HIGH YIELD Family Medicine Review for StEp 2 CK & Shelf Exam

0:00 let's discuss extremely high yield infectious disease topics and go through some questions that will increase your score on exam day what is the typical empiric treatment for patients with human bite wounds Augmentin human bite wounds are typically polymicrobial with both anaerobic and aerobic organisms it's also important to note that these wounds are typically left open to drain and heal by secondary intention because there is a higher risk of infection with closure of the wound

0:46 what is the likely causative microorganism in an alcoholic sailor that develops high grade fever hours after cutting his foot while sailing in the ocean the cut is surrounded by erythema and dark colored bullet with streaking erythema extending approximally up the limb the vibrio phoneificus so this is found in Marine environments and causes severe disease for example patients can present with rapidly Progressive septicemia or even

1:32 necrotizing fasciitis being infected with this microorganism is especially common in patients with liver disease what are the two most common causes of secondary bacterial pneumonia strep pneumoniae and staph aureus so patients with secondary bacterial pneumonia typically present with worsening fever and Pulmonary symptoms after initial symptomatic improvements what is the likely diagnosis in a patient with recently diagnosed

2:17 infective endocarditis that now presents with fever and left-sided chest or abdominal pain CT reveals a left-sided Pearl effusion and spenomegaly with a spanic fluid collection so the most likely diagnosis is a splenic abscess secondary to infective endocarditis so sphenic abscesses usually presents with a child of fever leukocytosis and left upper quadrant abdominal pain and treatment is with antibiotics plus a splenectomy

3:06 which heart valve is most frequently involved in bacterial endocarditis the mitral valve which heart valve is most frequently involved in bacterial endocarditis in IV drug users the tricuspid valve and recall that this is associated with organisms such as stuff Aureus pseudomonas and candida what is the most common symptom of bacterial endocarditis

3:56 fever so you can recall the signs or symptoms of bacterial endocarditis with pneumonic from Jane F fever R rough spots o Osler notes M murmur J Janeway lesions a anemia and nail bed hemorrhages e emboli what is the likely diagnosis in an a febrile farmer with right upper quadrant pain and a smooth round hepatic cyst with septations and eggshell calcifications on ultrasound

4:42 it kind of caucus granulosus infection so recall that this is a sestoed in patients with this infection can present with a lack of fever and cystic lesions however for an infection with entamoeba hysterical these patients would be febrile with a smooth cystic subcapsular mass what is the likely result of the following serologic tests in a patient vaccinated against hepatitis B so the question is basically asking if a patient is vaccinated against Hepatitis

5:28 B what changes would you see in the hepatitis surface antigen the hepatitis surface antibody and the hepatitis C or core antibody so in vaccinated patients the surface antigen would be negative the surface antibody would be positive and the core antibody would be negative oh I remember this concept is that for persons that are immune due to immunization they have the antibodies which would be positive so those positive antibodies make you anti-sick you can't get sick because

6:14 you're vaccinated or immunized against Hepatitis B so that's one way to remember this fat what is the likely result of the following serologic tests in a patient's naturally immunize against hepatitis B well the hepatitis surface antigen is negative hepatitis surface antibody is positive and the hepatitis core antibody is also positive so how you can remember this is when you see that the core antibody is positive

7:01 this means that the patient has come across hepatitis B so a positive core antibody means that the patient has come across hepatitis so that's either a previous or ongoing infection and as previously discussed when they surface antibody is positive then you are anti-sick so you can't really get sick from it so those two things are positive when you are naturally immune to hepatitis so it's very important that you know the difference between the test results for when a patient has received a vaccine against Hepatitis B versus you know

7:46 natural immunization against Hepatitis B so you can just rewind that and put it again just really emphasize this fact what is the likely result of the following serologic tests in a patient with chronic hepatitis B so the surface antigen is positive the surface antibody is negative and the core antibody is positive so let's break this down so in chronic Hepatitis B it makes sense that the core antibody would be positive

8:34 because remember a positive core antibody means that you have come across Hepatitis B so whether that is a previous or ongoing infection so that would of course be positive in chronic hepatitis B if your hepatitis surface antigen is positive that means that you are sick with Hep B that can be either an acute or chronic infection so hepatitis surface antigen means that you're sick with hip B so that will be positive in a patient with chronic hepatitis B what antibody is typically positive during the window phase of hepatitis B infection

9:25 IGM anti-hbc infants born to mothers with active Hepatitis B should be managed with what well first they need the hepatitis B vaccine and the immunoglobulin at Birth after they receive these two then they can go on to get their routine Hepatitis B vaccines at two and six months it's very important that you check serology's three months after the third

10:11 dose of the vaccine so that's around nine months to see if the infant is infected with hepatitis or not what is post-exposure prophylaxis for Hepatitis B exposure so if you are non-immune then you need to give immunoglobulin and the vaccine however if you are immune then don't give anything at all so non-immune means that they are unvaccinated or have an incomplete response to initial vaccination

10:57 so you give the immunoglobulin for immediate protection while the vaccine is also given but this takes time to build a response what is the likely causative organism in a male that presents with this cereal urinary frequency and mucopulent discharge Gram stain and urine culture are negative chlamydia so recall that the Gram stain shows gram-negative cocci in 95 of cases of gonococcal arthritis what is the likely diagnosis in a sex

11:45 worker that presents with fever chills polyarthralgia and postals on the chest and extensive surfaces of the forearms disseminated gonococcal infection how is the diagnosis of mucor mycosis established sinus endoscopy with biopsy and culture what is the likely diagnosis in a young

12:30 patient that presents with two days of fever altered mental status seizures and the lumbar puncture findings below so the opening pressure is normal protein is also normal red blood cells and white blood cells are high and there is a lymphocyte predominant so there's 90 percent the most likely diagnosis is Viral Encephalitis for example due to HSV what type of catheterization is recommended for patients with a neurogenic bladder to reduce the risk of catheter Associated UTI

13:25 clean intermittent catheterization this refers to the insertion and removal of a clean urinary catheter every four to six hours and this can be performed by the patient or a caregiver what is the likely causative organism in a patient that develops osteomyelitis after stepping on a rusty nail the nail participation shoes and Pierce the heel pseudomonas so stop Arias and pseudomonas are responsible for most deep infections following puncture

