In-Training ExamZebras 2013       Dan Girzadas Jr. MD
Financial Disclaimer   I am not a paid speaker.   I am not promoting any product.   Zebras are not commonly used in    ...
What’s a Zebra?     When you hear hoof beats, it’s usually      horses not zebras.     Think of the in-training as a saf...
What’s a Zebra? Objectives     The Attendee should be able to recognize      uncommon emergencies known to be used      o...
Zebra Subcategories   Cardiovascular          Heme-Onc   Toxicology              GI   Infectious Disease      Orthop...
Cardiovascular
   Torsades   QTc>500 is high risk   Romano-Ward (Autosom Dom)   Jervell and Lang-Nielson (Auto Rec,    Deafness)   L...
Murmur increased with   standing/valslavaMurmur decreased with   squatting or leg   elevationFluids and beta blockers   de...
   Syncope   Sudden death   Southeast Asian Men   Brugada Syndrome   AICD
1. Hypothermia2. Osborne    wave
1.   Vasculitis2.   Associated with colic,     gi bleed,     intussusception,     abdominal pain (65%)3.   Glomerulonephri...
Pericarditis
   Most Common Cause of    Cyanotic Heart Disease    over the age of 4   RV outflow    obstruction/VSD   Left sternal b...
Terrible T’s: Cyanotic HeartLesionsRight to Left Shunt   Transposition   Tetrology   TAVR   Truncus   Tricuspid/Pulmo...
1.   Hypertension/flushing2.   severe headache3.   Dx test:urine     catecholamines4.   Alpha and beta block     prior to ...
 Sudden painless  vision loss Associated with  HTN, vasculitis,  hypercoaguable,and  glaucoma Diffuse retinal  hemorrha...
1.   Sudden painless     vision loss2.   Ophth artery first     branch of     IC/embolic event3.   Pale retina and     che...
   3-5 Days following AMI   Associated with small to    medium inferior MI’s   Acute CHF with    holosystolic murmur  ...
Toxicology
   Welders/solderers/   smelters   Fever/chills/myalgias   Inhaled zinc oxide    fumes   Cough and hemoptysis   Can ...
1.   Agents that cause     SLUDGE + weakness     and seizures2.   All potent     organophosphates3.   Sarin/VX4.   Nerve a...
   Cause of 95% of deaths    from Mushroom    Poisoning   Intense Nausea/vomiting    that begins greater than    6 hours...
   Antivenin indications   Local progression   Coagulopathy   Systemic effects   SPREAD/BLED/ALMOST    DEAD   All co...
1.   Toxin in paint stripper that may cause     delayed endogenous production of     carbon monoxide2.   Methylene chlorid...
1.   Multi-use antidote2.   Gyromitra poisoning3.   One ancillary treatment for ethylene     glycol poisoning4.   Treat se...
1.   Blocks cytochrome A3,2.   Doesn’t bind hemoglobin3.   Acidosis/coma/shock/dyspnea4.   Industrial exposure     (plasti...
1.   Toxin blocks inhibitory glycine at post-     synapse brainstem and spinal cord2.   Muscle spasms/ conscious     “conv...
Sour gas leak kills worker: Employee never returned from    changing flow meter at remote gas facility (The Edmonton Journ...
1.   Toxin causing crampy abdominal pain2.   Vomit and diarrhea followed by     hypotension3.   Garlic odor to breath4.   ...
   Pregnant Mom ingests Amanita    Mushrooms. Should you induce    delivery? Should you advise the mom    that the baby h...
Infectious Disease
EOM weakness/diplopiaAbsence of papillary light reflex/blurred visionGeneralized muscle weakness, poor suck in    infants/...
Botulism
Infection following    laceration in fresh    water lakeMost common organism:    aeromonas hydrophiliaFQ/Bactrim/DoxyInfec...
   Parasitic infection    Taenia saginata, Taenia    solium   Seizures (#1 cause    adult-onset SZ world-    wide)   Ca...
1.   Posterior     cervical     adenopathy2.   Macular rash     starting at face     and moving to     trunk and arms3.   ...
