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USMLE Step 2 CK > 2025 Daily read Step2 CK > Flashcards

2025 Daily read Step2 CK Flashcards

(590 cards)

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1
Q

SvO2 is ↓ in all types of shock, except which?

A

Septic (anaphylaxis)

  • Type of distributive shock
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2
Q

Can give HPV vaccine to patients as young as which age?

A

age 9

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3
Q

Cervical cancer screening with pap test begins at which age?

A

age 21

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4
Q

Pt post-gastrectomy with symptoms sounding like c.diff but also symptoms like palpitations, sweating, or tachy?

A

Dumping syndrome

  • has vasomotor sx (eg, palpitations, tachy), diarrhea.
    -Seen post-gastrectomy, prolonged abx.
  • Can seem like c.diff. -
    Tx: Dietary mods.
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5
Q

Dumping syndrome tx

A

Dietary mods

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6
Q

What is the treatment for specific phobia?

A

Exposure therapy

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7
Q

Which drugs improve mortality in heart failure with reduced ejection fraction?

A
  1. ACEi/ARB/ Neprolysin
  2. B-blockers
  3. mineralocorticoid-R antagonists (*eplerenone, spironolactone)
  4. SGLUT-2 inhibitors (-eg, empagliflozin)
  • Srini
  • Hydralazine has no mortality benefit
  • Loops everyone gets, just sx
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8
Q

Intervention most likely to improve cardiovasc and overall long-term mortality in acute STEMI?

A

Prompt restoration of coronary blood flow (eg, PCI, fibrinolysis)

  • Percutaneous coronary intervention (PCI) = angioplasty + stent
  • Early reperfusion also reduces likelihood of complications such as peri-infarction pericarditis
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9
Q

Rec pharmacological therapy to reduce overall cardiovascular mortality in peripheral arterial disease?

A

Anti-platelet agent (eg, aspirin) and statin

  • Rec to prevent stroke and MI due to strong assoc between PAD and atherosclerosis
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10
Q

Skin findings inPAD

A

Pale (no blood)
Hairless
Scaly, dry
Thin skin (no blood = no nutrients)

Ulcers = round and ‘punched-out’

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11
Q

In septic shock, all paramers are ↓ except for ___

A

CO

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12
Q

↓ breath sounds + dullness to percussion

A

Can be either pleural effusion, or hemothorax

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13
Q

Describe how late decelerations look in relation to a contraction

A

Late decelerations begin at the peak of a contraction.
The peak of the decel is at end of contraction.

(Note: late decels are d/t uteroplacental insuff and subseq fetal hypoxemia)

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14
Q
A

Late decelerations

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15
Q

Which type(s) of deceleration(s) may indicate fetal hypoxia and/or acidosis?

A

Late and recurrent variable decelerations

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16
Q

Which type of study is useful for calculating relative risk (RR)?

A
  • CohoRt = Relative Risk
  • Case contrOl = Odds ratio
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17
Q

What statistical test is compares 2 categorical values?

A

Chi-square

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18
Q

What statistical test compares 3 or more means (numerical) values?

A

ANOVA

Compared to:
- Checking differences bw means of 2 more groups = t-test
- Checking differences bw 2 categorical groups = Chi-square (χ2 ) test

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19
Q

Hypercalcemia + ↓ PTH =

A

Malignancy (paraneoplastic syndrome PTHrP in SCC lung)

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20
Q

Hypercalcemia + ↑ PTH =

A

Primary hyperparathyroidism

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21
Q

What is the FeNa+ in pre-renal azotemia?

A

FeNa+ < 1%

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22
Q

FeNa+ in intra-renal azotemia?

A

FeNa+ >2%

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23
Q

What is a normal FEV1/FVC ratio?

A

> 70%

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24
Q

FEV1/FVC ratio in obstructive disease?