14:12 wounds the soul of a shoe though it's very warm and moist and is a hospitable environment for pseudomonas so that's why pseudomonas is more likely than stuff Oreos in this specific scenario what is the recommended treatment for Legionnaires disease macrolides or respiratory fluoroquinolone such as levofloxacin and moxifloxacin what is the next step in management for a patient being treated with ripe

14:59 therapy for TB for the past month that develops mild elevations in AST and ALT foreign with current treatments and monitor the lfts subclinical hepatotoxicity is common within the first few weeks of isonia State therapy it is typically self-limited and resolves without intervention so significant hepatotoxicity however warns switching treatment regimens what is the next step in management for

15:47 a patient with suspected ventilator Associated pneumonia with a chest x-ray demonstrating low bar infiltrates Gram stain and culture of respiratory secretions so this should be obtained prior to administering empiric antibiotics what is the likely diagnosis in an HIV patient with a CD4 counts of 25 that presents with three weeks of fever night sweats abdominal pain diarrhea and

16:33 weight loss chest x-ray CMV geology and PPD are all negative disseminated mycobacterium atheum complex or Mac infection so TB and CMP are less likely due to the fact that they have a normal chest x-ray and also that the CMP serology is negative what is the next step in management for a patient with HIV and a CD for accounts

17:21 of 85 that presents with dysphagia and substernal burning white plaques that are easily removable are present on the palette oral fluconazole so if symptoms don't improve with this medication then endoscopy would be warranted let's take a closer look at how to interpret the serologic test for hepatitis B because this is extremely high yield and it can be a bit confusing so we need to think about the antigens and the antibodies for hippie because

18:07 they mean completely different things let's first focus on the antigens when you think about the antigens I wanted to think of this phrase antigens they make you sick and easily spread the disease antigens make you sick and easily spread the disease so the Hepatitis B surface antigen that means that you are sick with Hep B this thickness could be either due to acute or chronic hepatitis B infection hepatitis B e antigen means that you easily spread the disease so this antigen refers to

18:54 the replication and transmissibility of hepatitis B so remember when you think of antigens think of the phrase that antigens make you sick and easily spread the disease so the surface antigen means that you're sick whether acute or chronic with hepatitis B the E antigen means that you easily spread the disease okay so just pause the video or take a screenshot and really Commit This to Memory but now let's move on to the antibodies so the antibodies are basically the opposite of the anti-gens so the surface

19:39 antibody means that you are anti-sik you can't get sick from Hepatitis B because you are immune from either receiving the vaccine or immune from recovery of a previous hepatitis B infection or exposure the E antibody means that your anti easily spread so you don't easily spread Hepatitis B there's low transmissibility however for the core antibody that means that you have come across Hepatitis B before so this could be due to a acute infection if there's an acute infection

20:25 then what you'll see is a positive IGM Hepatitis B core antibody however if it's a chronic infection you'll see a positive IGG Hepatitis B core antibody so the surface antibody is anti-sick you are immune either from receiving the vaccine or recovery from a previous infection Hepatitis E antibody that means they're anti-easally spread there's a low transmissibility the core antibody means that you have come across Hepatitis B before and whether that's an acute or chronic infection

21:11 okay I know that that's broken down a bit more easily let's do three practice questions two of them you've seen before but one of them is completely new so let's go through this together the question asks what is the likely result of the following serologic tests in a patient vaccinated against hepatitis B so this should look very familiar to you but let's go through it together so the Hepatitis B surface anti-gen is negative remember that the surface antigen means that you are sick with

21:56 head B but the fact that it's negative means that there's no active infection the hepatitis surface antibody is the opposite of the antigen and it is positive so remember that the hepatitis surface antibody is anti-sick so the fact that it is positive means that this patient is immune from either recovery from a previous infection or by receiving the vaccine the Hepatitis B core antibody is negative so the Hepatitis B core antibody means that you have come across Hepatitis B before so this could be

22:43 either an acute or chronic infection but it's negative so that means that there is no previous or ongoing infection so to sum it all up in a patient that is vaccinated against Hepatitis B you would expect to see a positive Hepatitis B surface antibody because that is anti-sick and that means that you are immune from either the vaccine or recovery okay great now let's move on to question number two of this short practice test series what is the likely result of the following serologic tests in a patient's naturally immunized against hepatitis B

23:34 again this one should look a bit familiar to you so the Hepatitis B surface antigen is negative so remember that Hepatitis B surface antigen means that you are sick with hepatitis B but it's negative in this patient so there is no active infection the Hepatitis B service antibody is positive remember that the Hepatitis B surface antibody means anti-sik is the opposite of the antigen so the fact that it is positive means that this patient is immune from either receiving the vaccine or recovery the Hepatitis B core antibody is also

24:22 positive the Hepatitis B core antibody means that the patient has come across Hepatitis B this could be either an acute or chronic infection so the fact that it's positive means that the patient had a previous infection so in a patient that is naturally immunized against Hepatitis B you would see positive Hepatitis B surface antibodies means that their anti-sick so they have some sort of immunity going on and the Hepatitis B core antibody would also be positive because that's referring to the previous infection that they had that made them naturally immunize right now now let's move on to the brand new

25:07 question what is the likely cause of the following serologic test results so right here we have the Hepatitis B surface antigen which is positive so remember this refers to the patient being sick with Hep B so yes they have an active infection going on here Hepatitis B surface antibody is negative so that means that they are anti-sick they do not have any immunity from the vaccine or from previous recovery the Hepatitis B core antibody is

25:53 positive remember that this Square antibody means that the patient has come across Hep B before so yes this patient has had a Prius infection or an ongoing infection also very important the IGM anti-hbc is also positive and this means that the patient has an acute ongoing infection so when we take a closer look at this we can see that the surface antigen is positive so they have an active infection the core antibody is also positive meaning that they have a previous or ongoing infection but we also see that the IGM anti-hbc is

26:43 a positive remember IGM acute IGG chronic IGM acute IGG chronic so the most likely cause of these serologic results is that this patient has an acute hepatitis B infection what is the likely diagnosis in a hemodynamically unstable patient that presents with fever vomiting and a diffuse conduit macular papilla rash on the trunk and extremities the patient recently had anterior packing in the emergency department for a nosebleed toxic shock syndrome