   Palatal Weakness   Pseudomembrane   Myocarditis   Tx: pcn or erythro    and antitoxin   Diphtheria
1.   Dermacentor tick is     vector2.   Rickettsial infection3.   Fever before rash     (ankles and wrists)/ bad     heada...
BIL R DR   Borellia   Ixodes   Lyme   Ricketsia   Dermacentor   RMSF
1.   Viral illness2.   Vectors: bats/foxes/     raccoons/skunks/livestock3.   Squirrels, hamsters and rats don’t carry the...
Wound Preparation: Buy orSell   Povidone-Iodine or Chlorhexidine in    wound   Shaving surrounding hair   Irrigation pr...
Category A Bioterrorism              Agents             USA Beats Extremist Plotters1.   Small Pox                 suppor...
1.   Tick borne illness2.   Like RMSF, but     rash less common3.   Liver dysfunction4.   Leukopenia/5.   encephalitis/ren...
1.   Protozoan infection2.   Heart failure     (#1cause in Latin     America)3.   Megaesophogus/4.   megacolon5.   Kissing...
   Worm, most    common parasitic    disease in the world   Eosinophilia   Pneumonitis/hemopt    ysis   Intestinal or ...
   Protozoan parasite   Malaria like, febrile    illness   Hemolysis/rings in    rbc’s   20% also have lyme    disease...
1.   Parasitic infection2.   Eating pork3.   Affects striated muscle4.   GI symptoms/periorbital     edema/ muscle spasms5...
1.   Cough, coryza and     conjunctivitis2.   Macular     erythematous rash     starts at hairline     and moves down to  ...
1.   Major Jones criteria for     Rheumatic Fever2.   Polyarthrits (Joints)3.   Carditis     (echO)4.   Subcutaneous nodul...
1.   Enter through skin     or be ingested2.    Hematuria/3.   hemetemesis/4.   cirrhosis/CNS     symptoms5.   DX confirme...
1.   Worm that sucks     blood from     intestinal villi2.   Anemia/ hi output     chf3.   Hand and foot     rash and prur...
   Toxic    appearing/fever   Headache   Coma   Periorbital edema   Proptosis    Cavernous sinus    Thrombosis
1.   Tender red nodules on lower     extremities2.   Causes: drugs/UC/strep3.   Tx:bedrest/intralesional     steroids/pota...
   A form of malaria   The most lethal form   Tx:Malarone or quinine and doxy or    mefloquine and doxy   Falciparum
Neurology/Neurosurgery
1.   Eye physical exam     finding2.   Interruption of     sympathetics3.   Causes include:4.   Internal carotid     disse...
Lower extremity weaknessBack painBand sensation around thoraxSphincter dysfunctionMRI shows no tumor, abscess   hematoma, ...
1.   Most common cause of optic nerve     related vision loss in 20-40yo’s2.   Painful , especially with eye movement3.   ...
   Tumor   Deafness/ataxia   Ipsilateral facial    weakness   Decreased corneal    reflex   Cerebellar signs   ACOUS...
   Loss of motor    function and    pinprick sensation   Retains position and    vibratory sense   10-20% recover    so...
   Penetrating trauma    to spinal cord   Ipsilateral    weakness/loss of    proprioception and    vibration   Contrala...
1.   Treatment of Cyclic Antidepressant     Seizures?2.   NaHCO33.   Phenytoin4.   Phenobarbital5.   Lorazepam6.   Lorazep...
   Hyperextension    cervical spine    trauma in old guy   Upper extremities    weaker than lower    extremities   MUD...
    Due to Lung tumor    or liver metastasis   Serotonin and other    vasoactive    substances   Right side valvular   ...
1.   Big ventricles on     brain CT2.   Dementia/ataxia/     incontinence3.   Normal pressure     hydrocephalus
1.   Autoimmune disease2.   Post synaptic antibodies causing     weakness3.   Affects young women and old guys4.   Avoid  ...
   Acute weakness   Classic patient is a male waking the next day    after a large meal   Ate carbohydrate rich meals ...
   SIADH vs. DI   Hyponatremia vs. hypernatremia   concentrated urine   dilute urine   Water restrict     NS or vasopr...
