayinterferewithintestinalabsorptionofotherdrugsStatinsMOA:hydroxymethylglutaryl(HMG)coenzymeA(CoA)reductaseinhibitorsIND:hypercholesterolemiaTOX:hepatotoxicity,rhabdomyolysisNiacinMOA:reducesreleaseofverylow-densitylipoprotein(VLDL)fromliverintocirculationIND:hypercholesterolemia:to↑high-densitylipoprotein(HDL)and↓LDLTOX:flushing,pruritus(bothreversiblewithaspirin),andhepatotoxicityGemfibrozil,clofibrateMOA:stimulateslipoproteinlipaseIND:hypercholesterolemia:to↓↓TGsTOX:myositis,hepatotoxicity

CoronaryArteryDisease

Whicharethesixcoronaryriskfactors?CADHDL1.Cigarettes2.Age(males>45andfemales>55areatincreasedrisk)andsex(males>females)3.Diabetesmellitus(greatestriskfactor)4.HTN5.DeathfromMIinfamilyhistory(FH)(males55y/o,females60y/o)6.↑LDL,lowHDL(35)

WhatisthecommonpresentationofapatientwithsymptomaticCAD?Angina pectoris ± radiation to jaw, left shoulder, or arm; exacerbated by exertion, relieved by rest, and

nitroglycerin

Whichgroupsofpatientscommonlydonotexhibitclassicanginalsymptomsinthesettingofmyocardialischemia?Elderly,women,anddiabetics(duetodiabeticneuropathy,hearttransplantpatients)

Whichtypeofanginaischaracterizedbychestpainanddyspneaatrest?

Unstableangina

WhataretheclassicECGfindingsduringananginalepisode?>1-mmST-segmentdepressionandT-waveinversion

WhatdiagnostictestsareoftenusedtoscreenforCAD?Exerciseorpharmacologicstresstestorimaging

WhichpatientsshouldundergoexerciseECGw/myocardialimaging+stressechointheworkupofCAD?Patients with Wolf-Parkinson-White syndrome, >1-mm ST depression on resting ECG; hx of percutaneous

transluminalcoronaryangioplasty(PTCA),onDigoxin,orthosewithleftventricularhypertrophy(LVH)

Whogetspharmacologicstresstest?Patientswithelectronicallypacedventricularrhythmandleftbundlebranchblock(LBBB)

WhatisthegoldstandardforthediagnosisofCAD?Coronaryarteriography

NamesixlifestylechangesthatshouldbesuggestedtoallpatientswithHTN:1.Weightloss

2.Sodiumrestriction3.Physicalexercise4.Smokingcessation5.Alcoholcessation6.Stressreduction

Whatmedicationsshouldbegiventoapatientwithacuteonsetofangina?Sublingualnitroglycerin

WhatmedicationsshouldbegivenasprophylaxisforanginaandMI?Long-actingnitrates,β-blockers,ASA,statin(andACEIinpatientswithh/oMI)

Whatarethekeystepsinthemedicalmanagementofapatientwithunstableangina?StartIV,administerO2,startheparin,ASA,β-blocker,nitroglycerin,morphine

Describehownitratesreduceangina:1.Venodilationcausesvenouspooling→↓preload→↓myocardialO2consumption2.Coronaryvasodilation→↑O2deliverytothemyocardium

Whatisthemostcommonsideeffectofnitrates?Headache

Describehoweachofthefollowingdrugsreducesangina:β-Blockers↓MyocardialO2use,↓afterload,↑coronaryfillingduringdiastoleNifedipineCoronaryarteriolarvasodilationVerapamilSlowscardiacconduction

Whatistheantianginaldrugofchoiceforprinzmetalangina?Diltiazem

WhichantianginaldrugmustbeusedwithcautioninpatientswithasthmaandCOPD?β-blockers

Whatinterventionisreservedforpatientswhoseanginacannotbecontrolledmedically?Percutaneoustransluminalcoronaryangioplasty(PTCA)

Whataretheindicationsforcoronaryarterybypassgrafting?Anginarefractorytomedicaltherapy,severeleftmaindisease,andtriplevesselcoronarydisease(ordoublevessel

diseaseinadiabetic)

MyocardialInfarction

WhatisthecommonpresentationofMI?Crushing retrosternal chest pressure occurring at rest and radiating to left arm, neck, or jaw; diaphoresis;

nausea/vomiting;dyspnea;andanxiety

WhatisacommonphysicalexaminationfindingduringanMI?S4gallop

Whicharethesixlife-threateningcausesofchestpainthatmustberuledoutinallpatients?1.MI

2.Aorticdissection3.Pulmonaryembolism(PE)4.Pneumothorax(PTX)5.Esophagealrupture6.Cardiactamponade

WhatarethekeystepsintheinitialmanagementofapatientwithsuspectedMI?Assessvitalsigns,administerO2,startIV,placeoncardiacmonitor,andobtainECG;administerASA,heparin,

nitrates,β-blockers,morphine,clopidogrel

WhataretheclassicECGabnormalitiesinanacuteMI?STelevationandQwaves

WhichECGfindingisverysensitiveandspecificforrightventricularinfarction?STelevationof1mminright-sidedleadV4

WhichcoronaryarteryislikelytobeoccludedinapatientwiththefollowingECGabnormalities?LargeRandST-segmentdepressioninV1,V2Rightcoronary(posteriorinfarction)QwavesandST-segmentelevationinleadsV1-V4Leftanteriordescending(anteriorinfarction)QwaveinleadsI,aVL,V5,V6Circumflex(lateralinfarction)QwavesandSTelevationinleadsII,III,aVFRightcoronary(inferiorinfarction)

WhichserologicmarkersaretypicallyusedtodiagnoseandfollowanMI?TroponinIandCK-MB

WhatmedicationisreservedforpatientswithMIsufferingfromanginathatisrefractorytoconventionalmedicalmanagement?

Thrombolyticsincludingtissueplasminogenactivatororstreptokinase

WhatinterventionisindicatedinpatientsduringanMIwhofailorcannottoleratethrombolytictherapy?PTCA

WhataretheclinicalmanifestationsofrightventricularMI?

ECGinf.changes,hypotension,clearlungs,jugularvenousdistension(JVD),rightventricularlift,tricuspidvalveregurgitation

Whichmedicaltherapyshouldbeavoidedinapatientwitharightventricularinfarction?Nitroglycerin(initialtherapyshouldinvolveIVfluidsto↑preload)

Whatlong-termmedicationshavebeenshowntoimprovemortalityinpatientswithMI?ASAandβ-blockers(acutely);ACEI,statins,andclopidogrel(longterm)

Arrhythmias

Namethearrhythmiaassociatedwiththefollowingclinicalfeatures:PRinterval>0.2s,oftenduetoincreasedvagaltonePrimary(1°)heartblockPRintervalgraduallyincreasestothepointatwhichaQRScomplexisdropped(Pwaveisnotconducted).2°MobitztypeIheartblock(Wenkebach)PRinterval>0.2swithoccasionaldroppingoftheQRScomplexatafixedinterval(ie,2:1or3:1)2°MobitztypeIIheartblockIrregularlyirregularpulsesandQRScomplexesAtrialfibrillationTypeofheartblockthatcommonlyarisesasasideeffectofmedicationincludingβ-blockers,digoxin,and

calciumchannelblockers2°MobitztypeIIheartblockSawtoothappearanceofPwavesAtrialflutterUsuallycausedbyconductionblockwithinthebundleofHis2°MobitztypeIIheartblockCompletedissociationbetweenPwavesandQRScomplexes3°orcompleteheartblockThreeormoreP-wavemorphologiesMultifocalatrialtachycardiaifHR>100,wanderingpacemakerifHR100AssociatedwithcannonAwavesinjugularveinsandwidenedpulsepressure3°heartblockIrregularlyirregularpulsesandQRScomplexesAtrialfibrillationCommonlycausedbyreentryParoxsymalSVTAssociatedwithCOPDAtrialfibrillation,atrialflutter,multifocalatrialtachycardiaTreatmentcommonlyincludesanticoagulation,ratecontrol,and/orcardioversion.AtrialfibrillationWideQRScomplexesnotprecededbyaPwavePrematureventricularcontraction(PVC)NormalQRSmorphologywitharateof150-200beats/minParoxsymalSVTPharmocologictreatmentincludesamiodarone,lidocaine,andprocainamide.VentriculartachycardiaMaybetreatedwithcarotidmassageorValsalvamaneuverParoxsymalSVTCommoncauseofpalpitationcausedbyectopicbeatsarisingfrommultipleVentricularfociPVCVentricular arrhythmia commonly caused by myocardial ischemia that may lead to hemodynamic

instability

VentriculartachycardiaFirst-linetherapyisdefibrillation;second-linetherapyisepinephrineorvasopressin.VentricularfibrillationandpulselessventriculartachycardiaPolymorphicwidecomplextachycardiaassociatedwithprolongedQTintervalTorsadedepointesTreatedidenticaltoventricularfibrillationifthereisnopulseVentriculartachycardiaTachyarrhythmiatreatedwithadenosine,verapamil,cardioversion,orradiofrequencyablationParoxsymalSVTNarrowcomplextachycardiainwhichPwavesfollowQRSJunctionaltachycardiaorWolff-Parkinson-WhiteTreatmentwithpacemakerisnecessary.Symptomatic2°MobitztypeIIheartblock,3°heartblock,andsinusnodedysfunction

Whatisthemostcommoncauseofatrialfibrillation?HTN

Whataresomeotherimportantcausesofatrialfibrillation?PIRATES

PulmonarydiseaseIschemiaofmyocardiumRheumaticheartdiseaseAnemiaoratrialmyxomaThyrotoxicosisEthanolSepsis

Whatarethetwomaincomponentsinthetreatmentofatrialfibrilation?Ratecontrolandlong-termanticoagulation(ie,metoprololandwarfarin)

Whatcriteriaareusedtodeterminewhetherwarfarinoraspirinisstartedinthetreatmentofatrialfibrillation?CHADS2 score: 1 point forCHF, hypertension, age >75,DM, 2 points for stroke or transient ischemic attack

(TIA).Score≥3receiveswarfarin.

Namethreeclinicalscenariosinwhichatropineisindicatedfortreatmentofabradyarrhythmia:1.Bradycardiacausinghemodynamicinstability2.Syncope3.CHF

CongestiveHeartFailure

NamesixcommonsymptomsofCHF:1.Dyspnea;exertionalinitiallybutoccursatrestasdiseaseprogresses2.Orthopnea3.Paroxysmalnocturnaldyspnea4.Coughandwheezing5.Weightgainduetoperipheraledema6.Worseningfatigue

Namefourcommonsignsofleft-sidedCHF:1.S3gallop2.Inspiratorycracklesorrales3.Laterallydisplacedpointofmaximalimpulse(duetocardiomegaly)4.Ventricularheave

Namefivecommonsignsofright-sidedCHF.1.Dependentedema2.Jugularvenousdistention(JVD)3.Hepatojugularrefluxandascites4.Atrialfibrillation5.Cyanosis

Whatisthepathophysiologicbasisofsystolicdysfunction?Decreasedcontractility

Whatarethetwocommoncausesofsystolicdysfunction?1.Ischemiccardiomyopathy2.Ischemicmyocarditis

Whatisthepathophysiologicbasisofdiastolicdysfunction?Decreasedventricularcompliance

Whatarethefourcommoncausesofdiastolicdysfunction?1.HTN2.Ischemiccardiomyopathy3.Hypertrophiccardiomyopathy4.Systemicdisorders(ie,amyloidosis,hemochromatosis)

Namefourcommonchestx-ray(CXR)abnormalitiesinCHF:1.Cardiomegaly2.Cephalizationofpulmonaryvessels(↑vascularityinlungfields)3.KerleyBlines(indicatingpleuralfluidinfissures)4.Pleuraleffusions

NametwocommonechocardiographicabnormalitiesinCHF:1.Decreasedejectionfraction2.Cardiomegaly

NametheCHFdrugassociatedwitheachofthefollowingstatements:ShowntodecreasemortalityinCHFACEinhibitors,β-blockers,andspironolactone(↓mortalityinclassIVCHF)UsedacutelyforworseningdyspneaandfluidretentionLoopdiureticsReduceafterloadbycausingvasodilationofbotharteriesandveinsACEinhibitorsReducesymptomsofCHFbyimprovingcontractilityDigitalisVasodilatorsusedinpatientsrefractorytoACEinhibitorsHydralazineandisosorbidedinitrateMaycausearrhythmias,yellow-tintedvision,anorexia,andnauseaDigitalisIntravenouspositiveinotropicagentsDopamine,dobutamine,andnesiritide

ValvularHeartDisease

Namethevalvulardefectassociatedwitheachofthefollowingmurmurs:Harshmidsystolicmurmurintherightsecondintercostalspaceattherightsternalborder,radiatinginto

theneckandapex

AorticstenosisBlowing,high-pitcheddiastolicmurmuratlefttwotofourthinterspacesradiatingtoapexAorticregurgitationBlowingholosystolicmurmuratapexradiatingintoleftaxillawithincreasedapicalimpulseMitralregurgitationLow-pitcheddiastolicmurmurattheapexthatgetslouderpriortoS1;anopeningsnapisoftenpresentjust

afterS2MitralstenosisSoft,latesystolicmurmuratleftsternalborderorapex,accompaniedbymidsystolicclickMitralvalveprolapseHarshmidsystolicmurmurintheleftsecondintercostalspaceattheleftsternalborderPulmonicstenosisBlowingholosystolicmurmuratlowerleftsternalborderradiatingtorightofsternum;mayincreasewith

inspirationTricuspidregurgitationHarshholosystolicmurmuratlowerleftsternalborder,accompaniedbythrillVentricularseptaldefectHarshmidsystolicmurmurinthethirdandfourthleft interspacesradiatingdownleftsternalborder;S4

andbiphasicapicalimpulseoftenpresentHypertrophiccardiomyopathy

Note:thevalvulardiseasesinthepreviousanswersareintheorderofincidence.

Namethevalvulardefectassociatedwiththefollowingfeatures:Canbecausedbypapillarymusclerupture2°toMIMitralregurgitationMaycauseleftatrialenlargement,atrialfibrillation,andpulmonaryedemaMitralstenosisandmitralregurgitationPresentswithtriadofangina,syncope,andexertionaldyspnea;boot-shapedheartonCXRAorticstenosisMaybeprecipitatedbyinfectiveendocarditis,aorticaneurysmaldilation,andconnectivetissuedisordersAorticinsufficiencyAtrioventricularblockMitralregurgitationCalcificdegenerationofacongenitalbicuspidvalveAorticstenosisIncreasedpulsepressureAorticinsufficiency

Cardiomyopathies

Whatarethemostcommonetiologiesofdilatedcardiomyopathy?ABCD

AlcoholabuseBeriberiCoxsackieBmyocarditis,cocaine,ChagasdiseaseDoxorubicintoxicity(alsopregnancy)

Namethetypeofcardiomyopathyassociatedwiththefollowingclinicalfeatures:Asymmetricseptalhypertrophy,banana-shapedleftventricle(LV);LVoutflowobstructionHypertrophicMay be caused by sarcoidosis, amyloidosis, scleroderma, hereditary hemochromatosis, endocardial

fibroelastosis,radiation-inducedfibrosis

RestrictiveCausessuddendeathinyoung,otherwisehealthyathletesHypertrophicFour-chamberhypertrophyanddilationaccompaniedbysystolicdysfunctionDilatedCardiomyopathymostcommonlycausedbyendomyocardialfibrosisRestrictiveMostcommontypeofcardiomyopathy,commonlyinheritedinautosomal-dominant(AD)fashionHypertrophicACEihavebeendemonstratedtodecreasemortalityDilatedSymptomsrelievedbysquatting(↑preload)HypertrophicImpairedleftventriculardiastolicfilling;maymimicconstrictivepericarditisRestrictiveExaminationrevealscardiomegaly,mitralregurgitation,andS3;balloon-shapedheartonCXRDilatedMitral regurgitation, sustained apical impulse, S4, and systolic ejection murmur; boot-shaped heart on

CXRHypertrophicβ-BlockersandcalciumchannelblockersprovidesymptomaticreliefHypertrophic

PericardialDisease

Whatisthecommonpresentationofpericarditis?Pleuriticretrosternalchestpain(↑whensupine,↓whensittingupandleaningforward),dyspnea,cough,andfever

Whatarethemostcommonetiologiesofserouspericarditis?Uremia,systemiclupuserythematosus(SLE),rheumaticfever,coxsackieviralinfection

Whatarethemostcommonetiologiesoffibrinouspericarditis?Uremia,SLE,rheumaticfever,coxsackieviralinfection,MI

Whatarethemostcommonetiologiesofhemorrhagicpericarditis?Trauma,malignancy,tuberculosis

Whatisatypicalexaminationfindinginpericarditis?Pericardialfrictionrub

WhataretheclassicECGfindingsinpericarditis?DiffuseSTelevation

Whatlife-threateningcomplicationofpericarditiscausesdistantheartsounds,JVD,hypotension,pulsusparadoxus,andelevatedcentralvenouspressure(CVP)oninspiration?

Cardiactamponade(Beck’striad=JVD,hypotension,muffledheartsounds)

Whatisthedefinitivetreatmentforacutedecompensationinapatientwithcardiactamponade?Pericardiocentesis

Which2°interventionmaybehelpfulinthemanagementofapatientwithcardiactamponade?Intravascularvolumeexpansion

Endocarditis

Whatarethethreemajorcategoriesofendocarditis?1.Infective2.Nonbacterialthromboticormarantic3.Libman-Sacksendocarditis

Whatisthecommonpresentationofinfectiveendocarditis(IE)?Fever(highinacuteendocarditis,low-gradeinsubacuteendocarditis),constitutionalsymptoms,anddyspnea

WhataretheclinicalsignsofIE?”JRNOFAME”JanewaylesionsRoth’sspotsNailbedhemorrhagesOsler’snodesFeverAnemiaMurmurEmboli

WhatcriteriaaretypicallyusedfordiagnosingIE?TheDukecriteria

WhatarethetwomajorDukecriteria?1.Twoconsecutivebloodcultures(12hapart)positiveforIE-causingorganism2.Echocardiogramdemonstratingvalvularvegetation,ringabscess,orotherevidenceofendocardialinfectionornewvalvemurmur

WhatarethefiveminorDukecriteria?1.Cardiacpredispositionincludingvalvularabnormality,congenitalheartdisease,orhypertrophiccardiomyopathyRiskofbacteremia:DM,indwellingcatheter,intravenousdrugabuse(IVDA),hemodialysis

2.Fever>38°C(100.4°F)3. Vascular phenomena: signs of embolic disease including septic pulmonary emboli, mycotic cerebral abscesses,Janewaylesions

4.ImmunologicphenomenaincludingRothspotsorOslernodes5.Singlepositivebloodculture

Howdoyoumakeadefinitivediagnosisofinfectiveendocarditis?2major;1major+3minor,or5minorcriteria

WhatisthemostcommonvalveaffectedbyIE?Mitralvalve

WhatisthemostcommonvalveaffectedbyIEinIVdrugusers?Tricuspidvalve

Namethetypeofendocarditisdescribedineachofthefollowingclinicalscenarios:25-y/oIVdruguserwithrapidonsetofhighfever,rigors,malaisewithtricuspidregurgitationAcuteIE60-y/ofemalewithmitralvalveprolapsewhohasrecentlyundergonedentalextractionpresentingwithlow-

gradefeverandflu-likesymptomsSubacuteIE65-y/omalewithmetastaticcoloncancerandanewmurmurconsistentwithmitralregurgitationNonbacterialthromboticendocarditis30-y/ofemalewithSLE

Libman-Sacksendocarditis

WhichorganismmostoftencausesacuteIE?Staphylococcusaureus

WhichorganismmostoftencausessubacuteIE?Streptococcusviridans

Whichorganismscancauseendocarditisbutarenottypicallyisolatedbyconventionalbacterialculture?HACEKorganisms(Haemophilusparainfluenzae,Actinobacillus,Cardiobacterium,Eikenella,Kingella)

Whataresomesequelaeofbacterialendocarditis?Valvularinjury,renalinjury(glomerulonephritis[GN]),septicembolitobrain/lungs/kidneyscausinginfarctionor

abscess

Whatisthemostcommoncauseofmyocarditisworldwide?Trypanosomacruzii(Chagasdisease)

What is the empiric treatment forapatientwith suspected endocarditis (beforeanorganism is isolated inbloodcultures)?

Anantistaphylococcalβ-lactamantibioticandanaminoglycoside

Whatisthesuggestedregimenofantibioticprophylaxisforpatientsatincreasedriskofendocarditis?Twogramsofamoxicillinpriortodentalprocedures

Whichpatientsshouldreceiveendocarditisprophylaxis?Patientswithprostheticheartvalves,previousbacterialendocarditis,high-riskpatients(ie,complexcyanoticheart

disease), and moderate-risk patients (ie, hypertrophic cardiomyopathy, MVP with regurgitation and/or thickenedleaflets,repairedintracardiacdefectsinpast6months)

RheumaticHeartDisease

Whattypeofinfectioncausesrheumaticfever?GroupAstreptococcalpharyngitis

Howdoesstreptococcalpharyngitiscauserheumaticheartdisease?Antistreptococcalantibodiescross-reactwithacardiacantigen.

Whatserologictestiselevatedinrheumaticheartdisease?Antistreptolysinantibodies(ASO),DNAseB

NamethefivemajorJonescriteriaforrheumaticheartdisease:”J NES”1.Joints(migratorypolyarthritis)2. :pancarditis3.N:subcutaneousnodules4.Erythemamarginatum5.Sydenhamchorea

NamethreeminorJonescriteriaforrheumaticheartdisease:1.Fever2.Arthralgia3.Leukocytosis

Whatisthemostcommonlyobservedvalvulardeformityinrheumaticheartdisease?

Mitralstenosis

Whattreatmentforstreptococcalpharyngitiscanpreventrheumaticheartdisease?Penicillin

Whatisthecriticaldeterminantofmorbidityinacuterheumaticfever?Degreeofmitralandaorticvalvestenosis/regurgitation

AorticDissection

Whatisthetypicalpresentationofanaorticdissection?Suddenonsetofsevere,tearingsubsternalpainradiatingtotheinterscapularregionoftheback

Whichphysicalexaminationfindingsarecharacteristicofanaorticdissection?UnequalBPintheextremities,newmurmurconsistentwithaorticregurgitation

WhatfindingonCXRsuggestsanaorticdissection?Widenedmediastinum

WhichcoronaryarteryismostcommonlyaffectedbyaorticdissectionandwhataretheassociatedECGfindings?Rightcoronaryartery.InferiorMI=STelevationII,III,aVF

Whatisthegoldstandardforthediagnosisofaorticdissection?Angiography(CTwithcontrast,transesophagealechocardiography,andMRIalsohavediagnosticuseandareless

invasive)

WhatmedicationispreferredforloweringBPinapatientwithanaorticdissection?Sodiumnitroprussideandβ-blockers

Whatisthedefinitivetherapyforanaorticdissection?Surgicalrepair

PeripheralVascularDisease

Whataretheriskfactorsforperipheralvasculardisease(PVD)?Similartocoronaryriskfactors;thoughdiabetesis#1

NamethePVDassociatedwiththefollowingfeatures:FocalneurologicfindingsCerebrovasculardiseaseAbdominalpainoutofproportiontoexaminationMesentericischemiaIntermittentclaudicationChronicarterialocclusivediseasePaininbuttocksandthighswithwalkingAortoiliacocclusivediseasePainincalveswithwalkingFemoral-poplitealocclusivediseaseAbdominalanginaChronicmesentericarterialocclusivedisease

Whatnoninvasivestudyisusedtodiagnosearterialocclusion?Dopplerultrasound

Whatisthegoldstandardforthediagnosisofarterialocclusion?Angiography

Whatisthesourceofmostembolicausingacutearterialocclusion?Cardiacmuralthrombus(commonlyinpatientswithatrialfibrillation)

Whatisthetreatmentofanacutearterialocclusion?Surgicalorpercutaneousthrombectomyormedicalthrombolysis

Whattypeoftherapymustbeadministeredtoallpatientswithah/oacutearterialocclusion?Warfarin

MaketheDiagnosis

56-y/o female presents with dyspnea on exertion (DOE); PE (physical examination): loud S1, delayed P2, earlydiastolicsound,andadiastolicrumble;transesophagealechocardiogram:mobile,pedunculatedleftatrialmass

Atrialmyxoma

60-y/o presents with chest pain relieved by sitting up and leaning forward; PE: pericardial friction rub; ECG:diffuseST-segmentelevation;echocardiogram:pericardialeffusionwiththickeningofthepericardium

Acutepericarditis

65-y/omalepresentswith1-weekh/ofeverandDOEandorthopnea;PE:newblowingholosystolicmurmuratapexradiatingintoleftaxilla;bloodcultures⊕forviridansstreptococci;echo:oscillatingmassattachedtomitralvalve

AcuteIE

60-y/o presents with dyspnea and palpitations; PE: 20 mm Hg decline in systolic BP with inspiration (pulsusparadoxus),↓BP,JVD,diminishedS1andS2;echo:largepericardialeffusion

Tamponade

58-y/omalewithMarfansyndromepresentswiththeabruptonsetoftearingchestpainradiatingtotheback;PE:↓BP,asymmetricpulses,decliningmentalstatus;CXR:widenedmediastinum

Aorticdissection

70-y/o diabetic with hypercholesterolemia presents with angina, syncope, DOE; PE: diminished, slowly risingcarotidpulses,crescendo-decrescendosystolicmurmuratthesecondinterspaceattherightuppersternalborder

Aorticstenosis

80-y/o diabetic with HTN and a h/o rheumatic heart disease presents with left-sided weakness; PE: pulses areirregularlyirregular;ECG:absenceofPwavesandirregularlyirregularQRScomplexes

Atrialfibrillation(leadingtoembolicstroke)

70-y/owithah/oCADpresentswithworseningDOE,orthopnea,andparoxysmalnocturnaldyspnea;PE:JVD,S3gallop, ⊕ hepatojugular reflex, bibasilar rales, and peripheral edema; CXR: cardiomegaly, bilateral pleuraleffusions

CHF

50-y/ochronicalcoholicpresentswithworseningDOE,orthopnea,andparoxysmalnocturnaldyspnea;PE:laterallydisplacedapicalimpulse;echocardiogram:four-chamberdilation,mitralandtricuspidregurgitation

Alcoholicdilatedcardiomyopathy

35-y/omalewithFHofsuddencardiacdeathpresentswithDOEandsyncope;PE:doubleapicalimpulse,S4gallop,holosystolicmurmuratapexandaxilla;echo:leftventricularhypertrophyandmitralregurgitation

Hypertrophiccardiomyopathy

40-y/oblackmalewithh/oHTNpresentswithchestpain,dyspnea,andsevereheadache;PE:BP=210/130inallfourextremities,flame-shapedretinalhemorrhages,papilledema;labs:negativevanillylmandelicacid(VMA)andurinecatecholamines,andcardiacenzymes

MalignantHTN

15-y/ofemalepresents1monthafterasorethroatwithfeverandjointpain.CBCshowsleukocytosis.Labs:ASO+Rheumaticfever

35-y/ofemalewithah/orheumaticfeverpresentswithworseningDOEandorthopnea;PE:loudS1,openingsnap,andlow-pitcheddiastolicmurmurattheapex;CXR:leftatrialenlargement

Mitralstenosis

65-y/omalepresentswith1-hh/osubsternalpressureandpainwithradiationintothejawandleftarm,nausea,anddiaphoresis;PE:S4gallop;labs:↑troponinandCK-MB;ECG:STelevationinleadsaVL,V1-V4

AnteriorMI

70-y/o female with DM andCAD presents with nausea and vomiting; PE: hypotension, clear lungs, JVD, rightventricularlift,andtricuspidvalveregurgitation;ECG:STelevationintheinferiorleads

RightventricularMI

40-y/oasymptomaticmale;PE:displacedanddiffuseapicalimpulse,diastolicmurmuratleftsternalborder,briskpulseswithrapidcollapse+“pistolshot”soundascultatedoverlargeperipheralarteries

Aorticregurgitation

PULMONARY

ChronicObstructivePulmonaryDisease

WhataretheclassicPFT(pulmonaryfunctiontest)valuesforobstructivelungdisease?FEV1/FVC80%

Namethetypeofobstructivepulmonarydiseaseassociatedwiththefollowingfeatures:Productivecoughonmostdaysduring3ormoreconsecutivemonthsfor2ormoreyearsthatisworstin

winterChronicbronchitisDyspneaandresultanthypertrophyofaccessorymusclesofinspirationEmphysemaCyanosis,rhonchi,wheezes,obesity,andsignsofright-sidedheartfailureChronicbronchitisNormalPaco2,mildly↓PO2EmphysemaHypertrophy/hyperplasiaofmucusglandsliningtheairwaysChronicbronchitisDestructionofalveolarwallsleadingtolossofelasticrecoilanddilationofairspacesEmphysemaAcuteorsubacuteonsetofdyspnea,expiratorywheezing,prolongedexpiratoryphase,accessorymuscleuseAsthmaPursed-lipbreathing,prolongedexpiratoryphaseEmphysemaCommonlycausedbycysticfibrosis(CF),severe/chronicpulmonaryinfection,orconnectivetissuediseaseBronchiectasis

Mucousplugging,airwaysmoothmusclehypertrophy,peripheraleosinophiliaAsthmaBarrelchest,↓breathsounds,hyperresonanttopercussionEmphysema↑Paco2,↓PO2,↑hematocrit(Hct)earlyinthecourseofdiseaseChronicbronchitisLunghyperinflationonCXREmphysema,asthmaAirwayirritabilitycausingreversiblebronchoconstriction;diagnosewithmethacholinechallengeAsthmaPermanentdilationofbronchiolesBronchiectasisMildly↓Pao2respiratoryalkalosisAsthmaHalitosis,hemoptysis,andproductivecoughBronchiectasisCXRmaydemonstratesubpleuralblebsorparenchymalbullae.EmphysemaExacerbationmay be triggered by cold air, exercise, inhaled dust, upper respiratory infection (URI), β-

blockers,stress.AsthmaCXRmayshowtram-tracklungmarkings.Bronchiectasis

Whatisthemostbeneficiallifestylemodificationforapatientwithchronicobstructivepulmonarydisease(COPD)?Smokingcessation

WhatprophylacticvaccinesarerecommendedforpatientswithCOPD?Influenzaandpneumococcalvaccines

WhatarethethreeclassesofbronchodilatorsusedforCOPDandasthma?1.β2-Selectiveagonists,ie,albuterol

2.Anticholinergics,ie,ipratropium3.Methylxanthine

WhatbronchodilatorcommonlyusedinCOPDforreliefofnocturnalsymptomscanalsocausenausea,vomiting,seizures,andarrhythmias?

Theophylline

WhattwoclassesofdrugsareusefulduringacuteCOPDexacerbations?1.Corticosteroids

2.Antibiotics

WhichtherapycanprovidesymptomaticreliefandimproveoutcomeinCOPDpatientswithhypoxemia?Supplementaloxygentherapy

WhatinheriteddisordercausesearlyprogressionofCOPD?α1-Antitrypsindeficiency

Namethetreatmentofchoiceforthefollowingclinicalscenariosinanasthmatic:First-linetherapyforacuteasthmaticattackO2,bronchodilators,steroidsSecond-linetherapyforacuteasthmaticattackMgSO4andintramuscularepinephrineInitialtherapyofmildasthma

InhaledalbuterolasneededMildasthmarefractorytoalbuteroltreatmentsInhaledglucocorticoidsAsthmaattacksrefractorytodailyalbuteroluseSystemicsteroidtherapy;usuallywithoralprednisoneorIVmethylprednisoloneProphylaxisforasthmaattacks(notincludingsteroids)Leukotrieneinhibitorsandcromolyn

Describehowglucocorticoidsactonairwaystocontrolasthma:↓Inflammationand↓reactivityofairwaystoirritants(eg,cold,cigarettesmoke,allergens,exercise)

Namethetreatmentforthefollowingclassesofasthmaticsymptoms:MildintermittentDailytreatment:none

Quickrelief:albuterolMildpersistentDailytreatment:low-dosesteroids,isoniazid(INH)

Quickrelief:albuterolModeratepersistentDailytreatment:low-mediumdoseINH,long-actingβ2-selectiveagonist

Quickrelief:albuterolSeverepersistentDailytreatment:high-dosesteroidINH,longactingβ2-selectiveagonist,oralsteroids

Quickrelief:albuterol

RestrictiveLungDisease

WhataretheclassicPFTsforrestrictivelungdisease?FEV1/FVC>70%

Namethespecifictypeoflungdiseaseassociatedwiththefollowingdescriptions:65-y/ohayfarmerwithrecentexposuretomoldyhaypresentswithchronicdrycough,chesttightness;PE:

bilateraldiffuserales;bronchoscopy:interstitialinflammation;bronchioalveolarlavage:lymphocyteandmastcellpredominance

Hypersensitivitypneumonitis35-y/omalepresentswithintermittenthemoptysisandhematuria;w/u:alveolarhemorrhageandacuteGNGoodpasturesyndrome40-y/owithprogressivehypoxemiaandcorpulmonale; lungbiopsy:chronic inflammationofthealveolar

wallinapatternconsistentwithhoneycomblung;bronchioalveolarlavage:mildeosinophiliaIdiopathicpulmonaryfibrosis58-y/oformershipbuilderpresentswiththeinsidiousonsetofdyspnea;transbronchialbiopsydemonstrates

interstitialpulmonaryfibrosis,ferruginousbodies;chestCT:demonstratespleuraleffusion,anddensepleuralfibrocalcificplaques

Asbestosis55-y/ominer (nonsmoker)withdyspneaanddrycough;PFTs:obstructiveandrestrictivepattern;CXR:

hilarlymphadenopathywitheggshellcalcificationsSilicosis60-y/omalewith100pack-yearh/osmokingpresentswithpleuriticchestpain,hemoptysis,anddyspnea;

PE:dullnesstopercussionandabsentbreathsoundsintherightlowerlungfieldPleuraleffusion(2°tomalignancy)50-y/o former heavy smoker presents with multiple lung and rib lesions; excisional biopsy: lesions

composed of cells (similar to the Langerhans cells of the skin) containing tennis racket—shaped Birbeckgranules

Eosinophilicgranuloma30-y/oblackfemalepresentswithDOE,fever,arthralgia;PE:iritis,erythemanodosum;labs:eosinophilia,

↑ serumACE levels; PFT: restrictive pattern; CXR: bilateral hilar lymphadenopathy; lymph node biopsy:noncaseatinggranulomas

Sarcoidosis”GRAIN”GammaglobulinemiaRhumetoidarthritisACEincreaseIntersitialfibrosisNoncaseastinggranulomas

HowisthediagnosisofLofgrensyndrome(foundin25%-50%)madeinsarcoidosispatients?Hilarlymphadenopathy,polyarthralgias,anderthemanodosum

Namethefourstagesofsarcoidosis:I.Hilarlymphadenopathyalone

II.Lymphadenopathy+infiltratesIII.InfiltratesaloneIV.Fibrosis

CysticFibrosis

WhatarethecommonpresentingsymptomsofaninfantwithCF?Meconiumileus,diarrhea,steatorrhea,malabsorption,failuretothrive,prolongedjaundice,recurrentURIs

WhatarethecommonpresentingsignsonexaminationofaninfantwithCF?Cyanosis,clubbing,hyperresonantlungfieldswithoccasionalcrackles,rectalprolapse,abdominaldistention

WhatisthetraditionaldiagnostictestforCF?Sweatchloridetest(⊕if>60mEq/L)

WhatisthedefinitivetestforCF?Geneticanalysis

WhichdrugsareknowntobebeneficialinthemanagementofCF?Bronchodilators,antibiotics,andanti-inflammatoryagents

WhatdietarysupplementsarenecessaryforpatientswithCF?PancreaticenzymesupplementsandvitaminsA,D,E,andK(thefat-solublevitamins)

Whichtwomethodsareusedtoclearexcesspulmonarysecretions?PhysicaltherapyandDNAsetherapy

DescribetheeffectofCFoneachofthefollowingorgans:LungsRecurrentpulmonaryinfections,bronchiesctasis.↑Residualvolume(RV)andtotallungcapacity

(TLC)inchronicdisease;↓forcedexpiratoryvolume(FEV)inthefirstsecond(FEV1)/FVCinacuteexacerbation;pulmonaryhemorrhagemayoccur

PancreasVariabledefectsinpancreaticexocrinefunction;maycausepancreaticinsufficiency,fattystool,weightlossIntestinesMucusplugs→smallbowelobstruction;meconiumileusinsomeinfantsSalivaryglandsDuctaldilation;squamousmetaplasiaofductalepitheliumandglandularatrophy

LiverPluggingofbilecanaliculi→cirrhosisEpididymisandductusdeferensObstruction→azospermiaandinfertility

Whatistheclassicfindingonpulmonaryexaminationinapatientwithidiopathicpulmonaryfibrosis?Fineexpiratorycrackles(velcrocrackles)

Howdoesinterstitiallungdiseaseaffectalveolargasdiffusionandlungvolumes?Interstitialfibrosisdecreasesgasdiffusionandlungvolumes.

Whichgroupofinterstitial lungdiseasescanpresentwithacombinationofobstructiveandrestrictivepatternonPFTs?

Pneumoconioses

Which group of interstitial lung diseases is caused by a deposition of immune complexes in the alveoli andgranulomaformation?

Hypersensitivitypneumonitis

Nameseveralcommonlyuseddrugsthatareknowntocauseinterstitiallungdisease:Bleomycin,vincristine,alkylatingagents,andamiodarone

WhataretypicalfindingsonCXRinapatientwithinterstitiallungdisease?Reticularorreticulonodularinfiltratesorhoneycomblung

Nametheinterstitiallungdisease(s)withthefollowingfindingsonCXR:BilaterallinearopacitiesandbroadpleuralplaquesAsbestosisNodularopacitiesintheupperlungzonesCoalworker’spneumoconiosis,silicosisDiffuseinfiltratesintheupperlungzonesBerylliosis,hypersensitivitypneumonitis

Patientswithsilicosisareatincreasedriskforwhichinfectiousdisease?Tuberculosis

Whatisthedefinitivediagnostictestforinterstitiallungdiseases?Biopsy

Whatarethetwogeneralprinciplesoftreatmentforhypersensitivitypneumonitisandthepneumoconioses?1.Corticosteroids2.Preventionofexposuretooffendingagents

Whatisthemainstayoftreatmentforpatientswithsarcoidosis?Corticosteroids

PleuralEffusion

Namethetypeofpleuraleffusion(transudate,exudate,orboth)associatedwiththefollowingfeatures:Commonpresentationincludesdyspnea,pleuriticchestpain,hemoptysis,cough.BothPathophysiologicmechanismisbasedonabreakdownofthepleuralmembraneandcapillaries.ExudateDuetoexcessproductionorinadequatereabsorptionofpleuralfluidBoth

PathophysiologicmechanismisbasedonchangesinStarling’sforces.TransudateDecreasedbreathsounds,↓tactilefremitus,anddullnesstopercussionintheregionoftheeffusionBothEffusioncontainingbacteriaExudateCommonlycausedbycirrhosis,nephroticsyndrome,proteinlosingenteropathy,orheartfailureTransudateCommonlycausedbymalignancy,tuberculosis,infection,SLE,rheumatoidarthritis(RA)ExudateMaybecausedbyaPEBothpH7.2,glucose50Exudate(Pleurallactatedehydrogenase[LDH])/(serumLDH)>0.6Exudate(Pleuralprotein)/(serumprotein)0.5TransudateSpecificgravityofeffusion>1.015Exudate

Namethreeconditionswhichmayleadtoapleuraleffusioncontainingamylase:1.Pancreatitis2.Esophagealrupture(traumaticorpostoperative)3.Malignancy

What term is used to describe an exudative pulmonary effusion which contains gross pus, has readily visiblebacteria,hasaglucose50,orapH7?

Empyema(complicatedparapneumoniceffusion)

Whattypeofanalysisshouldbeperformedonapatientinwhichmalignancyisthoughttobethecauseofapleuraleffusion?

Cytology

Whatclassofdrugsisoftenusedtotreatatransudativeeffusion?Diuretics

Whatprocedureisperformedtopreventreaccumulationofamalignantpleuraleffusion?Pleurodesis

Inadditiontoantibioticcoverageforpneumonia,whatistheappropriatemanagementforanempyema?Chesttubedrainage

What diagnosis is suggested by pleural fluid containing RBC >100,000 in the absence of trauma or pulmonaryinfarction?

Pleuralmalignancy

PulmonaryEmbolism

WhatistheincidenceofPEinautopsies?Greaterthan50%

WhatistheincidenceofPEinhospitalizedpatients?20%-25%

Whatistheetiologyof95%ofpulmonaryemboli?Dislodgedlowerextremitydeepvenousthromboses(DVT)

WhatisthemostcommonclinicalpresentationofPE?Sinustachycardia

WhataretheothercommonpresentingsymptomsofPE?Fever,pleuriticchestpain,cough,dyspnea/tachypnea,swollenandpainfulleg,andanxiety

WhatfactorsfavorthedevelopmentofaDVT?Virchow’striad1.Stasis2.Hypercoagulability3.Endothelialdysfunction

WhatarethetwomostcommonCXRfindingsinapatientwithPE?1.NormalCXR2.Cardiomegaly

WhataretheclassicCXRfindingsinapatientwithaPE?Pleuraleffusion,Hampton’shump(adistalwedge-shaped infarct), andWestermark’s sign (hyperlucency in the

regionoflungsuppliedbytheinfarctedartery)

WhatisthemostcommonECGfindinginapatientwithPE?Sinustachycardia

WhatistheclassicECGfindinginapatientwithPE?S1Q3T3(SwaveinleadI,QwaveandinvertedTinleadIII)

WhataremodifiedWell’scriteriaforDVT/PEriskstratification?3pointseach:noDxmorelikely,physicalsignsofDVT(asymmetricLEedema)1.5pointseach:tachycardia,hospitalizedinpastmonth/surgery,pasthxofDVT1pointeach:hemoptysis,malignancy0-1=lowrisk(ruleoutw/negD-dimer)2-6=intermediaterisk>7=highrisk(treatw/positiveLEDopplerUS)

WhattwodiagnostictestsarecommonlyusedtodiagnosePE?1.ChestCTwithcontrast2.Ventilation/perfusionscan(whencontrastiscontraindicated)

WhatisthegoldstandardtestfordiagnosisofPE?Pulmonaryangiogram

WhatserologictestcanassistinrulingoutPEwhennegativeinlow-riskpatients?D-dimer

WhatthrombolyticdrugmaybeusedinmassivePEcausinghemodynamicinstability?Tissueplasminogenactivator(t-PA)

Whattherapyisindicatedforhigh-riskpatientsduringthew/uofPEandforpatientsdiagnosedwithPE?IVheparin

Whatarethecontraindicationsforanticoagulationwithheparin?1.h/oheparin-inducedthrombocytopenia(HITS)2.Intracranialhemorrhageorneoplasm3.Recentmajorsurgery

4.Bleedingdiathesis

Whyshouldheparinbecontinuedforseveraldaysafterwarfarintherapyisbegun?1.Warfarintakesseveraldaystobecometherapeutic.2. Initially warfarin induces a hypercoagulable state (by inactivating proteins C and S), which may cause skinnecrosis.

Whatmethodsareusedforlong-termprophylaxisforpatientsatriskofdevelopingDVT?WarfarinorIVCfilter

WhatisanalternativetowarfarinforoutpatientDVTprophylaxis?Low-molecular-weightheparin

WhattypeoftumorscommonlycauseaDVTbyinducingahypercoagulablestate?Adenocarcinomas

WhatcommonlyusedmedicationincreasestheriskofDVT?Oralcontraceptives

WhatisthemostcommongeneticdiseasethatpredisposestothedevelopmentofDVT?FactorVLeiden

PulmonaryEdema

What syndrome is suggested by the presence of acute, refractory hypoxemia, decreased lung compliance, andpulmonaryedemainapatientwithnormalpulmonarycapillarywedgepressure?

Acuterespiratorydistresssyndrome(ARDS)

Whatsyndromeissuggestedbythepresenceofpulmonaryedemainapatientwithanelevatedpulmonarycapillarywedgepressure?

Cardiogenicpulmonaryedema

WhatarethediagnosticcriteriaforARDS?1.Acuteonsetofrespiratorydistress2.PaO2/FIO22003.BilateralpulmonaryinfiltratesonCXR4.Normalcapillarywedgepressure

WhatisthemostcommonriskfactorforARDS?Sepsis

NamefiveadditionalcommonriskfactorsforARDS:Lunginjuryduetoaspirationofgastriccontents,trauma,pancreatitis,drugoverdose,shock

WhattypeofrespiratorytherapyisindicatedinARDS?Mechanicalventilation

Pneumothorax

Whatarethetwomostcommonpresentingsymptomsinspontaneouspneumothorax(PTX)?Unilateralchestpainanddyspnea

WhatarethecommonpresentingsignsinapatientwithspontaneousPTX?

Tachypnea,unilateraldiminished/absentbreathsounds,andhyperresonancetopercussion

WhatisthemostcommoncauseofprimaryspontaneousPTX?Ruptureofsubpleuralapicalbullae

Whatarethemostcommoncausesof2°spontaneousPTX?COPD(mostcommon),CF,pulmonaryinfections(especiallyPCPpneumoniaandTB),trauma,andiatrogenic

WhatwidelyusedICUprocedurecarriestheriskofPTX?Placementofsubclavianorinternaljugularcentralvenouscatheters

WhatarethecommonpresentingsignsinapatientwithtensionPTX?Dyspnea,tachypnea,jugularvenousdistention,hemodynamicinstability,andlateraldisplacementoftrachea

WhatistheappearanceofaPTXonCXR?Pleuralstripewithabsentlungmarkings

WhataretheclassicfindingsonCXRintensionPTX?Hyperlucent lung field (ipsilateral), depressed diaphragm (ipsilateral), tracheal andmediastinal deviation (away

fromPTX),andcompressionofthecontralaterallung

WhatisthetreatmentofaspontaneousPTX?Asymptomatic→observationandO2therapy;symptomatic→mayrequirechesttubedrainage

WhatisthemanagementofatensionPTX?Emergentneedlethoracostomyatthesecondinterspaceatthemidclavicularline

WhichpatientswithPTXgettubethoracostomy?SymptomaticpatientsorPTX2/2underlyinglungdisease

WhichpatientswithPTXaretreatedwithneedleaspiration?Thosewithminimaldyspnea,

Pneumonia

Whatisthecommonpresentationoftypical(bacterial)pneumonia?Fever>39°C(102.2°F),chills,coughproductiveofbloodtinged,purulentsputum,andpleuriticpain(acute

onset)

Whatisthecommonpresentationofatypical“walking”pneumonia?Fever39°C(102.2°F),nonproductivecough,headache,andGIupset(insidiousonset)

Whatarethecommonphysicalfindingsinpneumonia?Bronchialbreathsounds,crackles,wheezes,egophany,dullnesstopercussion,andtactilefremitus

WhatistheclassicCXRfindingintypicalpneumonia?Lobarconsolidation

WhatistheclassicCXRfindinginatypicalpneumonia?Patchyalveolarinfiltrates

Namethemostcommonorganism(s)causingthefollowingpulmonaryinfection:LobarpneumoniaStreptococcuspneumoniaeBronchopneumonia

S.aureusandHaemophilusinfluenzaInterstitialpneumoniaMycoplasmapneumoniae(mostcommon),Legionellapneumophila,andChlamydiapneumoniaFungalpneumoniainAIDSpatientwithCD4+count200PneumocystisjiroveciTypicalpneumoniainneonateStreptococcusagalactiaeAlcoholicwithtypicalpneumoniaafteraspirationKlebsiellapneumoniaeAtypicalpneumoniainyoungerpatientwithpositivecoldagglutinintestM.pneumoniaeNeonatewithatypicalpneumoniaandtrachomaChlamydiatrachomatisDairyworkerwithatypicalpneumoniaCoxiellaburnettiRabbithunterwithatypicalpneumoniaFrancisellatularensisPetbirdownerwithpneumonia,splenomegaly,bradycardiaChlamydiapsittaciHospitalizedpatientwithlobarpneumoniaS.pneumoniae>S.aureusIVdruguserwithpneumoniaS.pneumoniae,K.pneumoniae,andS.aureusPatientrecoveringfromviralURIS.aureusandH.influenzaChickenfarmerfromtheOhiorivervalleywithatypicalpneumoniaHistoplasmacapsulatumPatientfromsouthwesternUnitedStateswithatypicalpneumoniaCoccidioidesimmitisMostcommoncauseofcommunity-acquiredpneumoniaS.pneumoniaeBesttreatedwithnaficillin,oxacillin,methicillin,orvancomycin(forpenicillin-resistantstrains)S.aureusCausesseverepneumoniainCFpatientsandreadilydevelopsmultidrugresistancePseudomonasspp.Coughproductiveofdarkred,mucoid,currantjellysputumproductioninanalcoholicordiabeticK.pneumoniaeRust-coloredsputumS.pneumoniaeLobar pneumonia in a smokerwithCOPD; sputumwith gram-negative rods andmany leukocytes;

besttreatedwithmacrolidesH.influenzaeRecommendedtreatmentincludesthird-generationcephalosporinorfluoroquinoloneGram-negativerods:Pseudomonasspp.,K.pneumoniae,andH.influenzaePneumoniafollowinginfluenzainfectionS.aureusAssociatedwithinhalationofcontaminatedwaterdropletsfromairconditionersL.pneumophilaLungabscesswithair/fluidlevelonCXRS.aureusPneumoniaaccompaniedbyhyponatremia,mentalstatuschanges,diarrhea,andLDH>700L.pneumophilaGram-positive,weaklyacid-fastorganismcausingpneumonia inpatientswithAIDS;associatedwith

peripheraleosinophiliaNocardiaasteroides

FungusballonCXRAspergillus

Namethemostcommoncausativepathogen(s)ofpneumoniaforeachofthefollowingagegroup:NeonatesGroupBstreptococci,Escherichiacoli,andC.pneumoniaeChildren(6weeksto18years)Respiratorysyncytialvirus(RSV)andotherviruses,M.pneumoniae,C.pneumoniae,andS.pneumoniaeAdults(18-40yearsold)M.pneumoniae,C.pneumoniae,andS.pneumoniaeAdults(45-65yearsold)S.pneumoniae,H.influenzae,anaerobes,viruses,andM.pneumoniaeAdults(>65yearsold)S.pneumoniae,viruses,anaerobes,H.influenzae,andgram-negativerods

Listtheappropriateempirictherapyandmostcommonorganismscausingpneumoniaineachofthefollowingscenarios:

Community-acquiredpneumoniainahealthypatient60y/oEmpirictherapy:macrolide(Azithromycin),fluoroquinolone(Levofloxacin),ortetracycline(Doxycycline)

Organisms:S.pneumoniae,M.pneumoniae,C.pneumoniae,H.influenzae,andrespiratoryvirusesCommunity-acquiredpneumoniainahealthypatient>60y/oorwithcomorbidities(CHF,COPD,DM,

alcoholic,renalorliverfailure)Empirictherapy:Second-generationcephalosporin (eg,cefuroxime)andamoxicillin; adderythromycin if

atypicalpathogensaresuspectedOrganisms:S.pneumoniae,H.influenzae,aerobicgram-negativebacilli,S.aureus,andrespiratoryviruses

Community-acquiredpneumoniainapatientrequiringhospitalizationEmpirictherapy:antipneumococcalfluoroquinoloneIV

Organisms: S. pneumoniae (including resistant strains), H. influenzae, M. pneumoniae, C. pneumoniae,polymicrobial

Community-acquiredpneumoniainapatientrequiringICUadmissionEmpiric therapy: antipseudomonal β-lactam (eg, cefepime) plus an antipseudomonal quinolone (eg,

ciprofloxacin)allIVOrganisms:S.pneumoniae (including resistant strains),Legionella spp.,H. influenzae, enteric gram-negativebacilli,S.aureus,andP.aeruginosa

Hospital-acquiredpneumoniaVancomycin,Cefepime,andciprofloxacin

Whichpatientsareatriskforventilator-associatedpneumonia(VAP)?Patientswithchesttrauma,GCS9,andmechanicalventilation

WhatcanbedonetohelppreventVAP?Raise head of bed >45°, maintain gastric acid, maximize nutrition, prevent colonization by healthcare

workers,anduserespiratoryequipmentinasterilefashion

Whichpatientsshouldreceivethepneumococcalvaccine?Patients>65y/oandimmunocompromisedpatients(includingpostsplenectomyandsicklecellpatients)

Namefourcommoncomplicationsoflobarpneumonia:1.Abscessformation(especiallyS.aureusandanaerobes)2.Empyemaorspreadofinfectiontothepleuralcavity3.Organizationofexudatetoformscartissue4.Sepsis

Whattypeofinfectionischaracterizedbylocalizedsuppurativenecrosisoflungtissue?Lungabscess

Nameseveralbacterialpathogenscapableofcausinglungabscess:Staphylococci,streptococci,gram-negativebacilli,anaerobes,andoralflora

Namethetwobacterialpathogenscommonlyassociatedwithlobarpneumoniacomplicatedbyempyema:S.pneumoniae>S.aureus

PulmonaryNeoplasms

WhatisthemostcommoncauseofcancerdeathsintheUnitedStatesforbothmalesandfemales?Lungcancer

Whatisthemostcommontypeofmalignantlungtumor?Metastasiclesions

Whatarethemostcommonprimarylungtumors?Adenocarcinomaandsquamouscellcarcinoma(equalincidence)

Whatarethecommonpresentingsymptomsoflungcancer?Cough,hemoptysis,dyspnea,chestpain,constitutionalsymptoms

Namethetype(s)ofprimarylungcancerassociatedwiththefollowingfeatures:Centrallocation”Sentral”isSquamouscellandSmall(oat)cellcarcinomasPeripherallocationAdenocarcinoma,largecell,andbronchioalveolarcarcinomaCommonlyfoundwithinlargebronchiSquamouscellandsmall(oat)cellcarcinomasClearlinktosmokingSquamouscellNoclearlinktosmokingBronchoalveolaradenocarcinomaMostmalignanttumor(oftenmetastaticatdiagnosis)Small(oat)cellcarcinomaOftensecretesparathyroidhormone(PTH)-relatedpeptideSquamouscellcarcinomaAssociatedwithproductionofADHandACTHSmall(oat)cellcarcinomaCarcinoembryonicantigen(CEA)⊕AdenocarcinomaSecretionof5-HTresultsintachycardia,diarrhea,skinflushing,wheezing.CarcinoidTumorcellsliningalveolarwallsBronchioloalveolaradenocarcinomaGiantpleomorphiccells,manycerebralmetastasis,poorprognosisLargecellAssociatedwithdermatomyositis,acanthosisnigricansAlltypesAssociatedwithperipheralneuropathyandLambert-EatonmyasthenicsyndromeSmall(oat)cellcarcinomaAssociatedwiththrombophlebitisandmaranticendocarditisAdenocarcinoma

Ineachofthefollowingclinicalscenarios,namethestructurebeingcompressedorirritatedbyalungtumor:Cough

PhrenicnerveHoarsenessRecurrentlaryngealnerveFacialandupperextremityswellingSuperiorvenacava(SVC)syndromePtosis,miosis,hemianhydrosisSympatheticcervicalganglion(Hornersyndrome)

Whatpercentageofsolitarypulmonarynodulesismalignant?40%

Whatisthedifferentialdiagnosisforasolitarypulmonarynodule?Infectiousgranuloma,carcinoma,benignneoplasm,bronchialadenoma,andpneumonia

AreroutineCXRsagoodwaytoscreenforlungcancer/carcinoma(CA)?No

WhatisaneffectivewaytolowertheriskoflungCA?Smokingcessation

Whatisthetreatmentforsmallcellcarcinoma?Radiationandchemotherapy

Whatisthetreatmentfornonsmallcellcarcinomathatislocal?Tumorresectionandradiationtherapy

Whatisthetreatmentfornonsmallcellcarcinomathathasmetastasized?Radiationandchemotherapy

Whatrarepleuraltumorisfoundinpatientswithah/ooccupationalexposuretoasbestos?Malignantmesothelioma

Decidewhetherthefollowingfeaturesofasolitarypulmonarynodulefavorabenignormalignantetiology:Age>40yearsMalignantSize>2cmMalignantWell-circumscribedmassBenignAbsenceofcalcificationorirregularcalcificationMalignantGrowthinlesionfrompreviousCXRsMalignantCentral,uniform,orlaminatedcalcificationBenign

MaketheDiagnosis

7-y/o with h/o environmental allergies presents in acute respiratory distress; PE: ↑ tachypnea expiratorywheezes, intercostal retractions, accessory muscle use; CXR: hyperinflation; complete blood count (CBC)showseosinophilia

Bronchialasthma

60-y/owitha50pack-yearh/osmokingpresentswithfeverandcoughproductiveofthicksputumforthepast4months;PE:cyanosis,crackles,wheezes;w/u:Hct=48,WBC=12,000;CXR:noinfiltrates

Chronicbronchitis

60-y/owitha 50pack-yearh/o smokingpresentswithDOEanddry coughbutno chestpain;PE: ↑breathsounds,hyperresonantchest,↑heartrate(HR),distantS1andS2;CXR:flatteneddiaphragm.

Emphysema

60-y/owith50pack-yearh/osmokingpresentswithfatigue,dyspnea,hoarseness,anorexia;PE:miosis,ptosis,anhydrosis, and dullness to percussion at right apex; chest CT: large hilar mass extending into the rightsuperiorpulmonarysulcus

Pancoasttumor,(mostlikelybronchogenicsquamouscellcarcinoma,causingHornersyndrome)

60-y/opatientindays4statuspost(s/p)totalkneereplacementhasthesuddenonsetoftachycardia,tachypnea,sharpchestpain,hypotension;arterialbloodgas(ABG):respiratoryalkalosis;ECG:sinustachycardia;venousduplexUS:clotinrightfemoralvein

Pulmonaryembolus

40-y/o white male presents with chronic rhinosinusitis, ear pain, cough, dyspnea; PE: ulcerations of nasalmucosa, perforation of nasal septum; w/u: ↑ (c-ANCA), red cell casts in urine; biopsy of nasal lesions:necrotizingvasculitisandgranulomas

Wegener’sgranulomatosis

50-y/o obesemalewith resistant hypertension complaining ofmorningheadache, awakeningwithout feelingrefreshed,anddaytimesleepiness

Obstructivesleepapnea

55-y/o female presents with dyspnea and nonproductive cough; PE: “velcro-like” basilar end-inspiratorycracklesandclubbing;CXR:basilarinfiltrates;PFTs:FEV1/FVC>70%,↓DLCO

Idiopathicpulmonaryfibrosis

40-y/oAfricanAmericanwomanpresentswith dyspnea andpolyarthritis; PE: acute, nodular erythematouseruption on extensor surface of lower extremities; CXR: hilar lymphadenopathy; biopsy would shownoncaseatinggranulomawithnoinfection

Sarcoidosis

INFECTIOUSDISEASES

Fever

Namethesix“do-not-miss”diagnosesofinfectionsthatpresentwithfeverandrash:1.Meningococcemia2.Bacterialsepsis(eg,Staphylococcus)3.Endocarditis4.Gonococcemia5.RockyMountainspottedfever(RMSF)6.Typhoidfever

Whatcriteriaareusedtodefinefeverofunknownorigin(FUO)?Temperature >38.3°C (101°F) for >3 weeks with failure to diagnose (despite 1 week of inpatient

investigationorseveraloutpatientvisits)

NamethreecommoncausesofFUOforeachofthefollowingcategories:

Infectious(30%-40%ofcases)Endocarditis,TB,andoccultabscess(usuallyabdominal)Neoplastic(20%-30%ofcases)Leukemia,lymphoma,andrenalcellCAAutoimmune(15%-20%ofcases)Giantcellarteritis,polymyalgiarheumatica,andjuvenileRA

Ear,Nose,andThroatInfections

Namefourriskfactorsforsinusitis:1.Smoking2.Viralinfection3.Allergies4.Barotrauma

Whatarethemostcommonbacterialpathogenscausingacutesinusitis?S.pneumoniae,H.influenzae,andMoraxellacatarrhalis

Whatsinusesaremostcommonlyinvolvedinacutesinusitis?Maxillarysinuses(drainsuperiorlyagainstgravity)

Namethreekeyclinicalfindingsofacutesinusitis:1.Purulentrhinorrhea2.Facialpain3.Maxillarytoothpain

Whatisthetreatmentofacutesinusitislasting>2weeks?Bactrim,amoxicillin,doxycycline(10daysPO),anddecongestants

Whatconditionresultsfromobstructionofsinusdrainageandongoinganaerobicinfection?Chronicsinusitis

Whatisthetreatmentofchronicsinusitis?6-12weeksPOantibiotics;surgicalcorrectionofobstructionforrefractorycases

Diabeticsareatincreasedriskfordevelopingwhattypeofseveresinusitis?Mucormycosis

Namefourpotentialcomplicationsofsinusitis:1.Meningitis2.Frontalboneosteomyelitis3.Abscessformation4.Cavernoussinusthrombosis

Wheredothemajorityofbleedsfromepistaxisoccur?Kiesselbachplexus(anteriornasalseptum)

Whatisthemostcommoncauseofepistaxisinkids?Explorationwithdigits

Whatarethetwomostcommonpathogenscausingotitisexterna(swimmer’sear)?1.Pseudomonas2.Enterobacteriaceae

WhatPEfindingisvirtuallypathognomonicforotitisexterna?

Pullingonpinnaorpushingtraguscausespain.

Whatisthetreatmentofchoiceforotitisexterna?Antibioticeardrops(dicloxacillinforacutedisease)

Whatgroupofpatientsisat↑riskforcomplicationsfromotitisexterna?Diabetics—↑riskofmalignantotitisexternaandosteomyelitisoftemporalbone/skullbase

Nametheresponsibleorganismandtreatmentforeachofthefollowingtypesofpharyngitis:Fever,sorethroat,andredeyeAdenovirusOralthrush;seeninAIDSandsmallkidsFungus(Candida)PathognomonicgraymembranesontonsilsDiphtheria(membranouspharyngitis)Highfever,sorethroatwithexudativetonsillitis,andcervicallymphadenopathy;coughusuallyabsentGroupAStreptococcusTonsillitis,splenomegaly,palatalpetechiae,andposteriorauricularlymphadenopathyEpstein-Barrvirus(EBV)(mononucleosis)

Tuberculosis

Decidewhethereachstatementismorecloselyassociatedwith1°or2°tuberculosis(TB):ClassicallyaffectslowerlobesPrimaryTBAssociatedwithreactivation2°TBFibrocaseouscavitarylunglesion2°TBGhoncomplexonCXRPrimaryTBAffectsapicallungs(↑affinityfor↑O2environment)2°TBPresentswithcough/hemoptysis,fever,nightsweats,weightloss2°TB

WhatistheprimarymodeoftransmissionofMycobacteriumtuberculosis?Respiratorydroplets

WhattermisusedtodescribethelymphaticandhematogenousspreadofTB,causingnumeroussmallfociofinfectioninextrapulmonarysites?

MiliaryTB

NamethefivemostcommonsitesofextrapulmonaryTB:1.Centralnervoussystem(CNS)(tuberculousmeningitis)2.Vertebralbodies(Pottdisease)3.Psoasmajormuscle→abscess4.Liver5.Cervicallymphnodes→scrofuloderma(massivelymphadenopathy)

HowisactiveTBinfectiondiagnosed?Clinicalandradiologicsignsof2°TBandacid-fastbacilliinsputum

WhatisaneffectivescreeningtoolforlatentTB?

Purifiedproteinderivative(PPD)test

WhatconstitutesapositivePPDtest?>5-mmindurationforHIV⊕orimmunocompromisedindividuals>10-mmindurationforhigh-riskindividuals>15-mmindurationforanyoneelse

WhatconditionoftencausesafalsenegativePPD?Immunosuppression→checkanergypanel

WhatisthemanagementofPPD⊕latentTB?Treatmentwithisoniazid(INH)for9months

WhatisthemanagementforactiveTB?Respiratory isolation, initial four-drug therapy: “RIPE”: Rifampin, INH, Pyrizinamide, Ethambutol →

narrowedwhensensitivitiesdetermined(treatfor>6months)Note:givevitaminB6withINH.

WhatisthemajortoxicityofmanyTBdrugs?Hepatotoxicity;checkLFTsifsymptomaticorh/oliverdisease

HumanImmunodeficiencyVirus

Whattestisusedtoruleoutthediagnosisofhumanimmunodeficiencyvirus(HIV)becauseofitshighsensitivity?Enzyme-linkedimmunosorbentassay(ELISA)(todetectantibodies[Ab]toviralproteins)

WhattestisusedtoconfirmapositiveHIVtestbecauseofitshighspecificity?Westernblotassay(highfalsenegativewithin2monthsofinfection)

WhatarethecommonpresentingsignsoftheviralprodromeofHIV,ie,acuteretroviralsyndrome?Fever(97%),fatigue(90%),lymphadenopathy(50%-77%),pharyngitis(73%),transientrash(40%-70%),or

headache(30%-60%)

HowisAIDSdefined?CD4+200cells/mLorserologicevidenceofAIDS-definingillness

WhatmutationmayconferresistancetoinfectionwithHIV?HomozygousdeletionofCCR5(orotherviralreceptors)

NametheAIDSopportunisticinfectionordiseaseassociatedwiththefollowing:FungalCandida(thrush),Cryptococcus(meningitis),P.jerovecipneumonia,histoplasmosis,andcoccidioidosisBacterialM.tuberculosis(TB),Staphylococcus,encapsulatedorganisms,andM.avium-intracellulare(MACcomplex)ViralHerpessimplexvirus(HSV),varicella-zostervirus(VZV)(shingles),cytomegalovirus(CMV)(retinitis),JC

virus(PML),Epstein-Barrvirus(EBV)(B-celllymphoma),andhumanherpesvirus(HHV)-8(Kaposisarcoma)ProtozoalToxoplasma(encephalopathy),andCryptosporidium(severewaterydiarrhea)

StatethetypicalCD4+countassociatedwitheachofthefollowingHIVcomplications:TBbecomesmorecommon400cells/mLSeriousopportunistsarefirstseen

200cells/mLToxoplasmosis,cryptococcosis100cells/mLMAC,CMV,andcryptosporidiosis50cells/mL

Whatconstituteshighlyactiveantiretroviraltherapy(HAART)?TwonucleosideRTinhibitorscombinedwithproteaseinhibitorornonnucleosideRTinhibitor

Note:nopatientshouldeverbeonmonotherapyduetotheriskofresistance.

Whattestisusedtomonitortheeffectivenessofantiretroviraltherapy?HIVpolymerasechainreaction(PCR)(measuresviralload)

NamethemedicalmanagementforthefollowingHIV⊕patients:CD4+500ordetectableviralloadInitiateHAARTCD4+200BactrimprophylaxisforPCPCD4+75AzithromycinprophylaxisforMACCD4+50FluconazoleprophylaxisforfungiPregnantHIV⊕patientZidovudine(azidothymidine[AZT])—↓verticaltransmission

Statethetreatmentofchoiceforimmunocompromisedpatientswithinfluenza:Prevention:trivalentinactivatedinfluenzavaccinePost-exposureprophylaxis:zanamiviroroseltamivir

Whyisoseltamivirpreferredinasthmaticsinthetreatmentofinfluenza?Zanamivirisassociatedwithbronchospasmin5%-10%ofpatientswithasthma.

UrinaryTractInfections

Namesixriskfactorsforurinarytractinfections(UTIs):1.Foleycatheter2.Diabetesmellitus3.Anatomicanomaly4.Pregnancy5.↑Sexualactivity6.H/oUTIorpyelonephritis

NamethreecommonpresentingsymptomsinUTI:1.Frequency2.Dysuria3.Urgency

Whattwoclinicalfindingssuggestpyelonephritis?1.Fever2.Back/flankpain

WhatisthemostcommonpresentingsymptominachildwithaUTI?Bedwetting

WhyarewomenattentimestheriskofmenfordevelopingaUTI?Theurethraisshorterinwomenandmorelikelytobecolonizedwithfecalflora.

Namethespecificurinaryfindingassociatedwitheachofthefollowing:MicroscopicanalysisinUTI>5WBC/high-powerfieldUrinedipstickinUTI↑Leukocyteesterace,↑nitrites(specificforgramnegatives)Clean-catchurinecultureinaUTI>100,000CFU/mLofbacteriaCharacteristicurinalysis(UA)findinginProteusinfection↑UrinepHCharacteristicUAfindingincystitisHematuriaCharacteristicUAfindinginacutepyelonephritisWBCcasts

ListthemostcommonUTIorganisms:”SEEKSPP”SerratiamarcescensE.coliEnterobactercloacaeK.pneumoniaeStaphylococcussaprophyticusProteusmirabilisP.aeruginosa

WhichUTI-causingbugisfrequentlynosocomial,drug-resistant,andmayproducearedpigment?S.marcescens

Whatisthefirst-lineantibioticforlowerUTIs?Bactrim(trimethoprim[TMP]-sulfamethoxazole[SMX])for3days;amoxicillinforEnterococcus

Whatisthetreatmentforpylonephritis?LevofloxacinPO7days(IVifpthasnausea/vomiting).

