Pérdidas en el sistema de Codensa

pain?

• Upper GI endoscopy

What is the test of choice for initial evaluation of a thyroid nodule?

• Fine-needle biopsy

Tx: normal pressure hydrocephalus

• Large volume serial LPs followed by ventriculoperitoneal shunting

Tx: central diabetes insipidus • Intranasal desmopressin acetate

Clinical presentation: ventricular aneurysm 2/2 MI (4)

• CHF sx MR Ventricular arrhythmias Thrombus formation

Tx: uric acid stones • Urine alkalinazation w/ oral potassium citrate/bicarobinate

What is the appropriate tx for the management of bone pain in patients with prostate cancer who have undergone orchiectomy?

• Radiation therapy

Tx (acute): MS exacerbation • IV steroids

Clinical presentation: phenytoin toxicity (3)

• Horizontal nystagmus Cerebellar ataxia Confusion

What class of drugs is first-line for diabetic neuropathy? • TCAs

Contraindications: anticoagulation therapy (4)

• Recent surgery Hemorrhagic stroke Bleeding diathesis Active bleeding

Tx (pharmacological): fibromyalgia (2) • TCAs (amitriptyline) Cyclobenzaprine

Dx: lupus nephritis

• Renal biopsy is required in all patients with new onset lupus nephritis

Etiologies: priapism (4)

• Sickle cell disease Perineal or genital trauma Neurogenic lesions (spinal cord injury) Medications (trazadone, prazosin)

Tx: S. viridans endocarditis (2) • IV penicillin G or IV cefriaxone

Tx (pharmacologic): diabetic gastroparesis (3)

• Metaclopramide (drug of choice) before meals Bethanechol Cisapride

Side effects: ACE inhibitors (9)

• Cough Angioedema Proteinuria Taste changes hypOtension Pregnany problems Rash Increased renin Lower angiotensin II

What is the initial DMARD of choice for RA? • Methotrexate

What is the prophylactic treatment for a cat bite?

• Five day course of amoxicillin/claulanate

Hyperactive deep tendon reflexes in a post-op patient is usually caused by what?

• Due to hypocalcemia from multiple blood transfusions and citrate chelating calcium

What is the most common manifestation of hemophilia? • Hemarthrosis

Clinical presentation: cavernous sinus thrombosis (4)

• Headache Low-grade fever Periorbital edema Cranial nerve palsies

What is the most common etiology of cavernous sinus thrombosis?

• Most cases are secondary to an infection located in the medial aspect of the face around the eyes and nose; sinus infections can be causes too.

Dx: cavernous venous thrombosis • MRI/CT w/ contrast

When should therapy for PE be initiated with respect to diagnostic testing if clinical suspicion is high?

• If suspicion is high, start treatment immediately, then do dx tests; stop heparin if negative

What is the major toxicity of mycophenolate? • Bone marrow suppression

What are the major toxicities of azathioprine? (3)

• Diarrhea Leukopenia Hepatotoxicity

Tx: Legionnaire's disease (2) • Azithryomycin Levofloxacin

Side effects: erythropoietin (3) • Wordening of hypertension Headaches Flu-like sx

!

hypertensive intraparenchymal hemorrhages

focal sx but can rapidly progress to signs of elevated ICP

Pathophysiology: cerebral salt-wasting syndrome (2)

• (1) inappropriate secretion of vasopressin, which causes water retention (2) increased secretion of ANP/BNP, which causes naturesis

What class of drug can be used as monotherapy in migraine headaches that present with vomiting and photophobia?

• Antiemetics such as prochlorperazine or metoclopramide

Tx: opiod withdrawal • methadone

Suspect [...] in patients with

malabsorption along with a history of living in tropical areas for more than one month

• Suspect tropical sprue in patients with malabsorption along with a history of living in tropical areas for more than one month

What cause of hypoxemia presents with an elevated PCO2 and normal A-a gradient?

•

Hypoventilation

Describe the PaCO2 and A-a gradient in hypoxemia caused by low FIO2.

• Normal PaCO2 Normal A- a gradient

Describe the PaCO2 and A-a gradient in V/Q mismatch

• PaCO2 normal A-a gradient increased

Describe the PaCO2 and A-a gradient in shunting

• Normal PaCO2 Increased A-a gradient that is refractory to O2

Complications: high PEEP ventilation (3)

• alveolar damage tension pneumothorax hypotension

What is the classic antibody associated with dermatomyositis? • anti-Mi-2

What other disease is more common in patients with dermatomyositis compared to the normal population?