   Lung Cancer   Proximal weakness   Presynaptic pathophysiology; Antibodies    to calcium channels   Grip gets strong...
OB-Gyne
   Test for greater than    30ml of fetal-maternal    hemorrhage in trauma   Indicates need for more    than usual    30...
   Upper Abdominal Pain   Pre-ecclampsia    complication?   Multiparous/ maternal    age >35   BP may be normal   Hem...
1.   Right sided thoraco-     abdominal pain2.   Adhesions around liver3.   Perihepatitis4.   Secondary to a pelvic     in...
1.   Which of the following vaccines and     immunoglobins are safe in     pregnancy?2.   Rabies=yes3.   Tetanus=yes4.   H...
Heme-Onc
1.   Most common inherited bleeding     disorder2.   Prolonged bleeding time3.   NL PT/PTT4.   Treat with desmopressin, fa...
   Coombs test direct is    positive :   Immune mediated    hemolytic anemias/    antibodies on the rbc   Coombs test i...
   Hemolytic anemia   Thrombocytopenia   Renal vascular    endothelial    injury/platelet thrombi   Kids   Ecoli 0157...
1.   Thrombocytopenia2.   Hemolysis/renal     failure/fever/multiple     organ ischemic     damage3.   Similar to HUS but ...
1.   Hemophilia with head injury     :Treatment?2.   100%, 50u per kg of Factor 8 BEFORE     CT BRAIN3.   Joint pain4.   5...
1.   Hemolytic anemia2.   Sulfa drugs, pyridium, nitrofurantoin     and fava beans3.   Heinz bodies (precipitated hgb with...
1.   Abdominal pain/weakness/psychiatric     symptoms2.   Diminished reflexes3.   DX test:Urine aminolevulonic acid and   ...
   Disease due to platelet autoantibodies   Pupura and bleeding with low platelets   Tx:steroids and sometimes    splen...
GI
   Marathon Runners   Youngish adults   Mobile Cecum   Surgical Tx   Cecal volvulus
   Most common Neonatal    GI Emergency   Vomiting/poor    feeding/abdominal    distension   Increased incidence with  ...
Orthopedics
1.   4-9yo child with a     limp/no fever2.   Avascular necrosis     of the femoral     head3.   Legg-Calve-     Perthes4....
1.   Salter Harris2.   1-M-E-     (metaphysis)-     epiphysis)-43.   This is a SH3
1.   Autoimmune disease in kids2.   Usually involves a single joint (knee) and not     destructive3.   Associated with iri...
Environmental
1.   How do you     remove jelly fish     Nematocysts?2.   Acetic acid     (vinegar)3.   Supportive care     afterward, pa...
1.   How do you treat pain from sea     urchins?2.   Immerse in hot water as high as 113F
1.   Prolonged     exposure can     cause chemical     burn2.   Classic patient is     brick layer or     mason3.   TX: tr...
A Few Radiation ?’s1.   Blocked by paper, blocked by clothing,     blocked by concrete2.   Alpha, beta, Gamma3.   The best...
Miscellaneous
   More Common left side   Dilatation of    pampiniform plexus   Venous drainage in to    left renal vein (caught    be...
1.   Autosomal-dominant disease2.   Mucosal telangiectasias3.   Epistaxis4.   Osler-Weber-Rondu syndrome
1.   Complication of hi potency     neuroleptics2.   Idiosyncratic reaction3.   Hyperthermia/rigidity/autonomic     instab...
1.   Elevated liver enzymes/prolonged     pt/increased ammonia level/2.   Nl bilirubin3.   Increased ICP4.   Chicken pox a...