27:30 and the organizing most commonly involved is staph aureus and patients can develop toxic shock syndrome if they did not remove a tampon if they did not remove nasal packing so you can see cases like this especially when you're preparing for a step three the CCS cases so think about toxic shock syndrome if a patient presents with these symptoms and signs what is the likely diagnosis in a patient with a recent UTI that presents with fever back pain vocal tenderness Over The L4 to L5 vertebrae and power vertebral muscle spasm

28:16 vertebral osteomyelitis so this can present um in patients that have a hematogenous spread of a ATI an initial workup includes doing acvc blood cultures ESR CRP and plain spinal accessories or MRI so the MRI of course is more accurate than the X-ray and it can be confirmed with a open or CT guided biopsy what is the treatment of choice in a pregnant patient with syphilis who has a penicillin allergy intramuscular penicillin G because a patient needs to be desensitized

29:03 penicillin is the treatment of choice for syphilis even in pregnancy regardless of drug allergies so remember that there are two types of penicillin iron penicillin you can have um penicillin G and penicillin V so how you can remember which is which is by saying hit the g for the sdd a patient presents with your current UTIs more than three months with transient improvement with antibiotics and painful ejaculation urine culture shows back to Uriel what is the diagnosis and treatment

29:48 so the diagnosis would be chronic bacteria prostatitis and you treat with six weeks of before when alone or your TMP SMX so chronic bacterial prostatitis is usually due to E coli going via the urethra to the prostate and diagnosis requires a urinalysis before and after a prostatic massage this your analysis would reveal urine leukocytosis or bacterial if there's a negative urine culture it is chronic prostatitis or chronic pelvic pain syndrome what is the likely diagnosis in an immunocompromised patient with fever

30:34 chloritic chest pain cough with hemoptysis and CT showing habitary nodules with surrounding ground glass opacities on CT invasive aspergillosis what is the treatment of choice of invasive aspergillosis IV boriconazole what is the recommended treatment for patients with cryptococcal meningo and cephalitis

31:25 amphoterosene B plus lucytosine so you typically give them these two medications for more than two weeks and until asymptomatic and you get a negative CSF after you reach these parameters you want to follow up by giving fluconazole for more than a year which organism can cause perfused water diarrhea due to germination of spores cluster deities so recall that this organism is a four forming gram-negative and aerobic

32:12 bacteria that releases exotoxins A and B it's also transmitted via the fecal oral root what is the treatment of choice of crew so if it's mild you want to give a coolness and steroids if it's moderates meaning that there is Strider at rest then give steroids and nebulize racemic epinephrine what pathogens most commonly cause croup and epiglottitis

33:03 Croup is most commonly caused by power influenza virus while epiglottitis is most commonly caused by age influenzae of course this is rapidly changing because of the hip vaccine there are other organisms that can cause this condition if you know them then leave them in the comment section below what is the treatment of choice of pyelonephritis in pregnant patients well you can use drugs such as cephalexin and phosphomycin but what's very very important is that you do not use fluoroquinolones to treat pollinate

33:51 priorities in pregnant patients recall that pork when the loans have teratogenic effects and can cause damage or deformation of cartilage what is the treatment of choice of uncomplicated outpatient pyelonephritis and uncomplicated inpatient Tylenol prices for uncomplicated outpatient polonephritis you can give oral fluoroquinolone such as Ciprofloxacin however for uncomplicated inpatient pyelonephritis you want to give safe track soon

34:40 when is breastfeeding contraindicated active tuberculosis maternal HIV infection herpetic breast lesions active varicella infection chemotherapy or radiation therapy active alcohol use galactosemia so as you can tell with this list most of these are maternal contraindications like things are things that are going on with the mom that would cause him not to be able to breastfeed or recommend it not to breastfeed at this time however

35:25 the only one that is an infant or neonate communication is galactosemia so that's very high yield to note what is the recommended treatment for confirmed gonorrhea infection single dose azithromycin and I am Ceftriaxone what condition can a positive tourniquet test indicate Dengue fever so this is associated with

36:10 a positive tornocate test which results in petite after blood pressure cuff inflation what is the best prognostic marker for primary CNS lymphoma degree of immunosuppression or CD4 counts what is the next step in management for a patient found to have positive HCB antibodies

36:56 hcv RNA testing so hepatitis C antibodies are positive in the acute and chronic faces of the infection previous hep C infection or simply false positive so we need to confirm the PCR testing of RNA so basically to diagnose hep C you need both positive serology and a positive hcv RNA levels what prophylactic medication should be initiated in a patient who is beginning high dose immunosuppression therapy following a renal transplant

37:50 trimethoprim for PCP and gun cyclovir or valgan cyclovir for CMB how would you treat these conditions uncomplicated outpatient treatment of community acquired pneumonia and uncomplicated inpatient treatment of community acquired pneumonia like which antibiotics would you give these patients well for uncomplicated outpatient treatment of community acquired pneumonia you give amoxicillin or doxycycline for uncomplicated inpatient

38:35 treatment of cap you can give a septraxone and a macrolyte such as azithromycin or fluoroquinolone monotherapy so if you're preparing for a use only step three exams Concepts like these are extremely high yield because examiners expect you to somehow confuse the different medications used based on if the pneumonia is complicated or uncomplicated or if it's treated inpatient or all patients so very important to take a note of this what is the treatments of choice of strep throats

39:23 a 10-day course of penicillin amoxicillin which prevents acute rheumatic fever so treating group a strep pharyngitis does prevent traumatic fever however it does not prevent pole strep glomerulonephritis it basically prevents the worst one which is rheumatic fever a Canelo is a gram-negative anaerobe commonly found in what situation or when would patients be infected with this organism

40:09 human bites so human bodies in general are polymicrobial in nature you can be infected with organisms such as Viridian step Oreos and bursts anaerobes when you're bitten by a human however if you see that the patient is infected with an organism such as pastorella then you want to consider a cat or dog bite so this isn't a question but a high yield learning point that I want you to commit to memory and that's the fact that Rhino sinusitis is more commonly caused by viral organisms so it does not require treatment with antibiotics