• Internal malignancies such as ovarian cancer; 10% of DM patients

What are the ways in which potassium can be removed from the body? (3)

• Dialysis Cation-exchange resins (kayexalate) Diuretics

Tx: primary biliary cirrhosis (2) • Ursodeoxycholic acid Cholestyramine

Tx: comedonal acne

• topical retinoids (first line) topical abx (mild-moderate) oral abx (severe)

Tx: nodulocystic acne • oral isotretinoin

What is appropriate blood product to administer for anemia?

• Packed red blood cells

Indications: platelet transfusion • platelet count < 10K

Indications: thyroid function testing (4)

• Hyperlipidemia Unexplained hyponatremia Elevated serum muscle enzymes Anemia

[...] is likely in a postoperative patient with JVP and new-onset RBBB

• Massive pulmonary embolism is likely in a postoperative patient with JVP and new-onset RBBB

Recurrent pneumonia in the same anatomic location is a red flag for [...]

• Recurrent pneumonia in the same anatomic location is a red flag for lung cancer

Clinical presentation: charcot joints (neurogenic arthropathy) (3)

• Functional limitation Deformity Degenerative joint disease

Tx (pharmacological): WFW w/ Afib and RVR

• Pharmacological (procainamide, e.g.) or electrical cardioversion; avoid AV nodal blockers

At what time point s/p acetaminophen ingestion does the Rumack- Matthew nomogram start?

• 4 hours

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121!

s/p acetaminophen ingestion? hours

If a patient presents with acetaminophen toxicity, what is the first step in treatment?

• Activated charcoal administration

Definition: eczema herpeticum

• Form of primary herpes simplex virus infection associated w/ atopic dermatitis

Tx: eczema herpticum • Acyclovir immediately (in infants)

A copious amount of purulent eye drainage in newborns who are two to five days old is most consistent with [...]

• A copious amount of purulent drainage in newborns who are two to five days old is most consistent with gonococcal

conjunctivitis.

New clubbing in patients with COPD often indicates the development of [...]

• New clubbing in patients with COPD often indicates the development of lung cancer

What is the treatment of choice for primary syphilis? What are the alternatives?

• IM benzathine pencillin; single oral dose of azithromycin or two-week course of doxycycline for penicilli-allergic patients

What classes of diuretic most commonly causes ototoxicity? (2)

• Aminoglycosides Loop diuretics

Tx (acute): ischemic stroke in a sickle cell patient • Exchange transfusion

Prophylaxis: human bite • Augmentin

What is the most common nephropathy associated with Hodgkin's lymphoma?

• Minimal change disease

What is the most common nephropathy associated with carcinomas?

• Membranous nephropathy

What is the most sensitive test to diagnose pancreatic exocrine failure?

• Fecal elastase study

An alcoholic patient preenting with chronic abdominal pain and diarrhea is classic for [...]

• An alcoholic patient preenting with chronic abdominal pain and diarrhea is classic for chronic pancreatitis

In what situations is the medial meniscus injured?

• Forceful torsion of the knee w/ the foot planted

Physical exam: medial

meniscus tear (3)

• Localized tenderness on medial side of knee Locking of the knee joint on extension McMurray's sign (palpable or audidible snap occurring while slowly extending the leg at the knee from full flexion while simultaneously applying tibial torsion)

Where do the majority of clavicular fractures occur? • Middle third of the bone

What is the classic event leading to clavicular fracture?

• Fall on an outstreched arm or direct blow to shoulder

Clinical presentation: clavicular fracture (3)

• Pain and immobility of the affected arm Contralateral hand is used to support weight of the affected arm Shoulder on affected side is displaced inferiorly or posterioly

Why must a careful neuromuscular exam be performed on patients with suspected clavicular fracture?

• Rule out damage to underlying brachial plexus and subclavian artery

If a bruit is heard just below the clavicle (fractured), what diagnostic study is indicated?

•

Angiogram

Clinical manifestations: acute appendicitis (3)

• Abdominal pain (McBurney's to RLQ progression) Fever N/V

If a patient waits more than 48 hours to seek medical attention w/ sx of appendicitis, what complications can occcur?

• High incidence of rupture w/ abscess formation

!

Tx: suspected perforation 2/2 appendicitis • exploratory laparotomy

If a patient w/ suspected psoas abscess (2/2 appendicitis) and is stable, what is the treatment? (4)

• IV hydration Abx Bowel rest Interval appendectomy

What carpal bone is most commonly injured in acute injury of the wrist?

• Scaphoid bone

What injury usually leads to scaphoid fracture?

• Fall on outstreched hand w/ dorsiflexion

What are scaphoid fractures of particular concern in acute wrist injury?