   Oral-eye-genital lesions   Erythema nodosum   Autoimmune   Cholchicine, prednisone, cyclosporine   Behcet’s disease
 Hocm Papillary muscle rupture  ludwigsReiter’sTransverse MyelitisGlaucoma E=M2C
Zebra lecture  pdf
Zebra lecture  pdf
Zebra lecture  pdf
Zebra lecture  pdf
Zebra lecture  pdf
Zebra lecture  pdf
Zebra lecture  pdf
Zebra lecture  pdf
Zebra lecture  pdf
Zebra lecture  pdf
Zebra lecture  pdf
Zebra lecture  pdf
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Zebra lecture pdf

  1. 1. In-Training ExamZebras 2013 Dan Girzadas Jr. MD
  2. 2. Financial Disclaimer I am not a paid speaker. I am not promoting any product. Zebras are not commonly used in medical practice and hence there is no company willing to pay doctors to promote their sale.
  3. 3. What’s a Zebra?  When you hear hoof beats, it’s usually horses not zebras.  Think of the in-training as a safari  Zebras are relatively rare clinical entities  Distraction  Foils  Sew doubt
  4. 4. What’s a Zebra? Objectives  The Attendee should be able to recognize uncommon emergencies known to be used on board exam questions (Zebras).  The Attendee will have familiarity with these uncommon emergencies and rule them in/out of a board question more quickly and confidently
  5. 5. Zebra Subcategories Cardiovascular  Heme-Onc Toxicology  GI Infectious Disease  Orthopedics Neuro/Neurosurgery  Miscellaneous OB-Gyne  Environmental
  6. 6. Cardiovascular
  7. 7.  Torsades QTc>500 is high risk Romano-Ward (Autosom Dom) Jervell and Lang-Nielson (Auto Rec, Deafness) Long QT Syndrome Treat with Mag, Pacing, Isoproteronol, 1b’s
  8. 8. Murmur increased with standing/valslavaMurmur decreased with squatting or leg elevationFluids and beta blockers decrease obstructionDecreased preload and increased inotropy worsen obstructionAssymetric LV wall thickeningHOCMBetablockers/AICD
  9. 9.  Syncope Sudden death Southeast Asian Men Brugada Syndrome AICD
  10. 10. 1. Hypothermia2. Osborne wave
  11. 11. 1. Vasculitis2. Associated with colic, gi bleed, intussusception, abdominal pain (65%)3. Glomerulonephritis (25-50%)4. Arthritis, scrotal swelling5. Palpable purpura on buttocks and lower extremities6. TX: Supportive care7. Henoch-Schonlein Purpura
  12. 12. Pericarditis
  13. 13.  Most Common Cause of Cyanotic Heart Disease over the age of 4 RV outflow obstruction/VSD Left sternal border murmur Squatting Boot heart with decreased lung markings Tetrology
  14. 14. Terrible T’s: Cyanotic HeartLesionsRight to Left Shunt Transposition Tetrology TAVR Truncus Tricuspid/Pulmonary Atresia Hypoplasts Ebstein’s, Some Coarcts
  15. 15. 1. Hypertension/flushing2. severe headache3. Dx test:urine catecholamines4. Alpha and beta block prior to surgery5. Pheochromocytoma
  16. 16.  Sudden painless vision loss Associated with HTN, vasculitis, hypercoaguable,and glaucoma Diffuse retinal hemorrhages; “Blood and thunder” Tx:asaCentral Retinal Vein Occlusion
  17. 17. 1. Sudden painless vision loss2. Ophth artery first branch of IC/embolic event3. Pale retina and cherry red macula4. Tx with ocular massage, topical beta blocker,paper bag,diamox,ant chamber paracentesis5. Central Retinal Artery Occlusion
  18. 18.  3-5 Days following AMI Associated with small to medium inferior MI’s Acute CHF with holosystolic murmur Treatment is surgical Papillary Muscle Rupture Stabilize with afterload reduction/nitroprusside
  19. 19. Toxicology
  20. 20.  Welders/solderers/ smelters Fever/chills/myalgias Inhaled zinc oxide fumes Cough and hemoptysis Can have abnormal CXR Gets better when away from the job Metal fume fever
