1
Q
B12 Deficiency
A
Associated with red beefy tongue, positive romberg and babinski signs, reduced position and vibration senses and paresthesias. Can be present even without anemia and macrocytosis.
2
Q
Epithelial Ovarian Cancer
A
Typical: solid pelvic mass in postmenopausal woman with bloating, increased abdominal size, urinary changes and pelvic pain.
- ddx would include leimyomas but these are estrogen dependent and often shrink after menopause.
3
Q
Enterovaginal Fistula
A
- should be suspected in postmenopausal woman with frequent UTIs, foul urine or vaginal discharge, stool from vagina.
- particularly in cases of diverticulitis or ulcerative/erosive colitis.
4
Q
Cholestasis of Pregnancy
A
presents with pruritis and elevated serum bile acids, plus or minus elevated LFTs
5
Q
The gold standard test for diagnosing steatorrhea/malabsorption is FECAL FAT TEST
A
6
Q
Folic acid supplementation in pregnancy
A
Pre-conception should start with 0.4 - 1mg qday and continue through pregnancy.
- if on carbemazepine or other folic acid lowering rx, should start with 1mg beginning at LEAST 3 months before conception and continue until 12 weeks GA, after which they can continue with 1mg or reduce to 0.4
7
Q
Genitourinary Malignancy
A
- should be suspected in all cases of gross hematuria until proven otherwise
- cystoscopy is required to investigate
- CT IVP (intravenous pyelogram) involves contrast injected into vein which concentrates in urine and images taken as it moves through urinary tract. Is NOT the same thing as a retrograde pyelogram, wherin the dye is injected into the ureter during a cystoscopy.
8
Q
Pediatric development
A
Reversing letters when writing is common and not concerning up to age 7. Should be reassessed after 7 years if performing otherwise normally.
9
Q
Newborn with inadequate fluid intake
A
- may develop HYPERNATREMIC dehydration because newborn has limited ability to concentrate urine.
- may present with lethargy, poor feeding. At risk for hypoglycemia and hyperosmolarity; other electrolytes would be WNL
10
Q
Terminal Ileitis
A
- inflammation of ileum (end) of small intestine. Common in chohn’s disease. Treatment would be IV steroids; surgical procedure when medical therapy fails or with perf, necrosis or other complication.
11
Q
HIV Transmission
A
- risk is increased with deep injury and hollow needles, decreased by solid needles
- in a needlestick injury, there is no risk of doctor infecting patient if needle is removed from operative field immediately
- Early drug prophylaxis reduces the risk for HIV infection and should NOT wait until patient’s HIV status is known
12
Q
Unexplained PVCs
A
For patients in whom otherwise unexplained PVCs have been identified, the initial step is to perform holter monitor to quantify the frequency of PVCs and determine if they are monomorphic or multimorphic.
- IF frequency is high, the next step is to order echo to rule out structural abnormalities.
13
Q
Low dose ASA in pregnancy (100-162mg)
A
- in higher risk populations (chronic HTN, DM, previous preterm pre-eclampsia), low dose ASA results in small decrease in preeclampsia.
- should be initiated at diagnosis of pregnancy, BEFORE 16 WEEKS, taken at bedtime and continued until 36 weeks gestation.
- optimal dose apperas to be greater than 100mg, commonly 162mg
14
Q
Protein C Deficiency
A
- Inherited thrombophilia causing higher risk of venous thrombosis.
- impaired inactivation of factors V and VIIIa. Aptt may be prolonged but can be normal. INR is normal.
- Best test is functional or antigen assay.
15
Q
Chronic Constipation
A
- treatment algorithm starts with dietary modification and bulk forming laxatives
- if this fails, trial stimulating agents or enemas
- indications for further investigations with colonoscopy would include age >50, rectal bleeding, anemia, weight loss or first degree relative with colon cancer or IBD
***A CT would be ordered in case of abdo pain that is NOT RELIEVED BY EVACUATING STOOL.
16
Q
Positive Likelihood Ratio
A
- True positive to false positive rate
- higher the ratio, the better the test
- combined with pre-test probability, provides post-test probability (probability that a patient with a positive test result has the disease).
17
Q
Likelihood ratios
A
- when discussing the results of a diagnostic test with a patient, the most important thing to be aware of is the PREVALENCE OF THE DISEASE and the POSITIVE LIKELIHOOD RATIOS, which, put together, give you the post-test probability (the chances the patient with positive test results actually has the disease).
18
Q
Anaphylaxis
A
- an allergic reaction following exposure to allergen that has previously caused anaphylaxis requires IMMEDIATE treatment with injectable epinephrine; it can be repeated once while waiting for emergency services.