SexuallyTransmittedDiseases

Name the sexually transmitted disease (STD) associated with the following descriptions and provide thetreatmentofchoice:

CluecellsinPapsmear;positive“whifftest”Bacterialvaginosis(eg,Gardnerellavaginitis)Tx:Flagyl(metronidazole)Soft,painfulsexuallytransmittedulcerassociatedwithinguinallymphadenopathyChancroid(causedbyHaemophilusducreyi)

Tx:ceftriaxone,ciprofloxacin,orerythromycinRaised,redpapules;biopsyshowsDonovanbodiesGranulomainguinale(causedbyCalymmatobacteriumgranulomatis)

Tx:doxycycline100mgbid×3weeksFirm,painlesschancrecausedbyaspirocheteSyphilis(causedbyTreponemapallidum)Tx:PenicillinGMostcommonSTD;frequentcauseofpelvic inflammatorydisease (PID) inwomenandurethritis in

men;associatedwithReitersyndromeChlamydialcervicitis(typesD-K)

Tx:azithromycin;erythromycininpregnancy;treatpresumptivegonorrheacoinfectionSmallpapule/ulcerthatleadstoenlargementoflymphnodes;causedbyC.trachomatisserotypesL1,

L2,orL3Lymphogranulomavenereum

Tx:sameasforChlamydialcervicitisSTD that can result in extragenital infections (eg, pharyngitis, proctitis, arthritis, and neonatal

conjunctivitis)Gonorrhea(causedbyNeisseriagonorrhoeae)

Tx:ceftriaxone;treatpresumptivechlamydiacoinfectionSTDresultinginbenignvenerealwartscausedbyhumanpapillomavirus(HPV)types6and11Condylomaacuminatum

Tx:cryotherapyortopicalpodophyllinPainfulvesicles/ulcers;cytologyshowsmultinucleargiantcells;diagnosewithTzanckprepHerpesgenitalis(mostoftenHSVtype2)

Tx:acyclovir(for1°infectionorsuppression)STDcausedbyflagellated,motileprotozoan;#2causeofvaginitisTrichomoniasis

Tx:flagyl(metronidazole)

Namethestageofsyphilisassociatedwitheachofthefollowingdescriptions:Rashonpalmsandsoleswithlymphadenopathy2°syphilisFirm,painlesschancre1°syphilisAfter1yearofinfection;canprogressto3°syphilisLatelatentFirstyearofinfection;nosymptoms,butpositiveserologyEarlylatentTabesdorsalis,aortitis,Argyll-Robertsonpupil,gummas3°syphilis

Namethreeteststhatcanbeusedtodiagnosesyphilis:1.Dark-fieldmicroscopy(visiblespirochetes)2.VDRL/RPR(fast,cheap,nonspecific)3.Fluorescenttreponemalantibody—absorbed(FTA-ABS)(sensitive,specific,positiveforlife)

Whatisthetreatmentforsyphilis?Penicillin(IVforneurosyphilis);↑doseby3xifundiagnosedfor>1year

What complication of syphilis treatment results in fever and flu-like symptoms caused by the massivedestructionofspirochetes?

Jarisch-Herxheimerreaction

Osteomyelitis

Whatarethetwomainroutesofinfectionforosteomyelitis?1.Directspread(80%)2.Hematogenousseeding(20%)

Wheredoeshematogenousosteomyelitistypicallyoccur?Metaphysesoflongbonesinchildren(↑vascularityofgrowthplates);vertebralbodiesofIVdrugabusers

Nametheorganismtypicallyresponsibleforosteomyelitisineachofthefollowingsituations:Newborn

Streptococcispp.orE.coliChildStaphylococcusaureusOtherwisehealthyadultS.aureusFootpuncturewoundPseudomonasspp.IntravenousdruguserPseudomonasspp.orS.aureusSicklecelldiseaseSalmonellaspp.Hipreplacement(orotherprosthesis)StaphylococcusepidermidisChronicosteomyelitisS.aureus,Pseudomonasspp.,EnterobacteriaceaeAsplenicpatientSalmonellaspp.

Whatistheclassicradiographicfindinginosteomyelitis?Periostealelevation

Whatisthegoldstandardforevaluationofosteomyelitis?MRI(canconfirmwithboneaspirationandculture)

Whatisthetreatmentregimenforpyogenicosteomyelitis?6-8 weeks of antibiotics; fluoroquinolones empirically → narrow as cultures come back; surgical

debridementifnecessary

Namefourcomplicationsofosteomyelitis:1.Chronicosteomyelitis2.Septicarthritis3.Systemicsepsis4.Drainingsinustract→squamouscellcarcinoma

Vector-borneIllness

Whatisthemostcommonvector-bornediseaseintheUnitedStates?Lymedisease

NametheorganismandthevectorinvolvedinLymedisease:BorreliaburgdorferiiscarriedbyIxodesticks.

WhatisthetreatmentforLymedisease?Ceftriaxone,high-dosepenicillin,ordoxycycline

NamethestageofLymediseaseassociatedwitheachofthefollowingclassicPEfindings:Migratorypolyarthropathy/arthralgias,meningitis,myocarditis (withconductiondefects),neurologic

problems2°LymediseaseErythemachronicummigransPrimaryLymediseaseEncephalitisandarthritisTertiary(3°)Lymedisease

Whichtick-bornediseasecanleadtosmallvesselvasculitis?RMSF

NametheorganismandthevectorinvolvedinRMSF:RickettsiarickettsiiiscarriedbyDermacentortick.

NamefourcommonPEfindingsinRMSF:1.Fever

2.Headache3.Myalgias4.Classicmaculopapularrash(beginsonpalms/soles→spreadscentrally)

Whatisthedifferentialdiagnosisforarashaffectingthepalmsandsoles?RMSF,2°syphilis,hand-foot-mouthdisease(coxsackieA),andKawasakisyndrome

WhatisthetreatmentforRMSF?Doxycycline;chloramphenicolinpregnantwomenandkids

Sepsis

Definesepsis?Aninfectionthatcausessystemicinflammatoryresponsesyndrome(SIRS)

DefineSIRS?Twoormoreofthefollowing:1.↓>38.0°C(100.4°F)or36.0°C(96.8°F)2.HR>903.RR>20orPCO232mmHg4.WBC>12,000or4000or>10%bandforms

Whattypeofbacteriacauseshockthroughendotoxin-mediatedvasodilation?Gram-negativebacteria

Nametheorganism(s)thatmostcommonlycausesepsisinthefollowinggroups:IVdrugabusersS.aureusAsplenic/sicklecellpatientsEncapsulatedbacteria(H.influenzae,Meningococcus,Pneumococcus)NeonatesGroupBstrep,Klebsiella,E.coliChildrenH.influenzae,Meningococcus,PneumococcusAdultsGram-positivecocci,anaerobes,aerobicbacilli

Statehoweachofthefollowingparametersisaffectedinsepticshock:Temperature↑(though15%presentwithhypothermia)Respirations↑HR↑BPortotalperipheralresistance(TPR)↓

Cardiacoutput↑Pulmonarycapillarywedgepressure↑(orsometimesnormal)

Whatisthefirst-linemanagementofsepticshock?AggressiveIVfluids,vasopressors,IVempiricantibiotics,andremovalofpotentialsource(eg,catheter,IV

line)

MaketheDiagnosis

18-y/ostudentreturnstoclinicwitharashafterbeingtreatedwithampicillinforfeverandsorethroat;PE:tonsillarexudatesandenlargedposteriorcervicallymphnodes;labs:↑lymphocytesand⊕heterophilAbtest

Infectiousmononucleosis(EBV)

17-y/o swimmer presents with pain and discharge from the left ear; PE:movement of tragus is extremelypainful.

Otitisexterna

2-m/o with maternal h/o rash and flu in first trimester presents with failure to attain milestones; PE:microcephaly, cataracts, jaundice, continuousmachinery-likemurmur at left upper sternal border (LUSB),andhepatosplenomegaly(HSM)

Congenitalrubella

8-y/o fromConnecticut presentswith fever, rash, headache, and joint pain after playing in thewoods; PE:distinctivemaculewithsurrounding6-cmtarget-shapedlesion

Lymedisease

Newbornwithh/ointrauterinegrowthretardation(IUGR)presentswithrashandmaternalh/o“flu”duringfirst trimester; PE: petechial rash, chorioretinitis, microcephaly, ↓ hearing, and HSM; CBC:thrombocytopenia;headCT:periventricularcalcifications

CongenitalCMV

25-y/o West Virginian male presents with fever, headache, myalgia, and a petechial rash that beganperipherallybutnowinvolveshiswholebody,evenhispalmsandsoles;⊕OX19andOX2Weil-Felixreaction

RockyMountainspottedfever(RMSF)

28-y/owith h/o syphilis treatment (5 h ago)with IM penicillin presentswith fever, chills,muscle pain, andheadache.

Jarisch-Herxheimerreaction

26-y/osexuallyactive,native-Caribbeanpresentswithpainless,beefy-redulcersof thegenitaliaand inguinalswelling;peripheralbloodsmear:DonovanbodiesonGiemsa-stainedsmear

Granulomainguinale

31-y/o obese female presents with pruritis in her skin fold beneath her pannus; PE: whitish-curd-likeconcretionsbeneaththeabdominalpannus;w/u:buddingyeaston10%KOHprep

Cutaneouscandidiasis

35-y/omalepresentswithrecurrentGiardiainfectionandrespiratoryinfections.Labs:↓serumIgGCommonvariableimmunodeficiencyakahypogammaglobulinemia

25-y/o femalepresentswithhomogenouswhite vaginal dischargewith fishy odor;PE:no vaginal erythema,vaginalpH>4.5,wetmount:“cluecells”

Bacterialvaginosis

25-y/ofemalepresentswith“cottage-cheese,”non-odorousvaginaldischargewithsignificantvaginalirritation.Candidalvaginitis

25-y/ofemalepresentswithyellow-green,pruritic,“frothy”vaginaldischarge;PE:erythemetouscervixTrichomonasvaginalis

30-y/oHIVpositivemanpresentswithnewerythemetousandviolaceousmaculesandlargenodulesthroughouthisbody.

Kaposi’ssarcoma(causedbyhumanherpesvirus8)

65-y/omanwholivesinnursinghomepresentswithheadache,lethargy,confusion,nausea,vomiting,diarrhea,andabdominalpain;PE:highfeverandrelativebradcardia;labs:hyponatremia,↑liverenzymes,↓phosphate,azotemia,↑creatininekinase

Legionellapneumophilapneumonia

GASTROENTEROLOGY

Diarrhea

Namethefourmajorpathophysiologicmechanismsforchronicdiarrhea:1.Increasedsecretion2.Alteredintestinalmotility3.Osmoticload4.Inflammation

Whattwolaboratorytestscanbeusedtodistinguishbetweenosmoticandsecretorydiarrhea?1.Fasting(persistentdiarrheaifsecretory)2.Stoolosmoticgap(gap>50→osmoticdiarrhea)

Whatadditionallabsareusefulinthew/uofosmoticdiarrhea?D-Xylosetest,Schillingtest(terminalileum),lactosechallenge,andpancreaticenzymes

Whatisthemaincauseofsurreptitiousdiarrhea?Mg2+laxativeoveruse

Whichsyndrome ischaracterizedby irregularbowelmovements,abdominalpain,andcomorbidpsychiatricdisorders(in50%ofcases)?

Irritablebowelsyndrome

Namethefoodpoisoningbacteriaassociatedwiththefollowing:ReheatedriceBacilluscereusReheatedmeatdishesClostridiumperfringensImproperlycannedfoodClostridiumbotulinumContaminatedseafoodorrawoystersVibrioparahaemolyticusandVibriovulnificusMeats,mayonnaise,custardsS.aureusUndercookedmeats

E.coliO157:H7Rawpoultry,milk,eggs,andmeatSalmonella

Namesixinfectiouscausesofbloodydiarrhea:1.Salmonella2.Shigella3.Campylobacterjejuni4.EnteroinvasiveandenterohemorrhagicE.coli5.Yersiniaenterocolitica6.Entamoebahistolytica

Namethediarrhea-causingorganismassociatedwiththefollowingstatements:MostcommoncauseofdiarrheaininfantsRotavirus10-12bloodyandmucousdiarrheastoolsperdayduetoingestionofcystsE.histolyticaComma-shapedorganismscausingrice-waterstoolsVibriocholeraSecondtorotavirusasacauseofgastroenteritisinkidsAdenovirus(serotypes40and41)Bloodydiarrhea;verylowID50;nonmotileShigellaUsuallytransmittedfrompetfecesY.enterocoliticaMotile;lactosenonfermenter;causesbloodydiarrheaSalmonellaComma-orS-shapedorganismscausingbloodydiarrhea;associatedwithGuillain-BarrésyndromeC.jejuniWaterydiarrheawithextensivefluidlossinAIDSpatientCryptosporidiumFoul-smellingdiarrheaafterreturningfromacampingtripGiardialambliaWaterydiarrheacausedbyantibiotic-inducedsuppressionofcolonicfloraClostridiumdifficileAvoidantibiotictherapy;hemolytic-uremicsyndrome(HUS)isapossiblecomplication.E.coli0157:H7AIDSCryptosporidium,Mycobacteriumaviumcomplex(MAC),IsosporaPseudoappendicitisYersinia

InflammatoryBowelDisease

Ulcerativecolitis(UC)orCrohn’sdisease?PancolitiswithcryptabscessesUCFistulasandfissuresCrohn’sdiseaseAssociatedwithankylosingspondylitisBothAssociatedwithsclerosingcholangitisUC

AmyloidosisCrohn’sdiseaseLongitudinalulcersCrohn’sdiseasePunched-outaphthousulcersCrohn’sdiseaseCanleadtotoxicmegacolonUCIncreasedriskofcolorectalcarcinomaUC>>>Crohn’sSkiplesionsCrohn’sdiseaseCaninvolveanyportionoftheGItract(usuallyterminalileumandcolon)Crohn’sdisease“Stringsign”onx-ray(duetobowelwallthickening)Crohn’sdiseaseAssociatedwithpyodermagangreosumBothTransmuralinflammationCrohn’sdiseaseNoncaseatinggranulomasCrohn’sdiseaseCobblestonemucosaCrohn’sdiseaseBloodydiarrheaUCWaterydiarrheaCrohn’sdiseaseNephrolithiasisCrohn’sdiseaseStrictureformationCrohn’sdiseasePsuedopolypsUCRectalinvolvementUCMaymimicacuteappendicitisCrohn’sdisease

Whatisthekeycomponentofadiagnosticw/uofapatientwithsuspectedinflammatoryboweldisease(IBD)?Colonoscopywithmucosalbiopsies

Whatadditionalradiologictestsareusefulinthew/uofCrohn’sdisease?UpperGIseriesandsmallbowelfollowthrough

WhatarethefiveclassesofmedicaltreatmentofIBD?1.Immunosuppressiveagents(6-MP,azathioprine,methotrexate,cyclosporine)2.5-ASAderivatives(mesalamine,sulfasalazine)3.Steroids(helpfulinacutediseaseandduringexacerbations)4.Antibiotics(metronidazoleforanaldisease)5.Monoclonalantibodiestotumornecrosisfactor(TNF)-a(infliximab)

WhataretheindicationsforsurgeryinapatientwithCrohn’sdisease?1.Intestinalobstruction(mostcommonindicationforsurgery)2.Anorectalabscesses

3.Abdominalabscesses(percutaneousdrainage)4.Fistulas5.Intractabledisease

WhatarethetwooptionsforoperativemanagementofanobstructioninCrohn’sdisease?Bowelresectionversusstrictureplasty

Whatcomplicationcanoccurinapatientwithmultiplebowelresections?Shortgutsyndrome(diarrhea,malabsorption)

IssurgeryusuallycurativeforCrohn’sdisease?No

WhataretheindicationsforsurgeryinapatientwithUC?1.Uncontrolledhemorrhage2.Fulminantcolitis3.Toxicmegacolon4.Dysplasiaorcancer5.Intractabledisease

Whatarethethreeclassicsignsandsymptomsoftoxicmegacolon?1.Fever2.Abdominalpain3.Acutelydistendedcolon

Whatistheinitialtreatmentoftoxicmegacolon?Nothingbymouth(NPO),IVfluidsnasogastric(NGT),andantibiotics

WhatsurgicaloptionsarecommonlyusedinpatientswithrefractoryUC?Totalproctocolectomy,distalrectalmucosectomy,andileonalpullthrough

WhatistheriskofcoloncancerinpatientswithUC?1%-2%at10years;1%increaseinriskeveryyearthereafter

WhataretherecommendationsforcoloncancersurveillanceinpatientswithUC?Yearlycolonoscopyafter10yearsofdisease

IssurgerycurativeforUCinvolvingthecolon?Yes

WhatextraintestinalmanifestationsofUCarecuredbysurgery?Pathologyoftheskin,eyes,andjoints

WhatextraintestinalmanifestationsofUCaremadeworsebysurgery?Liverdisease

Liver

Nametheviralhepatitisagent(s)describedbythefollowingstatements:Fecal-oraltransmissionHepatitisAvirus(HAV)andhepatitisEvirus(HEV)Infectionleadstoacarrierstate.HepatitisBvirus(HBV),hepatitisCvirus(HCV),andhepatitisDvirus(HDV)deltaagent

Note:80%ofpatientswithHCVand10%withHBVwilldevelopchronichepatitis.DefectivevirusrequiringhepatitisBsurfaceantigen(HBsAg)asitsenvelope

HDV(deltaagent)Sexual,parenteral,andtransplacentaltransmissionHBV,HCV,HDVHighmortalityrateinpregnantwomenHEVMostcommoncauseofhepatitisassociatedwithIVdruguseintheUnitedStatesHCVLongincubation(~3months)HBVIncreasedriskofhepatocellularcarcinomaHBV,HCVImmuneglobulinvaccineavailableHAV,HBV(andHDV)

Namethehepatitisserologicmarkerassociatedwiththefollowingdescriptions:AntigenfoundonsurfaceofHBV;continuedpresencesuggestscarrierstateHBsAgAntigenassociatedwithcoreofHBVHepatitisBcoreantigen(HBcAg)AntigenintheHBVcorethatindicatestransmissibilityHepatitisBeantigen(HBeAg)AbsuggestinglowHBVtransmissibilityHepatitisBeantibody(HBeAb)ActsasamarkerforHBVinfectionduringthe“window”periodHepatitisBcoreantibody(HBcAb)(IgMinacutestage)ProvidesimmunitytoHBVHBsAb

Whatisthe“window”periodofahepatitisinfection?PeriodduringacuteinfectionwhenHBsAghasbecomeundetectable,butHBsAbhasnotyetappeared

NameanimportantindicatorofhepatitisBtransmissibility:HBeAg

Namesixcommoncausesofcirrhosis:1.Chronicalcoholism2.Hereditaryhemochromatosis3.Primarybiliarycirrhosis4.Wilsondisease(hepatolenticulardegeneration)5.Viral(HBV,HCV)6.α1-Antitrypsindeficiency

Listtheeffectsofhepaticfailureonthefollowingbodysystems:OcularScleralicterusDermatologicJaundiceandspiderneviReproductiveTesticularatrophy,gynecomastia,andlossofpubichairHematopoieticAnemia,bleedingtendency(↓coagulationfactors),andpancytopeniaNeurologicComa,hepaticencephalopathy(asterixis,hyperreflexia),andbehavioralchangesRenalHepatorenalsyndrome(acuterenalfailure[ARF]2°tohypoperfusion)

GIEsophagealvaricies,pepticulcer,andhemorrhoids

Nametheliverdisorderassociatedwitheachofthefollowingfindings:MallorybodiesAlcoholichepatitisOcclusionofIVCorhepaticveinswithcentrilobularcongestion→congestiveliverdisease;associated

withpolycythemia,pregnancy,andhepatocellularcarcinomaBudd-ChiarisyndromeViralinfectionandsalicylatesinkidsReyesyndromeCopper deposition in liver, kidney, brain, and cornea→ asterixis, basal ganglia degeneration, and

dementiaWilsondisease(hepatolenticulardegeneration)AST:ALT>2AlcoholichepatitisMicrovesicularfattychangeoccurringwithfatalchildhoodhepatoencephalopathyReyesyndrome

Statetheetiologyofcirrhosisassociatedwiththefollowingclinicalorpathologicfindings:Panacinarpulmonaryemphysemaα1-AntitrypsindeficiencyDecreasedceruloplasminWilsondisease(hepatolenticulardegeneration)Triadofbronzediabetes,skinpigmentation,andmicronodularpigmentcirrhosisHereditaryhemochromatosisAntimitochondrialantibodiesPrimarybiliarycirrhosisKayser-FleischerringWilsondisease(hepatolenticulardegeneration)Micronodularfattyliver,portalHTN,asterixis,jaundice,andgynecomastiaChronicalcoholabuse↑ferritin,transferrin,andtotaliron;↓totaliron-bindingcapacity(TIBC)HereditaryhemochromatosisNote:totalbodyironissometimeshighenoughtotriggermetaldetectors.

Whattestcanbeusedtodeterminetheetiologyofascites?Paracentesisandserum-ascitesalbumingradient(SAAG)

What is themechanismofdisease indicatedby aSAAG1.1 versus>1.1? (SAAG=ascites albumin - serumalbumin)

SAAG1.1:proteinleakageSAAG>1.1:imbalanceofhydrostaticandoncoticpressure

NamefouretiologiesofasciteswithSAAG1.1:1.Malignancy2.Tuberculosis3.Pancreatitis4.Nephroticsyndrome

NamefiveetiologiesofasciteswithSAAG>1.1:1.Cirrhosis2.Hepaticmetastases3.Budd-Chiarisyndrome4.Cardiacdisease5.Myxedema

Whatarethefourtherapeuticoptionsforascites?1.Saltrestriction2.Diuretics(spironolactoneandfurosemide)3.Large-volumeparacentesis4.Peritoneovenousshunting

NamethethreegeneraletiologiccategoriesofportalHTN:1.Perisinusoidal(eg,splenic/portalveinthrombosis,schistosomiasis)2.Sinusoidal(cirrhosis→90%ofallcauses)3.Postsinusoidal(eg,rightheartfailure,hepaticveinthrombosis,constrictivepericarditis)

NamefivecomplicationsofportalHTN:1.Ascites2.Spontaneousbacterialperitonitis(SBP)3.Hepatorenalsyndrome4.Hepaticencephalopathy5.Esophagealvarices

WhatmustbepresentinasciticfluidtomakethediagnosisofSBP?>250PMNs/mLor>500WBCs

NamethreeclinicalfindingsinportalHTNresultingfromtheportal-systemiccollateralcirculation:1.Esophagealvarices2.Caputmedusa3.Hemorrhoids

Whatisthediagnostictestforbleedingvarices?Esophagogastroduodenoscopy(EGD)

WhatmethodsareusedtocontrolacuteupperGIbleedingcausedbybleedingesophagealvarices?Endoscopicsclerotherapy,bandligation,IVvasopressin,andballoontamponadewithSengstaken-Blakemore

tube

WhatisthemaininterventionalprocedureusedtomanageportalHTN?Shuntprocedure(eg,transjugularintrahepaticportacavalshunt[TIPS])

Whatisthemaincomplicationofashuntprocedure?Worseningofhepaticencephalopathy(2°tolflowtoliver)

Whatistheclassificationsystemusedincirrhosis?Child’scriteria(A,B,orC—worst)

WhatfivecriteriaareusedforclassificationintheChild’ssystem?1.Bilirubin2.Albumin3.Ascites4.Encephalopathy5.Nutrition

Nametwodrugsusedtotreathepaticencephalopathy:1.Lactulose(↓ammoniaabsorption)2.Neomycin(decreasesammoniaproductionfromGItract)

Whatistheonlydefinitivetherapyforcirrhoticliverdisease?Livertransplant

Whatarethethreeabsolutecontraindicationsforlivertransplantation?1.Infectionoutsideofhepatobiliarysystem(eg,AIDS)2.Metastaticliverdisease3.Uncorrectablecoagulopathy

MaketheDiagnosis

20-y/ofemalepresentswithbloodydiarrheaandjointpain;PE:abdominaltenderness,guaiac⊕stool;w/u:↑ESRandCRP,HLA-B27⊕;colonoscopy:granular,friablemucosawithpseudopolypsthroughoutthecolon

Ulcerativecolitis

28-y/o patient with h/o of UC presents with severe abdominal pain, distention, and high fever; PE: severeabdominaltenderness;w/u:leukocytosis;abdominalx-ray(AXR):dilated(>6cm)transversecolon

Toxicmegacolon

Acirrhoticpatientpresentswithmassivehematemesis;PE:jaundice,↓BP,↑HR,ascites;w/u:pancytopenia,↑ALTandAST;EGD:activelybleedingvesselwithnumerouscherryredspots

Esophagealvarices

38-y/omalewith recent h/o fatigue, excessive thirst, and impotence presentswith hyperpigmentation of hisskin;PE:cardiomegaly,HSM;w/u:↑glucose,ferritin,transferrin,andserumiron

Hemochromatosis(hereditary)

19-y/ofemalewithrecenth/obehavioraldisturbancepresentswithjaundiceandrestingtremor;PE:pigmentedgranulesincorneaandHSM;w/u:↓serumceruloplasmin

Wilsondisease

29-y/owithh/o intermittent jaundicesincereceivingbloodtransfusionaftermotorvehicleaccident (MVA)2yearsago;PE:rightupperquadrant(RUQ)tenderness,hepatomegaly;w/u:negativeHBVserology

ChronichepatitisC(HCV)infection

31-y/ofemalepresentswith10-monthh/ofoul-smelling,greasydiarrhea;PE:pallor,hyperkeratosis,multipleecchymoses,andabdominaldistention;w/u:abnormalD-xylosetest

Celiacdisease

Apatientwithrecenth/oantibioticuseforsinusinfectionpresentswithfever,bloodydiarrhea,andabdominalpain; PE: tender abdominal examination, guaiac positive stool;w/u: leukocytosis; colonoscopy: tan nodulesseenattachedtoerythematousbowelwallwithsuperficialerosions

Pseudomembranouscolitis(C.difficilecolitis)

60-y/owhitemalepresentswithsteatorrhea,weight loss,arthritis,and fever;w/u: smallbowelbiopsyshowsPAS-positivemacrophagesandgram-positivebacilli.

Whippledisease

Apatientpresentswithsuddenonsetofseverewaterydiarrhea,vomiting,andabdominaldiscomfort4haftereatingpotatosaladatapicnic;thesymptomsresolvespontaneouslywithin24h.

S.aureus-induceddiarrhea

23-y/ofemalewithh/odepressionpresentswithabdominaldiscomfortandirregularbowelhabits;w/u:stoolcultures,electrolytes,andimagingstudiesallWNL

Irritablebowelsyndrome

A patient traveling in Mexico presents with bloody diarrhea, vomiting, and abdominal cramps 16 h afterdrinkingtapwater;PE:low-gradefever,abdominalpain;w/u:ovaandparasitesinstool

Entamoebahistolytica—induceddiarrhea

19-y/o Jewish femalewithh/o chronic abdominal pain presentswith recurrentUTIs andpneumaturia;PE:diffuse abdominal pain; CT: enterovesical fistula; colonoscopy: skip lesions of linear ulcers and transversefissuresgivingcobble-stoneappearancetomucosa

Crohn’sdisease

28-y/ohomosexualmalepresentswithRUQpain,fever,anorexia,N/V,darkurine,andclay-coloredstool;PE:jaundice,tenderhepatomegaly;w/u:↑↑AST/ALT,↑bilirubin/ALP,normalWBC

Acuteviralhepatitis

54-y/omalewithh/oHCVpresentswithincreasedabdominalgirth,jaundice,andalteredmentalstatus;PE:asterixis, scleral icterus, hemorrhoids, bilateral lower extremity edema, ascites, and caput medusae; w/u:pancytopenia,↑AST/ALT/ALP/bilirubin;US:nodularliver

Portalhypertension/cirrhosis

26-y/o female presents with pale, foul-smelling, bulky stools associated with abdominal pain and bloatingoccurringaftermeals;PE:normal;w/u:fecalWBC/RBCWNL,↑osmoticgap,fecalfatWNL

Lactoseintolerance

28-y/omalewithh/oCrohndisease(s/psurgicalresection)presentswithincreaseddiarrhea,steatorrhea,andabdominal pain; PE: weight loss; w/u: fecal WBC/RBC WNL, ↑ osmotic gap, ↑ fecal fat, Schillings testabnormal

Malabsorption(shortgutsyndrome)

RENAL/GENITOURINARY

BasicMetabolismandElectrolytes

Howistheaniongapcalculated?Na+-(Cl-+HCO-3)

Whatisanormalaniongap?8-12mEq/L

Listsixcausesofnongapmetabolicacidosis:1.Diarrhea2.Renaltubularacidosis(RTA)3.Spironolactone4.Totalparenteralnutrition(TPN)5.Gluesniffing6.Hyperchloremia

Listninepossiblecausesofaniongapmetabolicacidosis:“MUDPILERS”

1.Methanol2.Uremia3.Diabeticketoacidosis(DKA)4.Paraldehyde5.INHorIrontabletoverdose6.Lacticacidosis7.EthyleneglycolorEthanol8.Rhabdomyolysis(massive)

9.Salicylatetoxicity

Listthemostcommonmechanismofrespiratoryacidosis:Hypoventilation; causes include lungobstruction (acute/chronic lungdisease) andneuromusculardisorders

(sedatives,weakeningofrespiratorymuscles)

Listfourcausesofrespiratoryalkalosis:1.Hyperventilation(2°tohypoxia)2.EarlyASAingestion3.Pregnancy4.Cirrhosis

Listfourcausesofchloride-responsive(dry)metabolicalkalosis:1.Excessivevomiting2.Villousadenoma3.Diuretics4.Contractionalkalosis

Listthreediseasescausingchloride-unresponsive(wet)metabolicalkalosis:1.Cushingsyndrome2.Connsyndrome3.Barttersyndrome

Ingestionofwhatsubstancecancausebothametabolicacidosisandrespiratoryalkalosis?ASA(salicylates)

Nametheprimaryacid/basedisturbanceandthecompensatoryresponsethathasoccurredinthefollowing:pH>7.4,PCO2>40mmHgMetabolicalkalosis→hypoventilationpH7.4,PCO2>40mmHgRespiratoryacidosis→renalHCO-3reabsorptionpH>7.4,PCO240mmHgRespiratoryalkalosis→renalHCO-3secretionpH7.4,PCO240mmHgMetabolicacidosis→hyperventilation

Nametheelectrolyteimbalanceassociatedwiththefollowingconditions:Diabetesinsipidus(DI),dehydration,andosmoticdiuresisHypernatremiaARF,adrenal insufficiency, spironolactone,rhabdomyolysis,acidosis, insulindeficiency,anddigitalis

poisoningHyperkalemiaSyndrome of inappropriate secretion of antidiuretic hormone (SIADH), volume depletion, water

intoxication,cirrhosis,heartfailure,andhyperglycemiaHyponatremiaDiarrhea,alkalosis,hypomagnesemia,laxativeabuse,RTA,vomiting,andBarttersyndromeHypokalemiaAcutepancreatitis,hypomagnesemia,post-parathyroidectomy(mostcommoncause)HypocalcemiaHyperparathyroidism and malignancy (eg, multiple myeloma, breast cancer, and squamous cell

cancers)HypercalcemiaMalnutrition,alcoholism,DKA,andpregnancyHypomagnesemia

NametheECGchangesassociatedwiththefollowingelectrolyteimbalances:HyperkalemiaInorder:1.Peaked↓waves2.↑PRinterval3.LossofPwave4.WidenedQRScomplex5.SinewaveHypokalemiaT-waveflattening,Uwaves,STdepression,andAVblockHypocalcemia↑QTintervalHypomagnesemiaTorsadedepointes

Namethemaincausesofhypercalcemia:”CHIMPANZEES”CalciumsupplementationHyperparathyroidism(mostcommon)Iatrogenic/ImmobilityMilk-alkalisyndromePagetdiseaseNeoplasm(verycommon)Zollinger-Ellison(ZE)syndromeExcessvitaminAExcessvitaminDSarcoidosis(orothergranulomatousdisease)

Providethetreatmentforthefollowingelectrolytedisturbances:HypernatremiaIsotonicNSorLR(correctovera48-72hperiod)HyperkalemiaIfNa+120→hypertonicNS;ifhypovolemic→isotonicNS(Note:rapid↑inplasmaNa+→centralpontine

myelinolysis);ifeuvolemicorhypervolemic→saltandwaterrestrictionHyponatremia”SeebigKdie”→”CBIGKayDi”Calciumgluconate(stabilizescardiacmembrane)BicarbonateInsulinandGlucoseKayexalateDiuretics(loop)andDialysisHypercalcemiaIVhydration,loopdiuretic(”loopslosecalcium”),bisphosphonates(especiallywhencausedbymalignancy)

Note:avoidthiazidediuretics.HypokalemiaPOsupplements,IVinfusionof10mEq/h,K+-sparingdiuretics

Whatelectrolyteimbalancecanresultinhypokalemiarefractorytosupplementation?Hypomagnesemia

Whatlababnormalitymaycauseserumcalciumtobefalselylow?Hypoalbuminemia

NamethetwoclassicPEfindingsassociatedwithhypocalcemia:1.Chvostek’ssign(facialspasmelicitedfromtappingthefacialnerve)

2.Trousseau’ssign(carpalspasmafterarterialocclusionwithBPcuff)

NamethetypeofRTAassociatedwitheachofthefollowing:DecreasedbicarbonatereabsorptionTypeII(proximal)AldosteronedeficiencyorresistenceTypeIVDecreasedH+excretion;nephrocalcinosisTypeI(distal)HyperkalemiaTypeIVMostcommonRTATypeIVFanconisyndromeTypeII(proximal)HyporeninemichypoaldosteronismTypeIVSeencommonlyindiabetesmellitusTypeIV

RenalFailure

WhatarethethreeetiologiesofARF?1.Prerenal(hypoperfusion)2.Intrinsic(renal)3.Postrenal(obstructive);canevaluatecausewithrenalUS

NamefivecausesofprerenalARF:1.Hypovolemia2.Heartfailure3.Sepsis4.Burns5.↓Renalbloodflow(RBF)(eg,↓ICO,renalarterystenosis)

NamefivecausesofintrinsicARF:1.Acutetubularnecrosis(ATN)2.Acuteinterstitialnephritis3.GN4.Autoimmunevasculitis5.Renalischemia(eg,thromboembolism)

NamefourcausesofpostrenalARF:1.Prostatedisease2.Nephrolithiasis3.Pelvictumors4.Recentpelvicsurgery

HowisFENa(fractionalexcretionofsodium)calculated?(UrineNa+/plasmaNa+)/(urineCr/plasmaCr)

WhichtypeofARFisassociatedwiththefollowingfindings?FENa1%Prerenal

FENa>4%PostrenalHyalineurinecastsPrerenalMuddybrown/granularcastsIntrinsic(ATN)BUN:Cr>20PrerenalRedcellcastsIntrinsic(GN)Whitecellcast±eosinophilsIntrinsic(allergicnephritis)EnlargedprostatePostrenal⊕ANCAIntrinsic(vasculitis)Urineosmolality>500PrerenalWhitecells,whilecellcastsPostrenal(pyelonephritis)

NamethreetypesofinsultstotheproximaltubulesthatresultinATN:1.Ischemia2.Directtoxins(contrastdye,amphoB,aminoglycosides)3.Myoglobinuria/hemoglobinuria

Whattwoclassesofdrugsmostcommonlycauseinterstitialnephritis?1.Penicillins2.Nonsteroidalanti-inflammatorydrugs(NSAIDs)

WhatuniqueUAfindingisassociatedwithdrug-inducedinterstitialnephritis?Eosinophilia

Whatlabvalueisusedtodiagnoseandfollowrenalfailure?Creatinine

Listtheeffectsofuremiaonthefollowingsystems:NervoussystemAsterixis,confusion,seizures,andcomaCardiovascularsystemFibrinouspericarditisHematologicsystemAnemiaandimmunosupressioncoagulopathyGIsystemNausea,vomiting,andgastritisDermatologicsystemPruritis,anduremicfrost(ureacrystalsonskin)insevereuremiaEndocrinesystemGlucoseintolerance

ListsixnonuremiccomplicationsofARF:1.Metabolicacidosis2.Hyperkalemia→arrhythmias3.Na+andH2Oexcess→pulmonaryedemaandCHF4.Hypocalcemia→osteodystrophy(fromfailuretosecreteactivevitaminD)

5.Anemia(↓erythropoietin[EPO]secretion)6.HTN(fromreninhypersecretion)

Whataretheindicationsfordialysistreatment?”AEIOUY”Acidosis(unresponsive)Electrolyteabnormality(hyperkalemia)Ingestionoftoxins(salicylates,barbiturates,lithium,ethyleneglycol)Overload(fluid)Uremicsymptoms(pericarditis,encephalopathy)Y-not?

Infections

What typeof infectionpresentswith flankpain, costovertebralangle tenderness, fever,dysuria,pyuria, andbacteriuria?

Acutepyelonephritis

Whatarethetwomajorcausesofpylonephritis?1.Ascendinginfection2.Hematogenousseeding

Whatarethemostcommonorganismsresponsibleforacutepyelonephritis?E.coli>Proteus>Enterobacter(sameasUTIs)

Whatisthegreatestriskfactorforpyelonephritis?Vesicouretericreflux(orincompetency)

Allchildren7y/opresentingwiththeirfirstUTIshouldundergowhatradiologictesttoscreenforreflux?Voidingcystourethrogram

Listthreepossiblesequelaeofacutepyelonephritis:1.Abscess2.Renalpapillarynecrosis3.Renalscars

What condition is characterized by broad renal scarring, loss of renal parenchyma over time, andthyroidizationofkidneys?

Chronicpyelonephritis

Which renal disease presentswithmultiple 3-4-cm cysts in bilaterally enlargedkidneys resulting in chronicrenalfailureinadults?

Autosomal-dominant(adult)polycystickidneydisease(ADPKD);50%haveend-stagerenaldisease(ESRD)byage60

WhatarethetwomostcommonpresentingsymptomsofADPKD?1.Pain2.Hematuria

WhatmaytheabdominalexaminationrevealinADPKD?Largepalpablekidney

NamefiveotherfindingsassociatedwithADPKD:1.Cerebrovascularaneurysm(berryaneurysm)2.HTN

3.Nephrolithiasis4.Mitralvalveprolapse5.Hepaticcysts

Whatistheprognosisforautosomal-recessivepolycystickidneydisease(PKD)?Deathinthefirstfewyearsoflife

GlomerularDisease

Whatsyndromeischaracterizedbyhematuria,ARF,HTN,andmildproteinuria?Nephriticsyndrome

What syndrome is characterized bymassive proteinuria (>3.5 g/d), generalized edema, hyperlipidemia, andhypoalbuminemia?

Nephroticsyndrome

Classifyeachofthefollowingstatementsascharacteristicsofnephroticornephriticsyndrome:IncreasedriskofinfectionsNephroticGrosshematuria,oliguriaNephriticAnticoagulationtherapyisindicatedtoreduceriskofDVTandrenalveinthrombosis.Nephrotic”Foamyurine”NephroticTransientoliguriausuallyfollowedbyspontaneousdiuresisNephriticHyperlipidemia,lipiduriaNephroticDyspneaandascitesNephrotic(severeedema)One-thirdofcasesassociatedwithsystemicdiseases(lupus,diabetes,oramyloidosis)NephroticSmokybrownurinewithRBCcastsNephrtic

Nametheglomerulopathymostcloselyassociatedwiththefollowingfindings:Apple-greenbirefringenceunderpolarizedlightRenalamyloidosisGNwithlensdislocation,nervedeafness,andposteriorcataractsAlportsyndromeNodularglomerulosclerosis,glomerularcapillarybasementmembranethickeningDiabeticglomerulosclerosis(Kimmelstiel-Wilsondisease)YoungAfricanAmericanmalesFocal-segmentalglomerulonephritis(FSGN)c-ANCAWegener’sgranulomatosisMostcommoncauseofnephroticsyndromeinchildrenMinimalchangedisease(lipoidnephrosis)MostcommoncauseofESRDintheUnitedStatesDiabeticglomerulosclerosisCommonlyassociatedwithHIVinfection,heroinaddiction,sicklecelldisease,andobesityFSGNMesangialwideningandrecurrenthematuriaandproteinuria

IgAnephropathy(Bergerdisease)AssociatedwithhepatitisCMembranoproliferativeglomerulonephritis(MPGN)RespondswelltosteroidsMinimalchangedisease(akasteroidresponsivenephropathy)RespondstoplasmaexchangeandpulsedsteroidsGoodpasturesyndromeX-linkedrecessivedefectina5chainofcollagentypeIV(COLA4A5)AlportsyndromeAsymptomaticfamilialhematuriaThinmembranedisease(glomerularbasementmembrane[GBM]isonly50%-60%ofnormalthickness)“Wirelooplesions”SLE—lupusnephropathy,diffuseproliferativepatternUpper-respiratorygranulomatousinflammation(→hemoptysis)andkidneywithnecrotizingvasculitisWegener’sgranulomatosisIncreasedASOtiterPostinfectiousGNMostcommonglomerulopathyworldwideIgAnephropathy(Bergerdisease)Pulmonaryhemorrhageandhemosiderin-filledmacrophagesinsputumGoodpasturesyndromeAssociatedwithURIorGIinfections,↑inkidsIgAnephropathy(Bergerdisease)AssociatedwithhepatitisBinfectionMembranousGNAntiglomerularbasementmembraneantibodiesGoodpasturesyndromeAntinuclearantibody(ANA)⊕SLEImmunofluorescence→”lumpy-bumpy”granularIgGorC3depositsPostinfectiousGNImmunofluorescence→smooth,linearIgGdepositsGoodpasturedisease(crescenticGN)Immunofluorescence→“spikeanddome”MembranousGNImmunofluorescence→“tram-track,”double-layeredbasementmembraneMembranoproliferativenephropathyGNassociatedwith↓complementlevels(3)SLE,MPGN,postinfectiousGNAssociatedwithmultiplemyelomaorchronicinflammatorydiseaseRenalamyloidosisLightmicroscopyappearsnormal;electronmicroscopyshowsfusionofepithelialfootprocesses.Minimalchangedisease

Givethetreatmentforeachofthefollowingglomerulopathies:FSGNSupportive(proteinandsaltrestriction,diuretictherapy,antihyperlipidemics)andprednisonePostinfectiousGNSupportive(prognosisverygood)WegenergranulomatosisHigh-dosesteroidsandcytotoxicagentsIgAnephropathySteroidsforflares(20%progresstoESRD)SLESteroids,andcyclophosphamide(foradvancedtypes)

RenalCalculi

Namethetypeofrenalcalculusassociatedwitheachofthefollowingfindings:1°hyperparathyroidismCalciumphosphateIdiopathichypercalciuriaCalciumoxalateRadiolucentstonesUricacidStaghorncalculiStruvite(MgNH4PO4)HexagonalcrystalsCystineAssociatedwithProteus,Pseudomonas,Providencia,andKlebsiellaUTIsStruvite(MgNH4PO4)Formsinacidicurine(pH5.5)UricacidAminoacidtransportdefectCystineGoat,myeloproliferativedisease,orchemotherapyUricacidCrohn’sdiseaseCalciumoxalateXanthineoxidasedeficiencyUricacid~80%ofrenalstonesCalciumoxalate/calciumphosphate

Nameeightriskfactorsfornephrolithiasis:1.↓fluidintake2.Hypercalcemia3.Gout4.Enzymedeficiency5.RTA6.Medications(allopurinol,chemotherapy,loopdiuretics)7.Inflammatoryboweldisease8.⊕FH

Whatisthetypicalpresentationofnephrolithiasis?Acuteonsetofsevere,colickyflankpainradiatingtothegroinwithN/Vandhematuria

Namethreeteststoevaluatefornephrolithiasis:1.UA(hematuria,pH,crystalsundermicroscope)2.AbnormalXR(90%ofstonesareradiopaque)3.HelicalCTscanwithoutcontrast(nowthetestofchoice)

Whatistheinitialtreatmentforcalculi?Hydrationandanalgesia

Whatantihypertensive↓[Ca2+]inurine?Thiazidediuretic

Stonesuptowhatsizecanpassspontaneously?

Typically5mm

Whatisthetreatmentforstones>5mmbut3cm?Extracorporealshockwavelithotripsy(ESWL)

UrinaryTract

Whatisthedifferentialdiagnosisofhematuria?”S2I3T3”StrictureStonesInfectionInflammationInfarctionTumorTraumaTB

Whatisthemostcommonmalignanttumoroftheurinarytract?Bladder(transitionalcell)cancer(Tinmales>60y/o)

Whatisthestrongestriskfactorforurinarytractmalignancies?Smoking(alsochronicinfections,anilinedye,calculi)

Whatisthemostcommonpresentingsymptomofbladdercancer?Painless,grosshematuria

Whatisthediagnostictestofchoice?Cystoscopywithbiopsy

Whatistheetiologyofsquamouscellbladdercancers?(rare)Schistosomahaematobium

Namefourtreatmentoptionsforbladdercancer:1.Intravesicalchemotherapy2.Transurethralresection3.Surgery±radiation4.Chemotherapyalone

Whatistheclassictriadofrenalcellcarcinoma?1.Hematuria2.Flankpain3.APalpablemass

Namefiveriskfactorsofrenalcellcarcinoma:1.Malegender2.Smoking3.Obesity4.AcquiredcystickidneydiseaseinESRD5.vonHippel-Lindaudisease

Prostate

Whatisthemostcommoncauseofcancerinmen?Prostatecancer(lungcanceristheleadingcausesofcancerdeathinmen,followedbyprostatecancer)

Whatdigitalrectalexamination(DRE)findingsuggestsprostatecancer?Firmnodules

Whatisthehistologictypeof>95%ofprostatecancers?Adenocarcinoma

Whatpercentageofpatientswithprostatecancerpresentwithmetastaticdisease?40%(mostareinitiallyasymptomatic)

Whatisthemostcommonsiteofmetastasisforprostatecancer?Bone(vertebrae);mustruleoutinanyelderlymalewithbackpain

WhydoobstructivesymptomsoccurlessfrequentlythaninBPH?CancerusuallybeginsintheperipheralzonewhileBPHoccursinthecentralzone.

Whatserummarkerisusedtodetectandfollowprostatecancer?Prostate-specificantigen(PSA)>4ng/mL

NamefourcausesofanelevatedPSAotherthancarcinoma:1.BPH2.Prostatitis3.UTI4.Prostatictrauma

Howisprostatecancerdefinitivelydiagnosed?Transrectalbiopsyofsuspiciouslesions

Nameanalternativetoprostatectomyfortreatmentoflocalizedprostatecancer:Radiationtherapy

Namethetwomostcommoncomplicationsofprostatectomy:1.Impotence2.Incontinence

Listthreetreatmentoptionsformetastaticdisease:Androgenablationvia:1.Luteinizinghormone-releasinghormone(LHRH)agonists(leuprolide)2.Antiantrogens(flutamide)3.Orchiectomy

Whatarethescreeningrecommendationsforprostatecancer?DREandPSAeveryyearforpatients>50y/o(orpatients>40y/oifAfricanAmericanor⊕FH)

WhatarethetwotypesofsymptomsthatresultfromBPH?1.Obstructive(hesitancy,weakstream,incompleteemptying,urinaryretention)2.Irritative(nocturia,↑frequency,urgeincontinence,openinghematuria)

WhatmaybefoundonPEinapatientwithBPH?Diffuselyenlargedprostatewitharubberytexture

IsPSAhelpfulinmonitoringBPH?No(usefulinposttreatmentcancerpatients)

NamefourcomplicationsofBPH:

1.Bladderoutletobstruction2.Urinarystasis(leadingtoinfectionsandcalculi)3.Chronicurinaryretentionandoverflow4.Renalfailure

Whatlabvaluecanhelpdetectobstructiveuropathy?Creatininelevel(elevatedifobstructivelesion)

WhatmedicaloptionsareusedtotreatBPH?5-α-Reductaseinhibitors(finasteride)andα-receptorblockers(terazosin)

WhataretheindicationsforsurgeryinBPH?Symptomaticobstruction:1.Postvoidresidualvolume>100mL2.Multipleboutsofgrosshematuria3.RecurrentUTIs

NamethemostcommonsurgicalprocedureforBPH:Transurethralresectionoftheprostate(TURP)

ErectileDysfunction

Namethetwocategoriesoferectiledysfunction(ED):1.Primary:neverbeenabletohavesustainederections2.Secondary:acquired

NamethreecausesofprimaryED:1.Psychologic2.Gonadal(↓testosterone)3.Endocrine(thyroid,Cushing,etc)

Namethreecausesof2°ED:1.Drug-induced(tricyclicantidepressants[TCAs],diuretics,antipsychotics)2.Vasculardisease(eg,veno-occlusivedysfunction)3.Neurologicdisease

WhatisonefindingthatcanmakethedistinctionbetweenpsychologicandorganicED?Nocturnalorearly-morningerections

ProvidefourtreatmentoptionsforED:1.Sildenafil(orotherPDE5inhibitors)2.Intracavernosalprostaglandins3.Vacuum-constrictiondevice4.Penileprosthesis

Whatdrugisanabsolutecontraindicationforpatientstakingsildenafil?Nitrates(combinedeffectsofloweringBP→myocardialischemia)

Testes

Namethetesticulardisorderassociatedwiththefollowingstatements:Failureofdescentoftesticlebefore1y/o;↑riskofcancerCryptorchidism

MalignanttesticulartumorthatishighlyradiosensitiveSeminomas=SensitivetoradiationWorstprognosisofalltesticulartumors;highlyinvasive;elevatedβ-hCGlevelsChoriocarcinomaSlow growing tumor usually discovered and removed before metastasis; most common type of

testicularcancerSeminomas(typeofgermcelltumor)Associatedwith an abnormallyhigh attachment of the tunica vaginalis around thedistal end of the

spermaticcord(bellclapperdeformity)Testiculartorsion(usuallybilateral)Usuallypresentsasafirm,painlessmassAlltesticulartumorsRapidonsetoftesticularpain,swelling,andabsenceofflowonDopplerultrasoundTesticulartorsion(testicleunsalvageableafter6h)BagofwormsontesticularexaminationVaricoceleα-Fetoprotein(AFP)isoftenelevatedinthisformoftesticularcancer.Endodermalsinustumor

TreatmentofcryptorchidismOrchiopexyafterage1butbefore5(topreservefertility);orchiectomylaterinlifetoavoidriskoftesticular

cancer

MaketheDiagnosis

25-y/o-AsianmalepresentswithN/V,andcolickyrightflankpain;PE:acutedistressandcostovertebralangle(CVA)tenderness;w/u:hematuriaanddiscreteradiopacitiesonabdominalXR

Renalstones

45-y/owithdocumentedh/oaorticatheromatousplaquespresentswithrecentonset,severeleftflankpain,andhematuria;abdCT:wedge-shapedlesionintheleftkidney

Renalinfarct

55-y/owithlongh/oDMpresentswithincreasingfatigueandedema;PE:↑BP,retinopathy,andpittingedema;w/u:severeproteinuriaandglycosuria

Diabeticnephropathy(glomerulosclerosis)

21-y/o sexually active female presents with frequency and dysuria; PE: afebrile, suprapubic tenderness, noCVAtenderness;w/u:E.coli⊕urinecultures

UTI

25-y/o male presents with hemoptysis, dark urine, and fatigue; PE: bilateral crackles at lung bases; w/u:oliguria,hematuria,andanti-GBMAbs

Goodpasturesyndrome

7-y/opresentsinstuporafteringestingantifreeze;PE:Kussmaulrespirationsandmentalstatuschanges;w/u:aniongapof21mEq/L

Metabolicacidosis(ethyleneglycoltoxicity)

6-y/oboypresentswithhematuriaandworseningvision;PE:cornealabnormalities,retinopathy,sensorineuralhearingloss;w/u:hematuriawithdysmorphicredcells

Alportsyndrome

3-y/oboywithh/orecentURIpresentswithfacialedema;PE:asciticfluidinabdomenandpedaledema;w/u:

4+proteinuriaand↓serumalbuminMinimalchangedisease

70-y/omalerecentlystartedonanACEinhibitorpresentswithweakness,N/V,andpalpitations;PE:areflexia;ECG:tall,peaked↓wavesandwideQRScomplex

Hyperkalemia

65-y/opatientwithh/osmallcelllungcancerpresentswithlethargy,confusion,andseizures;w/u:serumNa+

135mEq/L,urinaryNa+>20mEq/L,andurineosmolality>100mOsm/kgSIADH(hyponatremia)

Apatient s/p parathyroidectomy presentswithmuscle cramps, dyspnea, and tetanic contraction; PE: facialspasmwithtappingoverfacialnerve,carpalspasmwitharterialocclusionbyBPcuff;ECG:↑QTinterval

Hypocalcemia

A patient on a loop diuretic for CHF presents withmuscle weakness, fatigue, and ileus; PE: hyporeflexia,bradycardia;ECG:T-waveflattening,STdepression,andUwaves

Hypokalemia

Apatienthospitalized forCHFrecently startedonanaminoglycoside foraUTIdevelopsoliguria,N/V,andmalaise;PE:↑BPandasterixis;w/u:↑Cr,K+;UA:“muddybrown”casts,FENa+>3%

ARF(drug-inducedATN)

70-y/o-blackmalewithh/ooflifelongDMpresentswithperipheraledema,SOB,andoliguria;PE:auscultatoryrales, pitting edema, myoclonus, and uremic frost; serum electrolytes: ↑Cr, hyperkalemia, hypocalcemia,hyperphosphatemia

Chronicrenalfailure

A female presents with fever, chills, and flank pain; PE: CVA tenderness; UA: leukocyte esterase⊕, 30WBC/hpf

Pyelonephritis

32-y/omalepresentswithpainandhematuria;PE:↑BP,palpablekidney,andmidsystolicejectionclick;abdUS:multiplecystsofrenalparenchyma;cerebralangiogram:unrupturedberryaneurysm

Polycystickidneydisease

12-y/omalewithh/osorethroat2weeksagopresentswithlowurineoutputanddarkurine;PE:periorbitaledema;w/u:hematuria,↑BUNandCr,↑ASOtiter

PoststreptococcalGN

45-y/o-Asianmalewith h/o hepatitis B presentswithmalaise, edema, and foamy urine; PE: anasarca;w/u:proteinuria(>3.5g/d),hyperlipidemia,andhypoalbuminemia

MembranousGN

80-y/o male presents with urinary hesitancy, nocturia, and weak urinary stream; PE: diffusely enlargedrubberyprostate;w/u:↑Cr,↑PSA;UAiswithinnormallimits(WNL).

Benignprostatichyperplasia(BPH)

68-y/o-male smoker presents with flank pain and hematuria; PE: fever, palpable kidney mass; w/u:hypercalcemia,polycythemia

Renalcellcarcinoma

20-y/o male presents with acute onset of left testicular pain and N/V; PE: swollen, tender testicular intransverseposition,absentcremastericreflexonleftside;Doppler:noflowdetectedinlefttesticle

Testiculartorsion

85-y/omalepresentswithbackpain,weightloss,andweakurinarystream;PE:palpablefirmnoduleonDRE;w/u:↑PSA(5ng/mL)

Prostatecancer

65-y/o male smoker presents with painless gross hematuria and frequency; PE: obese; UA: hematuria,dysplasticcells;intravenouspyelogram(IVP):bladderfillingdefect

Bladdercancer(transitionalcellcarcinoma)

41-y/omalewithh/oHTNrecently startedonβ-blockerpresentswith impotence that started2monthsago.Reports no early-morning erections; PE: normal size testes and normal lower extremity sensation; w/u:testosterone/prolactinWNL

Drug-inducederectiledysfunction(ED)

22-y/omalewithh/ocryptorchismpresentswithpainlessenlargementofLtestes;PE:Lscrotalswellingandapalpablemass;w/u:↑AFP

Testicularcancer(endodermalsinustumor)

16-y/omalewithrecenth/ogastroenteritis2daysagopresentswithepisodicbrownurine;PE:unremarkable;w/u:hematuria,mildproteinuria,normalC3

IgAnephropathy

33-y/omale presentswith fever, hemoptysis, and hematuria; PE:weight loss and bilateral crackles at lungbases;w/u:hematuria,⊕c-ANCA;CXR:bilateralcavitarylesions

Wegenergranulomatosis

Apatienthospitalized and started onmethicillindevelops fever, arthralgias, andapruritic rash;PE: ↑BP,edema,anddiffuseerythematousrash;w/u:oliguria,↑Cr;UA:eosinophils,WBCs

Allergicinterstitialnephritis

65-y/omalewithmultiplemyelomapresentswithlethargyandbonepain;PE:alteredmentalstatus;ECG:↓QTinterval

Hypercalcemia

ENDOCRINE

Pituitary

Namethepituitarydisorderassociatedwitheachofthefollowing:MostcommonfunctionalpituitaryadenomaProlactinoma(adenoma)Deficiencyofgonadotropin-releasinghormone(GnRH)→no2°sexualcharacteristics;associatedwith

anosmiaKallmannsyndromePolyuria,polydipsia,hypernatremia;associatedwithtumor,infection,andautoimmunediseaseCentral/neurogenicDIHypopituitarismfrompostpartumpituitarynecrosisSheehansyndromeEnlargementofjaw,hands,feet,andcoarseningfacialfeatures2°to↑serumgrowthhormones(GH)AcromegalyPituitaryhypersecretionofADH→hyponatremia,↓urineoutput,mentalstatuschangesSIADH

Whatarethetwogeneralwayspituitarymassescanpresentclinically?1.Masseffects(bitemporalhemianopsia,CNpalsies)2.Endocrineeffects(amenorrhea,galactorrhea,hyperthyroidism,↓libido)

Whatisthetreatmentofchoiceforsymptomaticnonfunctionalpituitaryadenomas?Transspheniodalsurgicalresection

Whatisthemedicaltreatmentofchoiceforaprolactinoma?Bromocriptine

Whattwoproteinsareusedtodiagnoseacromegaly?1.GH2.IGF(insulin-likegrowthfactor)-1(madeinliverinresponsetoGH)

Whatmedicaltreatmentisusedtotreatacromegaly?Somatostatin(GHinhibitor)—usedifnosurgicalcure

Patientswithacromegalyareatincreasedriskforwhattypeofmalignancy?Colonicpolyps(closescreeningwithcolonoscopyisindicated)

NamethetwosubtypesofDIanddescribethemechanismofdisease:1.CentralDI:posteriorpituitaryfailstosecreteADH.2.NephrogenicDI:kidneysfailtorespondtoADH.

WhataresomecommonpresentingsymptomsinapatientwithDI?Polydipsia,polyuria,andpersistentthirstwithdiluteurine

WhatistherelationshipbetweenurineosmolalityandserumosmolalityinDI?Lowurineosmolalitywithhighserumosmolality

HowarepsychogenicpolydipsiaandDIdifferentiatedusingawaterdeprivationtest?DIpatientscontinuetoproduceahighvolumeofdiluteurinewhilepsychogenicpolydipsiapatientswillno

longerproduceurine.

Whatistheradiologictestofchoicetodetectpituitaryabnormalities?Magneticresonanceimaging(MRI)(bettersoft-tissueresolution)

Whichhormonelevelremainsnormalinpanhypopituitarism?Prolactin(underchronicinhibitionbydopaminesecretedbythehypothalamus)

Whichhormonesneedtobereplacedinpanhypopituitarism?Cortisol,levothyroxine,andestrogenortestosterone

NamefiveetiologiesofSIADH:1.CNS(headtrauma,subarachnoidhemorrhage,tumor,hydrocephalus)2.Pulmonary(smallcelllungCA,sarcoidosis,pneumonia,abscess)3.Endocrine(Connsyndrome,hypothyroidism)4.Drugs(antipsychotics,antidepressants,oralhypoglycemics)5.Surgery(intracranial,intrathoracic)

HowisthediagnosisofSIADHmade?Urine osmolality >50-100mOsm/kg (hyperosmolar urine) with current serum hyposmolarity, and urinary

sodium>20mEq/L

WhatisthetreatmentforSIADH?Fluidrestrictionandhypertonicsaline(acutely);demeclocycline(chronic)

WhatisthetreatmentofDI?CentralDI:DDAVP(desmopressin—anADHanalog)NephrogenicDI:saltrestrictionand↑waterintake

Thyroid

Namefourlabfindingsinhyperthyroidism:1.↓Thyroid-stimulatinghormone(TSH)(in1°)2.↑freeT43.↑totalT44.↑T3uptake

NamefourlabfindingsinhypOthyroidism:1.↑TSH(verysensitivefor1°)2.↓freeT43.↓totalT44.↓T3uptake

Describe how each of the following organ systems are affected by (1) hypothyroidism (HypO) and (2)hyperthyroidism:

MetabolismHypO:hypometabolicstate,coldintoleranceHyper:↑basalmetabolicrate(BMR),heatintoleranceCardiacHypO:exerciseintolerance,↓HR,shortnessofbreath,pericardialeffusionHyper:↑CO,↑HR,palpitations,cardiomegaly(long-term)OcularHypO:periorbitalmyxedemaHyper:staringgaze,lidlag;Graves→exophthalmosNeuromuscularHypO:hypoactivedeeptendonreflexes(DTR)Hyper:↑sympatheticactivity,finetremor,hyperactivereflexesSkinHypO:coarse,dryskin;hairlossHyper:warm,moist,andflushedskin;finehair;Graves→pretibialmyxedemaGIHypO:weightgain,constipationHyper:weightlossdespitehyperphagia,↑GImotilityOtherHypO:menorrhagia,↑pitchofvoice,depressionHyper:menstrualabnormalities,osteoporosis,anxiety,insomnia

Namethreepossibletreatmentsforhyperthyroidism:1.Propranolol(controlsymptoms)followedbyradioablation2.Antithyroiddrugs(methimazole,propylthrouvnel[PTU])3.Thyroidectomy

Whatisthemostcommonlong-termsideeffectofradioablationorthyroidectomy?HypOthyroidism

WhatisthetreatmentofchoiceforhypOthyroidism?Levothyroxine

Whatfearedcomplicationofhyperthyroidismcanbeinducedbyaninfectionorsurgery?

Thyroidstorm(tachycardia,high-outputcardiacfailure,andcoma)

Whatisthemortalityrateofthyroidstorm?25%

Whatisthetreatmentofthyroidstorm?1.β-blockers2.PTU3.Iodine4.Steroids

Namethethyroiddisorderassociatedwitheachofthefollowingstatements:Childwithcoarsefacialfeatures,shortstature,mentalretardation,andumbilicalherniaCongenitalhypothyroidism(cretinism)Goiteroccurringwithhighfrequencyiniodine-deficientareasEndemicgoiterPainless enlargement of thyroid of autoimmune etiology; requires long-term treatment with

levothyroxineHashimoto’sthyroiditisTriadofdiffusethyroidhyperplasia,ophthalmopathy,anddermopathyGravesdiseasePostviral,painfulinflammationofthyroid;usuallyself-limited,treatedwithASAorcorticosteroidsSubacute(granulomatous,deQuervain)thyroiditisPainlessgoiterthatcanoccurpostpartum;cancausehypothyroidismSubacutelymphocytic(painless)thyroiditisThyroid-stimulating immunoglobulin (TSI), a TSH-receptor Ab, stimulates thyroid hormone

productionGravesdiseaseExtremethyroidenlargement(>2kg)causingmasseffects;mostpatientsareeuthyroid;mayrequire

surgicaldebulkingMultinodulargoiterAntimicrosomalAb,antithyroglobulinAbHashimoto’sthyroiditisMostcommonthyroidcarcinomaPapillarycarcinomaCalcitonin-secretingtumorassociatedwithmultipleendocrineneoplasia(MEN)syndromesMedullarycarcinomaCarcinomapresentingasasinglenodulewithuniformfolliclesFollicularcarcinomaAggressivecarcinomaofolderpatientswithpleomophiccells;dismalprognosisAnaplastic(undifferentiated)carcinoma

Whichtwotypesofthyroidcancerhavetheworstprognosis?1.Medullary2.Anaplastic

Whatisthetestofchoiceforthedetectionofmetastasesfromthyroidmalignancies?Radioactiveiodinescan

Whatisthetreatmentforamalignantthyroidnodule?Surgicalresection

Aremostthyroidnodulesbenignormalignant?Benign

Whatfindingsareassociatedwith↑riskofthyroidcancer?

1.Priorneckradiation2.Coldnodule3.Firm,fixed,rapidlygrowingsolitarynodule4.Hoarseness/dysphagia

Whatisthediagnostictestofchoicetoevaluateathyroidnodule?Fineneedleaspiration(FNA)

NametheMENsyndromeassociatedwiththefollowingdescriptions:Pheochromocytoma,thyroidmedullarycarcinoma,andparathyroidadenomasMEN2(Sipplesyndrome)Tumorsofthepituitary,pancreaticisletcells,andparathyroidsMEN1(Wermersyndrome)Tumors in MEN2 plus tall, thin habitus, prominent lips, and ganglioneuromas of the tongue and

eyelidsMEN3(MEN2b)ADinheritanceAllMENsyndromes

Parathyroid

Nametheparathyroiddisorderassociatedwitheachofthefollowingstatements:Causedbychronicrenalfailureor↓vitaminD2°hyperparathyroidismMostcommonlyduetoparathyroidadenomas(90%)1°hyperparathyroidismEtiologiesincludecongenitalglandabsence,postsurgical,andautoimmunedestructionHypOparathyroidismCausedbyanautonomoushormonesecretingadenoma3°hyperparathyroidismAutosomal recessive (AR) end-organ resistance to PTH → short stature and short third/fourth

metacarpalsPseudohypoparathyroidism

Whatfoursystemsareprimarilyaffectedbyhyperparathyroidism?”Painfulbones,renalstones,abdominalgroans,andpsychicmoans”

1.Painfulbones:osteitisfibrosacystica,osteoporosis,fractures2.Renalstones:nephrolithiasis,nephrocalcinosis3.Abdominalgroans:constipation,pepticulcerdisease(PUD),pancreatitis,N/V4.Psychicmoans:depression,lethargy,seizures

Whatisthetreatmentofchronicsymptomatichypercalcemiafromhyperparathyroidism?Parathyroidectomywithpreoperativebisphosphonates

Nametwopostoperativecomplicationsofparathyroidectomy:1.Recurrentlaryngealnerveinjury(hoarseness)2.HypOcalcemia

AdrenalsandSteroids

Namethefouretiologiesforhypercortisolism:1.Exogenousglucocorticoids(mostcommonoverall)

2.PituitaryACTHhypersecretion(eg,adenoma)3.Hypersecretionofcortisol(eg,adrenalhyperplasia)4.EctopicACTH(eg,smallcelllungcancer)

Whatisthemostcommoncauseofendogenoushypercortisolism?Cushingdisease(1°pituitaryadenoma)

NameeightclassicclinicalfindingsofCushingsyndrome:1.Hyperglycemia/hypokalemia/HTN2.Virilizationandmenstrualdisorderinwomen3.Moonfacies4.Truncalobesity5.Buffalohump6.Skinchanges(thinning,purplestriae)7.Osteoporosis:vertebralcompressionfractures8.Immunesuppression-susceptibilitytoinfection

WhattwotestsareusedtoscreenforCushingsyndrome?1.Overnightlow-dosedexamethasonesuppressiontest2.24-hurine-freecortisol

Whattestisusedtolocalizethesourceofhypercortisolism?1.CheckACTHlevels(↑=ectopic/pituitary;↓=adrenal)2.High-dosedexamethasonesuppressiontest(whenACTH↑,suppressionsuggestspituitarydisease)

Nametheadrenaldisorderassociatedwitheachofthefollowingstatements:Aldosterone-secretingadenomacausingHTN,hypokalemic,hypernatremia,andmetabolicalkalosisConnsyndrome

(1°hyperaldosteronism)21-hydroxylasedeficiency(autosomalrecessive)→cortisoldeficiencyand↑adrenalandorgensCongenitaladrenalhyperplasiaEndotoxin-mediatedmassiveadrenalhemorrhageWaterhouse-Friderichsensyndrome(causedbyNeisseriameningitidis)Deficiencyofaldosteroneandcortisoloccurs2°toadrenalatrophyorautoimmunedestruction;may

causehypotension1°chronicadrenocorticalinsufficiency(Addisondisease)Hypothalamic-pituitary axis (HPA) disturbance (eg, abrupt cessation of glucocorticoid treatment)

causingfailureofACTHsecretion2°adrenocorticalinsufficiencyBilateral hyperplasia of zona glomerulosa caused by stimulation of renin-angiotensin-aldosterone

(RAA)system2°hyperaldosteronismResultsfromrapidsteroidwithdrawalorsudden↑inglucocorticoidrequirements1°acuteadrenocorticalinsufficiency(adrenalcrisis)Chromaffincelltumorusuallyinadults;resultsinepisodichyperadrenergicsymptomsPheochromocytomaMalignant, small, round, blue cell tumor of medulla in kids associated with N -myc oncogene

amplificationNeuroblastoma

Howis1°and2°adrenocorticalinsufficiencydifferentiated?2°isnotassociatedwithhyperpigmentation.

