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USMLE 2 Rapid Review

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"Sawtooth" P waves
Classic ECG finding in atrial flutter.
Angina is new, is worsening, or occurs at rest
Definition of unstable angina.
ACEI
Antihypertensive for a diabetic patient with proteinuria.
Hypotension, distant heart sounds, and JVD
Beck's triad for cardiac tamponade.
β-blockers, digoxin, calcium channel blockers
Drugs that slow AV node transmission.
Niacin
Hypercholesterolemia treatment that → flushing and pruritus.
Anticoagulation, rate control, cardioversion
Treatment for atrial fibrillation.
Immediate cardioversion
Treatment for ventricular fibrillation.
Dressler's syndrome: fever, pericarditis, ↑ ESR
Autoimmune complication occurring 2-4 weeks post-MI.
Treat existing heart failure and replace the tricuspid valve
IV drug use with JVD and holosystolic murmur at the left sternal border. Treatment?
Echocardiogram (showing thickened left ventricular wall and outflow obstruction)
Diagnostic test for hypertrophic cardiomyopathy.
Pulsus paradoxus (seen in cardiac tamponade)
A fall in systolic BP of > 10 mmHg with inspiration.
Low-voltage, diffuse ST-segment elevation
Classic ECG findings in pericarditis.
BP > 140/90 on three separate occasions two weeks apart
Definition of hypertension.
Renal artery stenosis, coarctation of the aorta, pheochromocytoma, Conn's syndrome, Cushing's syndrome, unilateral renal parenchymal disease, hyperthyroidism, hyperparathyroidism
Eight surgically correctable causes of hypertension.
Abdominal ultrasound and CT
Evaluation of a pulsatile abdominal mass and bruit.
> 5.5 cm, rapidly enlarging, symptomatic, or ruptured
Indications for surgical repair of abdominal aortic aneurysm.
Morphine, O2, sublingual nitroglycerin, ASA, IV β-blockers, heparin
Treatment for acute coronary syndrome.
Abdominal obesity, high triglycerides, low HDL, hypertension, insulin resistance, prothrombotic or proinflammatory states
What is the metabolic syndrome?
Exercise stress treadmill with ECG
Appropriate diagnostic test? ■ A 50-year-old male with angina can exercise to 85% of maximum predicted heart rate.
Pharmacologic stress test (e.g., dobutamine echo)
Appropriate diagnostic test? ■ A 65-year-old woman with left bundle branch block and severe osteoarthritis has unstable angina.
Angina, ST-segment changes on ECG, or ↓ BP
Signs of active ischemia during stress testing.
ST-segment elevation (depression means ischemia), flattened T waves, and Q waves
ECG findings suggesting MI.
Prinzmetal's angina
A young patient has angina at rest with ST-segment elevation. Cardiac enzymes are normal.
CHF, shock, and altered mental status
Common symptoms associated with silent MIs.
V/Q scan
The diagnostic test for pulmonary embolism.
Protamine
An agent that reverses the effects of heparin.
PT
The coagulation parameter affected by warfarin.
Hypertrophic cardiomyopathy
A young patient with a family history of sudden death collapses and dies while exercising.
Oral surgery—amoxicillin; GI or GU procedures—ampicillin and gentamicin before and amoxicillin after
Endocarditis prophylaxis regimens.
Pain, pallor, pulselessness, paralysis, paresthesia, poikilothermia
The 6 P's of ischemia due to peripheral vascular disease.
Stasis, hypercoagulability, endothelial damage
Virchow's triad.
OCPs
The most common cause of hypertension in young women.
Excessive EtOH
The most common cause of hypertension in young men.
Seborrheic keratosis
"Stuck-on" appearance.
Psoriasis
Red plaques with silvery-white scales and sharp margins.
Basal cell carcinoma
The most common type of skin cancer; the lesion is a pearly-colored papule with a translucent surface and telangiectasias.
Impetigo
Honey-crusted lesions.
Cellulitis
A febrile patient with a history of diabetes presents with a red, swollen, painful lower extremity.
Pemphigus vulgaris
+ Nikolsky's sign.
Bullous pemphigoid
- Nikolsky's sign.
Acanthosis nigricans. Check fasting blood sugar to rule out diabetes
A 55-year-old obese patient presents with dirty, velvety patches on the back of the neck.
Varicella zoster
Dermatomal distribution.
Lichen planus
Flat-topped papules.
Erythema multiforme
Iris-like target lesions.
Contact dermatitis
A lesion characteristically occurring in a linear pattern in areas where skin comes into contact with clothing or jewelry.
Pityriasis rosea
Presents with a herald patch, Christmas-tree pattern.
Alopecia areata (autoimmune process)
A 16-year-old presents with an annular patch of alopecia with broken-off, stubby hairs.
Pityriasis versicolor
Pinkish, scaling, flat lesions on the chest and back. KOH prep has a "spaghetti-and-meatballs" appearance.
Asymmetry, border irregularity, color variation, large diameter
Four characteristics of a nevus suggestive of melanoma.
Actinic keratosis
Premalignant lesion from sun exposure that can → squamous cell carcinoma.
Lesions of 1° varicella
"Dewdrop on a rose petal."
Seborrheic dermatitis. Treat with antifungals
"Cradle cap."
Acne vulgaris
Associated with Propionibacterium acnes and changes in androgen levels.
Herpes simplex
A painful, recurrent vesicular eruption of mucocutaneous surfaces.
Lichen sclerosus
Inflammation and epithelial thinning of the anogenital area, predominantly in postmenopausal women.
Squamous cell carcinoma
Exophytic nodules on the skin with varying degrees of scaling or ulceration; the second most common type of skin cancer.
Hashimoto's thyroiditis
The most common cause of hypothyroidism.
High TSH, low T4, antimicrosomal antibodies
Lab findings in Hashimoto's thyroiditis.
Graves' disease
Exophthalmos, pretibial myxedema, and ↓ TSH.
Iatrogenic steroid administration. The second most common cause is Cushing's disease
The most common cause of Cushing's syndrome.
Hypoparathyroidism
A patient presents with signs of hypocalcemia, high phosphorus, and low PTH.