• Risk of avascular necrosis due to tenuous blood supply

Physical exam: scaphoid fracture (4)

• Pain on the radial aspect of the anatomic snuffbox

Minimally decreased range of motion Decreased grip strength Swelling

Dx: scaphoid fracture • Plainn film x-rays

Tx: scaphoid fracture • thumb spica cast for 7-10 days followed by repeat x-rays

Risk factors: developmental dysplasia of the hip (4)

• Caucasian race First-born infants Breech position Family history

Dx: developmental dysplasia of the hip (2)

• Hip ultrasound (< 4 mo) Plain films (> 4 mo)

Tx: developmental dysplasia of the hip (2) • Hip harness Spica cast

What organs are most commonly injured with blunt abdominal trauma? (3)

• Spleen > liver > intestines

Definition: Kehr sign

• Ipsilateral shoulder pain referred from the abdomen due to irritation the phrenic nerve and diaphragm

Dx: blunt abdominal trauma (2)

• (1) FAST (2) CT w/ IV contrast (if FAST negative but suspicion high)

What radiographic sign on CXR indicates perforation of a hollow viscus?

• free air in the peritoneal cavity (usually under the diaphragm)

What diagnostic test should be used to confirm proper placement of a central venous catheter?

• Chest x- ray

Definition: Leriche syndrome

• Bilateral hip/buttock/thigh claudication Impotence Symmetric atrophy of bilateral extremities

Pathophysiology: Leriche syndrome

• Atherosclerosis at the bifurcation of the aorta into the common iliac arteries

On what side of the body is diaphragmatic rupture more common? Why?

• Left side because right side is protected by the liver

What is the most commonly injured ligament of the knee? • MCL

What kind of insult causes MCL injury?

• Forceful abduction of the knee, often with a torsional component of motion

Physical exam: MCL tear (2)

• Swollen knee due to effusion Positive valgus stress test

Dx: MCL tear • MRI

Tx: MCL tear • bracing and early ambulation

What are the components of the Glasgow Coma Score?

• Motor response (6) Verbal response (5) Eye opening (4)

At what GCS level does one intubate? • GCS of 8 = intubate

What is the most common site for metatarsal stress fracture? • Second metatarsal

Tx: stress fracture (metatarsal) • Rest, analgesia, hard-soled shoe

Tx: sharp, penetrating abdominal trauma in a hemodynamically unstable patient

• Exploratory laparotomy

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123!

Tx: sharp, penetrating abdominal trauma in a

hemodynamically stable patient

• exploratory laparoscopy

Definition: nursemaid elbow

• Subluxation of head of radius at elbow joint; due commonly to swinging children by the arm

Tx: nursemaid elbow

• Closed reduction by gentle passive elbow flexion and forearm supination

Definition: central cord syndrome

• Selective damage to central spinal cord due to hyperextension injuries in elderly patients w/ degenerative changes in the cervical spine

Clinical manifestations: central cord syndrome

• Upper extremity > lower extremity weakness

Clinical manifestations: anterior cord syndrome • bilateral spastic motor paresis

What is the most common etiology of anterior cord syndrome?

• Occlusion of the vertebral artery

What features distinguish pulmonary contusion from ARDS? (2)

• Unilateral infiltrate (usually bilateral in ARDS) Onset: usually within 24-48 hrs in ARDS vs within first 24 hours for contusion

What does treatment of asymptomatic patients with Paget's disease of bone consist of? And of symptomatic patients? • Asymptomatic: no treatment Symptomatic: bisphosphonates Sx: hypercalcemia (4)

• Stones (nephrolithiasis/nephrocalcinosis) Bone (bone aches/pains, osteitis fibrosa cystica) Groans (muscle pain, abdominal pain, gout, constipation) Psychiatric overtones (depression, fatigue, anorexia, lethargy, etc.)

Etiologies: primary hyperparathyroidism (3)

• Adenoma (80%) Hyperplasia (15-20%) Carcinoma (< 1% cases)

Lab studies & findings: primary hyperparathyroidism (4)

• BMP (Ca++ levels ↑) PTH levels normal or elevated Urine cAMP elevated

Chloride/phosphorous ratio > 33

Radiographic findings: primary hyperparathyroidism (2)

• Subperiosteal bone resoprtion Osteopenia

What imaging study is obtained before surgical treatment of primary hyperparathyroidism?

• Sestamibi scan

What are the indications for

parathyroidectomy in asymptomatic patients with primary hyperparathyroidism? (4)

• Serum calcium at least 1 mg/dl above ULN Young (< 50 y/o) BMD less than T -2.5 at any site Reduced renal function

If a sestamibi scan in a patient with primary hyperparathyroidism is negative but shows many abnormal glands, what kind of surgery is indicated?