- DO NOT GIVE ANTIHISTAMINES; may mask symptoms without preventing progression of life threatening reaction
19
Q
First herpes simplex outbreak in pregnancy
A
- if in 1st or 2nd trimester, oral acyclovir immediately
- IF THIRD TRIMESTER or at time of delivery, cesarean delivery should be offered to reduce risk for ascending perinatal or neonatal infection
- Women with known or recurrent genital HSV infection should be offered acyclovir suppression at 36 weeks GA, but if it is a PRIMARY presentation (first known) in third trimester, c-section should be encouraged due to high risk for viral shed.
20
Q
Thromboprophylaxis in cancer patients
A
Patients with active cancer who have recently undergone a pelvic surgical procedure require prophylaxis for thromboembolic events
- Subcutaneous unfractionated heparin is the prophylaxis of choice. Warfarin and ASA is not adequate. IV heparin is a THERAPEUTIC intervention rather than a prophylactic treatment.
21
Q
Coronary Artery Disease and HRT
A
HRT is CONTRAINDICATED in women with coronary artery disease.
- SSRIs or SNRIs such as venlafaxine, clonidine or oxybutinin are alternatives to manage vasomotor symptoms.
22
Q
PCOS
A
- presents with virilizing features (excessive hair growth, acne), obesity and oligomenorrhea.
- on labs, likely to have high rates of impaired glucose tolerance, may be associated with Acanthosis Nigricans (darkening of axillaie), a cutaneous marker of insulin resistance.
- cortisol levels should be part of investigation ONLY if there are additional physical features of cushing syndrome (moon facies, purple skin striae, proximal muscle weakness and acne).
23
Q
Acanthosis Nigracans
A
Darkening of skin at axillae, associated with insulin resistance (PCOS, diabetes, etc)
24
Q
Cushing Syndrome vs. Cushing’s Triad
A
- Cushing Syndrome - hypercortisolemia, presents with obesity, moon facies, purple skin striae, proximal muscle weakness and acne.
- Cushing’s Triad; Medical emergency associated with increased intracranial pressure/impending herniation. Bradycardia, widened pulse pressure and irregular respirations.
25
Irritable Bowel Syndrome - Investigations
- There are no specific investigations which diagnose IBS; is a clinical diagnosis.
- imaging would be indicated if there were concerning features such as bleeding, weight loss or progressive worsening of symptoms.
26
Gout
- sudden attack of acute arthritis, maximum inflammation developed within 1 day, redness observed over joints and painful/swollen first MTP joint.
- CAN PRESENT WITH FEVER!
- Risk factors include hyperuricemia, male sex, hypertension and multiple cardiovascular disease events.
27
Acute Compartment Syndrome
- occurs with increased pressure in a compartment and develops after trauma to tissue compartment.
- confirm diagnosis with compartment pressure measurements, then surgical decompression to definitively manage.
28
Letrozole
- an ovulation induction agent recommended for patients with oligo-ovulation or anovulation when trying to conceive.
- small risk of ovarian hyperstimulation
29
Hyperprolactinemia
- Pituitary adenoma is the most frequent cause of hyperprolactinemia, particularly when >100 ug/L.
- Dopamine is augmented (secreted to inhibit prolactin), stimulating GnRH neurons, altering pulsatility and causing amenorrhea.
- Treatment - Dopamine agonists (bromocriptine, cabergoline) decrease prolactin secretion and shrink tumor size.
30
Food poisoning differential
- S. Aureus causes vomiting soon after ingestion and quick recovery, usually food-borne
- Norovirus typically transmitted person-to-person, not usually through food or water
- Bacillus cereus usually causes diarrhea as well as vomiting
- C Dif and Cryptosporidium take longer to develop symptoms
31
Persistent Hoarseness in a smoker
- in a smoker, differential includes both laryngeal cancer AND lung cancer; in lung cancer it is caused by a malignancy involving the recurrent laryngeal nerve along its course under the arch of the aorta and back to the larynx
- therefore, first test should be CT chest and neck to determine whether to proceed with bronchoscopy or laryngoscopy
32
Simple Fibroadenoma of the Breast
- solid, firm or rubbery round/oval and smooth, easily mobile under the skin
- if diagnosed in woman older than 35 years, follow up in 3-6 months with breast exam. If still present, can excise/perform lumpectomy. Not considered a high risk lesion.
- Can become tender around menstrual periods
33
Hereditary Hemorrhagic Telangiectasia
- hereditary cause of arteriovenous malformations (AVMS).