Signs and symptoms of hypercalcemia
"Stones, bones, groans, psychiatric overtones."
1° hyperaldosteronism (due to Conn's syndrome or bilateral adrenal hyperplasia)
A patient complains of headache, weakness, and polyuria; exam reveals hypertension and tetany. Labs reveals hypernatremia, hypokalemia, and metabolic alkalosis.
Pheochromocytoma
A patient presents with tachycardia, wild swings in BP, headache, diaphoresis, altered mental status, and a sense of panic.
α-antagonists (phentolamine and phenoxybenzamine)
Should α- or β-antagonists be used first in treating pheochromocytoma?
Nephrogenic diabetes insipidus (DI)
A patient with a history of lithium use presents with copious amounts of dilute urine.
Administration of DDAVP ↓ serum osmolality and free water restriction
Treatment of central DI.
SIADH due to stress
A postoperative patient with significant pain presents with hyponatremia and normal volume status.
Metformin
An antidiabetic agent associated with lactic acidosis.
1° adrenal insufficiency (Addison's disease). Treat with replacement glucocorticoids, mineralocorticoids, and IV fluids
A patient presents with weakness, nausea, vomiting, weight loss, and new skin pigmentation. Labs show hyponatremia and hyperkalemia. Treatment?
< 7.0
Goal hemoglobin A1c for a patient with DM.
Fluids, insulin, and aggressive replacement of electrolytes (e.g., K+)
Treatment of DKA.
They can mask symptoms of hypoglycemia
Why are β-blockers contraindicated in diabetics?
Observational bias
Bias introduced into a study when a clinician is aware of the patient's treatment type.
Lead-time bias
Bias introduced when screening detects a disease earlier and thus lengthens the time from diagnosis to death.
Confounding variable
If you want to know if race affects infant mortality rate but most of the variation in infant mortality is predicted by socioeconomic status, then socioeconomic status is a _____.
Sensitivity
The number of true positives divided by the number of patients with the disease is _____.
Out
Sensitive tests have few false negatives and are used to rule _____ a disease.
Highly sensitive for TB
PPD reactivity is used as a screening test because most people with TB (except those who are anergic) will have a +PPD. Highly sensitive or specific?
Higher prevalence
Chronic diseases such as SLE—higher prevalence or incidence?
Higher incidence
Epidemics such as influenza—higher prevalence or incidence?
Prevalence
Cross-sectional survey—incidence or prevalence?
Incidence and prevalence
Cohort study—incidence or prevalence?
Neither
Case-control study—incidence or prevalence?
High reliability, low validity
Describe a test that consistently gives identical results, but the results are wrong.
Cohort studies can be used to calculate relative risk (RR), incidence, and/or odds ratio (OR). Case-control studies can be used to calculate an OR
Difference between a cohort and a case-control study.
The incidence rate (IR) of a disease in exposed − the IR of a disease in unexposed
Attributable risk?
The IR of a disease in a population exposed to a particular factor ÷ the IR of those not exposed
Relative risk?
The likelihood of a disease among individuals exposed to a risk factor compared to those who have not been exposed
Odds ratio?
1 ÷ (rate in untreated group − rate in treated group)
Number needed to treat?
Patients with IBD; those with familial adenomatous polyposis (FAP)/hereditary nonpolyposis colorectal cancer (HNPCC); and those who have first-degree relatives with adenomatous polyps (< 60 years of age) or colorectal cancer
In which patients do you initiate colorectal cancer screening early?
Prostate cancer is the most common cancer in men, but lung cancer causes more deaths
The most common cancer in men and the most common cause of death from cancer in men.
68%, 95.5%, 99.7%
The percentage of cases within one SD of the mean? Two SDs? Three SDs?
Number of live births per 1000 population
Birth rate?
Number of live births per 1000 women 15-44 years of age
Fertility rate?
Number of deaths per 1000 population
Mortality rate?
Number of deaths from birth to 28 days per 1000 live births
Neonatal mortality?
Number of deaths from 28 days to one year per 1000 live births
Postnatal mortality?
Number of deaths from birth to one year of age per 1000 live births (neonatal + postnatal mortality)
Infant mortality?
Number of deaths from 20 weeks' gestation to birth per 1000 total births
Fetal mortality?
Number of deaths from 20 weeks' gestation to one month of life per 1000 total births
Perinatal mortality?
Number of deaths during pregnancy to 90 days postpartum per 100,000 live births
Maternal mortality?
False. Patients may change their minds at any time. Exceptions to the requirement of informed consent include emergency situations and patients without decision-making capacity
True or false: Once patients sign a statement giving consent, they must continue treatment.
No. Parental consent is not necessary for the medical treatment of pregnant minors
A 15-year-old pregnant girl requires hospitalization for preeclampsia. Should her parents be informed?
Conflict of interest
A doctor refers a patient for an MRI at a facility he/she owns.
The patient is a danger to self, a danger to others, or gravely disabled (unable to provide for basic needs)
Involuntary psychiatric hospitalization can be undertaken for which three reasons?
False. Withdrawing and withholding life are the same from an ethical standpoint
True or false: Withdrawing life-sustaining care is ethically distinct from withholding sustaining care.
When there is no rationale for treatment, maximal intervention is failing, a given intervention has already failed, and treatment will not achieve the goals of care
When can a physician refuse to continue treating a patient on the grounds of futility?
Treat immediately. Consent is implied in emergency situations
An eight-year-old child is in a serious accident. She requires emergent transfusion, but her parents are not present.
Real threat of harm to third parties; suicidal intentions; certain contagious diseases; elder and child abuse
Conditions in which confidentiality must be overridden.
When treatment noncompliance represents a serious danger to public health (e.g., active TB)
Involuntary commitment or isolation for medical treatment may be undertaken for what reason?
Treat because the disease represents an immediate threat to the child's life. Then seek a court order
A 10-year-old child presents in status epilepticus, but her parents refuse treatment on religious grounds.
A patient's family cannot require that a doctor withhold information from the patient
A son asks that his mother not be told about her recently discovered cancer.
Emergent laparotomy to repair perforated viscus, likely stomach
Patient presents with sudden onset of severe, diffuse abdominal pain. Exam reveals peritoneal signs and AXR reveals free air under the diaphragm. Management?