Whatsubstancecanbemeasuredtodifferentiatebetween1°and2°hyperaldosteronism?Renin(↑in2°hyperaldosteronism)

Whatisthedrugofchoiceforhyperaldosteronism?Spironolactone(aldosteroneantagonist)

Whatisthe“ruleof10s”forpheochromocytomas?10%malignant

10%bilateral10%extraadrenal10%kids10%familial10%calcify

WhatarethefivePsofpheochromocytoma(symptoms)?Pressure,Pain(headache),Perspiration,Palpitations,andPallor

Whatsubstancesaresecretedfrompheochromocytomasandhowaretheydetected?Epinephrineandnorepinephrine;diagnosedby↑urinary secretionof catecholamines and theirmetabolites

(metanephrine,VMA,etc)

Whatisthetreatmentofapheochromocytoma?

Surgicalresection(preoperativeα-andβ-blockade)

Whyisitnecessarytoblockα-receptorsbeforegivingaβ-blocker?Topreventunopposedvasoconstriction

WhataretheelectrolyteandCBCabnormalitiesinAddisondisease?Hyponatremia,hyperkalemia,andeosinophilia

WhattestisusedtoevaluatetheetiologyofAddisondisease?ACTHstimulationtest(↑ACTHand↓cortisol=Addison;↓ACTHand↑cortisol=2°cause)

Whatisthetreatmentofadrenalinsufficiency?Replacementofglucocorticoidsandmineralcorticoids

WhatmustbeadministeredtoapatientwithAddisondiseaseduringperiodsofstress(eg,surgery,trauma,orinfection)?

Stress-dosesteroids

Whatarethetwomainetiologiesof1°hyperaldosteronismandtheirrespectivetreatments?Adrenaladenoma(Connsyndrome)→adrenalectomy;bilateralhyperplasia→spironolactone

Pancreas-DiabetesMellitus

Whatendocrinediseaseshouldbesuspectedinapatientwhopresentswithpoorwoundhealingorrecurrentvaginalcandidiasis?

Diabetesmellitus(DM)

Describetheclassicacutepresentationoftype1diabetesmellitus:Polydipsia,polyuria,polyphagia,weightloss,andDKAifextreme

Whatistheproposedmechanismofisletcelldestructionintype1DM?Environmentaltriggeringofautoimmunitytoisletβ-cells

Whatisthetheorizedcauseoftype2DM?Obesityincreasesinsulinresistanceandcausesβ-celldysfunction.

NamethreecriteriatodiagnoseDM:1.Fastingglucose>126mg/dL2.Randomglucose>200mg/dLwithsymptoms3.2-hrglucose>200mg/dLduring75-goralglucosetolerancetest(ontwoseparateoccasions)

WhatisHbA1candwhatisitusedfor?Percentofglycosylatedhemoglobininblood;usedtomeasurediabeticcontroloverlast90-120days(average

lifespanofRBC)-goal7%

NametheacutecomplicationofDMassociatedwiththefollowingdescriptions:Abdominal pain, vomiting,Kussmaul respirations, fruity/ acetonebreath odor, anion gapmetabolic

acidosis,andmentalstatuschangesusuallyprecipitatedbystress(infection,drugs,MI,ornoncompliancewithinsulintherapy)

DKA—type1DMProfounddehydration,extremehyperglycemia(>600mg/dL),mentalstatuschangeswithoutacidosisHyperosmolarhyperglycemicnonketoticcoma(HHNK)—type2DM

WhatarethethreemajorcomponentsofthetreatmentofDKA?1.Fluids(adddextrosewhenglucosefallsbelow200mg/dL)2.Insulin3.Potassium

WhymustK+bereplacedinapatientwithDKAeventhoughserumlevelsareusuallyelevated?AcidosisandinsulonopeniaforceK+outofcellsinitiallybutthetotalbodypotassiumlevelsmaybelow.

WhatisthemortalityrateofHHNK?50%

WhatisthemaintreatmentofHHNK?Aggressivefluidreplacementandinsulin

Describetheeffect(s)oflong-termDMoneachofthefollowingorgansystems:Cardiovascular(macrovascular)Atherosclerosis→CVA,MI,PVDUrinary(microvascular)Glomerular (glomerulosclerosis, proteinuria); vascular (arteriosclerosis → HTN, CRF); infectious (UTIs,

pyelonephritis,necrotizingpapillitis)Nervous(microvascular)Motorandsensoryperipheralneuropathy,autonomicdegeneration/dysfunction(orthostatichypotension)Eye(microvascular)Retinopathy,cataractformation,blindnessSkinXanthomas,abscessesfrom↑infectionsandpoorwoundhealing,fungalinfections

Whattwofactorsareshowntocorrelatewiththeseverityofmicrovascularcomplications?1.Glycemiccontrol2.Durationofdisease

WhatpreventivemeasuresmustbetakentominimizecomplicationsofDM?1Annualdilatedretinalexamination2.Microalbuminuriayearlywithspotmicroalbumin/Crratio,goal30mg/g3.Annualpodiatristexamination4.BPcontrol(130/80)5.Lipidcontrol(LDL100,TGs150,HDL>40)6.HbA1cevery3-6months(7%)

Nametheappropriatetherapyforeachofthefollowingclinicalscenariosinadiabetic:ProliferativeretinopathyLaserphotocoagulationMicroalbuminuriaACEinhibitororARBNeuropathyGabapentinandamitriptylineType1diabetesInsulinNewlydiagnosedtype2diabetesrefractorytolifestylemodificationsOralhypoglycemicsType2diabetesrefractorytomonotherapywithanoralhypoglycemicagentOralhypoglycemicagentwithadifferentmechanismorbegininsulintherapy

Foreachofthefollowingtypesofinsulin,statetheonset,peak,anddurationofaction:InsulinlisproOnset:5-10m;peak:60-90min;duration:2-4hNPHorLenteinsulinOnset:2h;peak:4-8h;duration:12-18hUltralenteinsulinOnset:3-5h;peak:10-16h;duration:12-20hInsulinglargineOnset:2h;peak:none(peakless);duration>24h

Foreachoralhypoglycemic,statethemechanismanduniquetoxicityofeach:Biguanides(eg,metformin)↓hepaticgluconeogenesisand↑peripheraluptakeofglucose;riskoflacticacidosis;contraindicatedinthe

elderlyandinptswithrenaldiseaseSulfonylureas(eg,glyburide,glipizide,glimepiride)↑insulinsecretion;maycausehypoglycemiaandweightgainThiazolidinediones(eg,pioglitazone,rosiglitazone)↑peripheralinsulinresponsiveness;maycauseweightgain,edema,andhepatotoxicityα-Glucosidaseinhibitors(eg,acarbose,miglitol)↑GIabsorptionofcarbohydrates;maycauseGIupset/flatulence

Namefourcausesof2°diabetesmellitus:1.Pancreaticdisease(eg,hemochromatosis,pancreatitis,pancreaticcarcinoma)2.Pregnancy(gestationaldiabetes)3.Cushingsyndrome4.Otherendocrinedisorders(eg,acromegaly,glucagonoma,hyperthyroidism)

Namethecriteriatodiagnosemetabolicsyndrome:Mustmeetthreeofthefollowingcriteria:1.Abdominalobesity2.TG≥150mg/dL3.HDL40inmenand50inwomen4.BP≥130/85mmHgortakingantihypertensivemeds5.Fastingglucose≥110mg/dL

Namethefollowingcomplicationsofdiabeticmanagement:Nocturnalhypoglycemiacausingelevatedmorningglucose2°toreleaseofcounterregulatoryhormonesSomogyieffectAbruptearly-morninghyperglycemiacausedbyreducedeffectivenessofinsulinDawnphenomenon

Nametheisletcelltumorassociatedwitheachofthefollowingstatements:

MostcommonisletcelltumorInsulinoma(β-celltumor)2°diabetesmellitus,necrolyticmigratoryerythemaGlucagonoma(α-celltumor)AssociatedwithZEsyndromeGastrinomaAssociatedwithWDHA(waterydiarrhea,hypokalemia,andachlorhydria)syndromeVIPoma2°diabetesmellitus,cholelithiasis,steatorrheaSomatostatinoma(δ-celltumor)ClinicallycharacterizedbyWhipple’striadInsulinoma(β-celltumor)

NametheclinicalfindingsofWhipple’striad:1.Hypoglycemia2.ConcurrentCNSdysfunction3.ReversalofCNSsymptomswithglucose

WhatisZEsyndrome?HypersecretionofgastricHCl,recurrentPUD,andhypergastinemia(associatedwithMEN)

HowisZEsyndromediagnosed?↑serumgastinlevelwithsecretinstimulationtest

MaketheDiagnosis

31-y/o presents with loss of libido, galactorrhea, and irregular menses; PE: bitemporal hemianopsia; w/u:negativeβ-hCG

Prolactinoma

Patienttakinglithiumpresentstoclinicwithpolyuriaandpolydipsia;w/u:urinespecificgravity1.005,urineosmolality200mOsm/kg,hypernatremia

Diabetesinsipidus(DI)

30-y/o white female presents with weight loss, tremor, and palpitations; PE: brisk DTR, ophthalmopathy,pretibialmyxedema;w/u:↓TSH,↑T4,↑T3index

Gravesdisease

40-y/ofemalepresentswithfatigue,constipation,andweightloss;PE:puffyface,colddryhands,coarsehair,andenlargementofthyroidgland;w/u:↑TSH,↓T3andT4,⊕antimicrosomalAbandantithyroglobulinAb

Hashimotodisease

32-y/ofemalewithh/orecurrentPUDpresentswithepisodesofhypocalcemiaandnephrolithiasis;w/u:fastinghypoglycemia,↑gastrinlevels,andhypercalcemia

MEN1

70-y/opresentswithepisodalHTN,nephrolithiasis,anddiarrhea;PE:↑BP,thyroidnodule;w/u:↑calcitoninlevels,↑urinarycatecholamines

MEN2

Afemalepatientpresentswithbonepain,kidneystones,depression,andrecurrentulcers;w/u:hypercalcemia,hypophosphatemia,andhypercalciuria

Hyperparathyroidism

35-y/ofemalepresentswithweightgain,irregularmenses,andHTN;PE:↑BP,weightinfaceandupperback,

hirsutism, multiple ecchymoses; w/u: ↑ ACTH levels and suppression with high-dose dexamethasonesuppressiontest

Cushingdisease

45-y/owithrecenth/ocoarseningoffacialfeaturespresentswithheadachesandstatesthathisshoesnolongerfit;PE:enlargedjaw,tongue,hands,andfeet,andbitemporalhemianopia;w/u:↑IGF-1

Acromegaly

9-y/o female presents with muscle cramps; PE: rounded face with flat nasal bridge, abnormal dentition,positiveTrousseau’ssignandChvostek’ssign,andshortenedmetacarpals

Albrighthereditaryosteodystrophy(pseudohypoparathyroidism)

50-y/o female presents with HTN, muscle weakness, and fatigue; w/u: hypokalemia, hypernatremia, andmetabolicalkalosis

Connsyndrome

30-y/ofemalepresentswithprogressiveweakness,weightloss,andN/V;PE:hyperpigmentationofskin,↓BP;w/u:hyperkalemia,hyponatremia,andeosinophilia

Addisondisease

40-y/opresentswithepisodesofHA,diaphoresis,palpitations,andtremor;PE:↑BP,↑HR;w/u:↑inurinaryVMAandhomovanillicacid

Pheochromocytoma

17-y/owhitefemalewithh/oDMpresentswithdiffuseabdominalpain,N/V,andslightconfusion;PE:↓BP,shallowrapidbreathingpattern;w/u:↑glucose(300mg/dL),hypokalemia,hypophosphatemia,andmetabolicacidosis

DKA-DMtypeI

60-y/odiabeticobesepatientfoundathomeconfusedanddisoriented;PE:↓BP,↑HR;w/u:glucose>1000,pHisWNL

HHNK-DMtypeII

50-y/o female presents with h/o weakness, blurred vision, and confusion several hours after meals, whichimproveswitheating;w/u:↑fastinglevelsofinsulinandhypoglycemia

Insulinoma

78-y/omalepresentswithrapidlygrowingpalpablethyroidmassandassociatedhoarseness;PE:firm,fixed,nontendernodule,anteriorcervicallymphadenopathy;FNA:“OrphanAnnie”nucleiandpsammomabodies

Papillarythyroidcarcinoma

21-y/o female presentswith increased amounts of dark facial hair, acne, andmenstrual abnormalities; PE:↑BP,hirsutism;w/u:↑androgensandcortisolprecursors(ie,progesterone)

Congenitaladrenalhyperplasia(21-hydroxylasedeficiency)

26-y/omalepresentswith tender thyroid,malaise, runnynose, and cough;PE: fever, tender thyroidbutnopalpablemass,cervicaladenopathy;w/u:↓uptakeonradioactiveiodineuptake(RAIU)

Subacute(deQuervain’s)thyroiditis

54-y/ofemalewithh/ouncontrolledDM-type2presentsforregularfollow-upvisit;PE:obese,↑BP(165/90);w/u:↑TG(230),↓HDL(40),↑HbA

1c(8.2)

Metabolicsyndrome

55-y/o female with rheumatoid arthritis presents with confusion, abdominal pain, and N/V after abruptlystoppingprednisonetreatment;PE:alteredmentalstatus,fever,↑HR,↓BP,noskinhyperpigmentation;w/u:normalK+,hyponatremia,eosinophilia,↓cortisol

Adrenalcrisis(2°adrenalinsufficiency)

HEMATOLOGY/ONCOLOGY

Anemias

Whataresomecommonpresentingsymptomsinananemicpatient:Fatigue,DOE,angina,headache,dizziness,andsyncope

Listfiveofthemostcommoncausesofmicrocyticanemia:1.Irondeficiency2.Leadpoisoning3.Chronicdisease(sometimesnormocytic)4.Sideroblastic5.Thalassemia

Listfourofthemostcommoncausesofnormocyticanemia:1.Sicklecell2.Aplastic3.Acutebloodloss4.Hemolyticanemia

Listfiveofthemostcommoncausesofmacrocyticanemia:1.Liverdisease2.VitaminB12deficiency3.Folatedeficiency4.Alcoholism5.Hypothyroidism

Whatistheprimarysiteofironabsorption?Duodenum

Whatarethetwomostcommoncausesofirondeficiencyanemiainadults?1.Menorrhagia2.GIbloodloss

What is themechanism of ischemic necrosis of the bones, lungs, liver, brain, spleen, or penis in sickle celldisease?

↓O2tension→abnormalRBCssickle→microvascularocclusions

Whattwocommonenzymedeficienciescancausehemolyticanemia?1.Glucose-6-phosphatedehydrogenase2.Pyruvatekinasedeficiency

WhattwoautoimmuneconditionsoftheGItractcancausemegaloblasticanemia?1.Perniciousanemia(duetolackofintrinsicfactor[IF]production)2.Crohn’sdisease(duetolackofIF-B12complexreabsorptionindistalileum)

Howdoesgastricresectioncausemegaloblasticanemia?Parietalcells,whichareresponsibleforIFproductionmayberemovedwhenthegastricfundusisresected.

Namethetype(s)ofanemiaassociatedwiththefollowingclinicalorpathologicfeatures:AbnormalSchillingtestPerniciousanemiaAngularchelitis,koilonychia,picaIrondeficiencyanemiaAutosplenectomySicklecellanemiaBasophilicstiplingoferythrocytes,blue/graydiscolorationatgumline,wrist/footdropMicrocyticanemia(leadpoisoning)CeliacsprueMegaloblastic(folatedeficiency)andirondeficiencyanemiasChronicatrophicgastritisPerniciousanemiaColoncancerIrondeficiencyanemia(early)andanemiaofchronicdisease(late)Crescent-shapederythrocytesandHowell-JollybodiesSicklecellanemia↓Serumiron,normaliron-bindingproteinsaturation,↓ferritin,↓TIBCAnemiaofchronicdisease↓Ferritin,↑redbloodcelldistributionwidth(RDW),↑TIBC, ↓Serumiron, ↓ iron-binding protein

saturationIrondeficiencyanemia↑Serumiron,maximaliron-bindingproteinsaturation,↓ferritin,normalTIBCIronoverload/hereditaryhemochromatosisDeficiencyofα-orβ-globingenesynthesisThalassemiaDeficiencyofdecayacceleratingfactorParoxysmalnocturnalhemoglobinuriaDemyelinationofthedorsalandlateraltractsofthespinalcordPerniciousanemiaDiphyllobothriumlatum(fishtapeworm)andG.lambliainfectionMacrocyticanemia(B12deficiency)↑reticulocytecount,indirecthyperbilirubinemia,↑LDH,andnegativedirectCoombstestHemolyticanemiaEnd-stageliverdiseaseMacrocyticanemiaOxidativestressonerythrocytesinaG6PD-deficientpatientHemolyticanemia”Fishmouthvertebrae”onradiographSicklecellanemiaGastriccarcinomaPerniciousanemiaGlossitisandperipheralneuropathyPerniciousanemiaHelmetcells,burrcells,triangularcellsMicroangiopathic anemia (2° to disseminated intravascular coagulation [DIC], TTβ-HUS), or mechanical

heartvalves)PersistentlyelevatedcreatinineAnemiaofchronicrenalfailureHighreticulocytecountHemolyticanemia(oracutehemorrhage)HypersegmentedPMNsVitaminB12orfolatedeficiencyanemiaHypothyroidismMacrocyticanemia

LeukemiasandlymphomasAutoimmunehemolyticanemiaFatigue,jaundice,darkurineafterconsumptionoffavabeansHemolyticanemia(duetoG6PDdeficiency)PancytopeniaandfattyinfiltrationofbonemarrowAplasticanemiaMalariaorbabesiosisHemolyticanemiaMaybecausedbyCrohn’sdiseaseoftheterminalileumMacrocyticanemia(B12deficiency)Microcytosis,atrophicglossitis,esophagealwebs(Plummer-Vinsontriad)Irondeficiencyanemia(longstanding)MostcommontypeofanemiaIrondeficiencyanemiaM.pneumoniaeinfectionColdautoimmunehemolyticanemiaNSAIDs,chloramphenicoluseAplasticanemiaPenicillin,cephalosporin,orquinidineuseAutoimmunehemolyticanemiaADdeficiencyofspectrin,positiveosmoticfragilitytestHereditaryspherocytosisPriapismSicklecellanemiaSLE, chronic lymphocytic leukemia (CLL), lymphomas, drugs;⊕ direct Coombs test (due to IgG

autoantibodies)WarmautoimmunehemolyticanemiaReducederythropoietinAnemiaofchronicdiseaseRingedsideroblastsSideroblasticanemiaSchistocytesMicrohemangiopathicanemiaSusceptibilitytoinfectionbyencapsulatedorganismsSicklecellanemia(duetofunctionalasplenia)Targetcells”HALT”HemolysisAspleniaLiverdiseaseThalassemiaUnconjugated bilirubinemia, ↑ urine urobilinogen, ↓ hemoglobin, hemoglobinuria, ↓ haptoglobin,

hemosiderosisHemolyticanemia

Namethetypeofthalassemiaresponsibleforeachofthefollowingfindings:β-Thalassemia associated with growth retardation, frontal bossing and HSM (from extramedullary

hematopoesis),jaundice,andironoverload(2°totransfusions),and↑HgbFβ-Thalassemiamajor(β-/β-)Note:β-thalassemiaminor(β+/β-)typicallyasymptomaticα-Thalassemiaassociatedwithmildmicrocyticanemia,usuallyasymptomaticα-Thalassemiaminor(twoallelesaffected)Note:whenonlyonealleleinvolved(carrierstate)→noanemiaα-Thalassemiaassociatedwithpallor,splenomegaly,chronichemolyticanemia,andintraerythrocytic

inclusions

HgbHdisease(threeallelesaffected)α-ThalassemiaassociatedwithstillbornfetusHydropsfetalis(allfourallelesaffected)

Namethreeinfectiousandthreenoninfectiouscomplicationsofsicklecelldisease:Infectious

1.Osteomyelitis(usuallyduetoSalmonella)2.PneumococcalandH.influenzaepneumonia3.ParvovirusB19infectioncausingaplasticanemia

Noninfectious1.High-outputcardiacfailure2.Splenomegaly(ininfants)3.Vasoocclusivecrises

Whatisthetreatmentofavasoocclusivesicklecrisis?Oxygentherapy,IVhydration,analgesia(usuallyopioids)

Whattreatmentmaybeusedinthesettingofseverevasoocclusivecrisesandchestsyndromewithrespiratorydistress?

Exchangetransfusions

Whatchemotherapeuticagentmaydecreasethefrequencyofsicklecellcrises?Hydroxyurea

CoagulationDisorders

Namethecoagulationdisorderassociatedwiththefollowingclinicalfeatures:

Classictriadofthrombocytopenia,hemolyticanemia,andARFHemolytic-uremicsyndrome(HUS)ClassictriadofHUS+feverandneurologicchangesTTPRemember: ”FAT RN”: Fever, Anemia (hemolytic), Thrombocytopenia, Renal failure, Neurologic

abnormalitiesCommonlyfollowsviralURIinchildrenbutmaybechronicinadultsIdiopathicthrombocytopenicpurpura(ITP)Commonlyoccursinthecontextofsepsis,majorhemorrhage(traumaticorobstetric),ormalignanciesDICX-linkeddisordercharacterizedbyhemarthrosesandGIbleeding;↑PTT,normalPT,plateletcount,

andbleedingtimeHemophiliaADdisordercharacterizedbyepisodesofeasybruising,mucosalandGIbleedingvonWillebranddiseaseTreatedwithFactorVIIIHemophiliaATreatedwithFactorIXHemophiliaBCommonlyinchildren;maybecausedbyE.coliO157:H7HUSSpontaneousbleedingfromsurgicalwoundsandvenipuncturesitesDICAssociatedwithlymphomas,leukemias,HIVinfection,andautoimmunediseasesITPIgGantiplateletantibodies(⊕Coombs)

ITP↑bleedingtime,↓FactorVIII,normalplateletcount,normalPTandPTTvonWillebranddiseaseProlongedPT,PTT,↑fibrinsplitproducts(D-dimer),↓Hct,↓plateletsDIC(alsoknownas“consumptivecoagulopathy”)Schistocytes,↑unconjugatedbilirubin,↑LDHTTPFirst-line therapy is oral steroids; second line is IV immunoglobulin (IVIG), splenectomy, or

chemotherapy(commonly,cyclophosphamide)ITPFirst-linetherapyisplasmapheresisorIVIG;splenectomyforrefractorycases(fatalifuntreated)TTPTreatment aimed at underlying disorder; treatment for coagulopathy with platelet transfusion,

cryoprecipitate;secondline:aminocaproicacidDICMilddiseasetreatedwithdesmopressin;severediseasetreatedwithFactorVIIIconcentratevonWillebranddisease

WBCNeoplasia

Name the general type of lymphoma (Hodgkin’s or non-Hodgkin’s lymphoma [NHL]) associated with thefollowingclinicalandpathologicfeatures:

ReedSternberg(RS)cellssecretinginterleukin(IL-5)Hodgkindisease(HD)Peakincidencefrom20to40yearsofage,morecommoninwomenNHLBimodalagedistributionbutmostcommoninyoungmenHDConstitutionalsymptomsincludingfever,nightsweats,weightlossBothMediastinallymphadenopathy,contiguousspreadHDSystemicadenopathyNHLRegionallymphadenopathyHDAssociatedwithEBV,HIVinfectionHDPeripherallymphadenopathy,noncontiguousspreadNHLLymphadenopathymaybecomepainfulwithalcoholconsumptionHDAssociatedwithimmunosuppressionincludingAIDSNHL

LeukemiasandLymphomas

Name the general type of leukemia (acute or chronic) associated with the following clinical and pathologicfeatures:

ImmatureblastcellspredominateAcute

MaturecelltypespredominateChronicBimodalagedistributionAcuteRapidonsetandquicklyprogressivediseaseAcuteIndolentcourseChronicCommoninmiddleadulthoodChronic

Whatarethethreemostcommonmedicalcomplicationsofend-stageleukemia?1.Hemorrhage(duetothrombocytopenia)2.Infection(duetoimmunosupression)3.Anemia(duetoinvolvementofbonemarrow)

Namethespecificleukemiaassociatedwitheachofthefollowingdemographics:Mostcommonleukemiaofchildhood,peakage3-4yearsAcutelymphocyticleukemia(ALL)MostcommonleukemiainadultsAcutemyelogenousleukemia(AML)Commonlyinmales60andolderCLL

Namethespecificleukemiaassociatedwitheachofthefollowingfindings:Veryhighwhitecellcounts,often>200,000Chronicmyelogenousleukemia(CML)IsolatedlymphocytosisCLLTdTpositivelymphoblastsALLLarge,immaturemyeloblastspredominateAMLSmudgecellsCLLBonemarrowisreplacedwithmyeloblasts.AMLPhiladelphiachromosomet(9:22)CMLAuerrodsAMLLowleukocyticalkalinephosphataseCML(aswellasparoxysmalnocturnalhematuria)Associated with fatigue, thrombocytopenia (easy bruising), signs of anemia, frequent infections,

leukemiacutis,andDICAMLBonepain,fever,generalizedlymphadenopathy,HSM,andsignsofCNSspreadALLExcellentprognosisiftreatedearlyALLMayprogresstoAMLCMLMostresponsivetotherapyALLAssociatedwithpriorexposuretoradiation

CMLPeripheralleukocytescontainingtartarateresistantacidphosphataseandcytoplasmicprojectionsHairycellleukemia

MyeloproliferativeDisorders

Namethefourchronicmyeloproliferativedisorders:1.Chronicmyelogenousleukemia2.Polycythemiavera3.Essentialthrombocytosis4.Myelofibrosiswithmyeloidmetaplasia

Namethemyeloproliferativedisorderassociatedwitheachofthefollowingclinicalandpathologicfindings:↑RBCmassandlow/normalerythropoietinPolycythemiaveraTeardropdeformityoferythrocytes,bonemarrowhypercellularityMyelofibrosiswithmyeloidmetaplasiaPlethoriccomplexion,pruritusaftershowering,epistaxis,blurredvision,splenomegaly,andepistaxisPolycythemiaveraErythromelalgia(throbbingorburningofhandsandfeet)EssentialthrombocytosisBasophiliaPolycythemiaveraWidespreadextramedullaryhematopoesiswithmegakaryocyticproliferationinthebonemarrowMyelofibrosiswithmyeloidmetaplasiaHyperviscositysyndromePolycythemiaveraandessentialthrombocytosisPeripheralthrombocytosis,bonemarrowmegakaryocytosis,andsplenomegalyEssentialthrombocytosisTreatedwithASA,phlebotomy,and/orhydroxyureaPolycythemiaveraTreatedwithplateletexchange(foracuteexacerbations),hydroxyurea,andanagrelideEssentialthrombocytosis

Nametheplasmacelldisorderassociatedwiththefollowingclinicalandpathologicfindings:Bonepain,osteopenia,pathologicfractures,and“punched-out”lyticlesionsonx-rayMultiplemyelomaRusselbodiesand“plymphocytes”(plasmacytoidlymphocytes)WaldenstrommacroglobulinemiaBence-JonesproteinuriaMultiplemyelomaandWaldenstrommacroglobulinemiaSmallM-spikeonplasmaelectrophoresisinanotherwisehealthypatientMonoclonalgammopathyofundeterminedsignificance(MGUS)Hypercalcemia;renalinsufficiencyMultiplemyelomaHyperviscositysyndromeWaldenstrommacroglobulinemiaLargeM-spikeonplasmaelectrophoresisMultiplemyelomaandWaldenstrommacroglobulinemiaPrimaryamyloidosisMultiplemyeloma

Namethedisease(s)orcondition(s)associatedwitheachofthefollowingperipheralbloodsmearfindings:Atypicallymphocytes

InfectiousmononucleosisAuerrodsAML(M3subtype)BasophilicstipplingLeadpoisoningBurrcells(echinocytes)BurnsanduremiaHeinzbodiesG6PDdeficiencyHelmetcells,schistocytesMicroangiopathichemolyticanemia(DIC,TTP,HUS)Howell-JollybodiesAsplenia(duetotraumaorfunctionalaspleniaduetosicklecelldisease)HypersegmentedPMNnucleiMegaloblasticanemiaLymphocyticcerebriformnucleiSézarysyndromeNucleatederythrocytesHemolyticanemiaRouleauformationMultiplemyelomaandWaldenstrommacroglobulinemiaSmudgecellsCLLSpherocytesHereditaryspherocytosisandhemolyticanemiaSpurcells(acanthocytes)Abetalipoproteinemia,liverdiseaseTargetcells(codocytes)Thalassemias,irondeficiencyanemia,liverdisease,andsicklecellanemiaTeardropcells(dacrocytes)MyelofibrosisToxicgranulationsinleukocytesSevereinfection

MaketheDiagnosis

50-y/owith h/o bonemarrow transplant forCML3weeks ago presentswith severe pruritis, diarrhea, andjaundice;PE:violaceousrashonpalmsandsoles;w/u:↓bilirubin,ALT,andAST

Graft-versus-hostdisease

1-y/o Greek child presents with pallor and delayed milestones; PE: pallor, skeletal abnormalities,splenomegaly;peripheralbloodsmear(PBS):hypochromicmicrocyticRBCs;targetcells,fragmentedRBCs;skullXR:“hair-on-end”appearance

β-Thalassemia

10-y/o with a h/o recurrent chest pain presents with fever and bilateral leg pain; PE: febrile, multiple legulcers;PBSshowssickle-shapederythrocytes;HgbelectrophoresisshowsHgbSband.

Sicklecellanemia

60-y/opresentswithheadache,vertigo,blurryvision,pruritus,jointpain;PE:↑BP,plethoric,splenomegaly;w/u:Hct60,mildleukocytosis,andhyperuricemia

Polycythemiavera

4-y/omalewitha1-weekh/ofever,pallor,headache,andbonetenderness;PE:fever,HSM,andgeneralized

nontenderlymphadenopathy;w/u:PBSrevealsabsolutelymphocytosiswithabundantTdT⊕lymphoblasts.Acutelymphoblasticleukemia

27-y/o presents with 2-month h/o fatigue, oropharyngeal candidiasis, pseudomonal UTI, and epistaxis; PE:numerouspetechiaeandecchymosesof skin,gingivalmucosalbleeding,guaiac⊕ stools;w/u:↑WBCs,PBSshows>30%myeloblastswithAuerrods.

Acutemyelocyticleukemia

17-y/o male presents with a 2-month h/o fever, night sweats, and weight loss; PE: nontender, cervicallymphadenopathy,andHSM;CBC:leukocytosis;CXR:bilateralhilaradenopathy;lymphnodebiopsy:Reed-Sternbergcells

Hodgkindisease

60-y/omale presentswith fatigue and anorexia; PE: generalized lymphadenopathy andHSM;CBC:WBC:250,000,⊕directCoombstest;PBS:small,roundlymphocytespredominatewithoccasionalsmudgecells.

Chroniclymphocyticleukemia

10-y/o Black child presents with a 3-week h/o a rapidly enlarging, painless mandibular mass; CBC: mildanemiaandleukopenia;cytogeneticsrevealat(8:14)translocation;excisionalbiopsy:“starry-sky”pattern

Burkittlymphoma

35-y/opresentswitha3-yearh/omildweightloss,anorexiapresentswithworseningDOE;PE:splenomegaly;CBC:mildanemia,WBC:125,000;PBS:granulocytosiswith10%myeloblasts; cytogeneticsreveala t(9:22)translocation.

Chronicmyelocyticleukemia

55-y/owitharecenth/ostreptococcalpneumoniapresentswithbonepainandweightloss;w/u:mildanemia,hypercalcemia;PBS:rouleau formation;UA:Bence-Jonesproteinuria; serumelectrophoresis:M-spike;XR:cranial“punched-out”lesions

Multiplemyeloma

18-y/o female develops dyspnea and decliningmental status 1 hour after aC-section complicated by excessbloodloss;PE:mucosalbleeding,largeclotinthevaginalvault;coags:↑PTandPTT,↓platelets,↑fibrinsplitproducts

Disseminatedintravascularcoagulation(DIC)

7-y/owithh/oviralURI1weekagopresentswithepistaxis;PE:petechialhemorrhagesofnasalmucosaandextremities;w/u:↓platelets,normalPTandPTT;bonemarrowbiopsy:↑↑megakaryocytes

Idiopathicthrombocytopeniapurpura(ITP)

8-y/owithah/ovomitinganddiarrheaaftereatingahamburger lastweekpresentswith fatigue,periorbitaledema, and oliguria; PE: purpuric rash; CBC: ↓ platelets; PBS: burr cells, helmet cells; UA: RBC casts,proteinuria,hematuria

Hemolytic-uremicsyndrome(HUS)

8-y/owithah/oenvironmentalallergiespresentswithapainfulrashonthelegs,abdominaldiscomfort,jointpain;UA:hematuriaandRBCcasts;renalbiopsy:glomerularmesangialIgAdeposits

Henoch-Schonleinpurpura

65-y/o female w/ fever and forgetfulness; labs: thrombocytopenia, anemia, shistocytes, ↑ LDH, elevatedcreatinine

Thromboticthrombocytopenicpurpura(Tx:plasmaexchange)

8-y/omale presents with a swollen painful knee; FH:maternal grandfather died from hemorrhage after acholecystectomy;PE:cutaneousecchymoses;w/u:grossbloodinswollenkneejoint,↑PTT,normalPT,plateletcount,↑bleedingtime

HemophiliaA

2-y/o male with a h/o recurrent epistaxis presents with the third episode of otitis media in 4 months; PE:eczematousdermatitis;w/u:thrombocytopenia,↓IgM,↑IgA

Wiskott-Aldrichsyndrome

Anewborndevelops jaundicerapidlyduring the firstdayof life;PE:HSM;w/u: severeanemia,⊕ indirectCoombstestinbothmotherandnewborn

Rhincompatibility

16-y/ofemalewithah/omenorrhagiapresentswithfatigue;PE:multiplecutaneousbruises;guaiac⊕stools;w/u:↑bleedingtime,↓FactorVIII,normalplateletcount,PTandPTT

vonWillebranddisease

40-y/ofemales/pchestradiationtherapyforchildhoodHodgkindiseasepresentswithnewmassinupperouterquadrantofbreast.

Breastcancer

65-y/omalewith100pack-yearhxpresentswithSOB;PE:JVD,muffledheartsounds;CXR:leftlowerlobemass,enlargedcardiacsilhouette;TTE:pericardialeffusion

Lungcancermetastasis topericardium(mostcommonbreastandlung;alsomelanoma,uterinecancer,andmesothelioma)

RHEUMATOLOGY/MUSCULOSKELETAL

SpinalDisorders

Namethelowerbackconditionassociatedwitheachofthefollowingfindings:Saddleanesthesiawithbowel/bladderdysfunctionCaudaequinasyndromePositive“shopping-cartsign”Spinalstenosis(patientsmorecomfortablewhenleaningforward)IncreasedpainatnightthatisunrelievedbypositionalchangesorrestMalignancyPositivestraightlegraiseHerniateddisk→nerverootimpingementIncreasedpainwithrest;painimproveswithactivityAnkylosingspondylitisParaspinousmusclepainBackstrain(muscle)orsprain(ligamentous)Pseudoclaudication,↑painwithwalkingSpinalstenosisPainradiatingfromlowerbackdowntothefootSciatica

Namefour“redflags”oflowbackpain:1.H/omalignancy2.Constitutionalsymptoms(fever,weightloss)3.Bladder/boweldysfunction4.Saddleanesthesia

Whatisthetreatmentforlowbackpainintheabsenceof“redflags”?

Conservative:NSAIDs/acetaminophen,1-3-daybedrest(85%resolvespontaneously)

Whatfourchronicinflammatoryconditionscausefusionofthesacroiliacjoints?Theseronegativespondyloarthropathies:

1.ankylosingspondylitis(AS)2.Reitersyndrome3.Psoriaticarthritis4.Enteropathicarthritis

Whathaplotypeistypicallyassociatedwith>90%ofseronegativespondyloarthropathies?HLA-B27

Joints

Whatisthedefinitivediagnosticprocedureforacutemonoarticulararthritis?Arthrocentesis

Interpreteachofthefollowingarthrocentesisleukocytecounts(cells/mm3):200WBCsNormaljointfluid2000WBCsNoninflammatory(eg,osteoarthritis[OA])2000-50,000WBCsMild-to-moderateinflammation(eg,rheumatologic)50,000-100,000WBCsSevereinflammation(eg,septicarthritisorgout)>100,000WBCsSepticjoint(untilprovenotherwise)

Whatdiseaseischaracterizedbymonoarticulararthritisduetouratecrystaldeposits?Gout

Whatarethetwomainetiologiesofhyperuricemia?1.Inadequateuricacidexcretion(mostofcases)2.Uricacidoverproduction(eg,malignancy,hemolysis,Lesch-Nyhansyndrome)

Whatisthemostcommonpresentingsymptom?Podagra(inflammationoffirstmetatarsophalangeal[MTP]joint)

Whydotophidevelop?Chronicgout→depositsofuratecrystals

Nametheclassicradiographicfindinginadvancedgout:Classic“rat-bite”appearancetojoint(punched-outerosionwithoverhangingcorticalbone)

Whatdoesthejointfluidaspirationofgoutreveal?Needle-shaped,negatively-birefringentcrystalsunderpolarizedlight

Whatisthetreatmentforacutegout?ColchicineandNSAIDs(eg,indomethacin)

Whatisthemaintenancetherapyforgout?Overproducers→allopurinol;underexcreters → probenecid/sulfinpyrazone (Note: continue colchicine because may precipitate acute

attack.)

Whatdiseaseischaracterizedbycalciumpyrophosphatecrystaldepositioninjoints?Pseudogout

Whatdoesthejointfluidaspirationofpseudogoutreveal?Positively-birefringentcrystalsunderpolarizedlight

Whatchronic,systemicinflammatoryarthritisisassociatedwithHLA-DR4serotype?Rheumatoidarthritis(RA)

Namethesevendiagnosticcriteriaforrheumatoidauthritis(RA):1.Morningstiffness(>1hour)2.Arthritisof threeormore jointsarea (14possibleareas include rightor leftproximal interphalangeal [PIP],metacarpophalangeal[MCP],wrist,elbow,knee,ankle,andMTPjoints)

3.Arthritisofone+handjoints(wrist,MCP,orPIP)4.Symmetricarthritis5.Rheumatoidnodules6.↑serumRF—70%ofcases7.Radiographicchanges:juxta-articulardecalcificationandlateerosions

Note:4of7requiredtoclassifyasRA

WhatisthetermfortheclassicjointdeformityassociatedwithRA?Boutonnieredeformity

NamefiveextraarticularmanifestationsofRA:1.Subcutaneousrheumatoidnodules2.Asymptomaticpericardialeffusions3.Anemiaofchronicdisease4.Nerveentrapment(eg,carpaltunnelsyndrome)5.Pulmonary(effusions,interstitialfibrosis,nodule)

WhatisthetreatmentforRA?Pain:firstline:NSAIDs,thensteroids;disease-modifying:firstline:

hydroxychloroquine,thenmethotrexate(MTX)andbiologicagents

NametwoofthenewerbiologicagentsusedtotreatRA:1.Infliximab(anti-TNF-aAb)2.Etanercept(anti-TNFreceptorAb)

WhatsyndromeischaracterizedbyRA,splenomegaly,andleukopenia?Feltysyndrome

Nametheseronegativespondylarthropathyassociatedwiththefollowingstatements:AssociatedwithsacroilitisAnkylosingspondylarthritisPrecipitatedbyGIorGUinfectionReactivearthritisAssociatedwithnailpittingandDIPjointinvolvementPsoriaticarthritisAssociatedwithinflammatoryboweldiseaseEnteropathicarthritis

WhatspecialtypeofreactivearthritismaybeseeninHLA-B27⊕males?Reitersyndrome

HowdoesReitersyndrometypicallypresent?

”Can’tSEE,can’tPEE,can’tCLIMBUPATREE”(conjunctivitis,urethritis,andarthritis)

NametwoclassicdermatologicfindingsofReitersyndrome:1.Keratodermablennorrhagicum2.Balanitiscircinata

WhatisthetreatmentforReitersyndrome?Erythromycin(forChlamydia)andNSAIDsforarthritis;maybenefitfromprolongedtetracycline(3months)

Osteoarthritis

Namethemostcommoncauseofarthritis:Osteoarthritis(OA)

Whatnoninflammatoryarthritisiscausedbywearandtearandisrelievedbyrest?OA

NamethreeriskfactorsforOA:1.Obesity2.⊕FH3.H/ojointtrauma

NamethreeclassicPEfindingsinOA:1.Heberden’snodes(DIP)2.Bouchardnodes(PIP)3.Markedcrepitusofaffectedjoint

WhatistheclassicradiographicappearanceofOA?Osteophytesandasymmetricjointspaceloss

WhatisthemanagementofOA?Isometricexercise to strengthenmusclesat joint;NSAIDs (includingcyclooxygenase [COX-2] inhibitors);

jointreplacementaslastresort

Bones

Namethemetabolicbonediseaseassociatedwitheachofthefollowingstatements:OsteopeniawithnormalbonemineralizationOsteoporosisResultsfromidiopathichyperactivityofbothosteoblastsandosteoclastsPagetbonedisease(osteitisdeformans)2°tovitaminDdeficiencyRickets(kids),osteomalacia(adults)VitaminCdeficiency→↓osteoidformationScurvyResultsfrompostmenopausalestrogendeficiency,physicalinactivity,orcalciumdeficiencyOsteoporosisFindingsincludeHarrisongroove,pigeonbreast,craniotabes,andrachiticrosaryRickets/osteomalaciaFindingsincludebleedinggumsand“woodyleg”ScurvyFindingsincludebonepain,deafness,andhigh-outputcardiacfailure

Pagetbonedisease(osteitisdeformans)Dualenergyx-rayabsorptiometry(DEXA)scanshowssignificantly↓bonedensityOsteoporosis↑ALP;scleroticlesionsonXRPagetbonedisease(osteitisdeformans)DeathordecayofboneduetolocalischemiaintheabsenceofinfectionAvascularnecrosis(AVN)

Namefiveriskfactorsforosteoporosis:1.Menopause2.Smoking3.Lowbodyweight4.Long-termheparinorglucocorticoiduse5.Alcoholism

Whatarethetreatmentoptionsforsenile(postmenopausal)osteoporosis?Mostimportantisprevention;treatmentoptions:estrogenreplacement(theonlytreatmentshownto↑bone

growth),Ca2+,vitaminD,exercise;secondbisphosphonatesandcalcitonin

WhatisthetreatmentforPagetbonedisease?Firstline:bisphosphonates;secondline:calcitonin

Whatbonediseaseischaracterizedbyidiopathicreplacementofbonewithfibroustissue?Fibrousdysplasia

Whatsyndromeischaracterizedbypolyostoticfibrousdysplasia,precociouspuberty,andcafé-au-laitspots?McCune-Albrightsyndrome

Whatpediatricdiseaseischaracterizedbythetriadofskulllesions,DI,andexophthalmos?Hand-Schüller-Christiandisease

Whatisthemostcommonprimarymalignanttumorofbone?Osteosarcoma

Wheredoesosteosarcomatypicallyoccur?Distalfemurandproximaltibia

Whatistheclassicradiographicappearance?”Sunburst”sign(lyticlesionwithspiculatedperiostitis)andCodmantriangle

FracturesandDislocations

(SeeChap.2)

MuscleDiseases

Namethetwomajorcategoriesofmusclediseases:1.Neurogenic(nopain,distalweakness,⊕fasciculations)2.Myopathic(oftenpainful,proximalweakness,nofasciculations)

Namethespecificskeletalmusclediseaseassociatedwiththefollowingclinicalandpathologicfindings:Anti-AChreceptorantibodies;associatedwiththymomasandautoimmunedisordersMyastheniagravis

MostcommonandmostlethalmusculardystrophyDuchenne’smusculardystrophyX-linkeddiseasecausedbyavarietyofmutations→↓functionaldystrophinBecker’smusculardystrophyParaneoplasticdisordercommonlyseeninpatientswithsmallcellcarcinomaofthelungLambert-EatonsyndromeDecreasingmusclestrengthwithrepetitivenervestimulationMyastheniagravisMusculardisorderassociatedwithgonadalatrophy,baldness,cataracts,cardiomyopathy,and↓IgGMyotonicdystrophyAntibodiestopresynapticCa2+channels;↑musclestrengthwithrepetitivenervestimulationLambert-EatonSyndromeProgressiveX-linkeddiseasecausingdeficiencyofdystrophinDuchennemusculardystrophyVariablemuscleweakness,mostpronouncedinoccularandfacialmusclesinitiallyMyastheniagravisPainful,autoinflammatorydisordercausingprogressive,symmetricmuscleweakness,dysphonia,and

↑serumCPKPolymyositisCalfpseudohypertrophyandGowersignDuchennemusculardystrophyGait instability (due to weakness of foot dorsiflexion) and involuntary muscle contraction on

examinationMyotonicdystrophy

Namethemuscletumorassociatedwitheachofthefollowingstatements:Mostcommontumorinfemales;estrogensensitive→maygrowduringpregnancyandregressduring

menopauseLeiomyomaAggressive,malignanttumorofskeletalmuscle;oneofthesmall,round,bluecelltumorsofchildhoodRhabdomyosarcoma

Rheumatology

Describetheeffect(s)ofSLEoneachofthefollowingorgans:SkinMalarrash,discoidrash,photosensitivityJointsArthritisandarthralgiaCentralnervoussystemNeuropsychiatricchangesorseizures(2°tocerebralvasculitis)HeartPericarditis,Libman-Sacksendocarditis(SLE→LSE)LungsPleuritis,pulmonaryfibrosisGIOralandnasopharyngealulcersKidneysWire-loopglomerularlesionsandmesangialimmunecomplexdeposits→glomerulonephritisHematologyHemolyticanemia,leukopenia,thrombocytopenia,Raynaud’sphenomena

WhatpathologicfindingiscommontoalltissuesaffectedbySLE?

Acutenecrotizingvasculitisofsmallarteriesandarteriolescausedbyimmunecomplexdeposition

Libman-Sacksendocarditiscausessterilevegetationstoformonbothsidesofwhichcardiacvalve?Mitralvalve

Namefivemedicationscapableofinducingalupus-likesyndrome:1.Hydralazine2.INH3.Phenytoin4.Procainamide5.Penicillamine

NamethediseaserelatedtoSLEthatischaracterizedbyimmunecomplexdepositionatthedermal-epidermaljunction:

Discoidlupuserythematosus

Describethediseaseassociatedwiththefollowingautoantibodies:ANA(antinuclearantibodies)SLE(sensitivebutnotspecificforSLE)Anti-ACh(acetylcholine)MyastheniagravisAntibasementmembraneGoodpasturediseaseAnticentromereCRESTsyndrome(Calcinosis,Raynaud’s,Esophagealdysmotility,Sclerodactyly,Telangiectasias)Anti-dsDNASLE(highlyspecificforSLE)AntiepithelialcellPemphigusvulgarisAntigliadinCeliacsprueAntihistoneDrug-inducedlupuserythematosusAnti-IgGFcRA(rheumatoidfactor[RF])Anti-Jo1MyositisAntimicrosomalHashimoto’sthyroiditisAntimitochondrialPrimarybiliarycirrhosisAnti-nRNP(nuclearribonucleoprotein)MixedconnectivetissuediseaseAntiplateletITPAnti-Scl-70(DNAtopoisomerase1)DiffusesclerodermaAnti-SmithSLE(highlyspecificforSLE)Anti-SS-A(Ro)andanti-SS-B(La)SjögrensyndromeAntithyroglobulinHashimoto’sthyroiditisAnti-TSHr(TSHreceptor)Gravesdisease

c-ANCAWegener’sgranulomatosisPerinuclearpatternofantineutrophilcytoplasmicantibodies(P-ANCA)Micropolyarteritisnodosa(PAN)andChurg-Strauss

Name the autoimmune disease of connective tissue associated with the following clinical and pathologicfindings:

Keratoconjunctivitis sicca or xerophthalmia, xerostomia, and evidence of other connective tissuedisease

SjögrensyndromeMyositisandheliotroperashDermatomyositisRapidlyprogressivediffusefibrosisofskinandinvolvedorgansincludingtheheart,GItract,kidney,

lung,muscle,andskinDiffusesclerodermaCRESTsyndromeLocalizedsclerodermaDiseaseofconnectivetissuethatlacksrenalinvolvementMixedconnectivetissuedisease

Whatisthemostcommoncauseofdeathduetoscleroderma?Renalcrisis(occursin50%deathsfromscleroderma;treatwithACEinhibitors)

Name the group of disorders characterized by extracellular deposition of protein in a β-pleated sheetconformation:

Amyloidosis(birefringencewithCongoRedstain)

Nametheeffectofamyloidosisoneachofthefollowingorgans:KidneysGlomerular,peritubular,andvascularhyalinizationLiverHepatomegaly(amyloiddepositioninspaceofDisse)HeartRestrictivecardiomyopathyTongueHypertrophyduetoamyloiddeposition

MaketheDiagnosis

25-y/omalepresentswithmorning stiffness, heel pain, andphotophobia;PE: ↓ lumbar spine extension andlateralflexion,tendernessoverlumbarspinousprocessesandiliaccrests;w/u:HLA-B27⊕;XR:bamboospine

Ankylosingspondylitis

50-y/o femalepresentswith long-standingh/omorning stiffness anddiffuse jointpain;PE:boutonierre andswanneckdeformitiesoffingers,shouldertendernessand↓rangeofmotion(ROM),symmetricandbilateralkneeswelling;w/u:RF⊕

Rheumatoidarthritis(RA)

25-y/omalewithah/ourethritis2weeksagopresentswithunilateralkneepain,stiffness,andeyepain;PE:conjunctivitis, edema and tenderness of left knee, mucoid urethral discharge; w/u: urethral swab is⊕ forChlamydia.

Reitersyndrome

45-y/o femalepresentswithdryeyesanddrymouth,PE:parotidglandenlargement;w/u:⊕ANA,RF,SS-

A/RotitersSjögrensyndrome

70-y/ofemalepresentswithpaininhandsthatisworseafteractivity;PE:Heberden’snodesandBouchard’snodes, bony enlargement at DIP joints, right knee effusion; w/u: RF and ESR areWNL; XR: joint spacenarrowing,osteophytes

Osteoarthritis(OA)

72-y/o female presents with a 6-week h/o morning stiffness in neck and shoulders; PE: low-grade fever,tendernesstopalpationplus↓ROMinneck,shoulder,andhipjoints;w/u:↑ESR,CRP,RFnegative

Polymyalgiarheumatica

50-y/omalepresentswithacuteonsetofsharppainintheleftgreattoe;PE:severetenderness,swelling,andwarmthoftheleftMTPjoint;synovialfluidanalysisshowsnegatively-birefringentcrystals.

Gout

25-y/oblack femalewitha1-weekh/opain in several jointspresentswithswelling,redness,andpain inherrightknee;PE:pustular lesionsonpalms, rightknee shows erythema, tenderness, and↓ROM;w/u: gram-negativediplococciinsynovialfluid

Gonococcalarthritis

28-y/ofemalepresentswithdifficultykeepinghereyelidsopenandholdingherheadupduringtheday;PE:weaknessoffacialmuscles,deltoids;⊕anti-AChtiter;CXR:anteriormediastinalmass

Myastheniagravis(associatedwiththymoma)

25-y/o female with h/o Raynaud’s phenomenon presents with arthralgias and myositis; w/u: esophagealhypomotilityand↑anti-nRNPtiters

Mixedconnectivetissuedisease

20-y/oblackfemalepresentswithfatigue,arthralgias,Raynaud’sphenomenon,andpleuriticchestpain;PE:butterflymalarfacialrash;w/u:↓platelets,proteinuria,and⊕ANA,anti-dsDNA,andanti-SmithAbs

SLE

20-y/o with a h/o developmental delay presents with facial weakness; PE: cataracts, marked weakness inmuscles of hand, neck, and distal leg, with sustainedmuscle contraction; genetic testing: cytosine-thymine-guanine(CTG)repeatexpansionwithinDMPKgene

Myotonicdystrophy

DERMATOLOGY

BasicVocabulary

Givethedermatologictermforeachofthefollowingdescriptions:Flat,nonpalpablelesion1cmindiameter;differentcolorsthatsurroundskinMaculeAmacule>1cmindiameterPatchPalpable,elevatedskinlesion1cmindiameterPapuleApapule>1cmindiameterPlaque

Minute,pinpoint,nonblanchinghemorrhagicspotsintheskinPetechiaeSimilartopetechiae,butlargerPurpuraFluid-containingblister0.5cmindiameterVesicleFluid-containingblister>0.5cmindiameterBullaBlistercontainingpusPustuleSolid,roundlesion;diameter=thicknessNoduleLeatheryindurationofskincausedbyscratchingLichenificationThickeningofthestratumcorneumHyperkeratosis

Infections

Foreachofthefollowingdescriptions,namethelesionandthetreatmentofchoice:InflammationofpilosebaceousunitbyPropionibacterium, causingcomedonesandpustules;↑during

pubertyandadolescenceAcnevulgarisTx:topicalantibiotics,Retin-A,benzoylperoxide,isotretinoinifscarringHoney-colored,crustyvesiclescommonlyoccurringaroundthemouthandnoseinchildren;causedby

StaphylococcusaureusorStreptococcuspyogenesImpetigoTx:washwithwarmcloth;Keflexoroxacillinfor7-10daysSubcutaneous,soft-tissueinfectionwithclassicsignsofinflammation;causedbyStaphylococcusaureus

orStreptococcuspyogenesCellulitisTx:Keflexordicloxacillinfor7-10daysErythematousrashalongmajorskinfolds;morecommonindiabetics;causedbyCorynebacteriumErythrasmaTx:erythromycinUmbilicated,pearly,dome-shapedpapulestypicallyoccurringinthegenitals;viraletiologyMolluscumcontagiosumTx:cryotherapyortrichloroaceticacid(manyresolvespontaneouslywithouttreatment)Tenderrednodulesontheanteriortibialareabilaterally2°topanniculitis;duetoinfections,drugs,or

inflammatoryboweldiseaseErythemanodosumTx:NSAIDs;treatunderlyingcause”Sunburnwithgoosebumps”appearance,Pastialine,strawberrytongue;causedbyS.pyogenesScarletfeverTx:penicillinSmallpinkpapulesingroupsof10-20onthetrunk;foundin30%ofpatientswithSalmonellatyphiRosespotsTx:cholecystectomyforchroniccarrierstateSuppurativeinflammationofthenailfoldsurroundingthenailplate;maybeduetostaphylococcaland

streptococcalinfectionParonychiaTx:warmcompress;KeflexifsevereInfection along a fascial plane causing severe pain and inflammation; caused by S. pyogenes or C.

perfringensNecrotizingfasciitisTx:extensivesurgicaldebridementplusclindamycinandpenicillinObstructedapocrinesweatglandsthatbecomeinfectedHidradenitissuppurativaTx:surgicaldebridementandantibioticsRecurrent,vesiculareruptionsthatoccuringroupsandarepainful;commonlyfoundatoral-labialor

genitallocations;diagnosewithTzancksmearHerpessimplexTx:oralacyclovir(IVifimmunocompromised)Benignpapillomaofviraletiology,mostcommonlyondorsumofhand;characteristickoilocytesVerrucavulgaris(commonwart)Tx:cryotherapyorsalicylicacidContagious, pruritic, “dewdrop” vesicles that occur in kids and can be reactivated into a painful,

dermatomaldistributioninadultsVaricella(chickenpoxandshingles)Tx:acyclovirforshingles;self-limitedinhealthykids;varicellavaccineavailableforimmunocompromisedPruriticpapulesinpubicarea,buttocks,andaxillacausedbyliceCrabs(Pediculosispubis)Tx:permethrin5%shampooContagious,erythematous,pruriticpapules,andburrowsinintertriginousareascausedbymitesScabies(Sarcoptesscabiei)Tx:permethrin5%creamforpatientandclosecontacts;washbeddingwithhotwaterRing-shaped,pruritic,erythematousplaquewithelevatedborders;causedbyfungusTinea(corporisifonbody;capitisifonhead)Tx:topicalantifungal;oralfortineacapitisorresistantlesionsErythematousscalingpatcheswithsatellitepustules,foundinintertriginousareasofadultsanddiaper

areasininfantsCandidaTx:reducemoisture;topicalnystatinSharplydemarcated,hypopigmentedmaculeswithcharacteristic“spaghettiandmeatball”appearance

onKOHprepTineaversicolorTx:seleniumsulfideshampooortopicalantifungal

PigmentaryLesions

Namethedermatologicdiseaseorfindingassociatedwitheachofthefollowingdescriptions:AR defect in melanin synthesis (though melanocytes are present); predisposition to multiple skin

disordersAlbinism(oculocutaneous)Acquiredlossofmelanocytes→depigmentedwhitepatchesVitiligoMask-likefacialhyperpigmentationassociatedwithpregnancyMelasma(chloasma)Pigmentedmaculescausedbymelanocytehyperplasia;donotdarkenwithsunlight(unlikefreckles)LentigoBenign,localizedovergrowthofmelanin-formingcellsoftheskinpresentatbirthNevocellularnevusAtypical,irregularlypigmentedlesionmayevolveintomalignantmelanomaDysplasticnevusCommonbenignneoplasmofolderadults;sharplydemarcatedplaqueswithapastedonappearanceSeborrheickeratosis(senilekeratosis)

Yellowishpapulesornodulesthattendtooccurontheeyelids;associatedwithhypercholesterolemiaXanthoma(ontheeyelids:xanthelasma)HyperpigmentationintheflexuralareasthatmaysuggestvisceralmalignancyAcanthosisnigricansAbnormal proliferation of connective tissue that may follow skin trauma; results in large, raised

tumor-likescarKeloidCapillaryhemangiomaappearingasapurple-redareaonthefaceorneckPort-winestainAutoimmunedisorderpresentingwithheliotropicpatchesoneyelidsDermatomyositisErythematousrashthatcanappearinChristmastreedistributionandisprecededbyaheraldpatchPityriasisroseaHyperpigmentation,cirrhosis,diabetesmellitus,OAofMCPjointsHemochromatosis

Nametheneurocutaneoussyndromecharacterizedbyeachofthefollowingfeatures:Port-winestainsoftheface,ipsilateralglaucoma,retinallesions,andhemangiomasofthemeningesSturge-WebersyndromeHypopigmentedmacules(ash-leafspots),adenomasebaceum,seizures,andmentalretardationTuberoussclerosisMultipleorganhemangioblastomas,cysts,andparagangliomasvonHippel-LindaudiseaseCafé-au-laitspots,acousticneuromas,andmeningiomasNeurofibromatosis

MiscellaneousDermatologicDiseases

Nametheblisteringdermaldiseaseassociatedwitheachofthefollowingdescriptions:Tense,hardsubepidermalbullaethattendtooccurintheelderly;antiepidermalBMAbsBullouspemphigoidPruritic subepidermal blisters occurring in groups; eosinophils and IgA deposits at tips of dermal

papillae;seeninceliacdiseaseDermatitisherpetiformisLarge intraepidermal blisters that often rupture and slough off (Nikolsky’s sign); can be fatal;

antibodiestodesmogleinPemphigusvulgarisHypersensitivityreactioncausingcharacteristicdiffuse,multishaped“target”lesionsErythemamultiformeSevere-febrileformoferythemamultiformecharacterizedbysystemictoxicity,hemorrhagiccrusting,

andoralmucosalinvolvementStevens-JohnsonsyndromeADdefectinhemesynthesis;blistersonsun-exposedareasofskin;urinefluorescesorange-pinkcolor

withWood’slampexaminationPorphyriacutaneatarda

Whatinflammatorydisorderischaracterizedbysilveryscalingplaquesovertheknees,elbows,andscalp?Psoriasis

Namethreeclassicclinicalfindingsinpsoriasis:1.Fingernailpitting2.Auspitzsign(removalofscalecausespinpointbleeding)3.Koebnerphenomenon(lesionsappearatsitesofcutaneoustrauma)

Whatisthetreatmentofchoiceforpsoriasis?Firstline:topicalsteroids;secondline:PUVA(PsoralensplusUVAlightrays)

Foreachofthefollowingdescriptions,namethelesionandthetreatmentofchoice:Pruritic, inflammatory disorders due to an inherited state of hypersensitivity to environmental

allergensAtopicdermatitisTx:steroids/antihistaminesforsymptomaticreliefLinear,pruriticrashcausedbytypeIVhypersensitivityreactiontopreviouslysensitizedsubstanceContactdermatitisTx:topicalsteroids;antihistaminesandsystemicsteroidsforseverecasesGreasy,erythematousscalingpatchesofthescalp,face,andears;“cradlecap”ininfantsSeborrheicdermatitisTx:seleniumsulfideorzincpyrithioneshampooforscalp,face,andtrunk;steroidsifsevereIntensely pruritic, transient, erythematous, papular wheals caused by mast cell degranulation and

histaminereleaseUrticaria(hives)Tx:steroids/antihistaminesforsymptomaticrelief

SkinCancer

Nametheskinmalignancyassociatedwitheachofthefollowingstatements:MostcommonskinmalignancyBasalcellcarcinomaAssociatedwithexcessivesunlightexposure;arisesfromdysplasticnevuscellsMalignantmelanomaAssociatedwitharsenicandradiationexposureSquamouscellcarcinomaActinickeratosisasaprecursor.SquamouscellcarcinomaPearlypapulewithtranslucentborderandfinetelangiectasiasBasalcellcarcinomaSmall,exophyticnodulewithcrustingorscalingSquamouscellcarcinomaS-100usedasatumormarkerMalignantmelanomaHistopathologycharacterizedby“keratinpearls”SquamouscellcarcinomaCharacterizedbyradialandverticalgrowthphasesMalignantmelanomaCharacterizedbylocallyaggressive,ulcerating,andhemorrhagiclesions;almostnevermetastaticBasalcellcarcinomaOccursinsun-exposedareasandtendstoinvolvethelowerpartofthefaceSquamouscellcarcinomaOccursinsun-exposedareasandtendstoinvolvetheupperpartofthefaceBasalcellcarcinoma

Whatismanagementforactinickeratosis:Biopsy;treatmentwithtopical5-fluorouracil(5-FU)orcryotherapy;preventionwithsunscreens

NametheABCDEcharacteristicsofmelanomas:Asymmetry(benignissymmetric)Border(benignissmooth)Color(benignissinglecolor)

Diameter(benignis6mm)Elevation(benignisflat)andEnlargement(benignisnotgrowing)

Whatisthemostimportantprognosticfactorinmalignantmelanoma?Depthofinvasion

Whatclinicalvariantofmalignantmelanomahasthepoorestprognosis?Nodularmelanoma

Whatclinicalvariantofmalignantmelanomaoftenappearsonthehandsandfeetofdark-skinnedpeople?Acral-lentiginousmelanoma

Whatchronicprogressivelymphomaarisesintheskinandinitiallysimulateseczema?Mycosisfungoides

Whatsyndromeischaracterizedbymycosisfungoides,erythroderma,andscaling?Sézarysyndrome

What connective tissue cancer presents with reddish-purple macules, plaques, or nodules on the skin andmucosaandiscausedbyHHV-8?

Kaposi’ssarcoma

Nametheclassicdermatologicfinding(s)associatedwitheachofthefollowingdiseases:GastricadenocarcinomaAcanthosisnigricansAddisondiseaseHyperpigmentationandstriaeRheumaticfeverErythemamarginatumKawasakisyndromeErythematouspalmsandsoles;dry,redlips;desquamationoffingertipsSeverechronicrenalfailureUremicfrostBacterialendocarditisOsler’snodes (tender, raised lesionsonpadsof fingersor toes) and Janeway lesions (small, erythematous

lesionsonpalmsorsoles)XerodermapigmentosumDryskinandmelanomaHypothyroidismCool,dryskinwithcoarsebrittlehairGravesdiseaseWarm,moistskinwithfinehair;pretibialmyxedemavonRecklinghausendisease(NFT1)Multiplecafé-au-laitspotsFamilialhypercholesterolemiaXanthomasSLEMalarrashandphotosensitivityPellagraDermatitis

Nametheclassicdermatologicfinding(s)associatedwitheachofthefollowinginfectiousdiseases:AnthraxVesicularpapulescoveredbyblackescharParvovirusB19

Erythemainfectiosum(slapped-cheekappearance)LymediseaseErythemachronicummigransPrimarysyphilisPainlesschancreSecondarysyphilisRashoverpalmsandsoles,condylomalatumRockyMountainspottedfever(RMSF)Rashoverpalmsandsoles(migratescentrally)CongenitalCMVPinpointpetechial“blueberrymuffin”rashHPV(ingenitalregion)CondylomataacuminataLeprosyHypopigmented,anestheticskinpatches

MaketheDiagnosis

30-y/omalewithh/orecurrentsinusitispresentsforsterilityevaluation;PE:heartsoundsarebestheardoverrightsideofchest.

Kartagenersyndrome

9-y/owithh/oeasybruisingandhyperextensiblejointspresentstotheERafterdislocatinghisshoulderforthefifthtimethisyear.

Ehlers-Danlossyndrome

5-y/opresentstotheERwithhissixthbonefractureinthepast2years;PE:bluishscleraandmildkyphosis;XR:fractureswithevidenceofosteopenia

Osteogenesisimperfecta(OI)

8-y/owithh/oseveresunburnsandphotophobiapresentstothedermatologistforevaluationofseverallesionsonthefacethathaverecentlychangedcolorandsize.

Xerodermapigmentosum

6-y/oboypresentstotheophthalmologyclinicwithsudden↓visualacuity;PE:unusualbodyhabitus,longandslenderfingers,pectusexcavatum,andsuperiorlydislocatedlens

Marfansyndrome

36-y/owithh/oceliacdiseasepresentswithclustersoferythematousvesicularlesionsovertheextensorsurfacesoftheextremities

Dermatitisherpetiformis

5-y/opatientpresentswithhoney-coloredcrustedlesionsattheangleofhismouth;Gramstainofpus:gram-positivecocciinchains

Impetigo

29-y/o HIV⊕ patient presents with multiple painless pearly-white umbilicated nodules on the trunk andanogenitalarea.

Molluscumcontagiosum

68-y/ofair-skinnedfarmerpresentswithlarge,telangiectatic,andulceratednoduleonthebridgeofthenose.Basalcellcarcinoma

11-y/o presentswith bilateralwrist pain and a rash; PE: erythematous, reticular skin rash of the face and

trunkwitha“slapped-cheekappearance”Erythemainfectiosum

43-y/ofemalepresentswithdifficultyswallowing;PE:bluishdiscolorationof thehandsandshiny, tightskinoverherfaceandfingers

Progressivesystemicsclerosis(scleroderma)

5-y/o-Asian boy presents with fever and diffuse rash including the palms and soles; PE: cervicallymphadenopathy,conjunctivalinjection,anddesquamationofhisfingertips;echocardiogramrevealsdilationofcoronaryarteries.

Kawasakisyndrome(mucocutaneouslymphnodesyndrome)

33-y/opatientpresentswith itchy,purpleplaquesoverherwrists, forearms,and inner thigh;PE:Wickhamstriae

Lichenplanus

10-y/opresentswith feversandpruritic rash spreading from the trunk to thearms;PE:“teardrop”-shapedvesiclesofvaryingstages

Varicella

29-y/oathletepresentswithared,pruriticskineruptionwithanadvancingperipheral,creepingborderontheforearm;w/u:septatehyphaeonKOHscraping

Tineacorporis(ringworm)

73-y/o presents with a painful, unilateral, vesicular rash in the distribution of the CN V1; PE: diminishedcornealsensation

Herpeszosterophthalmicus

31-y/o obese female presents with pruritis in her skin folds; PE: white curd-like concretions beneath theabdominalpanniculus;w/ushowsbuddingyeaston10%KOHprep

Cutaneouscandidiasis

PREVENTATIVEMEDICINE,ETHICS,ANDBIOSTATISTICS

PreventativeMedicine

Describetheappropriatescreeninginterventionforeachofthefollowingcancers:BreastcancerSelfbreastexaminationeverymonth,>20y/oClinicianbreastexaminationevery3yearsfrom20to40y/oandeveryyear>40y/oMammographyeveryyearfrom50to69y/oColoncancerHemocculteveryyear>50y/oFlexiblesigmoidoscopyevery3-5years>50y/o,orcolonoscopyevery10yearsNote:if⊕FH,startscreening10yearsbeforeageoffamilymemberwithCAatdiagnosis.ProstatecancerDREandPSAeveryyear>50y/oEndometrialcancerHigh-riskpatientsshouldbeofferedbiopsystartingat35y/oCervicalcancerFirstPapsmearby3yearsaftersexualactivityor21y/o;theneveryyearthereafter

At30y/o,afterthreeconsecutivenormalPaps→every2-3yearspelvicexaminationevery1-3yearsfrom20to40y/oandeveryyear>40y/o

Nametheadultimmunizationrecommendationsforeachofthefollowingdiseases:VaricellaAdultswithouth/ochickenpoxorhigh-riskpatients(eg,immunocompromised)HepatitisBAllyoungadultsandhigh-riskpatients(includinghealth-careworkers)PneumococcalAdministeroncetopatients>65y/oorthoseathighriskInfluenzaAnnuallyforpatients>50y/oorthoseathighriskMeningococcalHigh-riskpatients(eg,collegestudents,militarypersonnel)Measles,mumps,rubella(MMR)Everyonebornafter1956whohasnotyetreceivedvaccinationTetanusPrimaryvaccinationnecessaryforeveryone;boosterindicatedevery10yearsHepatitisATravelers,homosexualmales,andh/ochronicliverdiseaseorclottingdisorderNote:vaccinationtakes3-4weeks;giveIVIGforshort-termprophylaxisorh/oexposure.

