7s HEAVEN Flashcards
(98 cards)
1
Q
in central retinal artery occlusion, what does funduscopic exam show?
A
The retina is pale/whitened with a cherry red macula!
2
Q
pt with a painful, red eye (scleral injection) and opacification and ulceration of the cornea. he uses extended-wear contact lense and had difficulty removing the lenses last week. what is this? what bug causes it?
A
Contact lens-associated keratitis (infx of the cornea)
most cases are due to gram negatives like PSEUDOMONAS and serratia
3
Q
what is the most common brain tumor in children? bc of its location, it classically presents w/ seizures, weakness, and sensory changes; as well as signs of increased ICP.
A
Low-grade astrocytoma (pilocytic astrocytoma)
*glioblastomas are also supratentorial, high-grade astrocytic tumors that typically arise in the cerebral hemispheres and present w/ seizures and signs of increased ICP, but they are much less common than low-grade astrocytomas in children!
4
Q
how do you manage mild to moderate cancer-related pain when nonopioid analgesics are no longer effective?
A
short-acting opioids (morphine, hydromorphone, oxycodone)
- the dose and schedule can be varied depending on the pt’s pain pattern
- if the pt has pain requiring frequent dosing or if bedtime dosing does not provide adequate relief through the night, a long-acting opioid (sustained-release morphine) may be added
5
Q
when are antibiotics indicated in treatment of COPD acute exacerbation?
A
indicated in moderate-severe COPD exacerbation, defined as >/= 2 of the cardinal symptoms (increased dyspnea, increased cough, sputum production-change in color/volume) – especially indicated if there is increased sputum purulence
also indicated if mechanical ventilation is required (endotracheal intubation or noninvasive positive pressure)
6
Q
vaginal pruritus and discharge is CC of pt. on exam, she has thick yellow cervical discharge and the cervix easily bleeds on contact with a swab. what is empiric tx?
A
azithromycin and ceftriaxone
this pt has acute cervicitis with mucopurulent discharge and a friable cervix –either chlamydia or gonorrhea
7
Q
what drugs are commonly associated with SIADH? (elder pts are especially at risk)
A
SSRIs!!!!
also carbamazepine and NSAIDs
8
Q
how is diagnosis of a solid testicular mass made? and what is the initial management?
A
a painless hard mass felt in the testicle + suggestive ultrasound = DX
initial managment is removal of the testis and it’s associated cord – ORCHIECTOMY
9
Q
what is the mechanism by which vagal maneuvers (carotid sinus massage, cold-water immersion or diving reflex, Valsalva maneuver, eyeball pressure) slow the heart rate or terminate atrioventricular nodal reentrant tachycardia?
A
vagal maneuvers increase parasympathetic tone in the heart, resulting in a temporary slowing of CONDUCTION IN THE AV NODE and an increase in the AV node refractory period!
10
Q
what is necessary for diagnosis of ankylosing spondylitis?
A
demonstrating radiographic changes of the axial skeleton! – first get plain X-RAY of the pelvis, which will show SACROILIITIS
x-rays may be negative in early stages, in which cases MRI can confirm sacroiliitis
(fusion of the vertebral bodies with ossification of intervertebral discs [bamboo spine] is also suggestive of the dx)
***HLA-B27 is not specific for AS (even though there is a strong association) and is not necessary for dx
11
Q
a pt had speech and motor delays in early childhood and also displays features of ADHD and autism spectrum disorder in the classroom. Genetic testing demonstrates a significant CGG’ trinucleotide repeat expansion. what does he have? what is the classic phenotype?
A
Fragile X syndrome – x-linked disorder with expansion of CGG’ trinucleotide repeats in the fragile X mental retardation 1 gene on the X chromosome
classic phenotype in affected males: large head, long face, prominent forehead, protruding ears, and macroorchidism
12
Q
pelvic cramping during the first few days of menses with radiation to the upper thighs and back. physical exam is normal. what is this?
