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1
Q

Harsh, holosystolic murmur best heard the LLSB?

A

VSD

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2
Q

Next step in the setting of a suspected VSD murmur?

A

Echocardiogram to determine location and size, and to r/o other defects

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3
Q

Next steps if VSD is identified?

A

Large/symptomatic -> repair

Small -> close spontaneously in 75% of children by age 2 with no sequelae

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4
Q

Characteristics of large VSD murmur compared to small?

A

Softer (less turbulence across a larger defect)

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5
Q

Sequelae of large VSD?

A

Pulmonary overcirculation, pulmonary HTN, growth failure, CHF, Eisenmenger syndrome

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6
Q

Typical characteristics of innocent flow murmur of childhood?

A

Grade I or II midsystolic ejection murmur, decreases with standing/Valsalva
Low-pitched, musical, pure, or squeeky tone at LLSB (Still’s) or high-pitched at LUSB (pulmonary flow)

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7
Q

Differentiate thalassemia minor from iron deficiency anemia.

A

Both are microcytic

Iron deficiency: elevated RDW, decreased RBCs, decreased reticulocyte count

Thalassemia: normal RDW, normal RBC count, elevated reticulocyte count

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8
Q

Vitamin B12 deficiency is common after total or partial gastrectomy due to loss of intrinsic factor, and ultimately leads to megaloblastic anemia. What is the pathogenesis?

A

B12 is a necessary cofactor in purine synthesis and its deficiency causes defective DNA synthesis. This results in ineffective erythropoiesis and high numbers of immature megaloblasts in the bone marrow.

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9
Q

3 first-line treatments for smoking cessation?

A
  1. Nicotine replacement therapy
  2. Varenicline
  3. Bupropion

All in conjunction with counseling and supportive therapy

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10
Q

Next step in management of a second-degree perineal laceration with localized pain particularly with voiding and perineal edema in the immediate postpartum period?

A

Normal -> supportive care with NSAIDs and sitz baths

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11
Q

Cell-free fetal DNA testing is non-invasive and highly sensitive/specific as a screening test for fetal aneuploidy. It can be ordered at ___ weeks gestation; what should be done if it is abnormal?

A

10+ weeks

Confirm results by chorionic villus sampling at 10-12 weeks or amniocentesis at 15-20 weeks

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12
Q

Earliest available screening for aneuploidy?

A

First-trimester combined test (nuchal translucency, beta-hCG, pregnancy-associated plasma protein) -> 9-13 weeks

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13
Q

Which prenatal testing methods provide definitive karyotpic diagnosis?

A

Chorionic villus sampling

Amniocentesis

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14
Q

What is electrical alternans?

A

Varying amplitude of the QRS complexes

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15
Q

Electical alternans with sinus tachycardia is a highly specific sign for ___.

A

Large pericardial effusion

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16
Q

Rx supraventricular and ventricular tachycardias, particularly in WPW?

A

Procainamide

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17
Q

The majority of patients with mammary Paget disease (painful, itchy, eczematous, and/or ulcerating rash on the nipple that spreads to the areola) have an underlying breast ___.

A

Adenocarcinoma

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18
Q

Presentation - palpable, mobile, rubbery, firm breast mass without nipple changes

A

Fibroadenoma

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19
Q

Most common cause of acute back pain?

A

Lumbosacral strain

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20
Q

List the 6 major findings of Kawasaki disease.

A
  1. Fever for 5+ days
  2. Cervical lymph node >1.5 cm
  3. Rash
  4. Swelling and/or erythema of palms/soles
  5. Bilateral non-exudative conjunctivitis
  6. Mucositis

(need 4/5 in addition to fever)

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21
Q

Rx Kawasaki disease

A

IVIg within 10 days of fever onset to decrease risk of coronary artery aneurysm

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22
Q

Koplik spots?

A

Pathognomonic for measles

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23
Q

In severe, chronic aortic regurgitation, the left ventricle responds to volume overload in what manner and why?

A

Eccentric hypertrophy to increase LV compliance and contractility, allow for an increase in SV to maintain CO -> temporary asymptomatic period

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24
Q

What causes concentric LVH and how are sarcomeres added?