WhatvaccinesshouldbeavoidedinHIV⊕andpregnantpatients?Livevaccinations(MMR,oralpoliovaccine[OPV],VZV)Note:MMRshouldbegivenifCD4>500.

Whatistheregimenofchoiceforsmokingcessation?Bupropionplusnicotinereplacement(12monthsabstinencerate>30%;2×morethannicotinereplacement

alone)

Aging,Death,andDying

Namethechangesfoundintheelderlyineachofthefollowingcategories:PsychiatricDepressionandanxietymorecommon;suiciderateincreases.SexualMen:slowererection/ejaculation,↑refractoryperiodWomen:vaginalshortening,thinning,anddrynessNote:sexualinterestdoesnotdecrease.Sleeppatterns↓REM,slow-wavesleep;↑sleeplatency,awakeningsCognitive↓learningspeed;intelligencestaysthesame

Namethreeconditionsthatwouldqualifynormalbereavementaspathologicgrief:1.Prolongedgrief(>1year)2.Excessivelyintensegrief(sleepdisturbances,significantweightloss,suicidalideations)3.Griefthatisdelayed,inhibited,ordenied

NametheKubler-Rossstagesofdying:1.Denial2.Anger3.Bargaining4.Depression

5.AcceptanceNote:oneormorestagescanoccuratonceandnotnecessarilyinthisorder.

What termdescribes a centralizedprogramofpalliative and supportive services todyingpersons and theirfamilies,intheformofphysical,psychologic,social,andspiritualcare?

Hospice

Whatisthecriteriontoqualifyforthistypeofcare?Medicallyanticipateddeathwithin6months

MedicalEthics

Namethetermusedtodescribeeachofthefollowingethicalresponsibilities:Requiresphysiciansto“donoharm”NonmaleficenceRequiresphysicianstoactinthebestinterestsofthepatientBeneficence(mayconflictwithpatientautonomy)DemandsrespectforpatientprivacyandautonomyConfidentiality

Nametwosituationsinwhichaphysicianmustcompromisepatientconfidentiality:1.Potentialharmtoself(suicide)ortoathirdparty(Tarasoffdecision)2.Legallydefinedsituations(eg,reportablediseases,gunshotwounds,impaireddrivers)

Whatelementsarerequiredinordertoproveamalpracticeclaim?The“fourDs”:mustprovethatthephysicianshoweddereliction(deviationfromstandardofcare)ofaduty

thatcauseddamagesdirectlytothepatient

Whatarethefourkeycomponentstoinformedconsent?Thepatientmust:1.Understandthehealthimplicationsoftheirdiagnosis2.Beinformedofrisks,benefits,andalternativestotreatment3.Beawareofoutcomeiftheydonotconsent4.Havetherighttowithdrawconsentatanytime

Namefourexceptionstoinformedconsent:1.Patientnotlegallycompetenttomakedecisions.2.Inanemergency(impliedconsent).3.Patientwaivestherighttoinformedconsent.4. Therapeutic privilege-withholding information that would severely harm the patient or undermine

decision-makingcapacityifrevealed.

Whatarefivesituationsinwhichparent/legalguardianconsentisnotrequiredtotreataminor?1.Emergencies2.STDs3.Prescriptionofcontraceptives4.TreatmentofEtOH/drugtreatment5.Careduringpregnancy

Whatfourcriteriaqualifyaminorasemancipated?1.Ifminorisself-supporting2.Ifminorisinthemilitary3.Ifminorismarried4.Ifminorisaparentsupportingchildren

Whattypeofdirectiveisbasedontheincapacitatedpatient’spriorstatementsanddecisions?Oraladvancedirective(substitutedjudgmentstandard)

Whatwritten advancedirective gives instructions for the patient’s future health care shouldhe/she becomeincompetenttomakedecisions?

Livingwill;specificexamplesincludeDNR(donotresuscitate)orDNI(donotintubate)

Whatdocumentallowsthepatienttodesignateasurrogatetomakemedicaldecisionsincasethepatientlosesdecision-makingcapacity?

Durablepowerofattorney(moreflexiblethanalivingwill)

Whenarephysicianspermittedtorefuseafamily’srequestforfurtherinterventiononbehalfofanillpatient?Ongroundsoffutility(eg,maximalinterventionisfailing,norationalefortreatment,andtreatmentwillnot

achievethegoalsofcare)

BiostatisticsandClinicalTrials

Foreachdescription,namethepropertermandtheequationusedtocalculatethevalue:ProbabilitythatapersonwithoutthediseasewillbecorrectlyidentifiedSpecificity=TN/(TN+FP)ProbabilitythatapersonwhotestspositiveactuallyhasthediseasePositivepredictivevalue=TP/(TP+FP)ProbabilitythatapersonwhohasadiseasewillbecorrectlyidentifiedSensitivity=TP/(TP+FN)TotalnumberofcasesinapopulationatanygiventimePrevalence=(TP+FN)/(entirepopulation)NumberofnewcasesthatariseinapopulationoveragiventimeintervalIncidence=Prevalence×durationofdisease(approximately)Usedincase-controlstudiestoapproximatetherelativeriskifthediseaseprevalenceistoohighOddsratio=TP×TN/FP×FNUsedincohortstudiestocompareincidencerateinexposedgrouptothatinunexposedgroupRelativerisk=[TP/(TP+FP)]/[FN/(FN+TN)]ProbabilitythatpatientwithanegativetestactuallyhasnodiseaseNegativepredictivevalue=TN/(FN+TN)

Howareincidenceandprevalencerelated?Incidence×diseaseduration→prevalencePrevalence>incidenceforchronicdiseases;prevalence=incidenceforacutediseases

Whatqualityisdesirableforascreeningtool?Highsensitivity(SNOUT:SeNsitivityrulesOUT)

Whatqualityisdesirableforaconfirmatorytest?Highspecificity(SPIN:SPecificityrulesIN)

Whatisthetermforasituationwhereoneoutcomeismorelikelytooccurthananother?Bias

Namefourwaystoreducebias:1.Placebo2.Blindedstudies(single,double)3.Crossoverstudies(eachsubjectisowncontrol)4.Randomization

Namethetypeofstudyassociatedwiththefollowingdescriptions:Observationalstudywherethesampleischosenbasedonpresence/absenceofriskfactorsCohortstudy(eg,→providesrelativerisk)Surveyofapopulationatasinglepointintime;allowsforestimateofdiseaseprevalenceCross-sectionalsurveyExperimentalstudycomparingbenefitsoftwoormorealternativetreatmentsClinicaltrialObservationalstudywherethesampleischosenbasedondiseasepresence/absenceCase-controlstudy(usuallyretrospective)→providesoddsratioAssemblingdatafrommultiplestudiestoachievegreatstatisticalpowerMeta-analysis

Namethetermforeachofthefollowingdescriptions:ReferstothereproducibilityofatestReliabilityReferstotheappropriatenessofatest(whetherthetestmeasureswhatitissupposedto)ValidityAbsenceofrandomvariationinatest;consistencyandreproducibilityofatestPrecisionClosenessofameasurementtothetruthAccuracyHypothesispostulatingthatthereisnodifferencebetweengroupsNullhypothesis(H0)ErrorofmistakenlyrejectingH0(statingthatthereisadifferencewhentherereallyisnot)TypeIerror(α)ErroroffailingtorejectH0(statingthereisnodifferencewhentherereallyis)TypeIIerror(β)ProbabilityofrejectingH0whenitisinfactfalsePower(1-β)ProbabilityofmakinganαerrorPvalueTestthatcomparesthedifferencebetweentwomeansttestTestthatanalyzesthevarianceofthreeormorevariablesAnalysisofvariance(ANOVA)Testthatcomparespercentagesorproportionsχ2Absolutevaluethatindicatesthestrengthofarelationshipr(alwaysbetween-1and1)

Namethetypeofbiasdescribedineachofthefollowingexamples:ResponsestosubjectivequestionsareinfluencedbyknowingwhatlegofthestudyapatientisenrolledObservationalbiasConfoundingvariablesintroducedbyerrorsofmemorymadebyparticipantsaskedtorememberpast

eventsRecallbiasOccurswhensubjectsareassignedtoastudygroupinanonrandomfashionEnrollmentbiasBias that is dependent on the rate of disease progression; may lead to overestimation of screening

effectivenessindiseaseLengthbiasOccurswhenapatientchoosestoenrollinaparticularstudySelf-selectionbiasOccurs when screening tends to prolong the time between diagnosis and death without actually

affectingtruesurvivalLead-timebias

Epidemiology

Whatistheleadingcauseofmortalityineachofthefollowingagegroups:1yearCongenitalanomalies1-14yearsTraumainjuries15-24yearsTrauma(mostlycaraccidents)25-64yearsCancer(#1lung,#2breast/prostate,#3colon)≥65yearsCardiovasculardisease

CHAPTER2Surgery

TRAUMA

Shock

Defineshock:Inadequatetissueperfusion

Whatarethefourmaintypesofshock?1.Cardiogenic2.Septic3.Hypovolemic4.Neurogenic

Namethetypeofshockdescribedbelowandgivetheappropriatemanagement:Hypotension,↑pulmonarycapillarywedgepressure(PCWP),↓cardiacoutput(CO)Cardiogenic(usuallyleftventricularfailure)Treatment/therapy(Tx):inotropicagents,afterloadreductionTachycardia,↓systolicBP,↓pulsepressureHypovolemic(usuallysecondary[2°]tohemorrhageorburns)Tx:IVfluidreplacementwithisotonicRingerlactate(LR)ornormalsaline(NS);controllinghemorrhageif

applicableTachycardia,hypotension,↑CO,warmskinwithfullpulses,feverSeptic(usually2°togram-negativeorganisms)Tx:AggressiveIVfluids,antibiotics,vasopressorsasneededHypotensionandbradycardiaNeurogenic(lossofsympathetictone)Tx:IVfluids,vasopressorsandidentificationofneurologicdeficits

Whatarethefirstfivestepsintheassessmentofatraumapatient?1.Airway:secureairwaywhilemaintainingcervicalspinestability.2.Breathing:inspectforairmovement;assessoxygenationandventilation.3.Circulation:assesspulses,HR,BP;secureIVaccess.4.Disability:diagnoseneurologicdeficitsandestimateGlasgowComaScale(GCS).5.Exposure/environment:completevisualinspectionandpalpationofpatientwhilemaintainingnormalbody

temperature.

Namethediagnosisassociatedwitheachofthefollowingfindings:Hemotympanum,clearotorrhea/rhinorrhea,raccooneyes,andBattlesignBasilarskullfracture(Fx)Ecchymosisoflowerabdomenfromseatbelt(seatbeltsign)Smallbowelperforation(in20%ofcases)Hypotension,jugularvenousdistension(JVD),decreasedheartsoundsBecktriad(seenincardiactamponadeandtensionpneumothorax)BecktriadandpulsusparadoxusCardiactamponade

Unilateralabsenceofbreathsounds,JVD,mediastinalshiftTensionpneumothoraxParadoxicalchestwallmovementFlailchest(multipleribFxwithpulmonaryinjury)

GENERALSURGERY

Esophagus

Whatisthecommonpresentationoforopharyngealdysphagia?Difficultyswallowingliquids>solids

Whatisthecommonpresentationofesophagealdysphagia?Difficultyswallowingbothliquidsandsolids

Whatisthecommonpresentationofdysphagiasecondarytomechanicalobstruction?Difficultyswallowingsolids>liquids

Whatisthedifferentialdiagnosisoforopharyngealdysphagia?Zenkerdiverticulum,neurologicdisorders(cranialnerves,muscles),sphincterdysfunction,andneoplasm

Whattermisusedtodescribeafalsediverticulumabovethecricopharyngeusmuscle?Zenkerdiverticulum

Whattwotestsareessentialintheevaluationoforopharyngealdysphagia?Bariumswallowfollowedbyendoscopyifnodiverticulumisseen

Whatistheriskofendoscopywithoropharyngealdysphagia?RiskofesophagealperforationishighwithZenkerdiverticulum.Note:Zenkerdiverticulummustberuledoutwithabariumswallow.

WhatisthetreatmentofaZenkerdiverticulum?Myotomy±excisionofdiverticulum

Whatisthedifferentialdiagnosisforesophagealdysphagia?1.Achalasia2.Esophagealstricture3.Loweresophagealweb4.Scleroderma5.Esophagealcancer

Nametheesophagealdiseaseassociatedwiththefollowingcharacteristics:Inability of the lower esophageal sphincter (LES) to relaxwith loss of esophageal peristalsis; “bird

beak”appearanceonbariumswallowand↑restingpressureofLESonmanometryAchalasia(ganglioniclossofAuerbachplexus)Mayresultfromingestionofcausticagents(eg,lye,ovencleaners,batteries,ordraincleaners)EsophagealstrictureSyndromecharacterizedbyiron-deficiencyanemia,dysphagia,esophagealweb,andatrophicglossitisPlummer-VinsonsyndromeColumnarmetaplasiaofsquamousepitheliumofthedistalesophagusinresponsetoprolongedinjury

(often2°tolong-standinggastroesophagealrefluxdisease[GERD])

Barrettesophagus

Whattypeofmalignancyoccursinpatientswithlong-standingBarrettesophagus?Esophagealcancer(usuallyadenocarcinoma);10x↑risk→ruleoutwithendoscopy

Namesiximportantriskfactorsforesophagealcarcinoma:ABCDEF1.Achalasia2.Barrettesophagus3.Corrosiveesophagitis4.Diverticuli5.Esophagealwebs,ethanol(EtOH)6.Familial

Whatarethetwomainhistologictypesofesophagealcancer?Squamouscellcarcinomaandadenocarcinomanearthegastroesophageal(GE)junction

Whattypeofesophagealcancerisassociatedwithalcoholandtobaccouse?Squamouscellcarcinoma

Barrettesophagusisariskfactorforwhattypeofesophagealcancer?Adenocarcinoma

Whatdiagnostictestisnecessaryintheworkup(w/u)forallpatientswithsuspectedesophagealcancer?Esophagogastroduodenoscopy(EGD)withtissuebiopsy

Whatdiagnosismustberuledout inapatientwithsuddenonsetsevereretrosternalchestpainthat isworsewithswallowinganddeepinhalationfollowingEGD?

Esophagealperforation

Whatsyndromeischaracterizedbyesophagealperforationfollowingseverevomiting?Boerhaavesyndrome

WhatisthedifferencebetweenBoerhaaveandMallory-Weisstears?Mallory-Weiss:superficialtearsintheesophagealmucosa;Boerhaave:full-thicknessesophagealrupture

What term isused todescribe thecrunching soundheardwitheachheartbeat inapatientwithmediastinalemphysema?

Hamman’ssign

Whattestsareusedtomakeadefinitivediagnosisofesophagealperforation?Chest x-ray (CXR) (showing mediastinal/subcutaneous air, pneumothorax, left pleural effusion) and

esophagogram

Whatisthetreatmentofesophagealperforation?Thoracotomy,primaryrepair,anddrainagewithin24h(>50%mortalityiftreatmentdelayed)

Whatdisease ischaracterizedbysubsternalchestpain,heartburn,andregurgitation,commonlyworseaftermealsandinthesupineposition?

GERD

WhatpulmonaryconditionhasassociatedsymptomsthatmayalsobeseeninpatientswithGERD?Asthma(wheezing/cough/dyspnea)

NamethesixmajorriskfactorsforGERD:1.Obesity2.Pregnancy

3.Alcohol4.Caffeine5.Smoking(nicotine)6.Fattyfooddiet

NamethreediseasescloselyassociatedwithGERD:1.Slidinghiatalhernia2.Scleroderma3.Achalasia

NamethreediagnosticstudiesthatcanbeusedtomakeadiagnosisofGERD:1.EGD2.pHprobe3.Bariumswallow

Whatconditionisamajorconcerninpatientswithlong-standingGERD?Barrett’sesophagus(metaplasiaofdistalesophagus)

WhatisthemedicaltreatmentforBarrett’sesophagus?Antacids,H2blockers,orprotonpumpinhibitors(PPi)withsurveillanceEGDandbiopsies

NamefivepossiblecomplicationsofGERD:1.Ulceration2.Strictureformation3.Barrett’sesophagus4.Bleeding5.Aspirationofgastriccontents

WhataretheindicationsforsurgeryinapatientwithGERD?Failureofmedicaltreatment,strictureformation,severedysphasia,andBarrett’sesophagus

Stomach

Whatdiseaseischaracterizedbyerosionofthegastricorduodenalmucosa?Pepticulcerdisease(PUD)

WhataretheclassicsymptomsassociatedwithPUD?Epigastricpainrelievedwithantacids,nausea,“coffee-ground”emesis,melena,andhematochezia

Whatisthedifferentialdiagnosisofepigastricpain?1.PUD2.Gastritis3.Pancreatitis4.Cholecystitis5.Coronaryarterydisease(CAD)6.GERD

What pathogen is found in >90% of patients with duodenal ulcers and 70% of patients with gastric ulcerdisease?

Helicobacterpylori

AsidefromH.pyloriinfection,namefourothercommonriskfactorsforPUD:1.NSAIDs2.EtOH

3.Smoking4.Corticosteroids

WhatstudyisusedtodefinitivelydiagnosePUD?EGDwithbiopsies(forH.pyloriandtoruleoutgastriccancer)

Whatisthemostcommonlocationofa!gastriculcer?Bodyofthestomach

Whatisthemostcommonlocationofaduodenalulcer?Firstpartoftheduodenum

Namethetypeofpepticulcer(gastricorduodenal)associatedwitheachofthefollowingfindings:PainisworseduringmealsGastriculcer(painisGreaterwithmeals)→weightlossPainimprovesaftermealsDuodenalulcer(painDecreaseswithmeals)→weightgainAlmost100%associatedwithH.pyloriinfectionDuodenalulcerNSAIDs,alcoholuse,andsmokingareimplicatedinpathogenesisGastriculcerGastricacidproductionmaybereducedGastriculcerAssociatedwithZollinger-Ellisonsyndrome;↑serumgastrinlevelsDuodenalulcerMostcommontypeofPUDDuodenalulcer(twiceascommonasgastriculcers)Occurinthesettingof↓mucosalprotectionagainstgastricacidBoth

WhatarethefourtreatmentgoalsforPUD?1.Decreaseacidproduction2.Mucosalprotection3.EradicationofH.pylori4.Cancersurveillance(gastric)

Whatmedicationsareusedforacidsuppression?H2blockersandPPi

Whatmedicationsareusedformucosalprotection?Sucralfate,bismuth,andmisoprostol

WhatisthetreatmentforH.pylori?“Triple therapy” (PPi,bismuthsalicylate, and twoof the followingantibiotics:metronidazole, amoxicillin,

clarithromycin,ortetracycline);requires6-8weekstoheal

Whatdiagnosticstudymustbeperformedinpatientswithnonhealinggastriculcers?EGDwithbiopsy(mustruleoutgastricadenocarcinoma)

NamethreecommoncomplicationsofPUDrequiringintervention:1.Hemorrhagefromerosionofanulcerintoabloodvessel2.Perforation3.Obstruction

Whataretheclassicsymptomsofgastricoutletobstruction?Nausea/vomiting(N/V),crampyabdominalpain,weightloss,anddistended/dilatedstomach

Whatisthetypicalpresentationofaperforatedulcer?Sudden, severe onset abdominal pain radiating to back and shoulders,N/V, and peritoneal signs (rebound

tenderness,guarding,andmotionpainonexamination)

Whatfindingonx-rayisanabsoluteindicationforsurgery?Freeairunderthediaphragm

Whatisthetreatmentofaperforatedduodenalulcer?Nothingbymouth(NPO),IVfluids(IVF),antibiotics,andsurgery

Whatisalife-threateningcomplicationofaposteriorduodenalulcer?Massivehemorrhagefromerosionintothegastroduodenalartery

WhatarethekeystepsintheinitialmanagementofanypatientwithasevereupperGIbleed?ABCs, IV fluids (viabilateral largeperipheral IVs), nasogastric tube (NGT) suction,gastric lavage,blood

transfusionifnecessary

WhatisthemostimportantdiagnosticimagingtestinapatientwithasevereupperGIbleed?Endoscopy

WhattypeoftreatmentcanbeadministeredduringendoscopyinapatientwithanupperGIbleed?Injectionofbleedingvesselwithsclerosingorvasoconstrictiveagents

WhattypeoftreatmentisindicatedinpatientswithGIbleedingrefractorytoendoscopictreatment?Surgery

WhatisthedifferentialdiagnosisofanupperGIbleed?1.Duodenalulcer(40%)2.Gastriculcer(10%-20%)3.Gastritis(15%-20%),4.Varices(10%)5.Mallory-Weisstear(10%)

What term is used to describe a small esophageal tear near the GE junction, commonly occurring afterretching,thatmaycauseminorself-limitedupperGIbleeding?

Mallory-Weisstear

WhatcauseofupperGIbleedinghasthehighestpotentialforrapid,life-threateningexsanguination?Esophagealvarices

Namethetypeofulcerdefinedbelow:AcutegastriculcerfoundinburnandtraumavictimsCurling’sulcerAcutegastriculcerassociatedwithheadtraumaorsurgerycausingelevatedintracranialpressureCushing’sulcerUlcerataGIanastomoticsiteMarginalulcer

Namethetypeofgastritisassociatedwiththefollowingfindings:Autoimmune disorder with Autoantibodies to parietal cells and intrinsic factor (IF), Achlorhydria,

perniciousAnemia,andAgingTypeA(fundal)chronicgastritis(rememberthefiveA’sforTypeA)“Coffee-ground”emesisfrommucosalinflammationAcute(stress)gastritisH.pyloriinfectionTypeB(antral)chronicgastritis(B=bug)NSAIDingestion

TypeB(antral)chronicgastritisIncreasedriskofPUDandgastriccarcinomaTypeB(antral)chronicgastritisCriticallyillpatientsAcute(stress)gastritis

Whatpercentageofgastrictumorsaremalignant?90%-95%(95%arecarcinomas)

Whatarethemostcommonpresentingsymptomsinapatientwithgastriccarcinoma?Pain,anorexia,andweightloss

Whatarethemajorriskfactorsforgastriccarcinoma?Age>60,dietrichinnitritesandsaltsandlowinfreshvegetables,andchronicgastritis

Whathistopathologicfindingingastriccancerisassociatedwithprognosis?Depthofinvasion

Whatisthediagnostictestofchoiceinapatientwithsuspectedgastriccarcinoma?EGDwithbiopsiesandendoscopicultrasoundtodeterminedepthofinvasionandnodalmetastases

Whatarethethreemainpatternsofgastrictumorgrowth?1.Ulcerating(mostcommon)2.Fungating3.Diffuselyinfiltrating(linitisplastica)

Providethetermassociatedwitheachofthefollowingstatementsaboutgastriccarcinomametastases:MetastasestothepouchofDouglasinthepelvisBlumershelfMetastasestotheovaryKrukenbergtumorMetastasestotheleftsupraclavicularfossaVirchownodePeriumbilicallymphnodemetastasesSisterMaryJosephnode

Gallbladder

Whataretheriskfactorsforcholelithiasis?FourF’s:Fertile,Fat,Fortyyearsold,andFemale

Whatisthetypicalpresentationofcholelithiasis?Postprandialrightupperquadrant(RUQ)pain(usuallyafterfattymeals)withN/V

Whatarethetwotypesofstonesfoundinthegallbladder?1.Cholesterol(75%)2.Pigmentstones(25%)

Namethetypeofgallstoneassociatedwitheachofthefollowing:NativeAmericanCholesterolstoneCongenitalhemoglobinopathy,hemolyticanemiaPigmentstoneRadiopaquePigmentstone

Crohn’sdisease,cysticfibrosisCholesterolstoneRapidweightloss(ie,post-gastricbypass)Cholesterolstone

Whatisthediagnostictestforcholelithiasis?RUQultrasound(98%sensitiveandspecific!)

Whatarefivepossiblecomplicationsofcholelithiasis?1.Acutecholecystitis2.Choledocholithiasis3.Gallstonepancreatitis4.Gallstoneileus5.Cholangitis

Whatisthetreatmentforsymptomaticcholelithiasis?Electivecholecystectomy

Whataretheindicationsforsurgeryinanasymptomaticpatient?Sicklecelldiseaseandporcelaingallbladder(TriskofCA)

What term is used to describe prolonged blockage of the cystic duct by an impacted stone leading toinflammation,infection,andpossiblegangreneofthegallbladder?

Acutecholecystitis

Howdoesthepaindifferincholecystitiscomparedtocholelithiasis?Painincholecystitisismoresevereandprolonged.

WhatphysicalexaminationfindingischaracterizedbyinspiratoryarrestupondeeppalpationoftheRUQincholecystitis?

Murphy’ssign(acutecholecystitis)

Whataretheothercommonsignsandsymptomsofcholecystitis?Fever,N/V,tendergallbladder,leukocytosis,andreferredrightsubscapularpain

Whatarethreecommonfindingsonultrasound(US)inapatientwithacutecholecystitis?1.Gallbladderwallthickening2.Pericholecysticfluid3.Presenceofstones

Whattestmaybedoneinapatientwithacutecholecystitiswhentheultrasound(US)isequivocal?Hepatobiliaryiminodiaceticacid(HIDA)scan(failuretovisualizethegallbladder→acutecholecystitis)

Whatisthetreatmentofacutecholecystitis?IVF,antibiotics,andearly(72h)orlate(6weeks)cholecystectomy

Definecholedocholithiasis:Presenceofgallstoneswithinthecommonbileduct

Whatisthetreatmentforcholedocholithiasis?1.Endoscopicretrogradecholangiopancreatography(ERCP)withpapillotomyandstoneremoval2.Commonbileductexploration

Whataretwocommoncomplicationsofcholedocholithiasis?Cholangitisandpancreatitis

Whatischolangitis?

Infectionofthebiliarytree2°toobstruction

Whatarethetwomostcommoncausesofbileductobstruction?1.Gallstones2.Malignancy

Namefiveclassicsignsandsymptomsofobstructivejaundice:1.Jaundice2.Pruritus3.Darkurine4.Clay-coloredstool5.Weightloss(chronic)

WhatisCharcot’striadofcholangitis?1.RUQpain2.Jaundice3.Fever/chills

WhatisReynold’spentadofcholangitis?Charcot’striad+shockandalteredmentalstatus

WhatisCourvoisier’ssign?Painlessenlargementofthegallbladderwithjaundicecausedbycarcinomaoftheheadofthepancreas

Whatarethecommonlababnormalitiesinapatientwithcholangitis?Leukocytosis,↑directbilirubin,and↑alkalinephosphatase(sensitiveforbileductinflammation)

Whatisthediagnosticgoldstandardforcholangitis?ERCP

Whatorganismmostcommonlycausescholangitis?Escherichiacoli

Whatisthetreatmentforcholangitis?IVF, antibiotics, and relief of obstruction (ERCP with papillotomy, percutaneous transhepatic

cholangiography[PTC]withcatheterplacement,orsurgery)

Nametwoimportantcomplicationsofchroniccholangitis:1.Cholangiocarcinoma2.Cirrhosis

Whatisthecommoncomorbidityinpatientswithsclerosingcholangitis?Inflammatoryboweldisease(60%)

Whatisthesurgicaltreatmentofsclerosingcholangitis?Removalofextrahepaticbileducts(dueto↑CArisk)andhepatoentericanastomosisortransplantprocedure

Whatisthemostcommontypeofgallbladdermalignancy?Adenocarcinoma(90%)

Whatarethemajorriskfactorsforgallbladdercancer?Gallstonesandporcelaingallbladder(10%haveCA)

Whatisthenameformalignancyoftheintra-orextrahepaticbileducts?Cholangiocarcinoma

Whatarethemajorriskfactorsforcholangiocarcinoma?

Ulcerativecolitis,sclerosingcholangitis,andthorotrastcontrastdye

Whatisthenameofatumoratthejunctionoftheleftandrighthepaticducts?Klatskintumor

Whatsurgeryistypicallyperformedforadistalcholangiocarcinoma?Whippleprocedure(pancreaticoduodenectomy)

Pancreas

Nameninecausesofacutepancreatitis:“GETSMASHeD”1.Gallstones2.Ethanol,ERCP3.Trauma4.Steroids5.Mumps(viruses)6.Autoimmunedisorder7.Scorpionsting8.Hyperlipidemia9.Drugs(especiallydidanosine[DDI])

Whattermsareusedtorefertoperiumbilicalandflankecchymosesinhemorrhagicpancreatitis?Cullen’ssignandGrey-Turnersign,respectively

Namesixcomplicationsofacutepancreatitis:1.Systemicinflammatoryresponsesyndrome(SIRS)2.Necrosis3.Pseudocystformation4.Pancreaticascites5.Fistulaformation6.GIorbiliaryobstruction

Whataretwoclassicradiologicfindingsonabdominalx-ray(AXR)inacutepancreatitis?1.Asentinelloopofdilatedbowelinleftupperquadrant(LUQ)nexttoinflamedpancreas2.Thecolon cutoff sign: distended transverse colonwith an absence of colonic gas distal to the splenic

flexure

Whatisthemostappropriateradiologicstudyforseverepancreatitis?Abdominalcomputedtomography(CT)

Whatothertestshouldbeincludedinthediagnosticw/uofsuspectedgallstonepancreatitis?RUQultrasound(tolookforgallstones)

Howmanydaysafteraboutofgallstonepancreatitisshouldacholecystectomybeperformed?3-5daysafterresolutionofpancreatitis

Inapatientundergoingcholecystectomyforahistoryof(h/o)gallstonepancreatitis,whattestshouldbedoneintraoperatively?

Intraoperativecholangiogram(toruleoutcholedocholithiasis)

Howisprognosisestimatedinapatientwithacutepancreatitis?Ransoncriteria:0-2positives(5%mortalityrate),3-4(15%),5-6(40%),7-8(~100%)

WhataretheRansoncriteriaatpresentation?

1.Age>552.WBC>16,0003.Glucose>200mg/dL4.AST>2505.LDH>350

WhataretheRansoncriteriaafter48h?1.Basedeficit>42.↑inBUN>53.Fluidsequestration>6L4.Ca2+8.55.↓inHct>10%6.Pao260

Namefourcommonlaboratoryabnormalitiesinacutepancreatitis:1.↑↑Serumamylase(within24h)2.↑↑Serumlipase(72-96h)3.Hypocalcemia4.Glycosuria

Whatisthedifferencebetweenatruecystandapseudocyst?Atruecystislinedbyepithelialcells,whileapseudocystislinedbyfibroustissue.

Whenshouldapseudocystbedrainedinterventionally?Ifthecystis>6cmfor6weeks(50%resolvespontaneously),orifitisinfected

Whataretheproceduresforintervalpseudocystdrainage?Cystogastrostomy,cystojejunostomy,andcystoduodenostomy

Namefivecommoncausesofchronicpancreatitis:ABCCD1.Alcoholism(#1inadults)2.Biliarytractdisease3.Cysticfibrosis(#1inkids)4.Ca2+(hypercalcemia)5.Divisum(pancreasdivisum)

WhatisaclassicdiagnosticfindingseenonAXRinchronicpancreatitis?Calcificationofthepancreas

Whataretwoclinicalsignsofpancreaticinsufficiency?Diabetes(inadequateendocrinefunction)andsteatorrhea(inadequateexocrinefunction)

Whatisthegreatestriskfactorforpancreaticcancer?Smoking(3×↑risk)

Mostpancreatictumorsarefoundinwhatregionofthepancreas?Two-thirdsofpancreatictumorsarefoundinthepancreatichead.

Whatisacommonclinicalconsequenceofamassinthepancreatichead?Obstructive,painlessjaundicecausingmalabsorptionandCourvoisier’s(enlarged,palpable)gallbladder

WhatisTrousseau’ssyndrome?Migratory superficial thrombophlebitis associated with visceral cancer (commonly pancreatic

adenocarcinoma)

Whataretwoserologicmarkersofpancreaticcancer?1.Carcinoembryonicantigen(CEA)2.CA19-9

Whatistheprognosisforpancreaticadenocarcinoma?4%5-yearsurvival

Whatsurgicalprocedureiscommonlyusedforresectionofatumorintheheadofthepancreas?Whippleprocedure(pancreaticoduodenectomy)

Whatcharacteristicsofatumorarecontraindicationsforaggressivesurgicalintervention?Vascular encasement, liver metastasis, peritoneal implants, distal lymph node metastasis, and distant

metastasis

Liver

Namethemostcommon:BenignlivertumorHemangiomaPrimarylivercancerHepatocellularcarcinoma(hepatoma)LivercancerMetastasis

Whatisthefearedcomplicationofahepatichemangioma?Hemorrhage(donotbiopsy)

Whatisthetreatmentofahepatichemangioma?observation(surgeryonlyifsymptomatic)

Whatlivertumorisassociatedwithoralcontraceptivesandanabolicsteroids?Hepaticadenoma

Whatisthetreatmentofahepaticadenoma?Discontinuebirthcontrolpillsandobservation.

Namethetwomaintypesofliverabscesses:1.Pyogenic2.Parasitic

Whatpathogenmostfrequentlycausesparasiticabscesses?Entamoebahistolytica

WhatarethesymptomsofaparasiticabscesscausedbyE.histolytica?RUQpain,fever,andbloodydiarrhea

Whatisthetreatmentofaparasiticabscess?IVmetronidazole(surgeryonlyifrefractory)

WhatdiagnosisissuggestedbythepresenceofmultiplesmallhepaticcystsonCTscan?InfectionwithEchinococcusgranulosus(eosinophiliaanda©hemeagglutinationtestarealsocommon)

Whatprocedureiscontraindicatedintreatmentofhydatiddisease(Echinococcalcysts)?Aspiration(requiresopenproceduretoavoidcontaminationofperitoneal)cavity

Namethethreemostcommonorganismsfoundinapyogenicliverabscess:1.E.coli2.Klebsiella3.Proteus

Namethemajorriskfactorsforhepatocellularcarcinoma:“WATCHforABC”Wilson’sdiseaseα-1-AntiTrypsinCarcinogens(eg,aflatoxinB1,polyvinylchloride)HemochromatosisAlcoholiccirrhosisHepatitisBHepatitisC

Whereisthemostcommonsiteofmetastasisforhepatocellularcarcinoma?Lung

Whatarethetreatmentoptionsforhepatocellularcarcinoma?Surgicalresection,chemoembolization,localablation,ortransplantation(monitorwithα-fetoprotein)

Spleen

Whataretheindicationsforsplenectomyinapatientwithidiopathicthrombocytopenicpurpura(ITP)?Failedcorticosteroidtreatment

Namethreeabsoluteindicationsforsplenectomy:1.Hereditaryspherocytosis2.Splenictumors3.Massivesplenictraumaorspontaneousrupture

Whatisthemainpostsplenectomycomplication?Overwhelmingpostsplenectomysepsis(OPSS)

WhatarethethreemainorganismsresponsibleforOPSS?1.Streptococcuspneumoniae2.Neisseriameningitidis3.HaemophilusinfluenzaeNote:allareencapsulated.

WhatarecommonlyadministeredtopreventOPSS?Vaccinations

Hernias

Namethetwofactorsthatcontributetoherniaformation:1.Increasedabdominalpressure(heavylifting,cough,straining,pregnancy,ascites,obesity)2.Congenitaldefects

Nametheherniadescriptordefinedbelow:Herniasacthatreturns,eitherspontaneouslyoraftermanipulation,toitsnormalanatomiclocationReducible

HerniasacthatcannotbereducedIncarceratedIncarceratedherniasaccausingherniacontentstobecomeischemicandeventuallynecroticStrangulated(requiresemergentsurgery)

Namethetypeofherniadescribedbelow:Inguinalherniathatprotrudesfromtheperitonealcavitylateraltotheepigastricvessels;resultsfroma

patentprocessusvaginalisIndirectinguinalherniaInguinalherniathatprotrudesfromtheperitonealcavitymedialtotheepigastricvesselsDirect inguinalhernia(herniausuallypassesthroughHasselbach’sHasselbach’striangle2°toweaknessof

transversalisfascia)HerniaprotrudingthroughthefemoralsheathinthefemoralcanalmedialtothefemoralveinFemoralherniaHerniaprotrudingthroughtheesophagealhiatusHiatalhernia(commonlyleadstoacidrefluxdisease)IncarceratedherniainvolvingonlyonesideofthebowelwallRichter’sherniaMostcommonherniainbothmalesandfemalesIndirectinguinalherniaHerniathatismorecommoninfemalesthanmalesFemoralherniaTypeofherniathatmayresultingangrenousbowelwithoutcausingsmallbowelobstruction(SBO)Richter’shernia

Namethreecommoncomplicationsofahernia:1.Pain2.SBo3.Necrosisofstrangulatedbowel

Whatisthedefinitivetreatmentforahernia?Surgicalrepair

SmallIntestine

What condition commonly presents withSBO abdominal discomfort, N/V, distension, cramping, and high-pitchedbowelsounds?

WhatarethetwomostcommoncausesofSBO?1.Adhesions2.Hernias

WhatarefivelesscommoncausesofSBO?1.Neoplasms2.Intussusception3.Volvulus4.Gallstoneileus5.Crohn’sdisease

WhattypeofhernianeedstoberuledoutonphysicalexaminationinapatientwithsuspectedSBO?Incarceratedhernia

Whatarethreecommonfindingsinapatientwithstrangulatedbowel?1.Leukocytosis

2.Tachycardia3.Peritonealsigns

WhatisthekeycomponentofthehistoryinapatientwithsuspectedSBO?Previousabdominalsurgery(leadingtoadhesions)

WhatistheinitialmanagementofanadhesiveSBO?NPO,IVF,andNGTsuction

WhatradiographicstudiesarecommonlyperformedinpatientswithsuspectedSBO?Acuteabdominalseries(uprightAPCXR,uprightAXR,andflat-plateAXR)

WhatarethreecommonfindingsonAXRinapatientwithSBO?1.Distendedloopsofbowel2.Air-fluidlevels3.Paucityofgasincolon/rectum

DefinepartialSBO:Incompletebowelobstructionwiththepresenceofcolonicgas

Whatistheclassicacid-basedisturbanceinSBO?Hypovolemichypochloremichypokalemicalkalosis(secondarytovomitingornasogastricsuction)

WhydopatientswithSBOdevelophypokalemia?AlkalosisdrivesK+intocells.

WhatfindingonurinalysisischaracteristicofSBO?Paradoxicalaciduria

Whydoesaciduriaoccur?H+exchangedforNa+duringfluidresuscitation

WhatisthetreatmentofapartialSBO?Conservativemanagementandclosemonitoring

WhatisthetreatmentforacompleteSBO?Surgery

What type of obstruction is commonly associated with cramping abdominal pain, distention, nausea, andfeculentvomitus?

Largebowelobstruction(LBO)

WhatarethethreemostcommoncausesofLBO?1.ColonCA2.Diverticulitis3.Volvulus

WhatistheassumedcauseofLBOuntilprovenotherwise?Coloncancer

WhatarethethreestudiesnecessaryintheevaluationofLBO?1.Contrastenema2.CTscan3.Colonoscopyifpatientstable

Colon

WhatarethetwomostcommoncausesoflowerGIbleed(LGIB)?1.Diverticulosis2.Angiodysplasia(arteriovenousmalformation)

OfthetwomostcommonetiologiesforLGIB,whichismostlikelytopresentwithintermittentbleeding?Angiodysplasia

Whatisthesourceofbleedingindiverticulardisease?Erosionofadiverticulumintoacolonicbloodvessel

Inwhatagegroupisdiverticulardiseasemostcommon?>60yearsold

Whatisthemostcommonpresentingsymptomofdiverticulitis?Leftlowerquadrant(LLQ)pain

Whatisthestrongestriskfactorfordiverticulardisease?Low-fiberdiet

Whatisthebestradiologictestforthediagnosisofacutediverticulitis?Abdominal/pelvicCT

Whatisthemostcommonsiteofdiverticulardisease?Sigmoidcolon(95%)

Namefourcommoncomplicationsofdiverticulitis:1.Abscess2.Peritonitis3.Fistulaformation4.Obstruction

Patients who are status post (s/p) hysterectomy are at increased risk of developing what complication ofdiverticulitis?

Enterovaginalfistula

Whatisthetreatmentofaninitialattackofdiverticulitis?NPO,IVF,andantibiotics(ABx)(entericandanaerobiccoverage)

Whatistheriskofrecurrenceofanattackofdiverticulitisafteraninitialepisode?33%

Wheniselectivesurgeryindicatedfordiverticulitis?Afterthesecondattackorafterthefirstattackinayoung,diabetic,orimmunosuppressedpatient

Whatmustberuledoutineverypatientwithdiverticulitis?Colorectalcancer

Whatisvolvulusandwheredoesitmostcommonlyoccur?Completetwistingofthebowelarounditsmesentericbaseoccurringmostcommonlyinthesigmoidcolonin

elderlypatients

Howisvolvulusdiagnosed?Sigmoidoscopy(alsotherapeuticforanonstrangulatedvolvulus)orcontrastenema

Whatinflammatorydiseaseisoftencausedbyovergrowthofexotoxin-producingbacteria?

Pseudomembranouscolitis

Whatorganismismostcommonlyresponsibleforpseudomembranouscolitis?Clostridiumdifficile

Whattestsareusedforthediagnosisofpseudomembranouscolitis?ColonoscopyrevealingpseudomembranesorC.difficiletoxindetectedinstool

Whatistheearlyfindinginacutemesentericischemia?Abdominalpainoutofproportiontoexamination

Whatarethelatefindingsinacutemesentericischemia?Bloodydiarrhea,fever,andperitonitis(80%mortality)

Listthethreemaincausesofmesentericischemia:1.Embolization(atrialfibrillation)2.Thrombosis(atheroscleroticplaque)3.Nonocclusiveischemia(↓COormedications)

Whatisthedrugclassicallyassociatedwithmesentericischemia?Digoxin

Whatisthetriadofsymptomsinchronicmesentericischemia?1.Postprandialabdominalpain2.Weightloss3.Foodaversion/fear

Howmanyvesselsmustbeoccludedtoproducesymptomaticchronicmesentericischemia?Two out of threemesenteric arteries (celiac, superiormesenteric artery [SMA], inferiormesenteric artery

[IMA])

IschemicboweldiseasecommonlyaffectswhichpartoftheGItract?“Watershed”areas(splenicflexure,rectosigmoidjunction)

Whatisthediagnostictestofchoiceformesentericischemia?Arteriogram

Nametheautosomaldominantsyndromeassociatedwitheachofthefollowingfindings:Colonicpolyps,osteomas,andsofttissuetumors;associatedwithabnormaldentitionGardner’ssyndromeHundredsofcolonicpolyps;malignantpotential∼100%Familialadenomatouspolyposis(FAP)Colonicpolypsandcentralnervoussystem(CNS)tumors;malignantpotential∼100%Turcot’ssyndromeDefectinDNArepair→manycoloniclesions(especiallyproximal);malignantpotential∼50%Hereditarynonpolyposiscolorectalcarcinoma(HNPCC)orLynchsyndromeBenignhamartomasofGItract,melanoticpigmentationofhand,mouth,andgenitalia;nomalignant

potential(but↑riskofothertumors)Peutz-Jegherssyndrome

Namethetypeofneoplasticpolyp:Usuallybenignandpedunculated;mostcommontypeTubularadenoma(75%)Highlymalignant,sessiletumorwithfingerlikeprojectionsVillousadenomaSharesfeaturesofbothothertypesofpolypsTubulovillousadenoma

Namefivemajorriskfactorsforcoloncancer:1.Colonicvillousadenomas2.Inflammatoryboweldisease(IBD)3.↓IFiber,↑animalfatdiet4.Age>505.Positivefamily/personalhistory

Howdoescolorectalcarcinomatypicallypresent?Leftsidelesion→constipation;rightsidelesion→anemia(fromoccultbloodloss)

Inanolderadultmalewithiron-deficiencyanemiawhatdiagnosismustberuledout?Coloncancer(secondmostcommoncancerintheUnitedStates)

Whatisthecurrentrecommendationforcoloncancerscreening?Hemoccultanddigitalrectalexamination(DRE)everyyear>50y/oFlexiblesigmoidoscopyevery3-5years>50y/o,orcolonoscopyevery10yearsNote: if⊕ familyhistory (FH), start screening10yearsbefore the ageof the familymemberwithCAat

diagnosis.

Whatisthegoldstandardforthediagnosisofcoloncancer?Colonoscopywithtissuebiopsy

HowdoesrectalCAusuallypresent?Hematochezia,tenesmus,andincompleteevacuationofstool

Whatistheprimarytherapyforcolorectalcancer?Surgicalresection(adjuvanttherapyforStageIII)

Whatmarkercanbeusedtofollowprogressionofcoloncancertreatment?CEANote:CEAisnotspecificenoughtoserveasanadequatescreeningmethod.

Appendix

Whatarethetwomostcommoncausesofappendicealobstruction?Obstructionoftheappendixduetofecalithandlymphoidhyperplasia

Whatistheclassicpresentationofappendicitis?Acuteonsetofperiumbilicalpain(referredpain)followedbyN/V,anorexia,andrightlowerquadrant(RLQ)

pain(duetolocalizedperitonealirritation)

InwhatorderdopatientswithappendicitistypicallyexperiencethesymptomsofabdominalpainandN/V?PainprecedesN/Vinappendicitis.Note:nauseaandvomitingfollowedbyabdominalpainsuggestsgastroenteritis.

Howisthediagnosisofappendicitismade?Byhistoryandphysicalexamination

Whataretheclassicphysicalexaminationfindingsinapatientwithappendicitis?Low-gradefever,RLQpainwithlocalsignsofperitonealirritation(guarding,reboundtenderness)

Whatlabtestsaretypicallyorderedinthew/uofappendicitis?CBC(leukocytosis),urinalysis(r/oUTIorcalculus),andβ-hCG(allfemalepatients)

Whatradiologictestcanbedonewhenthediagnosisofappendicitisisindoubt?Abdominal/pelvicCTNote:ultrasoundisrecommendedinchildrenandpregnantwoman.

Whatisthebestradiologictestforevaluationofovariancausesoflowerabdominalpain?Ultrasound

WhatisthemostcommonemergencyabdominalsurgeryperformedintheUnitedStates?Appendectomy

Nameeachphysicalexaminationfindingdescribedbelow:Pointofmaximaltendernessone-thirdthedistancefromtheanterioriliacspinetotheumbilicusMcBurney’spointPaininRLQonpalpationofLLQRovsing’ssignPainoninternalrotationofthelegwithbothhipandkneeflexedObturatorsignPainonextensionofhipwithkneeinfullflexionPsoassign

Whatisthetreatmentofappendicitis?IVF,antibiotics,andsurgery

Whataretwocommonfearedcomplicationsofrupturedappendicitis?1.Peritonitis2.Abscessformation

Howisanabscesscausedbyappendicitismanaged?Percutaneousdrainage,antibiotics,andintervalappendectomy6-8weekslater

Howlongshouldapatientwithappendicitisbetreatedwithantibiotics?24h(nonperforated),7-10days(perforated)

Whatisthemostcommontumoroftheappendix?Carcinoidtumor

Whattypeofcellsgiverisetocarcinoidtumors?Neuroendocrine(Kulchitsky)cells

Whatsubstancesaresecretedfromcarcinoidtumors?Serotonin,histamine,andprostaglandins

Whattypeofcarcinoidtumorstendtobethemostaggressive?Ileal,gastric,andcolonic

Namefiveclinicalfindingsofcarcinoidsyndrome:1.Vasomotordysfunction2.GIhypermotility3.Bronchoconstriction4.Hepatomegaly5.Right-sidedheartvalvedegeneration

Metastasisofacarcinoidtumortowhatorganmayresultincarcinoidsyndrome?Liver

Whatlabtestisusedtodiagnosecarcinoidsyndrome?5-hydroxyindoleaceticacid(5-HIAA)inurine

Whatisthetreatmentforacarcinoidtumor?Surgicalresection(octreotideforcarcinoidsyndrome)

Breast

Whatisthesecondleadingcauseofcancerdeathamongwomen?Breastcancer

Namefiveriskfactorsforbreastcancer:1.Olderage2.FHofpremenopausalbreastcancer3.Nulliparity4.Ageofmenarche13orageatmenopause555.Firstpregnancyafterage34

Namefiveconditionsthatincreasetheriskofdevelopingbreastcancer:1.Lobular/ductalcarcinomainsitu(LCIS/DCIS)2.Atypicalhyperplasia3.BRCAI/IIgenepositive4.Sclerosingadenitis5.Cancerincontralateralbreast

Whatisthemostcommonsiteofbreastcancer?Upperouterbreastquadrant

Whataretheclassicsignsandsymptomsofbreastcancer?Mass,dimple,nippleretraction,nippledischarge,rash,localedema,andenlargedaxillarylymphnodes

Nametwoimagingtoolsusedtodetectbreastcancer:1.Mammography2.Ultrasound(bestforwomen30y/owithfibrousbreasttissue)

Whatfindingsonmammographyaresuspiciousformalignancy?Stellateorspiculatedmassandmicrocalcifications

Whatisthediagnosticevaluationofanonpalpable,suspiciouslesiononmammography?Stereotacticorneedlelocalizedexcisionalbiopsy

Namethebreastdiseaseassociatedwiththefollowingstatements:MostcommonbreastmalignancyDuctalcarcinoma(90%)MostcommontumorinyoungwomenFibroadenoma(benign)Peaud’orange(edemaofthedermis)appearanceInflammatorycarcinomaMostcommoncauseofbloodynippledischargeIntraductalpapillomaTumorcellsinvadeepidermallayerofskinnearthenipplePaget’sdiseaseofbreastIncreasedriskofCAinsamebreastDCIS(premalignant)IncreasedriskofCAineitherbreastLCIS(premalignant)Solid,mobile,andwell-circumscribedroundbreastmass

Fibroadenoma(benign)Breasttendernesswithmenstrualcycle;cystsandnodulesFibrocysticdisease(benign)Superficialinfectionofbreast;usuallycausedbyStaphylococcusaureus;associatedwithbreastfeedingMastitis

Namethetreatmentforeachofthefollowingbreastdiseases:FibroadenomaObservation±biopsyFibrocysticdiseaseVitaminEandNSAIDs(ifcystspresent→aspiration;ifbloodyaspirate→biopsy)MastitisContinuebreastfeeding;antibioticsDCISLumpectomyplusx-raytherapy(XRT)ortotalsimplemastectomyLCISClosefollow-up(f/u)orbilateralsimplemastectomyinhigh-riskpatientsInvasivecarcinomaLumpectomyplusx-rayXRTormodifiedradicalmastectomy(both±chemotherapy);axillarylymphnode

dissectionandsentinellymphnodebiopsy

Nametwopotentialcomplicationsofmodifiedradicalmastectomy:1.Armlymphedema2.Injurytonerves

Whatarethemajorsideeffectsoftamoxifen?Endometrialcanceranddeepvenousthrombosis(DVT)

Whatarethescreeningrecommendationsforbreastcancerprevention?1.Monthlyself-breastexaminations2.Annualclinicalbreastexaminationsafterage403.Mammographyevery1-2yearsafterage40,thenannualmammogramsafterage50

VASCULARSURGERY

Whatarethetwomajorriskfactorsforperipheralvasculardisease(PVD)?1.Smoking2.Diabetesmellitus(DM)

NametwocommonpresentingsymptomsofPVD:1.Intermittentclaudication2.Ischemicrestpain

WhatarethesignsofPVD?Absentpulses,trophicskinchanges(shinyskin,lossofhair,thickenedtoenails),dependentrubor,muscular

atrophy,andnecrotictissue(gangrene)

Onexamination,howcanonedifferentiatebetweenafootulcercausedbyischemiaversusvenousstasis?Ischemicfootulcerscommonlyoccuronthetoesorfeet,butulcerscausedbyvenousstasiscommonlyoccur

onthemedialmalleolus.

Whatarethesymptomsofclaudication?Reproduciblepaininthelowerextremities(usuallycalfmuscles)exacerbatedbywalkingandrelievedbyrest

Isclaudicationlimb-threatening?No(only5%willlosetheaffectedlimbin5years)

Defineischemicrestpain:Severefootpainatrest,usuallyinthedistalfootandarch,causedbyPVD

Whatsimplemaneuvermaybringsomerelieftopatientswithischemicrestpain?Placingfootindependentposition(eg,oversideofbed)

Whatdoesischemicrestpainsignify?Limb-threateningcondition(85%ofpatientswilllosetheaffectedlimbin5years)

Whatisthenameofthetriadthatincludesimpotence,buttockclaudication,andgluteusmuscleatrophy?Lerichesyndrome(causedbyaortoiliacocclusivedisease)

WhatisthegoldstandardforthediagnosisofPVD?Arteriogram(alwaysrequiredpreoperatively)

WhatconservativemeasuresarecommonlytakeninthemanagementofapatientwithPVD?Smokingcessation,exercise,andaspirin±clopidogrel

WhataretheinterventionaltreatmentoptionsforPVD?1.Percutaneoustransluminalangioplasty(PTA)—bestforfocal,shortdiseaseofproximalvessels2.Surgicalrevascularization3.Amputation

WhatarethesurgicalindicationsforPVD?Restpain,tissueloss,andincapacitatingclaudication

Whatarethe“sixP’s”ofacutearterialocclusion?Pain,Pallor,Pulselessness,Paralysis,Poikilothermia,andParesthesias

Whatisthemostcommoncauseofacutearterialocclusion?Embolization(85%arecausedbythrombiformedintheheart)

Whatarethetreatmentoptionsforacutearterialocclusion?1.Surgicalembolectomy2.Surgicalbypass3.Thrombolytictherapy

Whatmedicationmustbestartedineverypatientwithsuspectedarterialocclusion?Heparin

Whatarethesignsandsymptomsofcompartmentsyndrome?Reperfusioninjurycausingcalfpain(especiallyonpassivestretch),tenderness,paralysis,andparesthesiasNote:pulsesmaystillbepresentinaffectedcompartment.

Whatisthedefinitivetreatmentforcompartmentsyndrome?Emergentfasciotomy

Namefiveriskfactorsfordevelopmentofanabdominalaorticaneurysm(AAA):1.Atherosclerosis2.Smoking3.Hypertension4.Age>605.Malegender(M/F:4/1)Infrarenal

WhereisthemostcommonsiteofanAAA?Infrarenal

StatetheriskofruptureannuallyofanAAAwitheachofthefollowingdiameters:5cm4%(9%in5years)Between5and7cm7%(35%in5years)>7cm20%(75%in5years)

WhataretheindicationsforsurgeryinapatientwithanAAA?AAA>5cm,growthofAAA>4mm/y,orpatientissymptomatic

WhatistheclassicclinicaltriadofarupturedAAA?1.Abdominalpain2.Hypotension3.Pulsatileabdominalmass

WhatisthetreatmentforarupturedAAA?Emergentoperation(50%surgicalmortalityrate)

WhatarethecommonpostoperativecomplicationsinapatientafteranAAArepair?MI(#1causeofpostoperativedeath),colonicischemia,anteriorspinalsyndrome(causedbyocclusionofthe

arteryofAdamkiewicz),andacuterenalfailure

ORTHOPEDICS

Foreachdescription,nametheassociatedorthopedicinjuryanditstreatment:FxofthefifthmetacarpalresultingfromclosedfiststrikingahardobjectBoxerFxTx:closedreduction(CR)andulnarsplint(pinningforexcessangulation)Note:ifskinisbroken→debridementandABxforpresumedhumanoralpathogeninfectionMostcommonlyfracturedcarpalbone;tendernessinanatomicalsnuffboxScaphoidFxTx:thumbspicacastNote:radiographsmaybenormalupto2weeks;↑riskforavascularnecrosis(AVN)andnonunion.Most common Fx of wrist; fall on outstretched hand (FOOSH)→ Fx of distal radius with dorsal

displacementofdistalfragmentCollesFxTx:CRandcastimmobilizationUlnardiaphysealFxanddislocationofradialheadMonteggiaFx(aka“nightstickFx”)Tx:CRofradialheadandopenreduction,internalfixation(ORIF)ofulnaRadialheadsubluxation;occursafterbeingforcefullypulledbythehandNursemaidelbowTx:manualreduction(supinateat90°elbowflexion)RadialnervepalsyresultingfromdirecttraumatoupperarmHumerusFxTx:hangingarmcast;functionalbracingRadialshaftFxwithdislocationofdistalradioulnarjointGaleazziFxTx:ORIFandcastingofarminsupination

Mostcommonshoulderdislocation(95%);duetosubcoracoiddislocationAnteriorshoulderdislocationTx:CR,sling(2-6weeks),intenserehabilitationMostcommonFxinschool-agechildren;maythreatenthebrachialarterySupracondylarFxofhumerusTx:CRandpercutaneouspinningNote:↑riskofVolkmann’sischemiccontractureofforearmMostfrequentlyfracturedlongboneinkids;sometimesrelatedtobirthtraumaClavicularFx(commonlymiddlethird)Tx:slingPain/tendernessoveranteriorhumeralheadresultingfromimpingement;⊕Neer’ssignRotatorcuffinjuryTx:NSAIDs;steroidinjection;surgeryifrefractorytosteroidsMostcommontypeofhipdislocation;severetrauma(dashboardinjury)→internallyrotated, flexed,

andadductedhipPosteriorhipdislocationTx:orthopedicemergency:reductionundersedation;f/uwithserialimagingfor2years(↑riskofAVN)Fxassociatedwithfalls inosteoporoticwomenand↑riskofAVNandDVT→shortened,externally

rotatedlegFemoralneckFxTx:ORIFandparallelpinningorhemiarthroplasty;anticoagulateto↓riskofDVTFx most commonly associated with fat emboli syndrome (dyspnea, hypoxia, confusion, and scleral

petechiae)FxofthefemurTx:intramedullarynailingoffemurLowerextremityFxafterlandingonfootfromlargeverticaldrop;partof“lover’striad”(withlumbar

compressionFxandforearmFx)CalcanealFxTx:ORIFMostcommontypeofanklesprain(90%);resultsfromankleplantar-flexionLateralsprainTx:RICE:Rest,Ice,Compression,Elevation(to↓swelling)Extremeinversionofthefoot→FxoffibulaandavulsionatbaseofthefifthmetatarsalJonesFxTx:immobilizationwithoutweightbearingExtremeeversionofthefoot→FxoffibulaandavulsionofthemedialmalleolusPott’sFxTx:ORIF

ABDOMINALPAIN

Statethemostcommoncausesofabdominalpainineachofthefollowinglocations:Rightlowerquadrant1.Appendicitis2.Gynecologiccauses:ovariancyst,PID,ectopicpregnancy,etc3.Inflammatoryboweldisease-Crohn’sdisease>>UC4.Meckel’sdiverticulitis5.IntussusceptionLeftlowerquadrant1.Diverticulitis2.Gynecologiccauses(sameasRLQpain)3.Obstructingmass(eg,colonCA)

4.Constipation5.Sigmoidvolvulus(maybegeneralized)Rightupperquadrant1.Cholecystitis2.Choledocholithiasis/cholelithiasis3.Cholangitis4.Hepatitis5.Hepatictumor(commonlyhepatoma)6.Right-sidedpneumoniaEpigastrium1.Gastricorduodenalulcer2.Gastritis/gastroenteritis3.Pancreatitis4.MINote: peritonitis, SBO,mesenteric ischemia, pneumonia,MI, andgastroenteritismaypresentwith pain in

anyabdominallocation.

MAKETHEDIAGNOSIS

21 y/o male presents with hematemesis after ingestion of aspirin and seven shots of whiskey; physicalexamination(PE):diaphoretic,↑HR,epigastrictenderness;EGD:edematous,friablereddenedgastricmucosaAcutegastritis

Apatientwithh/oPUDpresentswithmelena;PE:↑HR,diaphoretic,epigastricabdominalpain;w/u:NGTaspirateisbloody;EGD:visiblebleedingvesseldistaltothepylorus

Bleedingduodenalulcer

A patient with h/o multiple abdominal surgeries presents with crampy abdominal pain, N/V, and ↓ bowelmovements; PE: hyperactive bowel sounds, abdominal distension; AXR: dilated small bowel loops, absentcolonicgas,andmultipleair-fluidlevels

SBO

40y/oG4P4obesewomanpresentswithconstantRUQpainradiatingtorightscapulawithassociatedN/V;PE:fever, respiratory pause induced by RUQ palpation, and a painful palpable gallbladder; w/u: ↑ WBC, ↑alkalinephosphatase(ALP);US:thickenedgallbladderwall,pericholecysticfluidwithgallstonespresent

Acutecholecystitis

39y/omalepresentswithdull, steadyepigastricpainradiating to thebackafteranalcoholbinge,N/V;PE:fever,↑BP,epigastric tenderness,guarding,anddistension;w/u:↑↑amylase/lipase,↑WBC;AXR:sentinelloop,coloncutoff

Acutepancreatitis

65y/oblackmalewithh/osmokingpresentswithanorexia,weight loss,pruritus,andpainlessjaundice;PE:palpablenontenderdistendedgallbladder,migratorythrombophlebitis;w/u:↑directbilirubin,ALP,CEA,andCA19-9;AbdCT:massinheadofpancreas

Pancreaticadenocarcinoma

60y/oblackmalewithh/oGERDpresentswithweight lossanddysphagia;EGD:partiallyobstructingmassnearGEjunction

Esophagealadenocarcinoma

61 y/o white female presents with right-sided breast mass; PE: breast dimpling, nipple retraction; w/u:mammography:irregularspiculatedmasswithcalcificationsinupperouterquadrant

Breastcancer

24 y/o female presentswith a breastmass; PE: solid,mobile,well-circumscribed rubbery breastmass;US:circumscribed,homogeneous,oval-shaped,hypoechoicmass

Fibroadenoma

65y/opresentswithsevereworseningLLQpain,N/V,anddiarrhea;PE:fever,LLQtenderness,localguardingandreboundtenderness;w/u:↑WBC;AbdCT:edematouscolonicwallwithlocalizedfluidcollection

Diverticulitis

30y/ofemalepresentswithperiumbilicalpainwhichhasnowmigratedtotheRLQfollowedbyanorexia,N/V;PE: low-grade fever, localRLQ guarding, rebound tenderness,RLQ tenderness uponLLQpalpation;w/u:urinepregnancytest(UPT)negative,↑WBCwithleftshift

Appendicitis

80y/owhitemalesmokerwithh/oCADpresentswithabruptonsetofsevereabdominalandbackpain;PE:↓BP,pulsatileabdominalmass

Abdominalaorticaneurysm

55 y/o presents with colicky abdominal pain, small-caliber stools, and occasional melena; PE: cachexia,abdominaldiscomfort,guaiac⊕;colonoscopy:obstructingmassseeninascendingcolon

Right-sidedcoloncarcinoma

80y/owomanpresentswithhalitosis,dysphagia,andregurgitationofundigestedfoods;w/u:bariumswallowshowsposteriormidlinepouch>2cmindiameterarisingjustabovethecricopharyngeusmuscle

Zenkerdiverticulum

55y/oAsian femalewithh/ohepatitisBvirus (HBV)presentswithdullRUQpain;PE:weight loss,painfulhepatomegaly, ascites, and jaundice; w/u: ↑ alanine transaminase/aspartate transaminase (ALT/AST), ↑ α-fetoprotein;AbdCT:massseeninrightlobeofliver

Hepatocellularcarcinoma

55 y/o with h/o choledocholithiasis presents with fever, chills, and RUQ pain; PE: jaundice; w/u: ↑WBC,bilirubin,andALP;US:stoneincommonbileduct

Cholangitis

A patient presents to ED aftermotor vehicle accident (MVA)with LUQ abdominal pain and left shouldertenderness;PE:guarding,reboundtenderness,↓BP,↑HR;US:presenceofintra-abdominalfluid

Spleniclaceration

43 y/omale presentswith epigastric pain, diarrhea, and recurrent peptic ulcers; PE: epigastric tenderness;w/u: ↑ fasting gastrin levels, paradoxic ↑ in gastrinwith secretin challenge; octreotide scan: detect lesion inpancreas

Zollinger-Ellisonsyndrome

AtraumapatientpresentstotheEDafterMVAwithright-sidedpleuriticchestpain,dyspnea,andtachypnea;PE:↓BP,⊕JVD,unilateralabsenceofbreathsounds,hyperresonanceonrightside,andtrachealdeviationawayfromrightside

Tensionpneumothorax

71y/owithh/oatrialfibrillationpresentswithacuteonsetabdominalpainandbloodydiarrhea;PE:writhinginpain, irregularly irregularheart rhythm,noperitoneal signs;w/u:arteriogramshows lackofvisualizationoftheSMAanditsbranches

Acutemesentericischemia

72 y/o presents with recurrent, low-grade, painless hematochezia; PE: guaiac⊕ stool;colonoscopy: slightlyraised,discrete,scallopedlesionwithvisibledrainingveininrightcolon

Angiodysplasia

73y/osmokerwithh/oatrial fibrillationandDMpresentswithacuteonsetofpainandnumbness in left leg;PE:cool,pulselessleftleg;w/u:arteriogramrevealscompleteocclusionofcommonfemoralartery

Acutearterialocclusion

63 y/o Japanesemalewith h/o atrophic gastritis presentswithweight loss, indigestion, epigastric pain, andvomiting;PE:supraclavicularlymphnode;w/u:anemia,⊕fecaloccultblood

Gastriccarcinoma

48 y/o with chronic watery diarrhea, hot flashes, and facial redness; PE: shows II/Vi right-sided ejectionmurmur;w/u:↑5-HIAAinurine

Carcinoidsyndrome

40 y/o presents with dysphagia, regurgitation, and weight loss; w/u: barium swallow demonstrates dilatedesophaguswithdistalnarrowing(birdbeak)

Achalasia

16y/owithstrongFHofcolorectalCApresentswithrectalbleedingandabdominalpain;w/u:anemia;flexiblesigmoidoscopy:>100adenomatouspolypsvisualized

Familialadenomatouspolyposis(FAP)

70y/omale smokerwithh/ounintentional10-lbweight losspresentswithdysphagia that startedwithsolidsandprogressedtoliquids;EGDwithbiopsy:abnormalityinupperone-thirdofesophagus

Esophagealsquamouscellcarcinoma

40 y/o obese female presenting with RUQ pain, pruritus, dark urine, and clay-colored stools; PE: fever,jaundice,andcutaneousxanthomas;w/u:↑ALPandbilirubin

Biliarytractobstruction

35 y/omale presentswith sudden, severe onset of abdominal pain radiating toback;PE: appears toxicwithperitonealsigns;CXR:freeairunderthediaphragm

Perforatedulcer

63y/omalesmokerwithh/ocardiacbypasssurgerypresentswithpaininbothlegsexacerbatedbywalkingandrelievedwithrest;PE:tissuebreakdownand↓hairgrowthoverdistalfoot,absentpulses;w/u:ankle-branchialindex(ABI)0.4;DopplerUS:arterialstenosis

Peripheralvasculardisease(PVD)

36y/ofemalewhorecentlycompletedacourseofABxforaUTIlastweekpresentswithwaterydiarrheaandabdominalcramps;PE:feverandlowerabdominaltenderness;w/u:↑WBC

Clostridiumdifficilecolitis

35y/oobesemalepresentswithburningsubsternalchestpain30-90minaftermealsandworsewithreclining;PE:normal;w/u:bariumswallowrevealshiatalhernia

GERD

CHAPTER3Neurology

HEADACHE

Namethetypeofheadache(migraine,tension,cluster,orsinus)associatedwiththefollowingfeatures:Aspirin, nonsteroidal anti inflammatory drugs (NSAIDs), sumatriptans, ergot alkaloids, and opiates

maybeusedasabortivetherapy.MigraineAssociatedwithnausea/vomiting(N/V),photophobia,phonophobiaMigraineβ-Blockers,calciumchannelblockers,ergots,antidepressants,anddepakoteareusedforprophylaxis.MigraineClassic symptoms include unilateral frontotemporal cephalgia with aura and visual symptoms (eg,

scintillatingscotoma).MigraineCharacterizedbyperiodsofmultipleheadachesofthesamecharacteralternatingwithsymptom-free

intervalsClusterIpsilateraltearing,conjunctivalinjection,Hornersyndrome,andrhinorrheaClusterPulsatileorthrobbingheadachesMigraineMaybeprecipitatedbyhormonalfactors(eg,oralcontraceptivepills[OCPs]ormenses)andemotional

ormetabolicstressMigraineHistoryofallergiesSinusLocalizedtendernessoversinsusesSinusMostcommontypeofheadacheinadultsTensionPathophysiologymayrelatetotheeffectofserotoninoncephalicbloodvessels.MigrainePatientsoftenhaveafamilyhistory(FH)ofheadaches.MigraineSymptomsareofteneradicatedby100%O2byfacemaskorserotoninagonists(sumatriptan).ClusterUnilateralboringperiorbitalheadacheworstinthetemporo-orbitalregionClusterVise-like,tighteningbilateralpainassociatedwithphotophobia,phonophobia,andnecktightnessTension4/1F/MincidenceMigraineApproximately95%ofcasesareinmales.Cluster

Whatarethesevenredflags(suggestingseriousunderlyingpathology)inthediagnosisofheadache?1.Suddenonsetofsevereheadache

2.Headachebeginningafterstraining,Valsalva,sexualactivity,orawakenspatientfromsleep3.Headachethatispersistentandworseningoveraperiodofweeksormonths4.Headacheassociatedwithfocalneurologicfindingsorachangeinmentalstatus5.Headacheassociatedwithmeningealsigns(includingnuchalrigidity,Brudzinski’sorKernig’ssign)6.Headacheassociatedwithfever7.Headacheinapatientwhohasneverexperiencedaheadachebefore

Whatcauseofheadacheisclassicallyassociatedwiththefollowing:Young,obesefemalew/papilledema,negativeCT/MRIPseudotumorcerebri(benignintracranialhypertension)PositiveBrudzinski’ssignMeningitis“Worstheadacheoflife”SubarachnoidhemorrhageInflammatorysystemicillnessinelderly;symptomsincludeunilateralheadacheintemporalregion,eye

pain,andvisionlossTemporalarteritis(giantcell)HighnumberofpolymorphonuclearcellsinCSFMeningitis(bacterial)BloodinCSFSubarachnoidhemorrhageLargedosesofVitaminAortetracyclinesPseudotumorcerebriMedicalemergencytreatedwithsteroidsTemporalarteritisBriefepisodesofpaininthefifthcranialnervedistributionTrigeminalneuralgiaInitialtreatmentoptionsincludeacetazolamideanddiureticsPseudotumorcerebriPolymyalgiarheumaticaTemporalarteritis

Whatarethecommonsituationsinwhichalumbarpuncture(LP)iscontraindicated?Acute head trauma or signs/symptoms of intracranial hypertension—in these settings, a lumbar puncture

shouldbeperformedonlyafteranegativeheadCTorMRI.