Diverticulosis
The most likely cause of acute lower GI bleed in patients > 40 years old.
HIDA scan
Diagnostic modality used when ultrasound is equivocal for cholecystitis.
Acute pancreatitis
Sentinel loop on AXR.
Fat, female, fertile, forty, flatulent
Risk factors for cholelithiasis.
Murphy's sign, seen in acute cholecystitis
Inspiratory arrest during palpation of the RUQ.
Campylobacter
Identify key organisms causing diarrhea: ■ Most common organism
Clostridium difficile
Identify key organisms causing diarrhea: ■ Recent antibiotic use
Giardia
Identify key organisms causing diarrhea: ■ Camping
ETEC
Identify key organisms causing diarrhea: ■ Traveler's diarrhea
S. aureus
Identify key organisms causing diarrhea: ■ Church picnics/mayonnaise
E. coli O157:H7
Identify key organisms causing diarrhea: ■ Uncooked hamburgers
Bacillus cereus
Identify key organisms causing diarrhea: ■ Fried rice
Salmonella
Identify key organisms causing diarrhea: ■ Poultry/eggs
Vibrio, HAV
Identify key organisms causing diarrhea: ■ Raw seafood
Isospora, Cryptosporidium, Mycobacterium avium complex (MAC)
Identify key organisms causing diarrhea: ■ AIDS
Yersinia
Identify key organisms causing diarrhea: ■ Pseudoappendicitis
Crohn's disease
A 25-year-old Jewish male presents with pain and watery diarrhea after meals. Exam shows fistulas between the bowel and skin and nodular lesions on his tibias.
Ulcerative colitis
Inflammatory disease of the colon with ↑ risk of colon cancer.
Uveitis, ankylosing spondylitis, pyoderma gangrenosum, erythema nodosum, 1° sclerosing cholangitis
Extraintestinal manifestations of IBD.
5-aminosalicylic acid +/− sulfasalazine and steroids during acute exacerbations
Medical treatment for IBD.
Mallory-Weiss—superficial tear in the esophageal mucosa Boerhaave—full-thickness esophageal rupture
Difference between Mallory-Weiss and Boerhaave tears.
RUQ pain, jaundice, and fever/chills in the setting of ascending cholangitis
Charcot's triad.
Charcot's triad plus shock and mental status changes, with suppurative ascending cholangitis
Reynolds' pentad.
↓ protein intake, lactulose, neomycin
Medical treatment for hepatic encephalopathy.
Establish the ABCs
First step in the management of a patient with acute GI bleed.
Hemolytic-uremic syndrome (HUS) due to E. coli O157:H7
A four-year-old child presents with oliguria, petechiae, and jaundice following an illness with bloody diarrhea. Most likely diagnosis and cause?
HBV immunoglobulin
Post-HBV exposure treatment.
TB medications (INH, rifampin, pyrazinamide), acetaminophen, and tetracycline
Classic causes of drug-induced hepatitis.
Biliary tract obstruction
A 40-year-old obese female with elevated alkaline phosphatase, elevated bilirubin, pruritus, dark urine, and clay-colored stools.
Femoral hernia
Hernia with highest risk of incarceration—indirect, direct, or femoral?
Confirm the diagnosis of acute pancreatitis with elevated amylase and lipase. Make patient NPO and give IV fluids, O2, analgesia, and "tincture of time"
A 50-year-old man with a history of alcohol abuse presents with boring epigastric pain that radiates to the back and is relieved by sitting forward. Management?
TICS—Thalassemia, Iron deficiency, anemia of Chronic disease, and Sideroblastic anemia
Four causes of microcytic anemia.
Fecal occult blood test and sigmoidoscopy; suspect colorectal cancer
An elderly male with hypochromic, microcytic anemia is asymptomatic. Diagnostic tests?
Sulfonamides, antimalarial drugs, fava beans
Precipitants of hemolytic crisis in patients with G6PD deficiency.
Factor V Leiden mutation
The most common inherited cause of hypercoagulability.
Hereditary spherocytosis
The most common inherited hemolytic anemia.
Osmotic fragility test
Diagnostic test for hereditary spherocytosis.
Diamond-Blackfan anemia
Pure RBC aplasia.
Fanconi's anemia
Anemia associated with absent radii and thumbs, diffuse hyperpigmentation, café-au-lait spots, microcephaly, and pancytopenia.
Chloramphenicol, sulfonamides, radiation, HIV, chemotherapeutic agents, hepatitis, parvovirus B19, EBV
Medications and viruses that → aplastic anemia.
Both have ↑ hematocrit and RBC mass, but polycythemia vera should have normal O2 saturation and low erythropoietin levels
How to distinguish polycythemia vera from 2° polycythemia.
Pentad of TTP—"FAT RN": Fever, Anemia, Thrombocytopenia, Renal dysfunction, Neurologic abnormalities
Thrombotic thrombocytopenic purpura (TTP) pentad?
Anemia, thrombocytopenia, and acute renal failure
HUS triad?
Emergent large-volume plasmapheresis, corticosteroids, antiplatelet drugs
Treatment for TTP.
Usually resolves spontaneously; may require IVIG and/or corticosteroids
Treatment for idiopathic thrombocytopenic purpura (ITP) in children.
Fibrin split products and D-dimer are elevated; platelets, fibrinogen, and hematocrit are ↓.
Which of the following are ↑ in DIC: fibrin split products, D-dimer, fibrinogen, platelets, and hematocrit.
Hemophilia A or B; consider desmopressin (for hemophilia A) or factor VIII or IX supplements
An eight-year-old boy presents with hemarthrosis and ↑ PTT with normal PT and bleeding time. Diagnosis? Treatment?
von Willebrand's disease; treat with desmopressin, FFP, or cryoprecipitate
A 14-year-old girl presents with prolonged bleeding after dental surgery and with menses, normal PT, normal or ↑ PTT, and ↑ bleeding time. Diagnosis? Treatment?
Monoclonal gammopathy, Bence Jones proteinuria, "punched-out" lesions on x-ray of the skull and long bones
A 60-year-old African-American male presents with bone pain. Workup for multiple myeloma might reveal?