A

Pressure overload (chronic HTN, aortic stenosis)

Sarcomeres added in parallel

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25
What causes eccentric LVH and how are sarcomeres added?
Volume overload (AR/MR, ischemic heart disease, dilated cardiomyopathy) Sarcomeres added in series
26
Sensorimotor polyneuropathy in diabetes is characterized by length-dependent axonopathy. Small fiber involvement causes ___, whereas large fiber involvement causes ___.
Small: pain and paresthesias Large: numbness, loss of proprioception and vibration sense, diminished ankle reflexes
27
Why do patients with CF sometimes present with bleeding diathesis?
Fat-soluble (ADEK) vitamin deficiency due to poor absorption from pancreatic insufficiency -> vitamin K is an important cofactor in activation of factors 2, 7, 9, 10, protein C and protein S
28
Typical lab findings in Vitamin K deficiency?
``` Increased PT and INR Normal aPTT (unless severe) ```
29
Typical lab findings of factor VIII deficiency (such as Hemophilia A)?
Increased aPTT, normal PT/INR
30
Pathogenesis of PSGN?
IC deposition in the glomerular mesangium and basement membrane -> complement system activation -> C3 accumulation in deposits
31
Lab findings in acute PSGN?
UA: +protein, +blood, +/- RBC casts Serum: decreased C3, possible decreased C4, increased serum Cr, increased anti-DNase B and AHase, increased ASO and anti-NAD
32
Presentation - microscopic or gross hematuria in childhood, sensorineural hearing loss, ocular defects
Alport syndrome (X-linked defect of type IV collagen)
33
Presentation - hematuria, proteinuria, respiratory symptoms
Goodpasture disease (IgG autoAb against glomerular and alveolar BM)
34
Two general presentations of vascular rings?
If encircling the trachea -> biphasic stridor that increases with increased work of breathing If encircling the esophagus -> solid-food dysphagia, vomiting, recurrent food impactions
35
Work-up/diagnosis of vascular rings?
Fluoroscopic esophagography -> compression CT scan -> delineate anatomy, evaluate associated abnormalities Direct laryngoscopy, bronchoscopy, echo -> possible concurrent cardiac/airway abnormalities
36
Most common cause of parathyroid hormone-independent hypercalcemia?
Humoral hypercalcemia of malignancy
37
Steps in diagnosing hypercalcemia?
1. Confirm (repeat testing, correct for albumin or measure ionized Ca2+) 2. Measure PTH 3a. If high-normal or elevated, PTH dependent 3b. If suppressed, PTH-independent -> 4. Measure PTHrP, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D
38
Most common cause of amaurosis fugax (painless, rapid, transient monocular vision loss)?
Retinal ischemia due to atherosclerotic emboli originating from the ipsilateral carotid artery
39
What is ocular tonometry used for?
Measuring intraocular pressure in patients with acute angle-closure glaucoma
40
Cause of laryngomalacia?
Collapse of supraglottic tissues on inspiration
41
Presentation of laryngomalacia?
Chronic inspiratory stridor that worsens when supine, improved when prone Peak at age 4-8 months
42
Dx laryngomalacia?
Visualization of the larynx with flexible fiberoptic laryngoscopy -> omega-shaped epiglottis, collapse of supraglottic structures during inspiration
43
What Rx often improves symptoms of laryngomalacia?
Rx of GER
44
Outcome of laryngomalacia?
Most will feed, grow, and ventilate normally with spontaneous resolution by 18 months
45
Common cause of chronic cough?
ACEIs
46
What is erythema nodosum?
Painful, subcutaneous nodules most common on the anterior legs
47
If erythema nodosum is identified in a patient, what is the next step and why?
Labs (CBC, LFTs, renal function) Antistreptolysin-O antibodies TB skin testing CXR - assess for sarcoidosis and TB Can be an early sign of more serious disease (streptococcal infection, sarcoid, TB, endemic fungal disease, IBD, Behcet) and identification of the cause may prevent morbidity
48
What is the key historical question to ask when beginning an evaluation for dysphagia?
Is there a history of difficulty initiating swallowing with cough, choking, or nasal regurgitation? If yes -> likely oropharyngeal dysphagia If no -> likely esophageal dysphagia
49
If oropharyngeal dysphagia is suspected, what is the next step?
Videofuoroscopic modified barium swallow
50
If esophageal dysphagia is suspected, what is the next question to ask?
Dysphagia with solids AND liquids at onset -> motility disorder Dysphagia with solids progressing to liquids -> mechanical obstruction
51
If a motility disorder is suspected, what is the next step?
Barium swallow followed by possible manometry
52
If a mechanical obstruction is suspected, what is the next step?