WhatistheriskofperforminganLPinthesettingofacuteheadtrauma?Uncalherniationanddeath

SEIZURES

Namethetypeofseizureassociatedwiththefollowingclinicalfindings:Brieflapsesofconsciousnesswithorwithoutrapideyeblinking,slighthead,andlimbjerkinginachildAbsenceseizureFirstlineoftherapymayincludevalproate,phenytoin,carbamazepine,phenobarbital,orneweragents

(levetiracetam,oxcarbazepine,lamotrigine)Tonic-clonicseizureSudden,briefmusclecontractions;firstlineoftherapyincludesvalproateandclonazepamMyoclonicseizuresCommonlymistakenasdaydreaminginayoungchildAbsenceseizureFirstlineoftherapyincludesethosuximideandvalproate.

AbsenceseizureLoss of consciousness followed by loss of postural control, a tonic phase ofmuscle contraction, and

clonicphaseoflimbjerkingTonic-clonicseizureMotor,sensory,visual,psychic,orautonomicphenomenawithpreservedlevelofconsciousnessSimplepartialseizure3-Hzspike-and-wavepatternonEEGAbsenceseizureMaybeassociatedwithcyanosisandurinaryorfecalincontinence;↑serumprolactinduringpostictal

periodTonic-clonicseizureMotor,sensory,visual,psychic,orautonomicphenomenawithpreservedlevelofconsciousnessSimplepartialseizureMotor, sensory, visual, psychic, or autonomic phenomena with diminished level of consciousness

and/orpostictalconfusionComplexpartialseizureSeizureinterfereswithasingleneurologicmodality(motor,sensory,orautonomicfunction)butdoes

notcauselossofconsciousness.SimplepartialseizureSeizurecommonlyinvolvesthetemporallobe.ComplexpartialseizureLackofpostictalstateAbsenceseizurePresents in infancy w/ sudden extensor/flexor trunk movements; psychomotor retardation; and

disorganizedhigh-voltageslowwaves,spikes,andsharpwavesonEEGWestsyndrome(infantilespasms)Tonic-clonic,generalizedseizureoccurringinchildren(6monthsto5years)causedbyfeverFebrileseizure

Whatisthetreatmentforfebrileseizures?Acetaminophen(nospecificseizuretreatmentisindicated)

Domostchildrenwithfebrileseizuresgoontodevelopepilepsy?No—theriskisbarelyhigherthaninthegeneralpopulation.

Whatarethecausesofsecondaryseizures?1.CNSinfection2.Trauma3.Stroke4.Drugwithdrawal(eg,ethylalcohol(EtOH),barbiturates,benzodiazepines,anticonvulsants)5.Toxins6.Metabolic(hypoxia,hypoglycemia,hyponatremia)7.Masseffect(fromtumororhemorrhage)8.Cerebraledema(malignantHTN,eclampsia)

Whatisthetreatmentforstatusepilepticus?1.ABC(airway,breathing,circulation)2.Rollpatientonsidetopreventaspiration3.IVdiazepamorlorazepamand/orphenytoin

CEREBRALVASCULATURE

Whatarethetwomainclassificationsofstrokeandwhatistheirrelativeincidence?1.Ischemic:>85%ofcases2.Hemorrhagic:15%ofcases

Whatarethemostcommoncausesofischemicstroke?1.Atheroscleroticcomplications2.Atrialfibrillation(embolifromclotformation)3.Endocarditis(septicemboli)4.Sicklecelldisease

Describethearterythathasbeenoccludedineachofthefollowingstrokesyndromes:ParesisandsensorylossofcontralaterallowerextremityAnteriorcerebralartery(ACA)Hemiparesis,contralateralhemisensoryloss,homonymoushemianopsia,aphasiaMiddlecerebralartery(MCA)supplyingthedominanthemisphereAltered mental status, memory deficits, hemisensory loss, homonymous hemianopsia with macular

sparingPosteriorcerebralartery(PCA)AmaurosisfugaxOphthalmicarteryVertigo,cranialnerve(CN)palsies,impairedlevelofconsciousness,dysarthriaBasilarartery1.Ataxia2.Nystagmus3.Paresisofconjugategaze4.Hornersyndrome5.Contralateraldecreasedpain/tempinfaceandbody6.DecreasedproprioceptioninLE>UE7.Dizziness8.N/VSuperiorcerebellarartery(lateralmedullarysyndrome)Urinaryincontinence,suckandgraspreflexesMCAorACAsupplyingthefrontallobe1.Ipsilateralnystagmus2.Facialparalysis3.Conjugategazeparalysis4.Deafness5.Tinnitus6.Ataxia7.Decreasedfacialsensation8.Contralateraldecreasedpainandtemp9.N/V,vertigoAnteriorinferiorcerebellarartery1.Ipsilaterallossofpainandtempinface2.Contralaterallossofpainandtempinbody3.Ipsilaterallaryngeal/pharyngealparalysis4.IpsilateralHornersyndrome5.Vertigo6.Ipsilateralataxia7.NauseaPosteriorinferiorcerebellarartery(Wallenbergsyndrome)Wernickeaphasia(fluentspeechwithoutmeaning;poorcomprehensionandwordrepetition)DominantinferiorMCABrocaaphasia(nonfluentspeechwithpoorrepetitionandnormalcomprehension)SuperiordominantMCA

Whatisthemostcommonsiteforischemic/embolicstroke?MCA

Whatisthemostcommonsourceofembolithatresultinstroke?Carotidatheroma

Name the term used to describe the infarction of white matter commonly associated with hypertension,diabetes,andcarotidatherosclerosis:

Lacunarinfarction

Namethetermusedtodescribetheinfarctionofgraymattercommonlyassociatedwithsustainedhypotension:Watershedinfarction(occursatthemarginofarterialterritories)

Whatisthepeakperiodforcerebraledemaafterastroke?2-5days

Namethreenoninvasive,non-pharmacologicinterventionsforloweringintracranialpressure(ICP)thatcanbeusedinthesettingofstrokeortrauma:

1.Elevatetheheadofthebedatleast30°(maximizevenousdrainage).2.Maintainnormothermia.3.MaintainPCO2≤35.

NamesixmedicalorsurgicalinterventionsforloweringICPthatcanbeusedinthesettingofstrokeortrauma:1.Lightsedation(ie,benzodiazepines,narcotics,propofol)2.Osmoticdiuresis(mannitol,hypertonicsaline)3.Cerebrospinalfluid(CSF)diversion(ventriculostomy)4.Chemicalparalysis(non-depolarizingmusclerelaxants)5.Barbituratecoma6.Decompressivecraniectomy

Namethetermusedtodescribeaneurologicdeficitcausedbyischemiathatresolveswithin24h:Transientischemicattack(TIA)

Whatistheprimaryradiologicstudynecessaryintheworkup(w/u)ofstroke?Computedtomographic(CT)scanoftheheadwithoutcontrast

Whatradiologicstudymaybeusefulindeterminingtheetiologyofanischemicstoke?Cerebralangiography

What radiologic study can provide useful information about the anatomy of a stroke if angiography iscontraindicated?

Magneticresonanceangiography(MRA)

Whatoralmedicationshavebeenshowntoimproveoutcomeinpatientswithacuteischemicstroke?Aspirin,clopidogrel,ticlopidine,andAggrenox

Whattypeoftherapyisindicatedinapatientatriskforcardioembolicstroke?AnticoagulationwithheparinfollowedbyCoumadin

Whatmedicalinterventionhasbeenshowntoimproveoutcomeinembolicstrokewhenadministeredwithin3h?

Tissueplasminogenactivator(tPA)

What surgical intervention is indicated for patients with symptomatic carotid stenosis causing >70%compromiseofthecarotidlumen?

Carotidendarterectomy

Whatprimarypreventativemeasuresarerecommendedinapatientatriskforischemicstroke?Smokingcessation,antihypertensivetherapy,glycemiccontrolindiabetics,andcholesterolloweringtherapy

INTRACRANIALHEMORRHAGE

Namethetypeofintracranialhemorrhageassociatedwiththefollowingfeatures:AssociatedwithcerebralarteriovenousmalformationsSubarachnoidandintraparenchymalhemorrhageCommonlycausedbyrupturedberryaneurysm;classicallypresentsas“theworstheadacheofmylife”SubarachnoidhemorrhageCommonlypresentswithheadacheandlethargyinapatientwithfocalmotorandsensorydefectsIntraparenchymalhemorrhageHematoma following the contour of a cerebral hemisphere on CT; due to laceration of bridging

cerebralveinsSubduralhematomaLens-shapedhematomaonCTscan;dueto lacerationofmiddlemeningealarteryduetofractureof

thetemporalboneEpiduralhematomaLumbarpuncture(LP)mustbeperformedinapatientwithsuspectedintracranialhemorrhageevenif

CTscanisnegative.SubarachnoidhemorrhageLucidintervalfollowedbyrapiddeclineinmentalstatusEpiduralhematomaMay present with meningeal signs, CN palsies, seizures, and focal neurologic signs; bloody or

xanthochromicCSFonLPSubarachnoidhemorrhage(secondarytorupturedaneurysm)MostcommontypeofintracranialhemorrhagefromtraumaSubduralhematoma(commonlyseeninalcoholicsandtheelderly)TreatedwithemergentneurosurgicalevacuationEpiduralhematoma(andsubduralhematoma>1cmorwithmidlineshift)Typeofintracranialhemorrhageseeninpatientswithlong-standing,poorlycontrolledhypertensionIntraparenchymalhemorrhage

Whatisthemostcommoncauseofsubarachnoidhemorrhage?Trauma

Whatisthemostcommoncauseofsubarachnoidhemorrhageinapatientwithanegativecerebralangiogram?Perimesencephalichemorrhage(duetoruptureofperimesencephalicveins)

Nameavascularcomplicationofsubarachnoidhemorrhagethatmaycausecerebralischemia:Vasospasm(peakincidence6-8daysafterhemorrhage)

Namefourconnectivetissuedisordersassociatedwithanincreasedriskofcerebralaneurysms:1.Ehlers-Danlossyndrome2.Polycystickidneydisease3.Marfan’ssyndrome4.CoarctationoftheAorta

NamethemostcommoncauseofsubarachnoidhemorrhageinIVdrugusers:Rupturedmycoticaneurysms(usuallyinMCAdistribution)

Whatarethetwoclassesoftreatmentforrupturedcerebralaneurysms?1.Surgicalaneursymclipping

2.Endovascularaneurysmembolization

Namethedisordercharacterizedbyrecurrentischemicorhemorrhagicstrokesduetoprogressiveidiopathicinternalcarotidarterystenosis:

Moyamoyadisease

Whatisthecharacteristicfindingofmoyamoyadiseaseoncerebralangiogram?“Puff of smoke”: due to formation of collateral cerebral vessels originating from the lenticulostriate and

thalamoperforatingarteries

BRAINTUMORS

Whatarethemostcommontypesofbraintumors?Metastatictumors

Nametheprimarybraintumorassociatedwitheachofthefollowingclinicalorpathologicfindings:2-yearsurvivalrateof26.5%withstandardtherapyGlioblastomamultiforme(GBM)Benigntumorderivedformarachnoidcapcellswithwell-delineatedmarginsMeningiomaEpstein-Barrvirus(EBV)⊕B-celltumoroftheCNSinAIDSpatientsCNSlymphomaMalignantpediatrictumorfoundexclusivelyintheposteriorfossaMedulloblastoma(metastasizesthroughCSFpathways)MostcommonpediatricintracranialtumorJuvenilepilocyticastrocytomaMostcommonpediatricsupratentorialtumorCraniopharyngiomaMostcommonpituitaryadenomaProlactinomaMostcommonpituitarytumorPituitaryadenomaMostcommonprimarybraintumorGlioblastomamultiformeMultiplelesionsatpresentationCNSlymphoma,metastasesSmallroundbluecelltumorMedulloblastomaTumorarisingfromependymalliningofventricularsystemthatmaycausespinalmetastasesEpendymomaTumorcharacterizedbyhighlymalignantcellsborderingnecroticareasGlioblastomamultiformeTumorderivedfromRathkepouchCraniopharyngiomaTumorofthedorsalrootthatmaygrowinadumbbellconfigurationthroughavertebralforamenSchwannomaTumorwhichoriginatesfromthevestibulardivisionofCNVIIISchwannomaTwotumorsoftenpresentingwithbitemporalhemianopia

1.Pituitaryadenoma2.Craniopharyngioma

TypeoftumorthatmaybefoundbilaterallyinpatientswithneurofibromatosisII

Acousticneuroma/SchwannomaVasculartumorofcerebellumandretinainpatientswithvonHippel-LindausyndromeHemangioblastomaAssociated with loss of heterozygosity in chromosomes 1p and 19q that commonly presents with

seizuresOligodendrogliomaTumorarisingnearforamenofMonroalmostexclusivelyinpatientswithtuberoussclerosisSubependymalgiantcellastrocytoma

Whatarethethreemodalitiesusedinthetreatmentofabraintumor?1.Surgery2.Chemotherapy3.Radiationtherapy

CNSINFECTIONS

Whatarethecommonsymptomsofmeningitis?Fever,headache,neckstiffness,photophobia,andchangeinmentalstatus

Whataretheclassicsignsofmeningitis?Changeinmentalstatusandmeningealsigns:Kernig’ssign,Brudzinski’ssign,andnuchalrigidity

Whattestisnecessarytomakethediagnosisofmeningitis?CSFanalysis(usuallyobtainedbyLP)

NamethetypeofmeningitisassociatedwiththefollowingCSFfindings:>1000polymorphonuclearleukocytes,↓glucose,↑protein,↑CSFpressureBacterialmeningitisIncreasedlymphocytes,minorelevationinprotein,normalCSFpressureViralmeningitisIncreasedlymphocytes,minorelevationinprotein,dramatically↓glucose,elevatedCSFpressureFungalmeningitisIncreasedlymphocytes,↑protein,↓glucoseTBmeningitis

Namethemostcommonbacterialpathogensresponsibleforcausingmeningitisandtheappropriatetreatment(Tx)foreachofthefollowingdemographicgroups:

1monthGroupBstrep(commonlyStreptococcusagalactiae),Escherichiacoli,andListeriaEmpiricTx:second-generationcephalosporinandampicillinNote:thereareotheracceptableempiricantibioticregimens.1-3monthsStreptococcuspneumoniae,Neisseriameningitidis,andHaemophilusinfluenzae(lesscommontodaydueto

vaccinations)EmpiricTx:second-generationcephalosporin,vancomycin,andsteroids3monthstoadulthoodS.pneumoniae(mostcommoncauseofmeningitisinadults),N.meningitidisTx:third-generationcephalosporin,vancomycin,andsteroidsAssociatedwithsurgeryortraumatotheCNSStaphylococcusaureusTx:VancomycinandceftazidimeAdults>60withchronicillness(includingalcoholics)S.pneumoniae,gram-negativebacilli,Listeria

Tx:third-generationcephalosporin,ampicillin,andsteroids

Namesevencomplicationsofmeningitis:1.Hyponatremia2.Seizures3.Subduraleffusion(especiallywithH.influenzaemeningitis)4.Cerebraledema5.Subduralempyema6.Brainabscess7.Ventriculitis

Namethetypeofmeningitisorencephalitisclassicallyassociatedwiththefollowingfeatures:Argyll-RobertsonpupilSyphilisFrequentcauseofencephalitisandintracranialmasslesionsinAIDSpatientswithCD4count200ToxoplasmosisLatinAmericanimmigrantwithseizuresNeurocysticercosis(duetoTaeniasolium)Lymphocyticmeningitis,cranialneuropathy,anderythemachronicummigransLymediseaseMaternalexposuretocatfecesToxoplasmosisMostcommoncauseofviralencephalitisHerpessimplexencephalitisPresentsinchildhood;elevatedgammaglobulinandmeaslesantibodiesinCSFSubacutesclerosingpanencephalitisProgressivedementiaandmyoclonusduetoabnormalisoformofprionproteinCreutzfeldt-JakobdiseaseMostcommontypeoffungalmeningitis;commonlyseeninimmunosuppressedpatients;birdsarethe

hostforthepathogenCryptococcalmeningitisParesisandtabesdorsalis(sensoryataxia)SyphilisRing-enhancinglesionsassociatedwithfocalneurologicdeficitsToxoplasmosis+IndiainkpreparationCrytococcalneoformansSubacuteonsetofhemiplegiaorvisualdeficitsinanAIDSpatientProgressivemultifocalleukoencephalopathy(causedbyJCvirus)

WhatCNSinfectioncommonlypresentswithfever,signsof↑ICP,focalneurologicsigns,andaring-enhancinglesiononCT?

Brainabscess

Whataretheorganismsmostcommonlyresponsibleforbrainabscesses?Anaerobes,gram-positivecocci,gram-negativerods

Whatistherecommendedempiricantibioticcoverageforbrainabscess?Metronidazoleandceftriaxone(oranotherthird-generationcephalosporin)

COGNITIVEDISORDERS

Deliriumordementia?

WaxingandwaninglevelofconsciousnessDeliriumUsuallyarapidonsetDeliriumCharacterizedbymemorylossDementia(thinkDeMEMtia)Associatedwithdisturbancesinsleep-wakecycleDeliriumOftenirreversibleDementiaAssociatedwithchangesinsensorium(hallucinationsandillusions)DeliriumInattentivenessDelirium

Namefourmajorcausesofdelirium.“HIDE”

1.Hypoxia2.Infection(oftenUTIs)andICUpsychosis3.Drugs(anticholinergics,opioids,steroids,barbiturates),andwithdrawal(especiallyEtOH)4.ElectrolyteandEndocrinecauses

Whichtwosyndromesareclassicallyseeninalcoholicsexperiencingdelirium?1.Wernicke’sencephalopathy2.Korsakoff’spsychosis

Whatistheprimarycauseofthesetwosyndromes?Thiaminedeficiency

Whatarethedifferencesbetweenthesetwo?Wernicke’s (ataxia, ophthalmoplegia, nystagmus, confusion) is the early manifestation and progresses to

Korsakoff’s(memorylossandconfabulation)ifleftuntreated.

Listfourimportantstepsintheevaluationofapatientwithnew-onsetdelirium:1.Checkvitals(includingO2saturation).2.Checkmedlist.3.Checklabvalues.4.Checkforoccultinfection.

Whatisthetreatmentcoursefordelirium?Addresstheunderlyingcause(s);neurolepticsforagitation

Whatcognitivedisorderischaracterizedbyprogressive,globalintellectualimpairment?Dementia

Whatispseudodementia?Signs/symptomsofdementiasecondarytodepression;reversiblew/treatment

Whatisthemostcommonetiologyfordementia?DementiaofAlzheimertype(DAT)—70%-80%ofcases

Nameothercommonetiologiesfordementia:“DEMENTIASS”Degenerativediseases(Parkinson,Huntington)Endocrine(thyroid,pituitary,parathyroid)Metabolic(electrolytes,glucose,hepatorenaldysfunction,ethanol)

Exogenous(COpoisoning,drugs,heavymetals)NeoplasticTraumaticInfectious(encephalitis,meningitis,cerebralabscess,syphilis,prions,HIV,Lyme)Affectivedisorders(ie,pseudodementia)Stroke(multi-infarctdementia,ischemia,vasculitis)Note:vascularcausesaccountfor10%ofdementias.Structural(normalpressurehydrocephalus[NPH])

Whattreatablecausesofdementiamustberuledout?VitaminB12deficiency,thyroid/parathyroiddisorders,uremia,syphilis,tumors(brain),NPH

Namethetypeofdementiaassociatedwiththefollowingfeatures:Associated with apolipoprotein E4 (ApoE4), amyloid precursor protein, presenilin, and a2-

macroglobulingenesAlzheimerRiskforthistypeofdementiareducedwithappropriateantihypertensiveandantiplateletmedicationsVascularormulti-infarctCognitiveimpairment,extrapyramidalsigns,andearlyvisualhallucinationsDementiawithLewybodiesInsidiousonsetofdifficultieswiththeactivitiesofdailylivingandcognitivedeclineintheabsenceof

otherneurologicdeficitsAlzheimerStepwisedementiainapatientwithfocalneurologicdeficitsVascularormulti-infarctDeathoccurs5-10yearsaftertheonsetofcognitivedecline.AlzheimerDementiaaccompaniedbychangesinpersonality,speechdisturbance,andextrapyramidalsignsPickTriadofchorea,behavioralchanges,anddementiaHuntingtonMostcommoncauseofdementia;donzepilmaybehelpfulAlzheimerRiskfactorsareidenticaltothoseofcerebrovasculardiseaseVascularormulti-infarctDifficultywithverticalgazeProgressivesupranuclearpalsyFrontotemporalatrophyPickProgressivedementia,urinaryincontinence,gaitdisorderNormalpressurehydrocephalusRapidly progressive dementia associated with pyramidal, extrapyramidal, and cerebellar motor

decline,myoclonus,andincreasedstartleresponseCreutzfeldt-Jakob

MOVEMENTDISORDERS

Namethemovementdisorderassociatedwiththefollowingfeatures:Resting tremor, bradykinesia, rigidity, and postural instability → treat with dopamine (DA)

replacementtherapyParkinsondiseasePediatriconsetofsuddenvocalormotortics

TourettesyndromeChorea,behavioralchanges,anddementiaHuntingtondiseasePosturaltremorintheabsenceofotherneurologicdeficitsEssentialtremorParoxysmalunilateralflailinglimbmovementsHemiballism(2°toalesionofthesubthalamicnucleus)AtrophyofthecaudateandputamenHuntingtondiseaseTremor, ataxia, dysarthria, facial dystonia, parkinsonian signs, cognitive decline secondary to

abnormalcoppermetabolismWilsondiseaseAssociatedwithschizophreniformchangesHuntingtondiseaseAutosomaldominantusuallypresentingbetweentheagesof35and50HuntingtondiseaseAutosomalrecessiveusuallypresentingbetweentheagesof5and15Friedreichataxia“Shufflinggait”andfestinationParkinsondiseaseKayser-FleischerringsWilsondiseaseTreatmentislargelysupportiveHuntingtondiseaseLossofneuronsinthesubstantianigraParkinsondiseaseAtaxia,areflexia,lossofvibration/positionsense,andcardiomyopathyFriedreich’sataxia

AMYOTROPHIC LATERAL SCLEROSIS, MULTIPLE SCLEROSIS, AND OTHERDEMYELINATINGDISEASES

Whatarethecommonsymptomsofamyotrophiclateralsclerosis(ALS)?Asymmetric,slowlyprogressivelimb,bulbarweaknesswithfasciculations(ie,difficultyswallowing)

WhataretheclassicsignsofALS?Uppermotorneuron(UMN)signs(spasticity,hyperreflexia,clonus,upgoingtoes,frontalreflexes)andlower

motorneuron(LMN)signs(flaccidparalysis,fasciculations)

WhatarethecommonEMGabnormalitiesinALS?Denervationpotentialsinatleastthreelimbs

Whatisthecommonpresentationofmultiplesclerosis(MS)?“Symptomsseparated in timeand space”;may include limbweakness, spasticity,opticnervedysfunction,

internuclearophthalmoplegia,paresthesias,tremor,urinaryretention,andvertigo

Whataretheclassicradiologicabnormalitiesonmagneticresonanceimaging(MRI)inapatientwithMS?Periventricularwhitematterlesions

WhataretheclassicCSFabnormalitiesinapatientwithMS?Oligoclonalbandsandmononuclearpleocytosis

Whatclassofmedicationscanbeusedduringexacerbations?

Steroids

Whatclassofmedicationscanbeusedtoprolongperiodsofremission?Immunosuppressants (cyclophosphamide, azathioprine,methotrexate) and immunomodulators (β-interferon

andcopaxone)

Namethedemyelinatingdisorderassociatedwiththefollowingclinicalandpathologicfeatures:MostcommondemyelinatingdisorderMSAscendingparalysis,facialdiplegia,andautonomicdysfunctionGuillain-BarrésyndromeLossofmyelinfromgloboidandperipheralneuronsKrabbediseaseCharcot’striad(intentiontremor,scanningspeech,andnystagmus)MSAutosomalrecessive(AR)disease→progressiveparalysis,dementia,ataxia;fatalinearlychildhoodMetachromaticleukodystrophySpinallesionstypicallyoccurinthewhitematterofthecervicalcordMSPostviralautoimmunesyndromecausingdemyelinationofperipheralnerves,especiallymotorfibersGuillain-BarrésyndromeMaypresentwith intranuclearophthalmoplegia (medial longitudinal fasciculus [MLF]syndrome)or

suddenvisuallossduetoopticneuritisMSAlbuminocytologicdissociation(↑CSFproteinwithnormalcellcount)Guillain-BarrésyndromeRapidlyfatalARdiseaseofchildhoodassociatedwithgloboidbodiesinwhitematterduetodeficiency

ofβ-galactocerebrosidaseKrabbediseaseSteroidsarecontraindicated.Guillain-BarrésyndromeGenetic disorder causing accumulation of very-long-chain fatty acids resulting in behavioral and a

diversearrayofchangesneurologicdeficitsAdrenoleukodystrophyHistoryofupperrespiratoryinfection(URI)orimmunization1weekpriorGuillain-Barrésyndrome

VERTIGO

Namethevertiginousdisorderassociatedwiththefollowingfeatures:Associatedwithpoppingsensationinthemiddleearaftersneezing,coughing,orstrainingEndolymphaticfistulaCausedbyheadinjury,maybeassociatedwithhearinglossLabyrinthineconcussionEpisodesofvertigotriggeredbysuddenchangesinposition;maybeassociatedwithrecenttraumaBenignpositionalparoxysmalvertigoProgressivehearingloss,episodicvertigoaccompaniedbynauseaandvomitingandsenseoffullnessin

theearMénièrediseaseSuddenonsetofnausea,vomiting,andvertigo;self-limiteddisorderVestibularneuronitisVerticalnystagmus,weakness,ataxia,CNpalsies

Infarctionofthevestibularsystem

NEUROMUSCULARDISEASE

Nametheneuromusculardiseaseassociatedwiththefollowingfeatures:Autoimmunediseaseusuallypresenting inwomenbetween theagesof20and40; symptoms include

ptosis,diplopia,andgeneralmusclefatigabilityMyastheniagravisX-linkedrecessivedisorderofdystrophinDuchenne’smusculardystrophyandBeckermusculardystrophy(milder)Classicallyseenw/smallcelllungcancerEaton-LambertsyndromeMarkedweaknessfollowingseizureactivityTodd’spostictalparalysisAutosomal dominant presenting between the ages of 7 and 20; affects the face and shoulder girdle;

normallifeexpectancyFascioscapulohumeraldystrophyMostcommontypeofmusculardystrophyDuchenne’smusculardystrophyBeginsinadulthood;affectsthepelvicandshouldermusclesLimb-girdledystrophyRelatedtodestructionofacetylcholinereceptorsMyastheniagravisMaybeassociatedwiththymomasMyastheniagravisPassedfrommothertooffspring;“raggedredfibers”onmusclebiopsyMitochondrialmyopathiesMuscleweakness,sparingofextraocularmuscles;relatedtoimpairedreleaseofacetylcholineEaton-LambertsyndromeAutosomalrecessiveglycogenstoragediseasethattypicallypresentswithcrampingafterexercisedue

tolacticacidbuildupMcArdlediseaseWeaknessworsensafterrepetitiveuseofmuscles,butimprovesafterinjectionofedrophonium.MyastheniagravisWeakness,myalgia,eosinophilia;historyofconsumingundercookedporkTrichinosisMusclespasms(includingfacialmuscles),trismus,opisthotonos,autonomicdysfunctionTetanusIdiopathic,acute,peripheralfacialweaknessBell’spalsyAutosomalrecessive,“floppyinfant,”delayedmilestones,progressiveatrophy,dysphagiaWerdnig-Hoffmann(type1proximalspinalmuscularatrophy)Weakness worsens after injection of edrophonium; miosis, urinary urgency, and diarrhea may be

present.OrganophosphatepoisoningElevatedlevelsofcreatinephosphokinase,pseudohypertrophyofcalves,lowerthannormalIQDuchenne’smusculardystrophyWeaknessimprovesafterrepetitivemuscularstimulation.Eaton-LambertsyndromeAutosomaldominantusuallypresentingbetweentheagesof20and30; inability torelax thegripor

releaseahandshakeMyotonicdystrophy

OPHTHALMOLOGY

Nametheophthalmologicdisorderwiththefollowingfeatures:AcutenarrowingofanteriorchamberangleassociatedwithprolongedpupillarydilationAngleclosureglaucomaTreatmentincludesophthalmicarterythrombolysis.CentralretinalarteryocclusionSudden onset of blurred vision, eye pain; examination demonstrates a hard, red, painful eye with

nonreactivepupilandincreasedintraocularpressure(IOP).AngleclosureglaucomaMostcommoncauseofpermanentbilateralvisuallossintheUnitedStatesMaculardegenerationGradualincreaseinIOPwithprogressiveeyepain,coloredhalosinvisualfield,andperipheralvision

lossOpenangleglaucomaSudden,painlessunilateralblindness; slowlyreactivepupilandcherryredspoton fovea;associated

withtemporalarteritisCentralretinalarteryocclusionMustbe treated emergentlyby lowering the IOPwithacetazolamide;pilocarpinemaybeusedonce

IOPislowered.AngleclosureglaucomaMorecommoninAfricanAmericans,age>40years,anddiabeticsOpenangleglaucomaDefinitivetherapyislaseriridotomy.AngleclosureglaucomaLoss of night and central vision; examination may show retinal pigment epithelium elevation or

hemorrhagicchanges.Maculardegeneration“Bloodandthunder”appearanceoffundusCentralretinalveinocclusion

Makethediagnosisbaseduponthefollowingophthalmologicsigns:Ptosis,miosis,enophthalmos,anhidrosisHornersyndrome(interruptionoftheunilateralsympatheticsystem)UnilaterallydilatedpupilwithslowresponsetolightandaccommodationAdie’spupil(postganglionicparasympatheticlesion)Smallpupilsthatfailtoreacttolight,butwithaccommodationpreservedArgyll-Robertsonpupil(neurosyphilis)Pupilisunreactivetodirectlight,buthasintactconsensualreflex.MarcusGunnpupil(afferentpupillarydefect)Pupilfixedanddilated,ophthalmoplegia,andcontralateralhemiparesisUncalherniationEyeispositioned“downandout.”ThirdcranialnervelesionVerticaldiplopiaFourthcranialnervelesionWeakabductionofeyeSixthcranialnervelesion

Providethelocationofthelesioncorrespondingtothefollowingvisualfielddefect:UpperquadrantanopsiaContralateralopticradiationsinthetemporallobeBitemporalhemianopsia

OpticchiasmHomonymoushemianopsiaContralateraloptictractMonocularblindnessIpsilateralopticnerveLowerquadrantanopsiaContralateralopticradiationsintheparietallobeHomonymoushemianopsiawithocularsparingContralateraloccipitallobe

SYNCOPE

Providethelikelyetiologyofsyncope(andrelatedmethodofevaluation)associatedwiththefollowinghistory:SignificantstressorfearVasovagal(tilttable)PatientisonCoumadin.Cardiac:arrhythmia(ECG)PriorTIAVascular(carotidUS)ProgressivelyworseningheadacheNeurologic:intracraniallesion(CT/MRI)UrinaryincontinenceNeurologic:seizure(CT/MRI,EEG)DiabeticEndocrine:hypoglycemia(giveglucose)

PERIPHERALNEUROPATHY

Whatarethecommoncategoricaletiologiesofperipheralneuropathy?1.Nutritional:deficiencyinvitaminsB1(thiamine),B6(historyofisoniazid),B12,andE2.Metabolic:diabetes,uremia,hypothyroidism3.Toxins:lead(wristorfooddrop)andotherheavymetals4.Medications:isoniazid,aminoglycosides,ethambutol,vincristine5.Infectious:Lymedisease,HIV,diphtheria6.Autoimmune:Guillain-Barre,lupus,scleroderma,sarcoidosis,amyloidosis,polyarteritisnodosa7.Anatomical/trauma:carpaltunnelsyndrome(secondarytorepetitiveactivity,acromegally,orhypothyroidism),radialnervepalsy(pressureparalysis),fractures

LOCALIZETHELESION

Absentreflexes,fasciculations,muscularatrophyLowermotorneuron

Hyperreflexia,muscularrigidityUppermotorneuron

Emotionallability,personalitychanges,apathy,inattention,disinhibitionFrontallobes

ExpressiveaphasiaBroca’sarea(dominantfrontallobe)

ReceptiveaphasiaWernicke’sarea(dominanttemporal/parietallobe)

InabilitytorepeatwithintactspeechandcomprehensionArcuatefasciculus

Decreasedmemory,hyperaggression,hypersexualityTemporallobes(amygdala)

Anomia,alexia,agraphia,acalculiaDominantparietallobe

Hemineglect(ignoringonesideofthebody)Nondominantparietallobe

VisualhallucinationsOccipitallobes

CranialnerveIII,IVdysfunctionMidbrain

CranialnerveV,VI,VII,VIIIdysfunctionPons

CranialnerveIX,X,XI,XIIdysfunctionMedulla

Ataxia,dysarthria,nystagmus,dysmetria,intentiontremorCerebellum

ProtrudingtonguedeviatingtotherightsideCNXII(hypoglossalnerve)ontherightside

Deafness,tinnitus,and/orvertigoCNVIII(vestibulocochlearnerve)

Anosmia(inabilitytosmell)CNI(olfactorynerve)

AbsentcornealreflexCNV(trigeminalnerve)

AbsentgagreflexCNIX(glossopharyngealnerve)orCNX(vagusnerve)

DifficultyturningheadtotheleftCNXI(spinalaccessorynerve)ontheleft

DilatedandnonreactivepupilCNIII(oculomotornerve)

Lossoftasteintheanteriortwo-thirdsofthetongue

CNVII(facialnerve)

Lossoftasteintheposteriorone-thirdofthetongueCNIX(glossopharyngealnerve)

RightshoulderdroopCNXI(spinalaccessorynerve)ontheright

Unilateralshootingpainsintheface(ticdoulorueux)CNV(trigeminalnerve)

HyperacusisCNVII(facialnerve)

HoarsenessCNX(vagusnerve)

InabilitytocloseeyesCNVII(facialnerve)

MAKETHEDIAGNOSIS

55-y/o male presents with lower extremity weakness and muscle atrophy; physical examination (PE): ⊕Babinski’ssign,fasciculations,upperextremityhyperreflexia,andspasticity

Amyotrophiclateralsclerosis

65-y/opresentswithagradualdeclineinmemoryandinabilitytocompleteactivitiesofdailyliving;headCT:markedenlargementofventriclesanddiffusecorticalatrophy

Alzheimerdisease

65-y/ofemalewithh/ospinalmetastasespresentswithpainradiatingdownthebackofleg,saddleanesthesia,urinaryretention;PE:absentanklejerkreflexes;lumbarCT:vertebralfracturewithlargebonyfragmentinlumbarspinalcanal

Caudaequinasyndrome

63-y/omalewithh/ocartoidatherosclerosispresentswithaphasiaandright-sidedweakness;PE:denserighthemiparesis,⊕Babinski’sonrightside

LeftMCAcerebrovascularaccident

20-y/opresentswithnausea,vomiting,andheadache2hafterbeinghitinthetemplewithabaseball;patientlostconsciousnessinitiallybutsoonrecovered;headCT:lens-shaped,right-sidedhyperdensemassadjacenttotemporalbone

Epiduralhematoma

40-y/owithh/oCampylobacterenteritis1weekagopresentswithascendingsymmetricmuscleweakness;PE:absentreflexes;w/u:CSFshows↑protein,normalcellular(albuminocytologicdissociation)

Guillain-Barrésyndrome

37-y/omalepresentswithpoormemory, depression, choreiformmovements, andhypotonia;FHof a fatherwhodiedat45afterworseningtremorsanddementia;brainMRI:markedatrophyofthecaudatenucleus

Huntingtondisease

25-y/o with h/o bilateral temporal lobe contusions 1 week ago presents with a sudden increase in appetite,sexualdesire,andhyperorality.

Klüver-Bucysyndrome

30-y/o female with insidious onset of diplopia, scanning speech, paresthesias, numbness of right upperextremity,andurinaryincontinence;w/u:CSFanalysisis⊕foroligoclonalbands;MRIshowsdiscreteareasofperiventriculardemyelination.

MS

65-y/ofemalewithh/oneurofibromatosistype2presentswithheadache,right-sidedlegjerking,andworseningmental status; PE: papilledema and right-sided pronator drift; head CT: dural-based, enhancing left-sidedbaseball-sizedtumor

Meningioma

50-y/o with a h/o squamous cell carcinoma of the lung presents with N/V, headache, and diplopia; PE:papilledema, left oculomotor palsy, right pronator drift; brain MRI: multiple round, ring-enhancing,hyperintensecortical,andcerebellarlesions

Metastasestobrain

30-y/o female presents with unilateral throbbing headache, nausea, photophobia, and scotoma. Similarsymptomsoccurmonthlyatthesametimeofhermenstrualcycle.

Migraineheadache

62-y/owithurinary incontinence, lossof short-termmemory,anddementia;PE:wide-basedgate;headCT:massivelydilatedventricularsystem

Normalpressurehydrocephalus

60-y/opresentswithgradual onset ofpill-rolling tremor;PE:masked facies, stoopedposture, shufflinggait,cogwheelmusclerigidity

Parkinsondisease

31-y/o presents with loss of libido, galactorrhea, and irregular menses; PE: bitemporal hemianopia; w/u:negativeβ-hCG

Prolactinoma(Prolactin-secretingpituitaryadenoma)

45-y/opresentswith the gradual onset of sharppain radiating fromhis buttocksdownhis leg that began 2weeksagowhileliftingaheavybox;PE:positivestraightlegraise

Sciatica(2°toacuteherniationofalumbardisc)

50-y/o with h/o polycystic kidney disease presents with “worst headache of life,” photophobia, nausea; PE:meningismus,impairedconsciousness,righteyedeviatesdownandout;w/u:CSFisxanthochromic.

Subarachnoidhemorrhage(2°torupturedberryaneurysmofposteriorcommunicatingartery)

32-y/omalewithh/oArnold-Chiarimalformationpresentswithbilateral upper extremitymuscleweakness;PE: loss of pain and temperature sensation, ↓DTR in upper extremities, and scoliosis; spineMRI: centralcavitationofthethoracicspinalcord

Syringomyelia

75-y/oalcoholicmaleonwarfarinforh/oatrialfibrillationpresentswithdecliningmentalstatus,headache,andpapilledema;headCT:crescenteric,hypodense2-cmfluidcollectionalongconvexityofskull

Chronicsubduralhematoma

30-y/ofemalewith⊕FHforrenalcellcarcinomapresentswithgaitdisturbanceandblurredvision;PE:retinalhemangiomas,nystagmus,cerebellarataxia,anddysdiadokinesia;brainMRI:twocerebellarcysticlesions

vonHippel-Lindaudisease

50-y/owithh/oalcoholismpresentswithpsychosis,bilateralCNVIpalsy,andataxia;brainMRI:mamillarybodyatrophy,periventricularhyperintensityonT2,anddiffusecorticalatrophy

Wernicke’sencephalopathy

5-y/o boy born 5 weeks premature by spontaneous vaginal delivery is found to have an IQ of 60.Developmentally,heinitiallysatat10months,saidhisfirstwordat18monthsandwalkedat20months.Onphysicalexamination,hecurrentlywalksonhistiptoeswithascissoringgait;hislegsarehypertonicbilaterallyw/briskpatellarreflexesandupgoingtoes.

Cerebralpalsy

50-y/omanw/historyofpolycystickidneydiseasepresentstotheEDwithaprogressivelyworseningheadache,which began acutely while working out at the gym. While in the ED he has had a decrease in level ofconsciousness.

Subarachnoidhemorrhage(secondarytoberryaneurysm)

12-mo/ogirlwithnormaldevelopmentuntilabouttheageof5months.Sincethatage,shehasregressedinbothcoordination and language, as she can no longerwalk and is not speaking her firstwords any longer.Herparentshavealsonoticedthatshehasdevelopedapeculiarbehaviorofwringingherhandsforlongperiodsoftime.

Rettsyndrome

55-y/ofemalepresentingwithheadachesandprogressivevisualloss.Physicalexamrevealsopticatrophyintherighteyeandpapilledemaintheleft.

Foster-Kennedysyndrome(commonlycausedbyafrontalmeningiomacausingelevatedintracranialpressureandmasseffectonasingleopticnerve)

52-y/omanwhois10dayss/pembolizationofananteriorcommunicatinganeurysm(followingsubarachnoidbleed)10daysago,nowpresentstotheEDwithanacutedeclineinmentalstatus.

Vasospasm

27-y/omanwhoisasymptomaticisfoundtohavepigmentedhamartomasoftheirisandpigmentedmaculesonhistorsoandupperback.Uponquestioning,hementionsthatfatherandbrotheralsohavethese“darkspots”ontheirskin.

NeurofibromatosistypeI

63-y/oman recentlydiagnosedwith lung cancerpresents to theEDwith acute onset of seizure activity.Hisfamilystatesthathehasbeenmoreconfusedandfatiguedlately.Hctisobtainedandisnormal.

Syndromeofinappropriatesecretionofantidiuretichormone(SIADH)

4-mo/o boy of Ashkenazi descent is brought in to see the pediatrician as his mom is concerned about hisdevelopment.Henolongerliftshishead,islessalert,andstartlesveryeasily.Uponphysicalexamination,hisdoctornoticesabrightredmaculasurroundedbyawhitishring.

Tay-Sachs

2-mo/oboyw/a2-dayhistoryoffever,nasaldischarge,anddecreasedoralintake.Uponphysicalexamination,he is ill appearing, unresponsive to stimulation, andhis anterior fontanelle is open andbulging.Fluid fromlumbarpuncturerevealsincreasedWBCandproteinlevelsanddecreasedglucose.

Acutebacterialmeningitis(Streptococcuspneumoniae,Neisseriameningitidis,Haemophilusinfluenzae)

65-y/owomanwitha4-monthhistoryofprogressivelyworseheadachepresentsforevaluation.AsubsequentMRIrevealsamassinvolvingthecorpuscallosumandbothfrontallobes.Biopsyshowsapoorlydifferentiatedtumorwithpleomorphiccellsandnuclearatypia.

Glioblastomamultiforme

61-y/omanpresentswithabroad-basedunsteadygait.Hedeniesvertigo.Onphysicalexamination,upperlimbcoordinationiswithinnormallimits,andwithouttremor.However,heisunabletowalkinastraightline,andhasnystagmus.

Cerebellarvermislesion

CHAPTER4PSYCHIATRY

DescribethetypesofdisordersthatfallundereachofthefollowingDSM-IVclassifications:AxisIClinicalpsychiatricdisordersAxisIIPersonalitydisordersandmentalretardationAxisIIIMedicalconditionsAxisIVSocialandenvironmentalfactorsAxisVGlobalassessmentoffunctioning(GAF)

MOODDISORDERS

Whatisthelifetimeincidenceofmajordepressivedisorder(MDD)?Approximately15%

Whatistherecurrencerate?>50%

NametheeightkeyfeaturesofMDDbesidesdepressedmood:“SIGECAPS”1.Sleepchanges(insomnia/hypersomnia)2.Inabilitytoexperiencepleasure,Interest↓3.Guiltorfeelingsofworthlessness4.Energy↓(fatigue)5.Concentration↓,indecisiveness↑6.Appetitedisturbancewithweightchange(>5%bodyweightin1month)7.Psychomotorchanges(agitationorretardation)8.Suicidalideations

WhatfeaturesarerequiredtomakethediagnosisforMDD?Twoepisodesofsustained,distinctdepressedmood(andatleastfoursymptomsfromthepreviousanswer)

for2weeks,separatedby2months

Whatisinthedifferentialdiagnosisforadepressivedisorder(d/o)?MDD, bipolar d/o, dysthymia, cyclothymia, secondary mood d/o, dementia, schizoaffective d/o, d/o not

otherwisespecified(NOS),andbereavement(2months)

Nametwotypesofsecondarymooddisorders:1.Moodd/oduetomedicalcondition(eg,endocrinopathies,cancer,CNSinfections)2.Substance-inducedmoodd/o(ie,steroids,reserpine,α-interferonethanol,benzodiazepines)Note:canbeduetointoxicationorwithdrawal

Depressionorbereavement?MoodfluctuatesBereavement

Pervasivelowself-esteemDepressionUsuallynotsuicidalBereavementMayhavesustainedpsychoticsymptomsDepressionSymptomsimprovewithtime(usuallygoneby6months)BereavementOftenopentosocialsupportBereavement

NamefoursleepchangesassociatedwithMDD:1.↑sleeplatency2.Earlymorningwaking3.↓stages3and4sleep4.↓rapideyemovement(REM)latencyandREMoccursearlierinthenight

Whattypeofdepression,morecommoninchildren,ischaracterizedbymoodlabilityandrejectionsensitivity?Atypicaldepression

WhataresomecommonpredisposingfactorsforMDD?Earlyparentalloss,psychiatricormedicalillness,andsubstanceabuse

WhatclassofdrugsiscommonlyusedfirstinthetreatmentofMDD?Selectiveserotoninreuptakeinhibitors(SSRIs)

NametwootherclassesofmedicationusedforMDD:1.Tricyclicantidepressants(TCAs)2.Monoamineoxidaseinhibitors(MAOIs)

Howlongdoantidepressantstypicallytaketohaveaneffect?4-6weeks

Whatisasafe,effectivetreatmentforrefractoryMDD?Electroconvulsivetherapy(ECT)

WhatisthesuiciderateinMDD?Approximately15%-30%

What is the distinctively abnormal, irritable, elevated, expansive mood that lasts >1 week or is severelyimpairing(eg,requiringhospitalization)?

Manicepisode

Whatarethesevenkeyfeaturesofmania?“DIGFAST”(atleastthreeoffollowingfordiagnosis):1.Distractibility2.Insomnia3.Grandiosity4.Flightofideasorracingthoughts5.PsychomotorAgitation6.Speechthatispressuredorhyperverbal7.Thoughtlessness(↑pleasurableactivities→↑consequences)

Whatisthediagnosiswhenlessseveremanicfeatures(ie,noimpairmentandabsenceofpsychoticfeatures)arepresentforatleast4days?

Hypomania

Whatisrequiredforthediagnosisofbipolard/o?Oneofmoremanicepisodes(seeabove)usuallyaccompaniedbyoneormoremajordepressiveepisodes

Providethebipolarclassificationgiventhefollowinghistoryofdisease:ManiaandmajordepressionTypeIHypomaniaandmajordepressionTypeIIFourormoremoodepisodesperyearRapidcyclingFullsymptomsofbothmaniaanddepressionintermixedoralternatingrapidlyforatleastaweekMixed

Whatisthedifferentialdiagnosisforbipolard/o?Bipolard/o (IandII),MDD,cyclothymia,schizoaffectived/o,borderlinepersonalityd/o, secondarymood

d/o

Whatisthetreatmentforanacutemanicepisode?First, manage agitation (benzos) and control mood (lithium, valproate, carbamazepine); then treat any

psychoses.

Whatisthetreatmentforbipolardepression?Moodstabilizingdrugs;ECTifrefractory

Namethemoodd/oassociatedwiththefollowingfeatures:Chronic d/o >2 years characterized by alternating hypomania and mild depression; absence of

euthymia>2monthswithnosignificantimpairmentCyclothymiaDepressedmood formost of the day, for >50% of days, lasting >2 yearswith at least two signs of

depressionwithinlast2monthsDysthymicd/oNote:inkidsdiagnosisrequiresirritabilityandatleast1yearof↓mood.DysthymiaplusMDDDoubledepression

SUICIDEANDVIOLENCE

Nametheriskfactorsforsuicide:“SADPERSONS”Sex—male(women>attempts;men>actualsuicides)Age(bimodal:↑15-24yearsandtheelderly)Depression(orotherpsychiatricd/o)Previousattempts(#1riskfactor)Ethanol(andothersubstanceabuse)RationalthoughtSicknessOrganizedplanNospouseSocialsupportlacking

Whatpercentageofthoseattemptingsuicidewillgivewarningsofintent?80%(askaboutsuicidalthoughts,intent,plan)

Whatistheapproachtoapatientwhovoicessuicidalintentions?Emergentinpatienthospitalization

Whatarethreetypesoffamilyviolence?1.Childabuse2.Partnerabuse3.Elderabuse

Whataresomeoftheriskfactorsforpartnerabuse?Pregnancy,youngage,socialisolation,childabuseinhome

Howcommonispartnerabuseinwomenseekingmedicalcare?>20%

Namethreefindingsthataresuggestiveofeachtypeofabuselistedbelow:Physicalchildabuse1.Healedfracturesatdifferentstages2.Cigaretteburns3.Retinalhemorrhage/detachmentNote:32%ofkids5y/oarephysicallyabused.Sexualchildabuse1.Genital/analtrauma2.STDs3.UTIsNote:25%ofkids8y/oaresexuallyabused.Elderabuse1.Evidenceofdepletedfinances2.Poorhygiene3.Spiralfractures

PSYCHOTICDISORDERS

Whatistermusedtodescribeanimpairmentintheabilitytojudgeboundarybetweenrealandunreal?Psychosis

Givetheappropriatetermforeachofthefollowingpsychoticsymptoms:FalsebelieforwrongjudgmentheldwithconvictiondespiteincontrovertibleevidencetothecontraryDelusionFalseperceptionofanactualexternalstimulusIllusionThoughtd/owherebyideasarenotlogicallyconnectedtothosethatoccurbeforeorafterLooseassociation

Misinterpretingothers’actionsorenvironmentalcuesasbeingdirectedtowardone’sselfwhen,infact,theyarenot

IdeaofreferenceSubjectiveperceptionofanobjectoreventwhennosuchexternalstimulusexistsHallucination

Whatistheprevalenceofschizophrenia?0.9%-1.2%

Whatistheriskofschizophreniainprimaryrelativesofaschizophrenic?

Siblings:10%;parentsofpatient:5.9%;kidsofpatient:12.8%

Whatistherateofsuicideinschizophrenics?10%at10years

Whatisthetypicalageofonsetforschizophrenia?Females:25-35,males:15-25

Whatisthedifferentialforschizophrenia?Schizoaffectived/o, schizophreniformd/o,briefpsychoticd/o,delusionald/o,bipolard/o,personalityd/o,

drugintoxicationorwithdrawal,andpsychoticd/oduetoamedicalcondition

Whatarethefivemaindiagnosticcriteriaforschizophrenia?1.Delusions2.Hallucinations3.Disorganizedspeech4.Grosslydisorganizedorcatatonicbehavior5.Negativesymptoms

Namethekeyfeaturesofschizophrenia:Two or more psychotic symptoms for >1 month; impairment of social/ occupational functioning; all >6

months

Whataretheguidelinesforhospitalizationforschizophrenia?Hospitalizeduringpsychoticepisodeifdangertoself/othersorunabletocareforself.

Howisschizophreniamanagedbetweenpsychoticepisodes?Treatantipsychoticsandsupportivepsychotherapy;symptommonitoring

Givethreeexamplesofpositivesymptomsthatarecharacteristicofschizophrenia:1.Hallucinations2.Delusions3.Disorganizedthoughtprocesses(eg,looseassociations)

Positivesymptomsrespondbesttowhattypesofdrugs?Traditionalantipsychotics(haloperidol)

Givefiveexamplesofnegativesymptomsthatarecharacteristicofschizophrenia:ThefiveA’s1.Affectflattened2.Alogia3.Anhedonia4.Avolition5.PoorAttention

Negativesymptomsrespondbesttowhattypesofdrugs?Atypicalantipsychotics(clozapine,risperidone);atypicalsforfourA’s

Whatfactorsareassociatedwithabetterprognosis?1.Goodpremorbidfunctioning(mostimportant)2.Acuteandlateonset3.Obviousprecipitatingfactors4.Strongsupportsystem5.Marriedstatus6.Positivesymptoms7.Familyhistoryofmoodd/o8.Earlyandcontinuedtreatment(includingmedicationcompliance)

9.Femalegender10.Absenceofstructuralbrainabnormality

Low-potencytraditionalantipsychoticagentsaremorelikelytocausewhattypesofsideeffects?Anticholinergic,sedation,andhypotension

High-potencytraditionalantipsychoticagentsaremorelikelytocausewhattypesofsideeffects?Neurologic(extrapyramidalsymptoms[EPS],dystonia,tardivedyskinesia,andsoon)

NametheDSM-IVsubtypeofschizophreniaassociatedwiththefollowingfeatures:DelusionsofpersecutionParanoidDisinhibition;poororganization,personalappearance,andgroomingDisorganized(akahebephrenic)One previous schizophrenic episode with attenuated symptoms, but no active positive psychotic

symptomsResidualCharacteristicsofmorethanonesubtypeUndifferentiatedBizarreposturing,mutism,stupor,orextremeexcitabilityCatatonicOlderageofonset,betterfunctioningthanothersubtypesParanoidAgeofonsettypicallybefore25yearsDisorganized

Namethepsychoticd/ocharacterizedbythefollowingdescriptions:Psychotic symptoms lasting >1 day, but 1 month (often with obvious precipitating psychosocial

stressor)Briefpsychoticd/oPsychoticsymptomslasting1-6monthsSchizophreniformd/oFixed,nonbizarredelusionalsystem;withoutotherthoughtdisordersorimpairedfunctioningDelusionald/oSymptoms ofmajormoodd/o aswell as of schizophrenia (with psychotic features occurring before

mooddisturbance);chronicsocialandoccupationalimpairmentSchizoaffectived/oCloudedconsciousness,predominantlyvisualhallucinations,oftenoccurringininpatientsettingPsychoticd/oduetoageneralmedicalconditionSocialwithdrawalwithoutpsychosisSchizoidpersonalityd/oOddthoughtpatterns(eg,magicalthinking)combinedwithpeculiarbehavior,withoutpsychosisSchizotypalpersonalityd/oAdoptingthedelusionalsystemofapsychoticpersonSharedpsychoticd/o(Folieàdeux)

Whattypeofdelusionald/oischaracterizedbythefollowing:OneisconspiredagainstPersecutory(mostcommon)OneislovedbyafamouspersonErotomanicOnepossessesgreattalentGrandioseOnehasaphysicalabnormalitySomaticBeliefthatspouse/loverisunfaithful

Jealous

ANXIETYDISORDERS

Whatanxietyd/oischaracterizedbytherecurrent,sudden-onsetchestpain,palpitations,tachypnea,dizziness,nausea,trembling,anddiaphoresisassociatedwithintensefear(andlastsfor10min)?

Panicd/o

Whatisthedifferentialdiagnosisforpanicd/o?Angina/myocardialinfarction(MI),substance-inducedanxiety,generalizedanxietyd/o,posttraumaticstress

disorder(PTSD),andthyroidstorm

Whatadditionalsymptomsthatfollowtheseattacksarerequiredtodiagnosepanicd/o?Persistentconcernaboutmoreattacksandworryingabouttheimplicationsofthepanicattacks

Whatphobiaisoftenassociatedwithpanicd/o?Agoraphobia

Ageatonset?Mid-tolatetwenties

Whatmedicalconditionscanbeassociatedwithpanicd/o?Mitral valve prolapse, hyperthyroidism, vitamin B12 deficiency, hypoglycemia, pheochromocytoma,

arrhythmia,andCNSdiseases

What anxiety d/o is characterized by marked, persistent fear of an object/situation which results in anunreasonableandexcessiveresponse,andthusthestimulusisavoided?

Specificphobia

Whatistheprevalenceofspecificphobias?10%-20%ofthepopulation(female>>males)

Howdoesspecificphobiadifferfromsocialphobia?Unlikesocialphobia,specificphobiaisafeardirectedtowardaspecificobjectorsituation.

Whatisthetreatmentofchoiceforspecificphobias?Exposuretherapy(eg,desensitization,flooding)

Whatanxietyd/ocanoccurafterapersonissubjectedtoatraumaticevent?PTSD

NamethefivemajorcriteriafordiagnosingPTSD:1.Exposuretoatraumaticeventcausingintensefearorhorror2.Reexperiencingtheevent(indreams,flashbacks,andsoon)3.Avoidingstimulirelatedtothetraumaandoverallemotional“numbing”ofresponsiveness4.Symptomsofhyperarousal/hypervigilance5.Clinicallysignificantimpairment

WhattwotraumaticeventsaremostlikelytocausePTSDinmalesandfemales?Males:Rape>combatFemales:Childhoodabuse>rape

WhatoftencomplicatesthetreatmentofPTSD?Substanceabuse

WhatisthetreatmentapproachforPTSD?First, addressanyunderlyingsubstanceabuse;SSRIs (fluoxetine)andMAOIs (phenelzine);β-blockers for

autonomicsymptoms;andbehavioraltherapyandsupportgroups

Whatanxietyd/oischaracterizedbysymptomsofPTSDthatoccurwithin4weeksofthestressorandlast4weeks?

Acutestressd/o

What anxiety d/o is characterized by excessiveworrying for >50%of the days over the past 6months thatcausessignificantimpairment?

Generalizedanxietyd/o;prevalence:4%-9%(females>>males)

Whatcomorbidityiscommoninapersonw/generalanxietyd/oDepression

Whatisthetreatmentofchoiceforgeneralizedanxietyd/o?Combinedtherapy:psychotherapyandmedication

Whatmedicationsarepreferredfortreatinggeneralizedanxietyd/o?Intermediate-actingbenzodiazepines (lessaddiction, last reasonably long)orbuspirone (preferable in those

withaddictionpotential);antidepressantsinpatientswithcomorbiddepression

What anxiety d/o is characterized by maladaptive behavioral symptoms related to an identifiable stressor,whichoccurswithin3monthsofatraumaticincidentandresultsinfunctionalimpairment?

Adjustmentd/o

Whattermisusedtodescriberecurrent,intrusive,senselessthoughts,images,andimpulses?Obsessions

Whattermisusedtodescriberepetitivebehaviorsdrivenbytheconsciouswilltorespondtoanobsessionandtherebydecreasetheanxietycausedbyit?

Compulsions

Namethreecommonobsessions:1.Contamination2.Symmetry3.Fearofbeingharmed(orharmingothers)

Namethreecommoncompulsions:ThreeC’sofCompulsion1.Cleaning2.Checking3.Counting

Namethreewaysinwhichobsessive-compulsivedisorder(OCD)differsfromobsessive-compulsivepersonalitytype:

1.Thed/ocausessignificantdistressandimpairedfunctioning.2.Patientsareawarethattheirbehaviorsareunreasonable,butarenotabletocontrolthem.3.Thepersonalitytypelackstrueobsessions/compulsions.

WhatisthetreatmentofchoiceforOCD?SSRIs(fluvoxamine)orTCAs(clomipramine),andcognitive-behavioraltherapy

SOMATOFORMDISORDERS

Whatsomatoformd/oischaracterizedbymultiple,oftenvagueandunrelated,physicalcomplaintsleadingtoexcessivemedicalattentionseekingandseverelyimpairedfunctioning?

Somatizationdisorder(F/M=5/1)

Typicalageofonset?Before30

Predisposingfactors?Geneticpredispositionandsexualabuse

Whatcombinationofcomplaintsfulfillsthediagnosticcriteriaforsomatizationd/o?Complaintsoffourpain,twoGI,onesexual/GU,andonepseudoneurologicsymptomsNote:cannotbeintentionalorfake

Treatmentforsomatizationd/o?Regularly scheduled visits to primary care physician; only order tests when there is evidence of illness;

antidepressantsforcomorbiddepression(avoidopiatesandbenzos)

Namethesomatoformd/ocharacterizedbythefollowingdescriptions:Prolongedpreoccupationwithconcernsofhavingaseriousillness(despitenegativemedicalworkups)

andexaggeratedattentiontobodilyormentalsensationsHypochondriasis

Conscious simulation of physical or psychologic illness solely to receive attention from medicalpersonnel

Factitiousd/o(Munchausensyndrome)Note:technicallynotasomatoformd/obecauseitisintentionalIntentionallysimulatingillnessforpersonalgain(usuallyfinancial)MalingeringNote:alsonotasomatoformd/o;suspectincasesinvolvinglitigationPreoccupationwithanimaginedphysicaldefect,causingsignificantlyimpairedsocialandoccupational

functioningBodydysmorphicdisorder(BDD)Suddenonsetofmotor/sensoryneurologicd/ofollowingatraumaticemotionaleventConversiond/o

EATINGDISORDERS

What eating d/o is characterized by refusal tomaintain normal bodyweight and extreme fear of becomingobese,resultinginlife-threateningweightloss?

Anorexianervosa;prevalence=1%inadolescentfemales(90%ofcasesarefemale)

Namefourimportantfeaturesinthepatienthistorythatsuggestanorexianervosa:1.Distortedbodyimage(perceiveselfasbeingfat)2.Intensefearofgainingweight,>15%lessthanidealbodyweight3.Amenorrhea4.Excessiveexercise

Whattestsshouldbeincludedintheworkupofanorexianervosa?Accurate height/weight measurements, ECG, electrolytes, CBC, total protein, β-hCG, thyroid tests, and

psychiatricevaluation

Whatistheappropriatemanagementofanorexianervosa?1.Correctnutritional/electrolytestatus2.Psychotherapy3.Monitorweight,food/calorieintake,andurineoutput

WhenshouldpatientsbehospitalizedSeveredehydration,starvation,hypotension,electrolyteproblems,hypothermia,riskofsuicide

Whatisthemortalityrateinanorexianervosa?6%-20%

What eating d/o is characterized by episodes of binge eating associated with emotional distress andaccompaniedbycompensatorybehaviorsaimedatpreventingweightgain?

Bulimianervosa

Namesixcompensatorybehaviorsthatpatientsemploytopreventweightgainfrombingeing:1.Self-inducedvomiting2.Diureticabuse3.Laxativeabuse4.Useofappetitesuppressants5.Vigorousexercise6.Medicationsintendedtospeedupthemetabolism(eg,thyroidhormone)

Namefourimportantfeaturesinthepatienthistorythatsuggestbulimianervosa:1.Distortedbodyimage2.Relativelynormalbodyweight3.Avoideatingaroundothers4.Morbidpreoccupationwithfood/eatingthatleadstobingeeatingepisodes

Namethreephysicalexaminationfindingsthatmaysuggestbulimianervosa:1.Bilateralparotidenlargement2.Periodontaldiseaseorextensivedentalerosions3.Russel’ssign

WhatisRussel’ssign?Scarringandabrasionsontheknucklesfromrepeatedself-inducedvomiting

Whatlaboratoryabnormalityisoftenseenwithbulimianervosa?Metabolicalkalosis(>50%)—fromvomiting

Whatisthetreatmentcourseforbulimianervosa?Cognitive-behavioraltherapyandSSRIs

Whatantidepressantiscontraindicatedinbulimia?Bupropion(Wellbutrin)—↑riskofseizures

SUBSTANCEABUSE

Whatisthelifetimeprevalenceofsubstanceabuse/dependence?∼13%

Providethetermusedtodefinethefollowing:Recurrent, maladaptive pattern of substance use for (12 months despite significant consequences

(physicalhazardorlegal,social,oroccupationalproblems)Abuse

Characterized by craving, tolerance, and/or withdrawal to substance; loss of control with apreoccupationforobtainingandusingthesubstance

DependenceMaladaptivebehaviorthatisrelatedtorecentingestionofasubstanceIntoxicationSubstance-specificsyndromefollowingadecreaseorcessationofregularuseWithdrawalTheneedtoincreasetheamountofaningesteddrugtoproducethesamedegreeofintoxicationTolerance

Notcountingtobaccoandcaffeine,whatisthemostcommonlyabusedsubstanceintheUnitedStates?Alcohol

Whatisashort,usefulscreeningtoolforalcoholism?“CAGE”questionsHaveyoufelttheneedtoCutdown?HaveyoueverfeltAnnoyedbycriticismofyourdrinking?HaveyoueverfeltGuiltyaboutdrinking?HaveyoueverhadanEyeopener?

Whatisthemajorcomplicationofalcoholwithdrawalandwhenisitmostlikelytooccur?Deliriumtremens(DTs);peakoccurrenceis2-7days.Note:DTsareamedicalemergency.

WhatisthemortalityrateofDTs?15%-20%

Whatisthemedicalmanagementofalcoholwithdrawal?Benzodiazepine taper for symptoms; haloperidol for hallucinations; thiamine, folate, and multivitamin

replacement;correctelectrolyteabnormalities;eventualgrouptherapyor12-stepprogram

NamethreeGIcomplicationsofalcoholism:1.GIbleeding(fromulcers,gastritis,esophagealvarices,orMallory-Weisstears)2.Pancreatitis3.Liverdisease

What syndrome of anterograde amnesia, confabulations, ataxia, and nystagmus results from chronicalcoholism?