A
primary dysmenorrhea (caused by increased prostaglandin release from endometrial sloughing during menses)
*in contrast, endometriosis presents as tenderness along the uterosacral ligaments, nodularity in the cul-de-sac, and adnexal enlargement due to an endometrioma. Pain from endometriosis usually precedes menses by a few DAYS.
13
Q
in hyperosmolar hyperglycemic state in type 2 DM, what is the reason for the altered sensorium?
A
neurologic symptoms (ranging from confusion to coma) are attributed to HIGH SERUM OSMOLALITY! (usually >320 mOsm/kg)
14
Q
52 yo man presents with decreased libido and inability to achieve/maintain erections. he also has fatigue, anorexia, and weight loss. he drinks alcohol. exam shows b/l gynecomastia and firm but small testes. lab shows normal TSH and decreased total T3 and T4. what is the dx?
A
Chronic liver disease (w/ cirrhosis)
- cirrhosis can cause hypogonadism due to primary gonadal injury or hypothalamic-pituitary dysfunction, leading to erectile dysfunction and testicular atrophy
- also associated w/ elevated circulating levels of estradiol (increased conversion from androgens), with findings of telangiectasias, palmar erythema, testicular atrophy, and gynecomastia
- cirrhosis also leads to decreased synthesis of serum binding proteins for thyroid hormones (thyroxine-binding globulin, etc), which lowers TOTAL T3 and T4 in circulation, however free T3 and T4 level are unchanged, and TSH will be normal (euthyroid status)
15
Q
what is observer bias?
A
when the investigator’s decision is adversely affected by knowledge of the exposure status
16
Q
what is selection bias?
A
it results from the manner in which the subjects are selected for the study, or from the selective losses from the f/u
17
Q
what is Winter’s formula? which is used to determine appropriate respiratory compensation in the case of a metabolic acidosis.
A
arterial pCO2 = 1.5 [HCO3] + 8 +/- 2
if appropriate compensation is not occurring, a mixed acid-base disorder may be present
18
Q
what are the most common causes of secondary clubbing of the digits?
A
LUNG MALIGNANCIES
cystic fibrosis
right-to-left cardiac shunts
19
Q
What are the Jones criteria (major and minor) for diagnosing acute rheumatic fever? and how many major or minor criteria must you meet for diagnosis?
A
Dx = evidence of a preceding Group A strep infx along with 2 major criteria, or 1 major + 2 minor criteria
Major criteria: Joints (Migratory arthritis), O (Carditis), Nodules (subcutaneous), Erythema marginatum, Sydenham chorea
Minor criteria: fever, arthralgias, elevated ESR/CRP, prolonged PR interval
20
Q
what should you offer mom if fetus is breach at 37 weeks of gestation and she wants a vaginal delivery?
A
External cephalic version – manual conversion of the fetus to vertex presentation
-a pt w/ a singleton breech fetus w/ no contraindications to vaginal delivery (eg, placenta previa, active herpes lesion, prior classical c-section [low transverse not contraindicated]) and no contraindications to ECV (eg, ruptured membrane, abnormal fetal heart tracing, oligohydramnios) SHOULD BE OFFERED ECV AT >/= 37 WEEKS GESTATION
21
Q
how should you evaluate minimal bright red blood per rectum based on age groups?
A
< 40 = anoscopy
40-49 = sigmoidoscopy
>50 = colonoscopy
22
Q
what is the most common cause of bacterial pneumonia in young children with CF?
A
staph aureus!!!
**especially in those with coexisting influenza infx!
OMG plz remember this
23
Q
in pts w/ Paget disease of bone, what do lab tests usually show?
A
Elevated Alk Phos
Elevated bone turnover markers like URINE HYDROXYPROLINE and PINP
NORMAL Ca and phosphorus!!
24
Q
HIV pt has a PPD skin test with >5mm induration and CXR is normal. He has no symptoms. How do you treat him?