A

FEV1/FVC = ↓↓ / ↓ ➞ ratio ↓

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25
If a patient is pulseless but we are getting a rhythm, what are the 3 potential diagnoses?
1. PEA (has a nl rhythm!) 2. Asystole (flatline) 3. V-tach (can be pulseless or have pulse)
26
Tx for: VT + pulse + HDUS
Synchronized cardioversion
27
Tx for: VT + no pulse
UNsynchronized cardioversion (defibrillator)
28
Tx for: VT + pulse + HDS
Amiodarone (or sotolol or lodocaine or procainamide)
29
Tx for: SVT + HDS
Adenosine (or B-block or CCB)
30
AVNRT is a type of ___
SVT
31
Low glucose level in CSF means ______
either bacterial or TB meningitis - viral has normal glucose level
32
CD4+ count in HIV pt that would put them at risk for toxoplasmosis
CD4+ <100
33
Tx for toxoplasmosis
Sulfadiazine + pyrimethamine
34
prophylaxis against toxoplasmosis: Which drug? When do you give it?
TMP-SMX Give if CD4+ count < 100
35
Tender erythematous streaks extending from wound + regional LAD =
Lymphangiitis
36
Tx for HSV?
Acyclovir or valacyclovir - not ganicyclovir (that's CMV)
37
clinical features of genital herpes?
Group of painful ulcers/vesicles Systemic sx (fever, malaise) *Regional LAD +/- *Dysuria + sterile pyuria (*can seem like UTI)
38
Tx for CMV?
Ganiciclovir - NOT acyclovir (that's HSV)
39
Which pulmonary condition do you confuse with cardiac tamponade?
Exac of COPD -can have JVD, muffled breath sounds, but no hypotens - Tamponade has triad JVD + muffled heart sounds + hypotensionn
40
subependymal nodules is characteristic feature of wicks peds syndrome?
Tuberous sclerosis
41
In which pediatric syndrome do you see hypopigmented macules?
Tuberous sclerosis (ash-leaf spots)
42
In which pediatric syndrome do you see big red blotch on the face?
Sturge-Weber syndrome (port wine stain)
43
Cardiac rhabdomyoma is a cardiac tumor assoc with which pediatric syndrome?
Tuberous Sclerosis
44
In which pediatric syndrome do you see inguinal and axillary freckling?
NF type 1
45
In which pediatric syndrome do you see Cafe-au-lait macules?
Neurofibromatosis type 1
46
In which pediatric syndrome do you see optic gliomas?
Neurofibromatosis type 1
47
What annual screenings do NF-1 patients need?
Annual ophthalmological screening exam + MRI brain / orbits for any new onset vision changes
48
In which pediatric syndrome do you see schwannomas
Neurofibromatosis type 2
49
↑ tactile fremitus + dullness to percussion =
Consolidation
50
TX transient synovitis?
Supportive, NSAIDs
51
How long does a patient need to have symptoms to be diagnosed with panic disorder?
Symptoms for ≥1 momnth
52
Kids aged 3-8 after viral illness. Poss fever (but low-grade, can be 100.1). Typ hip/thigh pain + limp +/- hip eff. Diagnosis?
Transient synovitis
53
Child w hip pain and limp several days after a viral URI with normal exam, labs, and X-ray. Dx?
Transient synovitis (AKA toxic synovitis) - Ultrasound reveals small unilateral or bilateral effusions (even when sx are confined to one hip)
54
NBS management in pt with overlapping features bw transient synovitis and septic arthritis?
Bilateral ultrasound ± arthrocentesis
55
Most lung conditions have ↓/absent breath sounds, except which one?
Consolidation (has ↑ breath sounds)
56
?Serum hypotonic is if _____ mOsm ; hypertonic is ______
< 275 mOsm. ; >295 mOsm
57
Tx empyema?
Chest tube (or video assist) AND abx
58
pleural fluid (physical characteristics of it) in a patient with empyema?
Thick, purulent, foul-smelling
59
lights criteria for exudative pleural effusions?
pl protein : ser protein > 0.5 pl LDH: ser LDH > 0.6 pl LDH > 133 (2/3 ULN) Only has to meet 1 of the above criterias
60
What comes first in the ratio we calculate in lights criteria for pleural effusionn
always pleural fluid / serum
61
What is the ULN that LDH must be greater than in exudative pleural effusion
> 133
62
Which type of parapneumonic effusion is characterized by the following values: pH < 7.2 Glucose < 60 mg/dl WBC > 50,000/mm3 Gram stain/culture: negative
Complicated parapneumonic - Bacteria eat the sugar (low glucose) and generate lactate (low pH) - Ddx. with empyema which has a (+) pleural gram stain / culture
63
Which type of parapneumonic effusion characterized by the following values: pH < 7.2 Glucose < 60 mg/dl WBC > 50,000/mm3 Gram stain/culture: positive
Empyema - Ddx. with complicated parapneumonic effusion which has a (-) pleural gram stain / culture
64
Which type of parapneumonic effusion is characterized by the following values: pH ≥ 7.2 Glucose ≥ 60 mg/dl WBC ≤ 50,000/mm3 Gram stain/culture: negative
Uncomplicated parapneumonic
65
Which type of parapneumonic effusion, uncomplicated or complicated, is characterized by pH < 7.2?
Complicated (bacterial generate lactate)
66
Complicated or uncomplicated parapneumonic pleural effusion has the following: - Leukocyte counts > 50,000 - pH < 7.2 - Glucose < 60
Complicated - Glucose is lower since the bacteria are eating the sugar - Empyema = if (+) gram stain showing bacteria / pus
67
potential paraneoplastic syndromes in lung squamous cell carcinoma?
Hypercalcemia (↑ PTHrP, stones bones groans) Hypertroph pulmonary osteoarthropathy (diffuse jt pains)
68
Potential paraneoplastic syndromes in SCLC?
SIADH (hyponatremia) Cushings (↑ ACTH) LEMS
69
SIADH is a paraneoplastic syndrome in which type of lung cancer?
Small cell lung cancer
70
Hypercalcemia is a paraneoplastic syndrome in which type of lung cancer?
Squamous cell carcinoma of the lung Hypercalcemia (↑ PTHrP, stones bones groans),
71
Tx exacerbation of COPD?
IV abx + steroids (systemmic, not ICS) + inhaled bronchodilators
72
Statistical test to check differences bw the means (numerical) of TWO groups ? (eg, comparing the mean BP bw men and women)
t-test Compared to: - Checking differences bw means of ≥3 groups = ANOVA - Checking differences bw 2 categorical groups = Chi-square (χ2 ) test
73
What is ambulation?
the act/action of moving about or walking
74
Where is a, b, c, d in the biostats table
75
How do you distinguish bw syringomyelia and anterior cord syndrome
Syringomyelina = Cape-like distrib (upper extremities, neck), loss of pain/temp, preserved DCML. Poss weakness. Ant cord syndrome = also preserved DCML. Also urinary incont. Here it's everything below lesion affected, wouldn’t just be arms.
76
What happens to acetylcholine with a drug that inhibits acetylcholinesterase
↑ acetylcholine (***OPPOSITE of anti-cholinergic toxicity symptoms!!)
77
*↑ Preload = improves or worsens HOCM murmur?
Improves murmur - ↑ preload (venous return) improves LVOT obstruction ➞ softer HOCM murmur)
78
parameters in septic shock? CO: SVR: PCWP: CVP: SvO2:
everything ↓, except CO and svO2(↑)
79
Tx for shingles?
Antiviral agents (eg, acyclovir, famciclovir, valacyclovir) -Not steroids
80
Hypotonic hyponatremia + low urine osm (<100 mOsm/kg) is diagnostic for _____ ?
Primary polydipsia
81
What value is considered low for urine osm?
<300 mOsm
82
Describe the HOCM murmur. How is this differentiated from the AS murmur?
HOCM murmur = SEM, crescendo-decrescendo @ LSB. No carotid radiation (AS radiates carotids, heard in R-2nd ICS, also cresc-decresc)
83
Most likely etio of hypercalcemia if calcium level >14?
Malignancy
84
Is the SN hearing loss in congenital infections B/L or U/L or either?
Can be either
85
*Girl with yellow-green cervical discharge, friable cervix. Recently treated for UTI but refractory sx. Dx?
Chlamydia/ gonorrhea (acute cervicitis +/- urethritis [dysuria, sterile pyuria]) Note: If cervical motion tenderness present - means PID
86
Microcytic anemia ↓Hb + ↓ ferritin = ACD or iron deficiency anemia?
Iron deficiency anemia (ACD has ↑ ferritin)
87
Which blistering skin disorder presents as groups of itchy rash with vesicles (or papules) & some crusted over on extensor surfaces (forearms, elbows, knees)
Dermatitis herpetiformis (Celiac’s)
88
Is HSN pneumonitis an obstructive or restrictive or none?
Restrictive
89
3 potential causes of hyponatremia in a euvolemic patient?
1. SIADH 2. Primary polydipsia 3. Beer potomania (malnutrition)
90
triad seen in congential rubella?
1. Cataracts 2. PDA 3. SN hearing loss
91
↓ breath sounds L-lung base + dullness to percussion =
1. Pleural eff 2. Atelectasis (eg, mucus plugging) 3. Hemothorax
92
Common complication of mature cystic teratoma (dermoid cyst)
Ovarian torsion
93
Ultrasound findings: heterogeneous, solid components, thin echogenic bands/hyperechogenic nodules, partial calcifications Dx?
Mature cystic teratoma (dermoid cyst) - Thin echogenic bands (hair) / hyper-echogenic nodules, - Partial calcifications [teeth])
94
Tx acute (<48h sx) symptomatic hyponatremia. What does the Na+ level need to be to receive treatment?
hypertonic 3% saline if Na <130 ?or is it <120?
95
Tx chronic (≥48h) symptomatic hyponatremia What does the Na+ level need to be to receive treatment?
Hypertonic 3% saline reserved for those w severe hyponatremia (Na <120) with severe sx (seizures) - because chronic has lower risk brain issues.
96
Mgmt for newborn to hepB(+) mom?
Give HepB immune globulin + hepB vaccine (within 12h of birth) to the neonate
97
If suspect septic arthritis in a kid or overlapping symptoms with transient synovitis, what is the NBS?
B/L hip ultrasound
98
Hypopigmented elliptical macule on chest =
Ash-leaf spot in tuberous sclerosis
99
What are charcot bouchard aneurysms?
Tiny aneurysm bubbles on lenticulostriate A.s ➞ affect deep brain structure
100
What virus do a lot of transplant patients get?
CMV
101
Treatment for botulism?
Equine anti-toxin (even before diagnostic confirmation testing)
102
causes of conductive hearing loss?
Otosclerosis Cholesteatoma Chronic otitis media Foreign body
103
Which drug should be given to all SAH patients to prevent complication of cerebral vasospasm ?
CCB - Cerebral vasospasm = delayed cerebral ischemia/stroke (FNDs)
104
Management peritonsillar abscess?
needle aspiration
105
Trismus muffled voice deviated uvula unilateral swelling Dx?
Peritonsillar abscess - Treatment is needle aspiration
106
Presence of WBC casts on urinalysis means it's always either one of two things =
AIN or pyelonephritis!
107
ADHD/autism symptoms, long face w large ears. Dx?
Fragile X - Also macroorchidism if >8yo
108
Adolescent initially presents w a single salmon-colored plaque that develops into generalized rash w multiple, oval, scaly papules and plaques in characteristic "christmas-tree" pattern on the trunk
Pityriasis rosacea single salmon-colored plaque = herald patch ____ - Adolescent/young adult - Self-limited - Image on the right is a herald patch
109
*Derm condition w the dandruff association?
Seborrheic dermatitis
110
CHF sx + holosytolic murmur @ LSB =
Tricuspid regurg
111
Normal PT
11-15 seconds
112
Normal PTT
25 - 40 seconds
113
Polyarteritis nodosa
Renal insuff/↑Cr (100%) GI - abdo pain Mononeuritis multiplex (70%) Spares the lungs (-)ANCA
114
Transient synovitis treatment
Supportive, NSAIDs
115
tuning fork lateralizes to the left ear Then AC > BC in both ears. Dx?
Right SN hearing loss - Weber test localizes to the unaffected hear
116
Toxoplasomsis treatment
sulfadiazine + pyrimethamine (note: CD4+ < 100)
117
Toxoplasmosis prophylaxis
TMP-SMX when CD4<100
118
Hyperaldosteronism presents with the following findings: (write hyper- or hypo- ______tension ______natremia ______kalemia ______ (metab/resp) ______ (acidosis/alkalosis)
Hypertension Hypernatremia Hypokalemia Metabolic alkalosis
119
Resistant HTN, hypokalemia and abdominal bruit. Dx?
Renal artery stenosis - D/t hyperaldosteronism: low renal perfusion → activate RAAS → induc aldosterone secr → augments K+ excretion → hypokalemia
120
**Tx primary hyperaldosteronism (conn's)
Aldosterone antagonists (eg, spironolactone, eplerenone)
121
Urinary chloride in metabolic alkalosis: Vomiting + nasogastric aspiration causes metabolic alkalosis with ↑ or ↓ urinary Cl?
Decreased urinary Cl- (<10) (volume loss, saline responsive) - vs Mineralocorticoid excess state: will result in high urine Cl- [>20] + hypervolemia (that thus will not be saline responsive)
122
NBS in workup of metabolic alkalosis is
Check urine Cl- _______________ -Saline responsive (urine chloride low [<10] because low vol): think about volume loss, activation of RAAS, causing Na+ in and H+/K+ out; Cl- is lost through gastric secretions - Saline resistant: think about other random causes (urine chloride high [>20] because hypervolemia) (e.g., hyperaldosteronism, Cushing's, genetic stuff)
123
What acid-base disorder may be caused by thiazide diuretics?
Metabolic alkalosis (same with loops)
124
What acid-base disorder may be caused by loop diuretics?
Metabolic alkalosis (same with thiazides)
125
Acid-base disturbance from laxative abuse?
Metabolic alkalosis - In laxative abuse, osmotic losses of potassium → hypokalemia → cellular buffering → H+ moves into cell → alkalosis - vs. the metabolic acidosis typically found w diarrhea)
126
Pt taking HCTZ, levothyroxine, and OTC mineral supplements (for osteoporosis) that develops symptomatic hypercalcemia, metabolic alkalosis, and AKI. Dx?
Milk-alkali syndrome (Hypercalcemia causes renal vasoconstriction with ↓ GFR and also causes diuresis due to impaired ADH activity, with hypovolemia and contraction alkalosis)
127
Young female with hypokalemia, metabolic alkalosis, normotension, and low urine Cl- Dx?
Surreptitious vomiting - Lose HCl and KCl via stomach - Low urine Cl- helps distinguish vomiting from other causes of hypokalemia, alkalosis, and normotension (eg, diuretic abuse, Bartter syndr, Gitelman syndr which all have high urinary chloride)
128
Young patient with HTN that develops severe hypokalemia after beginning low-dose thiazide diuretic (eg, muscle weakness, leg cramps). Dx?
PRIMARY hyperaldosteronism - Volume depletion → ↑ aldosterone → more Na+ in, H+/K+ out
129
_______ is the probability that when the test is negative, the disease is absent
NPV (vs - Specificity is the probability that when the disease is absent, the test is negative)
130
______ is the probability that when the disease is absent, the test is negative
Specificity (vs- NPV is the probability that when the test is negative, the disease is absent)
131
Recommended primary prophylaxis against MAC for HIV patients with CD4 count < 50
No longer rec MAC ppl
132
HIV with CD4 < 50, high fever, and watery diarrhea. Dx?
MAC
133
Is primary prophylaxis against CMV rec for HIV?
No (it's coccidiomycosis not cryptococcus)
134
Pneumocystis jirovecii prophylaxis in HIV patients should be started at CD4 counts < ______ with TMP-SMX.
CD4 < 200
135
HIV patient w CD4+ count 25 that presents with 3 weeks fever, night sweats, abdo pain, diarrhea, and weight loss. CXR, CMV serology, and PPD are all negative. Dx?
Disseminated MAC - TB and CMV are less likely given the normal CXR, induration, and negative CMV IgG
136
Normal ABG ranges for: 1. pH 2. pCO2 3. pO2
1. pH = 7.35 - 7.45 2. pCO2 = 33 - 45 3. pO2 = 75 - 105
137
Lab in primary hyperparathyroidism? PTH: Ca2+: Phosphorus:
PTH: ↑ or inapprop normal Ca2+: ↑ Phosphorus: ↓or can be nl in mild or early dz
138
Normal serum phosphorus range
3.0 - 4.5
139
Labs in secondary hyperparathyroidism due to CKD ? PTH: Ca2+: Phosphorus:
PTH: ↑ Ca2+: ↓ Phosphorus: ↑
140
Hypercalcemia + elevated PTH + high urine Ca2+ Dx?
Primary hyperparathyroidism - High urine Ca2+ helps distinguish from familial hypocalciuric hypercalcemia
141
In primary hyperparathyroidism, is serum phosphate ↑ or ↓ ?
Decreased (hypophosphatemia) - Due to ↑ PTH secretion (the primary defect) - Can be normal in mild disease (↓ in moderate to severe)
142
Pt presents asymptomatically with mild hypercalcemia, hypocalciuria and normal/high PTH levels. Dx?
Familial hypocalciuric hypercalcemia (FHH) - Due to defective Ca2+-sensing receptor (CaSR) - Higher than normal Ca2+ needed to suppress PTH - Hypocalciuria = want to reabsorb more Ca2+ to suppress the PTH - Low urine Ca2+ helps distinguish from primary hyperparathyroidism
143
↑ HbA2 and ↑ HbF = alpha or beta thalassemia?
Beta (↑ HbA2 and ↑ HbF is result of having little/no HbA) -HbH and Hb Barts = alpha thalassemia
144
Ventilator settings: If ↓ PaCO2 and ↑ pH → should _____(↑/↓) the RR or TV?
decrease RR or TV
145