Hodgkin's lymphoma
Reed-Sternberg cells
Non-Hodgkin's lymphoma
A 10-year-old boy presents with fever, weight loss, and night sweats. Examination shows anterior mediastinal mass. Suspected diagnosis?
Anemia of chronic disease
Microcytic anemia with ↓ serum iron, ↓ total iron-binding capacity (TIBC), and normal or ↑ ferritin.
Iron deficiency anemia
Microcytic anemia with ↓ serum iron, ↓ ferritin, and ↑ TIBC.
Chronic lymphocytic leukemia (CLL)
An 80-year-old man presents with fatigue, lymphadenopathy, splenomegaly, and isolated lymphocytosis. Suspected diagnosis?
Blast crisis (fever, bone pain, splenomegaly, pancytopenia)
A late, life-threatening complication of chronic myelogenous leukemia (CML).
Acute myelogenous leukemia (AML)
Auer rods on blood smear.
M3
AML subtype associated with DIC.
↓ Ca2+ , ↑ K− , ↑ phosphate, ↑ uric acid
Electrolyte changes in tumor lysis syndrome.
Retinoic acid
Treatment for AML M3.
CML
A 50-year-old male presents with early satiety, splenomegaly, and bleeding. Cytogenetics show t(9,22). Diagnosis?
Intracellular inclusions seen in thalassemia, G6PD deficiency, and postsplenectomy
Heinz bodies?
Glanzmann's thrombasthenia
An autosomal-recessive disorder with a defect in the GPIIbIIIa platelet receptor and ↓ platelet aggregation.
Parvovirus B19
Virus associated with aplastic anemia in patients with sickle cell anemia.
O2, analgesia, hydration, and, if severe, transfusion
A 25-year-old African-American male with sickle cell anemia has sudden onset of bone pain. Management of pain crisis?
Iron overload; use deferoxamine
A significant cause of morbidity in thalassemia patients. Treatment?
Infection, cancer, and autoimmune disease
The three most common causes of fever of unknown origin (FUO).
Fever, pharyngeal erythema, tonsillar exudate, lack of cough
Four signs and symptoms of streptococcal pharyngitis.
Postinfectious glomerulonephritis
A nonsuppurative complication of streptococcal infection that is not altered by treatment of 1° infection.
Encapsulated organisms--pneumococcus, meningococcus, Haemophilus influenzae, Klebsiella
Asplenic patients are particularly susceptible to these organisms.
105 bacteria/mL
The number of bacterial culture on a clean-catch specimen to diagnose a UTI.
Pregnant women. Treat this group aggressively because of potential complications
Which healthy population is susceptible to UTIs?
Coccidioidomycosis. Amphotericin B
A patient from California or Arizona presents with fever, malaise, cough, and night sweats. Diagnosis? Treatment?
1° syphilis
Nonpainful chancre.
Rubella
A "blueberry muffin" rash is characteristic of what congenital infection?
Group B strep, E. coli, Listeria. Treat with gentamicin and ampicillin
Meningitis in neonates. Causes? Treatment?
Pneumococcus, meningococcus, H. influenzae. Treat with cefotaxime and vancomycin
Meningitis in infants. Causes? Treatment?
Check for ↑ ICP; look for papilledema
What should always be done prior to LP?
Bacterial meningitis
CSF findings: ■ Low glucose, PMN predominance
Aseptic (viral) meningitis
CSF findings: ■ Normal glucose, lymphocytic predominance
Subarachnoid hemorrhage (SAH)
CSF findings: ■ Numerous RBCs in serial CSF samples
MS
CSF findings: ■ ↑ gamma globulins
Cutaneous anthrax. Treat with penicillin G or ciprofloxacin
Initially presents with a pruritic papule with regional lymphadenopathy and evolves into a black eschar after 7-10 days. Treatment?
Tabes dorsalis, general paresis, gummas, Argyll Robertson pupil, aortitis, aortic root aneurysms
Findings in 3° syphilis.
Arthralgias, migratory polyarthropathies, Bell's palsy, myocarditis
Characteristics of 2° Lyme disease.
Mycoplasma
Cold agglutinins.
Candidal thrush. Workup should include an HIV test. Treat with nystatin oral suspension
A 24-year-old male presents with soft white plaques on his tongue and the back of his throat. Diagnosis? Workup? Treatment?
≤ 200 for PCP (with TMP); ≤ 50-100 for MAI (with clarithromycin/azithromycin)
Begin Pneumocystis carinii pneumonia (PCP) prophylaxis in an HIV-positive patient at what CD4 count? Mycobacterium avium-intracellulare (MAI) prophylaxis?
Pregnancy, vesicoureteral reflux, anatomic anomalies, indwelling catheters, kidney stones
Risk factors for pyelonephritis.
7-10 days
Neutropenic nadir postchemotherapy.
Lesion of 1° Lyme disease
Erythema migrans.
Fever, heart murmur, Osler's nodes, splinter hemorrhages, Janeway lesions, Roth's spots
Classic physical findings for endocarditis.
Parvovirus B19
Aplastic crisis in sickle cell disease.
Taenia solium (cysticercosis)
Ring-enhancing brain lesion on CT with seizures
Actinomyces israelii
Name the organism: ■ Branching rods in oral infection.
Haemophilus ducreyi
Name the organism: ■ Painful chancroid.
Pasteurella multocida
Name the organism: ■ Dog or cat bite.
Sporothrix schenckii
Name the organism: ■ Gardener.
Toxoplasma gondii
Name the organism: ■ Pregnant women with pets.
Neisseria meningitidis
Name the organism: ■ Meningitis in adults.
Streptococcus pneumoniae
Name the organism: ■ Meningitis in elderly.
Klebsiella
Name the organism: ■ Alcoholic with pneumonia.
Klebsiella
Name the organism: ■ "Currant jelly" sputum.
Pseudomonas
Name the organism: ■ Infection in burn victims.
Pseudomonas
Name the organism: ■ Osteomyelitis from foot wound puncture.
Salmonella
Name the organism: ■ Osteomyelitis in a sickle cell patient.
