70 terms

COMLEX Level 3

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E. Coli (ETEC)
Epi: recent travel

Presentation: watery diarrhea

Labs:

Treatment:
E. Coli (EHEC)
Epi: undercooked beef (hamburger)

Presentation: bloody diarrhea
- a/w HUS

Labs:

Treatment: do NOT give platelet transfusions or antibiotics
Giardia
Epi: contaminated water (eg from a stream, camping)
- MSM

Presentation: Watery diarrhea; bloating, flatus, steatorrhea

Labs: stool ELISA antigen > 90% sens/spec

Treatment:
Rotavirus
Epi: unvaccinated or young infants

Presentation: watery diarrhea

Labs:

Treatment:
Shigella
Epi: daycare outbreak

Presentation: watery diarrhea, high fever
- a/w reactive arthritis

Labs:

Treatment:
Salmonella
Epi: chicken, eggs

Presentation: bloody diarrhea

Labs:

Treatment:
Vibrio parahaemolyticus
Epi: seafood

Presentation: bloody diarrhea

Labs:

Treatment:
Vibrio vulnificus
Epi: oysters, clams

Presentation: bloody diarrhea
- a/w liver disease, skin lesions

Labs:

Treatment:
Yersinia
Epi: vegetables, milk-derived products, meat (pork) infected with rat urine or feces

Presentation: bloody diarrhea

Labs:

Treatment:
Amebic diarrhea
Epi:

Presentation: bloody diarrhea
- may be a/w liver abscesses

Labs: 3-stool ova and parasite exam, serologic testing

Treatment: metronidazole
Campylobacter
Epi: MCC food poisoning

Presentation:
- A/W Guillain-Barre and reactive arthritis

Labs:

Treatment:
Bloody diarrhea
Infectious agents: campylobacter, salmonella, Vibrio parahaemolyticus & vulnificus, shigella, Yersinia, amebic, E. coli

Labs:
- Best initial test: fecal leukocytes
- Most accurate test: stool culture

Treatment, mild: hydration
Treatment, severe (blood, fever, abdominal pain, hypotension, tachycardia): fluorquinolones (e.g., ciprofloxacin)
Shagreen patch as seen in tuberous sclerosis
Tuberous sclerosis (aka Bournevilles disease, epiloia)
Epi: m = f

Cause:

Presentation: presents shortly after birth. Several skin findings, including shagreen patch (picture). The shagreen patch is a connective tissue nevus or collagenoma and typically appears as a white to yellow plaque with a pebbled surface on the lumbosacral area. The earliest sign of TS is often the ash leaf sign, which presents as a hypopigmented macule or patch on the trunk or extremity which is accentuated with Wood's lamp examination. Other skin manifestations that are common in TS include periungual fibromas (also known as Koenen's tumor) and adenoma sebaceum (facial angiofibromas). Patients with TS may also have a seizure disorder if the central nervous system is affected. In addition, these patients may have other features, such as retinal hamartomas, angiomyolipomas, cardiac rhabdomyoma, and pulmonary cysts

Diagnosis:

Labs:

Management:
Epiglottitis
Epi: men in their 60s
- unvaccinated children 2-4 YOA

Cause: H. influenza (25% of adult infxns), H. parainfluenza, S. pyogenes, S. pneumonia, S. aureus, Mycoplasma

Presentation:
- drooling
- high fever
- tripod position (hands on knees)
- inspiratory stridor
- muffled "hot potato" voice

Diagnosis: thumb sign on lateral neck x-ray

Labs: blood culture, epiglottic culture

Management: CAB, nasotracheal intubation, IV ceftriaxone
- rifampin prophylaxis to household contacts if H. influenzae (+)
Meningitis, bacterial, in an elderly patient
Epi: elderly

Cause:

Presentation: fever, poor appetite, AMS, fever, hypotension

Diagnosis:

Labs: CSF ↑ protein, ↓ glucose

Management:
-vancomycin (S. pneumonia)
-ceftriaxone (N. meningitides)
-ampicillin (Listeria)
Prinzmetal angina
Epi:

Cause: focal coronary artery vasospasm

Presentation: chest pain that is worse at rest than with exertion

Diagnosis:

Labs:

Management: nitrates and calcium channel blockers
Scoliosis - factors that increase risk of progression
Female
Greater initial Cobb angle
Thoracic curvature
Skeletal immaturity
Graves disease
Epi:

Cause: antibodies against TSH receptor bind and mimic effects of TSH (type II hypersensitivity)

Presentation: exophthalmos / proptosis
- thickening & redness of skin just below knee
- onycolysis

Diagnosis:

Labs: ↑ T4, ↓ TSH
- ↑ radioactive iodine uptake

Management: acutely - PTU or methimazole
- radioactive iodine
- propranolol (tx sympathetic symptoms)
Small bowel obstruction x-ray findings
air-fluid levels
dilated loops of bowel
Small bowel obstruction
Epi:

Cause: MCC post-op adhesions
- malignancy (not colon), Crohn's, hernias
-- MC malignancy is mucinous ovarian cancer

Presentation: nausea, abdominal pain, vomiting, no passage of stool

Diagnosis: upright abdominal x-ray shows air-fluid levels and dilated loops of bowel
Ovarian cancer
Epi: woman > 50
- choriocarcinoma at a younger age

Presentation: increasing abdominal girth, weight loss
- Mucinous → SBO
- Serous → ascites
- Granulosa cell → estrogen secretion

Diagnosis:

Labs:
- CA125 as marker of response to treatment, not for screening

Management: surgical debulking followed by chemotherapy
Acetylcholine
Levels of this neurotransmitter are associated with both prolongation of REM and increased total sleep time
Dopamine
Levels of this neurotransmitter are associated with decreased total sleep time alone
Norepinephrine
Levels of this neurotransmitter are associated with both decreased REM and decreased total sleep time
Serotonin
Levels of this neurotransmitter are associated with prolonged total sleep time and delta-wave sleep, no known effect on REM
Lead poisoning
Epi: low SES, works in ammunition factory, lives in old house, consumption of moonshine

Presentation:
- Children: hyperactivity, aggression, learning disability, impaired growth, constipation, mental lethargy
- Adults: abdominal pain, encephalopathy, peripheral neuropathy, renal failure

Diagnosis: lead level > 5 mcg/dl (kids)

Labs / imaging:
- peripheral smear shows microcytic, hypochromic anemia; increased free erythrocyte porphyrins (FEP), basophilic stippling
- dense lead lines on long bone x-ray

Management:
- report to DOH if > 15 mcg/dl in kids
- chelation if > 45 mcg/dl in kids (dimercaprol, succimer)
Diabetes mellitus, type I
Epi:
A/W autoimmune hepatitis (HLA DR3 / DR4)

Presentation: thirst, polyphagia, polydipsia, fatigue, frequent urination

Diagnosis:

Labs/imaging:
- thyroid function tests (20% have elevated thyroid Ab)

Management:
Autoimmune hepatitis
persistent hepatocellular necrosis

Epi: females in their teens
A/W DM type I (HLA DR3 / DR4)

Presentation:

Diagnosis:

Labs/imaging:

Management:
HLA B27 diseases
Ankylosing spondylitis
Anterior uveitis
Inflammatory bowel disease
Reactive arthritis
Polymyositis
inflammatory myopathy

Epi: adults

Presentation: b/l proximal muscle weakness a/w walking

Diagnosis:

Labs/imaging:

Management: steroids
Myasthenia Gravis
Epi:

Presentation:

Diagnosis: edrophonium testing

Labs/imaging:

Management: steroids
Raynaud's
Epi:

Presentation:

Diagnosis:

Labs/imaging:

Management: Ca channel blockers
Guillain-Barre
Epi:

Presentation:

Diagnosis:

Labs/imaging:

Management: plasmapheresis, IVIG
Multiple sclerosis
Epi:

Presentation:

Diagnosis:

Labs/imaging:

Management:
Vertebral artery dissection
Epi:

Presentation:

Diagnosis:

Labs/imaging: noncontrast CT

Management:
- occlusive: anticoagulation
- dissecting aneurysm: ligation, embolization
Milk alkali syndrome (Burnett's)
hypercalcemia caused by repeated ingestion of calcium and absorbable alkali

Epi:

Presentation:
- hypercalcemia: N/V, lethargy, AMS, depression, fatigue, dysrhythmias
- hypercalcemia -> nephrolithiasis (stones), bones (bone pain), anorexia, vomiting, constipation, MS changes (groans)
- untreated results in acute renal failure