How do SVR and afterload change during cardiogenic and obstructive shock?
↑
146
How do the following pressures change with pulmonary embolism? RA pressure: Pulmonary A. pressure: LAP:
RA pressure: increased Pulmonary A. pressure: increased LAP: decreased or normal
147
How does cardiac index change in septic shock?
Increased -Important distinguishing feature from cardiogenic and hypovolemic shock;
148
How does cardiac output change during cardiogenic and obstructive shock?
severely ↓
149
How does cardiogenic shock affect the following? CVP: PCWP: Cardiac index: SVR: SvO2:
CVP: increased PCWP: increased Cardiac index: decreased SVR: increased SvO2: decreased
150
In cardiac tamponade, cardiac output decreases due to ________ (↓ / ↑ ) left ventricular _________
↓ CO due to: ↓ LV preload
151
Pt post-MI day 5 sudden-onset cardiogenic shock harsh holosystolic murmur at LSB with palpable thrill Dx?
Interventricular septal rupture - Compare w papillary muscle rupture, leading to MR (no thrill, soft murmur) - Left-to-right shunt may manifest as ↑ in O2sat from right atrium to the right ventricle; signs of left and right HF are present (eg, pulmonary edema, JVD)
152
Pt s/p lung biopsy presents with severe SOB and CP w ↓ cardiac output + ↑ PCWP. Dx?
Cardiogenic shock (2/2 MI) - ↑ PCWP is indicative of cardiac etio (helps rule out pulm etio's, such as pneumothorax and PE since less blood is flowing to the LA) - Backup of blood into the lungs causes pulmonary edema - Peri-operative MI is common in patients undergoing noncardiac surgery; intra-operative hemorrhage requiring blood transfusion ↑ the risk
153
Electrical alternans - is specific but poorly sensitive for pericardial effusion w cardiac tamponade - it results from heart changing position within the fluid-filled pericardial sac w each heartbeat.  - Tx: emerg pericardiocentesis (to relieve pericardial pressure).
154
Young boy presents w advanced bone age, coarse pubic hair, and severe cystic acne. Low basal LH levels normal testicular exam. Dx?
Late-onset (nonclassic) congenital adrenal hyperplasia -Due to 21-hydroxylase deficiency → shunting to adrenal androgen production → peripheral precocious puberty
155
Late decelerations
156
Early decelerations
157
_______ measures ability of a test to correctly identify those with the disease
Sensitivity - answers how often a test misses a dz - It measures ability of a test to correctly identify those w the dz. A test w high sensitivity has low likelihood of missing dz. - NBME Q: Pt concerned about the accuracy of a test and if could have missed the ca. Basically questioning the failure rate in detecting her breast ca. disting from: PPV: measures the probability that a person with positive test actually has the disease. Doesn't tell you how often thw disease is missed.
158
Treatment?
Amiodarone
159
- MC benign bone tumor
160
Mgmt for stone retained in CBD (ie, choledocholithiasis)
ERCP immediately
161
If signs of cholecystitis + pericholecystic fluid (edema in gallbladder wall) or wall thicken. NBS
Antibiotics first Then cholecystectomy within 72h (gives time for abx to kick in)
162
Ascending cholangitis tx
Antibiotics first Then ERCP (within 24-48h)
163
Why no/minimal breast development in Turner's?
Ovarian dysgenesis causes EST deficiency → no breast development (girl will be like 15yo w tanner 1 breasts). -gpt: no breast devel means the ovaries are not functioning
164
*What are the only times we do ERCP?
1. Choledocholithiasis (stone in CBD) 2. Ascending cholangitis: After antibiotics
165
Give magnesium sulfate for preterm labor if < _____ weeks gestation
<32 weeks gestation
166
Distinguish between: 1. Chronic hypertension 2. Gestational hypertension 3. Preeclampsia
≥20 weeks = gestational HTN or preeclampsia. (preeclampsia if proteinuria or end-organ signs <20 weeks = chronic HTN
167
Management for preterm labor if <32 weeks gestation?
- Tocolytics (nifedipine, terbutaline) ➞ delay delivery - Corticosteroids (betamethasone) ➞ fetal lung maturity - Magnesium sulfate ➞ neuroprotection, ↓ risk cerebral palsy - If unknown GBS status/ no prenatal care ➞ GBS prophylaxis
168
What is the recommended management for pregnant patient 35 weeks gestation presenting with preterm labor + fetus in vertex presentation on ultrasound?
Expectant management - Betamethasone ± penicillin may be administered
169
Low serum osm + low urine osm(<300 mOsm) + hyponatremia Dx?
Primary polydipsia (ie, psychogenic)
170
Low ser osm + ↓ urine osm(<300 mOsm) + nl or ↑ Na+ Diagnosis =
DI (ADH deficient/resistant)
171
What level is considered high urine osmolarity? What does that indicate?
>600 mOsm Indicates solute diuresis/ concentrated urine (if also ↑ glu, it’s d/t hyperglycemia) - don’t confuse this w SIADH, both can be w head injury, and have ↓ Na+
172
↑ HbA2 and ↑ HbF =
B-thalassemia - Will have little/no HbA
173
Post-MI complication that looks like another MI several months later
LV aneurysm
174
Labs in hypovolemia? ADH: Renin: Aldosterone:
ADH: ↑ Renin: ↑ Aldosterone: ↑ - ↑ ADH due to angiotensin II, hypovolemia and hypotension. [goal is to replete volume] - ↑ Renin/aldosterone due to decreased renal perfusion → RAAS
175
Hyponatremia, low plasma osmolality (< 280), low urine osmolality (< 250). Dx?
Primary polydipsia - Hypo-osmolarity (< 280 mM) → ↓↓ ADH → pee out H2O → dilute urine - everything is diluted
176
NNT formula
NNT = 1/ARR ARR = c/(c + d) - a/(a + b)
177
Distinguish bw bipolar I and II
Bipolar I = requires a MANIC episode +/- depressive episode Bipolar II = requires DEPRESSIVE episodes + hypomanic
178
Auto-ntibodies in systemic sclerosis
Anti-topoisomerase I (anti-Scl-70) (diffuse SSc) Anti-centromere (limited SSc)
179
Small L-sided pleural effusion, POD 2 + stable patient. NBS?
Observation -if effusion grows or pt becomes symptomatic or an infection is suspected ➞ then do thoracocentesis
180
When to give a jaundiced infant exchange transfusion?
If bilirubin levels>25 or signs of bili encephalopathy
181
Infants 2-8 weeks old with direct hyperbulirubinemia Dx?
Biliary atresia -Direct bilirubin because it's obstructive jaundice
182
Baby w persistent or worsening jaundice after 2 weeks of age. Dx?
Biliary atresia
183
1-month-old w 1 week of jaundice, pale stool, hepatomegaly and conjugated hyperbilirubinemia. Dx?
Biliary atresia - Should be suspected in newborns with conjugated hyperbilirubinemia and hepatomegaly - Normal bilirubin production & conjugation; impaired excretion
184
Infant with high conjugated bilirubin NBS?
RUQ ultrasound -looking for absence of the gallbladder and/or no dilatation of the biliary tree
185
Dubin-Johnson has unconjugated or conjugated hyperbilirubinemia?
Conjugated - Normal LFTs and CBC - Due to defect in hepatic secretion of conjugated bilirubin - episodic jaundice + direct hyperbili
186
*Serotonin syndrome initial treatment?
Benzodiazepines - disting from bromocriptine (DA agonist for NMS)
187
↑ Ca2+ ↑ PTH + ↓ phosphate Dx?
Primary hyperparathyroidism
188
Labs in vitamin D deficiency? Ca2+ phosphate PTH Mg2+.
↓ Ca2+, ↓ phos, ↑ PTH (secondary hyperparathyroidism) normal Mg2+ - PTH ↑ to try to normalize calcium, but w/o vitamin D, calcium absorption from gut remains low
189
↓ calcium + ↑ PTH hallmark of which parathyroid disorder?
secondary hyperparathyroidism (note: if normal Cr/kidney function it rules out CKD as the cause of 2ry hyper-PTH. NBS? ser 25-OHvitD [to see if vitD def])
190
↓ calcium + ↑ PTH + normal creatinine NBS?
This is secondary hyperparathyroidism Since a normal Cr/kidney function it rules out CKD as the cause, the NBS is to check serum 25-OHvitD levels (to see if vitamin D deficiency is the cause)
191
Pregnant lady with (+)HSV + active lesions during labor. NBS?
Cesarean delivery -prevents vertical transmission and neonatal infect - if no active lesions: can undergo vag deliv.
192
Pregnant lady with (+)HSV + no active lesions during delivery. Require c-section? or can undergo vaginal delivery?
Vaginal
193
Lady at 36 weeks gestation + prior hx genital herpes BEFORE pregnancy. NBS?
Give acyclovir (HSV PPX) - helps to prevent active lesions at delivery - Acyclovir is given at > 36 weeks in pregnant patients with a prior history of genital herpes (either before or during pregnancy, doesn't matter), REGARDLESS of whether or not there are currently active lesions - No active genital lesions at deliver→ vaginal delivery - Active genital lesions or prodromal symptoms (e.g., burning pain) at delivery → c-section
194
Lady at 36 weeks gestation + history of genital herpes during pregnancy but no current active lesions. NBS?
Acyclovir as HSV ppx - Acyclovir is given at > 36 weeks in pregnant patients with a prior history of genital herpes (either before or during pregnancy, doesn't matter), REGARDLESS of whether or not there are currently active lesions
195
Right sided murmurs increase or decrease with inspiration?
Increase - remember, this is anatomical right-sided, not auscultation sites
196
Polyuria defines a urine output of > ____ L/day
>3 L/day
197
Young girl w recurrent UTIs since birth B\L focal parenchymal scarring + blunted calyces on imaging Dx?
Vesicoureteral reflux
198
VUR or PUVs Which one only in boys?
PUVs
199
Classic s/s of methamphetamine?
1. Tactile hallucinations (bugs crawling in skin, excoriations that don't improve with derm tx) 2. Psychotic sx/delusions 3. Weight loss 4. Poor dentition.
200
Agitation, insomnia, paranoid delusions, and tactile hallucinations (bugs under skin). Exam: appears thin, poor dentition, multiple sores on face and body. Dx?
Methamphetamine abuse - Severe tooth decay and excoriations due to skin picking are common signs of chronic methamphetamine abuse (Disting from: bipolar, which doesn't have the physical findings)
201
Is the urine calcium level high or low in primary hyperparathyroidism? What condition do we use urine calcium to distinguish this from?
High urine Ca2+. - High urine Ca2+ helps disting from familial hypocalciuric hypercalcemia
202
Eval breast mass with ______ if age > 30 , or _______ if age < 30
Mammography (if >30), or U/S (if <30)
203
MCC of mitral stenosis
Rheumatic heart disease
204
Location in which A-fib starts?
starts in the left atrium (pulmonary vein!)::LA/RA}
205
Patient with BP of 95/64 and HR 74/min are they stable or unstable?
Stable -Would be HDUS if HR >100 - ALWAYS ALWAYS ALWAYS check HR if ambiguous BP (like 100/70, or 90/60) bc otherwise just athletic.
206
A PPD is considered positive in general population if induration measures ____ mm
≥ 15mm
207
In acute stress disorder, how long do symptoms last?
sx last from ≥3 days to ≤1 month.  -Note: Bizarre psychotic sx and disorganized behavior are not typical. If so - it’s prob acute psychotic disorder.
208
For the following conditions, when does the HTN need to start? Chronic HTN Pre-eclampsia w/o severe feats Gestational HTN
Pre-eclampsia w/o severe feats & gestational HTN get dx’d when new HTN @ ≥20 weeks gestat. Whereas dx would be chronic HTN if @ <20 weeks.
209
BP criteria for any pregnant HTN condition?
SBP ≥140 or DBP ≥90
210
26M suicide attempt by med overdose. Had 2 seizures, fever, hypotension/tachy, AMS, dilated pupils that respond poorly to light, flushed & dry skin, ↓ bowel sounds, prolonged QRS. Dx?
TCA toxicity
211
What prophylactic meds should be started if pt is beginning high-dose immunosuppression therapy  s/p renal transplant?
TMP-SMX (for PCP) & Ganciclovir (for CMV)
212
Adolescent tall & skinny boy with groin pain and limp =
SCFE NBS? B/L hip xrays
213
Age of onset for - common variable immunodeficiency (CVID) - SCID -Bruton
- CVID: later in life (15-35 yo) - After puberty - SCID: is since birth - Brutons is >6 mOL. Remember this is x-linked/only in boys!
214
Are the follow B or T or combo problems? - common variable immunodeficiency (CVID) - SCID -Bruton
- CVID: just like Brutons but low plasma cells, not absent (all Ig levels are low) - SCID: combo B&T, severe -Bruton: B- cell defect (don’t mature into plasma cells —> ?absent plasma cells — decrease or absent? levels all Igs)
215
60-year-old man with HTN presents with acute shortness of breath and nonproductive cough. Exam shows:     *    BP: 140/105 mmHg     *    HR: 100/min, RR: 26/min     *    JVD, bibasilar crackles     *    S3 and S4 gallops     *    Retinal arteriolar narrowing, no papilledema     *    No peripheral edema Dx?
CHF (likely diastolic dysfunction from hypertension) - If constrictive pericarditis - would have pleuritic CP, poss coarse friction rub. Also possible hypotens, tachy, pulsus paradoxus, kussmal sign (↑ JVD during inspir)
216
ICU patient with new-onset fever, purulent drainage around NG tube, normal CXR. NBS?
CT of the sinuses Nosocomial sinusitis is common cause of unexplained fever in intubated ICU patients (with NG or endotracheal tubes)
217
13-month-old with:     *    ≥4 episodes of pneumonia     *    Severe varicella at 8 months     *    Oral thrush     *    Failure to thrive     *    WBC = 1500/mm³     *    CD4+ count = 225 (low)     *    Poor lymphocyte proliferation What is the most likely diagnosis?
Severe Combined Immunodeficiency (SCID) -Combined B- & T-cell dysfunction - Recurrent bacterial, viral, and fungal infections - Thrush = classic clue for T-cell defect - CD4+ count <500 and poor lymphocyte proliferation = T-cell problem - Early onset, FTT, life-threatening infections USMLE loves: Low CD4 + mixed infections + FTT = SCID Brutons - would only have bacterial infects (because B cell problem, normal T-cells)
218
POD2 patient with new AMS, RR = 6. Found unresponsive. Given morphine and enoxaparin Pupils 3mm No focal neuro signs No spontaneous movements of the extremities. Most likely cause? Whats the best initial test?
Cause: opioid-induced respiratory depression (Hypoventil ➞ ↑ CO2 ➞ resp acidosis ➞ CNS depression) Best initial test: ABG (to confirm hypercapnia) - RR <8 is red flag for opioid toxicity. Normal pupils don't rule it out. No need for CT unless FND or trauma.
219
78F 2week hx right knee pain, worsens with activity (stairs), morning stiffness, no swelling or erythema, full ROM, crepitus. PMH: GERD on omeprazole. What is the most approp initial pharmacotherapy? A) Acetaminophen B) Prednisone C) Colchicine D) Ibuprofen E) Ciprofloxacinn
A) Acetaminophen Dx: OA - Acetaminophen is 1st line for OA in elderly ➞ safe GI profile (impt w PPI use = GI risk), avoid NSAIDS in elderly if risk GI bleed, AKI, CVD. Clues: Elderly, weight-bearing joint, pain with use, brief morning stiffness, no signs of inflammation, crepitus, full ROM, no effusion - Prednisone = RA/ inflammatory, not OA - Colchicine = Gout (acute, red, swollen) - Ibuprofen = effective but higher risk in elderly - Ciprofloxacin = Irrelevant (no infection)
220
What is type I error (alpha)?
False positive – concluding there’s an effect when there isn’t one. Rejecting a true null hypothesis.
221
What causes a Type I error?
Setting a significance level (α) too high (e.g., >0.05)
222
What is a Type II error (β)?
False negative – failing to detect an effect that is truly there. Failing to reject a false null hypothesis.
223
What causes a Type II error?
Low power – usually due to small sample size or small effect size. - Power = Probability of correctly rejecting the null when it’s false (detecting a true effect). Power = 1 - β.
224
What is statistical power?
Probability of correctly rejecting the null when it’s false (detecting a true effect). Power = 1 - β - ↑ power by ➞ ↑ sample size, ↑ effect size, reduce variability, or ↑ alpha (risking more Type I error).
225
How can power be increased?
↑ sample size, ↑ effect size, reduce variability, or ↑ alpha (risking more Type I error).
226
What is the main benefit of a meta-analysis?
Increases power by pooling data from multiple studies to detect a true effect. - In general, power gets increased by ➞ ↑ sample size, ↑ effect size, reduce variability, or ↑ alpha (risking more Type I error).
227
When is a meta-analysis most useful?
When individual studies are underpowered or show borderline p-values (e.g., 0.07) - indiv studies are underpowered (like P=0.07, too high) → When indiv trials are too small to reach statistical signif (common p-values just above 0.05), meta-analysis lets us combine them to find a real effect!