40:54 however you should consider antibiotic treatments if any one or more of these are seen and that includes symptoms lasting greater than 10 days without Improvement symptoms are severe for example fever greater than 102 purlin mucus or Facial Pain for more than three days also if the viral oppository tract symptoms worsen after initial improvements so if you see any one of these things the likely diagnosis is acute bacterial Rhino sinusitis which is treated with oral antibiotics such as amoxicillin

41:40 it's also how you to know that patients with Rhino sinusitis do not require additional Imaging unless there's signs of extension into the central nervous system or orbits what is the treatment of choice of acute bacterial Rhino sinusitis oral antibiotics so if you're just bringing attention to my mini lecture on Brandy sinusitis then you most definitely already knew the answer to this but let's move on what is the treatment of choice of a breastfeeding patient with trichomonas

42:25 vaginalis a single dose of oral metronidazole two milligrams and then you want to discard the breast milk for 24 hours after you give the patient this medication so metronidazole can enter breast milk causing loose stools and candidiasis in exposed infants also it's ideal that just like for any other trichomonas vaginalis infection whether pregnant or not you always want to treat the partner what is the next best step in a patient with ongoing this cereal despite giving

43:12 azithromycin for non-gonococcal urethritis repeat urethral fluid Gram stain so there are other organisms that can cause non-gonococcal urethritis that are not responsive to azithromycin what is the most likely diagnosis in an immigrant from Africa Who develops cystitis with symptoms of dusterial and urinary frequency and terminal hematerial and peripheral eosinophilia

43:59 schistosomiasis so this condition has the greatest prevalence in Africa and is diagnosed with urine sediment microscopy which identifies the eggs once you confirmed diagnosis you want to treat with prequantil how can you confirm the correct placements of a endotracheal tube first you can check for the endotrophical tube depth second you can look for chest excursions if they're equal bilaterally you can also

44:45 auscultate the chest listening for bilateral equal birthstones or you can even do a chest x-ray so typically patients will present with right main stem bronchial intubation on exam day um signs of this include respiratory distress due to hypoventilation diminished or absent breath zones on the left side another common exam question is asking you what is the best way to differentiate between the two being placed in the esophagus or into the tracheal and the answer that examiners prefer is Captain graphy no this is a concept that students

45:33 commonly mix up which is the treatment of a tension pneumothorax versus a simple pneumothorax so let's take a minute and think about how would you treat these conditions so for attention pneumothorax you use needle decompression but for a simple pneumothorax you would do a chest tube insertion so in what condition would you see acute per operative hypercapnic and hypoxic respiratory failure so this can occur due to obstructive

46:19 sleep apnea so patients with obstructive sleep apnea are at increased risk of this condition um specifically for procedures involving sedation neuromuscular blockers opioids or anesthesia so mystery failure occurs in these patients it usually presents or results from hypoventilation and it is also associated with a respiratory acidosis which organ is a most commonly causes laryngotracheaitis the para influenza virus so how patients would typically present is with

47:05 inspiratory Strider a parking cough and hoarseness so to treat these patients you have to know whether or not Strider is present so if it is mild with no Strider at rest then the treatment is humidified air and maybe some steroids however if their symptoms are moderate or severe with Strider at rest then you will give steroids and nebulized epinephrine it's very important that you remember this key fact when treating patients with this condition always look to see whether or not they have shredded at rest to determine the best treatment option for that patient and to prevent this condition

47:50 contaminate surfaces you can use proper ventilation and hand washing as well to diagnose it it is typically a clinical diagnosis however if diagnosis is unclear you can do a PA neck x-ray that can show the staple sign due to subclotic narrowing that's very high yield because if examiners want to be not so kind and test you on you know superlottic or subclassic just know that in this condition it is subclottic narrowing which organism causes bronchiolitis

48:35 RSV so symptoms typically occur in the winter in patients that are around two years old they present with nasal congestion rhinorrhea coarse breast cells or wheezing and crackles so these patients with registered distress apnea hypoxia or even dehydration should be hospitalized ends on contact and droplet precautions to prevent the spread of this condition to treat it is usually supportive with IV fluids nasal bulb suctioning and humidified oxygen again this is another condition that is typically diagnosed clinically but if a patient is

49:22 experiencing a breakthrough RSV infection in infants who received the monoclonal antibody medication televisumab then they need to receive um n a a t testing that whole nucleic acid application testing and in these patients the RSV infection provides acute immunity and protection and at that point the politician map can be discontinued so some complications that can be seen in patients with bronchiolitis specifically if the patient is less than two months old are apnea and nurse nerve failure they can

50:08 also experience or current wheezing however if they are older or a full-term healthy infant then you don't typically see any complications in those patients so as I mentioned before to prevent this condition you can give a demonicola antibody television lab for infants that are less than 29 weeks gestation who have a chronic lung disease or prematurity or who have a hemodynamically significant congenital heart disease what is the most likely cause of recurrent pneumonia in an elderly smoker

50:54 bronchogenic carcinoma so a carcinoid tumor is a cause of endobronchial obstruction in a younger non-smoking patients however if it is an older patient like in this case a new suspect a bronchogenic carcinoma other causes to consider for non-resolving pneumonia are bronchial alveolar cell carcinoma a lymphoma eosinophilic pneumonia and Boop or bronchiolitis obliterins organizing pneumonia even drugs such as amiodarone can also cause non-resolving pneumonia and that of course is very high yield just make sure that you know everything about

51:40 amiodarone the mechanism of action all of the different complications when it is used everything like that it is an extremely high you drug so what is the best confirmatory test in this patient and remember we're referring to the Italy smoker with the recurring pneumonia so the best confirmary test is a flexible bronchoscopy so please note that this question is asking the best confirmatory test right it was the best Next Step then you could say a CT but because it's the best confirmatory test it is definitely the flexible bronchoscopy

52:25 what is the diagnostic test of choice in a patient with renal failure and a modified wall score greater than or a ventilation perfusion scan so if the patient did not have renal failure then you could go ahead and do a CT angiogram of the chest but it's very important that you look for like the bond the creatinine those in any evidence of renal theater in a patient that presents with symptoms or signs of a pulmonary embolism because that's one way that and you know the examiners like to tackle this is knowing which test is best for a patient with renal failure and without renal failure