Legionella pneumonia
A 55-year-old man who is a smoker and a heavy drinker presents with a new cough and flulike symptoms. Gram stain shows no organisms; silver stain of sputum shows gram-negative rods. What is the diagnosis?
Lyme disease, Ixodes tick, doxycycline
A middle-aged man presents with acute-onset monoarticular joint pain and bilateral Bell's palsy. What is the likely diagnosis, and how did he get it? Treatment?
S. aureus or S. epidermidis.
A patient develops endocarditis three weeks after receiving a prosthetic heart valve. What organism is suspected?
All-compartment fasciotomy for suspected compartment syndrome
A patient presents with pain on passive movement, pallor, poikilothermia, paresthesias, paralysis, and pulselessness. Treatment?
Spinal stenosis
Back pain that is exacerbated by standing and walking and relieved with sitting and hyperflexion of the hips.
MCP and PIP joints; DIP joints are spared
Joints in the hand affected in rheumatoid arthritis.
Osteoarthritis
Joint pain and stiffness that worsen over the course of the day and are relieved by rest.
Osteogenesis imperfecta
Genetic disorder associated with multiple fractures and commonly mistaken for child abuse.
Suspect ankylosing spondylitis. Check HLA-B27
Hip and back pain along with stiffness that improves with activity over the course of the day and worsens at rest. Diagnostic test?
Reactive (Reiter's) arthritis. Associated with Campylobacter, Shigella, Salmonella, Chlamydia, and Ureaplasma
Arthritis, conjunctivitis, and urethritis in young men. Associated organisms?
Gout. Needle-shaped, negatively birefringent crystals are seen on joint fluid aspirate. Chronic treatment with allopurinol or probenecid
A 55-year-old man has sudden, excruciating first MTP joint pain after a night of drinking red wine. Diagnosis, workup, and chronic treatment?
Pseudogout
Rhomboid-shaped, positively birefringent crystals on joint fluid aspirate.
Polymyalgia rheumatica
An elderly female presents with pain and stiffness of the shoulders and hips; she cannot lift her arms above her head. Labs show anemia and ↑ ESR.
Osgood-Schlatter disease
An active 13-year-old boy has anterior knee pain. Diagnosis?
Distal radius (Colles' fracture)
Bone is fractured in fall on outstretched hand.
Avascular necrosis
Complication of scaphoid fracture.
Wrist drop, loss of thumb abduction
Signs suggesting radial nerve damage with humeral fracture.
Duchenne muscular dystrophy
A young child presents with proximal muscle weakness, waddling gait, and pronounced calf muscles.
Developmental dysplasia of the hip. If severe, consider a Pavlik harness to maintain abduction
A first-born female who was born in breech position is found to have asymmetric skin folds on her newborn exam. Diagnosis? Treatment?
Slipped capital femoral epiphyses. AP and frog-leg lateral view
An 11-year-old obese, African-American boy presents with sudden onset of limp. Diagnosis? Workup?
Multiple myeloma
The most common 1° malignant tumor of bone.
Cluster headache
Unilateral, severe periorbital headache with tearing and conjunctival erythema.
β-blockers, Ca2+ channel blockers, TCAs
Prophylactic treatment for migraine.
Prolactinoma. Dopamine agonists (e.g., bromocriptine)
The most common pituitary tumor. Treatment?
Broca's aphasia. Frontal lobe, left MCA distribution
A 55-year-old patient presents with acute "broken speech." What type of aphasia? What lobe and vascular distribution?
Trauma; the second most common is berry aneurysm
The most common cause of SAH.
Subdural hematoma—bridging veins torn
A crescent-shaped hyperdensity on CT that does not cross the midline.
Epidural hematoma. Middle meningeal artery. Neurosurgical evacuation
A history significant for initial altered mental status with an intervening lucid interval. Diagnosis? Most likely etiology? Treatment?
Elevated ICP, RBCs, xanthochromia
CSF findings with SAH.
Guillain-Barré (↑ protein in CSF with only a modest ↑ in cell count)
Albuminocytologic dissociation.
Normal
Cold water is flushed into a patient's ear, and the fast phase of the nystagmus is toward the opposite side. Normal or pathological?
Lung, breast, skin (melanoma), kidney, GI tract
The most common 1° sources of metastases to the brain.
Absence seizures
May be seen in children who are accused of inattention in class and confused with ADHD.
Headache
The most frequent presentation of intracranial neoplasm.
Infection, febrile seizures, trauma, idiopathic
The most common cause of seizures in children (2-10 years).
Trauma, alcohol withdrawal, brain tumor
The most common cause of seizures in young adults (18-35 years).
IV benzodiazepine
First-line medication for status epilepticus.
Wernicke's encephalopathy due to a deficiency of thiamine
Confusion, confabulation, ophthalmoplegia, ataxia.
Seventy percent if the stenosis is symptomatic
What % lesion is an indication for carotid endarterectomy?
Alzheimer's and multi-infarct
The most common causes of dementia.
ALS
Combined UMN and LMN disorder.
Parkinson's disease
Rigidity and stiffness with resting tremor and masked facies.
Levodopa/carbidopa
The mainstay of Parkinson's therapy.
IVIG or plasmapheresis
Treatment for Guillain-Barré syndrome.
Huntington's disease
Rigidity and stiffness that progress to choreiform movements, accompanied by moodiness and altered behavior.
Sturge-Weber syndrome. Treat symptomatically. Possible focal cerebral resection of affected lobe
A six-year-old girl presents with a port-wine stain in the V2 distribution as well as with mental retardation, seizures, and leptomeningeal angioma.
Neurofibromatosis 1
Café-au-lait spots on skin.
Klüver-Bucy syndrome (amygdala)
Hyperphagia, hypersexuality, hyperorality, and hyperdocility.
Edrophonium
Administer to a symptomatic patient to diagnose myasthenia gravis.
Placental abruption and placenta previa
1° causes of third-trimester bleeding.
Snowstorm on ultrasound. "Cluster-of-grapes" appearance on gross examination
Classic ultrasound and gross appearance of complete hydatidiform mole.
46,XX
Chromosomal pattern of a complete mole.
Partial mole
Molar pregnancy containing fetal tissue.
Continuous, painful vaginal bleeding
Symptoms of placental abruption.