  21. 21. 1. Agents that cause SLUDGE + weakness and seizures2. All potent organophosphates3. Sarin/VX4. Nerve agents/Chemical warfare agents5. Treat with atropine (muscarinic symptoms) and 2-PAM (nicotinic symptoms)
  22. 22.  Cause of 95% of deaths from Mushroom Poisoning Intense Nausea/vomiting that begins greater than 6 hours post-exposure Hepatic toxicity AC/Pen g/silibinin/NAC Beware hypoglycemia Amanita phalloides Gyromitra similar presentation but can also cause seizures
  23. 23.  Antivenin indications Local progression Coagulopathy Systemic effects SPREAD/BLED/ALMOST DEAD All coral snake bites 10 vials for crotalids/3 vials for coral snakes
  24. 24. 1. Toxin in paint stripper that may cause delayed endogenous production of carbon monoxide2. Methylene chloride3. Methylene Chloride=Carbon Monoxide
  25. 25. 1. Multi-use antidote2. Gyromitra poisoning3. One ancillary treatment for ethylene glycol poisoning4. Treat seizures related to isoniazid poisoning5. Pyridoxine
  26. 26. 1. Blocks cytochrome A3,2. Doesn’t bind hemoglobin3. Acidosis/coma/shock/dyspnea4. Industrial exposure (plastics/photography/ electroplating), smoke inhalation5. Scent of bitter almonds6. Tx: hydroxocobalamine or sodium nitrite/sodium thiosulfate7. Cyanide poisoning
  27. 27. 1. Toxin blocks inhibitory glycine at post- synapse brainstem and spinal cord2. Muscle spasms/ conscious “convulsions”3. Tx:benzos/ neuro-muscular blockade4. Pt’s remain conscious5. Can cause rhabdomyolysis6. Strychnine poisoning
  28. 28. Sour gas leak kills worker: Employee never returned from changing flow meter at remote gas facility (The Edmonton Journal, March 8, 2008, Jennifer Fong).[8] Blocks cytochromes Acts similar to cyanide plus it is a lung and eye irritant Shorter acting so victims may recover from brief exposure Tx:Sodium nitrite/hydroxocobalomine? Hydrogen sulfide poisoning 3rd Cytochrome poison=CO
  29. 29. 1. Toxin causing crampy abdominal pain2. Vomit and diarrhea followed by hypotension3. Garlic odor to breath4. Weakness, paresthesias, and rash (Chronic)5. Arsenic poisoningBinds sulfhydryl groups/vasodilation/edema/tx with chelation BAL
  30. 30.  Pregnant Mom ingests Amanita Mushrooms. Should you induce delivery? Should you advise the mom that the baby has a high risk of hepatic damage? Neither. Amatoxins don’t cross the placenta.
  31. 31. Infectious Disease
  32. 32. EOM weakness/diplopiaAbsence of papillary light reflex/blurred visionGeneralized muscle weakness, poor suck in infants/ constipationCauses: improperly canned foods, honey (infants), wounds (rare) TX: pen in infants?/antitoxin for adults and immune globulin for infants<1yrBotulism Nerve conduction studies, Blood for botulinum toxin or positive stool Cx are Dx
  33. 33. Botulism
  34. 34. Infection following laceration in fresh water lakeMost common organism: aeromonas hydrophiliaFQ/Bactrim/DoxyInfection following laceration in sea waterMost common organism: vibrio species3rd Gen Ceph and Doxy
  35. 35.  Parasitic infection Taenia saginata, Taenia solium Seizures (#1 cause adult-onset SZ world- wide) Calcifications or cystic lesions in brain Mexican immigrants Undercooked pork Cystercircosis
  36. 36. 1. Posterior cervical adenopathy2. Macular rash starting at face and moving to trunk and arms3. Rubella4. German measles
  37. 37.  Palatal Weakness Pseudomembrane Myocarditis Tx: pcn or erythro and antitoxin Diphtheria