53:12 so of course you have to know the modified wall score remember that if they have a score greater than 4 then a p e is very likely while a score of less than four is unlikely for a PE so a patient would be assigned three points if they have clinical signs of a DVT and if an alternate diagnosis is less likely there'd be assigned a score of 1.5 if they had a previous p e or DBT a heart rate greater than 100 and a recent surgery or immobilization and they'd be assigned one point if they have hemoptysis or cancer

53:58 so this is a bit of a yes or no question do asymptomatic asthma patients have abnormal pfts no they don't they have normal pfts which type of lung cancer is associated with s i a d h small cell carcinoma so in these patients they present with a normal bulimic hyponatremium where the sodium is less than 120 so remember that ADH usually concentrates urine or causes water retention so in si ADH there will be water retention of course and loss of

54:47 sodium and potassium and the treatment for patients with this condition is water restriction another high yield back to note is that they are there are some drugs that actually blunt the response of the collecting tubal cells to ADH one such drug is lithium so lithium can blood the response of ADH and of course another high yield and a step one throwback is that ADH axon B collecting tubule so since 80 is usually concentrates urine if lithium is being taken by the patient it blunts the action of this ADH so it can concentrate urine so what happens is that they have dilute urine

55:34 so if you see an increased respiratory drive in patients with chronic opioid therapy or who are receiving chronic opioid therapy what can you suspect and you can suspect an acute underlying non-opioid related disease process because remember that opioid therapy causes a rosary depression not to increase respiratory drive so how the equation presents if they had a ventilator Associated pneumonia well they would have fever increased secretions worse in pulmonary infiltrates and an increase in

56:21 requirements for ventilator supports occurring more than 48 hours after mechanical ventilation so ventilation pneumonia is a common complication of Arts or ards it is most commonly caused by a micro aspiration of Berlin or pharyngeal organisms and as a result other signs that these patients can present with include leukocytosis tachypnea and decreased oxygenation so to diagnose these patients you can do a tricky bronchial aspirate for culture or respiratory sampling and doing these diagnostic tests helps you to really tailor the antibiotic

57:06 therapy that is needed for patients experiencing this condition what is the most helpful in diagnosing because of her current pneumonia in a patient with Parkinson's disease a video for a scopic swallowing study so to treat this type of pneumonia you would have to give the patient brought Spectrum antibiotics with anaerobic coverage for example clindamycin and other specific interventions that you could use would be thickened liquids and modified swelling techniques what are some common causes of post-operative hypoxemia

57:54 so if it's immediately after surgery you want to suspect Airway obstruction or edema that can present with Strider due to endotrachial intubation or pharyngeal muscle laxity another cause is a residual anesthetic effect and these patients present with a decrease or steroids tidal volume um also have a normal AA ingredients and the hypoxemia corrects with supplemental oxygen author causes of post-up hypoxemia include bronchospasm that presents with wheezing you also have pneumonia which is typically one to five days post up and then atelectasis which is two to

58:40 five days post-op and it's most common in patients who undergo thoraca abdominal surgeries and they have a retained secretions another cause of hypoxemia is pulmonary embolism at what diameter would a solitary pulmonary nodule actually be considered to be a mass and that is if it's more than three centimeters so a solitary pulmonary nodule more than two centimeters independently correlates with a greater than 50 chance of malignant probability what is the

59:29 is the chest x-ray that reviews a solitary pulmonary nodule and that is to compare the previous x-rays or CT scans and this is high yields everyone prepared for a step 2 CK or the step three exam would have known the answer to this question at this point so if the solitary pulmonary nodule has changed in size or appearance from the previous Imaging or if no previous image is available then the next step would be to do a CT of the chest okay now just a quick pop quiz benign or malignant or solitary pulmonary natives so if it's speculated an audio benign or

1:00:17 malign means benign heterogeneous pulmonary audio benign or malignants benign grounds glass module malignants so this is a high yields factor or slide for you to know this take some time right now and really Commit This to Memory and if you've reached this far in the video and you have not liked the videos yet please take a moment to pop that like button hit subscribe and that notification Bell so that you will never miss another how you video like this now we're going to look at some factors that increase the malignant probability

1:01:02 of solitary pulmonary nodules and this is a large size female sex Advanced patient age family or personal history of lung cancer a upper lobe location of the nodule and active or pre views smoking it's very hard you to know that nodules more than 0.8 centimeters require additional management or surveillance while not using less than 0.6 centimeters are unlikely to be malignant so if a patient presents with a pulmonary nodule that is 0.9 centimeters and they ask what is the best Next Step you want to look at an option that has

1:01:50 additional management or surveillance for that patient so let's take a closer look at inhalation injury treatment so all patients with inhalation injury should receive supplemental oxygen if the patient is stable with concerning features but no strong indicators for inhalation injury then you can do a bedside fiber optic laryngoscopy however if this patient is unstable with strong indications for inhalation injury then you'd want to do an endotracheal intubation it's very important to note that strong indicators for Airway injury would include or pharyngeal blistering or hypoxia or other such features another

1:02:36 how you have to note is that when you do a fiber optic laryngoscopy this provides visualization of this supraglottic structures and if our pharyngeal erythema blister narcissus present then aerate stabilation with intubation should be strongly considered what is the preferred agent to use for awake intubation ketamine so ketamine provides Association Amnesia and analgesia it causes a sympathetic surge by inhibiting the reuptake of catecholamines and that increases the blood pressure and causes bronchial smooth muscle relaxation which

1:03:25 are additional benefits in this patient who would require awake intubation so if a patient specifically has that bronchospasms and they need to be intubated using ketamine would be greatly beneficial for that patient since it does cause burnfield smooth muscle relaxation so a more in-depth question is why is awake intubation preferred over rapid sequence intubation in patients with difficult Airways this is a base of a discussion question so just take a moment and really think about that but basically during rapid sequence intubation the patient is fully paralyzed causing loss of all upper Airway tone all protective area reflexes