- most common symptom is recurrent nosebleeds, telangiectasias to skin, face, lips, tongue
- Rarely can cause large AVMs in lungs, liver or brain
34
Factor V Leiden
- the most common inherited condition causing thrombophilia
- Mutated factor V is harder to 'turn off' than the normal Factor V protein, making blood clots more likely.
- homozygous are high risk and need thromboprophylaxis following surgery. Otherwise not at high risk though can be in pregnancy.
- HRT and estrogen containing contraceptives are contraindicated
35
Inherited Thrombophilias
Factor V Leiden
Protein C Deficiency
Protein S Deficiency
Antithrombin Deficiency
36
Insulinoma
Fasting hypoglycemia with discrete episodes of neuroglycopenic symptoms (eg weakness, lightheadedness) and potentially autonomic symptoms. On labs, raised insulins.
- plasma C-peptide distinguishes endogenous (pancreas-secreted) vs. exogenous (injected) hyperinsulinemia, as it is released when proinsulin is cleaved into insulin.
37
Pruritic Vaginal Discharge
- Candida; pruritic. Most common cause of pruritic vaginal discharge. White and thick.
- Trichomonas; also pruritic, is protozoan, less common than fungal, discharge is malodorous, thin and greenish, including vulvar pain.
Bacterial vaginosis - malodorous, thin and green but typically not pruritic or painful.
Atrophic vaginitis - not associated with increased discharge but includes vulvar pain and pruritis.
38
Risk and Protective Factors for Epithelial Ovarian Carcinoma
Risk factors - things that increase lifetime # ovulatory cycles
- early menarche
- late menopause
- nulliparity
Protective factors - things that decrease lifetime # ovulatory cycles
- OCP
- breastfeeding
- parity
***Note; smoking is not a confirmed risk factor.
39
Primary Dysmenorrhea
- common in first 5 years of menstruation
- if not sexually active, NSAID is first line treatment
- if NSAID ineffective, OCP or hormonal IUD second line
40
Colon Cancer Screening (increased risk)
- Significant risk for individual with family member diagnosed with CRCx BEFORE age 50.
- Screening for first-degree relatives should start at age 40 or 10 years younger than age of onset of index case
41
Prostate Cancer Screening (increased risk)
- Routine PSA not indicated but greatest benefit appears to be in men aged 55-69
- screening should be discussed starting at age FORTY for:
1) men with fhx of prostate cancer in multiple generations, OR one or more first-degree relatives who were diagnosed with prostate cancer.
AND
2) Black men
42
PSA level <1ng/ML in man at age 60
Do not screen
43
PSA level <3ng/ML at age 70
Do not repeat screen
44
Thyroglossal Duct Cyst
- congenital anomaly that occurs due to persistence of thyroglossal duct, typically present as midline neck masses in children.
- Should be confirmed on imaging, then treated with surgical excision along with small portion of hyoid bone to prevent recurrence.
45
Child with non-painful nodule on midline of neck above thyroid notch, mobile and smooth.
Thyroglossal duct cyst. Image, then surgical excision.
46
Dementia Medications
Donepezil - acetylcholinesterase inhibitor
Memantine - NMDA receptor antagonist
47
Tetanus Vaccination
- Series started at 2 months, repeated at 4, 6, 12 and with booster at 4-6 years and 11-12.
- If childhood vaccinations not done, a single tetanus booster is NOT enough to ensure immunity and immune globulin and toxoid must be given in case of exposure.
48
Myofascial Pelvic Pain
- diagnosable as pain on palpation of pelvic floor diffusely (infection does not cause pelvic floor tenderness).
- management includes patient education and specialized pelvic floor physiotherapy
49
Contraceptive ring and sex
The contraceptive ring can safely be removed for up to THREE HOURS without need for alternative contraception, and if the ring is replaced after intercourse, a condom is not needed for contraception.
50
Distinguishing Delirium from worsening disease
- delirium is characterized by a disturbance in ATTENTION which develops over a shot period and tends to fluctuate throughout the day
51
Parkinson's Disease
- micrognathia (clock drawing), shuffling gait, intention tremor, cogwheel rigidity
52
Absolute Risk Reduction
Difference in results between two treatment groups (subtract one result from the other).
53
Pheochromocytoma
- paroxysmal hypertension and triad of headache, palpitations and sweating.
- Testing for plasma-free metanephrines and normetanephrines is best to confirm or exclude, THEN MRI of abdomen to confirm location.
54
Urine 5-hydroxyindoleacetic acid (5-HIAA)
- measures primary breakdown product of serotonin in 24-h sample; most useful for diagnosing and monitoring serotonin-releasing neuroendocrine/carcinoid tumors.
