I've got 99 problems and the first 98 are that I am 99 and hospitalized with a UTI
23 y/o, presenting with visual hallucinations, fine tremor and nausea x16 hours, hx of polysubstance abuse. No pupillary exam findings. Denies taking street drugs recently.
Alcohol Hallucinosis
Pearl: Visual but accusatory most common, 12-48 hours after last drink, DIFFERENT from hallucinations with DTs.
HPV testing is required to start at what time and what interval to follow?
21 and q3 three years until 30, at which point it either remains at q3 or becomes q5 if high risk HPV and cytology is performed
15 y/o without PMHx arriving home from a night out with friends found to have progressive confusion, agitation, hypertension, mydriasis. Labs pending.
Sympathomimetic Toxidrome
Pearl: Signs of acute catecholaminergic are most commonly drug side effects. PCP, "wet", cocaine, amphetamines are all examples.
The current initial age to start colon cancer screening in a NORMAL risk individual
3 y/o with <2 mm ulcers on the posterior oropharynx, low grade fever, goes to day camp. Other than pain with swallowing pt. seems unphased.
Herpangina/CXA
Pearl: HSV mucogingival dz usually has HIGH fever, malaise and ulcers are anterior buccal +/- lip involvement
75 y/o with chronic "dementia" times years, now complicated by visual hallucinations that pt. reports but is not bothered by as well as tremor. HDS afebrile.
Lewy Body Dementia
Pearl: Criteria includes progressive dementia + 2 of the following: fluctuating mentation, parkinsonism, visual hallucinations, delusions. Thought to account for a total of 20% dementia.
52 y/o arriving for a visit, current smoker. However, they note that they started later in life and have not smoked "that much". What pack year hx would this person require to meet criteria for lung cancer screening?
Pearl: Requirements include - >20 pack year, age > 50, and if they quit is has to be <15 years ago
14 y/o arriving for abdominal discomfort, found to have large volume ascites, no pmhx. Initial lab work revealed: Coombs negative hemolytic anemia, AST predominant transaminitis 400/100, ALP of 6, mixed elevated bilirubinemia to 2.5, cr of 2.5. Exam notable for AAOx2 and dysarthria.
Wilson's Disease
Pearls: A few here - although low ceruloplasmin is the "hallmark" of wilson's, the sensitivity/spef are both <50. AST:ALT ratio of 2.2, ALP/total bilirubin <4 are both >90 for both sense/spef.
52 y/o defers colonoscopy in lieu of FIT testing. What is the screening interval for testing ?
What is Annually
62 y/o with known small cell lung cancer stage 3 in treatment, arriving to the office for evaluation for new weakness. Labs in house are at baseline, CPK is not elevated. Exam pertinent for new mild right sided ptosis, cancer is on the left. EMG pending. Afebrile and hemodynamically stable. No rashes.
Lambert-Eaton Syndrome
Pearl: Most commonly secondary to cancer (of which, SCC is the most common) or autoimmunity. Most notable hallmark is improved weakness after use, but other very common symptoms include dysautonomia, areflexia.
45 y/o s/p STEMI complicated by mediastinitis treated appropriately with resolution of symptoms/fever, about to be downgraded, now having acute hallucinations and agitation. Vitals and labs unchanged.
ICU syndrome or psychosis/Delirium
Pearl: Delirium can affect any age, esp. with a prolonged ICU course. Hallucinations can be part of the presentation.
What is the range of breast cancer screening in AVERAGE risk women with life expectancy greater then 10 years?
What is 50-74/75
Pearl: If pt. has a life expectancy <10 years, consider reducing the rate of ALL screenings
12 y/o pt. left home during the school day due to URI symptoms. When parents arrive home, pt. is confused, febrile, and agitated. Her URI symptoms were malaise and rhinorrhea, mom also had the illness without complication. Arrives febrile and tachycardiac. Exam pertinent for muscular rigidity and confusion. No drug paraphernalia found, no hx of substance use, parents do not have any of their medications at home.
Dextromorphan Toxicity
Pearl: Found in mucinex/robitussion, common OTCs. Cases often reveal that OD was not intentional, mis-reading label is common.
Pt.'s father was diagnosed with colon cancer at the age of 35. What age should the pt. be tested?
What is 25
8 y/o with these progression of symptoms: rash around b/l ankles -> arthralgias and "coca-cola" urine -> hyperacute abdominal pain
What is HSP +/- IgA nephropathy
Pearl: There are distinct criteria for a lot of diseases, this is one of them: Characteristic rash is REQUIRED, followed by 2/4: Hematuria/proteinuria, abdominal pain, arthalgias, + biopsy. In this case, the abdominal pain is likely secondary to luminal hematoma causing intussusception, which is common in individuals with HSP.