  38. 38. 1. Dermacentor tick is vector2. Rickettsial infection3. Fever before rash (ankles and wrists)/ bad headache4. Tx:doxy or chloramphenicol5. Rocky Mountain Spotted Fever
  39. 39. BIL R DR Borellia Ixodes Lyme Ricketsia Dermacentor RMSF
  40. 40. 1. Viral illness2. Vectors: bats/foxes/ raccoons/skunks/livestock3. Squirrels, hamsters and rats don’t carry the disease4. TX: Irrigate wound with povidone-iodine solution5. HRIG 20IU/kg as much as possible around wound, plus 5 doses of vaccine (in the deltoid) on days 0,3,7,14,28.6. Only one survivor in US without pre/post exposure prophylaxis7. Rabies
  41. 41. Wound Preparation: Buy orSell Povidone-Iodine or Chlorhexidine in wound Shaving surrounding hair Irrigation pressure of 8 psi Scrub wound with sponge Wound soaking Best irrigation fluid
  42. 42. Category A Bioterrorism Agents USA Beats Extremist Plotters1. Small Pox  supportive2. Anthrax  AG/Cipro/Doxy3. Plague (Y. Pestis)  AG/Cipro/Doxy4. Botulism  Antitoxin5. Tularemia  AG/Cipro/Doxy6. Ebola et al.  Supportive
  43. 43. 1. Tick borne illness2. Like RMSF, but rash less common3. Liver dysfunction4. Leukopenia/5. encephalitis/renal failure6. Tx:doxy7. Bacteria is Ehrlichia8. Erlichiosis
  44. 44. 1. Protozoan infection2. Heart failure (#1cause in Latin America)3. Megaesophogus/4. megacolon5. Kissing bug6. Periorbital swelling7. Tx: nifurtimox or benznidazole8. Chaga’s Disease/trypanoso miasis
  45. 45.  Worm, most common parasitic disease in the world Eosinophilia Pneumonitis/hemopt ysis Intestinal or biliary obstruction Treat with mebendazole Ascaris lumbricoides
  46. 46.  Protozoan parasite Malaria like, febrile illness Hemolysis/rings in rbc’s 20% also have lyme disease/ same tick vector Treatment is quinine and clindamycin Babesiosis
  47. 47. 1. Parasitic infection2. Eating pork3. Affects striated muscle4. GI symptoms/periorbital edema/ muscle spasms5. Myocarditis/gi/pulmonary edema6. Eosinophilia7. Trichinosis
  48. 48. 1. Cough, coryza and conjunctivitis2. Macular erythematous rash starts at hairline and moves down to feet3. Koplick’s spots4. Supportive care5. Rubeola6. Measles
  49. 49. 1. Major Jones criteria for Rheumatic Fever2. Polyarthrits (Joints)3. Carditis (echO)4. Subcutaneous nodules (Nodules)5. Erythema marginatum (Erythema)6. Chorea (Sydenham’s) Aschoff Body: Damaged collagen
  50. 50. 1. Enter through skin or be ingested2. Hematuria/3. hemetemesis/4. cirrhosis/CNS symptoms5. DX confirmed with eggs in feces and rectal biopsy/6. Tx:prazaquantel7. Schistosomiasis
  51. 51. 1. Worm that sucks blood from intestinal villi2. Anemia/ hi output chf3. Hand and foot rash and pruritus4. Mebendazole for treatment5. Hookworm
  52. 52.  Toxic appearing/fever Headache Coma Periorbital edema Proptosis Cavernous sinus Thrombosis
  53. 53. 1. Tender red nodules on lower extremities2. Causes: drugs/UC/strep3. Tx:bedrest/intralesional steroids/potassium iodide4. Erythema nodosum
  54. 54.  A form of malaria The most lethal form Tx:Malarone or quinine and doxy or mefloquine and doxy Falciparum
  55. 55. Neurology/Neurosurgery
  56. 56. 1. Eye physical exam finding2. Interruption of sympathetics3. Causes include:4. Internal carotid dissection/pancoast tumor /CVA/herpes zoster5. Ptosis/miosis/anhidrosis6. Horner’s syndrome
  57. 57. Lower extremity weaknessBack painBand sensation around thoraxSphincter dysfunctionMRI shows no tumor, abscess hematoma, or disc problemLP shows pleocytosisSome association with MSMultiple other etiologiesTransverse MyelitisTX: Steroids or immunoglobulin but both are controversial