Diagnosis:

Labs/imaging:
- EKG hypercalcemia: QT shortening, PR lengthening

Management: IV fluids, furosemide
Erb-Duchenne's Palsy
Epi:

Presentation:

Diagnosis:

Labs/imaging:

Management:
Focal nodular hyperplasia
Epi: young to middle aged adults, F>M

Presentation:

Diagnosis:
- gross path: poorly encapsulated nodule with central depressed stellate scar that contains blood vessels and is often solitary

Labs/imaging:
- CT: hypervascular mass containing arteriovenous connections

Management: observation unless symptomatic
- if painful, surgery or IR
Hemochromatosis
Epi:

Presentation:

Diagnosis:

Labs/imaging:

Management:
Hepatocellular carcinoma
Epi:

Presentation:

Diagnosis:

Labs/imaging:

Management:
Placental abruption, risk factors
hypertension
cocaine
trauma
extremities of age (< 15, > 40)
smoking
h/o placental abruption
thrombophilia
Preeclampsia
Epi:

Presentation: if severe, sx a/w end-organ damage, e.g., headaches, blurry vision, scotomas, scintillation, RUQ pain, peripheral edema

Diagnosis:
- mild: 140/90, 1+ dipstick or > 300 / 24hr
- severe: 160/110, 3+ dipstick or > 500 / 24hr

Labs/imaging:

Management:
- if severe: MgSO4 4-6 g bolus, followed by 1-2 g/hr drip
Pancreatic cancer
Epi:

Presentation: painless, progressive, obstructive jaundice; abdominal pain radiating to back, indigestion, fatigue, anorexia, weight loss, n/v
- Courvoisier's sign: nontender palpable gallbladder
- Trousseau's sign: migratory thrombophlebitis

Diagnosis:

Labs/imaging:
- best initial: CT abdomen shows pancreatic mass, dilated pancreatic and bile ducts, hepatic metastases, or vascular involvement
- ERCP

Management:
- if pancreatic head tumor w/o mets, can Whipple (pancreaticoduodenectomy)
- tumors involving gastroduodenal artery have better prognosis
- tumors involving superior mesenteric artery, portal vein, aorta, IVC have worse prognosis
- 5-FU and gemcitabine improve only short term prognosis
Benzodiazepine intoxication
Mechanism: GABA agonist

Intoxication: amnesia, sleep, respiratory depression

Antidote:
Heroin intoxication
Mechanism: opioid

Intoxication: decreased, consciousness, pinpoint pupils (miosis), respiratory depression

Antidote:
Lysergic acid diethylamide (LSD) intoxication
Mechanism:

Intoxication: richer colors, more profound music, heightened taste

Antidote:
Phencyclidine piperidine intoxication
Mechanism:

Intoxication: vertical and horizontal nystagmus, intense psychosis, violence, rhabdomyolysis, hyperthermia

Antidote:
Cocaine intoxication
Mechanism:

Intoxication: tachycardia, hypertension, insomnia, mydriasis, aggression, psychosis, tactile hallucinations (itching)

Antidote:
Urethral injury
Epi:

Presentation: pain, hematuria or meatal bleeding, dysuria, urinary retention
- Types 1-5

Diagnosis:

Labs/imaging: retrograde urethrogram

Management: placement of suprapubic catheter
- delay surgery 6-12 weeks
Tetanus
Epi: IV drug user, elderly, patients with ulcers

Presentation: focal or diffuse muscle weakness, lockjaw

Diagnosis:

Labs/imaging:

Management: BZDs to control spasms, neuromuscular blockade if need to manage airway, metronidazole
- consider tetanus immunoglobin or toxoid in those with wounds and questionable vaccination history
Salicylate toxicity
Epi:

Presentation: dizziness, tinnitus, LOC, death
MCC aspirin

Diagnosis:

Labs/imaging: ABG
- mixed respiratory alkalosis, metabolic acidosis, anion gap

Management: dialysis, sodium bicarbonate
Transfusion reaction, febrile non-hemolytic (FNHTR)
recipient antibodies against donor leukocytes

Epi:

Presentation: fever during or after blood transfusion

Diagnosis:

Labs/imaging:

Management: use leukoreduced blood products, Tylenol
Transfusion reaction, acute hemolytic
Epi:

Presentation: fever, chills, hypotension, hemoglobinemia, hemoglobinuria, chest and/or flank pain

Diagnosis:

Labs/imaging:

Management: IV fluids and diuretics to preserve fluid volume and kidney function
Transfusion reaction, delayed hemolytic
Epi:

Presentation: mild anemia and/or hyperbilirubinemia, slight fever, 3-10 days after transfusion

Diagnosis:

Labs/imaging:

Management: IV fluids and diuretics
Transfusion reaction, allergic
Epi:

Presentation: urticaria

Diagnosis:

Labs/imaging:

Management: stop transfusion, antihistamines
Transfusion reaction, anaphylactic
Epi:

Presentation: difficulty breathing, LOC, respiratory arrest, shock

Diagnosis:

Labs/imaging:

Management: stop transfusion, epinephrine
- if previous anaphylaxis, pre-treat with glucocorticoids, washed RBCs, volume-reduced platelets
Transfusion reaction, bacterial contamination
Epi:

Presentation: fevers, chills minutes to hours after transfusion; septic shock, DIC

Diagnosis:

Labs/imaging:

Management: maintain blood pressure, broad-spectrum antibiotics
Lateral epicondylitis
overuse injury of common extensor tendon, MC extensor carpi radialis brevis tendon

Epi:

Presentation:

Diagnosis: Cozen's test - wrist extension with ulnar deviation

Labs/imaging:

Management: rest, ergonomic changes, ice, bracing, NSAIDs, OMT (CS: flex elbow, extend wrist)
Trisomy 13 (Patau)
Epi:

Presentation: holoprosencephaly, omphalocele, polydactyly, cleft lip & palate, VSD, cystic kidney, eye defects

Diagnosis:

Labs/imaging:
- 20 week quad screen: AFP, estriol, HCG, and inhibin-A all normal
- Confirmatory amniocentesis / karyotyping

Management:
Bacterial vaginosis
Epi: 40-50% of vulvovaginitis; premenopausal women

Presentation: fishy smelling discharge

Diagnosis:

Labs/imaging: wet prep (clue cells)
- thin, grey homogenous discharge
- pH > 4.5
- fishy odor

Management: PO or intravaginal metronidazole or clindamycin
von Willebrand disease
Epi:

Presentation: excessive bleeding

Diagnosis:

Labs/imaging: (+) ristocetin assay; prolonged PTT
- prolonged bleeding time
- normal platelet count

Management:
Methanol toxicity
Mechanism:

Intoxication:
- anion gap metabolic acidosis (low HCO3)
- acute renal failure
- blurred vision

Antidote/Tx: bicarbonate (for acidosis), ethanol, fomepizole
- hemodialysis if: ingestion > 30 ml, serum methanol > 20 mg/dL, visual change, lack of acidosis improvement despite multiple bicarb tx
Stroke, anterior cerebral artery
-Contralateral lower extremity weakness / gait disturbance
-Personality change / psychiatric disturbance
-Urinary incontinence
Stroke, middle cerebral artery
-Contralateral upper extremity, face, and leg weakness
-Motor aphasia
-Apraxia / neglect
-Eyes deviate toward side of lesion
-Contralateral homonymous hemianopsia with macular sparing
Stroke, posterior cerebral artery
-Prosopagnosia
-CN3 palsy
-Contralateral hemiplegia
-Homonymous hemianopsia
-Visual neglect
Stroke, vertebrobasilar artery
supplies brainstem - bilateral findings
-"drop attack" / "locked in" syndrome
-Vertigal nystagmus
-Dysarthria, dystonia, a/dysphasia
-Sensory changes in face & scalp
-Ataxia / gait abnormalities
-Hemianopsia
Stroke, posterior inferior cerebellar artery
-Ipsilateral face / contralateral body
-Vertigo
-Horner's syndrome
-Vomiting
-Gait ataxia
-Truncal lateropulsion, limb incoordination
-Ipsilateral occipital headache
Stroke, Lacunar infarct
absence of cortical deficits
-Ataxia
-Parkinsonian signs
-Sensory deficits
-Hemiparesis, esp in face
-Possible bulbar signs
Stroke, ophthalmic artery
-Amaurosis fugax