• Bilateral neck exploration w/

intraoperative PTH level

What is the most common mechanism of atrial flutter?

• Re-entrant rhythm in within the atria

Pathophysiology: respiratory alkalosis of pregnancy

• Progesterone → ↑ respiratory rate via stimulation of dorsal respiratory group → chronic compensated respiratory alkalosis

Tx: congenital prolonged QT syndrome (Jervell-Lange-Nielson syndrome or Romano-Ward)

• beta blockers

Clinical manifestations: Jervell-Lange- Nielson syndrome (2)

• Syncopal episodes w/o following disorientation Hearing impairment

What is the most common form of drug-induced chronic renal failure?

• Analgesic nephropathy

!

What is the best initial screening test for adrenal insufficiency?

• Cosyntropin stimulation test w/ cortisol and ACTH levels

What is the most common cause of ductopenia in adults?

• Primary biliary cirrhosis

What is the only drug FDA approved for ALS treatment? What is its mechanism?

• Riluzole; glutamate inhibitor

What kind of immunological response is induced by the 23-valent pneumococcal vaccine?

• T-cell-independent B- cell response

What diagnostic study is required whenever a new diagnosis of myasthenia gravis is made? Why?

• Chest CT to look for thymoma (present in 15% of cases)

Hypocalcemia with concordant changes of serum calcium and

phosphate levels are usually caused by [...]

• Hypocalcemia with concordant changes of serum calcium and phosphate levels are usually caused by vitamin D deficiency

Clinical manifestations: primary syphilis

• painless chancre that resolves in 3-6 weeks

Clinical manifestations: secondary syphilis (2)

• truncal rash that extends to the periphery, including palms and soles generalized lymphadenopathy

What type of urethral injury is most commonly associated with pelvic fractures?

• Posterior urethral injury

Clinical manifestations: posterior urethral injury (2)

• Suprapubic pain Inability to void following major trauma

Physical exam: posterior urethral injury (3)

• blood at the urethral meatus high-riding prostate due to displacement of the prostate by a pelvic hematoma scrotal hematoma

Tx: Carbon monoxide poisoning • 100% oxygen via nonrebreather facemask

If a patient with suspected PVD has normal ABIs, what further testing should be pursued?

• Exercise ABIs

What injury is most commonly associated with anterior cord syndrome?

• Burst fracture of the vertebra

What is the next step in a patient with a gunshot wound below the nipple who is hemodynamically unstable?

• Exploratory laparotomy

What are the first compensatory physiological changes to hemorrhage? (2)

• Tachycardia Peripheral vasoconstriction

Clinical manifestations: retroperitoneal abscess (3)

• Fever Chills Deep abdominal pain

Tx: pancreatic abscess

• Immediate placement of a percutaneous drainage catheter with culture of the drained fluid and surgical debridement

Tx: mastitis (3)

• antibiotics (dicloxacillin or cephalosporins) Analgesics Continuation of breast-feeding from the affected breast

What is the radiologic finding for blunt aortic injury? • Widened mediastinum

What is the most common cause of spinal cord ischemia and infarction?

• Thoracic and thoracoabdominal aortic aneurysm repair surgeries

Clinical presentation: anterior spinal artery syndrome (5)

• Flaccid paralysis Bowel/bladder Incontinence Sexual dysfunction Hypotension Loss of tendon reflexes

Dx: esophageal perforation • Water-soluble contrast esophagram

Where do diabetic foot ulcers classicaly occur?

• Plantar surface of the foot under points of greatest pressure

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125!

Clinical manifestations: early

dumping syndrome (4)

• postprandial abdominal cramps weakness light-headedness diaphoresis

What imaging modalities is can detect uric acid stones? (2) • CT abdomen IVP

Parotid surgery involving the deep lobe of the parotid gland carries a

significant risk of [...] palsy

• Parotid surgery involving the deep lobe of the parotid gland carries a significant risk of facial nerve palsy

What is the most common bone in the body to be affected by stress fractures?

• Tibia

Where do tibial stress fractures classically occur?

• Anterior part of the middle third of the tibia

What are the best diagnostic modalities for tibial stress fractures? (2)

• MRI Bone scan

What are the most common causes of syringomyelia? (2)

• Arnold-Chiari malformation Prior spinal cord injuries (classically, whiplash from MVA)

Definition: Ludwig angina

• rapidly progressive bilateral cellulitis of the submandibular and sublingual spaces

What is the classic etiology of Ludwig angina?