1:04:13 and respiratory drive so if intubation is unsuccessful which can happen in patients with difficult Airways the patient can rapidly become hypoxic and experience Cardiac Arrest if you choose to do rapid sequence intubation so this is why and awake intubation is preferred because the patient can independently maintain their upper Airway tone and spontaneous ventilation as well next question in an emergency situation which is better a tracheostomy or cricothyroid oxy and if you said cricothyroidotomy then

1:04:58 you are correct so this procedure should be done in hypoxic unstable patients who cannot be oxygenated or ventilated due to an upper Airway obstruction what are some risk factors for extubation failure so we have week cough for instruction in poor mental status older than 65 years old comorbic conditions pneumonia as an initial cause of respiratory failure is another risk factor too and if they have a positive fluid balance 24 hours prior to excavation

1:05:45 another high yield fact on this page so if you want to pause it and just commit this memory then go right ahead if not let's move on to even more high-end Concepts so what are some symptoms or signs of impending respiratory failure and that includes a pH less than 7.35 and a paco2 greater than 45 hypoxemia air respiratory rate great greater than 25 per minute for two hours and clinical signs of respiratory failure what is the next best step in a patient with post-extubation Strider this is reintubbation and mechanical

1:06:32 ventilation so laryngeal edema presents with post-extubation Strider and resistor failure risk factors collateral edema we kind of brushed on that before but that includes female gender and prolonged duration of intubation so administration of a multiple dose regimen of steroids prior to extubation can prevent laryngeal edema and excavation failure what are the predictors of 30-day mortality in pulmonary embolism hypotension tachycardia tachypnea hypothermia

1:07:19 hypoxemia altered mental status and history of cancer as well as a patient older than eight years old so all of those producers I just mentioned are clinical predictors there are also radiological predictors such as a right ventricle dysfunction and you have black predictors such as troponin and BNP so a high you back to commit to memory is that if a patient presents with fever a low P2 and necessary alkalosis due to tachypneal then this patient could very well have acute PE so this is a high use

1:08:04 fat because examiners like to throw fever in there to make you second guess yourself and I think oh maybe it's um pneumonia or some infection infectious cause but fever does present in quite a number of patients with pulmonary embolism so remember that fact when is an inferior vena cava filter indicated in a patient with a pulmonary embolism the anticoagulation is contraindicated or ineffective low cardiopulmonary Reserve burn through pulmonary embolism on anticoagulation so filters may also be placed prophylactically in patients who are

1:08:50 unlikely to tolerate another PE now we're going to look at the management of PES so our patients with PE should receive anticoagulation unless they have contraindications they should also receive symbolizes if they have a PE with hypotension and a low bleeding risk they should also receive embalectomy if they have shock or failed thrombolysis with persistent hypotension so now we're going to take a closer look at post-intensive care syndrome so some risk factors for this condition include Arts ICU delirium how long is a

1:09:36 mechanical ventilation symptoms of a major depressive disorder PTSD decreased mobility and Independence decrease attention and to memory to manage patients with these conditions you prevent with early therapy participation and you treat the psychiatric symptoms as well and now we're going to look closer at pulmonary contusions so these patients typically present with chest pain shortness of breath hemoptysis and Rosary symptoms may be delayed for 24 hours from the time of injury and to diagnose patients with a

1:10:21 pulmonary contusion you will have a chest x-ray showing irregular localized or pacifications at the size of injury it's important to know that CT scan is more diagnostically sensitive and to treat these patients you want to provide them with adequate pain control to avoid hypoventilation and also provide supportive care such as pulmonary hygiene such as chest Physio and suctioning as well as supplemental oxygen and ventilatory support So symptoms typically resolve within three to five days it is extremely high yield that you do not confuse pulmonary contusions with art so art describes a non-cardiogenic

1:11:08 pulmonary edema that typically results from a systemic disease process such as pancreatitis sepsis or lung injury while of course a pulmonary contusion is seen after trauma or injury so what are the guidelines for lung cancer screening well it is recommended that you do a yearly low dose CT scan off the chest if the patient is between 50 to 80 years old and if they have greater than a 20 pack your smoking history and currently smoking or quit smoking less than 15 years ago so we're going to look at the pulmonary function test results and how you can

1:11:56 manage patients with asthma do you admit them or discharge them so if it is greater than 70 percent you would discharge home if it is between 40 to 69 percent you would admit to the word if it is less than 40 percent you would admit to ICU it's very important to know that signs of imperative circadia include confusion drowsiness depressed respiratory drive and severe hypoxemia what is the current diagnostic criteria for abpa an elevated

1:12:41 aspergillus-specific ige with elevated total ige a positive aspergillus specific IGG eosinophilia a positive skin test reactivity for aspergillus and to treat these patients you would give them systemic glucocorticoids and antibunal therapy with either foreign so when you think about post or pulmonary complications what conditions give rise to or what conditions are associated with the greatest risk factor for developing posts of pulmonary complications while these conditions include COPD

1:13:27 heart failure sleep apnea and sacred smoking so posted pulmonary complications are common after thoracic and upper abdominal surgery due to reduced lung volumes from diaphragmatic dysfunction and splinting so common pulse up pulmonary complications include atelectasis infection hypoxia and necessary failure and patients can do incentive spirometry and deep breathing exercises post up to increase lung volumes and diminish the chances of getting atelectasis how is the AAA gradient affected in atelectasis

1:14:15 so it is increased due to intrapulmonary shunting so athletes typically occurs two to five days posed up and symptoms include increased work of breathing or hypoxemia chest x-ray also reveals linear opacifications in the bilateral lung bases and to treat these patients if they have minimal restore secretions then CPAP however if they have cochlear structural secretions then aggressive pulmonary hygiene such as chest Physio and suctioning is highly highly recommended so what are some diagnostic features of tuberculosis pleural effusions

1:15:00 well first they are lymphocytic and oxidative plural effusions patients will have elevated adenosine diaminase levels and probiopsy with histopathologic demonstration can show plural granulomas so if a patient is being treated with steroids for a condition what are some indications for Google quartz Accord cessation first is that therapeutic benefits has been achieved second is that they may be experiencing uncontrolled side effects such as hypertension and third severe complications such as steroid induced psychosis another high in Factor nodes is that HB access