Self-limited, painless vaginal bleeding
Symptoms of placenta previa.
Never
When should a vaginal exam be performed with suspected placenta previa?
Tetracycline, fluoroquinolones, aminoglycosides, sulfonamides
Antibiotics with teratogenic effects.
Obstetric conjugate: between the sacral promontory and the midpoint of the symphysis pubis
Shortest AP diameter of the pelvis.
Betamethasone or dexamethasone × 48 hours
Medication given to accelerate fetal lung maturity.
Uterine atony
The most common cause of postpartum hemorrhage.
Uterine massage; if that fails, give oxytocin
Treatment for postpartum hemorrhage.
IV penicillin or ampicillin
Typical antibiotics for group B streptococcus (GBS) prophylaxis.
Sheehan's syndrome (postpartum pituitary necrosis)
A patient fails to lactate after an emergency C-section with marked blood loss.
Inevitable abortion
Uterine bleeding at 18 weeks' gestation; no products expelled; membranes ruptured; cervical os open.
Threatened abortion
Uterine bleeding at 18 weeks' gestation; no products expelled; cervical os closed.
β-hCG; the most common cause of amenorrhea is pregnancy
The first test to perform when a woman presents with amenorrhea.
Menometrorrhagia
Term for heavy bleeding during and between menstrual periods.
Asherman's syndrome
Cause of amenorrhea with normal prolactin, no response to estrogen-progesterone challenge, and a history of D&C.
Weight loss and OCPs
Therapy for polycystic ovarian syndrome.
Clomiphene citrate
Medication used to induce ovulation.
Endometrial biopsy
Diagnostic step required in a postmenopausal woman who presents with vaginal bleeding.
Stable, unruptured ectopic pregnancy of &lt; 3.5 cm at &lt; 6 weeks' gestation
Indications for medical treatment of ectopic pregnancy.
OCPs, danazol, GnRH agonists
Medical options for endometriosis.
"Chocolate cysts," powder burns
Laparoscopic findings in endometriosis.
Ampulla of the oviduct
The most common location for an ectopic pregnancy.
Ultrasound
How to diagnose and follow a leiomyoma.
Regresses after menopause
Natural history of a leiomyoma.
Trichomonas vaginitis
A patient has ↑ vaginal discharge and petechial patches in the upper vagina and cervix.
Oral or topical metronidazole
Treatment for bacterial vaginosis.
Intraductal papilloma
The most common cause of bloody nipple discharge.
OCP and barrier contraception
Contraceptive methods that protect against PID.
Endometrial or estrogen receptor- breast cancer
Unopposed estrogen is contraindicated in which cancers?
Consider Fitz-Hugh-Curtis syndrome
A patient presents with recent PID with RUQ pain.
Paget's disease
Breast malignancy presenting as itching, burning, and erosion of the nipple.
CA-125 and transvaginal ultrasound
Annual screening for women with a strong family history of ovarian cancer.
Kegel exercises, estrogen, pessaries for stress incontinence
A 50-year-old woman leaks urine when laughing or coughing. Nonsurgical options?
Anticholinergics (oxybutynin) or β-adrenergics (metaproterenol) for urge incontinence.
A 30-year-old woman has unpredictable urine loss. Examination is normal. Medical options?
↑ serum FSH
Lab values suggestive of menopause.
Endometriosis
The most common cause of female infertility.
Colposcopy and endocervical curettage
Two consecutive findings of atypical squamous cells of undetermined significance (ASCUS) on Pap smear. Follow-up evaluation?
Lobular carcinoma in situ
Breast cancer type that ↑ the future risk of invasive carcinoma in both breasts.
Neuroblastoma
Nontender abdominal mass associated with elevated VMA and HVA.
Esophageal atresia with distal TEF (85%). Unable to pass NG tube
The most common type of tracheoesophageal fistula (TEF). Diagnosis?
Mild illness and/or low-grade fever, current antibiotic therapy, and prematurity
Not contraindications to vaccination.
Ophthalmologic exam, CT, and MRI
Tests to rule out shaken baby syndrome.
CF or Hirschsprung's disease
A neonate has meconium ileus.
Duodenal atresia
Bilious emesis within hours after the first feeding.
Correct metabolic abnormalities. Then correct pyloric stenosis with pyloromyotomy
A two-month-old presents with nonbilious projectile emesis. What are the appropriate steps in management?
Selective IgA deficiency
The most common 1° immunodeficiency.
Febrile seizures (roseola infantum)
An infant has a high fever and onset of rash as fever breaks. What is he at risk for?
High-dose aspirin for inflammation and fever; IVIG to prevent coronary artery aneurysms
Acute-phase treatment for Kawasaki disease.
Phototherapy (mild) or exchange transfusion (severe)
Treatment for mild and severe unconjugated hyperbilirubinemia.
Reye's syndrome
Sudden onset of mental status changes, emesis, and liver dysfunction after taking aspirin.
Suspect retinoblastoma
A child has loss of red light reflex. Diagnosis?
HBV, DTaP, Hib, IPV, PCV
Vaccinations at a six-month well-child visit.
Precocious puberty
Tanner stage 3 in a six-year-old female.
RSV bronchiolitis
Infection of small airways with epidemics in winter and spring.
Surfactant deficiency
Cause of neonatal RDS.
Chronic granulomatous disease
What is the immunodeficiency? ■ A boy has chronic respiratory infections. Nitroblue tetrazolium test is +.
Wiskott-Aldrich syndrome
What is the immunodeficiency? ■ A child has eczema, thrombocytopenia, and high levels of IgA.
Bruton's X-linked agammaglobulinemia
What is the immunodeficiency? ■ A four-month-old boy has life-threatening Pseudomonas infection.
Intussusception
A condition associated with red "currant-jelly" stools.
Coarctation of the aorta
A congenital heart disease that cause 2° hypertension.
Amoxicillin × 10 days
First-line treatment for otitis media.
Parainfluenza virus type 1
The most common pathogen causing croup.
Kwashiorkor (protein malnutrition)
A homeless child is small for his age and has peeling skin and a swollen belly.