228
Does meta-analysis reduce confounding or selection bias?
No – those are addressed during individual study design.
229
What is healthy worker effect (selection bias subtype)?
Workers tend to be healthier than the general population → underestimates disease rates when comparing occupational exposures.
230
What type of study design is most vulnerable to selection bias?
Case-control studies, because participants are selected based on outcome status.
231
What is the most effective intervention to prevent readmission after a COPD exacerbation in a stable outpatient already on optimal medical therapy?
Pulmonary rehabilitation
232
Is long-term prednisone recommended after a COPD exacerbation?
No It increases risk of side effects (e.g., osteoporosis, DM) without long-term benefit
233
Is incentive spirometry useful in COPD management?
No – Its used postoperatively to prevent atelectasis, not helpful in chronic COPD
234
What is the most appropriate management for a euthymic bipolar patient on lithium at 16 weeks gestation?
Continue lithium—do not switch or stop if patient is stable and past the 1st trimester. - main risk of discontinuing mood stabilizers during pregnancy is relapse of bipolar disorder, espmania—this poses risks to both mother and fetus.
235
Which bipolar medications are contraindicated in pregnancy due to teratogenicity?
Valproic acid (neural tube defects), carbamazepine (NTDs, craniofacial defects) - Lithium is not totally c/i (absolute risk of ebsteins anomaly is very low, and also only during 1st tri)
236
Why is switching from lithium to valproic acid or carbamazepine in pregnancy a bad idea?
Both are more teratogenic than lithium—do not switch stable patients to these during pregnancy.
237
Infant + irritable + vomiting + no testes palpable on one side
Testicular torsion (complication of cryptorchidism) Disting from: Incarcerated inguinal hernia - would have firm tender mass in inguinal canal
238
What is the strongest RF for developing breast ca in a 58yo woman with no persona history and a paternal cousin who was recently diagnosed with breast ca?
Age of the patient! Age >50 is no.1 RF for breast ca
239
Pneumothorax
240
Smoker + Horner's + shoulder/arm pain + atrophy hand/arm muscles NBS?
NBS is CXR Pancoast (Superior sulcus) tumor - Typical USMLE tries to mislead you think Rheumatoid arthritis (even if patient has RA), rotator cuff injury, or cervical radiculopathy - Pancoast commonly affects ulnar N. too
241
What is the likely diagnosis in a patient with significant smoking history who presents with shoulder pain, weight loss, and this CXR?
Pancoast (Superior sulcus) tumor - CXR shows apical mass
242
Q: What is the first step in managing bradycardia in a hypothermic patient (core temp <35°C)?
Active rewarming — not atropine or pacing. USMLE loves this: Treat the hypothermia first — bradycardia often resolves with rewarming. Ex's of active rewarming methods"     *    Warmed IV fluids     *    Bair Hugger / forced-air blankets     *    Heated oxygen   
243
What is the MCC of primary adrenal insufficiency (Addison’s disease) in developed countries?
Autoimmune adrenalitis (often part of autoimmune polyglandular syndrome) - Pt may have other autoimmune conditions
244
Hyperpigmentation + hyponatremia + hyperkalemia + hypotension + fatigue =
Primary adrenal insufficiency (Addison’s disease) - Hyperkalemia is due to aldosterone deficiency, which impairs renal potassium excretion.
245
A patient with vitiligo, fatigue, postural hypotension, and oral pigmentation has low 8 AM cortisol, eosinophilia, tonsillar enlargement. NBS?
Suspect primary adrenal insufficiency (Addison's) → so check ACTH (will be high) - treat with hydrocortisone + fludrocortisone.
246
A study is underpowered if P-value is ______
> .05 (ie, if it's not statistically signif), suggests not enough power to detect a difference
247
What type of bias occurs when a study fails to adjust for variables related to both the exposure and the outcome?
Confounding bias - Occurs when extraneous variables (eg,, comorbidities) distort the observed association between exposure (eg, dialysis center) and outcome (eg, survival).
248
In outcome comparison studies, why is adjusting only for age and sex often insufficient?
Because comorbidities and other health factors may influence outcomes. Failing to adjust for these introduces confounding bias, invalidating conclusions about causality.
249
A study comparing 5-year survival rates between two dialysis centers finds a statistically significant difference (p = 0.0278), adjusted only for age and sex. What is the most likely flaw?
Failure to adjust for comorbidities (confounding bias). Survival differences may be due to baseline patient health, not dialysis center quality.
250
↓ GnRH + ↓ FSH + ↓ EST =
Hypogonadotropic hypogonadism (eg, anorexia nervosa, stress, pituitary tumor)
251
↑ GnRH + ↑ FSH + ↓ EST in a patient with negative B-hCG, normal prolactin, normal thyroid panel =
Premature ovarian insufficiency - Smoking is a RF - Suspect if ↑ FSH in woman <40 w irreg cycles - Always rule out pregnancy, thyroid, and PRL first - but if those are normal, test FSH
252
What is the most likely cause of hypokalemia and metabolic alkalosis in a patient with low urine chloride?
Vomiting or nasogastric suction. -Low urine chloride (<20 mEq/L) suggests volume depletion with secondary hyper-aldosteronism (saline-responsive metabolic alkalosis).
253
What lab finding helps differentiate vomiting from diuretic use as a cause of metabolic alkalosis?
Urine chloride: 1. Vomiting: Low (<20 mEq/L) due to volume depletion + Cl- loss in the vomit. 2. Diuretics: High (>20 mEq/L) because chloride is lost in the urine.
254
What is the best treatment for chloride-responsive metabolic alkalosis caused by vomiting?
Normal saline (0.9% NaCl). - It corrects volume depletion + provides chloride to allow kidneys to excrete bicarb and correct alkalosis.
255
What does high serum bicarbonate (>40) with hypokalemia and low urine chloride suggest?
Metabolic alkalosis 2/2 vomiting-induced volume depletion - with RAAS activation worsening K+ and H+ losses.
256
What type of bias is introduced when treatment groups are chosen by clinicians rather than randomly assigned?
Confounding by indication (a form of selection bias). - Physicians may preferentially give a treatment based on perceived patient risk (like giving to sicker patients), leading to unequal baseline characteristics.
257
What study design element minimizes selection bias and confounding?
Randomization. It distributes both known and unknown confounders equally between groups.
258
Management for NMS?
1st discontinue drug! Then give dantrolene
259
Distinguish placenta previa from placental abruption
Previa = painless vaginal bleeding w normal FHR tracing (no fetal distress) Abruption = Painful vaginal bleeding, constant abdo pain w abnormal FHR tracing (eg, decelerations) (fetal distress)
260
A 44-year-old woman has difficulty combing her hair, brisk reflexes, unintentional weight loss, and a resting HR of 115. Most likely diagnosis?
Hyperthyroid myopathy - Proximal muscle weakness + hyperthyroid sx - Myopathy isn't only for hypothyroid
261
What neuromuscular condition is classically associated with proximal muscle weakness + brisk reflexes + weight loss + tachycardia?
Hyperthyroid myopathy - Gpt says this is commonly tested on USMLE!
262
How do reflexes differ between polymyositis and hyperthyroid myopathy?
 Polymyositis = Normal or ↓   Hyperthyroid myopathy = Brisk/ ↑
263
Breastfeeding baby with bloody stools in + eczema + poor weight gain
Milk protein allergy
264
Management for milk protein allergy
Switch to soy-based formula - Remember milk protein allergy presents as breastfeeding baby with bloody stools in + eczema + poor weight gain
265
Management for infant with physiologic GERD
Reassure parents + give vitamin D (if breastfed) - Remember physio GERD is the "happy spitter" + normal weight gain, non red flags.
266
14-year-old boy with back pain worse at night. No neuro signs. Relieved with ibuprofen.
Osteoid osteoma - Night pain + NSAID relief = classic - Diaphysis or posterior spine - Xray: radiolucent core with sclerotic rim
267
Benign bone tumor near knee in adolescent. Painless, hard, non-tender mass.
Osteochondroma - Metaphysis, near growth plate -  Xray: bony spur projects away from joint - Cortex continuous with native bone - Stops growing with skeletal maturity
268
What part of the bone is affected by osteochondroma?
Metaphysis - Near growth plate - Bone spur grows outward - Cortex & medulla are continuous with parent bone
269
20–40yo with knee pain & swelling. Xray: eccentric lytic lesion in epiphysis with “soap bubble” appearance.
Giant Cell Tumor of Bone - Epiphysis of long bones (esp. distal femur, proximal tibia) - Pain, swelling, possibly aggressive - Xray: soap bubble lesion - Tx: surgical curettage
270
What distinguishes delusional disorder from schizophrenia?
Delusional disorder = ≥1 delusion lasting ≥1 month, no functional impairment, no negative symptoms, and no bizarre behavior. Schizophrenia = functional decline, may have bizarre delusions, and shows negative symptoms.
271
How is major depressive disorder with psychotic features distinguished from schizophrenia?
In MDD w psychotic features = psychosis occurs only during depressive episodes and mood symptoms are prominent In schizophrenia = psychosis occurs independently of mood symptoms
272
Which disorder involves long-standing distrust and suspicion without psychosis?
Paranoid Personality Disorder
273
Which disorder involves social detachment, emotional flatness, and no interest in relationships, but no psychosis?
Schizoid Personality Disorder
274
Promethazine
Anti-emetic medication that has some DA antagonism and can therefore lead to NMS!
275
Rigidity + ↑ CK + antipsychotic use
NMS
276
What is the most characteristic neuromuscular finding in NMS?
Lead-pipe rigidity (sustained muscle rigidity without clonus)
277
What lab value is typically markedly elevated in NMS?
Creatine kinase (CK) — due to severe rhabdomyolysis
278
What is the most appropriate first step in management of NMS?
Discontinue the antipsychotic medication immediately
279
What are the two pharmacologic treatments that may be used in severe NMS? (after discontinuing the drug)
Dantrolene (muscle relaxant) and bromocriptine (dopamine agonist)
280
What feature helps differentiate serotonin syndrome from NMS?
Hyperreflexia and clonus in serotonin syndrome vs Rigidity and ↓/normal reflexes in NMS
281
How do you differentiate lithium toxicity from NMS if both involve confusion and tremor?
Lithium toxicity typically includes GI symptoms, ataxia, and ↑ lithium levels (>1.5 mEq/L)
282
Wants relationships but fear rejection
Avoidant personality disorder
283
How does Paranoid Personality Disorder differ from Delusional Disorder, Persecutory Type?
Paranoid PD = generalized, non-fixed suspicion. Delusional disorder = fixed false belief (eg, “My neighbor is poisoning me”) without broader personality traits.
284
What classic behavioral pattern helps distinguish Paranoid PD from Schizoid PD?
Paranoid = wants relationships but avoids them due to suspicion. Schizoid = lacks interest in relationships altogether and is emotionally detached.
285
Dilated pupils, diaphoresis, myalgias, abdominal cramping, nausea, and restlessness, starting 1–2 days after hospital admission =
Opioid withdrawal - Clue: Think: “flu-like + GI upset + autonomic signs (sweating, dilated pupils)” - USMLE loves: Happens when opioids are suddenly stopped in the hospital
286
Patient on risperidone becomes febrile, confused, tachycardic, and develops lead-pipe rigidity. What’s the diagnosis?
NMS - Clue: Antipsychotic use + rigidity + fever + ↑CK - Buzz: Dopamine blockade → rigid not clonic
287
Key distinguishing features of benzodiazepine withdrawal?
Seizures, insomnia, anxiety, psychosis, tremors - Impt: Looks like alcohol withdrawal but no GI issues or hallucinations usually
288
Which toxidrome involves GI upset, tremor, and confusion with ataxia in late stages and is often dose-dependent?
Lithium toxicity - Clue: GI first, then neuro signs (ataxia, tremor) - Don’t fall for: Normal lithium level = not toxicity
289
What two toxidromes have dilated pupils and diarrhea, but differ based on reflexes?
Opioid withdrawal → no clonus, just myalgias/restlessness Serotonin syndrome → clonus + hyperreflexia
290
How do bowel sounds differ in opioid withdrawal vs NMS?
 Opioid withdrawal = Hyperactive bowel sounds NMS = Normal or ↓ (due to rigidity)
291
What feature on neuro exam helps you rule IN serotonin syndrome and rule OUT opioid withdrawal?
Inducible or spontaneous clonus - USMLE loves: “Lower extremity clonus” = serotonin syndrome
292
Nausea, vomiting, abdominal cramping, diarrhea, and muscle aches characterizes which common withdrawal syndrome?
Opioid withdrawal
293
Elderly patient with bipolar disorder that develops confusion, tremors, ataxia, vomiting, and seizures 2 weeks after beginning atenolol and hydrochlorothiazide? Dx?
Lithium toxicity
294
What is the difference between Bipolar I and Schizoaffective disorder?
Bipolar I = Psychosis only occurs during mood episodes (manic or depressive). Schizoaffective = Psychosis occurs for ≥2 weeks without mood symptoms Psychotic features must present with mood symptoms for Bipolar (if psychotic features are present in the absence of mood symptoms, consider schizoaffective)
295
What makes a mood episode schizoaffective rather than mood disorder with psychotic features?
Presence of psychotic symptoms alone for ≥2 weeks, outside of any mood symptoms.
296
Can you diagnose Bipolar I disorder if the manic episode occurred years ago and isn’t current?
Yes. A single manic episode ever = Bipolar I, even if current mood is depression or euthymia.
297
Diagnosis of _______ requires at ≥2 weeks duration of psychotic symptoms without a major mood episode
Schizoaffective disorder
298
A patient has persecutory delusions and hallucinations for the past 3 years. 6 months ago he started having sadness, guilt, insomnia, decreased concentration, and sleep issues. Rapid dx
Schizoaffective disorder - Delusions / hallucinations for > 2 weeks in absence of mood symptoms (ie, they are not mood congruent) - If a mood disorder with psychotic features (i.e., depression or bipolar), psychotic features appear exclusively during manic or depressive episodes (ie, mood-congruent)
299
Patient presents with symmetric resting tremor in both hands, muscle stiffness, and slow finger movements. Also has history of bipolar disorder controlled with valproate and risperidone. dx?
Drug-induced parkinsonism - Typically presents with bradykinesia, rigidity, and tremor
300
Patient develops agitation and visual hallucinations 12 hours after hospitalization. Vital signs are within normal limits. Also has history of cocaine, marijuana, and alcohol abuse.
Alcoholic hallucinosis - Typically develops within 12-24h and resolves within 24-48h - Vital signs are stable and sensorium is intact (patient is alert, oriented, and not confused) (vs. delirium tremens - agitated, disoriented, confused)
301
Which symptoms of alcohol withdrawal occur during the 12 - 48h time period?
Withdrawal seizures and alcoholic hallucinosis
302
What is the timing of onset for delirium tremens (DTs)?
48–96 hours after last drink.
303
What vital sign abnormalities are typical in delirium tremens but not in alcoholic hallucinosis?
Fever, HTN, tachycardia—autonomic instability.
304
Which alcohol withdrawal condition is a medical emergency requiring ICU admission and IV benzos?
Delirium tremens
305
What early symptoms of alcohol withdrawal can begin as early as 6–12 hours after last drink?
Tremulousness, anxiety, insomnia, palpitations.
306
What is the treatment for both alcoholic hallucinosis and delirium tremens?
Benzodiazepines (eg, lorazepam, diazepam) to prevent progression and control symptoms.
307
Alcoholic, confusion, agitation, hallucinations, fever, unstable vitals, 3 days after admission =
Delirium tremens
308
What drug withdrawal presents with nausea, muscle/joint aches, diarrhea, abdominal cramping, and pupillary dilation?