67 y/o with multiple back-to-back admissions for COPD exacerbation (3 within a month, also visited urgent care once) arriving from home for AMS, spouse noted they were confused and combative. Vitals unremarkable, afebrile. Labs unremarkable. Becomes better in a few days without intervention
CCS psychosis
Pearl: Tricky entity - unlike other CCS ADRs, less predictable. Has been documented to occur, after 1st dose of CCS, prolonged use, and after discontinuation.
42 y/o pt., newly diagnosed cirrhotic in the context of alpha 1AT arriving for annual visit. She is wondering about her risk of liver cancer. In cirrhotics, what is the recommended screening guidelines
US +/- AFP q6 months
DAILY DOUBLE
Serotonin Syndrome
Pearl: Similar to CCS, serotonin syndrome does not have a set threshold that causes symptoms. More likely in pt.'s on multiple serotonergics, but can happen on a single serotonergic, and does not necessarily correlate directly with initiation of the med or increase in dose.
Hunter's criteria: Helps make clinical diagnosis.
Pt.'s family has a long hx of colon cancer: Father was diagnosed at 52, grandfather diagnosed at 40. What is the recommended screening age?
What is 40
This is a tricky one - recs are for FIRST degree relatives only in terms of early screening, grandfather does not count. For first degree relatives, it is recommended either TEN YEARS BEFORE that person diagnosed or FORTY, and whatever comes first
32 y/o with hx of left eye blindness from retinal A. occlusion, pulmonary arterial hypertension, mitral regurgitation on exam pending echo with: acute onset kidney failure, encephalopathy, lace like rash, and demand ischemia.
What is (Catastrophic) APLS
Pearl: APLS criteria is basically: clotting + serology results (beta2, cardiolipin, antiphospholipid). However, >3 organ system dysfunction in <1 week is considered "catastrophic APLS", essentially triggered hypercoagulability, which changes management. The rash is livedo reticularis, which is exceptionally common in APLS
58 y/o brought to the hospital after being found at a CVS, accosting patrons. No spouse or anyone else in his house. Closet relative is his son, who tells you he called him 2 months ago and he was complaining of memory difficulties and muscle spasms. Exam pertinent for AAOx1 and ataxia. The diagnosis is confirmed by Real-time Quaking Induced conversion.
What is CJD
Pearl: Cases do exist (saw 1 my intern year) RtQIC is the current way this is confirmed - board exams may still ask for "14-3-3 protein", but that has much lower sense/spef. RtQIC has 100% sensitivity. It is done on CSF
50 y/o with refractory GERD undergoes an endoscopy, barrett's pathology discovered. When is he next due for an endoscopy?
Within one year
Pearl: This is mostly a tested question, if GI is on board usually, they manage this for you (however, would not 100% rely on that either). Once Barrets is discovered, one more endoscopy should be performed that year (no specified interval) and then if still normal every 3-5 years
10 y/o is brought to the hospital for confusion and agitation. Over the last week, she has developed ataxia, lateral gaze deviation, and encephalopathy. HDS, afebrile. Exam pertinent for areflexia. Diagnosis is confirmed by serology.
What is Bickerstaff Encephalitis
Pearl: The two most common variants of GBS are: miller fisher syndrome and Bickerstaff Encephalitis. They share a significant overlap in terms of symptoms (Ataxia, ophthalmoplegia, areflexia) and both can be diagnosed via anti-GD1q antibodies. Bickerstaff encephalitis is the same symptoms as miller fisher syndrome, but includes encephalopathy and possible brainstem involvement
21 y/o is diagnosed with UC via colonoscopy, pathology shows sigmoid colitis but no dysplasia. When is pt. NEXT due for a colonoscopy?
What is 29-31
Pearl: AFTER diagnosis, as long as there is no metaplasia, UC/Crohn's pt.'s need to be screened 8-10 years later to evaluate for disease progression. If there is still no metaplasia, screening is then every 1-2 years.
What is Primary Hyperinsulinism
Pearl: Hypoglycemia in a newborn is usually caused by perinatal stress, LGA/SGA, sepsis or maternal DM. Additional causes include inborn errors of metabolism. Without acidosis, IEOM with hypoglycemia is either: insulin related or fatty acid chain disorder. FACD is identified on the newborn screen, and has manageable hypoglycemia. In true primary hyperinsulinism, there is nonstop insulin release, and these kids cannot wean no matter what you do.