  58. 58. 1. Most common cause of optic nerve related vision loss in 20-40yo’s2. Painful , especially with eye movement3. Afferent pupillary defect4. Associated with MS5. IV steroids or nothing, prednisone has worse outcome6. Optic neuritis
  59. 59.  Tumor Deafness/ataxia Ipsilateral facial weakness Decreased corneal reflex Cerebellar signs ACOUSTIC NEUROMA/CPA tumor
  60. 60.  Loss of motor function and pinprick sensation Retains position and vibratory sense 10-20% recover some motor function Give steroids Anterior Cord Syndrome
  61. 61.  Penetrating trauma to spinal cord Ipsilateral weakness/loss of proprioception and vibration Contralateral loss of pain-temp Brown- Sequard Syndrome
  62. 62. 1. Treatment of Cyclic Antidepressant Seizures?2. NaHCO33. Phenytoin4. Phenobarbital5. Lorazepam6. Lorazepam=yes
  63. 63.  Hyperextension cervical spine trauma in old guy Upper extremities weaker than lower extremities MUD Central cord syndrome
  64. 64.  Due to Lung tumor or liver metastasis Serotonin and other vasoactive substances Right side valvular heart disease Diarrhea Facial Flushing Carcinoid Syndrome
  65. 65. 1. Big ventricles on brain CT2. Dementia/ataxia/ incontinence3. Normal pressure hydrocephalus
  66. 66. 1. Autoimmune disease2. Post synaptic antibodies causing weakness3. Affects young women and old guys4. Avoid steroids/aminoglycosides/narcotics5. Myasthenia gravis
  67. 67.  Acute weakness Classic patient is a male waking the next day after a large meal Ate carbohydrate rich meals Low k/high K/abnormal thyroid function on lab testing TX: cautiously manage hypo/hyperkalemia, manage hyperthyroidism with propranolol Familial periodic paralysis/Thyrotoxic periodic paralysis
  68. 68.  SIADH vs. DI Hyponatremia vs. hypernatremia concentrated urine dilute urine Water restrict NS or vasopressin Tumor central or renal
  69. 69.  Lung Cancer Proximal weakness Presynaptic pathophysiology; Antibodies to calcium channels Grip gets stronger over seconds Muscarinic insufficency Eaton-Lambert syndrome
  70. 70. OB-Gyne
  71. 71.  Test for greater than 30ml of fetal-maternal hemorrhage in trauma Indicates need for more than usual 300micrograms of rhogam in rh- females greater than 12 weeks pregnant. Kleihauer-Betke test Other tests like K-B are flow cytometry and rosette test
  72. 72.  Upper Abdominal Pain Pre-ecclampsia complication? Multiparous/ maternal age >35 BP may be normal Hemolysis,elevated liver enzymes, low platelets/ HELLP syndrome
  73. 73. 1. Right sided thoraco- abdominal pain2. Adhesions around liver3. Perihepatitis4. Secondary to a pelvic infection5. Chlamydia or gonorrhea6. Fitz-Hugh Curtis syndrome
  74. 74. 1. Which of the following vaccines and immunoglobins are safe in pregnancy?2. Rabies=yes3. Tetanus=yes4. Hepatitis B=yes5. Influenza=yes6. Varicella=no7. (Shot’s gonna HIRT)
  75. 75. Heme-Onc
  76. 76. 1. Most common inherited bleeding disorder2. Prolonged bleeding time3. NL PT/PTT4. Treat with desmopressin, factor 8,cryopercipitate5. Von Willebrand’s disease
  77. 77.  Coombs test direct is positive : Immune mediated hemolytic anemias/ antibodies on the rbc Coombs test indirect is used for: Antibodies in the serum Autoimmune hemolytic anemia Hd of newborn, drugs, scd, thalasemia, mult myeloma, hodgkin/hiv
  78. 78.  Hemolytic anemia Thrombocytopenia Renal vascular endothelial injury/platelet thrombi Kids Ecoli 0157:H7 HUS Supportive Care, Dialysis, watch for hyperkalemia