1:15:47 suppression is more likely in prolonged serious that is to reduce more than three weeks or with higher doses or with even administration of steroids so answers are being prescribed for more than three weeks of daily use then at that point you definitely want to recommend that these patients receive tapering of their steroids and not just suddenly stoppings so what is the stop band survey for Osa this is snoring tiredness well excessive daytime tiredness observed apneas or choking spells blood pressure elevated BMI greater than

1:16:35 35 H greater than 50 next size in men greater than 17 inches women greater than 16 inches and gender male so that is the stock Bank survey for objective sleep apnea what is the drug of choice in a patient with the Pea one milligram of epinephrine every three to five minutes so remember that or try not to confuse the fact that you have epinephrine that is given in pea however if a patient is bradycardic but they do have a pulse that's when you can give IV atropine because IV

1:17:21 attribune is indicated in symptomatic bradycardia with like hypertension and heart failure or they have to have a pulse so sinus bradycardium in the absence of a pulse represents PA and not a symptomatic bradycardia so that's an important distinction to be aware of when reading to these very long clinical vignettes on exam day another high you drop to note is sodium bicarbonate which is useful for cardiac arrest due to hyperkalemia metabolic acidosis or TCA overdose what is the most likely diagnosis of non-resolution of pneumonium in a patient with an extensive smoking

1:18:07 history and obstructing endoprachal malignancy so the next best step in management in a patient that presents like this is a chest CT scan which can help diagnose conditions like a malignancy as well as other causes of non-resolving pneumonia such as an abscess or empyema what is the treatment of choice of acute bronchitis symptomatic treatment so typically antibiotics are not recommended in these patients and you can diagnose a patient with acute bronchitis if they have a cough lasting greater than five days or even up to five well not five three

1:18:53 weeks and it occurs due to a preceding viral respiratory infection what are signs of COPD exacerbation increase this meal increase butane volume increase speed and prevalence what is the diagnostic test of choice in an unstable patient with a suspected massive PE an emergency bedside Echo so a CT angiogram is unsafe in hemodynamically unstable patients so whenever looking at the next best test always check to see whether or not the

1:19:39 patient is stable or not because that would definitely let you know which answer would be the best answer choice for that patient what Echo findings are likely to be seen on Echo in a patient with a massive acute PE a small under filled left ventricle also it's important to note that an acute rise in right ventricular afterload causes right ventricular dilation too so what is decoupling or decoupling in organ donation what is that concept refer to well that is a fact that Physicians

1:20:26 typically only discuss like if a patient has a brain death however organ donation is then discussed by the organ procurement organization so the physician does not discuss brain death so the treating position would not talk to the patient's family Apple the patient being brain death and then immediately mentioning organ donation this is done differently so Physicians discussed that hey their loved one is um brain dead and then you have organ donation discussions being done by the organ procurement organization so it's important to know that duties of the treated physician is to discuss impending death with a family provide

1:21:13 care until death and also to defer any donor discussions to the um the opio and the duties of the opio is to assess donor eligibility discuss donation with the family and provide support and counseling as well so now we're going to take a closer look at cop variance as well so patients with this condition have a chronic non-productive cough that is worse at night and wheezing and wrong car typically absence and this condition is triggered by exercise fourth expiration and allergen exposure upper Airway cough syndrome while patients with this condition have

1:21:59 rhinorrhea and or parental Cobblestone name what is the most reliable test for confirming tracheal rather than esophageal and a trickle tube placement well if you're this far in the lecture here then you definitely know the answer to this because I said it first for the first question the answer is capnography so a normal waveform with all four faces on catnogram indicates correct ET placement while a flat waveform indicates improper esophageal placements you can also do a um okay litmus paper test so if a carbon

1:22:48 dioxide is present the litmus paper changes from purple to yellow and this lets you know that the tube is in the tracheal where if there is no color chain then that means it is in the esophagus what is pulmonary cachexis syndrome or how these patients present well they present with a loss of lean muscle mass associated with chronic lung disease they have a BMI less than 20 or experience weight loss greater than five percent of their body weight what is the most important factor in determining the prognosis of patients with COPD

1:23:33 feb1 what is the test of choice for the evaluation of tension pneumothorax in the acute setting the bedside ultrasound which interventions are the most important ways to maximize viability of organs for donation maintain a new bulimia by administering IB fluids and desmopressin so that's when pressing reduces the diuretic impact of central diabetes insipidus it's also provides ionotropic or pressure support to maintain the blood pressure and you can also use warm air

1:24:19 blankets to help maintain the temperature as well what lab tests should be done before and after initiation of tpn so patience on t-pin are at high risk of developing hypoposphatemia which is a prominent manifestation of reheating syndrome a condition that develops due to fluid and electrolyte chips when chronically malnourished patients are re-initiated on adequate nutrition so patients with repeating syndrome are at risk of developing seizures abdomyolysis and the lifter in cardiovascular complications so it's very important that before and after you initiate tpn

1:25:04 that you will look or assess the serum phosphate levels what is the major cause of hypoxemia in patients with COPD so patients with hypoxemium who have COPD this is due to the EQ mismatch and this is actually worse than if the patient has COPD exacerbations and typically if you give supplemental oxygen in these patients the hypoxemia will improve primarily by increasing the oxygen Exchange in the lung regions that have a low VQ ratio so our popcorn calcifications or hamartomas benign or malignants

1:25:51 they are benign how do you manage newborns with ttn supportive care because they have self-presolution in one to three days so some risk factors for ttn include C-sections prematurity and maternal diabetes these patients typically present with tachypneum increased work of breathing and clear breath zones on chest x-ray you will see hyperinflation or a pattern diaphragm fluid in the fissures and prominent vascular markings or even mild cardiomegaly what are the best initial steps in

1:26:37 treating patients who have isolated habitual snoring smoking cessations if they are smokers as well as elimination of alcohol intake before bedtime basically any habits that they perform that could be causing snoring they need to stop it and that's a best initial step for stopping isolated habitual snoring and what is the most likely diagnosis in a two-year-old with painless hematochezia and a positive technetium nine to nine scan Metals diverticulum

1:27:26 where does technetium 99 concentrate in patients with Metals diverticulum the parietal cells of the diverticulum and stomach what is the treatment of choice of a pregnant patient who is incidentally found to have gallstones and is asymptomatic no treatment is needed because most pregnancy-related gallstones resolve spontaneously within two months of delivery