• Infector second or third mandibular molar

Clinical manifestations: Ludwig angina (4)

• Fever Dysphagia Odynophagia Drooling

What is the most common cause of death with Ludwig angina? • asphyxiation

Tx: Ludwig angina (2) • Antibiotics Removal of infected molar

Definition: Legg-Calve-Perthes disease

• Idiopathic avascular necrosis of the femoral capital epiphysis

Tx: Legg-Calve- Perthes disease (2)

• Observation and bracing Surgery if the femoral head is not well contained within the acetabulum

What is the typical course of a congenital hydrocele?

• Spontaneous resolution by 12 months

If a congenital hydrocele does not disappear within a year, what treatment may be indicated? Why?

• Surgical repair due to the risk of inguinal hernia

Clinical presentation: trichinellosis (4)

• GI sx followed by triad of:Periorbital edema Myositis Eosinophilia

Tx: severe symptomatic hyponatremia (< 120 meq/L)

• hypertonic saline (3%) infusion

What type of catherization is best for minimizing UTIs?

• Intermittent catheterization

Clinical manifestations: irritable bowel syndrome (4)

• abdominal pain w/ diarrhea and/or constipation pain relief with bowel movements bloating sense of

incomplete emptying

Prophylaxis: M. avium complex in HIV patient (2)

• Azithromycin or clarithromycin

What is the mechanism by which fluphenazine (antipsychotic) causes hypothermia?

• Disrupts thermoregulation and the body's shivering mechanism

What are the routine screening guidelines for C. trachomtis?

• All sexually active women < 24 y/o and other asymptomatic women at increased risk for infection

What is the best initial diagnostic test for squamous cell carcinoma of the head/neck?

• Panendoscopy (esophagoscopy, bronchoscopy, laryngoscopy)

Describe the following parameters in tumor lysis syndrome: calcium,

• Calcium: decreased Phosphate: Increased Potassium: increased Uric acid:

!

phosphate, potassium, uric acid increased

What is the most significant cause of morbidity in patients with traumatic brain injury?

• Diffuse axonal injury

In cases of suspected child abuse, what test should be ordered?

• Complete skeletal survey

What is the leading complication of surface body burns?

• Bacterial infection leading to sepsis and septic shock

Clinical presentation: esophageal perforation (2)

• acute-onset severe substernal pain subcutaneous emphysema in the neck/mediastinal emphysema

Clinical presentation: acute mediastinitis (5)

• Fever Chest pain leukocytossis sternal wound drainage mediastinal widening on chest x-ray

Tx: acute mediastinitis (3)

• Drainage Surgical debridement Prolonged antibiotic therapy

Tx algorithm: diverticulitis

complicated by abscess

• Conservative medical therapy initially CT guided percutaneous drainage (if > 3 cm); if < 3 cm, IV abx and observation If unresolved after drainage, surgery for drainage and debridement

What surgery should be performed for diverticulitis? What are the indications?

• Sigmoid resection; fistulas, perforation with peritonitis, obstruction and recurrent attacks

What is the only region of the bladder covered by peritoneum?

• Dome of the bladder

Definition: Volkmann's ischemic contracture

• Final end point of compartment syndrome in which the dead muscle has been replaced by fibrous tissue

What is the immediate management of splenic trauma in a hemodynamically stable patient? And hemodynamically unstable?

• IV fluids first, then: Stable: CT abdomen Unstable:

exploratory lapartomy

Definition: torus palatinus

• benign bony growth (exostosis) located on the midline suture of the hard palate

After blunt trauma to the chest, if an x-ray shows a deviated

mediastinum with a mass in the left lower chest, one should suspect a [...]

• After blunt trauma to the chest, if an x-ray shows a deviated mediastinum with a mass in the left lower chest, one should suspect a diaphragmatic hernia w/ herniation of abdominal viscera

Dx: diaphragmatic hernia (2) • Barium swallow or CT scan w/ oral contrast

What can happen to the extremities upon reperfusion after ischemia (4-6 hours)?

• Ischemia-reperfusion injury leading to compartment syndrome

Tx: compartment syndrome • emergent fasciotomy

Tx: cardiac tamponade

• immediate decompression by pericardiocentesis or surgical pericardiotomy

Radiologic findings: acute cardiac tamponade

• normal cardiac silhouette w/o tension pneumothorax

[...] is the preferred way to establish an airway in an apneic patient with a cervical spine injury

• Orotracheal intubation with rapid sequence intubation is the preferred way to establish an airway in an apneic patient with a cervical spine injury

What are the best methods for

In document Denice Jeanneth Romero López Universidad de La Salle, Bogotá (página 99-0)