55
Chromogranin A (CgA)
Commonly secreted by neuroendocrine tumor cells
56
Neuroendocrine Tumor
- tumor which contains nerve and hormone producing cells
- can be found in GI, pancreas, lung or adrenals
- may be functional (release hormones) or non-functional (do not release hormones)
57
Multiple Endocrine Neoplasia (MEN1)
Hereditary condition predisposing to neuroendocrine cancers, most commonly associated with pancreatic neuroendocrine tumor.
58
Granulomatosis with Polyangitis
- Suspect in nasal discharge, cough with hemoptysis and urine findings, as well as positive rheumatoid factor and ANCA
- Nasal or oral inflammation (oral ulcers, nasal discharge)
- Abnormal chest radiograph (nodules, fixed infiltrates, cavities)
- Microscopic Hematuria
- Granulomatous inflammation on biopsy of an artery or perivascular area
59
Antibiotic associated with QT Prolongation
Azithromycin
60
Specificity
Proportion of negative results on screening tests to total number of true-negative results
61
Normal Pressure Hydrocephalus Triad
New and rapid deterioration in memory/cognitive deficits, imbalance (falls and trouble walking) and urinary incontinence.
62
Lewy Body Dementia
Needs at least one of the following:
- hallucinations, extrapyramidal symptoms, fluctuation in cognitive function or sleep disorder
63
Furosemide and Chloride
- furosemide inhibits Na-K-Cl cotransporter in loop, impairs chloride reabsorption and leads to net gain of bicarbonate.
- DISCONTINUE in all patients with alkalosis.
64
Frontotemporal Dementia
- apathy, dietary change, behavioural disinhibition, decline in cognitive and executive abilities.
- MRI would show frontotemporal atrophy
65
Adrenal Insufficiency in Adult (low cortisol)
- classic symptoms are fatigue, weight loss, GI issues, hypotension, hyponatremia and hyperkalemia
- diagnosable with adrenocorticotropic hormone stimulation test - inject ACTH and then check cortisol levels periodically. If they do not respond, suspect adrenal insufficiency.
- treated with cortisol (prednisone) and aldosterone (flucortisone)
66
Lumbar Spine Stenosis
Suspect in patient who has calf pain which is relieved when leaning forward and who has no strength or sensory deficits.
67
Increased nuchal translucency
Associated with Down Syndrome and Congenital Heart Defects (much less likely other structural defects such as diaphragmatic hernia, ophalocele and skeletal dysplasia).
68
Zollinger-Ellison Syndrome
- Gastrin-secreting tumor (Gastrinoma) leading to excessive gastric acid production, resulting in recurrent peptic ulcers and other gastrointestinal symptoms.
- found in pancreas or small intestine
- Blood test = SERUM GASTRIN.
Suspect in young patient with recurrent or multiple peptic ulcer with no or few risk factors.
69
Steroid-Induced Bipolar Disorder
Mania within days of starting steroid therapy. Usually resolves with discontinuation of steroid.
70
Complex Regional Pain Syndrome
- pain, swelling, spontaneous sweating, skin sensitivity, loss of muscle mass and decreased ROM.
71
Dupuytren Contracture
- thickening of the palmar fascia.
- associated with Diabetes (occurs in 16-42%)
72
Varicocele
- painless swelling in scrotum, separate from testis.
- if on R side, may be associated with renal pathology but left sided typically benign
- associated with male factor infertility
73
Right-sided varicocele should raise concern for?
Carcinoma of the kidney
74
Antiphospholipid Antibody Syndrome
- suspect in cases of prolonged APTT which does NOT correct on a mixing study, suggesting presence of antiphospholipid antibodies.
- next diagnostic test is lupus anticoagulant to screen for APLAs.
75
<30 minutes of morning stiffness, 45 years or older, and persistent usage related pain in 1 or more joints
Osteoarthritis
76
Joint stiffness lasting longer than 30 minutes in AM
Suspect something other than OA.
77
Scarlet Fever Rash
Generalized erythema, small raised papules which blanches when pressure applied to skin
- tends to spare perioral region and is accentuated in axillae
78
Endometrial Polyp
- Frequent cause of postmenopausal vaginal bleeding, typical finding is nonspecific endometrial thickness or sometimes intrauterine lesion, doppler US showing vascular stalk is consistent with polyp.