If history of prior radiation, caustic injury, complex stricture, or surgery from esophageal/laryngeal cancer -> barium swallow followed by possible endoscopy If no -> upper endoscopy
53
Renal artery stenosis typically presents with uncontrolled hypertension. What is a highly specific exam finding? What is seen on imaging?
Lateralizing abdominal bruit Atrophy of the affected kidney
54
Describe the effects of renal artery stenosis on the RAAS system.
Decreased renal perfusion of the affected kidney (post-stenotic, atrophy) -> increased renin secretion -> RAAS system -> secondary hyperaldosteronism -> HTN -> unaffected kidney experiences high systemic pressures -> suppresses local renin secretion
55
Initial treatment of choice in asymptomatic or mildly symptomatic patients with hyponatremia due to SIADH?
Fluid restriction
56
DDx - hypervolemic hyponatremia?
Heart failure Renal failure Liver cirrhosis
57
DDx - hypovolemic hyponatremia?
Dehydration
58
DDx - euvolemic hyponatremia?
SIADH
59
MOA - demeclocycline?
Decreases responsiveness to ADH at the level of the renal collecting tubule (treat SIADH if conservative measures fail to treat)
60
In a normal distribution, how are the mean, median, and mode related?
They are all equal.
61
In a positively skewed distribution (tail on the right), how are the mean, median, and mode related?
Mean > median > mode
62
In a negatively skewed distribution (tail on the left), how are the mean, median, and mode related?
Mean < median < mode
63
Horner syndrome + cervical paravertebral mass?
Neuroblastoma
64
Neuroblastoma arises from neural crest cells, which are precursors to what structures?
Sympathetic ganglia | Adrenal medulla
65
Possible clinical features of neuroblastoma?
``` <2 y/o Abdominal mass periorbital ecchymoses (orbital mets) Spinal cord compression from epidural invasion (dumbbell tumor) Opsoclonus-myoclonus syndrome Horner syndrome ```
66
Diagnostic findings of neuroblastoma?
Elevated catecholamine metabolites Small, round blue cells on histology N-myc gene amplification
67
Cause of acute contralateral hemiparesis?
Lacunar stroke leading to internal capsule infarct
68
Findings of early septic shock?
Hyperdynamic CV state in response to peripheral vasodilation with capillary leak and intravascular hypovolemia -> increased SV, HR, pulse pressure -> bounding peripheral pulses
69
Define pulsus paradoxu?
20+ mm Hg drop in systolic blood pressure with inspiration
70
Pulsus paradoxus is most commonly seen in patients with ___.
Cardiac tamponade
71
Cause of Meniere disease?
Increased volume and/or pressure of endolymph
72
While Meniere is a clinical diagnosis, what should be done as part of the work-up?
Audiometry to fully characterize/follow hearing loss MRI to r/o CNS lesions
73
Lab findings of Addison's disease (primary adrenal insufficiency)?
``` Aldosterone deficiency Non-anion gap metabolic acidosis Hyperkalemia Hyponatremia Hypercalcemia Eosinophilia ```
74
4 general etiologies of primary adrenal insufficiency?
AI Infection (TB, HIV, fungal, etc.) Hemorrhagic infarction (meningococcemia, anticoagulants, etc.) Metastatic cancer (eg, lung)
75
Dx primary adrenal insufficiency?
Measure ACTH and serum cortisol with high-dose (250 micrograms) ACTH stimulation test Primary: low cortisol, high ACTH Secondary/tertiary: low cortisol, low ACTH
76
Characteristics of a pathologic murmur?
Harsh, holosystolic, diastolic Grade III+ Increases with standing/Valsalva Loud, fixed split, or single S2
77
EKG findings of hypertrophic cardiomyopathy?
LVH: tall R wave in aVL + deep S wave in V3 Repolarization changes in anterolateral leads (I, aVL, V4, V5, V6)
78
If an initial pen light exam does not reveal any conjunctival and corneal abrasions or foreign bodies in the setting of a high-velocity ocular injury, what should be done next?
Fluorescein examination; if not demonstrated, but high suspicion remains, CT or U/S; NEVER MRI (magnetic)
79
Possible exam findings of HSV encephalitis?
Hemiparesis, CN palsies, hyperreflexia
80
Possible CSF findings of hSV encephalitis?
Increased WBCs (lymphocytic predominance) Normal glucose Increased protein Often increased RBC
81
Rx HSV encephalitis
IV acyclovir immediately after obtaining CSF
82
Rx cryptococcal meningoencephalitis?
IV amphotericin + flucytosine
83
Compare the symptoms of neurogenic vs. vascular claudication.
Neurogenic: - Posture-dependent pain - Lumbar extension worsens, flexion relieves - Lower-extremity numbness/tingling/weakness - LBP Vascular: - Exertionally-dependent - Rest relieves - Lower-extremity cramping/tightness, NO weakness - Possible buttock, thigh, calf, or foot pain

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