Opioid withdrawal (eg, heroin) - Other common findings (but not req'd) include yawning, lacrimation, and piloerection. - In contrast to other withdrawal states (eg, alcohol, benzo's) w similar sx, in opioid dependence, HR, BP, and temperature are often normal and mental status remains unchanged.
309
Patient stopped taking fluoxetine and lorazepam yesterday after 2 years of continuous therapy and now complains of insomnia, dysphoria, irritability, and anxiety. What is the most likely explanation?
Benzo withdrawal - Abrupt discontinuation of benzos can result in life-threatening withdrawal syndrome and cause early rebound effects of insomnia and anxiety and it can be hard to differentiate between the return of the anxiety disorder; also ↑s risk for seizures
310
“Flu-like” symptoms Myalgias, diarrhea, vomiting Dilated pupils, yawning, lacrimation, rhinorrhea Piloerection, insomnia, sweating Patient profile: Young, thin, anxious, restless
Opioid withdrawal (heroin, oxy, morphine) - USMLE Trick: Looks sick but vitals okay — NOT life-threatening - In contrast to other withdrawal states (eg, alcohol, benzo's) w similar sx, in opioid dependence, HR, BP, and temperature are often normal and mental status remains unchanged. - Mnemonic: “It sucks to come off opiates” = everything runs (nose, eyes, bowels)
311
Miosis (pinpoint pupils) Respiratory depression, bradycardia Constipation, sedation, coma Hypoventilation = cause of death
Opioid intoxication - USMLE Trick: Sedated + slow + small pupils - Tx: Naloxone (Narcan)
312
Anxiety, insomnia, tremors Seizures, psychosis, hallucinations
Benzo withdrawal - Can look like alcohol withdrawal - USMLE Trick: Recent stop of benzo or taper after chronic use - Mnemonic: “Benzo withdrawal = brain on fire” Dangerous? Yes — can be fatal
313
Crash: Depression, fatigue, hypersomnia Hyperphagia (eat a lot), vivid dreams
Stimulant withdrawal (cocaine, amphetamine) - Not dangerous — just miserable - USMLE Trick: Think of someone after a binge — sad + sleepy - Intoxication? Opposite: agitated, tachy, mydriasis (big pupils)
314
Difference in presentation between placenta previa and vasa previa?
Placenta previa = heavy, persistent bleeding - Placenta previa = Profound bleeding; Vasa previa = Vanishing bleeding - Placenta previa reflects maternal blood loss and has signs of maternal hemorrhagic shock (eg, hypotens/tachy) Vasa previa = minimal, transient bleeding - Vasa previa reflects fetal blood loss
315
Painless ROM with blood-tinged fluid + known vasa previa Mom: Stable Fetus: Bradycardia or decels NBS?
Vasa previa Do emergency C-section immediately - DO NOT wait for steroids or labs - USMLE Trigger: In vitro fertilization (↑ vasa previa risk)    
316
Painful bleeding, firm uterus, maybe contractions Mom: May be unstable (shock, tender uterus) Fetus: Can show distress or demise Dx?
Placetal abruption
317
Pregnant patient with painless third-trimester bleeding with a normal fetal heart tracing?
Placenta previa - Painless bleeding helps r/o placental abruption; normal FHR helps distinguish placenta previa from vasa previa (which would have a FHR <110 bpm)
318
What pregnancy complication is associated with painless third trimester bleeding with fetal bradycardia (FHR <110)?
Vasa previa
319
What pregnancy complication is associated with painless third trimester bleeding without fetal bradycardia?
Placenta previa - Fetal bradycardia would suggest vasa previa
320
__________ is a complication of pregnancy that presents with a triad of ROM, painless vaginal bleeding, and fetal bradycardia (FHR <110)
Vasa previa
321
How is placenta previa usually diagnosed?
Ultrasound (prenatal visit)
322
True or false? The majority of placenta previas resolve spontaneously
True - Therefore continue with routine care and do an ultrasound in third trimester to check for resolution
323
Which pregnancy disorder may present with minimal vaginal bleeding, focal pain, and a distended uterus with high-frequency contractions?
Placental abruption (concealed) - Abruption typically presents with abdo and/or back pain and vaginal bleeding (which can range from severe to absent, as bleeding may be concealed behind the placenta) - Blood may have a uterotonic effect, causing a firm uterus and unusually low-amplitude but frequent contractions
324
What is the most common risk factor for placental abruption?
Hypertension (assoc preeclampsia, cocaine use)
325
Pregnant patient at 35 weeks gestation with abdominal pain, painful vaginal bleeding and a firm, tender uterus. Dx?
Placental abruption - Also may have high-frequency, low-intensity uterine contractions (abrupt and strong) - Bleeding may be concealed - Compare with uterine rupture (loss of contraction and loss of fetal station)
326
What is the initial management for a hemodynamically unstable pregnant patient who presents with placental abruption?
Hemodynamic support (IV fluids and/or blood transfusion) followed by emergency C-section - The left lateral decubitus position displaces the uterus off the aortocaval vessels and maximizes cardiac output
327
Pregnant patient with painful third-trimester bleeding, tender abdomen, an irregular mass, and prior cocaine use and C-section?
Uterine rupture - Irregular mass due to palpable fetal parts through the ruptured uterus - Placental abruption would present with a painful abdomen and a rigid/hypertonic uterus
328
Which childhood exanthem can present with a fine, blanching rash developing after a sore throat?
Scarlet fever (GAS) - Kawasaki - would have no sore throat or pharyngitis. Would have conjunctivitis and fever for ≥5d
329
What pediatric infection is associated with "beefy-red tongue" concurrent with pharyngitis?
Scarlet fever - "Strawberry" tongue (also seen in Kawasaki disease)
330
Child presents with a strawberry tongue. What are the two potential diagnoses?
Scarlet fever or Kawasaki
331
Kid with slapped cheek rash
fifth disease/erythema infectiosum due to parvo B19
332
_________ is a severe, traumatic vascular injury that should be suspected if there is a widened mediastinum, tracheal and esophageal deviation, and hemothorax
Aortic rupture - Usually pt had a deceleration injury - Confirm dx with CT angiography Other findings may include: - Pseudo-coarctation (due to obstructive intimal flap) - Hoarseness (due to compressed left recurrent laryngeal nerve)
333
This on xray after deceleration injury =
Aortic rupture xray shows widened mediastinum - Do CT angio
334
Patient had a pure sensory stroke, which brain structure was most likely affected?
Thalamus - Possibly lacunar infarct - Lacunar infarct = lenticulostriate vessels
335
A child with a history of neurofibromatosis I that presents with unilateral vision loss, proptosis, and optic disc pallor. NBS?
do brain MRI for optic glioma
336
What is the most appropriate routine screening in a child with NF1?
Annual ophthalmologic exam to screen for optic pathway gliomas (even if asymptomatic). - USMLE trick: MRI is only done if symptomatic, not routinely.
337
What are the 3 skin findings in NF1?
1. Café-au-lait spots 2. Axillary or inguinal freckling 3. Cutaneous neurofibromas
338
What would be the next step if a child with NF1 develops headaches, vision loss, or other neuro symptoms?
MRI of the brain to evaluate for CNS tumors (eg, optic glioma, astrocytoma) - Note: Not done routinely — only if new symptoms develop. - What is routinely done are yearly ophtho exams
339
What 3 syndromes/conditions are associated with pheochromocytoma?
1. MEN 2A/2B 2. NF-1 3. VHL
340
What is the definition of precocious puberty?
Early onset of secondary sexual characteristics in girls <8, and boys <9  
341
What is the key hormone profile in central precocious puberty?
High LH/FSH Responds to GnRH stimulation with further rise in LH
342
What is the key hormone profile in peripheral precocious puberty?
Low LH/FSH No response to GnRH stimulation
343
What are common causes of peripheral precocious puberty? (5 listed here)
1. Estrogen-secreting ovarian tumor (eg, granulosa cell tumor) 2. Adrenal tumors 3. McCune-Albright syndrome 4. Exogenous estrogen exposure 5. CAH (eg, 21-hydroxylase deficiency)
344
A 7yo girl presents with breast development and vaginal bleeding. She has a large unilateral ovarian mass. Dx?
Granulosa cell tumor (estrogen-secreting → peripheral precocious puberty) - 1st line tx = unilateral oophorectomy
345
Treatment for tinea capitis
Oral antifungals (like griseofulvin or terbinafine) - Presents with scaly patches with alopecia with black dots that represent broken hairs, and cervical LAD
346
Child has scaly patches on head with alopecia with black dots that represent broken hairs, and cervical LAD. Dx?
Tinea capitis - Tx = oral antifungals (like griseofulvin or terbinafine)
347
When is routine GBS screening performed in pregnancy?
36–38 weeks gestation with a rectovaginal culture.
348
What is the treatment for a GBS-positive rectovaginal culture?
Intrapartum IV penicillin during labor.
349
Who gets automatic intrapartum antibiotics for GBS (no need for culture)?
1. GBS bacteriuria or UTI in current pregnancy 2. Previous infant with early-onset GBS infection 3. Unknown GBS status AND:     *    <37 weeks gestation     *    Intrapartum fever     *    ROM ≥18 hour
350
What should you do if a woman at 30 weeks is worried about Group B Strept infectionn?
Reassure and tell her she will be screened with a culture at 36–38 weeks.
351
If a patient tests GBS(+) early in pregnancy from a urine culture and was treated. Does she still require intrapartum prophylaxis?
he still gets intrapartum IV penicillin, even if she was treated earlier.
352
Patient has a febrile non-hemolytic transfusion reaction. NBS?
Stop transfusion Give acetaminophen (anti-pyretic) - Will be stable w no hemolysis - Prevent by using leukoreduced blood products
353
What size induration is positive on a PPD test in a patient with HIV
positive if ≥5 mm for: immunocompromised patients (HIV, on prednisone, transplant) or evid TB exposure or recent contact
354
What is bethanechol and what is it used for?
Muscarinic agonist drug that stimulates bladder detrusor contraction. Used in urinary retention (esp, neurogenic bladder) - It's like the opposite of oxybutinin (which relaxes bladder detrusor to help treat overactive bladder/urge incont)
355
What is oxybutinin and what is it used for?
Anti-muscarinic drug used for urge incontinence (overactive bladder). It relaxes the detrusor muscle - It's like the opposite of bethanechol (which stimulates detrusor to help relieve urinary retention)
356
What is tamsulosin and what is it used for?
alpha-1 blocker - It helps contract ureter smooth muscle to help distal ureteral stones pass - Treats BPH ➞ relaxes smooth muscle in bladder neck & prostate to improve urine flow - Occasionally used in urinary retention due to outlet obstruction (eg, post-op, neurogenic) - AE ortho hypotens
357
Bladder training, mirabegron, and oxybutynin are used to treat what type of incontinence?
Urge incontinence (overactive bladder) - 1st-line should consist of lifestyle mods (reduce alcohol/caffeine) + bladder training/ timed void - Oxybutinin is anti-muscarinic (relaxes bladder detrusor) - A newer agent, mirabegron (β3-adrenergic agonist) may be offered to patients who can't take anti-muscarinic drugs (eg, glaucoma) - Think about training the bladder to not be so hyperactive
358
Which NSAID is used as a tocolytic?
Indomethacin (ENDOmethacin ENDs contractions caused by prostaglandins) "It's Not My Time" I - Indomethacin N - Nifedipine M - Magnesium sulfate T - Terbutaline
359
Which CCB is used as a tocolytic?
Nifedipine "It's Not My Time" I - Indomethacin N - Nifedipine M - Magnesium sulfate T - Terbutaline
360
Why would you give a tocolytic?
Tocolytics are generally used to decrease contraction frequency in {{c1::preterm}} labor - Gives enough time to administer betamethasone (promote fetal lung maturity) or transfer to appropriate medical center for level of care needed
361
If there is fetal distress, and NBS maternal repositioning is unsuccessful, what are the subsequent intrauterine resuscitation measures that can be taken?
Amnioinfusion C-Section (emergent) Tocolytics (if tachysystole present) If maternal repositioning is unsuccessful, then you must ACT (Amnioinfusion, C-section, Tocolytics)
362
Healthy patients in preterm labor at < {{c2::34}} weeks should receive _______ to postpone delivery.
Tocolytics - eg, indomethacin (given <32 weeks), nifedipine (given 32-34 weeks) - Benefits of tocolytics do not outweigh the risks after 34 weeks
363
What is a positive thompson test? What does it indicate?
when there is lack of {{c2::plantar flexion}} when the {{c3::calf}} is squeezed Due to Achilles tendon rupture
364
These skin findings + warm extremities arterial or venous insufficiency?
Chronic venous insufficiency
365
Warm legs + edema + hyperpigmentation = vs Cool legs + hair loss + painful ulcers =
Warm legs + edema + hyperpigmentation = venous insufficiency *img is venous vs Cool legs + hair loss + painful ulcers = arterial
366
What is the recommended treatment for atrophic vaginitis refractory to vaginal moisturizer and lubricant?
Topical vaginal estrogen
367
What's another name for atrophic vaginitis?
GU syndrome of menopause
368
Postmenopausal woman presents with vaginal pruritus / dryness, dysuria / dyspareunia, and increased urinary frequency and urgency? Urinalysis is normal. Dx =
Atrophic vaginitis (genitourinary syndrome of menopause) - Next steps: lubricants & moisturizers. If refractory ➞ vaginal estrogen - D/t ↓ EST support after menopause causing loss of epithelial elasticity - In the urethra/trigone, this loss of support → urge incontinence - Can also see petechiae/fissures/bleeding d/t thin tissue - Dyspareunia d/t narrowed vagina and dryness from less lubrication
369
What is the initial management for mild atrophic vaginitis?
Vaginal moisturizer and lubricant - Also called GU syndrome of menopause - If refractory ➞ give vaginal EST
370
WAGR syndrome is a combination of:
Wilms tumor Aniridia (absence of iris) Genitourinary abnormalities Range of developmental delay - In children with known WAGR, abdo U/S is performed q3 months in infancy/early childhood to screen for early detection of Wilms tumor
371
What's another name for hereditary hemorrhagic telangiectasia?
aka Osler-Weber-Rendu syndrome - Presents with blanching skin lesions (telangiectasias), recurrent epistaxis, skin discoloration, AVMs (stroke in kids), GI bleeding, and hematuria
372
Presents with blanching skin lesions, AV malformations, recurrent epistaxis, skin discoloration, GI bleeding, and hematuria. Dx =
Hereditary hemorrhagic telangiectasia (aka Osler-Weber-Rendu syndrome) - Assoc with widespread AVMs - AVMs in the lung can result in right-to-left shunting with chronic hypoxemia (clubbing), reactive polycythemia, and hemoptysis -AVMs cause hemorrhagic stroke
373
Patient with epistaxis, red blanchable papules on the lips, digital clubbing, and isolated polycythemia on laboratory exam. Dx =
Hereditary hemorrhagic telangiectasia (aka Osler-Weber-Rendu syndrome) - Assoc with widespread AVMs - AVMs in the lung can result in right-to-left shunting with chronic hypoxemia (clubbing), reactive polycythemia, and hemoptysis
374
Patient with one day of unilateral knee pain/swelling? Labs reveals significant hypercalcemia Dx =
Pseudogout (acute calcium pyrophosphate deposition disease - Note that pseudogout can happen acutely (just like regular gout) - Likely 2/2 hyperparathyroidism; pseudogout is also seen with hypothyroidism and hemochromatosis
375
Patient with brownish skin pigmentation, elevated fasting glucose, and elevated LFTs. Dx =
Hereditary hemochromatosis - Other common manifestations: hypogonadism, arthralgias, and hepatomegaly - "Bronze diabetes"; bronze color due to hemosiderin deposition in dermal macrophages
376
Middle-aged patient with recently diagnosed diabetes mellitus that presents with pseudogout and hepatomegaly? Dx =
Hereditary hemochromatosis - Hereditary hemochromatosis is assoc with pseudogout and should be suspected in a young patient w diabetes and hepatomegaly