Wernicke-Korsakoffsyndrome

WhatamIhighon?CNSandrespiratorydepression,euphoria,pinpointpupils,nausea,and↓GImotilityOpioids(goosebumps→coldturkey);inspectfortrackmarksalongveinsPsychomotoragitation,dilatedpupils,euphoria,↑heartrate(HR)andBP,prolongedwakefulnessand

attention,delusions,↑painthresholdAmphetaminesAllofthesymptomslistedintheprevioustwoquestions,plustactilehallucinations,angina,andsudden

cardiacdeathCocaineIntenseviolence,psychosis,anddelirium;psychomotoragitation,nystagmus,ataxia;rhabdomyolysis

andhyperthermiaPhencyclidinehydrochloride(PCP)Restlessness,insomnia,flushing,GIdisturbance,anxiety,diuresis,cardiacarrhythmia

CaffeineDelusions,visualhallucinations,postuseflashbacksLysergicaciddiethylamide(LSD)Light-headedness, euphoria, disinhibition, hallucinations, ataxia, confusion; breathing problems and

facialwithchronicuseInhalants(hydrocarbons,glues,volatilecleaners,etc)Disinhibition,emotionallability,slurredspeech,ataxia,blackouts,comaAlcoholEuphoria,heightenedsensation,increasedappetite,drymouth,conjunctivalinjection,apathyCannabinoidsIncreasedmuscularity,acne,testicularatrophy;chronicusemaycausepsychosisand/ordepressionAnabolicsteroids

WhatamIcomingdownfromandhowisittreated?Anxietyand“flu-likesymptoms”(insomnia,piloerection,fever,rhinorrhea,yawning,↑GImotility)Opioids→naltrexone/naloxoneforoverdose;methadonefordetoxificationRecurrenceofsudden-onset,homicidalviolence,andpsychosisPCP→antipsychoticsandbenzodiazepines

Hypersomnolence,fatigue,depression,malaise,severecravingfordrug(peaks2-4daysafterlastdose)Cocaine→haloperidol, benzodiazepines, antiemetics, anti-inflammatory (formyalgias); bromocriptine for

withdrawalPostuse“crash”(lethargy,headache,hunger,depression,dysphoricmood,alteredsleep)Amphetamines→similartococaineTremor,↑HRandBP,malaise,nausea,seizures,agitation,deliriumAlcohol→(similartococaine)

CHILDHOODDISORDERS

Namethed/oofchildhooddescribedbyeachofthefollowingstatements:Repetitive behaviors (in patient 18 y/o) that violate social norms; may exhibit physical aggression,

crueltytoanimals,vandalismandrobbery,alongwithtruancy,cheating,andlyingConductd/oRemember:predominantlyactionsRecurrentpatternofnegativistic,hostile, anddisobedientbehavior towardauthority figures; loss of

temperanddefiance(butnottheftlying)Oppositionaldefiantd/oRemember:predominantlywordsDevelopmentally inappropriate degrees of inattention, impulsiveness, and hyperactivity at home, in

school,andinsocialsituations;presentbeforeage7Attention-deficithyperactivitydisorder(ADHD)Pervasive developmental disorder (PDD) with stereotyped movements and nonprogressive

impairmentsinsocialinteractions,communication,andbehaviorAutismProgressivesyndromeofautism,dementia,ataxia,andpurposelesshandmovements;associatedwith

hyperammonemia;principallyingirlsRettsyndromePDDwithsevere impairment insocial skillsandrepetitivebehaviors, leading to impairedsocialand

occupationalfunctioningbutwithoutsignificantdelaysinlanguagedevelopmentAspergerd/o

Excessiveanxietyconcerningseparationfromhomeorfromthosetowhomthechildisattached

Separationanxietyd/oMultiple motor and ≥1 vocal tics that persist at least 1 year. Examples of tics include: grimacing,

blinking,echopraxia,coprolalia(33%),andecholalia.Tourett’sd/o(shouldalsoevaluateforADHD[50%]andOCD[40%])Voluntaryorinvoluntaryrepeatedpassageoffecesintoinappropriateplacesafterage4,notduetoa

medicalconditionFunctionalencopresis(r/oHirschsprung’sdisease)Voluntaryorinvoluntaryrepeatedvoidingofurineintobedorclothesafterage5,notduetoamedical

conditionFunctionalenuresis(r/oUTI,diabetes,seizures)IQ≤70withimpairedadaptivefunctioningintwoormoreofthefollowing:communication,self-care,

academics,homeliving,socialskills,workMentalretardation(90%aremildlyretardedw/IQbetween55and70)

PERSONALITYDISORDERS

Namefourqualitiesthatdistinguishapersonalityd/ofromapersonalitytrait:1.Maladaptive2.Enduring(lifelong)3.Inflexible4.Impairssocial/occupationalfunctioning

ListthethreeclusterApersonalitydisorders:“Weird”1.Paranoid2.Schizoid3.Schizotypal

ListthefourclusterBpersonalitydisorders:“Wild”1.Histrionic2.Borderline3.Antisocial4.Narcissistic

ListthethreeclusterCpersonalitydisorders:“Worried”1.Avoidant2.Obsessive-compulsive3.Dependent

Namethepersonalityd/ocharacterizedbyeachofthefollowingstatements:Socialinhibition(butdesiresrelationships),sensitivetorejection,inferioritycomplexAvoidant(C)Peculiarappearance,interpersonalawkwardness,“magical”oroddthoughtpatterns,nopsychosisSchizotypal(A)Impulsive, unstable mood, chaotic relationships, sense of feeling empty and alone, self-mutilation,

females>>malesBorderline(B)Senseofentitlement,grandiosity,lackempathyforothers,insistsonspecialtreatmentwhenillNarcissistic(B)Suspiciousanddistrustful,usesprojectionasprimarydefensemechanism

Paranoid(A)Lacksself-confidence,submissive,andclingyDependent(C)Unabletomaintainintimaterelationships,extroverted,melodramatic,sexuallyprovocativeHistrionic(B)Disregardsandviolatesrightsofothers,criminality,males>females;18y/o=conductd/oAntisocial(B)Lifelongpatternofvoluntarysocialwithdrawal,nopsychosis,showsminimalemotionsSchizoid(A)

MISCELLANEOUSPSYCHIATRICDISORDERS

Namethedissociatived/ocharacterizedbyeachofthefollowingstatements:Presenceoftwoormoredistinctpersonalitiesthatrecurrentlytakecontroloftheperson’sbehaviorDissociativeidentityd/oSuddentravelawayfromhomewithconfusionandamnesiaaboutidentity.Assumptionofnewidentity

iscommon.PsychogenicfuguePersistentorrecurrentfeelingofdetachmentfromone’sbodyorselfDepersonalizationd/o

Namethesexuald/ocharacterizedbyeachofthefollowingstatements:DeficientorabsentsexualfantasiesordesireHypoactivesexualdesired/oInvoluntaryspasmofmusculatureofvaginawhichinterfereswithsexualintercourseVaginismusRevulsiontoandavoidanceofsexualcontactSexualaversiond/oPersistentdelayorabsenceoforgasmfollowingsexualexcitementOrgasmicd/oPersistentejaculationwithminimalstimulationPrematureejaculationInabilitytoattainormaintainanerectiontocompletesexualactivityMaleerectiled/o(impotence)—20%-50%duetomedicationormedicalconditionInadequatesubjectiveexcitementandlubricationinfemalesFemalesexualarousald/oDistressaboutassignedsex;desiretobeorinsistingoneistheoppositesexGenderidentityd/oRecurrentandintensesexualarousalinresponsetounusualobjectsorfantasieslasting≥6monthsParaphilias

Nametheparaphilia:ObservingunsuspectingpersonVoyeurismCross-dressingTransvestismExposureofone’sgenitalstostrangersExhibitionism(M>>F)Useofinanimateobjects(underwear)Fetishism(M>>F)Actsofbeingbeaten,humiliated,bound,madetosufferSexualmasochism

PrepubescentchildrenPedophiliaSufferingofvictimSexualsadism(M>>F)RubbingnonconsentingpersonFrotteurism

Namethesleepd/ocharacterizedbyeachofthefollowingstatements:Disturbanceininitiating,maintaining,orfeelingrestedaftersleepPrimaryinsomnia

DaytimedrowsinesswithirresistiblesleepattacksNarcolepsyProlongedsleep,excessivedaytimesleepinessPrimaryhypersomniaEpisodes of breathing cessation during sleep accompanied by snoring, gasping, morning headache,

daytimesleepiness,inattention;predisposedbyobesitySleepapneaMismatchbetweenenvironmentdemandsandperson’ssleep-wakepatternCircadianrhythmsleepd/oAgonizing,deepcreepingsensationsinlegorarmmuscles,relievedbymovingormassageRestlesslegsyndromeAwakenwithscream,intenseanxiety(sleepstage3to4);morningamnesiaofepisodeSleepterrord/oDistressingdreamscausingrepeatedawakenings(duringREM);mayrecalldetailinthemorningNightmared/oEpisodeofcoordinatedmovement(eg,walking)withpersonunresponsiveduringepisode(sleepstage3

to4);morningamnesiaSleepwalkingd/o

Nametheimpulsecontrold/ocharacterizedbyeachofthefollowingstatements:EpisodesoflossofcontrolofaggressiveimpulsesoutofproportiontoprecipitantIntermittentexplosived/oStealingunnecessaryortrivialitemsKleptomaniaMaladaptivegamblingbehaviorPathologicgamblingIntentionalfiresettingandfascinationwithfirePyromaniaPullingoutofone’sownhair,resultinginnoticeablehairlossTrichotillomania

PSYCHOPHARMACOLOGY

Antidepressants

Foreachofthefollowingdrugs,provide:(1)themechanismofaction(MOA),(2)indication(s)(IND),and(3)significantsideeffectsanduniquetoxicity(TOX)(ifany):

TCAs(imipramine,clomipramine,amitriptyline,desipramine,nortriptyline,doxepin,amoxapine)MOA:preventsreuptakeofnorepinephrine(NE)and5-hydroxytryptamine(5-HT)

IND: depression, enuresis (imipramine), depression in elderly (nortriptyline), OCD (clomipramine),depressionwithpsychoticfeatures(amoxapine),fibromyalgia

TOX: sedation (desipramine is least sedating), anticholinergic effects, lethal in overdose → respiratorydepression,hyperpyrexia,and

TriCs:Cardiacarrhythmia,Convulsions,ComaSSRIs(fluoxetine,paroxetine,sertraline,citalopram,fluvoxamine,escitalopram)MOA:selectivelyblocksreuptakeof5-HT(usuallyrequires2-3weekstotakeeffect)IND:depression,premenstrualsyndrome(flouxetine),OCD(fluvoxamine)TOX: agitation, insomnia, sexual dysfunction, “Serotonin syndrome” with MAOIs (muscle rigidity,

hyperthermia,cardiovascularcollapse)BupropionMOA:heterocyclicagent;hasweakreuptakeblockingeffectsonserotoninandNE;alsoaffectsreuptakeof

dopamineIND:depression,smokingcessation;alsousedinADHDTOX:agitation,seizures,insomnia(↓sexualsideeffects)TrazodoneMOA:mainlyinhibitsserotoninreuptakeIND:depressionTOX:Posturalhypotension,sedation,priapism

VenlafaxineMOA:inhibits5-HTandNEreuptakeIND:depression,generalizedanxietyd/oTOX:stimulanteffects,minimaleffectsonP450MirtazapineMOA:5-HT2receptorantagonistanda2-antagonist→↑NEand5-HTreleaseIND:depressionTOX:highlySedating,↑appetite,↑cholesterol,weightgainMAOIs(TIP:Tranylcypromine,Isocarboxazid,Phenelzine)MOA:nonselectiveMAOIsIND:atypicaldepressions,anxietydisorders,paindisorders,eatingdisordersTOX: hyperadrenergic crisiswith tyramine (cheese, liver, redwine, agedmeets) ormeperidine ingestion;

serotoninsyndrome(diarrhea,nausea,headache,tremor,neuromuscularirritability,hyperthermia,HTN,seizures,death)withSSRIs

LithiumMOA:preventsgenerationof(IP3)and(DAG)2°messengersystemsIND:bipolard/o(preventsandtreatsacutemania)TOX:hypothyroidism,nephrogenicdiabetesinsipidus(DI),teratogenesis(Ebsteinanomaly)

Antipsychotics

Whatisthenameforstereotypedoral-facialmovementsthatoccurasaresultoflong-termantipsychoticuse?Tardivedyskinesia

Describethechronologyofextrapyramidalsideeffectsfromneurolepticmedications:“Ruleof4s:”4h:acutedystonia,4days:akinesia,4weeks:akathesia,4months:tardivedyskinesia(usually

irreversible)

Whatisthecharacteristictriadofneurolepticmalignantsyndrome(NMS)?1.Musclerigidity2.Autonomicinstability3.Hyperpyrexia

WhatisthetreatmentforNMS?Dantroleneanddopamineagonists

Foreachofthefollowingdrugs,provide:(1)themechanismofaction(MOA),(2)indication(s)(IND),and(3)significantsideeffectsanduniquetoxicity(TOX)(ifany):

Traditionalhigh-potencyantipsychotics(haloperidol,perphenazine,trifluoperazine)MOA:D2dopaminereceptorantagonists(alsoblocka2,muscarinic,andhistaminicreceptors)IND:schizophrenia,psychosis(especiallypositivesymptoms)TOX:↑neurologic(eg,extrapyramidal)sideeffects(SEs),NMS,tardivedyskinesiaTraditionallow-potencyantipsychotics(chlorpromazine,thioridazine)MOA:D2dopaminereceptorantagonists(alsoblocka2,muscarinic,andhistaminicreceptors)IND:schizophrenia,psychosisTOX: ↓ neurologic SEs, ↑ anticholinergic and endocrine SEs; cardiac conduction defects and retinal

pigmentation(thioridazine),cornealandlenticulardeposits(chlorpromazine)Atypicalantipsychotics(clozapine,risperidone,olanzapine,quetiapine)MOA:5-HT2antagonists;D4andD1>D2receptorantagonistsIND:schizophrenia,psychosis(especiallynegativesymptoms);OCD/anxietyd/o(olanzapine)TOX: ↓ anticholinergic and EPS, ↑ hematologic SEs; agranulocytosis (clozapine → weekly WBC

monitoring)

Namethedrugofchoiceineachofthefollowingclinicalsettings:Depressionwithinsomnia;chronicpainAmitriptyline(Elavil)OCDClomipramine(Anafranil)orfluvoxamine(Luvox)DepressionwithanorexianervosaorbulimiaDesipramine(Norpramin)—stimulatesappetiteDepressionwithpsychoticfeaturesAmoxapine(Asendin)RefractorypsychosiswithpredominantlynegativesymptomsClozapine(Clozaril)Panicd/owithagoraphobiaImipramine(Tofranil)ADHDinchildrenMethylphenidate(Ritalin,Concerta,Methylin)

AdultADHDBupropion(Wellbutrin,Zyban)Premenstrualdysmorphicd/oFluoxetine(Paxil)TrichotillomaniaClomipramine(Anafranil)Intractablehiccups,withnauseaandvomitingChlorpromazine(Thorazine)MDDFluoxetine(Paxil)AnxietyintheelderlyBuspirone(BuSpar)—lesssedatingTouretted/oPimozide(Orap)AlcoholwithdrawalsymptomsChlordiazepozide(Librium)SmokingcessationBupropion(Wellbutrin,Zyban)Generalizedanxietyd/o

Venlafexine(Effexor)orbuspirone(Buspar)EnuresisImipramine(Tofranil)UsedtodecreasealcoholdependenceDisulfiram(Antabuse)andnaltrexone(ReVia)PanicattacksClonazepam(Klonopin)OverdosewithbenzodiazepinesFlumazenil(Romazicon)HypertensivecrisisfromtyramineandMAOIsPhentolamineAtypicaldepressionMAOIs(eg,Phenelzine)NarcolepsyModafinil(non-amphetaminestimulant)

Listtheuniquetoxicitiesofthefollowingpsychiatricdrugs:TCAs“ThreeC’s:”Convulsions,Cardiacarrhythmias,andComaAntipsychoticsGalactorrhea(fromdopamineblockade)Trazodone(Desyrel)PriapismClozapine(Clozaril)Agranulocytosis—monitorCBCsweekly;seizuresMAOIsHyperadrenergic/hypertensivecrisis(withtyramine)Lithium(Eskalith)NephrogenicDI,hypothyroidism,teratogenesisThioridazine(Mellaril)Cardiacconductionabnormalities,irreversibleretinalpigmentationChlorpromazine(Thorazine)Cornealandlenticulardeposits,jaundice,NMSFluphenazine(Prolixin)Hepatotoxicity,NMS

Carbamazepine(Tegretol)Aplasticanemia,hepatoxicityValproate(Depakene)Hepatotoxicity (rare, but lethal), syndrome of inappropriate secretion of antidiuretic hormone secretion

(SIADH),Stevens-Johnsonsyndrome,teratogenesisLamotrigine(Lamictal)Stevens-Johnsonsyndrome,toxicepidermalnecrolysisHaloperidol(Haldol)Arrhythmias(includingtorsades),NMS

Nametheshort-actingbenzodiazepines:“TOMisShort”Triazolam(Halcion)Oxazepam(Serax)Midazolam(Versed)

Nametheintermediate-actingbenzodiazepines:“TALC”Temazepam(Restoril)

Alprazolam(Xanax)Lorazepam(Ativan)Clonazepam(Klonopin)

Namethelong-actingbenzodiazepines:“CD”Chlordiazepoxide(Librium)Diazepam(Valium)

Namethebenzodiazepinesacceptableforuseinpatientswithhepaticdysfunction(Note:Theseagentsarenotmetabolizedbyliverandareexcretedbykidneys.)

“LOT”Lorazepam(Ativan)Oxazepam(Serax)Temazepam(Restoril)Note:chlordiazepoxide(Librium)oftenusedforDTsifnoevidenceofhepaticdysfunction

MAKETHEDIAGNOSIS

20y/ofemalepresentswithexcessiveanxietyaboutavarietyofeventsformorethanhalfofthedaysforthelast7months.

Generalizedanxietyd/o

68-y/oveteranpresentswithcomplaintsofvividflashbacks,hypervigilance,anddifficultyfallingasleepforthepastseveralyears;PE:patientappearsveryanxious.

Posttraumaticstressd/o

28-y/omalewhosystematicallycheckseachlockinhishousemultipletimesbeforeleaving,oftencausinghimtobeoveranhourlateformeetings

Obsessive-compulsived/o(OCD)

29-y/o male presents with a 9-month h/o insatiable urges to rub himself against strangers, which he hasregrettablyacteduponseveraltimes.

Frotteurism(sexualparaphilia)

22-y/ofemalecollegestudentwhois20%belowheridealbodyweightcomplainsofnothavinganymenstrualcyclesand“feelingfat”

Anorexianervosa

26-y/ofemalemedicalstudentforthepast9monthsisconvincedshehassystemiclupuserythematosus(SLE)anddespitenumerousnegativeworkups,shefearsshewillhavetodropoutofschool.

Hypochondriasis

17-y/ofemalepresentswithcomplaintsof“feelingfat”andh/oeatingdinneraloneinherbedroom;PE:normalheightandweight,dentalerosions,and⊕Russel’ssign

Bulimia

24-y/owithh/odepressionpresentswithinabilitytosleep,andauditoryhallucinations;PE:easydistractibilityandpressuredspeech;W/U:normalTSHandnegativetoxicologyscreen

Bipolard/o(manicepisode)

21-y/ofemalewithnoh/otraumapresentstotheERbecauseshecannotfeelormoveherlegs;w/u:completelywithinnormallimits(WNL);detailedhistoryrevealsthatherboyfriendof8yearsleftherthismorning.

Conversiond/o

43-y/o alcoholicwith h/o confabulation and amnesia presents toER after falling down; PE: nystagmus andataxicgait;w/u:macrocyticanemia

Wernicke-Korsakoffsyndrome

6-y/opresentswith8-monthh/ohyperactivity,inattentiveness,andimpulsivitybothatschoolandathome;PEandw/uareessentiallyWNL.

ADHD

33-y/o female presents to your office distressed after turning down a lucrative job offer because of therequirementtospeakinfrontofpeople.

Socialphobia

9-y/o boy with 2-year h/o involuntary tics is brought to your office because he has recently been shoutingobscenities.

Tourettesyndrome

33-y/ofemalenursepresentswithrecentoccurrencesofhypoglycemia;PE:revealsmultiplecrossedscarsonabdomen;w/u:insulin/C-peptideratio>1.0

Factitiousd/o(Munchausensyndrome)

16-y/o with h/o sudden-onset daytime sleep attacks with loss of muscle tone and audiovisual hallucinationswhilewakingandfallingasleep

Narcolepsy

19-y/owith8-monthh/odeterioratinggradesandsocialwithdrawalpresentswithauditoryhallucinations;PE:oddthinkingpatterns,tangentialthoughts,andflattenedaffect;w/u:negativetoxicologyscreen

Schizophrenia

48-y/ofemalepresentswithrecenth/oearlymorningwaking,↓appetite,feelingsofguilt,andlossofinterestinherusualhobbiesoverthepast3months;PEandlabsareWNL.

Majordepressived/o

3-y/omalewithh/oofpoorcuddlingpresentswithseverelydelayedlanguageandsocialdevelopment;PE:lessthannormalintelligencewithunusualcalculatingabilities,andrepetitivebehaviors

Autism

62-y/omanwith h/o diabetes,MI, and anxiety,who recently (∼1week ago) stopped one of hismedicationsbecauseofinsuranceissues.Afewdaysago,hec/onausea,vomiting,sweating,andfeelingweak.Nowpresentsw/generalizedseizure

Sedative-hypnoticwithdrawal(anti-anxietymeds)

29-y/owomanwithh/omultiplemedical issues.Haspreviousnegativeworkup for seizuredisorder; chronicpaininherhead,neck,back,elbows,andkneesofunknownetiology;hasnotbeenabletoattainorgasmformanyyears;andhasalonghistoryofdysphagiaand“foodallergies”requiringdietaryrestrictions

Somatizationd/o

42-y/o woman presents w/a 2-year h/o the following symptoms: sweating, trembling, choking sensation,tachycardia, chest tightness, fear of losing control and dying. These symptoms develop soon after being insituationswhereshefeelsshecannotescape.

Panicattack

22-y/owomanwithmaladaptivecopingpatternstoroutinestress,emotionallability,feelingsofabandonment,andcuttingmarksonherarmsandlegs

Borderlinepersonalityd/o

34-y/omanwithh/oschizophreniabecomescombativeintheED.HeisinitiallymanagedwithseveraldosesofIMhaloperidol.A fewhours laterhebecomes agitated once again and is givenhigh-dose ziprasidone. Soonafter, he becomes deliriouswith unstable blood pressures. In addition, he becomes diaphoretic, febrile, andrigid,andstartstoseize.

Neurolepticmalignantsyndrome

11-y/ogirlishavingproblemsatschool.Shehastroublemakingfriendsandisawkwardinsocialinteractions.Althoughshehasnoproblemswithlanguageorwritingskills,sheoftenbecomeslostinthedetailsofherschoolassignmentsandthushasdifficultycompletingthem.Wheninterviewed,thegirlspeaksingreatdetailaboutherschoolwork,butdoesnotmakeeyecontactandappearsuncomfortable.

Aspergersyndrome

8-y/oobeseboywithmentalretardation,smallstature,hypogonadism,compulsiveeatingPrader-Willisyndrome

27-y/owomancomplainsofamildchronicdepressedmoodthathasoccurredmoredaysthannotforthepast3years.Thesadnesshasnotgoneawayformorethanacoupleofconsecutivedays.Inaddition,shedeniesanyperiodofseveredepressionduringthistime.

Dysthymicd/o

CHAPTER5ObstetricsandGynecology

OBSTETRICS

Completethefollowingformulas:Gestationalage(GA)/estimateddateofconfinement(EDC)=AgeoffetusfromlastmenstrualperiodNooflivebirths/1000people=BirthrateNooflivebirths/1000females15-44yearsold=FertilityrateNoofneonataldeaths/1000livebirths=Neonatalmortalityrate(Noofstillbirths+neonataldeaths)/1000totalbirths=PerinatalmortalityrateNoofinfantdeaths/1000livebirthsuptofirstyearoflife=Infantmortalityrate

DiagnosisofPregnancy

Whataretypicalsignsandsymptomsofearlypregnancy?Amenorrhea, nausea, vomiting (N/V), breast tenderness, Chadwick’s sign (bluish discoloration and

congestedappearanceofvagina),andHegar’ssign(softeningoflowersegmentofuterus)

AtwhatGAcanfetalhearttones(FHT)bedetectedbyDoppler?10weeks

AtwhatGAcantheultrasound(US)detectagestationalsacandcardiacactivity?5weeksandafter6weeks,respectively

Namethethreesignsoffetalviabilityduringpregnancy:1.Fetalheartactivity2.Fetalmovementdetectionbyexaminer3.Embryo/fetusultrasonicrecognition

Howearlycanhumanchorionicgonadotropin(β-hCG)bedetectedinurineorserum?Asearlyas8-9daysafterovulation

Whatisthedoublingtimeofβ-hCGinearlypregnancy?2days

Whendoesβ-hCGpeakinpregnancy?8-10weeksGA

Namethreeclinicalscenariosinwhichquantificationofβ-hCGishelpful:1.Diagnosingectopicpregnancy2.Monitoringneoplastictrophoblasticdisease

3.Screeningfetalaneuploidy

Dating

WhatisNägelerule?EDC=LMP+7days-3months+1year(basedonregular28-daycycle)

Whatisthemostcommoncauseofsize-for-datesdiscrepancy?Inaccuratedating

AdefiniteLMPshouldbeusedtodatethepregnancyiftheEDCdeterminedbyafirstvssecondvsthirdTMUSarewithinhowmanydaysoftheLMP?

Firsttrimester:7daysSecondtrimester:14daysThirdtrimester:21days

PhysiologicChangesinPregnancy

Whatarethephysiologicchangesofpregnancyinthefollowingsystems?

Cardiovascular↑heart rate (HR)andSV→↑CO;systolicejectionmurmur(SEM)isnormal finding;diastolicmurmur is

NEVERanormalfinding;↓BP(especiallydiastolic)—lowestat24weeks

Respiratory↑ tidal volume and minute ventilation, ↓ total lung capacity (elevation of diaphragm), ↑ total body O

2consumption,andhyperventilation(optimizesCO2andO2transferbetweenmotherandfetus)

GastrointestinalN/V,refluxesophagitis,hemorrhoids,andcholestasis

Renal↑Glomerularfiltrationrate(GFR)50%,↓BUNandCr,urinarystasis,andasymptomaticbacteriuriain∼5%

Hematologic↓Hematocrit (Hct):↑plasmavolumeby40%(due to↑plasma>RBC);hypercoagulable state:↑clotting

factors(↓proteinS),↑venousstasis,andendothelialdamage

Dermatologic↑ estrogen → spider angiomata and palmar erythema; ↑ melanocyte stimulating hormone →

hyperpigmentationofnipples,abdominalmidline(lineanigra),andface(chloasma/melasma)

Endocrine↑hCG,humanplacentallactogen(hPL—insulinantagonistwithdiabetogeniceffect),progesterone,estrogen,

thyroid-bindingglobulin,T3andT4(euthyroidstate),andprolactin

GeneralPrenatalCare

Whatlabsshouldbeobtainedatthefirstprenatalvisit?CBC,Rhfactor,antibodyscreen,Papsmear,gonorrhea,andChlamydiacultures,urinalysis(UA)andculture,

rubella,syphilis,hepatitisB,HIV

Whyisfolateanessentialpartofprenatalvitamins?Provento↓riskofneuraltubedefects(NTD)

After20weeksgestation,atwhatrateshouldfundalheightincrease(approximately)?1cmperweek

Teratogens

AtwhatGAarestructuralabnormalitiesmostlikelytooccurasaresultofteratogens?3-8weekssinceconception(organogenesisphase)

Nametheteratogeniceffectsofthefollowingsubstances:Angiotensin-convertingenzymeinhibitors(ACEi)Renaldysgenesis→oligohydramnios,pulmonaryhypoplasia,andlimbcontracturesTetracyclineDiscoloredteethandenamelhypoplasiaAminoglycosidesAcousticnervedamage→deafnessOralhypoglycemicsNeonatalhypoglycemiaDilantinFetalhydantoinsyndrome:craniofacialandlimbdefects,mentaldeficienciesValproicacidSpinabifidaIsotretinoinCraniofacial(smallears),centralnervoussystem(CNS),cardiac,andthymusdefectsIndomethacinConstrictionofductusarteriosusDiethylstilbesterol(DES)Clearcellvaginalcancerandcervical/uterinemalformationsinfemaleoffspringThalidomideLimbreductiondefectsAlcoholFetal alcohol syndrome: craniofacial defects (absent philtrum, flattened nasal bridge, microphthalmia),

growthrestriction,brain,cardiac,andspinaldefectsTobaccoGrowthrestrictionRadiationGrowthrestriction,CNSdefects,leukemia

ANTEPARTUM

MedicalConditionsinPregnancy

GestationalDiabetesMellitus

Whatistheprevalenceofgestationaldiabetesmellitus(GDM)?∼7%ofpregnanciesNote:mostcommonmedicalcomplicationofpregnancy

WhatarefiveriskfactorsforGDM?1.>25y/o2.Obesity3.⊕familyhistory(FH)ofdiabetesmellitus(DM)4.Previousinfant>4000g5.Previous(h/o)polyhydramnios

HowisGDMdiagnosed?Screenedwithglucosechallengetest(50-gglucose);diagnosedwithglucosetolerancetest(100-gglucose)

WhatarethreecomponentsofGDMmanagement?1.AmericanDieteticAssociation(ADA)diet;insulinifnecessary2.USforfetalgrowthassessment3.Nonstresstest(NST)startingat30-32weeksifrequiringhypoglycemics

WhatistheWhiteClassificationforGDM?A1:dietcontrolledA2:requiringhypoglycemics

WhatpercentageofwomenwithGDMwilldevelopovertDMaftertheirpregnancy?>50%

PreexistingDiabetesMellitus

HowispreexistingDMmanaged?Insulin, check baseline TSH, baseline ophthomology examination, baseline preeclampsia labs, monitor

HgbA1c,US,andmaternalserumalpha-fetoprotein(MSAFP)checkat16-20weeks,fetalechocardiogramat20weeks,twiceweeklyNSTstartingat30-32weeks

Whenshouldelectivecesareansection(CS)beconsideredinapatientwithDM?Fetalweight>4500g(mayconsiderelectivedeliveryat36-38weekswithevidenceoffetallungmaturity)

WhatarethematernalcomplicationsofDM?Preeclampsia/eclampsia(twofold↑risk),hyperglycemia,retinopathy,diabeticketoacidosis(DKA)

WhatarethefetalcomplicationsofDM?Macrosomia (>4500 g), cardiac defects, caudal regression (malformations associated with poor glucose

control),polyhydramnios,hypoglycemiasecondary(2°)tohyperinsulinemia,intrauterinefetaldeath(IUFD)

WhataretheobstetricalcomplicationsofDM?Pretermlabor(PTL)andshoulderdystocia

HypertensioninPregnancy

Namethehypertensivedisorder(d/o)ofpregnancydescribedbelow:BP≥140/90beforepregnancyordiagnosedbefore20weeksGAChronichypertension(HTN)

BP140/90-160/110,proteinuria300-5000mg/24h,or1-2+ondipstickPreeclampsia(mild)BP>160/110,proteinuria>5000mg/24h,or3-4+ondipstickPreeclampsia(severe)PreeclampsiawithseizuresEclampsia

DefinetheHELLPsyndrome:Hemolyticanemia,Elevated(LFTs),LowPlatelets

Whatareothersignsandsymptomsofseverepreeclampsia/eclampsia?Headache(HA),blurredvision,epigastricpain,hyperreflexia,andclonus

Whataretheriskfactorsforpreeclampsia?Multifetalgestation,nulliparity,⊕FH,maternalage20or>35y/o,chronicHTN,AfricanAmerican,GDM,

SLE

Whatisthemanagementofmildpreeclampsiawithimmaturefetus?BedrestandmonitoringofBP,weight,andserial24°urineprotein levelsandpreeclampsia labs (Cr,uric

acid,CBC,LFTs)

Whatisthemanagementofseverepreeclampsiaandeclampsia?Magnesiumsulfate(MgSO4)until12-24hpostpartum(PP),normalizeBP,anddelivery;iffetalormaternal

deteriorationatanygestationalage→inducelabor(deliveryisthedefinitivetreatment)

OtherMedicalConditionsinPregnancy

Whatpercentageofmaternalmortalitiesareduetopulmonaryembolism?10%(no1causeofmaternaldeath)

Whatisthetreatmentfordeepvenousthrombosis(DVT)orpulmonaryembolism(PE)inpregnancy?Heparinorlow-molecular-weightheparin(neverwarfarin!)

Whatisthedrugofchoiceforhyperthyroidisminpregnancy?Propylthiouracil(PTU)

Whyshouldasymptomaticbacteriuriabetreatedinpregnantwomen?25%willdevelopacute,symptomaticinfectionifuntreated

Whatisthemostcommoncauseofsepticshockinpregnancy?Acutepyelonephritis

Whatisthemanagementofacutepyelonephritis?Hospitalization,urineandbloodculture,IVhydration,IVABX,urineculture1-2weeksaftercompletionof

treatment/therapy(testofcure)

WhatistheminimummedicaltreatmentforHIV⊕pregnantwomen?Azidothymidine(AZT)after14weeksGAthroughlaborformom;AZTfornewborn

WhatistherateofverticaltransmissionofHIVonAZTprophylaxis?∼8%(↓from25%withoutprophylaxis)

WhatmodeofdeliveryisrecommendediftheHIVviralload>1000at36weeksGA?Scheduledc-section

What mode of delivery is recommended in a pregnant woman with active herpes lesions during theintrapartumperiod?

C-section

WhenisuniversalGBSscreeningperformed?36weeksGA

WhatanatomymustbeswabbedforacompleteGBSculture?Lowervaginaandrectum(throughsphincter)

WhatisthedrugofchoiceforGBSpositivepatientsduringtheintrapartumperiod?Penicillin

WhenGBSstatusisunknown,whenisantibiotictreatmentindicated?GA36weeks, rupture ofmembranes >18 hours, intrapartum temperature >38°C, h/oGBS+ urine culture

duringcurrentpregnancy,h/opreviousinfantwithGBSsepsis

Whatischorioamnionitisandhowisittreated?Infectionoftheamnioticfluid(mostcommoncauseofneonatalsepsis);broad-spectrumABXanddelivery

ObstetricalComplications

Whatisthedifferentialdiagnosisforbleedinginthefirsttrimester?Ectopic pregnancy, spontaneous abortion (SAB), postcoital bleeding, vaginal/cervical lesion, molar

pregnancy,nonobstetriccause

EctopicPregnancy

Whatisthedefinitionofanectopicpregnancy?Pregnancyoutsideuterinecavity(98%occurinthefallopiantubes)

WheredothemajorityofectopicpregnanciesoccurFallopiantube(98%),mostoccurinampulla

Whatarefiveriskfactorsforectopicpregnancy?1.h/opelvicinflammatorydisease(PID)orpriorectopic2.Pelvicsurgery3.DESexposureinutero4.Intrauterinedevice(IUD)usage5.Endometriosis

Whatistheclinicaltriadofectopicpregnancy?1.Amenorrhea2.Abdominalpain3.Irregularvaginalbleeding

Namethreesignsofarupturedectopicpregnancy:1.Hypotension2.Tachycardia3.Reboundtenderness

Whatisthedifferentialdiagnosisforsuspectedectopicpregnancy?Surgicalabdomen,abortion,ovariantorsion,andrupturedovariancyst

Whatarefourmethodsusedtodiagnoseectopicpregnancy?1.PositivepregnancytestwithemptyuterusbyUS2.ProlongedhCGdoubling3.Progesterone25ng/mL4.Surgicalabdomen

Whatmedicationcanbeofferedforastable,unrupturedectopicpregnancy3.5cmand6weeksGA?Methotrexate

Whatisthedefinitivetreatmentformostotherectopicpregnancies?Laparoscopicsurgery

Abortion

Definespontaneousabortion(SAB)ormiscarriage:Lossofpregnancybefore20weeksGAordeliveryoffetus500g

Namethetypeofabortiondescribedbelow(all20weeksGA)andappropriatetreatment:Intrauterinebleedingwithoutdilationofcervixandnoexpulsionofproductsofconception(POC)ThreatenedTx:afterdocumentingalivefetus,pelvicrestIntrauterinebleedingwithdilationofcervixandnoexpulsionofPOCInevitableTx:surgicalevacuationofuterinecontentsPartialexpulsionofPOCIncompleteTx:possiblehospitalization,possiblehemodynamicresuscitation,andcurettage

CompleteexpulsionofPOCCompleteTx:none

Deathofembryo/fetuswithretentionofPOCMissedTx:surgicalevacuationofuterinecontentsifthereisnospontaneousresolution

≥2consecutiveorthreetotalSABsRecurrentTx:basedontypeofabortion

Whatisthemostcommoncauseofafirsttrimesterfetaldeath?Chromosomalabnormality

Whataresigns/symptomsofSAB?Vaginalbleeding,cramping,abdominalpain,decreasedsignsorsymptomsofpregnancy

Whatisthemostcommonmethodofsurgicalevacuationofuterinecontentsinthefirstandsecondtrimesters?Firsttrimester:dilationandcurettage(D&C)Secondtrimester:dilationandevacuation

AntepartumandIntrapartumHemorrhage

Halfofallthirdtrimesterbleedingiscausedbywhattwoconditions?1.Placentalabruption2.Placentaprevia

Whatisararebutimportantcauseofthirdtrimesterbleedinginvolvingthefetus?Vasaprevia

DefineplacentalabruptionPrematureseparationofnormallyimplantedplacenta

Nameeightriskfactorsforplacentalabruption:1.HTN2.↑maternalage3.Multiparity4.AfricanAmerican5.Pretermprematureruptureofmembranes(PPROM)6.Smokingtobacco

7.Cocaineuse8.Trauma

Whatarethesignsandsymptomsofplacentalabruption?Painfulbleeding,contractions,andfetaldistress/death

Howisplacentalabruptiondiagnosed?Clinically;thereisahighsuspicionifplacentapreviaisruledoutbyUS

Howisplacentalabruptionmanaged?Hemodynamic support, RhoGAM if appropriate, hospitalization; bed rest if preterm; induction of mature

fetusorC-sectionifunstablefetusormother

Whatarefourcomplicationsofplacentalabruption?1.Hypovolemicshock2.Disseminatedintravascularcoagulation(DIC)3.Pretermdelivery4.Fetaldeath

Defineplacentaprevia:Implantationofplacentaovercervicalos(complete,partial,ormarginal)

Namefourriskfactorsforplacentaprevia:1.h/oC-section2.Age>35years3.Multiparity4.Smoking

Whatisthemostcommonsignofplacentaprevia?Painlessbleeding

Howisplacentapreviadiagnosed?Ultrasound

Howisplacentapreviamanaged?Hemodynamicsupport,RhoGAMifappropriate,expectantmanagement;deliverybyCSiffetusismatureor

ifpatientisunstable

Namefourcomplicationsofplacentaprevia:1.Hypovolemicshock2.Pretermdelivery3.↑fetalanomalies(2x)4.Placentaaccreta

Defineplacentaaccretaanditsvariants,incretaandpercreta:Accreta:placentaabnormallyAttachestomyometriumIncreta:InvadesmyometriumPercreta:Penetratesthroughmyometriumtoserosa

Whatarefourriskfactorsforplacentaaccreta?1.Placentaprevia2.h/oc-section3.h/ocurettage4.Gravidasixormore

Whatarethesignsandsymptomsofplacentaaccreta?Antepartumbleeding(ifassociatedwithplacentaprevia,otherwiseasymptomatic)

Howisplacentaaccretadiagnosed?USorMRI(falsepositivecanoccurwithboth)

Howisplacentaaccretamanaged?UterinepackingtostopPPbleedingorhysterectomy

Definevasaprevia:Fetalvesselspassingovertheinternalcervicalos→cordcompressionandpossibly,rupture

Whatistheincidenceoffetalmortalityifthefetalvesselruptures?>50%

Whatisamajorriskfactorforvasaprevia?Velamentouscordinsertionwithmultiplegestation

Whatfetaltracingisassociatedwithrupturedfetalvessel?Sinusoidalwave(indicatingfetalanemia)

Whatisthetreatmentforvasaprevia?Emergentc-section

Whatisararebutdevastatingcauseofbleedingassociatedwithabdominalpainduringlabor?Uterinerupture

Whatarefourriskfactorsforuterinerupture?1.Priorc-section2.Trauma3.Overdistenteduterus4.Abnormalplacentation

PretermLabor

Whatispretermlabor(PTL)?Laborbefore37weeksGA

WhatareeightriskfactorsforPTL?1.Pretermruptureofmembranes2.h/oPTL3.Infection4.Multiplegestation5.Uterineorfetalanomaly6.Preeclampsia7.Lowsocioeconomicstatus8.Smokingtobacco

WhataretheclinicalpredictorsofPTL?Persistentuterinecontractions,fetalfibronectin(ifnegative,canhelpruleoutPTL),ongoingcervicaldilation

>3cmoreffacement>80%,vaginalbleeding,andrupturedmembranes

What are the positive and negative predictive values (PPV and NPV) for delivery within 14 days for fetalfibronectin?

PPV:16%;NPV:99%

HowisPTLmanaged?Hydration,empiricABXifGBSunknown,tocolysis,andsteroidsiffetus24-34weeksGAornegativefetal

lungmaturitytestbetween34and37weeksGA

Namefourtocolyticagents:1.MgSO42.Nifedipine3.Indomethacin4.Terbutaline

NamethreeserioustoxicitiesofMgSO4:1.Lossofreflexes2.Respiratorydepression3.Cardiacarrest

WhatisthetreatmentforMgtoxicity?Calciumgluconate

Whatarecommonsideeffectsof:NifedipineHeadacheIndocinOligohydramniosTerbutalineHypoglycemiaandtachycardia

PrematureRuptureofMembranes

Defineprematureruptureofmembranes(PROM):Spontaneousruptureofmembranesbeforeonsetoflabor;ifoccurringpreterm→PPROM

HowisPROMdiagnosed?“Gushof fluid”pervagina, sterile speculumexamination (avoiddigital examination) tovisualizedilation/

effacement;positivepool,nitrazine(alkalineblue),orferningtest

HowisPROMmanaged?Iftherearesignsofchorioamnionitis(fever,↑WBC,maternal/fetaltachycardia,uterinetenderness)treatwith

antibioticsanddelivery;inductionoflaborwithin24hofPROMiffailuretoprogress

HowisPPROMmanaged?Hospitalization,bedrest,antibiotics(topreventinfectionandtodelaylabor),+/-steroids

Whatisprolongedruptureofmembranes?Ruptureofmembraneslasting>18hbeforedelivery

WhatisthemajorfetalcomplicationassociatedwithPPROMat≥26weeksGA?Pulmonaryhypoplasia

AmnioticFluidAbnormalities

Whattermisusedtodescribeanamnioticfluidindex(AFI)5?Oligohydramnios

Whatarethetwobasicmechanismsofoligohydramnios?1.↓fetalurineoutput

2.Chronicleakthroughmembranes

Whatconditionsareassociatedwitholigohydramnios?Congenital abnormalities, rupturedmembranes, uteroplacental insufficiency,HTN,DM,ACEi, orNSAID

usage,posttermpregnancy,andtwin-twintransfusionsyndrome

WhattermisusedtodescribeAFI>25?Polyhydramnios

Whatarethethreebasicmechanismsofpolyhydramnios?1.↑fetalurineoutput2.↓fetalswallowing3.Transudationoffluidfromexposedmeninges(asinspinabifida)

Whatconditionsareassociatedwithpolyhydramnios?NTD,alimentarycanaldefect,hydrops,DM,andtwin-twintransfusionsyndrome

RhIncompatibility

IfthemotherisRh−Rh−andthefatherisRh+Rh+,whatpercentageoftheiroffspringwillbeRh+?100%

IfthemotherisRh−Rh−andthefatherisRh+Rh−,whatpercentageoftheiroffspringwillbeRh+?50%

IfawomanisRh−Rh−,bywhatmechanismcanshebecomeanti-D(IgG)positive?Previouspregnancy,bloodtransfusion,traumaincurrentpregnancy

Whatistheeffectofanti-DonanRh+fetus?Anti-DcancrosstheplacentaandcausehemolysisoffetalRBCs.

Name the fetal conditioncharacterizedby severehemolyticanemiaresulting inahyperdynamic state,heartfailure,diffuseedema,ascites,andpericardialeffusion:

Erythroblastosisfetalis

WhichpatientsshouldreceiveRhoGAMandwhy?Rh-/Ab-womenatriskforbeingpregnantwithRh+fetus

AtwhatgestationalageshouldpregnantwomenreceiveRhoGAMevenwithoutahistoryofbleeding?28weeks

MultipleGestation

Whatisthetermgiventofetaltwinsresultingfromfertilizationoftwoova?Dizygotic(alwaystwoamnionandtwochorion)

Whatisthetermgiventotwinsresultingfromonefertilizedovumthatdividesintotwo?Monozygotictwins

Ethnicity (especiallyAfrican descent), ↑ age, ↑ parity, andFHare contributing factors to ↑monozygotic ordizygotictwinning?

Dizygotic

Forthefollowingtypesofmonozygotictwins,howmanydaysafterfertilizationdidtheovumlikelydivide?Twochorion,twoamnion(DiDi),twoplacenta2-3days(beforetrophoblasticdifferentiation)Onechorion,twoamnion(MoDi),oneplacenta3-8daysOnechorion,oneamnion(MoMo),oneplacenta8-13daysConjoinedtwins13-15days(afterformationofembryonicdisk)

Whatsignsorsymptomsshouldraisethesuspicionofamultiplegestationpregnancy?Uterus larger than dates, excess maternal weight gain, hydramnios or unexplained maternal anemia,

auscultationofmorethanonefetalheart,h/oovulationinductionorinvitrofertilization(IVF);confirmationbyUS

Whatsyndromeinmonochorionictwinsoccurswhenthearterialcirculationofonetwinisincommunicationwiththevenouscirculationoftheother?

Twin-to-twintransfusionsyndrome

Whataresonographicfindingsofdichorionic,diamnionictwins?Twoplacentas,twinpeaksign,andthickinter-twinmembrane

Describethedifferencesbetweenthedonorandrecipienttwinintwin-to-twintransfusionsyndrome:Donor:anemia,growthrestriction,andoligohydramniosRecipient:polycythemia,hypervolemic,cardiomegaly,andcongestiveheartfailure(CHF)

Howaretwinsdelivered?Iffirsttwinisvertexandsecondtwinisnotsignificantlylarger,thentrialoflabor(TOL);otherwiseCS

Whatisthemostcommoncauseofposttermpregnancy?Inaccuratedating

Whattwocongenitalabnormalitiesareassociatedwithposttermpregnancy?Anencephalyandadrenalhypoplasia

FetalDiagnosticTestingandMonitoring

Whataretheindicationsforprenatalgeneticanalysisofafetus?Advancedmaternalage(AMA),⊕FHorpreviouschildwithchromosomalabnormality,fetalabnormalityon

US,abnormalserummarkerscreening,andunexplainedintrauterinegrowthretardation(IUGR)

Whatscreeningtestsareavailableforprenataldiagnosisofgeneticabnormalities?Sequentialscreen(firsttrimesternuchaltranslucencywithblooddrawplussecondtrimesterblooddraw)and

quadruplescreen(secondtrimesterblooddraw)

Atwhatgestationalagedoyouperformanuchaltranslucency?10-14weeks

Whatfourparametersaretestedinaquadscreen?1.MSAFP2.Estriol3.hCG4.InhibinA

NamefivecausesofelevatedMSAFP:

1.NTD2.Inaccuratedating3.Multiplegestation4.Fetalabdominalwalldefect5.Fetaldeath

Whatthreetestsareavailableforcheckingafetalkaryotype?1.Amniocentesis2.Chorionicvillussampling(CVS)3.Percutaneousumbilicalbloodsampling(PUBS)

Atwhatgestationalageisanamniocentesisperformedandwhatistheincidenceofcomplications?16-21weeksGA;1/200-1/300

AtwhatgestationalageisCVSperformedandwhatistheincidenceofcomplications?9-11weeksGA;0.5%-1%

WhatistheadvantageofCVSoveramniocentesis?Offersprenatalgeneticdiagnosisinthefirsttrimesterandallowsearlierandsaferpregnancyterminationif

desired

WhatisararefetalcomplicationofCVS?Limbreductiondefects

Inadditiontokaryotype,whatinformationdoesacordocentesisreveal?Fetalhematocrit,plateletcount,andfetalbloodtype

Whattwotestsarecommonlyusedtoassessfetallungmaturity?1.Lecithin/sphingomyelinratio>22.PresenceofphosphatidylglycerolinamnioticfluidNote:bothobtainedbyamniocentesis

WhatconstitutesareactiveNST?≥2accelerations(increasedHR),each≥15bpmabovethebaselinefor≥15s,allwithin20min

Whatarethefiveparametersofabiophysicalprofile(BPP)?“TesttheBaby,MAN!”1.Tone(extension/flexionoflimb)2.Breathing3.GossMovement4.AFI5.NST

WhenisaBPPperformed?WhentheNSTisnon-reactiveorequivocal

WhatisanormalBPPscore?8-10

INTRAPARTUM

NormalLaboranddelivery

Triage

Whatisthetermforirregularcontractionsnotassociatedwithcervicaldilationoreffacement?BraxtonHickscontractionsorfalselabor

Whatisthetermforregularuterinecontractionsthatcauseprogressivecervicaldilationand/oreffacement?Labor

Namethreewaystoconfirmruptureofmembranesonvaginalexamination:1.Positivepooling(lowsensitivity)2.Ferningtest3.Nitrazinetest(turnsblueduetoincreasedpH)

Doblood,semen,andvaginitiscauseafalse-positive-orafalse-negativenitrazinetest?Falsepositive

NamefiveparametersevaluatedoncervicalexaminationtoproduceaBishop’sscore:1.Dilation2.Effacement3.Station4.Consistency5.Position

Whatisthemostcommonfetalpresentation?Vertex,occiputanterior

ProgressionofLabor

Whatarethecardinalmovementsoflabor?Engagement,descent,flexion,internalrotation,extension,externalrotation(restitution),andexpulsion

Definethefollowingstagesoflabor:FirststageOnsetoflabor→fullcervicaldilation(10cm)Firststage:latentphaseOnsetoflabor→∼4cmcervicaldilationFirststage:activephase∼4cm→10cm(rapiddilation)SecondstageCompletecervicaldilation→deliveryofinfantThirdstageDeliveryofinfant→deliveryofplacenta(shouldbe30min)

Whatarethethreesignsofplacentalseparation?1.Risingandfirmingofuterus2.Gushofblood3.Umbilicalcordlengthening

Identifythedegreeoflacerationdescribedbelow:InvolvingtheskinormucosaFirstdegreeInvolvingthefasciaandmusclesofperinealbodySeconddegreeInvolvingtheanalsphincterThirddegree

Involvingtheanalmucosa(exposinglumenofrectum)Fourthdegree

IntrapartumFetalAssessment

WhatisthenormalrangeofafetalHR(FHR)?120-160bpm

Whatisthedifferentialdiagnosisforfetalbradycardia?Fetaldistress,localanesthetics,andcongenitalheartblock(seenwithmaternalSLE)

Whatisthedifferentialdiagnosisforfetaltachycardia?Fetal infection or arrhythmia; maternal fever, anxiety or thyrotoxicosis; terbutaline; fetal movement and

stimulation

WhatisthedefinitionofareactiveFHRtracing?>2accelerations(TinHR),each>15bpmabovethebaselinefor>15s,allwithin20min

Identifythefollowingthreetypesofdecelerationsandnametheiretiologies:Symmetric deceleration that begins and ends at around the same time as contractions; looks like

“mirrorimage”ofcontractionEarlydeceleration;duetoheadcompressionstimulatingvagusnerveMost common; sharp drop and return to baseline, often preceded and followed by an acceleration

(shoulders)andoccurringatanytimeVariabledeceleration;duetocordcompressionBeginsatthepeakofacontractionandslowlyreturnstothebaselineaftertheendofacontractionLatedeceleration;duetouteroplacentalinsufficiency

Whichtypeofdecelerationismostworrisome,requiringinterventionifitbecomesrepetitive?Latedeceleration

Whichtypeofdecelerationisnormalandrequiresnointervention?Earlydeceleration

Whichtypeofdecelerationisabnormalandrequiresinterventiondependingonitsseverity?Variabledeceleration

Nameanalternativetesttofetalscalpbloodsampling:Scalpstimulation(digitalstrokingoffetalscalpthatevokesanaccelerationsuggestsnormalscalppH)

AbnormalLaborandDelivery

Whatisthetermforinitiatinglaborinanonlaboringpatient?Induction

Whatarethemostcommonindicationsforlaborinduction?Maternal:PreeclampsiaandDMFetal:chorioamnionitis,IUGR,postterm,andhydrops

Name three methods used to promote cervical maturation (or ripening), which would improve inductionresults:

1.Prostaglandingel/insert2.Laminaria3.IntrauterineFoleyballoon

Nametwocommonmethodsusedtoinducelabor:1.Pitocin(oxytocin)2.Amniotomy

Nametwocomplicationsassociatedwithpitocin:1.Uterinehyperstimulation(stoppitocin,leftlateralposition,O2)2.Waterintoxication(preventwithstrictI/Omanagement)

Whattermisusedtodescribestrengtheningcontractionsinalaboringpatient?Augmentation

Nametwomethodsusedtoaugmentlabor:1.Pitocin2.Amniotomy

WhatmustbeconfirmedpriortoperformingamniotomyEngagementoffetalheadintomaternalpelvis

Whattermisusedtodescribedifficultlabor?Dystocia

Whatarethe“threeP’s”associatedwithdystocia?Abnormalitiesof:1.Power:uterinecontractilityandmaternalexpulsiveeffort(poor)2.Passenger:fetus(malpresentation,breechpresentation,shoulderimpaction,hydrocephalus)3.Passage:pelvis(androidandplatypelloidpelvictypes,uterinefibroid)

Namethefollowingtypesofbreeches(buttockpresentation):Flexedhipsandextendedfeet→feetarenearfetalheadFrank(mostcommon)Flexedhipsandoneortwoflexedknees→atleast1footnearbreechCompleteOneortwohipsextended→atleast1footbelowbreechFootling(leastcommon)

Howisfull-term,laboring,andbreechusuallymanaged?c-section

Whattwoothermethodsareusedtomanagebreechpresentation?1.Externalcephalicversion2.Trialofvaginaldelivery

Defineshoulderdystocia:Impactionofshoulderbehindpubicsymphysisafterdeliveredhead

Whataretheriskfactorsforshoulderdystocia?Macrosomia,GDM,maternalobesity,andposttermdelivery

Whatarethefetalcomplicationsofshoulderdystocia?Fractureofhumerus/clavicle,brachialplexusinjury(Erb’spalsy),hypoxia,anddeath

Namethefollowingmaneuversthatcanhelpdisplacetheshoulderimpaction:PressureonmaternalabdomenbehindpubicsymphysisSuprapubicpressureSharpflexionofmaternalhipsMcRobertsmaneuverPressureonposteriorshoulder,rotatingitincorkscrewfashion

WoodscorkscrewmaneuverPressure on accessible shoulder, pushing it toward anterior chest and decreasing shoulder-shoulder

diameterRubinmaneuverSweepposteriorshoulderacrosschest,deliveringarm,androtateshouldergirdletoobliquediameter

ofpelvisDeliveryofposteriorshoulderFractureofclavicleFractureofclavicle(lastresort)

Replaceinfant’sheadbackinpelvisandperformCSZavanellimaneuver(lastresort)

WhatarethefourmostcommonindicationsforCS?1.PriorCS2.Labordystocia3.Fetaldistress4.Breechpresentation

Womenwithwhatkindofprioruterineincisionarecandidatesforvaginalbirthaftercesarean(VBAC)trialoflabor(TOL)?

Lowtransverse,lowvertical

WhatisthemajorcomplicationassociatedwithVBAC?Uterinerupture

POSTPARTUM

Complications

Whatisthedefinitionofpostpartum(PP)hemorrhage?Lossof>500ccbloodaftercompletionofthirdstageoflabor

WhatarethethreemostcommoncausesofPPhemorrhage?1.Uterineatony2.Retainedplacenta3.Cervical/vaginallaceration

Whataretheriskfactorsforuterineatony?Uterineoverdistension(multiplegestation,hydramnios,macrosomia),multiparity,generalanesthesia,andh/o

PPhemorrhage

DescribethemanagementofPPhemorrhage:Uterine massage → oxytocin, methergine, or prostaglandin → explore uterus for retained placenta and

explorecervixandvaginaforlacerations→surgicalintervention

WhatarethesurgicalinterventionsforPPhemorrhage?PostpartumD&C,uterinearteryembolization,andhysterectomy

WhatarethreesymptomsofPPendometritis?1.Fever≥38°C(100.4°F)within36hofdelivery

2.Uterinetenderness3.Malodorouslochi

WhataresixriskfactorsforPPendometritis?1.DeliverybyCS2.Lowsocioeconomicstatus3.Youngage4.Prolongedrupturedmembranes5.Bacterialcolonizationoflowergenitaltract6.Steroids

WhatisthetreatmentforPPendometritis?Broad-spectrumABXuntilafebrilefor24h

Whatkindofcontraceptionisappropriatewhenamotherisbreastfeeding?Progestin-onlypills,Depo-ProveraMirenaorParaguardIUD,andImplanon

NamethefollowingPPpsychologicreactions:Mildtosuicidaldepressionthatbeginsat∼4weeksPPandcanlastupto1yearPPPPdepression(mayaffectupto20%ofPPmothers)TransientsymptomsofdepressionthatusuallyresolvebyPPday10Maternity/PPblues(mayaffectupto70%ofPPmothers)

Whatclinicalassessmenttoolisusedtohelpdiagnosepostpartumdepression?Edinburghdepressionscale

GYNECOLOGY

BenignGynecology

Menstruation

Describetheendocrinechangesthatoccurduringeachofthefollowingphasesofmenstruation:Follicularphase(proliferative,days1-14)1.Follicle-stimulatinghormone(FSH)→folliculardevelopment2.Estrogen→endometrialproliferationandthenFSHsuppression3.ProgesteronelowOvulation(day15)Estrogen-inducedluteinizinghormone(LH)surge→ovulationLutealphase(secretory,days15-28)1.Corpusluteumsecreteprogesterone→endometriummaturation2.↓LHandFSH3.Corpusluteumregress→↓progesteroneandestrogen

Whatconditionischaracterizedbypainfulcrampinginthelowerabdomen,withsweating,N/V,andHA—alloccurringjustbeforeorduringmenses?

Dysmenorrhea

Whatisthetreatmentforprimarydysmenorrhea?NSAIDs,oralcontraceptivepills(OCP)

Whatisthetreatmentforsecondarydysmenorrhea?Treatunderlyingdisease(endometriosis,PID,ovariancyst,fibroids)

Whatisthetermforsomaticandpsychologicsymptomsthatoccurinthesecondhalfofthemenstrualcycle,interferewithworkandpersonalrelationships,andarefollowedbysymptom-freeperiods?

Premenstrualdysphoricdisorder(PMDD)

NamesomecharacteristicphysicalsymptomsofPMDD:Bloating,breastpain,skindisorders,HA,pelvicpain,N/V,edema,andcravings

NamesomecharacteristicpsychologicsymptomsofPMDD:Irritability,aggression,tension,anxiety,sadness,moodlability,anddepression

NamesixtreatmentoptionsforthesymptomsofPMDD:1.Dietandexercise2.Selectiveserotoninreuptakeinhibitor(SSRI)3.Diureticforedema4.OCPs5.Supportbraforbreastpain6.Reassurance

AbnormalUterineBleeding

Namethetermusedtodescribethefollowingtypesofabnormaluterinebleeding:Heavy(>80cc)orprolonged(>7days)occurringatnormalintervalsMenorrhagiaIrregularmenstrualbleedingMetrorrhagiaFrequentperiodsPolymenorrheaMenses>35daysapartOligomenorrheaAbsenceofmenstrualbleedingAmenorrhea(pregnancyismostcommoncause)

Whatistheworkupforabnormaluterinebleeding?1.Excludepregnancy2.Ruleoutstructuraletiology3.Considerdysfunctionaluterinebleeding,suchasanovulatorysource

Whatisthedifferentialdiagnosisformenorrhagiaandmetrorrhagia?“LACCE”LeiomyomaAdenomyosisCervicalcancerCoagulopathyEndometrialhyperplasia,orendometriosis,polyps,cancer

Contraception/Sterilization

Whatisthegeneralmechanismofaction(MOA)ofOCP?Ovulationsuppression

Estrogen:inhibitsFSH→preventsselectionandmaturationofdominantfollicleProgestin:inhibitsLH→preventsovulation

WhatarethreeotherMOAsofbothcombinationandprogestin-onlyformulations?1.Thickencervicalmucus2.↓fallopiantubemotility3.Causeendometrialatrophy

WhataretheadvantagesofOCPs?1%failureratewithperfectuse,usually↓cramping,protectagainstovarianandendometrialcancer,↓PID

andectopicpregnancies,↓boneloss,andcauselightermenstrualflow

WhatarethedisadvantagesofOCPs?Daily pill; no protection against STDs; side effects: ↑ risk of irregular bleeding, nausea, irritability,

amenorrhea,andbreasttenderness;thrombosis;myocardialinfarction(MI);cerebrovascularaccident(CVA);andgallstones

WhatarethecontraindicationstoOCPs?Pregnancy, h/o thromboembolic d/o or stroke, chronic liver disease, undiagnosed uterine bleeding, breast

cancer/carcinoma(CA),endometrialCA,smokinginwomen>35y/o

HowmanyhoursafterintercoursemustOCPsbetakentoactasemergencycontraception?Within72h(repeatin12h)

Whataretheadvantagesofprogestin-onlypills(mini-pills)?Idealfornursingmothersandwomenwhocannottakeestrogenformedicalreasons

Whatarethedisadvantagesofprogestin-onlypills?Higherfailurerate(3%-6%),strictcompliancenecessary(musttakepillsametimeeveryday)

WhatareothermethodsofcombinedestrogenandprogesteronecontraceptivesbesidesOCPs?Vaginalcontraceptiveringandthetransdermalcontraceptivepatch

Whatisthenameofthesingle-rodcontraceptiveimplant?Implanon

Whatslow-releasing,IMinjectionofprogesteroneisgivenevery3monthsforcontraception?Depo-Provera

WhatarethesideeffectsofDepo-Provera?Irregularbleeding,conceptiondelayed9monthsfollowinglastinjection,HA,andweightgain

Whatisthemechanismofaction(MOA)ofthelevonorgestrelIUD?Levonorgestrelcausesthickenedcervicalmucousmakingspermunabletocomeincontactwiththeovum.

WhatisMOAofthecopperIUD?Copperworksasafunctionalspermacide,inhibitingspermmotilityandacrosomalenzymeactivation.

WhatarethesideeffectsofthelevonorgestrelIUD?Irregularbleedingduringthefirst3-6months,ovariancysts,acne,moodalteration

WhatarethesideeffectsofthecopperIUD?Increasedmenstrualbleedingandcramping

Whatarefourmethodsofpermanentsterilization?1.Tuballigation2.Hysteroscopicsterilization(Essure)

3.Hysterectomy(notdoneforsolepurposeofpermanentsterilization)4.Vasectomyformen

Menopause

Whatisthedefinitionofmenopause?Nomensesfor>1year

WhatisthemeanageofmenopauseintheUnitedStates?51years

Whatarethesignsandsymptomsofperimenopauseandmenopause?Hot flashes, irritability, insomnia,depression,memory loss,dyspareunia,urinaryurgency,vaginalatrophy,

and↓bonemass

Howismenopausediagnosed?Basedonhistory,↑FSH

Namethethreeindicationsforhormonereplacementtherapy(HRT):1.Treatmentofvasomotorsymptoms2.Preventionofosteoporosis(raloxifeneabetterchoice)3.Reliefofgenitourinarysymptoms(topicalestrogenspreferred)

WhatarefivecontraindicationstoHRT?1.Uterinebleedingofunknownorigin2.Liverdisease3.h/oDVTorPE4.h/obreastCA5.h/oendometrialCA

BasedontheWomen’sHealthInitiative,HRTisnolongerindicatedtopreventwhatdisease?Coronaryheartdisease

Infections

WhatagegrouphasthehighestincidenceofPIDintheUnitedStates?15-25years

AsidefromagewhataretheotherriskfactorsforPID?Multiplesexualpartners,newsexualpartner,unprotectedintercourse,h/oSTD,andh/oinvasivegynecologic

procedures

NametwoorganismsthatcausethemajorityofPIDcases:1.Neisseriagonorrhoeae2.ChlamydiatrachomatisNote:EscherichiacoliandBacteroidescausemostoftheremainderofcases.

WhatsignsarelikelytobefoundonPEinPID?Abdominaltenderness,adnexaltenderness,elevatedtemperature,andcervicalmotiontenderness(chandelier

sign)

Whatisthedifferentialdiagnosisforacutepelvicpain?“AROPE”

AppendicitisRupturedovariancystOvariantorsion/abscessPIDEctopicpregnancy

WhatarethecriteriaforhospitalizationinPID?Pregnancy,peritonitis,N/V,orabscess(tuboovarianorpelvic)

WhatisthetreatmentofPID?Broad-spectrumcephalosporinanddoxycycline(Chlamydiacoverage)

Whatconditionpresentswithrightupperquadrant(RUQ)pain,fever,N/V,andasignificanth/oPID?Fitz-Hugh-Curtissyndrome

Namethecauseofvaginitisandappropriatetreatmentineachofthefollowingclinicalscenarios:PositivewhifftestandcluecellsonwetprepBacterialvaginosisTx:metronidazolePruritisanderythema,whitedischarge,pseudohyphaein10%KOHCandida→azoleTx:antifungalsPruritis,frothydischarge,motileandflagellatedorganismsonwetprep,“strawberrycervix”Trichomonas→metronidazole(musttreatpartner)Tx:metronidazole

WhatisthetreatmentforaBartholinglandabscess?Incision and drainage (I&D),Word catheter for drainage,warm sitz baths;marsupialization for refractory

disease

Endometriosis/Adenomyosis

What disorder is characterized by the growth of functional endometrial glands and stroma outside of theuterus?

Endometriosis

Whatisthetypicalparityandageofapatientwithendometriosis?Nulliparousfemalesintwentiesandthirties

Whereisendometriosismostcommonlyfound?Uterosacralligaments,cul-de-sac,ovaries,fallopiantubes,cervix,andcolon(rarelyinlungs,bladder,kidney,

spine,arms,andlegs)

Nametwoclassicsymptomsofendometriosis:1.Cyclicpelvicpain(lesionsstimulatedbyestrogen)2.Dyspareunia

Namethreeclassicsignsofendometriosis:1.Fixedretroverteduterus(byadhesions)2.Nodularityofuterosacralligamentsandcul-de-sac3.Tenderovarianmasses

Whatisthedifferentialdiagnosisforchronicpelvicpain?Irritable bowel syndrome, interstitial cystitis, fibromyalgia, degeneratingmyomas, primary dysmenorrhea,

depression,andpriorpsychiatricabuse

Howisthediagnosisofendometriosisconfirmed?Laparoscopicvisualizationandbiopsy

What is the term for the classic lesion filledwith dark, old blood and found on the ovary in patients withendometriitis?

Chocolatecyst(endometrioma)

Whatisthetermforold,end-stageendometrioticlesions?Blackorpowderburn

Whatarethreemedicaltreatmentoptionsforendometriosis?1.Hormonalcontraception2.Gonadotropin-releasinghormone(GnRH)agonist(Lupron)3.Androgenagonist(Danazol)

Whatarethesurgicalproceduresforthetreatmentofendometriosis?Lysisofadhesionsandexcisionofendometriomasforthosewhowanttopreservefertility;totalhysterectomy

andbilateralsalpingo-oophorectomy(TAHBSO)forseveredisease

Whattermdescribestheconditioninwhichendometrialtissueisfoundwithinthemyometrium?Adenomyosis

Adenomyosispeaksinwhichdecades?Fortiesandfifties(commonlyinmultiparousfemales)

Whatisthetriadofsymptomsinadenomyosis?1.Dysmenorrhea(noncyclic)2.Menorrhagia3.Enlargeduterus

Whatisthedifferentialdiagnosisofadenomyosis?Myomas,dysfunctionaluterinebleeding,andpregnancywithbleeding

Whatisthedefinitivemethodofdiagnosisandultimatetreatmentofadenomyosis?Hysterectomy

Leiomyoma/Leiomyosarcoma

Whatisthemostcommonpelvictumor?Leiomyoma(myoma/fibroid)=benignneoplasmofsmoothmuscle

Whatistheprevalenceofleiomyomasinwhiteandblackwomen?Foundin25%ofwhitewomenand50%ofblackwomen(usuallyofreproductiveage)

Namefivetypesofdegenerationsaleiomyomamayundergoonceitoutgrowsitsbloodsupply:1.Hyaline2.Myxomatous3.Calcific4.Red(painfulhemorrhageoftenwithpregnancy)5.Cystic

Whatsymptomsareassociatedwithleiomyoma?Abnormaluterinebleedingandpelvicpressure(majority,however,areasymptomatic)

Howareleiomyomasdiagnosed?

Usuallybybimanualpelvicexamination;imaging:US,abdominalx-ray(concentriccalcifications),CTandMRI(rarelynecessary)

Whatarethesurgicaloptionsforunremitting,symptomaticleiomyomas?Myomectomy and uterine artery emoblization for patients who wish to preserve fertility, otherwise

hysterectomy

OvarianCyst

Whatisthemostcommontypeoffunctionalovariancyst?Follicularcyst(usuallyasymptomatic)

WhattypeofovariancystdevelopsbilaterallyinresponsetoelevatedhCGlevels?Thecaluteincyst

Howareovariancystsdiagnosed?PelvicexaminationandUS

Whatisthedifferentialdiagnosisforanadnexalmass?Ovarian cyst, ectopic pregnancy, ovarian torsion, tuboovarian abscess (TOA), endometrioma, fibroid, and

ovarianneoplasm

PelvicMass

Whatisthemostlikelydiagnosisforapelvicmassassociatedwiththefollowingfindings?Painless,heavyuterinebleedingLeiomyomaAmenorrheaPregnancyDysmenorrheaEndometriosis,adenomyosis,ectopicpregnancy,corpusluteumwithendometriomaPostmenopausalOvariancancerSignificanth/oPIDTOA

GYNECOLOGYONCOLOGY

VulvarDysplasiaandCancer

Whatarethesignsandsymptomsofvulvarcancer(CA)?Pruritis,raisedwhitelesion,ulceration,exophyticmass,andbleeding(mostareasymptomatic)

Howisvulvarcancerdiagnosed?Biopsyanysuspiciouslesion

Whatisthemostcommonhistologictypeofvulvarcancer?Squamouscellcarcinoma

CervicalDysplasiaandCancer

Whataretheriskfactorsforcervicaldysplasiaandcervicalcancer?Human papillomavirus (HPV) infection (especially types 16, 18, 31, 33), early intercourse, multiple sex

partners,lowsocioeconomicstatus,cigarettesmoking,andHIV

Whatisthemostimportantscreeningtoolforcervicaldysplasiaandcancer?Papsmear

WhataretheguidelinesforinitiatingroutinePapsmears?StartannualPapsmearoneverywoman>21y/oorwithin3yearsofonsetofsexualactivity

Whatarethetwomajortypesofcervicalcancers?1.Squamouscellcarcinoma(90%)2.Adenocarcinoma(includingclearcellcarcinomafromDESexposure)

Whatarefivesymptomsofcervicalcancer?1.Postcoitalbleeding2.Irregularbleeding3.Lowerextremityedema4.Renalfailure5.Pelvicpain/pressure

Whichcanceristheonlygynecologiccancerthatisstagedclinicallyandnotsurgically?Cervicalcancer

Describethegeneralanatomicspreadofcervicalcancerineachofthefollowingstages:StageIConfinedtocervixStageIIExtendsbeyondcervixbutnottopelvicwall,involvesuppertwo-thirdsofvaginaStageIIIExtends topelvicwall, involves lowerone-thirdofvaginaand/orcauseshydronephrosisornonfunctioning

kidneyStageIVExtendsbeyondpelvis,involvesbladderorcolonmucosa

Whataretreatmentoptionsforcervicalcancer?Conization, trachelectomy, radical hysterectomy, primary chemoradiation and ajuvant chemoradiation. Tx

optionsdependonstageandpatient’sdesiretopreservefertility.