  79. 79. 1. Thrombocytopenia2. Hemolysis/renal failure/fever/multiple organ ischemic damage3. Similar to HUS but more neuro signs4. Tx: plasma exchange, steroids, supportive care5. TTP or TTP-HUS
  80. 80. 1. Hemophilia with head injury :Treatment?2. 100%, 50u per kg of Factor 8 BEFORE CT BRAIN3. Joint pain4. 50%, 25u per kg of Factor 8
  81. 81. 1. Hemolytic anemia2. Sulfa drugs, pyridium, nitrofurantoin and fava beans3. Heinz bodies (precipitated hgb within RBC)4. African-Americans higher risk5. G6PD deficiency
  82. 82. 1. Abdominal pain/weakness/psychiatric symptoms2. Diminished reflexes3. DX test:Urine aminolevulonic acid and porphobilinogen4. Tx: Supportive care, iv glucose, hemin, B6, stop offending drug5. Acute Intermittent Porphyria
  83. 83.  Disease due to platelet autoantibodies Pupura and bleeding with low platelets Tx:steroids and sometimes splenectomy Acute in kids/chronic in adults ITP
  84. 84. GI
  85. 85.  Marathon Runners Youngish adults Mobile Cecum Surgical Tx Cecal volvulus
  86. 86.  Most common Neonatal GI Emergency Vomiting/poor feeding/abdominal distension Increased incidence with prematurity Pneumatosis intestinalis/hepatic portal air NEC Vanc/Gent/Clinda ICU and Surgery Consults
  87. 87. Orthopedics
  88. 88. 1. 4-9yo child with a limp/no fever2. Avascular necrosis of the femoral head3. Legg-Calve- Perthes4. 12-15 yo with groin/hip/thigh/5. knee pain6. SCFE
  89. 89. 1. Salter Harris2. 1-M-E- (metaphysis)- epiphysis)-43. This is a SH3
  90. 90. 1. Autoimmune disease in kids2. Usually involves a single joint (knee) and not destructive3. Associated with iridocyclitis, inflammatory bowel disease, Reiter’s syndrome4. Polyarticular version with positive ana titers and more destructive5. Systemic version has high fevers,rash,pericarditis,negative ana,joint destruction6. Treat with asa or steroids7. Juvenile rheumatoid arthritis
  91. 91. Environmental
  92. 92. 1. How do you remove jelly fish Nematocysts?2. Acetic acid (vinegar)3. Supportive care afterward, pain relief, wound care, and for Chironex envenomnations antivenin
  93. 93. 1. How do you treat pain from sea urchins?2. Immerse in hot water as high as 113F
  94. 94. 1. Prolonged exposure can cause chemical burn2. Classic patient is brick layer or mason3. TX: treat with copious water irrigation4. Portland Cement
  95. 95. A Few Radiation ?’s1. Blocked by paper, blocked by clothing, blocked by concrete2. Alpha, beta, Gamma3. The best marker for outcome:4. 24 hour lymphocyte count5. Blood 200 rads/gi 600 rads/cns 2000 rads6. New patient: remove clothing, wash, place sheet
  96. 96. Miscellaneous
  97. 97.  More Common left side Dilatation of pampiniform plexus Venous drainage in to left renal vein (caught between SMA and AO) Valsalva makes veins more prominent Men may have decreased fertility Boys may retroperitoneal mass Varicocele
  98. 98. 1. Autosomal-dominant disease2. Mucosal telangiectasias3. Epistaxis4. Osler-Weber-Rondu syndrome
  99. 99. 1. Complication of hi potency neuroleptics2. Idiosyncratic reaction3. Hyperthermia/rigidity/autonomic instability/altered mental status4. Tx:rapid cooling/ fluids/ benzos/ dantrolene/bromocriptine/ECT?5. Neuroleptic malignant syndrome
  100. 100. 1. Elevated liver enzymes/prolonged pt/increased ammonia level/2. Nl bilirubin3. Increased ICP4. Chicken pox and ASA5. Reye’s syndrome
  101. 101.  Oral-eye-genital lesions Erythema nodosum Autoimmune Cholchicine, prednisone, cyclosporine Behcet’s disease
  102. 102.  Hocm Papillary muscle rupture ludwigsReiter’sTransverse MyelitisGlaucoma E=M2C

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