377
Late decels
378
Bronchiectasis (recurrent respiratory infections) + recurrent sinusitis + situs inversus + infertility. Dx =
Primary ciliary dyskinesia (Kartagener's) - Bronchiectasis may present with dyspnea, {{c1::hemoptysis}}, and purulent sputum. Also foul-smelling sputum, recurrent infections, digital clubbing, nasal polyps. It's obstructive lung dz.
379
Who needs endocarditis prophylaxis for dental/respiratory procedures?
1. Prosthetic heart valves 2. Prior infective endocarditis 3. Unrepaired cyanotic congenital heart defects (or repaired with residual defects) 4. Heart transplant recipients who develop valve abnormality Not needed for regular valve defects (like MVP w or w/o murmur), rheumatic heart dz, CABG, pacemaker or ICD
380
What drug is used for infective endocarditis prophylaxis? What if they are allergic?
Amoxicillin/Ampicillin/Cefazolin If allergic ➞ Macrolide (eg, azithromycin) or doxycycline
381
Which skin cancer typically presents as an elevated nodule with telangiectasias, rolled borders, central crusting, and/or ulcerations?
Basal cell carcinoma (nodular type) - Photo shows SCC (ulcerated) 1st vs BCC (nodular type) 2nd
382
Which skin cancer presents as an ulcerative red lesion with frequent scale?
Squamous cell carcinoma - Photo shows SCC 1st vs BCC 2nd
383
Which skin cancer presents as a "pink, pearl-like papule" with telangiectasias?
Basal cell carcinoma - Photo shows SCC 1st vs BCC 2nd
384
What skin malignancy is most likely in a patient with a significant history of sun exposure and a slow-growing lesion (pictured below)?
Basal cell carcinoma - Typically appears as a pearly-pink papule with telangiectatic vessels; it may have central ulceration! Basal cell carcinoma: - Favors the upper part of the face - Evolution is measured in years - Does not metastasize. Death is due to local invasion ("rodent ulcer"). Can be a waxy, raised lesion, or an ulcer.
385
Treatment for tinea versicolor?
Topical anti-fungal (ketoconazole or selenium sulfide)
386
What skin condition presents as erythematous, greasy patches w yellow scale in oily areas like: sides of nose, eyebrows, along ears and beard area, and scalp (dandruff). Rash worsens w cold weather and stress.
Seborrheic dermatitis
387
Vasovagal syncope with typical prodrome + normal ECG + exam. NBS?
No further workup - Don't pick Tilt table testing (this is reserved for patients with recurrent syncope of unclear origin, not a single classic vasovagal syncope episode)
388
What is a tilt table test used for?
To distinguish between vasovagal or orthostatic syncope (like if a patient had recurrent syncope of unclear origin, not a single classic vasovagal syncope episode) - Normal = HR ↑ , BP barely changes - Positive test = development of hypotension and bradycardia OR slow progressive hypotension with presyncope/syncope
389
Which type of syncope is often preceded by nausea, bradycardia, and/or a feeling of warmth throughout the body?
Vasovagal syncope - Triggers include prolonged standing, emotional distress, and painful stimuli - In patients with single, classic episode of vasovagal syncope, no further workup is needed!
390
Loss of consciousness after shaving / head turning / tight collars. Dx =
Carotid sinus hypersensitivity
391
Young adult with 1 month history of fever and malaise who develops symptoms of CHF with cardiomegaly on imaging. Dx =
Viral myocarditis - Symptoms are those of decompensated HF (dyspnea, orthopnea, peripheral edema)
392
Patient with a recent URI presents with CHF, dilated ventricles with diffuse hypokinesia, and low ejection fraction on echo. Dx =
DCM - Often seen following viral myocarditis (particularly after Coxsackievirus B infection) - Treatment is supportive
393
A child presents with fever and signs of heart failure after several days of a URI (runny nose and nasal congestion). Dx =
Viral myocarditis - Signs of HF include cardiomegaly, mitral regurg, pulm edema, hepatomegaly, etc. (left-HF → right-HF) - Inflammatory damage (eg, virus, toxin, HSR) induces release of cross-reactive antigens and auto-Abs against heart tissue causing myocarditis - Acute rheumatic fever can also cause myocarditis, but typically presents with fever + arthritis weeks after untreated GAS pharyngitis
394
What cardiac pathology results in inflammation with global enlargement, 4-chamber dilation, and diffuse hypokinesis?
Myocarditis - Major cause of sudden cardiac death (SCD) in adults < 40yo - Due to lymphocytic inflammation of myocardial tissue + edema → weakened tissued + dilated chambers
395
What is pulsus paradoxus and where do we see it?
↓ in amplitude of systolic BP by > 10 mmHg during inspiration Seen in cardiac tamponade. Also asthma, OSA, pericarditis, and croup NOT myocarditis
396
Postpartum woman presents with lactation failure, amenorrhea, fatigue, and hypotension for months after a spontaneous vaginal delivery that was complicated by uterine atony. Dx =
Sheehan syndrome (pituitary INFARCT - not hemorrhage) - Symptoms are due to hypopituitarism 2/2 ischemic infarction and necrosis of the pituitary gland following massive obstetric hemorrhage
397
Paroxetine
SSRI
398
Which type of psychotherapy seeks to correct faulty assumptions and negative feelings that exacerbate psychiatric symptoms?
CBT (specifically exposure with response prevention subtype) - The patient is taught to identify maladaptive thoughts and replace them with positive ones - MC used to treat depressive and anxiety disorders - May also be used for paranoid personality disorder, OCD, somatic sx disorders, hoarding disorder, eating disorders
399
Patient s/p Roux-en-Y gastric bypass surgery presents with abdominal bloating, diarrhea, and macrocytic anemia. Dx =
SIBO - Macrocytic anemia due to vitamin B12 deficiency - Contrast with dumping syndrome - which presents as colicky abdominal pain, nausea, shakiness, and diarrhea 15-30 minutes post-prandial
400
What does PTH normally do to phosphate?
PTH normally lowers phosphate by ↑ing urinary excretion so if ↓ PTH (hypoparathyroidism) ➞ phosphate will ↑
401
What electrolyte abnormality is typically the cause of hypocalcemia in a patient with alcohol use disorder?
Severe hypomagnesemia - Severe hypomagnesemia → ↓ PTH release and resistance to PTH → hypoparathyroidism with ↓ Ca2+ and ↓ phosphate (vs. other causes of hypoparathyroidism)
402
What is the total body phosphate level in a patient with type 1 diabetes? (↑ or ↓ )
Decreased - Phosphate and glucose are buddies. If glucose can't get into the cell, phosphate can't either (both stay in serum). Cells deplete their intracellular stores. This causes low total body phosphate despite high concentrations in serum
403
What is the serum level of calcium in secondary hyperparathyroidism? (↑ or ↓ )
Decreased (hypocalcemia) - Decreased calcium is the defect causing the ↑ PTH
404
How do the following laboratory values change in patients with osteomalacia? PTH: Serum calcium: Serum phosphorus: Alkaline phosphatase:
Parathyroid hormone: {{c1::increased}} Serum calcium: {{c1::decreased or normal}} Serum phosphorus: {{c1::decreased}} Alkaline phosphatase: {{c1::increased}}
405
How do you distinguish Huntington disease from Wilson disease?
Both have neuropsych symptoms and some parkinsonism symptoms but hungintons has no assoc with liver disease!
406
Which blistering skin disorder presents as groups of pruritic vesicles, papules, or bullae located on extensor surfaces?
Dermatitis herpetiformis - Often found on the extensor surfaces (eg, knees, elbows), also buttocks, back. - Do not confuse with contact dermatitis (eg, poison ivy): Typically localized itchy erythematous papules + vesicles (in severe cases) with serous oozing.
407
Adolescent with history of T1DM presents with weight loss, iron deficiency anemia and a pruritic, vesicular rash on the elbows and knees. Dx =
Celiacs - Iron deficiency results from poor iron resorption in the duodenum - Assoc with other autoimmune conditions like T1DM - Dermatitis herpetiformis - Confirm with anti-TTG antibody testing
408
Patient with an intensely pruritic and burning rash (pictured below)? The patient has also experienced occasional diarrhea and weight loss. Dx =
Celiacs with dermatitis herpetiformis
409
What is the heme AE with clozapine that must be monitored for?
Agranulocytosis but answer is specifically Neutropenia! Thus, monitor WBCs/absolute neutrophil count frequently - Neutrophils are the main components of the granulocyte population. - Agranulocytosis = severe neutropenia - They test agranulocytosis is neutropenia - don't fall for distractors like "lymphocytopenia" or "all leukocytes low"
410
Patients taking clozapine require regular monitoring of ________
absolute neutrophil count (because AE agranulocytosis) - Discontinue if agranulocytosis develops - Neutrophils are the main components of the granulocyte population. - Agranulocytosis = severe neutropenia
411
For SBO: If the patient had abdominal surgery/cesarean-section, the SBO is due to _________ . If the pt has Crohn’s, the SBO is due to ________.
Abdominal surger or C-section ➞ adhesions Crohn's ➞ strictures
412
What is lead time bias?
The typical example is apparent prolongation of survival in patients to whom a test is applied, without changing prognosis of the disease
413
↑ FSH with absent breast development and no pubic hair. NBS?
Karyotype analysis - Likely Turners ➞ 1ry ovarian insufficiency (streak ovaries)
414
Adolescent girl with primary amenorrhea + uterus present on ultrasound + high FSH levels. NBS?
Karyotype analysis - High FSH indicates a peripheral cause, such as hypergonadotropic amenorrhea (eg, Turner syndrome)
415
Primary amenorrhea + cubitus valgus + short height =
Turners - NBS? karyotype
416
Trauma patient with a widened mediastinum ± left-sided hemothorax with tracheal deviation. Dx =
Aortic injury / rupture - Hemothorax leads to the tracheal deviation; rupture will lead to hypotension - Xray shows the widening/tracheal deviation/hemothorax - Dx conf: with CT scan + angiography - Other findings may include pseudocoarctation (due to obstructive intimal flap) and hoarseness (due to compressed L-recurrent laryngeal N)
417
What is the best initial test for blunt aortic trauma?
CXR - Should be ruled out in patients with blunt deceleration trauma (MVA or fall from > 10 feet) - Xray shows the widening/tracheal deviation/hemothorax
418
Which one usually occurs in children between 5-7 years old. Legg-Calve-Perthes or SCFE?
Legg-Calve-Perthes (xray attached) - while SCFE occurs in individuals aged 10-16 years old
419
Which of the following is self-limited (~2-3 years) Legg-Calve-Perthes or SCFE?
Legg-Calve-Perthes (xray attached) - Femoral head begins healing after 1y and new subchondral bone develops; new bone replaces the old bone in 2-3 years
420
Which of the following is associated with an insidious onset of hip pain Legg-Calve-Perthes or SCFE?
Legg-Calve-Perthes (xray attached) - Initially a painless limp, followed by an insidious onset of hip pain
421
Which of the following is associated with acute hip/knee pain and altered gait Legg-Calve-Perthes or SCFE?
SCFE - Typically has more pain associated with it than Legg-Calvé-Perthes
422
Which of the following always requires surgery Legg-Calve-Perthes or SCFE?
SCFE - Requires fixation with a screw, and there may be a prophylactic screw fixation of the contralateral hip as well - Note: Legg-Calvé-Perthes requires surgery if patient is ≥ 6 years old
423
What is the management for patients < 6 y/o with refractory Legg-Calvé-Perthes?
Casting and bracing - If femoral head deformity develops or ROMO worsens - 1st-line treatment before for patients < 6 y/o with Legg-Calvé-Perthes is reduced weight-bearing and physical therapy
424
8 year old boy presents with chronic hip/knee pain with limited internal rotation/abduction of the affected hip. The gait is antalgic. Dx =
Legg-Calvé-Perthes = Idiopathic osteonecrosis of the femoral head that typically presents in boys age 4 - 10 years old; initial Xrays may be negative - Antalgic = shorter time weight bearing on the bad side secondary to pain - Compare with SCFE (10 - 16 y/o and obese with posterior displacement of femoral head; "slip on the fat")
425
What is the initial management for patients < 6 years old with Legg-Calvé-Perthes ?
Limited weight bearing and physical therapy - If age <6 and refractory ➞ cast and brace (if femoral head deformity develops or ROM worsens). - If age ≥ 6 ➞ surgery is more beneficial (bc the bone formation capacity is too limited to repair the femoral head damage)
426
What is postexposure prophylaxis for hepatitis B? Unvaccinated/incomplete vaccination: Non-responder: Previous vaccination (confirmed antibody response) or prior resolved infection:
Un-vaccinated/incomplete vaccination: {{c1::Hep B immunoglobulin + full vaccine series}} Non-responder: {{c1::2 doses Hep B immunoglobulin}} Previous vaccine series (confirmed antibody response) or prior resolved infection: {{c1::none}}
427
13M with right thigh pain Dx = Tx =
SCFE with Salter-Harris type 1 fracture at growth plate ➞ tx: surgical stabilization of the femoral head - Xray img is from NBME (as so is the info below) - Limp - Can have fracture at growth plate - Usually kids 10-15yo - Pain often refers to the knee - Dx: xray both hips, lateral & frog-leg
428
A young woman presents with irritability, weight loss, and decreased sleep. She has lots of energy and isn't eating because she's not hungry. Exam: erythema of the turbinates and nasal septum. BMI is 19.5. Dx =
Cocaine use disorder
429
A seemingly manic patient that also has autonomic hyperactivity (dilated pupils, diaphoresis, tremor, HTN) ➞ think?
Stimulant intoxication (cocaine, amphetamines..) - Dont confuse with PCP (nystagmus!)
430
What is the preferred diagnostic study for suspected aortic dissection in hemodynamically unstable patients or those with renal insufficiency?
Transesophageal echocardiography (TEE) - vs. CT angiography in stable patients without renal insufficiency
431
What is the preferred route of intubation in a cervical spine trauma patient without significant facial trauma?
Orotracheal intubation (because risk respiratory compromise) - Doing it orally is best (better than NG or surg tracheostomy)
432
What is the first step in the management of cervical spinal trauma?
Spinal immobilization
433
Patient is in preterm labor at 36w gestation. What is the management?
Expectant labor management - do NOT give tocolytics (only if <32w or 32-34w) -- too risky now
434
FEV1 = 67% of predicted FVC = 95% of predicted FEV1/FVC ratio = 0.65 Obstructive or restrictive?
Obstructive - obstructive is anything with FEV1/FVC <70% or 0.70 (even 67% is enough) = low
435
What acid/base disturbance does primary hyperaldosteronism cause?
Metabolic alkalosis - Pt w HTN + hypokalemia
436
Which immunodeficiency presents with recurrent infection, failure to thrive, chronic diarrhea, and thrush?
SCID - Susceptible to viral and fungal infections due to no T cells - Susceptible to bacterial and protozoal infections due to no B cells
437
Infant that presents with failure to thrive, lymphadenopathy, and leukocytosis with a history of Pneumocystis jirovecii and Candida infection?
HIV infection - Due to selective loss of CD4+ T lymphocytes; however, absolute lymphocyte count is normal (vs. SCID) - Dx is confirmed with PCR reaction testing - LAD and leukocytosis = HIV - Absent lymph nodes, and leukopenia or ↓ absolute lymphocyte count = SCID
438
Best long-term treatment for SCID
stem cell transplant - IVIG is a treatment option, but not best long-term/definitive
439
Patient with progressive achy left groin pain Dx =
Avascular necrosis (osteonecrosis) - most likely due to alcohol
440
LH & FSH levels in turners
Increased - if ↓ LH/FSH (means functional hypothal amenorrhea d/t stress/*strenuous exercise/anorexia)
441
The absence of bleeding following a progestin withdrawal challenge indicates?
low estrogen in functional hypothalamic amenorrhea (eg, high performing athletes, anorexia nervous) or ovarian failure (eg, Turners?) or from inadequate endometrial lining (eg, Asherman syndr)
442
What is the first-line treatment for trigeminal neuralgia?