EndometrialHyperplasiaandCancer

Whataresixmajorriskfactorsforendometrialhyperplasiaandendometrialcancer?Unopposedestrogenexposure:1.Obesity2.Nulliparity3.Latemenopause>55years4.Chronicanovulation5.Polycysticovariansyndrome(PCOS)6.Tamoxifen

Whatisthetypicalpresentationofendometrialhyperplasia?Abnormaluterinebleedingoroligomenorrhea

Howisendometrialhyperplasiadiagnosed?EndometrialbiopsyorD&C

Whatisthetreatmentforendometrialhyperplasia?Progestin therapy for simple, complex, and atypical simple hyperplasia; TAHBSO for atypical complex

hyperplasia

WhatisthemostcommongynecologiccancerintheUnitedStates?Endometrialcancer

Whatisthemostcommonsymptomofendometrialcancer?Postmenopausalbleeding(>90%)

Whatisthedifferentialdiagnosisforpostmenopausalbleeding?Endometrial hyperplasia or cancer, uterine/cervical polyp, exogenous estrogens, cervicalCA, and atrophic

vaginitis(ifolderpatient,mustruleoutmalignancy)

Howisendometrialcancerdiagnosed?Endometrialbiopsy

Whatpercentageofwomenwithpostmenopausalbleedingwillhaveendometrialcancer?10%

Whatfoursurgicalproceduresareinvolvedinthestagingofendometrialcancer?1.Explanatorylaparotomy2.TAHBSO3.Pelvicwashing(cytology)4.Pelvicandaorticlymphnodedissection

OvarianCancer

Whichgynecologiccancerhasthehighestmortalityrate?Ovariancancer(usuallydiagnosedatStageIIIorIV)

Whatarethethreebasichistologictypesofovariancancers?1.Epithelial2.Germcell3.Sexcord-stromal

Epithelial

Epithelialovariancanceraccountsforwhatpercentageofovarianmalignancies?90%

Whataretheriskfactorsforovariancancer?Advancedage,Caucasianrace,nulliparity,andFHofbreastcolonorovariancancer

Whataretheprotectivefactorsforovariancancer?Breastfeeding,OCP,tuballigation,hysterectomy,andmultiparity

Whataretheearlyandlatestagesignsofovariancancer?Early:asymptomatic

Late:pelvicmass,fluidwave,bowelobstruction

Whatarethethreegoalsofsurgeryinepithelialovariancancer?1.Establishdiagnosis2.Stage(extentofdisease)3.Debulkallvisiblediseaseifadvancedcancer(includeTAHBSOandnodes)

Nametwoadjuvantchemotherapiesforepithelialovariancancer:1.Carboplatin2.Paclitaxel

Nonepithelial

Whattwohistologictypescomprisethenonepithelialtumors?1.Germcelltumors(GCT)2.Sexcord-stromaltumors

WhatpercentofGCTsarebenign?95%

InwhatagegroupareGCTsusuallydiagnosed?Teensandtwenties

GCTsarisefromwhatkindofcells?Totipotentialgermcells

WhatarethesignsandsymptomsofGCTs?May grow rapidly → pain from distension, torsion, or hemorrhage; adnexal mass, ascites, and pleural

effusion

WhatethnicitiesareatgreaterriskfordevelopmentofGCTs?Asians/AfricanAmericans

Describethegeneralanatomicspreadofovariancancerineachofthefollowingstages:StageILimitedtoovariesStageIIExtensionfromovariestopelvisStageIIIExtensiontoabdominalcavityStageIVDistantmetastaticdisease

NamethetypeofGCTscharacterizedbyeachofthefollowingstatements:MostcommonmalignantGCT;maybebilateral;↑LDH;excellentprognosisDysgerminomaYolksactumor;Schiller-Duvalbodies;↑alpha-fetoprotein(AFP);poorprognosisEndodermalsinustumorComprise 30% of all ovarian neoplasms; benign cystic teratoma; struma ovarii; and carcinoid

syndrome;derivedfromembryonictissueMatureteratomaCalcifications (like benign teratoma); cells from all three germ layers; excellent prognosis in early

stagesImmatureteratomaRare;usuallydiagnosedat20years;↑β-hCGChoriocarcinoma

Namethetypeofsexcord-stromaltumorcharacterizedbelow:Estrogensecretion→precociouspuberty;endometrialhyperplasia;Call-Exnerbodies;inhibintumor

markerGranulosa-thecacelltumorTestosteronesecretion→virilization;hirsutism;testosteronetumormarkerSertoli-Leydigcelltumor

Whatsyndromeischaracterizedbythetriadofovariantumor,ascites,andrighthydrothorax?Meigsyndrome

GestationalTrophoblasticNeoplasm

Whatisgestationaltrophoblasticneoplasm(GTN)?Rareneoplasmsderivedfromabnormalproliferationofplacentaltissue

Identifythefollowingthreetypesofhydatidiformmoles(molarpregnancies):SpermfertilizesanovumthatlacksDNA;karyotypeofproductis46XX(paternalDNAduplicates),no

fetalparts,oftensignsofhyperemesisgravidarum,hyperthyroidism(rare)CompletemoleTwospermsfertilizenormalovum,karyotypeofproductis69XXY,fetalpartspresentIncompletemoleBenignGTNthathasbecomemalignant,penetratesmyometrium,rarelymetastasizesInvasivemole

Whatarethesignsandsymptomsconsistentwithmolarpregnancy?Passageofgrape-likevesicles,new-onsetHTN20weeksGA

Whatdiagnosticabnormalitiesaretypicalofmolarpregnancy?hCG>100,000;absenceoffetalheartsounds;“snowstorm”onUS

Whatarethefourmajorcomponentsofthemanagementofamolarpregnancy?D&C to evacuate and terminate pregnancy, follow-up with weekly hCG, CXR and LFTs to check for

metastasis

Whatmalignantgestationaltrophoblastictumormayoccurwithorafterpregnancy(includingectopic,molar,orabortion)?

Choriocarcinoma

Whatisthecharacteristichistopathologyofchoriocarcinomaandhowdoesitspread?Invasivesheetsoftrophoblastsassociatedwithhemorrhageandnecrosis;metastasizeshematogenously

Whatisthetreatmentforchoriocarcinoma?Chemotherapy(almost100%remissionifnonmetastatic)

REPRODUCTIVEENDOCRINOLOGY

Infertility

Whatisthedefinitionofinfertility?

Inabilitytoconceiveafter12monthsofunprotectedsexualintercourse

Whatistheincidenceofinfertilityamongcouples?15%

Whatarefourmajorcategoriesofinfertility?1.Malefactor(30%)2.Ovulatorydefect(30%)3.Tubalfactor(30%)4.Unknown/otherfactors(10%)

Whatlaboratorystudiesareusefulintheevaluationofaninfertilecouple?TSH,FSH,andprolactinandsemenanalysis

Whatisanormalspermcountinsemenanalysis?>20million/mL

Whatarethreemethodsusedtoestablishovulation?1.Basalbodytemperature:should↑by0.5°C(32.9°F)afterovulationoccurs2.Progesterone:↓ng/mLinlutealphaseconfirmovulation3.Endometrialbiopsy:shouldseesecretoryphase

Howaretheuterusandfallopiantubesevaluatedintheworkupoffemalefactorinfertility?Hysterosalpingography: lookforobstruction→ifnegative→exploratorylaparoscopy: lookforadhesions,

endometriosis

Whatisthetreatmentofinfertilitycausedbyanovulation?ClomipheneorFSH

DysfunctionalUterineBleeding

Definedysfunctionaluterinebleeding:Anovulatory,abnormaluterinebleedingduetohormonaldisruptionandnotduetoorganiccause(eg,polyps/

cervicitis)

Howisdysfunctionaluterinebleedingdiagnosed?Diagnosis of exclusion; must rule out organic lesions of reproductive tract, iatrogenic causes, gestational

disorders,andcoagulopathies

Nametwocommonsituationsinwhichdysfunctionaluterinebleedingmayoccur:1.Extremesofreproductivelife:adolescentswhohavenotyetestablishedregularcyclesandperimenopausal

women2.Afterchangesinlifestyle:factorssuchasdietandstresscancauseregularcyclestobecomeirregular

Amenorrhea

Whatisthedefinitionofprimary(1°)amenorrhea?Absenceofmensesbyage16despitesecondarysexualcharacteristics

WhataretheMullerianstructures?Fallopiantubes,uterus,andupperone-thirdofvagina(notovaries)

Whatarethreegeneralcausesof1°amenorrhea?

1.Outflowtractobstruction2.Ovarianfailure3.Hypothalamicdisorder

Iftheuterusisabsent,whattestshouldbeorderedintheworkupof1°amenorrhea?Karyotype

Whatisthedefinitionof2°amenorrhea?Absenceofmenses>6monthsinawomanwithh/onormalmenses

Whatisthemostcommoncauseof2°amenorrhea?Pregnancy

Namethecauseof2°amenorrheadescribedbelow:Uterinescarring,adhesionsfromD&C,CS,ormyomectomyAshermansyndromeSurgicalorobstetricaltraumaCervicalstenosisPan-hypopituitarismresultingfrompituitaryinfarctioncausedbyPPshockorhemorrhageSheehansyndrome

↑prolactinproductionProlactinomaIdiopathicorduetowedgeresectionofovaryPrematureovarianfailureExcessiveexercisingHypothalamicetiology

↓T3/T4→↑thyrotropin-releasinghormone(TRH)andprolactinHypothyroidismChronicanovulation,↑LH/FSHratio;triadofamenorrhea,hirsutism,andobesityPolycysticovariansyndrome(PCOS)SideeffectofantipsychoticmedicationsDrug-inducedhyperprolactinemia

PatientswithPCOSareatriskforwhatthreeconditions?1.Infertility2.DM3.Endometrialhyperplasia/CA

Providethetreatmentforthefollowingcausesofamenorrhea:HypothalamicTumorremoval,weightgain,stressrelief,andexogenousGnRHPituitaryTumorremoval,bromocriptine(prolactininhibitor),andexogenousFSH/LHOvarianPCOS:Clomipheneforfertility,progestin-containingcontraceptiontopreventendometrialhyperplasia,and

weightlosstopreventDMOvarianfailure:OCPs,donoreggUterineSurgeryforlysisofadhesions

UROGYNECOLOGY

PelvicProlapse

Namefourtypesofpelvicprolapses:1.Cystocele2.Rectocele3.Enterocele4.Uterineprolapse

Whataretheriskfactorsforpelvicorganprolapse?Childbirthinjury,aging,estrogendeficiency,connectivetissueweakness,constipation,obesity,andcoughing

Whatarethesignsandsymptomsofpelvicorganprolapse?Pressure,organprotrusion,incontinence,dyspareunia,groinpain

Howispelvicorganprolapsediagnosed?Manualinspectionofurethra,vagina,perineum,andanalsphincter

Whatarenonsurgicalmanagementoptionsforpelvicorganprolapse?Lifestyle changes: stop smoking, lose weight, Kegel exercises, prevent constipation; pessary: intravaginal

devicetosupportprolapse

Whenissurgicaltreatmentagoodoptionforpelvicorganprolapse?Symptomaticprolapserefractorytopessary

UrinaryIncontinence

Providethenameandtreatmentforeachtypeofincontinencedescribedbelow:Bladderpressure→urethralpressureduetoincreasedabdominalpressurefromcoughing,sneezing,

runningStressincontinence(usuallyduetourethralhypermobility±sphincterdysfunction)Tx:Kegelexercises,estrogentherapy,alpha-adrenergicdrugs,surgery(Burch,transvaginaltape[TVT])OveractivityofbladdersmoothmuscleDetrusorinstabilityorurgeincontinence(maybeduetoneurologicdiseaseorirritation)Tx:anticholinergicsandtimedvoiding

OverdistensionofbladderOverflowincontinenceTx:alpha-adrenergics,striatedmusclerelaxants,andself-catheterization

MAKETHEDIAGNOSIS

40-y/o G4P5 female who just delivered twins followed by two whole placentas now has copious vaginalbleeding;PE:∼800ccbloodin5min,boggyuterus

Uterineatony

60-y/o postmenopausal, nulliparous, obese female with 5-year h/oHRT presents with vaginal spotting; PE:normalpelvicexamination;workup(w/u):abnormalendometrialbiopsy

Endometrialcancer

39-y/oG2P1blackfemaleat28weeksgestationpresentswithincreasingleftlowerquadrant(LLQ)tenderness;PE:abdominaltenderness,asymmetricuterineshape;US:5cmX7cmuterinemass

Submucosalleiomyoma(withreddegeneration)

45-y/o female with recent h/o hysterectomy now presents with constant urinary leakage; PE: clear fluid invaginalvault;w/u:clearfluid,Cr=15,⊕methylenebluetest

Vesicovaginalfistula

30-y/oG1P0obese female at 32weeks gestation (verifiedbyLMP)presents forher first prenatal visit;PE:fundalheight=37cm,FHTarewithinnormallimits(WNL);US:AFI=27withsingleintrauterinepregnancy;glucola=210mg/dL

Gestationaldiabetesmellitus(GDM)

23-y/oG1P0femaleat12weeksgestationpresentswithvaginalspottingandN/V;PE:3-cmcervicaldilation;US:intrauterinepregnancywithcardiacactivity

Inevitableabortion

25-y/o G1P1 female who just delivered a 3500-g baby continues to have vaginal bleeding after delivery ofplacenta;PE:vaginallacerationdissectingtheperineumwithanintactanalsphincter

Second-degreelaceration

23-y/onulligravid femalewithmultiplepartnerspresentswithabdominal tendernessand fever;PE:cervicalmotiontenderness,uterinetenderness,noadnexaltenderness,nogenital lesions;US:uterusandadnexaeareWNL.

Pelvicinflammatorydisease(PID)

32-y/oG2P1femaleat37weeksgestationpresentsinlabor;PE:activephaseoffirststageoflabor;w/u:FHR=130bpm,tracingshowsshallowsymmetricaldecelerationsinthe“mirrorimage”ofeachcontraction.

Fetalheadcompression

42-y/oG2P1Asianfemaleat10weeksgestationpresentswithN/V;PE:↑HR,↑BP,closedcervicalos;w/u:β-hCG=10,000;USshows“snowstorm”patternandnoIUP;karyotype:46XX

Completemolarpregnancy

18-y/o sexually active female presents for annual gynecologic examination; PE: red and tender cervix, nouterineoradnexaltenderness;w/u:nogrowthonculture

CervicitisfromChlamydiainfection

68-y/oCaucasianfemalewithh/oovariancancer,surgicalstaging,andtaxol/carboplatintherapy2yearsagonowpresentswithbloating;PE:ascitesandweightloss;w/u:CA-125=1200

Recurrentovariancancer

19-y/o G1P0 black female with twin gestation at 35 weeks gestation presents with headaches and blurredvision;PE:BP =148/102, facial edema, no abdominal tenderness or hyperreflexia;w/u: 2 protein on urinedipstick

Mildpreeclampsia

28-y/oG3P2 female presents at term in labor; PE: fetal head at top of fundus byLeopoldmaneuvers;US:breechpresentationwithbothfeetnearfetalhead

Frankbreech

30-y/oG2P1femaleat34weeksgestationpresentedwithPTLandhasbeenonMgSO4for24h;PE:lethargy,↓↓DTRs;w/u:ECGshows↑PRandQTintervals.

Magnesiumtoxicity(>10meq/L)

17-y/o G1P1 single female who is 7 months PP now presents with 6-month h/o weight loss, insomnia, anddysphoria;PE:poorattentiontopersonalappearance;w/u:TFTsareWNL.

Postpartumdepression

31-y/onulligravidfemalewithh/oinfrequentmensesandType2DMpresentswithinfertility;PE:obese,facialhair,femalephenotype;w/u:LH/FSH>3;progesteronechallengetestinducesmenses.

Polycysticovariansyndrome(PCOS)

18-y/oG1P0 female at 22 weeks gestation presents with persistent N/V; PE: poor skin turgor, drymucousmembranes;w/u:hypochloremicalkalosis;TFT,LFTs,amylase,andlipaseareallWNL.

Hyperemesisgravidarum

37-y/oG2P1blackfemaleat34weeksgestationwhosmokes1/2ppdpresentswithpainfulvaginalbleedingandcontractions;PE:↑HR,uterinetenderness,bloodinvaginalvault

Placentalabruption

65-y/oG4P4femalewithh/ochronicbronchitispresentswithurinaryincontinencewhencoughingorlaughing,butdeniesnocturia;PE:incontinencewhenaskedtocough,cottonswabtest=45°;UAandcultureareWNL.

Stressincontinence

24-y/o G1P0 female at 28 weeks gestation presents for a routine US; PE: consistent with 28-week twingestation; US: same-sex twins sharing one placenta, with polyhydramnios of one amniotic sac andoligohydramniosoftheother;fetalweightdifference>20%

Twin-to-twintransfusionsyndrome

21-y/ofemalewithh/oPIDpresentswithcrampingandvaginalspotting;PE:abdominaltenderness;w/u:⊕β-hCG;US:emptyuterus

Ectopicpregnancy

23-y/oG2P2femalewithh/ouncontrolledType1DMpresents1dayafterCSwithfever;PE:fever=38.8°C(102°F),uterinetenderness,andmalodorouslochi;w/u:WBC=16,000;UAandurineculturearenegative.

Endometritis

39-y/oG2P1femaleat18weeksgestationpresentsforroutineprenatalcarevisit;PE:consistentwith18-weekpregnancy;w/u: triple screen shows ↓AFPand estriol, and ↑ β-hCG;US: thickened nuchal skin and shortfemurs

Downsyndromefetus(increasedlikelihood)

30-y/oG1P0Caucasian femaleat32weeksgestationpresentswithmalaise,N/V,andabdominal tenderness;PE:BP=150/98,RUQtenderness;w/u:platelets=70,000,↑LFTs;peripheralbloodsmearshowshemolysis.

HELLPsyndrome

36-y/o HIV-positive female with h/o tobacco and heroin use presents with vaginal spotting; PE: cachexia,friablecervixwithamass

Cervicalcancer

27-y/onulligravidfemalepresentswith6-monthh/opelvicpainthatincreaseswhensheismenstruating;PE:tenderleftovary;US:3-cmleftadnexalmass;UA,cultures,andpregnancytestareallnegative.

Endometrioma

29-y/o G1P0 female at 31 weeks gestation presents with complaint of leaking clear fluid; she deniescontractions,vaginalbleeding,orfevers;PE:sterilespeculumexaminationshowspoolofclearfluidinvaginalvault;w/u:nitrazinetestisblue.

Pretermprematureruptureofmembranes(PPROM)

61-y/o G5P5 female with h/o traumatic labor 20 years prior presents with pelvic pressure and urinaryfrequency;PE:cervixvisualizedandpalpatedjustbehindtheintroitus

Prolapseduterus

36-y/o G2P2 female with h/o abdominal hysterectomy for unrelenting postpartum hemorrhage andhypotension(8monthsago)presentswith2°amenorrheasincethen;w/u:negativeβ-hCG,↓serumprolactin

Sheehansyndrome

24-y/oG1P0femaleat33weeksgestationishospitalizedforpolyhydramniosofunknownetiology;PE:fundalheightgreaterthandates;w/u:fetalhearttracingshowssinusoidalwavepattern.

Cordprolapsed

32-y/oG3P3withh/o retainedplacenta requiringD&C,nowat 12monthspostpartumwith lack ofmensessincedelivery

Ashermansyndrome

27-y/oG2P1withh/opriorcesareansectionattemptingtrialoflaborafterc-sectionwithchangeinstationfrom+1to2andlossofuterinetoneseenontocometryandrecurrentlatedecelerations

Uterinerupture

22-y/oG0 attempting pregnancy for 12months without success. She reports symptoms of headache, visionchanges,andgalactorrhea.PE:WNL

Pituitaryadenoma(prolactinsecreting)

17-y/ofemalepresentswithvulvarpainandextremedifficultywithplacementofatampon.PE:positiveQ-tiptest

Vulvarvestibulitis

26-y/oG2P1femalewhopresentswith1-weekhistoryofthin,malodorousdischarge,worseafterintercourse.Wetmountreveals>20%cluecells.

Bacterialvaginosis

CHAPTER6Pediatrics

GENETICDEFECTS

Namethetrisomyinthefollowingdescriptions:Endocardial cushion defects, duodenal atresia, Hirschsprung disease, hypothyroidism, mental

retardation(MR),leukemia,Alzheimer-likedementiaTrisomy21(Downsyndrome)Trisomyassociatedwithrocker-bottomfeetandmicrognathiaTrisomy18(Edwardsyndrome)Trisomy associated with micophthalmia, holoprosencephaly, polydactyly, microcephaly, and cleft

lip/palateTrisomy13(Patausydrome)MostcommonchromosomalabnormalityTrisomy21(Downsyndrome)

Whatsyndromeischaracterizedbythekaryotype45,XO?Turnersyndrome

NamefivedysmorphicfeaturesassociatedwithTurnersyndrome:1.Lymphedemaofthehandsandfeet2.Shield-shapedchest3.Widelyspacednipples4.Webbedneck5.Lowhairline

NamethecommoncardiacdefectsassociatedwithTurnersyndrome:Coarctationoftheaorta,bicuspidaorticvalve,andaorticstenosis

Whatgonadalabnormalityoccursin100%ofTurnerpatients?Gonadaldysgenesis

WhatisthetreatmentregimenforTurnerpatients?Growthhormoneforshortstatureandestrogen/progesteroneforsecondarysexualdevelopment

Whatisthemostcommoncauseofhypogonadisminmales?Klinefeltersyndrome(47,XXY)

WhatarefiveclinicalmanifestationsofKlinefeltersyndrome?1.Smallphallus2.Smalltestes(hypospermia)3.Gynecomastia4.Increasedheight5.LearningdisabilitywithnormalIQ

WhatisaBarrbody?AninactivatedXchromosomeassociatedwithKlinefeltersyndrome

WhathormoneisusedtotreatKlinefeltersyndrome?

Testosterone(improvessecondarysexualcharacteristicsandpreventsgynecomastia)

WhatsyndromeisassociatedwithuncontrollableappetiteandPickwickiansyndrome?Prader-Willisyndrome

WhatisthemodeofinheritanceinPrader-Willisyndrome?Paternalimprinting

Whatdiseaseisknownasthe“happypuppet”syndrome?Angelman syndrome, due to ataxic gait and tiβ-toe walk (patients also have severeMR and episodes of

uncontrollablelaughter)

WhatisthemodeofinheritanceinAngelmansyndrome?Maternalimprinting

Whatinheritedsyndrome,characterizedbyseverementalretardation,iscausedbytrinucleotiderepeats?FragileXsyndrome

CONGENITALHEARTDISEASE

Namethefivecongenitallyacquiredcyanoticheartlesions:“12345”1.Truncusarteriosus(onearterialvesseloverridesventricles)2.Transpositionofthegreatvessels(twoarteriesareswitched)3.Tricuspidatresia4.TetralogyofFallot5.Totalanomolouspulmonaryvenousreturn(fivewords)

Namethecyanoticheartlesiondescribedinthefollowingsituations:Mostcommoncyanoticlesionpresentinginthefirst2weeksoflifeTranspositionofthegreatvessels“Boot-shapedheart”anddecreasedpulmonaryvascularmarkingsonchestx-rayCXRTetralogyofFallotCardiomegalyandan“egg-shapedsilhouette”onCXRTranspositionofthegreatvesselsTreatmentconsistsofarterialswitchperformedinthefirst2weeksoflife.Transpositionofthegreatvessels(leftventriclewilldecompensateifprocedureisdelayed>2weeks)CardiacdefectwhereinpulmonaryvenousbloodisdirectedtotherightatriumTotal/paritalanomalouspulmonaryvenousreturnCharacterized by periods of increased right outflow obstruction that cause cyanosis by increasing

right-to-leftshuntingTetralogyofFallot(”tetspells”)

NamethefourdefectsintetralogyofFallot:“PROVe”1.Pulmonicstenosis2.Rightventricularhypertrophy3.“Overridingaorta”4.Ventricularseptaldefect(VSD)

Whatcongenitalheartlesionisdefinedastricuspidvalvedisplacementintotherightventricle?Ebsteinanomaly

WhichmaternallyingesteddrugisassociatedwithEbsteinanomalyinthechild?Lithium

Namethreeacyanoticheartlesions:1.VSD2.Atrialseptaldefect(ASD)3.Patentductusarteriosus(PDA)—allcontaintheletter“D”.

Whatisthemostcommoncongenitalheartdefect?VSD

Whatisthefearedcomplicationofalarge,untreatedVSD?Eisenmengersyndrome

Whatresultsfromadeficiencyoftheendocardialcushion?Atrioventricular(AV)canaldefect—ostiumprimumASDandinletVSD

WhatcongenitalinfectionisassociatedwithaPDA?Rubell-A→PDA

Whatisthemodeofinheritanceinhypertrophiccardiomyopathy?Autosomaldominant

Whataretheprominentsymptomsinhypertrophiccardiomyopathy?Chestpain,dyspneaonexertion,andsyncope(commoncauseofsuddencardiacdeathinathletes)

NamethebradyarrhythmiainthefollowingECGdescriptions:ProlongedPRintervalwitharegularrhythmFirst-degreeheartblockProgressiveprolongationofthePRintervaluntilaQRScomplexismissedMobitztypeI(Wenckebach)SuddendisruptioninAVconductionwithnoprogressiveprolongationofthePRintervalMobitztypeII“CompleteAVdissociation”Third-degreeheartblock

Whatarethemostcommoncausesofsinustachycardia?Fever,dehydration,exercise,andanemia

NamethekeyECGmanifestationofWolff-Parkinson-Whitesyndrome:Deltawave(causedbypreexcitationoftheventricleviaanaccessorypathway)

WhichantiarrhythmicdrugiscontraindicatedinWolff-Parkinson-Whitesyndrome?Digoxin (by slowing theAVnode, an accessory pathway can repolarize andpotentially create a reentrant

circuit)

DEVELOPMENT

Milestones

Atwhatageisanaveragechildexpectedto:Walk

12monthsRun18monthsDisplaystrangeranxiety7monthsUseapincergrasp9months(thenumber“9”ismadewhenthepincergraspisheldupsidedown)Holdtheirheadup3monthsSitupwithoutsupport6monthsSaytheirfirstword12months(1wordat1year)Usetwo-wordcombinations24months(2wordsat2years)Usethree-wordsentences36months(3wordsat3years)Crawl9monthsWalkupanddownstairs24monthsFeedhimself/herselfwithutensils18months

Listthesequenceofeventsthatoccurinfemalepuberty:Thelarche(breastdevelopment)

Pubarche(developmentofpubichair)GrowthspurtMenarche(firstmenstrualperiod)

Listthesequenceofeventsthatoccurinmalepuberty:TesticularenlargementPubarche

PenileenlargementGrowthspurt

NametheTannerstage:BreastbuddevelopmentandenlargementofareolardiameterTannerstageIIIncreaseddarkeningofscrotalskinTannerstageIV

Vaccinations

Namethecurrentrecommendedchildhoodvaccinations:HepatitisBvaccine,diphtheriatoxoid,tetanustoxoid,pertussisvaccine,Haemophilusinfluenzaetypeb(Hib)

vaccine, pneumococcal vaccine, poliomyelitis vaccine, rotavirus vaccine, influenza vaccine, measles vaccine,mumpsvaccine, rubellavaccine,varicellavaccine,HepatitisAvaccine,meningococcalvaccine,HPVvaccine(girlsonly)

Whatvaccineisadministeredshortlyafterbirth?HepatitisBvirusvaccine(hepatitisBatBirth)

Listthevaccinationregimenforthefollowingorganisms:HepatitisBBirth/1-2months,6-18monthsPolio

2months,4months,6-18months/4-6yearsMeasles,mumps,andrubella(MMR)12-15months,4-6yearsDiphtheria-tetanus-pertussis(DTaP)2months,4months,6months,15-18months/4-6years;tetanusboosterrequiredevery5-10yearsHaemophilusinfluenzaetypeb(Hib)2months,4months,6months,12-15monthsPneumococcus(PCV)2months,4months,6months,12-15months

WhattypeofpoliovaccineisrecommendedintheUnitedStates?Inactivatedpoliovaccine(IPV)(theoralvaccine[OPV]isthenumberonecauseofpoliointheUS)

Whatagemustachildbeinordertoreceiveavaricellavaccination?>12months

Namethevaccination(s):ContraindicatedinimmunocompromisedpatientsMMR,varicella,andoralpoliovaccine(OPV)ContainingeggproteinMMRandinfluenzaRequiredinasplenicpatientsPneumococcal,meningococcal,andHibvaccines(thesearetheencapsulatedorganismvaccines)Contraindicatedinpatientswithprogressiveneurologicdisordersorencephalopathywithin7daysof

administrationDTaP(thepertussiscomponentisassociatedwithseizures)ConjugatedvaccinationsHib,meningococcal,andpneumococcalvaccines

FailuretoThrive

Definefailuretothrive(FTT):FTTisaconditioninwhichachild’sweightorheightislessthanthethirdtofifthpercentileforageorhas

fallenacrosstwomajorpercentiles.

ListthemajorriskfactorsofFTT:1.Lowsocioeconomicstatus2.Lowmaternalage3.Lowbirthweight4.Caregiverneglect5.Pathologicdisease

WhatarecommonorganiccausesofFTT?1.Congenitalheartdisease2.Cysticfibrosis3.Celiacdisease4.Pyloricstenosis5.Infection6.Gastroesophagealreflux

IMMUNODEFIENCYSYNDROMES

AtwhatagedoT-cellimmunodeficienciespresentandwhattypeofinfectionsoccur?1-3months;broadrangeinfections(fungal,bacterial,viral)

ListtwoofthemostcommonT-celldeficiencysyndromes:1.DiGeorgesyndrome2.Ataxia-telangiectasia

WhatistheembryonaldeformityinDiGeorgesyndrome?Agenesis of the third and fourth pharyngeal pouch (responsible for the development of the thymus and

parathyroidgland)

ListtheclinicalmanifestationsofDiGeorgesyndrome:CATCH-22Cardiacanomalies(tetralogyofFallot,interruptedaorticarch,andvascularrings)AbnormalfaciesThymichypoplasiaCleftpalateHypocalcemia22(chromosome22q11microdeletion)

Listthecharacteristicsofataxia-telangiectasia:Cerebellar ataxia, oculocutaneous telangiectasia, decreased T-cell function, and low antibody levels

(consideredtobecombinedimmunodeficiencyinsometexts)

AtwhatagedoB-celldeficiencysyndromestypicallypresent?6months(maternalantibodiesprotectinfantuptothisage)

WhattypeofinfectionsoccurinB-celldeficiencysyndromes?Recurrentupperrespiratoryinfectionsandbacteremiacausedbyencapsulatedorganisms

NamethethreemostcommonB-celldeficiencysyndromes:1.X-linkedagammaglobulinemia2.Commonvariableimmunodefiency3.SelectiveIgAdeficiency

Namethediseasecharacterizedbyatotallackofantibodyproduction:X-linked(Bruton)agammaglobulinemia

Namethediseasecharacterizedbyrecurrentrespiratory,GI,andurinarytractinfections:SelectiveIgAdeficiency

ListthetwomostcommoncombinedB-andT-cellimmunodeficiencysyndromes:1.Severecombinedimmunodeficiencydisease(SCID)2.Wiskott-Aldrichsyndrome

WhatisthetreatmentofSCID?Bonemarrowtransplantationiscurative.

ListtheclinicalmanifestationsofWiskott-Aldrichsyndrome:WATERW—↓IgM(Wupsidedown)↑IgAThrombocytopeniaEczemaRecurrentinfections

Whataretheclinicalmanifestationsofphagocyticimmunodeficiencysyndromes?

Poorwoundhealing,abscessformation,andgranulomas

Namethetwomostcommonphagocyticsyndromes:1.Chronicgranulomatousdisease2.Chediak-Higashisyndrome

Whatisthemodeofinheritanceinchronicgranulomatousdisease?X-linkedrecessive

Whatchemicalprocessarepatientsafflictedwithchronicgranulomatousdiseaseunabletoperform?Oxidativeburstthatproduceshydrogenperoxide

What is the mode of inheritance in Chediak-Higashi syndrome and what is the defective immunologicalprocess?

Autosomalrecessiveandneutrophilchemotaxis

WhatistheoculocutaneousmanifestationofChediak-Higashisyndrome?Albinism

CHILDABUSE

Namethefinding(s)suggestiveofabuseinthefollowingscenarios:CutaneousvisualexaminationEcchymosesofvaryingageandpatterninjuries(ironorcigaretteburns,immersionburns,beltmarkings)OcularexaminationRetinalhemorrhages(shakenbabysyndrome)RadiologicfilmSpiralfracturesGenitourinaryexaminationSexuallytransmitteddiseases,genitaltraumaHeadCTscanSubduralhemorrhage(shakenbabysyndrome)

CerebralPalsy

Whatdefinesanonprogressive,nonhereditarydisorderofmovementandposture?Cerebralpalsy(CP)

ListtheriskfactorsofCP:1.Prematurity2.MR3.Lowbirthweight4.Fetalmalformation5.Neonatalseizures6.Neonatalcerebralhemorrhage7.Perinatalasphyxia

WhatisthemostfrequentpresentingsignofCP?Delayedmotordevelopment(oftenmisseduntilchildfailstomeetdevelopmentalmilestones)

WhatpercentageofCPpatientsdisplayMR?

About50%(notallhaveMR)

WhatisthemostcommonformofCP?Pyramidal(characterizedbyspasticityinallaffectedlimbs)

WhatisthetreatmentofCP?Benzodiazepines,dantrolene,andbaclofen(goalistoreducespasticity)

FebrileSeizures

Whatdefinesanon-epilepticseizureinchildren6months-5yearsofageassociatedwithfevers?Febrileseizures

Whatisthecauseoffebrileseizures?Therapidityoffeveronset,nottheabsolutetemperature,isthedeterminingfactor.

SimpleorComplexFebrileSeizure?Duration15minSimpleMorethanoneseizureina24-hperiodComplexNecessitatesalumbarpuncture,laboratorystudies,EEGandCT/MRIComplexCharacterizedbyageneralizedseizureSimple(complexseizurestendtobefocal)Associatedwitha2%riskofepilepsySimple(riskingeneralpopulationwithoutfebrileseizuresis1%)

NEONATOLOGY

WhatdeterminestheApgarscore?APGARAppearance(blue/pale,pinktrunk,allpink)Pulse(0,100,>100)Grimacewithstimulation(0,grimace,grimaceandcough)Activity(limp,some,active)Respiratoryeffort(0,irregular,regular)

DeterminetheApgarscore:Newbornwith a pink trunk, heart rate of 50, a grimace and coughwhen stimulated, strongmuscle

tone,andanirregularrespiratoryeffort7A blue newborn with a heart rate of 30, a grimace when stimulated, appears limp, and has no

respiratoryeffort2

Nametheorganismresponsibleforthecongenitalinfectioninthefollowingclinicalscenarios:A 3-wk/o female infant found to have leukocoria (absent red reflex), a continuous machine-like

murmur,“blueberrymuffin”skinand“saltandpepper”retinitisRubellA—PDAA 1-mo/o male found to have periventricular calcifications on head MRI, hepatosplenomegaly,

chorioretinitis,andaleftinguinalherniaCytomegalovirusA3-d/omalefoundtohaveskinvesiclesandkeratoconjunctivitisHerpessimplexvirusA2-wk/ofemalefoundtohaveosteochondritis,periostitis,amaculopapularrash,andthe“snuffles”TreponemapallidumA1-wk/omalefoundtohavegeneralizedcalcificationsonheadMRIandchorioretinitisToxoplasmagondiiA16-mo/oinfantfoundtohavesensorineuralhearinglossRuBELLa—childrenwithcongenitalrubellacannotheartheBELL.

WhatHIVserologicalmarkerisusedtodetecttheHIVstatusinaninfantofaHIV-positivemother?HIVDNAPCR

Whatthreeorganismsarethemostlikelycausesofneonatalsepsis?GEL1.GroupBstreptococci2.E.coli3.Listeriamonocytogenes

Whatisthetreatmentregimenforaneonatewithsuspectedsepsis?Ampicillinandgentamicinfor7days

Whatisthemostcommoncauseofrespiratoryfailureinaprematurenewborn?Respiratorydistresssyndrome(RDS)

WhatisthepathogenesisofRDS?Lackofadequatesurfactantproductioncausingalveolarcollapse

WhatisthetypicalpresentationofRDS?Tachypnea,grunting,retractions,andnasalflaringinthefirstfewhoursoflife

WhatisthetypicalcourseofRDS?Progressiveworseningandpendingrespiratoryfailureinthefirst48-72hoursoflife

WhatarethecharacteristicfindingsonCXRofRDS?Diffuseatelectasisandaground-glassappearance

WhatisthetreatmentofRDS?Usuallyrequiresintubationandsurfactantadministration

WhatarethecomplicationsoftreatmentofRDS?Bronchopulmonarydysplasia,retinopathyofprematurity,andbarotraumafrommechanicalventilation

Whatisphysiologicjaundice?Transient,unconjugatedhyperbilirubinemiacausedbylargebilirubinloadthatoverwhelmsamaturingliver

system

Whatthreefeaturesdifferentiatephysiologicjaundicefrompathologicjaundice?Thefollowingthreeareallfeaturesofpathologicjaundice:1.Hyperbilirubinemiainthefirst24h2.Prolongedjaundice3.Conjugatedhyperbilirubinemia

Namethefatalcomplicationofneonatalhyperbilirubinemia:Kernicterus(bilirubinstainingofthebasalganglia,pons,andcerebellum)

Namethetwotherapiesavailableforseverejaundice:1.Phototherapy2.Exchangetransfusion

Whatisthepathognomonicradiographicfindinginpatientswithnecrotizingenterocolitis?Pneumatosisintestinalis

Namethelikelycongenitalanomalyinthefollowingclinicalscenarios:Neonate with inability to feed, excessive salivation, and recurrent aspiration pneumonia with a

polyhydramnioticmotherTracheoesophagealfistulaNeonatewithbiliousemesisanda“double-bubble”signonabdominalradiographDuodenalatresiaNeonatebornwithabdominalvisceraherniatingthroughtheumbilicus,containedinasacOmphalocele(gastroschisiscontainsnosac),omphaloceleassociatedwithothercongenitalanomalies

INFECTIOUSDISEASE

NamethecomplicationsofGroupAstreptococcalinfections:Peritonsillarabscess,retropharyngealabscess,rheumaticfever,poststreptococcalglomerulonephritis

Whichcomplicationisnotavoidedwithantibiotictreatment?Poststreptococcalglomerulonephritis(PSGN)

NamethefourclinicalmanifestationsofPSGN:Hematuria,oliguria,hypertension,andedema

Whatarethemajormanifestationsofacuterheumaticfever?JONESJoints(migratorypolyarthritis)O—pancarditis(” ”isintheshapeofaheart)SubcutaneousNodulesErythemamarginatumSydenhamchorea

Whatisthecriticaldeterminantofmorbidityinacuterheumaticfever?Mitralandaorticvalvestenosis/regurgitation

Nametheviralexanthemassociatedwiththefollowingclinicalmanifestations:Cough,coryza,conjunctivitisMeaslesFeverwithavesicularrashatdifferentstagesVaricella(chickenpox)Maculopapularrash,febrileseizures,andHHV-6infectionRoseolainfantum

“Slapped-cheek”appearancewithparvovirusB19infectionErythemainfectiosum(fifthdisease)

PainfululcersonthetongueandoralmucosaandamaculopapularrashonthedistallimbsandbuttocksHand,foot,andmouth(andbutt)disease

Whatisincludedinthedifferentialdiagnosisforupperairwayobstruction?

Foreignbodyaspiration,croup,epiglottitis,retropharyngealabscess,bacterialtracheitis,angioedema

Crouporepiglottitis?MostcommonlycausedbyparainfluenzavirusinfectionCroupPresentswithhighfever,“sniffing-dog”position,toxicappearance,anddroolingEpiglottitisVeryrareduetotheHibvaccinationEpiglottitisRespondstoracemicepinephrineCroupRequiresemergentendotrachealintubationEpiglottitis“Steeplesign”onanteroposterior(AP)neckfilmsCroup(thinkofaGroupofpeoplegoingtothesteeple)Presentswithinspiratorystridoranda“barky”coughCroup

Whatthreebacteriamostfrequentlycauseotitismedia(OM)?S.pneumoniaNon-typeableH.influenzaMoraxellacatarrhalis

WhatarethefindingsofOMonotologicexamination?Bulging tympanicmembrane (TM), loss of TM light reflex, decreasedmobility of the TM on pneumatic

otoscopy

WhatisthetypicaltreatmentforOM?High-doseamoxicillin(80-90mg/kg/d)for10days,resistantorganismsrequireamoxicillin-clavulanicacid

(Augmentin)

Whatpathogencausesmostcasesofbronchiolitis?Respiratorysyncytialvirus

Whatistherecommendedtreatmentforaneonatewithbacterialmeningitis?Ampicillinandcefotaxime(olderchildren—vancomycinandceftriaxone)

Specifytheorganismassociatedwithgastroenteritisinthefollowingcases:Neurologicsymptomsofseizures,mentalstatuschanges,andlethargyShigellaCapableofcausingsepsisandmeningitisSalmonellaMostcommonnonbacterialagentRotavirus(incidencenowdecreasingwithvaccination)“Pseudoappendicitis”pictureYersiniaHemolyticuremicsyndromeE.coliO157:H7(90%ofcases)

NEPHROLOGY

Whatisthemostfrequentclinicalsignofvesicoureteralreflux?RecurrentUTIs

Whatisthediagnostictestofchoiceinvesicoureteralreflux?Voidingcystourethrogram(VCUG)

Namethemostcommonpenilecongenitalanomaly:Hypospadias

Whatarethetwomajorcomplicationsofcryptorchidism?1.Impairedspermproduction2.Increasedriskofmalignancy

Namethefourcharacteristicsofnephroticsyndrome:1.Proteinuria2.Hypoalbuminemia3.Hyperlipidemia4.Edema

Whatisthemostcommoncauseofnephroticsyndromeandwhatisthetreatment?Minimalchangedisease;steroids(bestprognosis)

Whatisthehallmarkofglomerulonephritis?Hematuria

Nametheglomerulonephritisinthefollowingsituations:Hematuriaprecededbypharyngitis2weekspriorAcutepoststreptococcalglomerulonephritis(mostcommon)HematuriawithaninsidiousregressiontorenalfailureandencephalopathyRapidlyprogressiveglomerulonephritisPalpablepurpuraonthelowerlimbsandbuttocksfollowedbyabdominalpainandhematuriaHenoch-SchonleinpurpuraNephriticclinicalpictureaccompaniedbysensorineuralhearinglossAlportsyndromeElevatedASOtiterandlowcomplementC3levelsAcutepoststreptococcalglomerulonephritis

GASTROENTEROLOGY

Namethegastrointestinaldiseasecharacterizedbythefollowingdescriptions:MostcommonindicationforsurgicalinterventionAppendicitisMostcommoncauseofbowelobstructioninchildren2yearsIntussusceptionCharacterizedbyprojectile,non-biliousvomitinginfirstbornmales2-5weeksofagePyloricstenosisAircontrastenemaisdiagnosticandtherapeutic.IntussusceptionPhysicalexaminationrevealsanolive-shaped,mobile,non-tendermass.PyloricstenosisManifestsascrampy,abdominalpainwithemesisandbloody,mucousystool(”currantjelly”stool)IntussusceptionPresentsaspainless,rectalbleedingMeckeldiverticulumFailureofganglioniccellmigrationHirschsprungdisease

Arisesfrom“leadpoints”andisdescribedasa“sausage-likemass”onexaminationIntussusceptionDiagnosisrequiresatechnetiumpertechnetatescanthatdetectsectopicgastricmusoca.MeckeldiverticulumDiagnosisrequiresultrasoundandtreatmentisbysurgicalpylorotomy.PyloricstenosisTypicallypresentsasbiliousemesisinachild1monthofageandisdiagnosedbyanupperGIseriesMalrotationRisk factors include Meckel diverticulum, intestinal lymphoma, Henoch-Schonlein purpura, celiac

disease,cysticfibrosis,andinfection.Intussusception(allcanactaspotential“leadpoints”)NamethemajorcharacteristicsofMeckeldiverticulum:Ruleof2sMalesareaffected2timesasoftenasfemales2feetfromtheileocecalvalve2typesofectopicmucosa(gastricorpancreatic)2%ofpopulation2monthsto2yearsofage

ENDOCRINOLOGY

WhatdiseaseresultsfromthelackofinsulinproductionbyBcellsinthepancreas?Insulin-dependentdiabetesmellitus(type1)

Whatarethecharacteristicsofdiabeticketoacidosis(DKA)?Hyperglycemia,ketoacidosis,dehydration,andlethargy

Whatisthetypicalpresentationofatype1diabeticpatient?Polyuria,polydypsia,fatigue,andabdominalpain

Whatthreescreeningtestsshouldbeperformedregularlyinthepediatricpatientwithtype1diabetes?1.Urinescreeningformicroalbuminemia2.Ophthalmologicexaminationforretinopathy3.Lipidprofileforhyperlipidemia

WhatarethetreatmentgoalsforDKA?Fluidresuscitation,insulintherapy,andelectrolytemanagement

WhatisthemostfearedcomplicationinthetreatmentofapatientinDKA?Cerebraledema(insulindrivesglucoseintocellsthusalteringosmoticpressure)

Constitutionaldelayorfamilialshortstature?NormalgrowthvelocityatorbelowthefifthpercentileConstitutionaldelayGrowthcurvesfallbelowthefifthpercentilewithabnormalgrowthvelocityFamilialshortstatureDelayinboneageConstitutionaldelayPubertyistypicallydelayedConstitutionaldelayNormalboneageFamilialshortstature

Listthesixmostcommonpathologiccausesofshortstature:1.Growthhormonedeficiency2.Primaryhypothyroidism3.Cushingdisease4.Chronicsystemicdisease5.Psychosocialdeprivation6.Turnersyndrome

Whatcongenitalhormonaldeficiencycancauseseverementalretardation?Congenitalhypothyroidism

Whatisthemostcommonenzymedeficiencyincongenitaladrenalhyperplasia?21-hydroxylasedeficiency

Whataretheclinicalmanifestationsof21-hydroxylasedeficiency?Ambiguousgenitalia,hyponatremiaandhyperkalemia (from lackofaldosterone),andhypoglycemia (from

insufficientcortisol)

Theelevationofwhathormoneisdiagnosticfor21-hydroxylasedeficiency?17-hydroxyprogesterone

Whathormonaltherapyisusedtotreat21-hydroxylasedeficiency?Glucocorticoids(forsuppressionofandrogenproduction)+/-mineralocorticoids(forelectrolytebalance)

HEMATOLOGY

Namethecauseofanemiainthefollowingdescriptions:MostcommoncauseofanemiainthepediatricpopulationIrondeficiencyPatientspresentwithbone/chestpain,dactylitis,priapismorstrokesSicklecelldiseaseHasanautosomaldominantmodeofinheritanceandisdiagnosedbyapositiveosmoticfragilitytestHereditaryspherocytosisCharacterizedbyadepletionofNADPHandaninabilitytoreplenishreducedglutathioneGlucose-6-phosphatedehydrogenasedeficiency(G6PD)Inherited hemolytic anemia caused by malformation or malfunction of globin subunits of the

hemoglobinmoleculeThalassemiaTreatmentofacutesymptomsconsistsofoxygen,analgesia,antibiotics,andexchangetransfusionSicklecelldiseaseCompleteabsenceofall4-alpha-globingenesBart’shemoglobinAbsenceof3-alpha-globingenesHemoglobinHdiseaseCharacterizedbyhighlevelsofhemoglobinFBeta-thalassemiamajor(Fmajor)CharacterizedbyhighlevelsofhemoglobinA2Beta-thalassemiaminor(Aminor)Historyofdrinking>24ouncesofcow’smilkperdayortransitiontocow’smilkbefore12monthsIrondeficiencyanemiaPresentswithperipheralneuropathyandparesthesiasandcausesposteriorcolumnspinaldegenerationVitaminB12deficiency

Typicallyfoundonnewbornscreen,althoughmaypresentafter4monthsofagewhenhemoglobinFlevelsbegintodecline

SicklecelldiseaseX-linkedrecessivediseasethatpresentsduringoxidativestresscausedbyfavabeansordrugexposure

(dapsone,sulfonamides,andantimalarials)G6PDPatientsareatgreatestriskforinfectionandsepsisfromH.influenzaandS.pneumoniaeSicklecelldisease(spleenmaybecompromisedduetoautoinfarction)CausedbyadefectiveDNArepairmechanismandpresentswithhyperpigmentationandcafé-au-lait

spotsFanconianemia

Namethecomplicationofsicklecelldiseasedescribedinthefollowing:CausedbyinfarctionandhemolysisoflungtissueAcutechestsyndromePainfulswellingofthehandsandfeetDactylitisPotentiallyfatalcomplicationtypicallyinducedbyparvovirusB19infectionAplasticcrisis(mustcheckreticulocytecountinsicklepatients)Complicationthatcausespain,priapism,gallbladderdisease,chronicrenalfailure,splenicinfarction,

andavascularnecrosisofthefemoralheadVasoocclusiveepisodeSicklecellscausemicrovascularobstructionandleadtofibrosisofthespleenAutoinfarction(increasedsusceptibilityofinfectionwithencapsulatedorganisms)

Namethecoagulationdisorder(s)inthefollowingdescription:X-linkedrecessivediseasecausedbyadeficiencyinfactorVIIIHemophiliaAX-linkedrecessivediseasecausedbyadeficiencyinfactorIXHemophiliaBTreatedwithdesmopressinacetate(DDAVP)vonWillebranddiseaseandhemophiliaA(DDAVPcausesreleaseoffactorVIIIandvWFfromendothelial

cells)Bleedingsitesarefrommucousmembranes,skin,andvaginaduringmenstruationvonWillebranddiseaseBleedingcauseshemarthrosesandintramuscularbleedsHemophiliaAandBIncreaseinPTTwithnormalPTandplateletaggregationHemophiliaA/BandvonWillebranddisease

PULMONOLOGY

What common disease is described as a reversible airway obstruction with accompanying bronchialhypersensitivity?

AsthmaSpecifytherecommendedtreatmentregimeninthefollowingasthmacases:Patientwithsymptoms3d/wkLow-doseinhaledcorticosteroids(mildpersistent)Patientwithsymptoms2d/wkShort-actinginhaledbeta-2agonistasneeded(mildintermittent)PatientwithsymptomscontinuallyduringthedayandfrequentlyatnightHigh-doseinhaledcorticosteroidsandalong-actingbeta-2agonist(severepersistent)

PatientwithsymptomsdailyandseveraltimesaweekatnightLow-dose inhaled corticosteroids and a long-acting beta-2 agonist ormedium-dose inhaled corticosteroids

(moderatepersistent)PatientpresentingtotheERwithanacuteexacerbationABC’s,nebulizedbeta-2agonist,nebulizedanticholinergic,steroidload+/-supplementaloxygen.Ifseverly

ill,considerepinephrineSC,magnesiumsulfateorterbutaline.

Whatdiseaseiscausedbyadefectinthechloridechannelonepithelialcells?Cysticfibrosis(CF)

NamethemodeofinheritanceandthechromosomeresponsibleforCF:Autosomalrecessiveonchromosome7(cysticfibrosis)

WhatgastrointestinalmanifestationintheneonateispathognomonicforCF?Meconiumileus(intestinalobstructionfollowinginspissationofmeconium)

WhatisthemostcommonmanifestationofCFininfantsandchildren?Failuretothrive

NamethemostcommonclinicalmanifestationsofCFinthefollowingorgansystems:Respiratory1.Nasalpolyps2.Sinusitis3.Bacterialpneumonia4.Digitalclubbing5.Cough6.HemoptysisGastrointestinalPancreaticinsufficieny(causingmalabsorption,diarrhea,andfailuretothrive),diabetes,rectalprolapse,and

meconiumileusHepatobiliaryNeonataljaundice,portalhypertension,andcirrhosisReproductiveImpairedfertilityinmales

NamethediagnostictestofchoiceinCF:Sweatchloridetest

WhatistherecommendedtreatmentforCF?Inhaledrespiratorytreatments,chestphysiotherapy,pancreaticenzymes,vitamins,andantibiotics(asneeded)

ONCOLOGY

Whatisthemostcommonchildhoodmalignancy?Leukemia(acutelymphocyticleukemiaisthemostcommon)

Acutemyelogenousleukemia(AML)oracutelymphocyticleukemia(ALL)?AfricanAmericanmaleofanyageAMLWhitemale,3-5yearsofageALL

Namethe(AML)subtypeassociatedwiththefollowing:

DisseminatedintravascularcoagulationM3(3words,acutepromyelocyticleukemia)CNSinvolvementandgingivalhyperplasiaM5

Whatisthetypicalinitialpresentationofapatientwithleukemia?Malaise,fever,bruising,andweightloss

Whatarethetypicallatepresentingsignsofleukemia?Bonepainandarthralgia

Theclusterofpetechiae,pallor,ecchymoses,and fever inapatientwithahistoryof leukemia isevidenceofwhatpathophysiologicprocess?

Bonemarrowfailure

Whatisthetreatmentforleukemia?Steroids,vincristine,intrathecalmethotrexate,andasparaginase

Whatisthemostcommonsolidtumorandthesecondmostcommonmalignancyinchildhood?CNStumors

WheredoCNStumorstypicallyoccur?Infratentorial (cerebellum,midbrain, brainstem) in patients 1-11 years old, supratentorial in patients 1 and

>11

Nametheclinicalmanifestationsofinfratentorialtumors:Truncalataxia,coordination/gaitdisturbances,andheadtilt(duetocranialnervepalsies)

Whatarethesymptomsofincreasedintracranialpressure(ICP)?Headaches,vomiting,andlethargy

WhatarethesignsofincreasedICP?Hydrocephalus,papilledema,andCushingtriad(hypertension,bradycardia,Cheyne-Stokesrespirations—all

latefindings)

Non-HodgkinlymphomaorHodgkindisease?Represents60%ofpediatriclymphomasNon-HodgkinlymphomaBimodaldistributionofage(14-35yearsand55-74years)HodgkindiseaseDiagnosedbytheidentificationofReed-SternbergcellsincanceroustissueHodgkindiseasePresentswithcompressionsymptomsastumorcellsrapidlyproliferateNon-HodgkinlymphomaMostcommonlypresentswithpainless,firmlymphadenopathyHodgkindiseasePeakincidencebetweentheagesof7and11Non-Hodgkinlymphoma

Namethemalignancyofprimitiveneuralcrestcellsoftheadrenalmedullaandsympatheticganglia:Neuroblastoma

Whatbodyregiondoneuroblastomasmostcommonlyarisefrom?Abdomen

Whattwodiagnostictestsprovidethedefinitivediagnosisofneuroblastoma?Elevatedurinarycatecholaminesandpathologicalidentificationoftumortissue

WhatclinicalmanifestationsmayoccurinpatientswithWilmstumorassociatedwithothersyndromes?WAGRWilmstumor(asymptomaticflankmass)AniridiaAmbiguousGenitaliaMentalRetardation

Ewingsarcomaorosteosarcoma?OccursonthemidshaftofbonesEwingsarcoma(osteosarcomaoccursonthemetaphysis)Morelikelytohaveclassic“sunburstappearance”onradiographOsteosarcomaMalignanttumorofmesenchymalcellsOsteosarcomaUndifferentiatedsmallroundbluecellsEwingsarcomaSurgeryandradiationtherapyareeffective.Ewingsarcoma(osteosarcomadoesnotrespondtoradiation)20%withmetastasesatdiagnosisOsteosarcomaandEwingsarcoma

RHEUMATOLOGY

Whatpediatricdiseaseischaracterizedbyjointpain,fatigue,rash,lymphadenopathy,andfailuretothrive?Juvenileidiopathicarthritis(JIA)

WhatlaboratorymarkerindicatesanincreasedriskofuveitisinpatientswithJIA?(+)ANA

WhatisthetreatmentforJIA?Anti-inflammatorydrugs,immunosuppressivetherapy,andphysicaltherapy

WhatdiseaseischaracterizedbyGottrenpapules,violaceousdermatitis,andproximalmuscleweakness?Dermatomyositis

Whatlaboratoryvalueissignificantlyincreasedinpatientswithdermatomyositis?Serumcreatininekinase

Namethevasculitideassociatedwiththefollowingdescriptions:Positivec-ANCAWegenergranulomatosisPalpablepurpura,abdominalpain,andhematuriaHenoch-SchonleinpurpuraRecurrentupperandlowerrespiratorytractinfectionsWegenergranulomatosisTreatedwithIVIGandaspirinKawasakidiseaseTreatedwithcorticosteroidsandcyclophosphamideWegenergranulomatosisCoronaryarteryaneurysmsarethemostconcerningcomplicationKawasakidisease

WhataretheclinicalmanifestationsofKawasakidisease?

MyHEARTMy—Mucousmembranechanges(fissuredlipsand“strawberrytongue”)Handsandextremitychanges(erythema,desquamation,andedema)Eyechanges(conjunctivitiswithlimbicsparing)Adenopathy(cervical,atleast1.5cm)Rash(ofteningroinarea,polymorphous)Temperature(>101.4°Ffor5days)

NEUROLOGY

Whatneurologicaldefectisdiagnosedbyanincreasedmaternalserumalpha-fetoproteinlevel?Neuraltubedefect

Whatmineralsupplement,whentakenbyapregnantmother,canreducetheincidenceofneuraltubedefects?Folicacid

Whattypeofseizurepresentsinchildren10yearsofage?Absenceseizures

NametheEEGpatternthatisdiagnosticofabsenceseizures:Three-per-secondspikeandwavepattern

What seizure, occuring in children between 2 and 7 months of age, manifests as extensor-flexor spasmsoccuringupto100timesinaday?

Infantilespasms

NametheEEGpatternthatisdiagnosticofinfantilespasms:Hypsarrhythmia(chaoticpattern)

Namethephakomatosiswiththefollowingcutaneousmanifestations:Café-au-laitspots(hyperpigmentedmacules)Neurofibromatosistype1(vonRecklinghausendisease)Ash-leafspots(hypopigmentedmacules)TuberoussclerosisPort-winestainsdistributedontrigeminalnerveV1Sturge-Weberdisease

MISCELLANEOUS

Atwhatagedoesanaveragepediatricpatienttripletheirbirthweight?1year

Whatcriterionmustbemetbeforeachildcanridefaceforwardinacarseat?Childmustbe1yearofageand20lb.

Whatvitaminsupplementmustachildreceivethatisstrictlybreast-fed?VitaminD

Whatisthedifferentialdiagnosisforaninfantwithleukocoria(lackofaredreflex)?Retinoblastoma,retinopathyofprematurity,andcongenitalcataracts

WhatisapositiveBarlowtest?Posterior-superiordislocationofthehipwithpositivepressure(occursindevelopmentalhipdysplasia)

WhatisOrtolanimanuever?Clickonhipabduction(occursindevelopmentalhipdysplasia)

Namethepathologiccauseofalimpinthefollowingclinicalscenarios:

Obese,adolescentmalewithreferredpaintothekneeSlippedcapitalfemoralepiphysis(SCFE)

Painlesslimpina5-year-oldchildcausedbyavascularnecrosisofthefemoralheadLegg-Calve-Perthesdisease

12-year-oldwithtibialtuberositypointtendernessOsgood-Schlatterdisease

WhatradiographicviewisoptimaltodiagnoseSCFE?Frog-leglateralview(demonstratesepiphysealdisplacement)

Nametheorganismmostlikelyresponsibleforosteomyelitisinthefollowingsituations:MostcommoncauseofosteomyelitisS.aureusSicklecelldiseaseSalmonellaCommoninpuncturewoundsthroughthesoleofashoePseudomonasaeruginosa

MAKETHEDIAGNOSIS

Newborn infant presents with tachypnea and poor feeding tolerance; continuous machine-like murmur onexamination

Patentductusarteriosus

1-wk/o infant inNICU found tohave low set ears, flat occiput, simian crease, smallmouth, andprotrudingtongue;holosystolicmurmuronPE

Trisomy21(Downsyndrome)

1-wk/o infant presents with positive hip click and dislocation of the hipwith posterior pressure on routinenewbornexamination

Developmentalhipdysplasia

2-y/opresentswithsudden-onsetdyspneaandrespiratorydistress;PErevealsdecreasedbreathsoundsontherightside.

Foreignbodyaspiration

13-y/opresentswith fever, emesis, anddiffuseperiumbilical pain thathas localized to theRLQ;PE revealsguarding,tenderness,andpositivepsoasandobturatorsigns.

Appendicitis

4-mo/o presents with pallor; PE reveals splenomegaly and a II/VI systolic ejection murmur; HgbelectrophoresisshowshighHgbSconcentration.

Sicklecelldisease

2-y/opresentswith2-dayh/oofnon-bloody,waterydiarrhea,andvomiting;childattendsdaycare;PEshowsmilddehydrationbutisotherwisenormal.

Viralgastroenteritis

8-y/opresentswithpainfulpurpuraafterjumpingonatrampoline;PErevealspalpablepurpuraonthelegsandbuttockswithmildabdominaldiscomfortonexamination.

Henoch-Schonleinpurpura

5-y/omalewithh/ohemarthrosisandsubcutaneousbleeding;prolongedPTTandlowfactorVIIIHemophiliaA

Newborn with h/o trisomy 21 and in utero polyhydramnios presents with bilious emesis; Abdominal x-rayshows“double-bubble”sign.

Duodenalatresia

8-y/owithah/oIDDMpresentswithabdominalpainandN/V;PErevealstachycardia;ABGshowsacidosis;urineispositiveforketones.

Diabeticketoacidosis

13-y/opresentswithjointpainandfevers;PErevealsasalmon-coloredrashandlymphadenopathy;highWBCandESR

Juvenileidiopathicarthritis

8-y/owithh/osicklecelldiseasepresentswithsevereabdominalpainprecipitatedbyN/V.Vasoocclusivepainepisode

1-y/o presents with irritability and crampy, intermittent abdominal pain with diarrhea; stools are guiacpositive;PErevealstubular,“sausage-likemass.”

Intussusception

5-y/opresentswithrecurrentURIanddiarrhea;PEshowsnasalpolyps,failuretothrive;sweatchloridetestis>60mmol/L.

Cysticfibrosis

14-y/omalepresentswithgynecomastia;PErevealsatallmalewithasmallphallusandsmalltestes.Klinefeltersyndrome

4-y/opresentswithnew-onsetweightloss,polyphagia,andpolyuria;PErevealsdehydrationbutisotherwisenormal;glucoseis400mg/dL.

Insulin-dependentdiabetesmellitus(IDDM)

13-y/oobesemalepresentswithapainfullimp;frog-leglateralx-rayshowsepiphysealdisplacementSlippedcapitalfemoralepiphysis

10-y/owithh/osicklecelldiseasepresentsinrespiratorydistress;↓hematocritand↓O2satAcutechestsyndrome

2-y/opresentswithpainless,rectalbleeding;radionuclidescanrevealsectopicgastricmucosaproximaltotheileocecalvalve.

Meckeldiverticulum

2-y/opresentswithfeversandearpulling;TMiserythematousandbulgingwithoutaredreflexAcuteotitismedia

12-y/opresentswithpainandlocalizedswellinginthedistalfemur;↑alkalinephosphataseandx-rayshowsalyticbonelesionwitha“sunburst”appearance

Osteosarcoma

1-mo/o infantwithnosignificantmedicalhistory is foundtohaveaIII/VIharshholosystolicmurmurheardbestattheleftlowersternalborderonroutineexamination.

Ventricularseptaldefect

1-d/o femalepresentswith ambiguous genitalia onnewborn exam; labs reveal hyponatremia, hyperkalemia,andhypoglycemia;highlevelsof17-hydroxyprogesterone

Congenitaladrenalhyperplasia

4-y/opresentswithbonepain,arthralgia,andlethargy;PErevealspallor,ecchymoses,andafever;labsshowanemiaandthrombocytopenia.

Acutelymphocyticleukemia

4-y/opresentswithbarkycough,fever,andrhinorrhea;x-rayreveals“steeplesign.”Croup

8-y/owithh/obowelandbladderdysfunctionpresentswithatuftofhairinthelowerback;scoliosisisnotedonPE.

Spinabifidaocculta

5-y/opresentswith6dayh/ohighfevers;PErevealsconjunctivitiswith limbicsparing,adenitis, strawberrytongue,andfissuredlips;plateletcountishighandhematocritislow.

Kawasakidisease

6-y/ochildpresentsafterepisodesof“daydreaming”inclassdescribedas“blankstares”;EEGrevealsthree-per-secondspikeandwavepattern.

Absenceseizure

3-y/oboypresentswithrecurrentUTIs;VCUGrevealsabnormallyplacedureteralinsertionintothebladder.Posteriorurethralvalve

4-y/opresentswithperiorbitaledemaonroutineexam;UArevealssevereproteinuriaandlipidprofileshowshyperlipidemia.

Minimalchangedisease

8-y/owithh/osicklecelldiseasepresentswithfpallorafterviralprodrome;reticulocytecountis1%Aplasticcrisis

15-y/opresentswithfeversandexudativepharyngitis;PErevealsgeneralizedlymphadenopathy;bloodsmearrevealsatypicallymphocytesandheterophileantibodytestispositive.

Mononucleosis

1-d/o,30-weekpremiepresentswithretractions,nasalflaring,andcyanosis;CXRshowsdiffuseatelectasis.Respiratorydistresssyndrome

2-mo/oinfantpresentswithrespiratorydistressandepisodicperiodsofcyanosis;PErevealsrightventricularheaveandaloudsystolicejectionmurmur;CXRshows“boot-shapedheart.”

TetralogyofFallot

10-y/opresentswith feversandapruriticrashspreading fromthe trunk to thearms;PErevealsvesiclesofvaryingstages.

Varicella

8-y/opresentswithpersistentnighttimecoughing;audbilewheezesareheardandmothersmokes2ppd.Asthma

15-y/o presents with primary amenorrhea; PE reveals widely spaced nipples, webbed-neck, and acrescendo/decrescendosystolicmurmurattheRUSB.

Turnersyndrome

Cyanotic newborn presents with respiratory distress; right ventricular heave and a loud S2; CXR revealscardiomegalyandan“egg-shapedsilhouette.”

Transpositionofthegreatvessels

1-mo/o first bornmale presentswithprojectile nonbilious vomiting;PE reveals amobile, non-tender, olive-shapedmassintheepigastricarea.

Pyloricstenosis

4-y/o presentswith armpain following trauma;historypermom is inconsisentwith injury; x-ray reveals aspiralfracture.

Childabuse

12-y/opresentswithsymptomatic,episodicpalpitationsduringexercise;ECGreveals“deltawaves.”Wolff-Parkinson-Whitesyndrome

3-y/o presents with one generalized seizure lasting 1 min; no significant PMH; PE reveals fevers but isotherwisenormal.

Simplefebrileseizure

2-wk/o presents with bilious emesis; upper GI series reveals an abnormally placed cecum and ligament ofTreitz.

Malrotation

6-mo/o presents with cough, rhinorrhea, and fevers in December; CXR shows peribronchial thickening;nasopharyngealaspiraterevealsRSVantigen.

Bronchiolitis

15-y/oathleteexperiencessuddencardiacdeathduringabasketballgame;pathologicexamrevealsamuscularintraventricularseptumandsignificantLVH.

Hypertrophicobstructivecardiomyopathy

8-y/opresentswithfever,photophobia,stiffneck,andheadache;PEreveals(+)KernigandBrudzinskisigns;LPshowsnormalglucoseandlowWBCs.

Viralmeningitis

7-y/opresentswitha1-yearh/oleavingseatduringclass,blurtingoutanswers,andinterruptingathome;PEandlabsarenormal.

Attention-deficithyperactivitydisorder(ADHD)

CHAPTER7EmergencyMedicine

TRAUMA

Listthestepsinvolvedintheprimarysurveyofatraumapatient:“ABCDEFG”(shouldtake30s),IV/O2/monitorAirway:assureclear,unobstructedairway;controlcervicalspinewithback-boardorcervicalcollar.Breathing:assesschestwallmotion;auscultateforbilateralsymmetricbreathsounds.Circulation: check pulse, assess vitals, two large-bore IVs with 3:1 isotonic fluid resuscitation, note

hemorrhages.Disability:levelofconsciousness(GCS),papillaryexamination,movementofextremities.Exposure:removeclothingfromheadtotoetounmaskinjuries;warmwithblankets.Foley:assessneed(contraindicatedifbloodaturethralmeatus,highridingprostateonrectalexamination).Gastrictube:assessneedfornasogastric(NG)ororalgastric(OG)tube(contraindicatedifconcernforbasilar

skullfracture).