- HRT should be avoided as bleeding can develop
79
Infectious Mononucleosis
- can present as mild inflammation of the liver with mild malaise
80
Nectrotizing Enterocolitis
- suspect in preterm infant with bloody diarrhea, gastric distension, feeding difficulties
- Pneumatosis Intestinalis on imaging is pathognomonic
80
Leptospirosis
- bacterial infection from contaminated water or soil causing fever, chills, muscle aches.
- if jaundice develops, called 'Weil's Disease', or icteric phase; can affect heart, CNS and muscles.
81
Duodenal Atresia
- newborn with early and forceful vomiting of bile tinged fluid, abdominal distension, jaundice and absence of BMs after meconium passage.
- On imaging, "double bubble" sign is pathognomonic.
82
Multiple Myeloma
- clinical picture is weight loss, hypercalcemia, renal impairment and anemia as well as body aches/pains
83
First-line mania treatments
- Olanzapine (particularly if agitation)
- Carbamazepine (not as effective for agitation)
- Lithium
84
Umbilical Cord Prolapse
- In any case of acutely abnormal heart tracing, particularly when onset is at same time as rupture of membranes, umbilical cord prolapse should be suspected
- particularly common in preterm pregnancies, labor with unstable presentation (transverse lie), and spontaneous rupture of membranes
- management includes extreme trendelenburg positioning and provider lifting presenting part off cord if visible. Proceed immediately to c-section.
85
Otoacoustic Emissions Test
The routine newborn hearing screen. Probe inserted into baby's ear, plays tones, assesses how inner ear responds.
86
Oseltamivir
"Tami-Flu"; influenza treatment
- should be given to pregnant women with suspected or documented influenxa infection.
87
Achalasia
- suspect in cases of long-term symptoms of regurgitation, especially while recumbent
- "Bird Beak Sign" on imaging (tapering of inferior esophagus)
88
Paraesophageal hernia
- esophageal dilatation seen on imaging
89
Polymyalgia Rheumatica
- increasing fatigue, pain and stiffness to multiple joints with out swelling or discoloration, slightly decreased ROM, normocytic anemia and elevated ESR or CRP
- treated with glucocorticoid. Second line is methotrexate if prednisone not effective.
90
Endometriosis
- dysmenorrhea, menorrhagia, painful nodularity of uterosacral ligaments or posterior fornix, sometimes adnexal mass, immobility of uterus and cervix. On US, may be ovarian cysts (endometriomas), rectovaginal septum nodules or both.
91
Bronchogenic Lung Cancer
- patient who is older than 50 years with hemoptysis and substantial smoking history
- XR typically shows PERIHILAR MASS and MEDIASTINAL LYMPHADENOPATHY.
- Next best step is flexible bronchoscopy, fewer complications than fine needle biopsy.
92
Tetany (caused by low calcium)
- involuntary muscle contractions and spasms
- Tingling/burning in peri-oral and extremities
- Laryngospasm
- Cardiac Arrrhythmias
93
Acute Prostatitis
Symptoms: fever, chills, pain with urination and ejaculation, urinary retention.
Exam: prostate exam not recommended!
Treatment:
Moderate: 14 days of Ceftriaxone (IV), Cipro or TMP/SMX.
SEVERE: Pip-Tazo, switch to oral agent with clinical improvement, 4 weeks of treatment.
Note - test for gonorrhea andchlamydia.
94
Chronic Prostatitis
Definition: symptoms >3 months, may be subacute (prior bacterial prostatitis or recurrent lower UTI and perineal discomfort).
Treatment: Cipro x 4 weeks, or TMP/SMX or Doxycycline x 6 weeks.
Consider: Prostate MRI to r/o calcifications and abscess.
95
Chlamydia
Treatment: azithromycin or doxycycline to cover chlamydia, cefixime to cover gonorrhea.
- abstain from sex during and for 7 days after treatment
- partners should be treated
96
Gonorrhea
Treatment: Cefixime or ceftriaxone (one dose) to cover gonorrhea, azithromycin or doxycycline to cover chlamydia. Azithro preferred as it is one time only.
97
Epididymo-orchitis
ceftriaxone and doxycycline
98
Antibiotic therapy for Chorioamnitis
Ampicillin and Gentamycin, PLUS metronidazole IF c-section delivery
99
Endometritis (0-6 weeks postpartum)
MILD: Amoxi-clav +/- doxycycline
Severe: IV Ceftriaxone and Metronidazole +/- doxycycline
100
Postpartum patient with endometritis not responsive to therapy and getting extremely sick. Which condition should you suspect?
Septic pelvic vein thrombophlebitis, treat with pip-tazo.
- check for pulmonary emboli and heparin therapy recommended with antibiotics.
101
LMCC study
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