Carbamazepine or oxcarbazepine - Carbamazepine was on actual exam! - Trigeminal neuralgia causes repetitive, unilateral, shooting pain in a distribution of CN V lasting < 1min.
443
What hematologic pathology is associated with restless legs syndrome (RLS)?
Iron deficiency anemia Other possible causes of RLS include: - Uremia - Diabetes mellitus - Parkinson disease - Pregnancy
444
↓ mobility and bulging of the tympanic membrane. Dx =
Acute otitis media (AOM)
445
What is the next step for a child that presents with symptoms concerning for acute mastoiditis?
Empiric IV antibiotics & drainage - Abx should cover: Strep pneumo, Strep pyogenes, and Staph aureus (Pseudomonal coverage if hx of such infection or recent abx use) → ceftriaxone, ampicillin/sulbactam, levofloxacin - Drainage of purulent material can be achieved with tympanostomy (± ear tube placement) or mastoidectomy - If 2/2 exacerbation of chronic otitis media → surgical debridement and vancomycin Imaging (eg, CT or MRI [children]) indicated for: - Sx that don't improve after 48h of treatment - Suspected intracranial complication - Planned surgical intervention
446
Patient noticed hypopigmented skin lesions on her trunk after returning from a summer vacation in Florida. Dx =
Pityriasis versicolor - - Typically noticed after sun exposure as the surrounding skin gets darker (lesions do not tan in the sunlight, so they will be more prominent in summer/after sun exposure)
447
Child notices multiple, pruritic hypopigmented skin lesions on the face and trunk after beginning summer camp. Dx =
Pityriasis versicolor (aka tinea versicolor) - Typically noticed after sun exposure as the surrounding skin gets darker (lesions do not tan in the sunlight, so they will be more prominent in summer/after sun exposure)
448
Tx tinea versicolor
Topical anti-fungals incl: topical ketoconazole selenium sulfide terbinafine - Mupirocin = tx’s impetigo & other superficial bact infections - Oral griseofulvin = tx’s tinea capitis.
449
Newborn with bilious emesis and dilated loops of bowel on X-ray. NBS?
Contrast enema Helps differentiate between: Meconium ileus (microcolon on enema due to unused colon) and Hirschsprung disease (transition zone on enema)
450
What congenital disease can present as failure to pass meconium in a 2 day old, or as constipation in a 2 year old?
Hirschsprung disease - FTPM → explosive diarrhea (squirt) - Constipation → overflow incontinence
451
Rapid diagnosis: Tight anal sphincter with explosive release of stools and air upon removal of finger.
Hirschsprung disease ("squirt sign"
452
What intervention prevents errors when concerns are raised but dismissed by senior staff?
Team-based safety communication (eg, simulation training) - Poor teamwork is the leading root cause of sentinel events
453
What MSK pathology is characterized by impaired relaxation after a single muscle contraction?
Myotonic dystrophy - Myotonia = difficulty relaxing muscles
454
What is the recommended treatment for a newborn of a mother with active hepatitis B?
Hepatitis B immune globulin + HBV vaccine within 12 hours of birth - Compare with routine HBV vaccination, which is recommended within 24hof birth - Same ppx as healthcare worked exposed to blood from hepB positive patient.
455
What is the recommended prophylaxis for an unvaccinated healthcare worker that is exposed to blood from a hepatitis B positive patient?
Hepatitis B vaccine and hepatitis B immune globulin - Same as newborn to active hepB mom
456
No.1 RF for cerebral palsy
Prematurity
457
Until what gestational age are tocolytics given in the management of preterm labor?
<34 weeks - Give along with steroids (for lung maturity) - Tocolytics = to postpone deliv - At >34 weeks gestat, tocolytics such as indomethacin and nifedipine are not recommended as risks of indomethacin (oligohydramnios, closure of ductus arteriosus) and nifedipine (maternal hypotens/tachy) outweight the risks of premature deliv.
458
Meds that improve mortality in HFrEF=
1. ACEi’s/ARBS 2. B-blockers 3. mineralocorticoid-R antagonists (*eplerenone, spirono) 4. SGLUT-2 inhibitors. - CCBs (eg, amlodipine, diltiazem) have not been shown to provide sympto or mortality benefit in HFrEF and have no direct role in mgmt!!
459
What pulmonary pathology is shown in the CXR?
Pneumothorax - Presence of the white visceral pleural line, pulmonary vessels are not visible beyond the visceral pleural boundary
460
Hemodynamically unstable patient with penetrating trauma to the 6th intercostal space and an equivocal FAST exam. NBS?
Ex-lap - Indics for ex-lap are: HDUS, peritoneal signs, evisceration - Anything below 4th ICS (nipple) can affect abdo organs.
461
hemodynamically stable patient with penetrating abdominal trauma, rebound tenderness, and guarding. NBS?
Ex-lap - Indics for ex-lap are: HDUS, peritoneal signs, evisceration
462
Hemodynamically stable patient with penetrating abdominal trauma without peritonitis, evisceration, or impalement? NBS?
FAST → if negative → {{c1::CT}} - With peritonitis → exploratory laparotomy
463
Which heart chamber composes the majority of the anterior surface of the heart?
Right ventricle - Thus in a penetrating trauma at the LLSB, the right ventricle would be hit (pleura would be injured but the lung would not be).
464
Which movement-related symptom presents as slow, writhing movements, especially in the fingers?
Athetosis -"writhing, snake-like movement"; seen with Huntington disease
465
Which movement-related symptom presents as a sudden, brief, uncontrolled muscle contraction?
Myoclonus - eg, jerks, hiccups - May be seen with Creutzfeldt-Jakob disease and renal / liver failure - May also be seen in traumatic settings, eg, cardiac arrest causing prolonged cerebral hypoxia (posthypoxic myoclonus)
466
Young patient with hepatosplenomegaly, resting tremor, dysarthria, parkinsonism, and dementia. Dx =
Wilson disease - D/t copper bound to DA and accumulation of copper in the putamen/basal ganglia/striatum
467
MCC of viral meningitis
Enteroviruses (like coxsackie B)
468
What is the treatment for delirium tremens?
Benzo's (eg, chlordiazepoxide, lorazepam)
469
Patient develops confusion, agitation, diaphoresis, and tremors three days after being admitted to the hospital following a motor vehicle accident. Exam: tachycardia, tachypnea, hypertension. Dx =
Delirium tremens - Defined by autonomic excitation, agitation, tremor, and altered sensorium 48 - 96h after the last drink
470
Vital sign changes (tachycardia, hypertensive), tremors, and anxiety POD 2-4. Dx =
Delirium tremens - Defined by autonomic excitation, agitation, tremor, and altered sensorium 48 - 96h after the last drink Tx: Benzo
471
Formula for sensitivity
a/a+c
472
Patient with a long history of schizoaffective disorder presents with lip smacking, sticking out their tongue, and squirming movements of the torso. Dx =
TArdive dyskinesia
473
Farmer presents to the hospital with agitation, vomiting, and watery eyes? Exam: 1 mm pupils bilaterally and increased bowel sounds. Dx =
Organophosphate (AChEi) poisoning
474
A woman presents with infertility and chronic pelvic pain with a fixed, immobile uterus on exam?
Endometriosis - Pelvic adhesions may interfere with oocyte release and/or block sperm entry, thus causing infertility; resection of lesions improves conception rates
475
Dysmenorrhea, dyspareunia, and dyschezia -=
Endometriosis
476
Elderly lady with dementia irritable and started on risperidone. Now can’t sit still. NBS?
This is akathisia (EPS from risperidone) NBS is discontinue drug, or try decreasing dose.
477
Loperamide
anti-diarrheal - Common used in opioid withdrawal
478
Patient presents with a significant smoking history that presents with daytime headaches, dizziness, and nausea. CBC reveals elevated hemoglobin levels. The patient works in a parking garage. Dx?
CO poisoning - Chronic tissue hypoxia → ↑ EPO → erythrocytosis → secondary polycythemia → ↑ hemoglobin
479
Group of individuals present with headache, nausea / vomiting, and confusion after eating at an indoor barbecue. Exam of one patient reveals tachycardia, tachypnea, and pinkish-skin hue. Dx?
CO poisoning - Diagnosis is confirmed by measuring carboxyhemoglobin levels (> 3% in non-smokers; > 10% in smokers) via CO-oximetry of ABG
480
Treatment for tinea versicolor
topical ketoconazole or selenium sulfide
481
if a patient is depressed and drove by the hardware store to get rope to hang himself, but didn't end up going in to buy it, do you still need to admit him involuntarily?
Yes
482
True/false: Hematuria a possible UTI symptom.
True
483
A prepubescent, non-sexually active minor has a Neisseria gonorrhoeae infection. NBS?
this is indicative of sexual abuse (contact CPS!)
484
Patient with a slow-growing, painless mass in the mandible. The mass recently began draining a purulent discharge with small yellow granules. The patient's history is significant for a recent tooth extraction. Dx =
Actinomyces - Gram stain often shows filamentous, branching gram-positive rods
485
Rapid Diagnosis 6-week-old baby presents with persistent, progressively increasing jaundice with high direct bilirubin and hepatomegaly.
Biliary atresia - 2-8 weeks old
486
Can a patient be diagnosed with brain death if they have intact deep tendon reflexes?
Yes - Absent brain-originating motor responses (brainstem reflexes), Apnea - Mvmts originating in spinal cord (eg, *DTRs) may be present.
487
What is the likely diagnosis in a child with sore throat who is presumed to have croup, but not responding to racemic epinephrine?
Bacterial tracheitis - nor does epiglottitis (or retropharyngeal or peritonsillar abscesses)
488
What is an upper airway condition that improves with racemic epinephrine?
Croup
489
What type of study analysis uses the data of all patients who initially enrolled in the study, including drop-outs?
Intention-to-treat analysis - A method of statistical analysis in which the initial randomized tx groups are compared regardless of the treatment they eventually receive, (ie, regardless of medication nonadherence or refusal of allocated treatment). This method preserves the balance between the two groups created by randomization and reduces selection bias
490
Which blood transfusion therapy contains fibrinogen (factor I), factor VIII and XIII, vWF, and fibronectin?
{{c1::Cryoprecipitate}}
491
Platelet transfusion is generally reserved for __________
patients with active bleeds and platelet counts < 50,000/mm3 or < 10,000 with no bleeding
492
Which blood transfusion reaction presents with respiratory distress, hypotension, and noncardiogenic pulmonary edema?
Transfusion-related acute lung injury (TRALI) - Occurs within 6h; fever and chills are common - Stop transfusion - Treated with IV fluids, vasopressors, and respiratory support - Noncardiogenic pulmonary edema means PCWP is low-normal
493
Which blood transfusion reaction is caused by donor anti-leukocyte antibodies against recipient neutrophils and pulmonary endothelial cells?
Transfusion-related acute lung injury (TRALI) - Neutrophil mediated damage results in sudden onset of hypoxemia during transfusion, resulting from capillary endothelium damage and resultant exudative fluid loss - Patients will have infiltrates on CXR
494
What transfusion reaction presents as respiratory distress, hypertension, tachycardia, and/or pulmonary edema (+/- S3 and JVD) within 6-12 hours of a transfusion?
TACO - Treat with suppl O2 + diuretics - Order a CXR to confirm pulmonary edema and exclude other causes of respiratory distress - Preventive measures incl: limiting transfusion volume, transfusing slowly, and administering pretransfusion diuretics - Compare with TRALI, which presents with signs of hypovolemia (non-cardiogenic pulmonary edema)
495
Patient develops persistent headache, confusion, difficulty concentrating, and poor sleep for the past month after hitting their head. Dx =
Post-concussion syndrome - Other manifestations include amnesia, vertigo, and mood alterations; symptoms typically resolve with symptomatic treatment within a few weeks to months following the TBI - Postconcussion syndrome (PCS) mnemonic: CASH'D Confusion Altered mood Sleep disturbances Headache Difficulty concentrating
496
Football player involved in a hard tackle, wobbly but no LOC; normal exam with no focal deficits -- next steps?
Dx = Mild concussion → remove from the game → no img needed} → gradual return-to-play protocol Mild → discharge home - No focal neurologic deficit, loss of consciousness < 60 seconds, no headache (or improving), no amnesia Severe → admit and observe - Focal neurologic deficit, loss of consciousness > 60 seconds, headache present (or worsening), retrograde or anterograde amnesia Return-to-Play Protocol - 24-48 hours rest (both physical and cognitive) - Slowly increase activity to pre-injury level (minimum 5 days & patient must be asymptomatic) - If symptoms arise during return-to-play, advise rest and return to previously tolerated activity level
497
Intermittent solid / liquid dysphagia may indicate which 2 conditions?
Eosinophilic esophagitis Esophageal spasm
498
A critically ill patient with gallbladder wall thickening / distention and pericholecystic fluid without gallstones on imaging studies. Dx =
Acalculous cholecystitis - Due to gallbladder stasis; may present with unexplained fever, RUQ pain, and leukocytosis post-surgery - Ddx. with subphrenic or subhepatic abscess (2/2 perionitis from perforated ulcer / abdominal surgery)
499
Female presents with sudden-onset unilateral pelvic pain with free fluid in the pelvis on ultrasound after strenuous exercise (eg, sex). Pregnancy test is negative. Dx =
Ovarian torsion - Free pelvic fluid helps differentiate a ruptured cyst from ovarian torsion (enlarged, edematous ovaries on ultrasound) - The timing and hCG test differentiates from ectopic pregnancy - Hemoperitoneum may present with hypotension
500
Female presents with sudden-onset unilateral pelvic pain with an enlarged, edematous ovary on ultrasound. Pregnancy test is negative. Dx =
Ovarian torsion - Absence of free pelvic fluid helps differentiate ovarian torsion from a ruptured cyst
501
What eye movement is associated with phencyclidine (PCP) intoxication?
Nystagmus
502
What drug intoxication presents with violence, psychomotor agitation, analgesia, and nystagmus?
Phencyclidine (PCP) - Patients initially may appear catatonic and rigid (PCP is a sedative hypnotic/dissociative anesthetic that generally acts as a downer), but these pts can quickly become violent + have superhuman strength - MOA: blocks NMDA receptors and inhibits reuptake of DA, NE, 5HT = SNS effects (like stimulants) - Also may present with impulsivity, tachy, HTN, psychosis, delirium, and seizures
503
What blunt chest trauma complication is characterized by unilateral decreased breath sounds and patchy, irregular alveolar infiltrate on imaging < 24 hours after the injury?
Pulmonary contusion - Symptoms of hypoxia, tachypnea, tachycardia (distress) - The infiltrate is NOT restricted by anatomical borders - The infiltrate is analogous to ARDS (due to leaky capillaries)
504
Irregular, nonlobular lung infiltrates on chest X-ray in the setting of blunt thoracic trauma. Dx =
Pulmonary contusion - Peripheral, anterior ground-glass opacities in both lungs, or one
505
What is the first-line therapy for aborting status epilepticus?
IV / IM benzodiazepines - Status epilepticus: ≥ 5 mins of continuous seizure activity (clinical or electrographic) or recurr seizures w/o recovery in between - First-line tx: Benzo (lorazepam, midazolam, diazepam) - If seizures continue: IV phenytoin / fosphenytoin, levetiracetam, or valproic acid → IV phenobarbital → general anesthesia with IV midazolam, propofol or barbiturates
506
What imaging technique is the preferred diagnostic study for toxic megacolon?
plain abdominal xray - Diagnosis is made by radiologic evidence of colonic distention with manifestations of severe systemic toxicity (eg, fever, tachy, leukocytosis, anemia) - Barium contrast and colonoscopy are contraindicated (dt risk of perforation)
507
When do you use a voiding diary?