Lesch-Nyhan syndrome (purine salvage problem with
Defect in an X-linked syndrome with mental retardation,
HGPRTase deficiency)
gout, self-mutilation, and choreoathetosis.
Patent ductus arteriosus (PDA)
A newborn female has continuous "machinery murmur."
SSRIs
First-line pharmacotherapy for depression.
MAOIs
Antidepressants associated with hypertensive crisis.
Patient on dopamine antagonist
Galactorrhea, impotence, menstrual dysfunction, and ↓ libido.
Conversion disorder
A 17-year-old female has left arm paralysis after her boyfriend dies in a car crash. No medical cause is found.
Displacement
Name the defense mechanism: ■ A mother who is angry at her husband yells at her child.
Reaction formation
Name the defense mechanism: ■ A pedophile enters a monastery.
Isolation
Name the defense mechanism: ■ A woman calmly describes a grisly murder.
Regression
Name the defense mechanism: ■ A hospitalized 10-year-old begins to wet his bed.
Neuroleptic malignant syndrome
Life-threatening muscle rigidity, fever, and rhabdomyolysis.
Anorexia
Amenorrhea, bradycardia, and abnormal body image in a young female.
Panic disorder
A 35-year-old male has recurrent episodes of palpitations, diaphoresis, and fear of going crazy.
Agranulocytosis
The most serious side effect of clozapine.
Schizophreniform disorder (diagnosis of schizophrenia requires ≥ 6 months of symptoms)
A 21-year-old male has three months of social withdrawal, worsening grades, flattened affect, and concrete thinking.
Weight gain, type 2 DM, QT prolongation
Key side effects of atypical antipsychotics.
Acute dystonia (oculogyric crisis). Treat with benztropine or diphenhydramine
A young weight lifter receives IV haloperidol and complains that his eyes are deviated sideways. Diagnosis? Treatment?
Neuroleptics
Medication to avoid in patients with a history of alcohol withdrawal seizures.
Conduct disorder
A 13-year-old male has a history of theft, vandalism, and violence toward family pets.
Rett's disorder
A five-month-old girl has ↓ head growth, truncal dyscoordination, and ↓ social interaction.
Acute mania. Start a mood stabilizer (e.g., lithium)
A patient hasn't slept for days, lost $20,000 gambling, is agitated, and has pressured speech. Diagnosis? Treatment?
Malingering
After a minor fender bender, a man wears a neck brace and requests permanent disability.
Factitious disorder (Munchausen syndrome)
A nurse presents with severe hypoglycemia; blood analysis reveals no elevation in C peptide.
Substance abuse
A patient continues to use cocaine after being in jail, losing his job, and not paying child support.
Phencyclidine hydrochloride (PCP) intoxication
A violent patient has vertical and horizontal nystagmus.
Depersonalization disorder
A woman who was abused as a child frequently feels outside of or detached from her body.
Frotteurism (a paraphilia)
A man has repeated, intense urges to rub his body against unsuspecting passengers on a bus.
Tardive dyskinesia. ↓ or discontinue haloperidol and consider another antipsychotic (e.g., risperidone, clozapine)
A schizophrenic patient takes haloperidol for one year and develops uncontrollable tongue movements. Diagnosis? Treatment?
Dissociative fugue
A man unexpectedly flies across the country, takes a new name, and has no memory of his prior life.
Stasis, endothelial injury and hypercoagulability (Virchow's triad)
Risk factors for DVT.
Pleural/serum protein > 0.5; pleural/serum LDH > 0.6
Criteria for exudative effusion.
Think of leaky capillaries. Malignancy, TB, bacterial or viral infection, pulmonary embolism with infarct, and pancreatitis
Causes of exudative effusion.
Think of intact capillaries. CHF, liver or kidney disease, and protein-losing enteropathy
Causes of transudative effusion.
Fatigue and impending respiratory failure
Normalizing PCO2 in a patient having an asthma exacerbation may indicate?
Sarcoidosis
Dyspnea, lateral hilar lymphodenopathy on CXR, noncaseating granulomas, increased ACE, and hypercalcemia.
Obstructive pulmonary disease (e.g., asthma)
PFT showing ↓ FEV1/FVC.
Restrictive pulmonary disease
PFT showing ↑ FEV1/FVC.
Diffuse interstitial pulmonary fibrosis. Supportive care. Steroids may help
Honeycomb pattern on CXR. Diagnosis? Treatment?
Radiation
Treatment for SVC syndrome.
Inhaled β-agonists and inhaled corticosteroids
Treatment for mild, persistent asthma.
Hypoxia and hypocarbia
Acid-base disorder in pulmonary embolism.
Squamous cell carcinoma
Non-small cell lung cancer (NSCLC) associated with hypercalcemia.
Small cell lung cancer (SCLC)
Lung cancer associated with SIADH.
SCLC
Lung cancer highly related to cigarette exposure.
Spontaneous pneumothorax. Spontaneous regression. Supplemental O2 may be helpful
A tall white male presents with acute shortness of breath. Diagnosis? Treatment?
Immediate needle thoracostomy
Treatment of tension pneumothorax.
Age &gt; 45-50 years; lesions new or larger in comparison to old films; absence of calcification or irregular calcification; size &gt; 2 cm; irregular margins
Characteristics favoring carcinoma in an isolated pulmonary nodule.
ARDS
Hypoxemia and pulmonary edema with normal pulmonary capillary wedge pressure.
Mycobacterium tuberculosis
↑ risk of what infection with silicosis?
Right-to-left shunt, hypoventilation, low inspired O2 tension, diffusion defect, V/Q mismatch
Causes of hypoxemia.
Cardiomegaly, prominent pulmonary vessels, Kerley B lines, "bat's-wing" appearance of hilar shadows, and perivascular and peribronchial cuffing
Classic CXR findings for pulmonary edema.
Type I (distal) RTA
Renal tubular acidosis (RTA) associated with abnormal H+ secretion and nephrolithiasis.
Type II (proximal) RTA
RTA associated with abnormal HCO3 − and rickets.
Type IV (distal) RTA
RTA associated with aldosterone defect.
Hypernatremia
"Doughy skin."
Cirrhosis, CHF, nephritic syndrome
Differential of hypervolemic hyponatremia.