Name six situations that preclude patients with C-spine collars from being cleared clinically (withoutradiographicimaging):

1.Intoxication(oranyalteredlevelofconsciousness/inabilitytocommunicate)2.Focalneurologicimpairments3.Posteriormidlinecervicalspinetenderness4.Painful,distractinginjury5.High-riskmechanism(MVA)6.Neckrotationto45°withpain

Whatmethodisusefulintheevaluationofbluntabdominaltrauma?Focusedassessmentwith sonography for trauma “FAST” (evaluates pericardium, perihepatic, perisplenic,

andpelvis)

TOXICOLOGY

WhatsubstancesupplementsgastriclavageintheprocessofGIdecontamination?Activated charcoal (plus sorbitol for catharsis); CI in AMS, bowel obstruction/ perforation, acid/alkali

ingestion

Foreachofthefollowingdrugs/toxins,describetheclinicalpictureofoverdoseandtheantidote/treatment:Ethyleneglycol(antifreeze)Aniongapmetabolicacidosiswith↑serumosm,calciumoxalatecrystalsinurinecauserenalstones.Treatment/therapy(Tx):ethanol,fomepizole,dialysisMercuryErethism(insomnia,delirium,↓memory),peripheralneuropathy,skindiscolorationTx:dimercaprol,succimerAcetaminophenAxearly,thennausea/vomiting,↑liverfunctiontests(LFTs)andprolongedprothrombintime(PT)at24-48

h,fulminanthepaticfailureat3-5days

Tx:N-acetylcysteine(within8-10h)WarfarinBleeding(↑PT/INR)Tx:freshfrozenplasma(FFP)(acutely),vitaminKAntimuscarinics,anticholinergics“Dryasabone(dryskin),redasabeet(flushed),blindasabat(mydriasis),madasahatter(delirium)”;Anti-

SLUDGETx:physostigmine(acetylcholinesteraseinhibitor)DigoxinN/V,dysrhythmias,↑K+,colorvisionchanges(yellow-greenhaze),AMSTx:manageK+,lidocaine,andantidigoxinFabTheophyllineHematemesis,seizures/coma,dysrhythmias,↓BPTx:activatedcharcoal,cardiacmonitoringArsenicFatigue,seizures;Meeslinesinfingernails(chronic)Tx:dimercaprol,succimerMethanolAnion gapmetabolic acidosis with ↑ serumosm, blindness (distinguishes from ethylene gycol), optic disc

hyperemiaTx:ethanol,fomepizole,dialysisAspirin(salicylates)Aniongapmetabolicacidosis(normalserumosm),respiratoryalkalosis,tinnitus,garlicodorTx:alkalinizationwithbicarb,hemodialysisCyanideLethargy,lossofconsciousness(LOC),dysrhythmias,cherry-redskincolor,bitteralmondodorTx:sodiumthiosulfateandamylnitriteTissueplasminogenactivator(tPA),streptokinaseBleedingTx:aminocaproicacidIsoniazid(INH)Peripheralneuropathy,confusionTx:pyridoxine(vitaminB6)BenzodiazepinesDrowsiness,weakness,ataxiaTx:flumazenil(cautioninpatientsonchronicbenzos,precipitatesseizures)LeadAtaxia,peripheralneuropathy,microcyticanemia(withbasophilicstippling),leadlinesongumsTx:CaEDTA,penicillamine,dimercaprolTricyclicantidepressants“ThreeC’s”1.Cardiacarrhythmias2.Convulsions3.ComaTx:Sodiumbicarbonate(ifQRS>100ms),benzosforseizures,cardiacmonitoringAlkaliagents(draincleaner,dishwasherdetergent)Mucosalburns,dysphagia,droolingTx:milk/water,thennothingbymouth(NPO)

β-blockers↓HR,hypotension,confusion,possiblehypoglycemiaor↑K+

Tx:glucagon,Ca2+(stabilizecardiacmembranes)HeparinBleeding(↑[PTT]),thrombocytopeniaTx:protaminesulfate

OpioidsRespiratoryandCNSdepression,miosis,constipationTx:naloxone(Narcan)Carbonmonoxide(CO)Headache,confusion,dyspnea,cherry-redskin(later)Tx:100%O2orhyperbaricO2(ifpregnantorCNSdysfunction)QuinidineV-tach,torsadedepointes,cinchonismTx:Mg2+(IV)IronErosivegastritis,N/V,lacticacidosisTx:deferoxamineOrganophosphates(anticholinesterases)“SLUDGE”(Salivation,Lacrimation,Urination,Defacation,GastricEmptying),wheezing,miosisTx:atropine,pralidoximeIsopropylalcohol(rubbingalcohol)Intoxication,↓respiratoryrate(RR),ketosis,andelevatedosmolargap(noacidosis)Tx:CV/respiratorysupport,dialysis

ENVIRONMENTALEMERGENCIES

Nametheenvironmentalinsultassociatedwitheachofthefollowingfindings:Osborne(J)waveonECGHypothermia(35°C[95°F])Envenomationmaycauselocal,generalized,oranaphylacticreactionsHymenoptera(eg,beestings)Typeofburninitiallycausingpainless,dry,white,cracked,andinsensateskinFull-thicknessthird-degree-andfourth-degreeburnsLossofthermoregulatorymechanisms,causingCNSdysfunctionanddryskinHeatstrokeExtensivedeeβ-tissueinjuryundernormalskinpluscardiacdysrhythmiasElectricalinjury(AC→V-fib;DC→asystole)Typeofburncausingred,blistered,edematous,andpainfulskinPartial-thickness(1°and2°)burns

Howispercentofbodysurfaceareaaffectedbyburnscalculated?Ruleofnines:9%(eacharmandhead/neck),18%(eachsideoftorsoandeachleg),1%(groin)

WhentotransfertoburncenterBurninvolving>20%totalbodysurfacearea(TBSA);burn>10%inpt10yearsor>50years;fullthickness

burnof>5%TBSA;significantburnofface/hands/genitalia/perineum;significantelectrical/chemical/inhalationinjury

SignofinhalationinjuryFacialburn,singednasalhairs,carbonaceoussputum,hypoxia

FluidresuscitationforburnptsParklandFormula(>20%TBSA)—4cc×wt(kg)×%TBSA

MAKETHEDIAGNOSIS

75-y/oobesemanwithh/oofsmokingandHTNpresentswithsuddenonsetsevereabdominalpain,dizziness,

andhypotension.TripleArupture

27-y/omale s/pMVAand left clavicle fracturepresentswith shortness of breath (SOB)and left-sided chestpain;PE:cyanotic,decreasedbreathsoundsleftside,RR30,HR110,BP90/70,increasedJVD

Tensionpneumothorax(PTX)

35-y/owomans/precentrighttibialfracturepresentswithrightlegburningandweakness;PE:capillaryrefill>2s,tenseskin,numbnessintoes

Compartmentsyndrome

23-y/omanpresentswithhallucinations, chestpain, anddiaphoresis;PE: temp38°C (100.4°F),HR118,BP165/95,anddilatedpupils

CocaineOD

75-y/omanwithh/odepressionpresentswithhallucinationsanddysrythmia;PE:dilatedpupils,warmskin,tachycardia,temp38.8°C(102°F);w/u:ECGwithwideQRScomplex

Anti-cholinergicOD,tricyclicantidepressants(TCAs)

Debilitated70-y/owomanpresentswithdeliriumonanAugustafternoon;PE:dry,hotskin,corebodytemp40°C(104°F);w/u:Cr2.2,UA=myoglobinuria

Heatstroke

40-y/oburnvictimpresentswithheadache,dizziness,andconfusion;PE:ruddycomplexion,orientedtopersononly,Pao285,arterialbloodgas(ABG)7.30,carboxyhemoglobin(COHb)17%

COpoisoning

32-y/o woman presents with painful, pruritic skin lesion on arm 4 days after insect bite while camping insoutheast United States; PE: violin-shaped lesion with necrotic base and central black eschar, temp 38°C(100.4°F)

Brownreclusespiderbite

50-y/omanpresentswithnewonsethematuriaandheadache;PE:BP200/180,papilledemaHypertensiveemergency

52-y/oalcoholicmalepresentswithstuporandshivering;PE: temp27.2°C(81°F),HR50,RR9,BP100/80,dilatedpupils;w/u:ECGwithJwave

Severehypothermia

45-y/owomanunrestraineddriverinhighspeedMVApresentsobtunded;PE:BP95/80,HR132;w/u:CXR:firstandsecondribfractures,widenedmediastinum,lossofaorticknob

Traumaticaorticrupture

32-y/omaleburnvictimpresentswithblistersoverhischest,abdomen,andbotharms.WhatisTBSAburned?36%

35-y/o tomato farmer presents with drooling, vomiting, wheezing, and uncontrollable sweating for the pasthour;PE:BP100/70,HR40,RR6,mioticpupils,garlicbreath,moistskin

Organophosphatepoisoning

APPENDIXAbbreviations

AAaminoacid

Abantibody

ABGarterialbloodgas

ABXantibiotics

ACEangiotensin-convertingenzyme

ACEIACEinhibitor

AChacetylcholine

ACLanteriorcruciateligament

ACTHadrenocorticotropichormone

ADautosomaldominant

ADHantidiuretichormone

ADHDattention-deficithyperactivitydisorder

ADPadenosinediphosphate

AFPalpha-fetoprotein

Agantigen

AIDSacquiredimmunodeficiencysyndrome

ALLacutelymphocyticleukemia

ALPalkalinephosphatase

ALSamyotrophiclateralsclerosis

ALTalaninetransaminase

AMLacutemyelogenousleukemia

ANAantinuclearantibody

ANOVAanalysisofvariance

ANSautonomicnervoussystem

ARautosomalrecessive

ARBangiotensinreceptorblocker

ARDSacuterespiratorydistresssyndrome

ASAaspirin

ASDatrialseptaldefect

ASOantistreptolysinO

ASTaspartatetransaminase

ATPadenosinetriphosphate

ATPaseadenosinetriphosphatase

AVatrioventricular

AXRabdominalx-ray

AZTazidothymidine

BAL

Britishanti-Lewisite

bidtwicedaily

BMbasementmembrane

BPbloodpressure

BPHbenignprostatichyperplasia

BPPVbenignparoxysmalpositionalvertigo

BRbilirubin

BUNbloodureanitrogen

Bxbiopsy

CAcancer/carcinoma

CADcoronaryarterydisease

cAMPcyclicadenosinemonophosphate

CBCcompletebloodcount

CCKcholecystokinin

CEAcarcinoembryonicantigen

CFcysticfibrosis

CFTRcysticfibrosistransmembraneregulator

cGMPcyclicguanosinemonophosphate

CHFcongestiveheartfailure

CIcontraindication

CINcervicalintraepithelialneoplasia

CLLchroniclymphocyticleukemia

CMLchronicmyelogenousleukemia

CMVcytomegalovirus

CNcranialnerve

CNScentralnervoussystem

COcardiacoutput

CoAcoenzymeA

COPDchronicobstructivepulmonarydisease

COXcyclooxygenase

CPcerebralpalsy

CPKcreatinephosphokinase

Crcreatinine

CRFchronicrenalfailure

CRPc-reactiveprotein

CSceasareansection

CSFcerebrospinalfluid

CTcomputedtomography

CVcardiovascular

CVAcerebrovascularaccidentorcostovertebralangle

CXRchestx-ray

dday(s)

DorDAdopamine

DAGdiacylglycerol

DESdiethylstilbestrol

DHTdihydrotestosterone

DIdiabetesinsipidus

DICdisseminatedintravascularcoagulation

DIPdistalinterphalangealjoint

DKAdiabeticketoacidosis

DMdiabetesmellitus

DNAdeoxyribonucleicacid

DNIdonotintubate

DNRdonotresuscitate

d/odisorder

DOEdyspneaonexertion

DREdigitalrectalexamination

dsdoublestranded

DSMDiagnosticandStatisticalManualofMentalDisorders

DTPdiphtheria-tetanus-pertussis

DTRdeeptendonreflex

DTsdeliriumtremens

DVTdeepvenousthrombosis

dxdiagnosisordiagnose

dzdisease

Eepinephrine

EBVEpstein-Barrvirus

ECGelectrocardiogram

ECTelectroconvulsivetherapy

EDVend-diastolicvolume

EEGelectroencephalogram

EGDesophagogastroduodenoscopy

ELISAenzyme-linkedimmunosorbentassay

EMelectronmicroscopy

EOMextraocularmuscle

EPSextrapyramidalsymptoms

ERemergencyroom

ERCP

endoscopicretrogradecholangiopancreatography

ESRerythrocytesedimentationrate

ESRDend-stagerenaldisease

ESVend-systolicvolume

EtOHethanol

FAsfattyacids

FAPfamilialadenomatouspolyposis

FFPfreshfrozenplasma

FHfamilyhistory

FNfalsenegatives

FOBTfecaloccultbloodtest

FPfalsepositives

FSHfolliclestimulatinghormone

FTA-ABSfluorescenttreponemalantibody—absorptiontest

FUOfeverofunknownorigin

Fxfracture

G6PDglucose-6-phosphatedehydrogenase

GABAγ-aminobutyricacid

GBMglomerularBM

GCTgermcelltumor

GERDgastroesophagealrefluxdisease

GFRglomerularfiltrationrate

GGTγ-glutamyltranspeptidase

GHgrowthhormone

GIgastrointestinal

GNglomerulonephritis

GnRHgonadotropin-releasinghormone

GTPguanosinetriphosphate

GUgenitourinary

hhour(s)

HAheadache

Hbhemoglobin

HBVhepatitisBvirus

hCGhumanchorionicgonadotropin

HDLhigh-densitylipoprotein

HHVhumanherpesvirus

HIVhumanimmunodeficiencyvirus

HMG-CoAhydroxymethylglutaryl-CoA

h/ohistoryof

HPAhypothalamic-pituitaryaxis

HPVhumanpapillomavirus

HRheartrate

HRThormonereplacementtherapy

HSMhepatosplenomegaly

HSVherpessimplexvirus

HTLVhumanT-celllymphotrophicvirus

HTNhypertension

HUShemolytic-uremicsyndrome

Hxhistory

ICPintracranialpressure

ICUintensivecareunit

IFintrinsicfactor

Igimmunoglobulin

ILinterleukin

IMintramuscular

INDindication(s)

INHisoniazid

INRInternationalnormalizedratio

IOP

intraocularpressure

IP3inositoltriphosphate

IPVinactivatedpoliovaccine

IUDintrauterinedevice

IUFDintra-uterinefetaldesease

IUGRintrauterinegrowthretardation

IVintravenous

IVCinferiorvenacava

IVIGIVimmunoglobulin

JVDjugularvenousdistension

Lleft

LADleftanteriordescending

LBOlargebowelobstruction

LCAleftcoronaryartery

LDHlactatedehydrogenase

LDLlow-densitylipoprotein

LESloweresophagealsphincter

LFTliverfunctiontest

LHluteinizinghormone

LLQleftlowerquadrant

LLSBleft-lowersternalborder

LMNlowermotorneuron

LMPlastmenstrualperiod

LOClossofconsciousness

LPlumbarpuncture

LPSlipopolysaccharide

LTleukotriene

LUQleftupperquadrant

LUSBleft-uppersternalborder

LVleftventricle

MAOImonoamineoxidaseinhibitor

MCLmedialcollateralligament

MCVmeancorpuscularvolume

MENmultipleendocrineneoplasia

MHCmajorhistocompatibilitycomplex

MImyocardialinfarction

MLFmediallongitudinalfasciculus

MMRmeasles,mumps,rubella

MOAmechanismofaction

MPTP1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine

MRImagneticresonanceimaging

MSmultiplesclerosis

MTPmetatarsal-phalangeal

MTXmethotrexate

MVAmotorvehicleaccident

NEnorepinephrine

NGTnasogastrictube

NOSnototherwisespecified

NPVnegativepredictivevalue

NSAIDnonsteroidalanti-inflammatorydrug

N/Vnausea/vomiting

OAosteoarthritis

OCPoralcontraceptivepills

OGTorogastrictube

OPVoralpoliovaccine

PANpolyarteritisnodosa

p-ANCAperinuclearpatternofantineutrophilcytoplasmicantibodies

PASperiodicacid-Schiff(stain)

PBS

peripheralbloodsmear

PCLposteriorcruciateligament

PCPPneumocystiscariniipneumoniaorphencyclidinehydrochloride

PCRpolymerasechainreaction

PCWPpulmonarycapillarywedgepressure

PDApatentductusarteriosus

PEphysicalexaminationorpulmonaryembolism

PFKphosphofructokinase

PFTpulmonaryfunctiontests

PGprostaglandin

PIDpelvicinflammatorydisease

PIHpregnancy-inducedhypertension

PKUphenylketonuria

PMLprogressivemutifocalleucoencephalopathy

PMNpolymorphonuclear

PMRpolymyalgiarheumatica

PNHparoxysmalnocturnalhemoglobinuria

PNSperipheralnervoussystem

PObymouth

PPDpurifiedproteinderivative

PPIprotonpumpinhibitor

PPRFparapontinereticularformation

PPVpositivepredictivevalue

prnasneeded

PSAprostate-specificantigen

Ptpatient

PTprothrombintime

PTCApercutaneoustransluminalcoronaryangioplasty

PTHparathyroidhormone

PTTpartialthromboplastintime

PUDpepticulcerdisease

PVDperipheralvasculardisease

Pxprognosis

Rright

RArightatrium

RAArenin-angiotensinaldosterone

RBCredbloodcell

RCArightcoronaryartery

RDSrespiratorydistresssyndrome

REMrapideyemovement

RFrheumatoidfactor

RLQrightlowerquadrant

ROMrangeofmotion

RPRrapidplasmareagin

RRrespiratoryrate

RSVrespiratorysyncytialvirus

RTArenaltubularacidosis

RUQrightupperquadrant

RVrightventricle

RVHrightventricularhypertrophys

ssecond(s)

S1(2,3,4)1stheartsound(2nd,3rd,4th)

SAsino-atrial

SAHsubarachnoidhemorrhage

SBOsmallbowelobstruction

SCsubcutaneousorsicklecell

SDstandarddeviation

SEsideeffects

SEMstandarderrorofthemean

SESsocioeconomicstatus

SGOTserumglutamicoxaloacetictransaminase

SGPTserumglutamicpyruvatetransaminase

SLEsystemiclupuserythematosus

SMXsulfamethoxazole

SOBshortnessofbreath

sssinglestranded

SSPEsubacutesclerosingpanencephalitis

SSRIselectiveserotoninreuptakeinhibitor

STDsexuallytransmitteddisease

SVstrokevolume

SVTsupraventriculartachycardia

Sxsymptom(s)

t1/2half-life

T3triiodothyronine

T4thyroxine

TBtuberculosis

TCAtricyclicantidepressant

TGtriglyceride

TIBCtotaliron-bindingcapacity

TMtympanicmembrane

TMPtrimethoprim

TNtruenegatives

TNFtissuenecrosisfactor

TNMtumor,node,metastasis

TOXtoxicity

TPtruepositives

tPAtissueplasminogenactivator

TPRtotalperipheralresistance

TRHthyrotropin-releasinghormone

TSHthyroid-stimulatinghormone

TSStoxicshocksyndrome

TTPthromboticthrombocytopenicpurpura

Txtreatment/therapy

TXAthromboxane

UAurinalysis

UGIupperGI

UMN

uppermotorneuron

URIupperrespiratoryinfection

UTIurinarytractinfection

USultrasound

VDRLvenerealdiseaseresearchlaboratory

Vfibventricularfibrillation

VHLvonHippelLindau

VLDLvery-low-densitylipoprotein

VMAvanillylmandelicacid

V/Qventilation/perfusionratio

VSDventricularseptaldefect

vWFvonWillebrandfactor

VZVvaricella-zostervirus

WBCwhitebloodcell

WNLwithinnormallimits

XLx-linked

XRx-ray

y/oyearold

ZEZollinger-Ellison

1°/2°/3°primary/secondary/tertiary

5-FU5-fluorouracil

5-HIAA5-hydroxyindoleaceticacid

5-HT5-hydroxytryptamine(serotonin)

↑Highorincreases

↓Lowordecreases

→Leadstoorcauses

∼approximately

⊕positive

>>>muchgreaterthan

muchlessthan

Index

AAA.SeeAbdominalaorticaneurysmAbdominalaorticaneurysm(AAA)AbdominalpainAbdominaltraumaAbetalipoproteinemiaAbortionAbscess(es)inappendicitisBartholinglandbrainliverlung

AbsenceseizureACA.SeeAnteriorcerebralarteryAcanthosisnigricansAcarboseAccuracyAcebutololACEi.SeeAngiotensin-convertingenzymeinhibitorsAcetaminophenAcetylsalicylicacid(ASA)AchalasiaAcid/basedisturbancesAcidosisAcnevulgarisAcousticneuromaAcquiredimmunodeficiencysyndrome(AIDS)Acral-lentiginousmelanomaAcromegalyActinickeratosisActinobacillusActivatedcharcoalAcutechestsyndromeAcutelymphoblasticleukemiaAcutelymphocyticleukemia(ALL)Acutemyelogenousleukemia(AML)AcuteotitismediaAcuterenalfailure(ARF)Acuterespiratorydistresssyndrome(ARDS)AcutestressdisorderAcutetubularnecrosisAcyclovirAddisondiseaseAdenocarcinomabronchioalveolarcervicalesophagusgallbladdergastriclungpancreatic

prostateAdenomaadrenalcolonhepaticpituitary

AdenomyosisAdenovirusADHD.SeeAttention-deficithyperactivitydisorderAdie´spupilAdjustmentdisorderAdnexalmassADPKD.SeeAutosomal-dominantpolycystickidneydiseaseAdrenalcrisisAdrenaldisordersAdrenocorticalinsufficiencyAdrenoleukodystrophyAdvancedirectivesAgammaglobulinemiaAggrenoxAgingAgoraphobiaAIDS.SeeAcquiredimmunodeficiencysyndromeAlbinismAlbuterolAlcoholabuselivercomplicationsscreeningteratogeniceffectswithdrawalsymptoms

AlcoholicdilatedcardiomyopathyAlkaliagentsAlkalosisAlkylatingagentsALL.SeeAcutelymphocyticleukemiaAllopurinolAlportsyndromeAlprazolamALS.SeeAmyotrophiclateralsclerosisAlzheimerdiseaseAmenorrheaAminoglycosidesAmiodaroneAmitriptylineforpatientswithdiabetesmellitus

AML.SeeAcutemyelogenousleukemiaAmniocentesisAmnioticfluidabnormalitiesAmniotomyAmoxapineAmoxicillinAmphetaminesAmpicillinAmylaseAmyloidosis

renalAmyotrophiclateralsclerosis(ALS)AnabolicsteroidsAnalysisofvariance(ANOVA)Anaplasticcarcinoma,thyroidAnemiasAneurysm,abdominalaorticAngelmansyndromeAnginaAngiodysplasiaAngiotensin-convertingenzymeinhibitors(ACEi)Angiotensinreceptorblocker(ARB)AngleclosureglaucomaAniongapAnklesprainAnkylosingspondylitisAnorexianervosaANOVA.SeeAnalysisofvarianceAntacidsAnteriorcerebralartery(ACA)AnthraxAntibiotics.Seealsospecificdrugsdiarrheaandforinflammatoryboweldiseaseforosteomyelitisforotitisforpneumoniaforsinusitisforskininfections

Anticholinergics.SeealsospecificdrugsAntidepressants.SeealsospecificdrugsAntiemeticsAntifungalsAntihistamines,forskindisordersAntihypertensives.SeealsospecificdrugsAntimuscarinicsAntipsychotics.SeealsospecificdrugsAntiretroviraltherapyAntisocialpersonalitydisorderAntistreptolysinantibodiesAntithyroiddrugsα1-AntitrypsindeficiencyAnxietydisordersAorta,coarctationofAorticdissectionAorticinsufficiencyAorticregurgitationAorticstenosisAortoiliacocclusivediseaseApgarscoreAphasiaAplasticanemiaAplasticcrisisAppendicitisARB.SeeAngiotensinreceptorblocker

ArcuatefasciculusARDS.SeeAcuterespiratorydistresssyndromeARF.SeeAcuterenalfailureArgyll-RobertsonpupilArrhythmiasArsenicArterialocclusionArtery(ies),cerebralArthritisArthrocentesisASA.SeeAcetylsalicylicacid5-ASAderivativesAsbestosisAscitesAshermansyndromeAsparaginase,forleukemiaAspergerdisorderAspergillusAspirin.SeeAcetylsalicylicacidAspleniaAsthmaAtaxiatelangiectasiaAtopicdermatitisAtrialfibrillationAtrialflutterAtrialmyxomaAtrialseptaldefectAtrialtachycardia,multifocalAtrioventricularcanaldefectAtropineAttention-deficithyperactivitydisorder(ADHD)AugmentationoflaborAutismAutoantibodiesAutoimmunehemolyticanemiaAutoinfarctionAutosomal-dominantpolycystickidneydisease(ADPKD)AvascularnecrosisAvoidantpersonalitydisorderAzathioprineAzidothymidine(AZT)AzithromycinAZT.SeeAzidothymidine

B

B12deficiencyanemiaBacilluscereusBaclofenBacterialvaginosisBacteriuria,inpregnancyBactrimBarlowtest

BarrbodyBarrettesophagusBartholinglandabscessBart´shemoglobinBasalcellcarcinoma,skinBasilararteryBasilarskullfractureB-cellimmunodeficiencysyndromesBDD.SeeBodydysmorphicdisorderBecktriadBeckermusculardystrophyBeestingsBell´spalsyBeneficenceBenignpositionalparoxysmalvertigoBenignprostatichyperplasiaBenzodiazepinesBenzoylperoxideBereavementBergerdiseaseBerylliosisBeta-2agonistsβ-hCG.SeeHumanchorionicgonadotropinBiasBiguanidesBileductobstructionBiliarytractobstructionBiophysicalprofile(BPP)BiostatisticsBipolardisordersBirthrateBishop´sscoreBisphosphonatesBladdercancerBleomycinβ-Blockerserectiledysfunctionandindicationsandcontraindicationsoverdoseforpheochromocytomaforthyroidstorm

BlueberrymuffinrashBlumershelfBluntabdominaltraumaBodydysmorphicdisorder(BDD)BoerhaavesyndromeBonedisordersBorderlinepersonalitydisorderBorreliaburgdorferiBouchardnodesBoutonnieredeformityBoxerfractureBPP.SeeBiophysicalprofileBradyarrhythmiaBradycardia,fetal

Brainabscessesoflesionsoftumorsof

BraxtonHickscontractionsBreastcancerBreastdisordersBreastfeedingBreechpresentationBromocriptineBronchiectasisBronchioalveolarcarcinomaBronchiolitisBronchitisBronchodilatorsBronchopneumoniaBrownreclusespiderbitesBruton´sagammaglobulinemiaBudd-ChiarisyndromeBulimianervosaBullaBullouspemphigoidBupropionBurkittlymphomaBurnsBuspirone

C

χ2CaffeineCAGEquestionsCalcanealfractureCalcitoninCalciumchannelblockersarrhythmiaduetoforcardiomyopathy

CalymmatobacteriumgranulomatisCampylobacterjejuniCancer,screeningforCandidalvaginitisCandidiasiscutaneousvaginal

CannabinoidsCaptoprilCarbamazepineCarbonmonoxidepoisoningCarcinoembryonicantigen(CEA)CarcinoidsyndromeCarcinoidtumorCardiactamponadeCardinalmovementsoflabor

CardiobacteriumCardiogenicshockCardiologyinternalmedicineCardiomyopathiesCarotidatheromaCarotidendarterectomyCase-controlstudyCatatonicschizophreniaCaudaequinasyndromeCD4+cellsCEA.SeeCarcinoembryonicantigenCefepimeCefotaximeCeftriaxoneCefuroximeCeliacdiseaseα-Celltumorβ-Celltumorδ-CelltumorCellulitisCentralnervoussystem(CNS)infectionslymphomatumors

CentralretinalarteryocclusionCephalosporinsCerebellarvermislesionCerebralangiographyCerebralpalsyCerebralvasculaturedisordersCervicalcancerCervicaldysplasiaCervicalmaturationCervicalstenosisCervicitisCesareansectionCF.SeeCysticfibrosisChadwick´ssignChagasdiseaseChancroidChandeliersignCharcot´striadChediak-HigashisyndromeChestpainChestradiographincongestiveheartfailureininterstitiallungdiseaseinlungcancerinpneumoniainpneumothoraxinpulmonaryembolism

CHF.SeeCongestiveheartfailureChildabuseChildhooddisordersChild´scriteria

ChlamydiapneumoniaeChlamydiapsittaciChlamydiatrachomatisChlamydialcervicitisChloasmaChloramphenicolChlordiazepoxideChlorpromazineChocolatecystCholangiocarcinomaCholangitisCholecystectomyCholecystitisCholedocholithiasisCholelithiasisCholesterolstoneCholestyramineChorioamnionitisChoriocarcinomaChorionicvillussampling(CVS)ChronicarterialocclusivediseaseChronicgranulomatousdiseaseChroniclymphocyticleukemia(CLL)ChronicmesentericarterialocclusivediseaseChronicmyelogenousleukemia(CML)Chronicobstructivepulmonarydisease(COPD)Churg-StrausssyndromeChvostek´ssignCiprofloxacinCircadianrhythmsleepdisorderCirrhosisCitalopramCK-MB.SeeCreatinekinaseMBfractionClaudicationClavicularfractureClindamycinClinicaltrialsCLL.SeeChroniclymphocyticleukemiaClofibrateClomipramineClonazepamClonidineClopidogrelClostridiumbotulinumClostridiumdifficileClostridiumperfringensClozapineClusterheadacheCML.SeeChronicmyelogenousleukemiaCMV.SeeCytomegalovirusCN.SeeCranialnervesCNS.SeeCentralnervoussystemCoagulationdisordersCoalworker´spneumoconiosisCoarctationoftheaorta

CocaineCoccidioidesimmitisCodmantriangleCognitivedisordersCognitive-behavioraltherapyCohortstudyColchicineColitis.SeePseudomembranouscolitis;UlcerativecolitisCollesfractureColoncancerriskfactorsscreeningulcerativecolitisand

ColoncutoffsignColondisordersCommonvariableimmunodeficiencyCompartmentsyndromeCompleteabortionCompletebreechpresentationCompleteheartblockComplexpartialseizureCompulsionsConductdisorderCondylomaacuminatumConfidentialityCongenitaladrenalhyperplasiaCongenitalheartdiseaseCongenitalhypothyroidismCongenitalinfectionsCongenitalrubellaCongestiveheartfailure(CHF)ConnsyndromeConstitutionaldelayContactdermatitisContraceptionConversiondisorderCOPD.SeeChronicobstructivepulmonarydiseaseCopperIUDCordocentesisCoronaryarterybypassgraftCoronaryarterydiseaseCorticosteroidsCorynebacteriumCoumadinCourvoisier´ssignCoxiellabrunettiCranialnerves(CN),lesionsofCraniopharyngiomaCreatinekinaseMBfraction(CK-MB)CreatinineCRESTsyndromeCreutzfeldt-JakobdiseaseCrohn´sdiseaseCromolynCross-sectionalsurvey

CroupCryptococcalneoformansCryptorchidismCryptosporidiumCullen´ssignCurling´sulcerCushing´sulcerCushingsyndromeCVS.SeeChorionicvillussamplingCyanideCyanoticheartlesionsCyclophosphamideCyclosporineCyclothymiaCysticfibrosis(CF)Cytomegalovirus(CMV)

D

DactylitisDantroleneDawnphenomenonDDAVPd-dimerdeQuervainthyroiditisDeathanddyingDeceleration,fetalheartrateDeepvenousthrombosis(DVT)DeliriumDeliriumtremens(DT)DelusionDementiaDependenceDependentpersonalitydisorderDepersonalizationdisorderDepo-ProveraDepressionpostpartum

DermatitisDermatitisherpetiformisDermatologyDermatomyositisDES.SeeDiethylstilbestrolDesipramineDesmopressinDevelopmentalmilestonesDiabetesinsipidusDiabetesmellitusinchildrencoronaryarterydiseaseandgestationaljuvenileperipheralvasculardiseaseand

preexistingDiabeticglomerulosclerosisDiabeticketoacidosis(DKA)DialysisDiarrheaDiastolicdysfunctionDiazepamDIC.SeeDisseminatedintravascularcoagulationDicloxacillinDiethylstilbestrol(DES)DiGeorgesyndromeDigitalisDigoxinDilantinDilatedcardiomyopathyDiltiazemDiphtheriaDiphtheria-tetanus-pertussis(DTaP)vaccineDiscoidlupuserythematosusDisease-modifyingdrugsDisorganizedschizophreniaDisseminatedintravascularcoagulation(DIC)DissociativeidentitydisorderDisulfiramDiureticsDiverticulitisDiverticulosisDizygotictwinsDKA.SeeDiabeticketoacidosisDobutamineDominantparietallobe,lesionsofDopamineDownsyndromeDoxepinDoxycyclineDSM-IVclassificationsDT.SeeDeliriumtremensDTaPvaccine.SeeDiphtheria-tetanus-pertussisvaccineDuchenne´smusculardystrophyDuctalcarcinomaDukecriteriaDuodenalatresiaDuodenalulcerDurablepowerofattorneyDVT.SeeDeepvenousthrombosisDysgerminomaDysmenorrheaDysphagiaDysplasticnevusDysthymiaDystocia

E

EatingdisordersEaton-LambertsyndromeEbsteinanomalyEBV.SeeEpstein-BarrvirusEchinococcusgranulosusEclampsiaECT.SeeElectroconvulsivetherapyEctopicpregnancyEdwardsyndromeEGD.SeeEsophagogastroduodenoscopyEhlers-DanlossyndromeEikenellaEisenmengersyndromeElderabuseElderlypatientsElectricalinjuryElectrocardiogramElectroconvulsivetherapy(ECT)ElectrolyteimbalancesELISA.SeeEnzyme-linkedimmunosorbentassayEmancipatedminorEmergencycontraceptionEmphysemaEmpirictherapy,pneumoniaEmpyemaEncephalitisEndocarditisEndocrinesystemEndodermalsinustumorEndolymphaticfistulaEndometrialcancerEndometrialhyperplasiaEndometriomaEndometriosisEndometritis,postpartumEnrollmentbiasEntamoebahistolyticaEnterobacterEnterobactercloacaeEnterobacteriaceaeEnteropathicarthritisEnterovaginalfistulaEnuresisEnvironmentalemergenciesEnzyme-linkedimmunosorbentassay(ELISA),forHIVEosinophiliaEosinophilicgranulomaEpendymomaEpidemiologyEpiduralhematomaEpigastricpainEpiglottitisEpinephrineEpistaxis

Epstein-Barrvirus(EBV)ErectiledysfunctionErrorErythemainfectiosumErythemamultiformeErythemanodosumErythrasmaErythroblastosisfetalisErythromycinEscherichiacoliinfoodpoisoninginhemolyticuremicsyndromeininfectiousdiarrheainmeningitisinosteomyelitisinpneumoniainpyelonephritisinsepsisinurinarytractinfections

EscitalopramEsophagealcancerEsophagealdisordersEsophagealperforationEsophagealstrictureEsophagealvaricesEsophagogastroduodenoscopy(EGD)EssentialthrombocytosisEssentialtremorEstrogenEtanerceptEthambutolEthyleneglycolEwingsarcomaExhibitionismExtracorporealshockwavelithotripsyExtrapulmonarytuberculosisExudatepleuraleffusionEyedisorders

F

FactitiousdisorderFactorVLeidenFailuretothrive(FTT)Familialadenomatouspolyposis(FAP)FamilialhypercholesterolemiaFamilialshortstatureFanconianemiaFAP.SeeFamilialadenomatouspolyposisFascioscapulohumeraldystrophyFebrileseizuresFeltysyndromeFemalesexualarousaldisorder

FemoralherniaFemoralneckfractureFemoral-poplitealocclusivediseaseFemurfractureFENaFertilityrateFetalheartrate(FHR)FetishismFetusdiagnostictestingandmonitoringheadcompressionheartratehearttonesintrapartumassessmentpresentationviability

FeverFHR.SeeFetalheartrateFibroadenomaFibrocysticdiseaseFibrousdysplasiaFirst-degreeheartblockFitz-Hugh-CurtissyndromeFlailchestFluconazoleFlumazenilFluoroquinolone5-Fluorouracil(5-FU)FluoxetineFluphenazineFlutamideFluvoxamineFocal-segmentalglomerulonephritisFolate,prenatalFolatedeficiencyanemiaFolicacidFolieàdeuxFollicularcarcinoma,thyroidFollicularcyst,ovarianFoodpoisoningFootlingbreechpresentationForeignbodyaspirationFoster-KennedysyndromeFracturesFragileXsyndromeFrancisellatularensisFrankbreechpresentationFriedreich´sataxiaFrontallobes,lesionsofFrotteurismFTT.SeeFailuretothrive5-FU.See5-FluorouracilFunctionalencopresisFUO.SeeFeverFurosemide

G

G6PDdeficiency.SeeGlucose-6-phosphatedehydrogenasedeficiencyGabapentin,forpatientswithdiabetesmellitusGaleazzifractureGallbladdercancerGallbladderdisordersGallstonesGardnerellavaginitisGardnersyndromeGastriccarcinomaGastricoutletobstructionGastriculcerGastrinomaGastritisGastroenteritisGastroenterologyGastroesophagealrefluxdisease(GERD)Gastrointestinaltractbleedinglowerupper

GBM.SeeGlioblastomamultiformeGBS.SeeGroupBstreptococciGCT.SeeGermcelltumorsGDM.SeeGestationaldiabetesmellitusGemfibrozilGenderidentitydisorderGeneralizedanxietydisorderGeneticdefectsGenitourinaryinternalmedicineGentamicinGERD.SeeGastroesophagealrefluxdiseaseGermcelltumors(GCT)GestationalageGestationaldiabetesmellitus(GDM)Gestationaltrophoblasticneoplasm(GTN)GiardialambliaGlaucomaGlimepirideGlioblastomamultiforme(GBM)GlipizideGlomerulardiseaseGlomerulonephritisGlucagonomaGlucocorticoidsGlucose-6-phosphatedehydrogenasedeficiency(G6PDdeficiency)α-GlucosidaseinhibitorsGlyburideGoiterGonococcalarthritisGonorrheaGoodpasturesyndromeGoutGraft-versus-hostdisease

GranulomainguinaleGranulosa-thecacelltumorGravesdiseaseGrey-TurnersignGriefGroupAstreptococciGroupBstreptococci(GBS)GTN.SeeGestationaltrophoblasticneoplasmGuillain-Barrésyndrome

H

H2blockersHAART.SeeHighlyactiveantiretroviraltherapyHACEKorganismsHaemophilusducreyiHaemophilusinfluenzaeinmeningitisinotitismediainpneumoniainsepsis

HaemophilusinfluenzaeB(Hib)vaccineHaemophilusparainfluenzaeHairycellleukemiaHallucinationHaloperidolHamman´ssignHampton´shumpHand,foot,andmouthdiseaseHand-Schüller-Christiandisease“Happypuppet”syndromeHashimoto´sthyroiditisHbA1cHeadacheHeartdisease,congenitalHeatstrokeHebephrenicschizophrenia.SeeDisorganizedschizophreniaHeberden´snodesHegar´ssignHelicobacterpyloriHELLPsyndromeHemangioblastomaHemangioma,hepaticHematochromatosisHematologyHematuriaHemiballismHemoglobinHdiseaseHemolyticanemiaHemolyticuremicsyndrome(HUS)HemophiliaHemorrhage,postpartumHenoch-Schönleinpurpura

HeparinHepaticencephalopathyHepatitisadultimmunizationrecommendationschildhoodimmunizationrecommendations

Hepatobiliaryiminodiaceticacid(HIDA)scanHepatocellularcarcinomaHereditaryhematochromatosisHereditarynonpolyposiscolorectalcarcinoma(HNPCC)HereditaryspherocytosisHerniasHerniateddiskHerpesgenitalisHerpessimplexHerpeszosterHgbHdiseaseHHNK.SeeHyperosmolarhyperglycemicnonketoticcomaHiatalherniaHibvaccine.SeeHaemophilusinfluenzaeBvaccineHIDAscan.SeeHepatobiliaryiminodiaceticacidscanHidradenitissuppurativaHighlyactiveantiretroviraltherapy(HAART)HipdislocationHipdysplasiaHirschsprungdiseaseHistoplasmacapsulatumHistrionicpersonalitydisorderHIV.SeeHumanimmunodeficiencyvirusHivesHLA-B27haplotypeHLA-DR4serotypeHNPCC.SeeHereditarynonpolyposiscolorectalcarcinomaHodgkin´slymphomaHormonereplacementtherapy(HRT)HornersyndromeHospiceHRT.SeeHormonereplacementtherapyHumanchorionicgonadotropin(β-hCG)Humanimmunodeficiencyvirus(HIV)neonatalinpregnancyvaccinesand

HumanpapillomavirusHumerusfractureHuntingtondiseaseHUS.SeeHemolyticuremicsyndromeHydatidiformmoleHydralazineHydrocephalusHydropsfetalisHydroxychloroquine21-HydroxylasedeficiencyHydroxyureaHymenopteraHyperaldosteronism

HyperbilirubinemiaHypercalcemiaHypercholesterolemiafamilial

HypercortisolismHyperemesisgravidarumHyperkalemiaHyperkeratosisHypernatremiaHyperosmolarhyperglycemicnonketoticcoma(HHNK)HyperparathyroidismHyperprolactinemiaHypersensitivitypneumonitisHypersomnia,primaryHypertensionportalinpregnancy

HypertensiveemergencyHypertensiveurgencyHyperthyroidismHypertrophiccardiomyopathyHyperuricemiaHypoactivesexualdesiredisorderHypoalbuminemiaHypocalcemiaHypochondriasisHypogammaglobulinemiaHypoglycemicsHypokalemiaHypomagnesemiaHypomaniaHyponatremiaHypoparathyroidismHypospadiasHypothalamicetiologyHypothermiaHypothyroidismHypovolemicshockHypsarrhythmia

I

ICP.SeeIntracranialpressureIDDM.SeeInsulin-dependentdiabetesmellitusIdeaofreferenceIdiopathicpulmonaryfibrosisIdiopathicthrombocytopenicpurpura(ITP)IgAnephropathyIllusionImipramineImmunizationforadultsforchildren

ImmunodeficiencysyndromesImmunosuppressants,forMSImpetigoImplanonIncarceratedherniaIncidenceIncompleteabortionIndomethacinInductionoflaborInevitableabortionInfantmortalityrateInfantilespasmInfarctionmyocardialvestibularsystem

Infectiousdiseasescentralnervoussysteminchildrencongenitalear,nose,andthroathumanimmunodeficiencyvirusofkidneysosteomyelitisPIDsepsissexuallytransmitteddiseasestuberculosisurinarytractinfectionsvector-borneillness

InfectiveendocarditisInfertilityInflammatoryboweldiseaseInflammatorycarcinoma,breastInfliximabInfluenzavaccineInformedconsentInguinalherniaINH.SeeIsoniazidInhalantsInotropicagentsInsomnia,primaryInsulin,fordiabetesmellitusInsulinglargineInsulinlisproInsulin-dependentdiabetesmellitus(IDDM)InsulinomaIntermittentexplosivedisorderInterstitiallungdiseaseInterstitialnephritisInterstitialpneumoniaIntoxicationIntracranialhemorrhageIntracranialpressure(ICP)IntraductalpapillomaIntraparenchymalhemorrhage

IntrapartumIntrauterinedevices(IUDs)IntussusceptionIpratropiumIrondeficiencyanemiaIronpoisoningIrritablebowelsyndromeIschemicboweldiseaseIschemicrestpainIschemicstrokeIsletcelltumorsIsocarboxazidIsoniazid(INH)IsopropylalcoholpoisoningIsosorbidedinitrateIsosporaIsotretinoinITP.SeeIdiopathicthrombocytopenicpurpuraIUDs.SeeIntrauterinedevices

J

Jarisch-HerxheimerreactionJaundice,neonatalJCvirusJIA.SeeJuvenileidiopathicarthritisJointdisordersJonescriteriaJonesfractureJunctionaltachycardiaJuvenileidiopathicarthritis(JIA)Juvenilepilocyticastrocytoma

K

KallmannsyndromeKaposisarcomaKartagenersyndromeKawasakisyndromeKayexalateKeflexKeloidKeratosisKernicterusKidney(s)inchildrenfailureglomerulardiseaseinfectionsstones

Kimmelstiel-Wilsondisease

KingellaKlatskintumorKlebsiellaKlebsiellapneumoniaeKleptomaniaKlinefeltersyndromeKlüver-BucysyndromeKorsakoff´spsychosisKrabbediseaseKrukenbergtumorKübler-Rossstagesofdying

L

LabetalolLaboranddeliveryabnormalnormalpostpartumcomplications

LabyrinthineconcussionLacerations,childbirth-relatedβ-Lactamantibioticsforpneumonia

LactoseintoleranceLactuloseLacunarinfarctionLambert-EatonsyndromeLamotrigineLargebowelobstruction(LBO)Largecellcarcinoma,lungLateralmedullarysyndromeLBO.SeeLargebowelobstructionLeadpoisoningLead-timebiasLegg-Calve-PerthesdiseaseLegionellapneumophilaLeiomyomaLeiomyosarcomaLengthbiasLenteinsulinLentigoLeprosyLerichesyndromeLesionsLeukemiaLeukocoriaLeukotrieneinhibitorsLeuprolideLevofloxacinLevonorgestrelLevothyroxineLewybodydementiaLGIB.SeeLowergastrointestinaltractbleeding

Libman-SacksendocarditisLichenplanusLichenificationLidocaineLimb-girdledystrophyLimpLipidlevelsLipoidnephrosisListeria,inmeningitisListeriamonocytogenesLithiumLiverdisordersfailuretransplantation

LivingwillLobarpneumoniaLobularcarcinomaLofgrensyndromeLooseassociationLorazepamLowbackpainLowergastrointestinaltractbleeding(LGIB)Low-molecular-weightheparinLSD.SeeLysergicaciddiethylamideLumpectomyLungabscessLungcancerLupus-likesyndromeLymediseaseLymphogranulomavenereumLymphomaBurkitt´scentralnervoussystemHodgkin´snon-Hodgkin´s

LynchsyndromeLysergicaciddiethylamide(LSD)

M

MacrocyticanemiaMacrolides,forpneumoniaMaculardegenerationMaculeMagnesiumsulfate(MgSO4)Magneticresonanceangiography(MRA)Majordepressivedisorder(MDD)MalabsorptionMaleerectiledisorderMalignanthypertensionMalignantmelanomaMalingering

MallorybodiesMallory-WeisstearMalpracticeMalrotationMammographyManiaMAOIs.SeeMonoamineoxidaseinhibitorsMarcusGunnpupilMarfansyndromeMarginalulcerMastectomyMastitisMaternalimprintingMaternalserumalfa-fetoprotein(MSAFP)MCA.SeeMiddlecerebralarteryMcArdlediseaseMcBurney´spointMcCune-AlbrightsyndromeMcRobertsmaneuverMDD.SeeMajordepressivedisorderMeaslesMeasles,mumps,rubella(MMR)vaccineforadultsforchildren

MeckeldiverticulumMedicalethicsMedulla,lesionsofMedullarycarcinoma,thyroidMedulloblastomaMegacolon.SeeToxicmegacolonMegaloblasticanemiaMeigsyndromeMelanomaMelasmaMembranoproliferativeglomerulonephritisMembranousglomerulonephropathyMENsyndromes.SeeMultipleendocrineneoplasiasyndromesMénièrediseaseMeningiomaMeningitisMeningococcalvaccineMeningococcusMenopauseMenorrhagiaMenstruationMentalretardationMercuryMesalamineMesentericischemiaMesothelioma,malignantMeta-analysisMetabolicacidosisMetabolicalkalosisMetabolicsyndromeMetabolism

MetachromaticleukodystrophyMetforminMethadoneMethanolMethicillinMethimazoleMethotrexateMethyldopaMethylphenidateMethylprednisoloneMethylxanthineMetoprololMetronidazoleMetrorrhagiaMgSO4.SeeMagnesiumsulfateMGUS.SeeMonoclonalgammopathyofundeterminedsignificanceMI.SeeMyocardialinfarctionMicroangiopathicanemiaMicrocyticanemiaMicropolyarteritisnodosaMidazolamMiddlecerebralartery(MCA)MiglitolMigraineheadacheMiliarytuberculosisMineralocorticoidsMinimalchangediseaseMinor(s)MirtazapineMiscarriageMissedabortionMitochondrialmyopathiesMitralregurgitationMitralstenosisMitralvalveprolapseMixedconnectivetissuediseaseMMRvaccine.SeeMeasles,mumps,rubellavaccineMobitztypeIheartblockMobitztypeIIheartblockModafinilMolarpregnancyMolluscumcontagiosumMonoamineoxidaseinhibitors(MAOIs)Monoclonalantibodies,forinflammatoryboweldiseaseMonoclonalgammopathyofundeterminedsignificance(MGUS)MononucleosisMonozygotictwinsMonteggiafractureMooddisordersMoraxellacatarrhalisMorphineMortalitycausesMortalityratesMotorneuron,lesionsofMovementdisorders

Moyamoyadisease6-MPMRA.SeeMagneticresonanceangiographyMS.SeeMultiplesclerosisMSAFP.SeeMaternalserumalfa-fetoproteinMucormycosisMüllerianstructuresMulti-infarctdementiaMultinodulargoiterMultipleendocrineneoplasia(MEN)syndromesMultiplegestationMultiplemyelomaMultiplesclerosis(MS)MunchausensyndromeMurphy´ssignMuscledisordersMusculardystrophyMyastheniagravisMycobacteriumaviumcomplexMycobacteriumtuberculosisMycoplasmapneumoniaMycosisfungoidesMyelofibrosiswithmyeloidmetaplasiaMyeloproliferativedisordersMyocardialinfarction(MI)MyoclonicdystrophyMyoclonicseizureMyositisMyotonicdystrophyMyxoma,atrial

N

NaficillinNägele´sruleNaloxoneNaltrexoneNarcissisticpersonalitydisorderNarcolepsyNecrotizingenterocolitisNecrotizingfasciitisNegativepredictivevalueNeisseriagonorrhoeaeNeisseriameningitidisNeomycinNeonates,mortalityrateNeonatologyNephriticsyndromeNephritisNephrolithiasisNephroticsyndromeNesiritideNeuraltubedefect

NeuroblastomaNeurocysticercosisNeurofibromatosisNeurogenicshockNeurolepticmalignantsyndrome(NMS)NeurologyNeuromusculardiseaseNeuropathy,peripheralNevocellularnevusNevusNiacinNicotinereplacementNifedipineNightmaredisorderNightstickfractureNitratesNitrazinetestNitroglycerinNitroprussideNMS.SeeNeurolepticmalignantsyndromeNocardiaasteroidesNodularmelanomaNoduleNon-Hodgkin´slymphomaNonmaleficenceNonsteroidalanti-inflammatorydrugs(NSAIDs)Nonstresstest(NST)NormalpressurehydrocephalusNormocyticanemiaNortriptylineNSAIDs.SeeNonsteroidalanti-inflammatorydrugsNST.SeeNonstresstestNullhypothesisNursemaidelbowNystatin

O

Oatcellcarcinoma,lungObservationalbiasObsessionsObsessive-compulsivedisorder(OCD)ObstructivesleepapneaObturatorsignOccipitallobes,lesionsofOCD.SeeObsessive-compulsivedisorderOddsratioOlanzapineOligodendrogliomaOligohydramniosOligomenorrheaOmphaloceleOncology

OpenangleglaucomaOphthalmicarteryOphthalmologicdisordersOpioidsOpportunisticinfections,inpatientswithAIDSOppositionaldefiantdisorderOPSS.SeeOverwhelmingpostsplenectomysepsisOraladvancedirectiveOralcontraceptivesadvantages/disadvantagescontraindicationsdeepvenousthrombosisandhepaticadenomaandhypertensionandmechanismsofaction

OrganophosphatepoisoningOrgasmicdisorderOrthopedicinjuriesOrtolanimaneuverOsbornewaveOseltamivirOsgood-SchlatterdiseaseOsler´snodesOsmoticdiarrheaOsteitisdeformansOsteoarthritisOsteogenesisimperfectaOsteomalaciaOsteomyelitisOsteoporosisOsteosarcomaOtitisexternaOtitismediaOvariancancerOvariancystsOverflowincontinenceOverwhelmingpostsplenectomysepsis(OPSS)OvulationOxacillinOxazepam

P

PvaluePagetdiseasebonebreast

PancoasttumorPancreaticcancerPancreaticdisordersPancreaticinsufficiencyPancreatitisPanhypopituitarism

PanicdisorderPapsmearPapillarycarcinoma,thyroidPapuleParacentesisParanoidpersonalitydisorderParanoidschizophreniaParaphiliasParathyroiddisordersParathyroidectomyParietallobes,lesionsofParkinsondiseaseParonychiaParoxetineParoxysmalnocturnalhemoglobinuriaPartialseizurePartnerabuseParvovirusB19PatausyndromePatchPatentductusarteriosusPaternalimprintingPathologicgamblingPathologicjaundicePCOS.SeePolycysticovarysyndromePCP.SeePhencyclidinehydrochloridePE.SeePulmonaryembolismPediculosispubisPedophiliaPellagraPelvicinflammatorydisease(PID)PelvicmassPelvicorganprolapsePelvicpainPemphigusvulgarisPenicillaminePenicillinPenicillinGPepticulcerdisease(PUD)Percutaneoustransluminalcoronaryangioplasty(PTCA)PerforatedulcerPericardialdiseasePericardiocentesisPericarditisPerimenopausePerimesencephalichemorrhagePerinatalmortalityratePeripheralneuropathyPeripheralvasculardisease(PVD)PeritonitisPermethrinPerniciousanemiaPerphenazinePersonalitydisordersPetechiae

Peutz-JegherssyndromePhagocyticimmunodeficiencysyndromesPhakomatosisPharyngitisPhencyclidinehydrochloride(PCP)PhenelzinePhenoxybenzaminePhentolaminePhenytoinPheochromocytomaPhobiaPhysiologicjaundicePickdiseasePID.SeePelvicinflammatorydiseasePigmentstonePigmentarylesionsPilocyticastrocytoma,juvenilePimozidePindololPioglitazonePitocinPituitaryadenomaPituitaryglandPityriasisroseaPlacentaaccretaPlacentapreviaPlacentalabruptionPlacentalseparationPlaquePleuraleffusionPleurodesisPlummer-VinsonsyndromePMDD.SeePremenstrualdysmorphicdisorderPneumococcalvaccinePneumococcusPneumoconiosesPneumocystisjiroveciPneumoniaPneumonitis,hypersensitivityPneumothorax(PTX)PodagraPodophyllinPoliovaccinePolycystickidneydiseasePolycysticovarysyndrome(PCOS)PolycythemiaveraPolyhydramniosPolymenorrheaPolymyalgiarheumaticaPolymyositisPolyps,colonPons,lesionsofPorphyriacutaneatardaPortalhypertensionPort-winestain

PositivepredictivevaluePosteriorcerebralarteryPosteriorurethralvalvePostinfectiousglomerulonephropathyPostmenopausalbleedingPostpartumcomplicationsPostpartumdepressionPostpartumendometritisPostpartumhemorrhagePoststreptococcalglomerulonephritisPosttermpregnancyPosttraumaticstressdisorder(PTSD)Pott´sfracturePowerPPDtest.SeePurifiedproteinderivativetestPPi.SeeProtonpumpinhibitorsPrader-WillisyndromePrecisionPrednisonePreeclampsiaPregnancy.SeealsoLaboranddeliveryabortionamnioticfluidabnormalitiesdatingdiabetesmellitusinectopicfetaldiagnostictestingandmonitoringhemorrhageduringhypertensioninintrapartummolarmultiplegestationothermedicalconditionsphysiologicchangesposttermprematureruptureofmembranes(PROM)prenatalcarepretermlabor(PTL)Rhincompatibilityteratogensvaccinesand

PrematureejaculationPrematureovarianfailurePrematureventricularcontraction(PVC)Premenstrualdysmorphicdisorder(PMDD)PrenatalcarePrenatalgeneticanalysisPrevalencePreventativemedicinePrimaryheartblockPrimaryhypersomniaPrimaryinsomniaPrinzmetalanginaProbenecidProcainamideProgesterone

ProgestinProgressivemultifocalleukoencephalopathyProgressivesupranuclearpalsyProlactinomaPROM.SeePrematureruptureofmembranesPropionibacteriumPropranololPropylthiouracil(PTU)PropylthrouvnelProstateProstatecancerProstate-specificantigen(PSA)ProstatectomyProteusProteusmirabilisProtonpumpinhibitors(PPi)PSA.SeeProstate-specificantigenPseudocystPseudogoutPseudohypoparathyroidismPseudomembranouscolitisPseudomonasspp.PseudomonasaeruginosaPseudotumorcerebriPsoassignPsoriasisPsoriaticarthritisPsychogenicfuguePsychosisPsychoticdisordersPTCA.SeePercutaneoustransluminalcoronaryangioplastyPTL.SeePretermlaborPTSD.SeePosttraumaticstressdisorderPTU.SeePropylthiouracilPTX.SeePneumothorax;TensionpneumothoraxPubertyPUD.SeePepticulcerdiseasePulmonaryedemaPulmonaryembolism(PE)PulmonaryfibrosisPulmonaryhypoplasiaPulmonaryinternalmedicinePulmonaryneoplasmsPulmonicstenosisPulmonology,pediatricPurifiedproteinderivative(PPD)testPurpuraPustulePVC.SeePrematureventricularcontractionPVD.SeePeripheralvasculardiseasePyelonephritisPyloricstenosisPyrizinamidePyromania

Q

QuetiapineQuinidineQuinolone

R

rvalueRadiationRansoncriteriaRash,feverwithReactivearthritisRecallbiasRectalcancerRecurrentabortionReduciblehernia5-α-ReductaseinhibitorsReitersyndromeRelativeriskReliabilityRenalamyloidosisRenalarterystenosisRenalcalculiRenalcellcarcinomaRenalcrisisRenalfailureRenalinfarctRenalinternalmedicineRenaltubularacidosisReninResidualschizophreniaRespiratoryacidosisRespiratoryalkalosisRespiratorydistresssyndrome,neonatalRespiratorysyncytialvirus(RSV)RestlesslegsyndromeRestrictivecardiomyopathyRestrictivelungdiseaseRetainedplacentaRetin-ARettsyndromeReyesyndromeReynold´spentadRhincompatibilityRhabdomyosarcomaRheumaticfeverRheumaticheartdiseaseRheumatoidarthritisRheumatologyRhoGAMRichter´shernia

RicketsRickettsiarickettsiiRifampinRisperidoneRMSF.SeeRockyMountainspottedfeverRockyMountainspottedfever(RMSF)RosespotsRoseolainfantumRosiglitazoneRotatorcuffinjuryRotavirusRovsing´ssignRSV.SeeRespiratorysyncytialvirusRubbingalcoholpoisoningRubellaRubinmaneuverRussel´ssign

S

SAAG.SeeSerum-ascitesalbumingradientSAB.SeeSpontaneousabortionSacroiliacjointsSalicylatetoxicitySalicylicacidSalmonellaspp.SarcoidosisSBO.SeeSmallbowelobstructionScabiesScalpstimulationScaphoidfractureScarletfeverSCFE.SeeSlippedcapitalfemoralepiphysisSchistosomahaematobiumSchizoaffectivedisorderSchizoidpersonalitydisorderSchizophreniaSchizophreniformdisorderSchizotypalpersonalitydisorderSchwannomaSciaticaSCID.SeeSeverecombinedimmunodeficiencysyndromeSclerodermaSclerosingcholangitisScreening,forcancerScurvySeborrheicdermatitisSeborrheickeratosisSecondaryseizuresSecretorydiarrheaSedative-hypnoticwithdrawalSeizuresβ-Selectiveagonists

SelectiveIgAdeficiencySelectiveserotoninreuptakeinhibitors(SSRIs)SeleniumsulfideSelf-selectionbiasSeminomaSenilekeratosisSensitivitySentinelloopSeparationanxietydisorderSepsisSepticshockSeronegativespondyloarthropathySerratiamarcescensSertoli-LeydigcelltumorSertralineSerum-ascitesalbumingradient(SAAG)Severecombinedimmunodeficiencysyndrome(SCID)SexualaversiondisorderSexualmasochismSexualsadismSexuallytransmitteddiseasesSézarysyndromeSharedpsychoticdisorderSheehansyndromeShigellaShock.SeeSepticshockShortgutsyndromeShortstatureShoulderdislocationShoulderdystociaShuntproceduresSIADH.SeeSyndromeofinappropriatesecretionofantidiuretichormoneSicklecellanemiaSideroblasticanemiaSildenafilSilicosisSimplepartialseizureSinusheadacheSinustachycardiaSinusitisSipplesyndromeSIRS.SeeSystemicinflammatoryresponsesyndromeSisterMaryJosephnodeSjögrensyndromeSkincancerSkindisordersSkininfectionsSLE.SeeSystemiclupuserythematosusSleepapneaSleepterrordisorderSleepwalkingdisorderSlippedcapitalfemoralepiphysis(SCFE)Smallbowelobstruction(SBO)SmallbowelperforationSmallcellcarcinoma,lung

SmallintestinedisordersSmokingcessationSMX.SeeSulfamethoxazoleSocialphobiaSolitarypulmonarynoduleSomatizationdisorderSomatoformdisordersSomatostatinSomatostatinomaSomogyieffectSpecificphobiaSpecificitySpermcountSpherocytosisSpiderbites,brownrecluseSpinabifidaoccultaSpinaldisordersSpinalstenosisSpironolactoneSplenectomySplenicdisordersSpleniclacerationSpondyloarthropathySpontaneousabortion(SAB)SpontaneousbacterialperitonitisSquamouscellcarcinomacervicalesophaguslungskinvulva

SSRIs.SeeSelectiveserotoninreuptakeinhibitorsStagesoflaborStaphylococcusaureusinendocarditisinfoodpoisoninginmeningitisinosteomyelitisinpneumoniainsepsisskininfectionwith

StaphylococcusepidermidisStaphylococcussaprophyticusStatinsStatusepilepticusSterilizationSteroidresponsivenephropathySteroidsforAddisondiseaseanabolicforasthmaforinflammatoryboweldiseaseforkidneydiseaseforleukemiaforMS

forpsoriasisforrheumatoidarthritisforskindisorders

Stevens-JohnsonsyndromeStomachdisordersStrangulatedbowelStrangulatedherniaStreptococcalpharyngitisStreptococcusStreptococcusagalactiaeStreptococcuspneumoniaeinmeningitisinotitismediainpneumonia

Streptococcuspyogenes,skininfectionwithStreptococcusviridansStreptokinaseStressincontinenceStrokeSturge-WebersyndromeSubacutesclerosingpanencephalitisSubacutethyroiditisSubarachnoidhemorrhageSubduralhematomaSubependymalgiantcellastrocytomaSubstanceabuseSuicideSulfamethoxazole(SMX)SulfasalazineSulfinpyrazoneSulfonylureasSunburstsignSuperiorcerebellararterySuprapubicpressureSupraventriculartachycardia(SVT),paroxysmalSVT.SeeSupraventriculartachycardiaSweatchloridetestSwimmer´searSyncopeSyndromeofinappropriatesecretionofantidiuretichormone(SIADH)SyphilisSyringomyeliaSystemicinflammatoryresponsesyndrome(SIRS)Systemiclupuserythematosus(SLE)Systolicdysfunction

T

ttestTachycardia,fetalTaeniasoliumTamoxifenTamponade.SeeCardiactamponade

TannerstagesTardivedyskinesiaTay-SachsTCAs.SeeTricyclicantidepressantsT-cellimmunodeficiencysyndromesTemazepamTemporalarteritisTemporallobes,lesionsofTensionheadacheTensionpneumothorax(PTX)TeratogensTeratomaTerazosinTerbutalineTestesTesticulartorsionTetanusTetanusvaccineTetracyclineTetralogyofFallotThalassemiaThalidomideThecaluteincystTheophyllineThiazidediureticsThiazolidinedionesThinmembranediseaseThioridazineThird-degreeheartblockThreatenedabortionThrombocytosis,essentialThrombolyticsThromboticthrombocytopenicpurpura(TTP)ThrushThyroidcancerThyroiddisordersThyroidstormThyroiditisTiclopidineTineaTissueplasminogenactivator(tPA)TMP.SeeTrimethoprimTNF-α.SeeTumornecrosisfactor-aTobaccoTocolyticagentsTodd´spostictalparalysisToleranceTonic-clonicseizureTophiTorsadedepointesTorsion,testicularTotalanomalouspulmonaryvenousreturnTourettesyndromeToxicmegacolonToxicology

ToxoplasmagondiiToxoplasmosistPA.SeeTissueplasminogenactivatorTracheoesophagealfistulaTransientischemiaattack(TIA)Transitionalcellcancer,bladderTransplantation,liverTranspositionofthegreatvesselsTransudatepleuraleffusionTransvestismTranylcypromineTraumaTraumaticaorticruptureTrazodoneTremorTreponemapallidumTriazolamTrichinosisTrichloroaceticacidTrichomonasvaginalisTrichomoniasisTrichotillomaniaTricuspidatresiaTricuspidregurgitationTricyclicantidepressants(TCAs)TrifluoperazineTrigeminalneuralgiaTrimethoprim(TMP)TripleAruptureTrisomy13.SeePatausyndromeTrisomy18.SeeEdwardsyndromeTrisomy21.SeeDownsyndromeTroponinITrousseau´ssignTrousseausyndromeTruncusarteriosusTrypanosomacruziiTTP.SeeThromboticthrombocytopenicpurpuraTuberculosisTuberoussclerosisTubularadenomaTubulovillousadenomaTumornecrosisfactor-a(TNF-a),forinflammatoryboweldiseaseTurcotsyndromeTurnersyndromeTwinsTwin-to-twintransfusionsyndromeType1diabetesmellitusinchildren

Type2diabetesmellitusTypeIerrorTypeIIerrorTyramine

U

UlcerativecolitisUltralenteinsulinUltrasound(US)forappendixdisordersforbreastcancerforgallbladderdisordersforpancreasdisordersinpregnancy

UmbilicalcordprolapseUncalherniationUndifferentiatedschizophreniaUremiaUrinaryincontinenceUrinarytractUrinarytractinfections(UTI)UrticariaUS.SeeUltrasoundUterineatonyUterinebleeding,abnormalUterineruptureUTI.SeeUrinarytractinfections

V

VaccinesVaginalbirthaftercesarean(VBAC)VaginismusVaginitisValidityValproicacidValvularheartdiseaseVancomycinVAP.SeeVentilator-associatedpneumoniaVaricellaadultimmunizationrecommendationschildhoodimmunizationrecommendationsclinicalmanifestations

Varices.SeeEsophagealvaricesVaricoceleVasapreviaVasculardementiaVasculardisordersVasculitidesVasoocclusivecrisisVasopressinVasospasmVBAC.SeeVaginalbirthaftercesareanVector-borneillnessVelcrocracklesVenlafaxine

VenousstasisVentilation/perfusionscanVentilator-associatedpneumonia(VAP)VentricularfibrillationVentricularseptaldefectVentriculartachycardiaVerapamilVerrucavulgarisVertigoVesicleVesicoureteralrefluxVesicovaginalfistulaVestibularneuronitisVestibularsysteminfarctionVestibulitis,vulvarVibriocholeraVibrioparahaemolyticusVibriovulnificusVillousadenomaVincristineViolenceVIPomaVirchownodeVirchow´striadVisualfielddefectsVitamins,prenatalVitaminB12deficiencyVitaminDsupplementationVitiligoVoidingcystourethrogramVolvulusvonHippel-LindaudiseasevonRecklinghausendiseasevonWillebranddisease

VoyeurismVulvarcancer

W

WaldenstrommacroglobulinemiaWallenbergsyndromeWarfarinWaterhouse-FriderichsensyndromeWatershedinfarctionWegener´sgranulomatosisWell´scriteriaWerdnig-HoffmannWermersyndromeWernicke-KorsakoffsyndromeWernicke´sarea,lesionsofWernicke´sencephalopathyWestsyndromeWestermark´ssign

Westernblot,forHIVWhipplediseaseWhippleprocedureWhipple´striadWhitebloodcellneoplasiaWilmstumorWilsondiseaseWiskott-AldrichsyndromeWithdrawalWolff-Parkinson-WhitesyndromeWoodscorkscrewmaneuverWristfracture

X

XanthomaXerodermapigmentosumX-linkedagammaglobulinemia

Y

YersiniaYersiniaenterocolitica

Z

ZanamivirZavanellimaneuverZenkerdiverticulumZidovudineZincpyrithioneZollinger-Ellisonsyndrome