When presentation is for mixed incontience. Like someone showing s/s of both urge and stress incontinence.
508
In a patient with atherosclerotic disease, when do you give warfarin over aspirin for embolic prophylaxis?
If the patient has A-fib or a mechanical valve
509
When do you do a carotid endarterectomy over medical management for carotid stenosis?
If asymptomatic with ≥80% stenosis ➞ carotid endarterectomy If sx (eg, TIA) with 50-70% stenosis ➞ carotid endarterectomy if no sx and stenosis is <80% ➞ medical management - Note: always give ASA (?or warfarin if A-fib or mechanical valve) after the endarterectomy
510
Main drugs causing agranulocytosis (neutropenia)?
PTU, methimazole CLozapine Sometimes if severe toxicity ➞ anti-IBD drugs (sulfasalazine...)
511
What is the effect of corticosteroids on leukocyte count
causes leukocytosis (not ↓ WBC)
512
WPW treatment
Must ablate the accessory pathway (AVRT). DO cardiac electrophysiology study first though to map out. - Note: delta waves on EKG - AVRT episodic arrhythmia life-threatening
513
What would cause a low-voltage EKG?
Pericardial effusion possibly with tamponade if hypotension
514
MCC for refractory hypertension (to meds) in old people?
Renal artery stenosis
515
Patient with refractory hypertension. ACEi is added. HTN improves but develops severe kidney disease. Dx =
Bilateral renal artery stenosis - ACEi c/I in B/L because of efferent dilation (lowers GFR) - ACEi only can be given in renal artery stenosis if it's U/L
516
initial tx for calcium level of 14.2
Normal saline - This is for Calcium ≥14 (regardless of if there are sx or not) - If calcium 12-14 ➞ only tx if sx
517
Why is there infertility in PCOS?
LH/FSH imbalance → lack of LH surge. In ovary this results in *failure of follicle maturation & oocyte release (eg, anovulation). - not 1ry ovarian insufficiency!
518
18-month-old girl with seizures, lurching gait, loss of speech, and minimal hand use. Dx =
Rett syndrome - Characterized by normal development until age 5-18 months - Deceleration of head growth is a classic feature and can be an early sign - Stereotypical hand movement - Gait abnormality - Microcephaly - Seizure - Breathing abnormalities - Sleep changes - Autistic features
519
Tx for HTN in Conn's syndrome?
mineralocorticoid (aldosterone) receptor antagonists - NOT ACEi's! - adenoma ➞ surgery -B/L hyperplasia (or adenoma + refuse surgery) ➞ meds
520
A tuning fork held over the middle of the forehead sounds louder in the left ear.  Tuning fork sounds are better heard with air conduction bilaterally.
Right-sided sensorineural hearing loss - If it were conductive, would be BC > AC in affected ear
521
What complication to watch out for with a scaphoid fracture?
Osteonecrosis
522
Young boy presents with advanced bone age, coarse pubic hair, and severe cystic acne with low basal LH levels and normal testicular exam. Dx =
Late-onset (nonclassic) congenital adrenal hyperplasia - Due to 21-hydroxylase deficiency → shunting to adrenal androgen production → peripheral precocious puberty
523
What are the only 2 contraindications to breastfeeding?
galactosemia or moms w HIV (regardless of viral load or tx)
524
A postpartum mother with hepatitis infection wants to know if she is able to breastfeed?
Yes The only absolute contraindications to breastfeeding: - Infants with classic galactosemia - Mothers with HIV (regardless of viral load or treatment) Breastfeeding is NOT contraindicated in: - Mothers with hepatitis B, hepatitis C, CMV - Mothers who smoke tobacco (though they should be encouraged to quit)
525
Premenopausal woman with aversion to sexual intercourse due to muscle spasm/pain with penetration? External pelvic examination is unremarkable. Dx?
Genito-pelvic pain / penetration disorder (vaginismus) - Treatment aimed at relaxing the vaginal muscles (eg, desensitization therapy, Kegel exercises) - Differentiated from vulvodynia - by absence of pain to superficial touch of the vaginal vestibule
526
Which female reproductive pathology may present with vaginal tissue narrowing or clitoral tissue shrinkage?
Atrophic vaginitis - vs. vulvodynia, which causes dyspareunia due to a sharp, burning pain on the vulvar vestibule often triggered by touch. Patients may have vestibular erythema but no associated vaginal tissue narrowing or clitoral tissue shrinkage
527
Child presents with unilateral hemiparesis that self-resolved within 4-hours following a seizure. Dx =
Todd paralysis - Self resolves within 36h
528
-Common options for maintenance tx for bipolar =
Lithium (reduces risk suicide) & Valproate. Also, quetiapine and lamotrigine have demonstrated effect
529
When to treat hyperkalemia?
if K+ levels ≥6.5 &/or if rapidly increasing K+ due to tissue breakdown
530
Fine crackles indicate?
Interstitial lung disease - whereas coarse wet crackles indicate pulmonary edema
531
This pt's NST is nonreactive bc has no accelerations.  Nonreactive NSTs are concerning for fetal hypoxemia and acidemia; however, MCC of a nonreactive NST is a *quiet fetal sleep cycle (which lasts ≤40 min).
532
Which congenital infection has bilateral periventricular calcifications in brain?
CMV
533
Treatment of breast milk jaundice is = Treatment of breastfeeding jaundice =
breast MILK jaundice ➞ supplementation with formula feeds breastFEEDING (lactation failure) jaundice ➞ increasing feeding frequency
534
Howell-Jolly bodies = are nuclear remnants within RBCs (typ removed by the spleen). Their presence strongly suggests *asplenia or functional hyposplenism.
535
Most effective treatments for depressive episodes in bipolar patients?
Lithium Lamotrigine quetiapine lurasidone
536
Which drug maintains patent ductus arterioles (to keep it open for surgery)?
prostaglandins (PGE1)
537
Reflexes in NMS
No hyperreflexia (just normal 2+ DTRs)
538
Tx for hyperkalemia. What level does K+ need to be at?
K+ ≥6.5
539
Tx protocol for hyperkalemia
if K+≥6.5 1st ➞ rapid IV calcium gluconate (to stabilize cardiac membrane) 2nd ➞ IV insulin + glucose (for K+ shift) 3rd ➞ eliminated K+ either: via Kidneys (diuretics), via stool (patiromer), or via blood (dialysis).
540
When is the onset of amniotic fluid embolism?
either during or immediately after delivery - Will have DIC in amniotic fluid embolism, no fever - vs PE in pregnancy ➞ any time during pregnancy up to few days after delivery
541
Fever, flank pain, and bilateral diffuse crackles in pregnancy. Dx =
pyelonephritis complicated by ARDS - ↑ progesterone → ureteral dilation → urinary stasis and hydronephrosis → pyelonephritis → ARDS - Amniotic fluid embolism would have DIC, but no fever
542
Tx s.pneumo meningitis
a 3rd gen cephalo (eg, ceftriaxone) vancomycin dexamethasone (to reduce inflammatory morbidity) Ampicillin is added if age >50 or immunocompromised (for listeria)
543
Does DIC have low or high fibrinogen?
low -Other lab evidence of DIC includes: thrombocytopenia, elevated PT and PTT. - Tx: supportive (eg, hemodynam stabilization)
544
Initial evaluation of patient presenting with mixed incontinence?
voiding diary (to help distinguish predominant type like stress vs urge)
545
What does MRI of the spinal look like in a patient with Guillain-Barre?
Often normal because only peripheral nerves affected.
546
Treatment for ruptured ectopic pregnancy with HDUS?
Surgery - HDUS because hemoperitoneum from rupture - If stable ➞ give MTX
547
Kawasaki treatment =
IVIG and aspirin!
548
HA + galactorrhea + weight gain + Brady in a 31yo woman
hypothyroidism
549
Which type of leukemia has smudge cells?
CLL
550
Which type of leukemia has auer rods?
AML
551
At what age do you start mammography breast cancer screening in women at average risk?
start at age 50 - do it every 2 years! - Stop at age 74!
552
At what age do you start pap testing for cervical cancer screening in women at average risk?
Start at age 21 - Do Pap smear q3y, until age 65!
553
At what age can you stop mammography breast cancer screening in women at average risk?
stop at age 74 - Start at age 50 - do it every 2 years! until 74 yo
554
At what age you stop pap testing for cervical cancer screening in women at average risk?
Stop at age 65 - Start age 21, continue q3y until age 65!
555
Women at average risk for cervical cancer begin pap testing at age ____ and continue every ___ year(s) up until age _____.
begin pap testing at age 21 and continue every 3 year(s) up until age 65.
556
Women at average risk for breast cancer begin mammography screening at age ____ and continue every ___ year(s) up until age _____.
begin at age 50 and continue every 2 year(s) up until age 74
557
558
Most appropriate pain management for patient w advanced prostate cancer with bony metastasis, status-post orchiectomy?
{{c1::Radiation therapy}} - Think I remember seeing this on NBME or something - Bisphosphonates are useful for controlling chronic pain, but radiation is more helpful for acute pain; anti-androgen therapy is not needed in patients that have undergone orchiectomy - External beam radiotherapy (EBRT) is the preferred treatment for patients with localized skeletal metastasis, providing pain relief and improved mobility
559
BCC
560
What is the immediate tx for severe hypercalcemia (> 14 mg/dL or symptomatic)?
{{c1::Normal saline and calcitonin::2}} - Calcitonin + NS substantial = are effective within 12 - 48 hrs - Bisphosphonates are effective by 2nd to 4th day and provide a more sustained effect, thereby maintaining control of the hypercalcemia - IV fluids will promote urinary excretion of calcium - Calcitonin "tones down" calcium and prevents bone resorption - Consider hemodialysis for refractory life-threatening hypercalcemia, or if other therapies are c/i
561
irregular patches of hair loss with broken hair shafts of differing lengths. Dx =
Trichotillomania - Erythema (characteristic of tinea capitis) and total hair loss in those areas (as seen in alopecia areata) are not present
562
Presence of pulsus paradoxus indicates what?
Cardiac tamponade!
563
FEV1 65% of predicted FVC 58% of predicted FEV1/FVC 85% Obstructive or restrictive?
Restrictive - decreased (<80% of predicted) FEV1, FVC, and TLC.  - As both FEV1 and FVC are decreased somewhat proportionally, the FEV1/FVC ratio remains normal or may be increased
564
Prevent TIA in A-fib patients with which drug?
Anticoagulation with warfarin or DOAC (incas Xa inhibs like rivaroxaban)
565
seizure microcephaly chorioretinitis which congen infect ?
Congenital toxoplasmosis - Can have microcephaly (brain atrophy) OR macrocephaly (hydrocephalus) depending - Also diffuse intracranial calcifications - I thought it was CMV
566
30F w 4d hx B/L lower extremity weakness + numbness. incident of urinary incontinence today. No PMHx, no meds. Exam: Upper extremities nl, but both legs diffusely weak w incr DTRs w extensor plantar response.  Sensation to pinprick is decr below level of umbilicus, and vibration is absent in toes.  Dx?
Transverse myelitis - answer was: segmental inflammation of the spinal cord - Has autonomic dysfunction w bowel/bladder dysfunction (eg, urine incont) -Tx: IV glucocorticoids
567
muscle weakness + weight gain + bone demineralization + hypertension + 3mo hirsutism Dx?
Cushing syndrome or hypercortisolism - The muscle weakness is d/t muscle atrophy (glucocorticoid-induce myopathy)
568
Normal expected rate of cervical change in active phase labor
≥1cm every 2 hours! - Note: active phase is when cervical dilation ≥6-10cm
569
Biphasic stridor that improves w neck extension Dx?
Vascular ring
570
Infant with inspiratory stridor that worsens with feeding, crying, or prone position. Dx?
Laryngomalacia - Floppy supraglottis
571
AOM kid treated with abx, but symptoms persist NBS?
oral abx - initially gave amoxicillin - If sx persist ≥2d after 1st abx or if recurr AOM within 30d ➞ give amox/clav
572
Mucopurulent discharge urethral meatus + mult sex partners Urinalysis: ↑ WBC, (+) leukocyte esterase Gram stain of urethral discharge shows no organism Culture of discharge and urine show no growth after 48h Dx?
Chlamydia urethritis - Dx can be made with NAAT of clean catch urine - Tx: azithro or doxy
573
Young female with hypokalemia, metabolic alkalosis, normotension, low urine Cl-. Dx =
Surreptitious vomiting - Lose HCl and KCl via stomach - Low urine Cl- helps disting vomiting from other causes of hypokalemia, alkalosis, and normotension (eg, diuretic abuse, Bartter syndr, and Gitelman syndr which all have high urine chloride)
574
What acid-base disturbance is classically found in patients with laxative abuse?
Metabolic alkalosis - Vs. the metabolic acidosis typically found with diarrhea - In laxative abuse, osmotic losses of K+ → hypokalemia → cellular buffering → H+ moves into cell → alkalosis - In secretory diarrhea, ↑ cAMP → activation CFTR Cl- channels → ↑ Cl-/HCO3- exchange → bicarb loss in stool → acidosis
575
What acid-base disorders are associated with aspirin (salicylate) toxicity? Early vs late
Early: {{c1::pure resp alkalosis}} Late (> 12h): {{c1::mixed resp alkalosis and metabolic acidosis}} w {{c1::normal}} pH - Resp alkalosis (d/t ↑ resp drive); metabolic acidosis (d/t ↑ production/ ↓ elim of organic acids and anaerobic metabolism; use Winter formula to make sure there's 2 coexisting primary issues - The PaCO2 will be lower than the predicted resp compensation by Winter formula (d/t concur resp alkalosis) - Sx of fever, tinnitus, tachypnea - Early: ASA stimulates medullary resp center Medium: ASA is an acid ➞ forms lactic acid and causing metabolic acidosis
576
What acid-base disorder may be caused by thiazide diuretics?
{{c1::Metabolic alkalosis}}
577
Winter's formula: If the measured (actual) PCO2 < predicted PCO2, then the metabolic acidosis has a concomitant ________
{{c1::respiratory alkalosis}} - PCO2 = 1.5[HCO3-] + 8 ± 2
578
What is winter's formula?
PCO2 = 1.5[HCO3-] + 8 ± 2 - If measured (actual) PCO2 < predicted PCO2 ➞ then the metabolic acidosis has a concomitant resp alkalosis!
579
Cushing syndrome is more likely to present with hypokalemia or hypocalcemia?
Hypokalemia! - Excess cortisol binds mineralocorticoid-Rs ➞ causing ↑ retention of water + Na+, w ↑ excr K+ and H+ - These mechanisms lead to hypernatremia + HTN as well as hypokalemia + metabolic alkalosis
580
Group A strept is also known as ______
S.pyogenes
581
582
Which of these two murmurs is louder with Valsalva? Aortic stenosis or HOCM
HOCM
583
Which transfusion reaction causes DIC?
Acute hemolytic transfusion rxn (AHTR)
584
Military recruit collapses during training on a hot, humid day. Disoriented fever 105.8 °F (41 °C) bleeding from the nose
{{c1::Exertional heat stroke}} - vs. heat exhaustion = Presents: lower-grade fever (< 104 °F) and no AMS - DIC → coagulopathic bleeding
585
DIC labs = Platelet count PT PTT Fibrinogen D-dimer
Platelet count ↓ PT ↑ PTT ↑ Fibrinogen ↓ D-dimer ↑
586
Indications for sequential PCV15 vaccine, followed by PPSV23 vaccine 6-12 months later, in adults?
{{c1:: Age ≥ 65 or if ≥ 65 ➞ give if very high risk patients (asplenia, cochlear implants, immunocompromised, CKD)
587
African-American male presents w fever, jaundice, dark urine and the periph smears attached?
{{c1::Glucose-6-phosphate dehydrogenase (G6PD) deficiency}} - Blood smear shows bite cells (first photo) and Heinz bodies (second photo)
588
HIV w CD4+ 175/mm3 presents w fever, dry cough, and hypoxia. Labs: elevated LDH CXR: diffuse, bilateral infiltrates
Pneumocystis pneumonia - Severe hypoxia and B/L interstitial infiltrates in HIV pt w CD4+ < 200/favors this dx; post-transplant pts have a more acute course -Tx: TMP-SMX -Note: the difference in presentation bw AIDS (indolent) vs immunocompromised (acute resp failure)
589
Poorly controlled HIV + develops multiple violaceous papules in groin region?
Kaposi sarcoma (HHV-8 infection) - Lesions can present in a variety of colors that can incl: purple, pink, red, and brown on LEs, face (esp. nose), and oral mucosa.
590
1 week following a stressful event, would hallucinations be characteristic of acute stress disorder?
NO - This would be a characteristic of brief psychotic disorder - Brief psychotic disorder is usually {{c1::stress}} related

USMLE Step 2 CK (4 decks)

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