Hypocalcemia
Chvostek's and Trousseau's signs.
Malignancy and hyperparathyroidism
The most common causes of hypercalcemia.
Hypokalemia
T-wave flattening and U waves.
Hyperkalemia
Peaked T waves and widened QRS.
IV hydration and loop diuretics (furosemide)
First-line treatment for moderate hypercalcemia.
Prerenal
Type of ARF in a patient with FeNa < 1%.
Nephrolithiasis
A 49-year-old male presents with acute-onset flank pain and hematuria.
Calcium oxalate
The most common type of nephrolithiasis.
Cerebral berry aneurysms (AD PCKD)
A 20-year-old man presents with a palpable flank mass and hematuria. Ultrasound shows bilateral enlarged kidneys with cysts. Associated brain anomaly?
Nephritic syndrome
Hematuria, hypertension, and oliguria.
Nephrotic syndrome
Proteinuria, hypoalbuminemia, hyperlipidemia, hyperlipiduria, edema.
Membranous glomerulonephritis
The most common form of nephritic syndrome.
IgA nephropathy (Berger's disease)
The most common form of glomerulonephritis.
Alport's syndrome
Glomerulonephritis with deafness.
Wegener's granulomatosis and Goodpasture's syndrome
Glomerulonephritis with hemoptysis.
Glomerulonephritis/nephritic syndrome
Presence of red cell casts in urine sediment.
Allergic interstitial nephritis
Eosinophils in urine sediment.
Nephrotic syndrome
Waxy casts in urine sediment and Maltese crosses (seen with lipiduria).
Uremic syndrome seen in patients with renal failure
Drowsiness, asterixis, nausea, and a pericardial friction rub.
Wait, surgical resection, radiation and/or androgen suppression
A 55-year-old man is diagnosed with prostate cancer. Treatment options?
DI
Low urine specific gravity in the presence of high serum osmolality.
Fluid restriction, demeclocycline
Treatment of SIADH?
Renal cell carcinoma (RCC)
Hematuria, flank pain, and palpable flank mass.
Choriocarcinoma
Testicular cancer associated with β-hCG, AFP.
Seminoma—a type of germ cell tumor
The most common type of testicular cancer.
Transitional cell carcinoma
The most common histology of bladder cancer.
Central pontine myelinolysis
Complication of overly rapid correction of hyponatremia.
Anion gap acidosis and 1° respiratory alkalosis due to central respiratory stimulation
Salicylate ingestion → in what type of acid-base disorder?
Respiratory alkalosis
Acid-base disturbance commonly seen in pregnant women.
DM, SLE, and amyloidosis
Three systemic diseases → nephrotic syndrome.
RCC or other erythropoietin-producing tumor; evaluate with CT scan
Elevated erythropoietin level, elevated hematocrit, and normal O2 saturation suggest?
Likely BPH. Options include no treatment, terazosin, finasteride, or surgical intervention (TURP)
A 55-year-old man presents with irritative and obstructive urinary symptoms. Treatment options?
Antipsychotics (neuroleptic malignant syndrome)
Class of drugs that may cause syndrome of muscle rigidity, hyperthermia, autonomic instability, and extrapyramidal symptoms.
Acute mania, immunosuppression, thin skin, osteoporosis, easy bruising, myopathies
Side effects of corticosteroids.
Benzodiazepines
Treatment for DTs.
N-acetylcysteine
Treatment for acetaminophen overdose.
Naloxone
Treatment for opioid overdose.
Flumazenil
Treatment for benzodiazepine overdose.
Dantrolene or bromocriptine
Treatment for neuroleptic malignant syndrome.
Nitroprusside
Treatment for malignant hypertension.
Rate control, rhythm conversion, and anticoagulation
Treatment of AF.
Rate control with carotid massasge or other vagal stimulation
Treatment of supraventricular tachycardia (SVT).
INH, penicillamine, hydralazine, procainamide
Causes of drug-induced SLE.
B12 deficiency
Macrocytic, megaloblastic anemia with neurologic symptoms.
Folate deficiency
Macrocytic, megaloblastic anemia without neurologic symptoms.
Treat CO poisoning with 100% O2 or with hyperbaric O2 if severe poisoning or pregnant
A burn patient presents with cherry-red flushed skin and coma. SaO2 is normal, but carboxyhemoglobin is elevated. Treatment?
Bladder rupture or urethral injury
Blood in the urethral meatus or high-riding prostate.
Retrograde cystourethrogram
Test to rule out urethral injury.
Widened mediastinum (> 8 cm), loss of aortic knob, pleural cap, tracheal deviation to the right, depression of left main stem bronchus
Radiographic evidence of aortic disruption or dissection.
Free air under the diaphragm, extravasation of contrast, severe bowl distention, space-occupying lesion (CT), mesenteric occlusion (angiography)
Radiographic indications for surgery in patients with acute abdomen.
Pseudomonas
The most common organism in burn-related infections.
Parkland formula
Method of calculating fluid repletion in burn patients.
50 cc/hour
Acceptable urine output in a trauma patient.
30 cc/hour
Acceptable urine output in a stable patient.
Third-degree heart block
Cannon "a" waves.
Hypotension and bradycardia
Signs of neurogenic shock.
Hypertension, bradycardia, and abnormal respirations
Signs of ↑ ICP (Cushing's triad).
Hypovolemic shock
↓ CO, ↓ pulmonary capillary wedge pressure (PCWP), ↑ peripheral vascular resistance (PVR).
Cardiogenic shock
↓ CO, ↑ PCWP, ↑ PVR.
Septic or anaphylactic shock
↑ CO, ↓ PCWP, ↓ PVR.
Fluids and antibiotics
Treatment of septic shock.
Identify cause; pressors (e.g., dobutamine)
Treatment of cardiogenic shock.
Identify cause; fluid and blood repletion
Treatment of hypovolemic shock.
Diphenhydramine or epinephrine 1:1000
Treatment of anaphylactic shock.
Continuous positive airway pressure
Supportive treatment for ARDS.
A patient with chest trauma who was previously stable suddenly dies
Signs of air embolism.
AP chest, AP/lateral C-spine, AP pelvis
Trauma series.