1:28:13 what is the treatment of choice of a pregnant patient with symptoms of recurrent biliary colic or acute cholecystitis cholecystectomy so it's very important that you take a closer look at how these patients present in the previous question we had a pregnant patient and their gallstones were incidentally found and they had absolutely no symptoms so no treatment was needed however in this question the patient has symptoms of her recurrent biliary colleague or acute closest so the treatments are the management of these patients change

1:28:59 based on their presentation very high you to know this foreign of an anal abscess incision and drainage antibiotics are also needed if the patient has diabetes immunosuppression extensive cellulitis or valvular heart disease patients with anal abscesses are at greatest risk of developing which condition

1:29:46 a fistula which organism can cause perfused water diarrhea due to germination of spores C difficile so recall that this organism is for forming gram-positive and an anaerobic bacteria each releases exotoxins A and B and it is transmitted through the fecal oral root injury to the vagus nerve during gastric surgery can result in which condition

1:30:37 gastroparesis what is the next best step in a patient that swallowed a fish bone and experiences of dinofascial a flexible endoscopy what is first line treatment for GERD in an infant with appropriate weight gain reassurance and lifestyle modification so this can include upright positioning

1:31:23 after feeds burping during fees frequent small volume beads it's important to note that gr has Peak symptoms at four months and self-resolves by age 12 to 18 months H2 receptor antagonists like famotidine are indicated in patients with GERD who have a poor weight gain irritable despite lifestyle modifications or a trial of a diet free of cow's milk so again it's important to look at the symptoms or the clinical findings of these patients so if there's an infant with appropriate weight gain I'm just in reassurance and lifestyle modification

1:32:09 but if the awaken is not appropriate then you may have to consider giving H2 receptor antagonists what is the diagnostic test of choice of pyloric stenosis abdominal ultrasound what is the most likely diagnosis in a patient that has very umbilical abdominal pain and diarrhea each time they eat ice cream but have no symptoms when they eat cheese

1:32:55 lactose intolerance so this is pretty straightforward but examiners like to mention different dairy products where their patient may have symptoms when they consume ice cream but none with cheese and it's just a way of trying to confuse you and to choose another answer but basically cheese and live Culture Yogurt have less lactose content and tend to cause few or no symptoms it's also important to recall that Celine disease can also present with gear distress however they also present with growth failure and weight loss

1:33:44 a hemodynamically stable Earthly patient presents with painless blood per rectum after IV fluids type and Cross Match what is the next step in management colonoscopy recall that diverticulosis patients present with painless hematochezia in an elderly patient however for diverticulitis they have left lower quadrant pain fever no blood per rectum and a colonoscopy is contraindicated due to a risk of

1:34:30 preparation is the bun to creatinine ratio greater than 20 to 1 in upper GI bleeds yes however in lower GI bleeds it is normal so that's an important fact to remember button to creatine ratio greater than 20 to 1 think upper giably if it's a normal ratio think lower GI bleed what is the underlying cause of indirect inguinal hernia

1:35:20 failed obliteration of processor's functionalis what are the two most common causes of blood streaks stools in a well-appearing infants less than six months old anal fissures or none ige mediated food protein induced allergic proxyl colitis it is also important to note that the elastic condition is most common in age one to four weeks what is the next best step in a

1:36:08 breastfed infants who has fpiap recall that fpiap is the condition that we just talks about food protein induced allergic Proctor colitis the next best step is to eliminate common triggers from the maternal diet for example Dairy and soy soy based formula is not recommended due to the potential cross reactivity between Cold's milk and soy protein what is the next first step in a formula

1:36:54 fed infant who has fpiap hypoallergenic hypoallergenic formula or hydrolyzed formula what is the prognosis for patients with fpiap tolerance of offending protein by age one so typically for these patients their symptoms resolve within two weeks of dietary elimination of the food allergen if ultrasound findings are absent or

1:37:42 inconclusive for acute cholecystitis what is the next best step hide a scan which condition causes isolated gastric viruses and left-sided partial hypertension and congestive spinomegali Hispanic vein thrombosis if a patient presents with clinical features of acute pancreatitis what is the best next step in establishing this diagnosis

1:38:30 serum blood tests only it's important to note that two of the three are required to diagnose acute pancreatitis the first being acute onset of persistent severe epigastric pain second elevation of serum lipase or amylase greater than three times the upper limits of normal of course lipase is more specific and third characteristic findings of pancreatitis on abnormal Imaging which can be contrast enhanced CT scan or MRI what is the next best step in management

1:39:17 in a patient that does drink alcohol with clinical features of acute pancreatitis elevated lipase and normal abdominal ultrasound lipid panel so if alcohol or gallstones isn't the cause of acute pancreatitis then you need to evaluate for a hypertriglyceridemia with a serum lipid panel what is the most likely diagnosis in a patient who is being treated for acute pancreatitis then they develop fever

1:40:04 leukocytosis hypotension and rights upper quadrant abdominal pain infected pancreatic necrosis so the diagnosis condition you need to do an abdominal CT scan with contrast and for treatment you can give meropenum or fluoroquinolone and metronidazole what is the standard composition of Angel feeding of calorie per kilogram per day and gram per kilogram per day any patient

1:40:52 with adequate Baseline nutrition 30 calories per kilogram per day and one gram per kilogram per day for protein or protein lower calorie Intel fees can also be considered for patients with severe malnutrition in order to prevent refeeding syndrome what is the best diagnostic test in a patient with rapid onset very umbilical pain benign exam findings and ionic Gap metabolic acidosis and a recent MI

1:41:47 abdominal CT and geography because we're thinking that this patient may have acute mesenteric-ish email which artery is most commonly occluded in Ami or acute mesenteric is female the superior mesenteric artery a which antihypertensives can cause pancreatitis thiocides such as Hydrochlorothiazide

1:42:33 and most Loop Diuretics such as Furosemide what is the underlying cause of eosinophilic esophagitis chronic th2 mediated inflammatory response triggered by food antigen exposure what is the treatment of choice of eosinophilic esophagitis Priceline treatment is Elimination Diet

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