A
Tx latent TB with 9 months of ISONIAZIDE + pyridoxine
25
how does acute interstitial nephritis present? what drugs cause it?
maculopapular rash, fever, new drug exposure, +/- arthralgias
labs show AKI, pyuria, hematuria, WBC casts, eosinophilia, URINARY EOSINOPHILS
drugs that can cause it = penicillins, cephalosporins, *TMP-SMX*, rifampin, NSAIDs, and diuretics
(can also be caused by infectious agents- Legionella, TB, strep)
26
what electrolyte abnormality can Trimethoprim cause, especially at high-doses (which may be required when treating HIV pts)?
Hyperkalemia!!
- due to blockade of the epithelial Na channel in the collecting tubule
- it also competitively inhibits renal tubular creatinine secretion and may cause an artificial increase in serum creatinine w/o affecting GFR
27
in a pt that drinks a lot of alcohol (which is also evident by their macrocytic anemia, thrombocytopenia, and >2:1 ratio of AST to ALT) and has signs of decompensated CHF, what measure is most likely to reverse their heart function?
complete abstinence from alcohol!!
- Alcoholic cardiomyopathy (a dx of exclusion) is dilated cardiomyopathy in pts with a hx of alcohol abuse and there is no other potential cause of cardiomyopathy suspected or identified
- the degree of LV dysfunction is directly related to the daily amount and overall duration of alcohol intake
- abstinence is associated with improvement or normalization of LV function over time
28
what are the characteristics of fetal hydantoin syndrome, usually caused my phenytoin or carbamazepine use in pregnancy?
```
midfacial hypoplasia
microcephaly
cleft lip and palate
digital hypoplasia
hirsutism
developmental delay
```
29
pt was in a bad car wreck. CXR shows persistent pneumothorax despite chest tube placement and pneumomediastinum, and he has subcutaneous emphysema (palpable crepitus below the skin) on PE. what is this most likely?
Tracheobronchial rupture
-right mainstem bronchus is most commonly injured
*esophageal rupture following blunt trauma is rare!! manifestations would include pneumomediastinum and pleural effusions
30
how is Mg excreted?
Mg is solely excreted by the kidneys!!
| *so a common risk factor for Mg toxicity is renal insufficiency!!
31
what is the most beneficial long-term tx for stress urinary incontinence?
Urethral sling surgery!!
- stress urinary incontinence is associated w/ urethral hypermobility w/ or w/o pelvic organ prolapse (cystocele)
- all pts should be advised to do Kegel exercises (1st suggestion before jumping to surgery)
32
name this defense mechanism:
| an individual transforms unacceptable emotions or impulses into their extreme opposites.
Reaction formation
*ex: a woman is pissed about having to care for her neglectful father. she masks these unacceptable angry emotions by professing to be happy that her father is living with her.
33
pt with a Marfanoid body habitus in addition to fair hair and eyes, developmental delay, and cerebrovascular accident. what is this?
Homocystinuria
Dx made be on elevated homocysteine and methionine levels
Tx includes vit B6, folate, and vit B12 to lower homocysteine levels. also antiplatelets or anticoagulation should be given to prevent stroke, coronary heart dz, and venous thromboembolic dz
34
what drug frequently prescribed in the treatment of acne commonly causes a phototoxic drug reaction?
Doxycycline!
35
an HIV pt with a CD4 count <50 has fatigue, low-grade fever, wt loss, and frequent, low-volume stools that are often bloody. what organism is causing his diarrhea?
CMV!!
in contrast, MAC does infect with a CD4 count <50, but pts have Watery diarrhea and a high fever.
36
what is the condition that classically affects new mothers who hold their infants with the thumb outstretched (abducted/extended)?
pain can be elicited with direct palpation of the radial side of the wrist at the base of the hand.
De Quervain tenosynovitis
-inflammation of the abductor pollicis longus and extensor pollicis brevis tendons as they pass through a fibrous sheath at the radial styloid process
Also the Finkelstein test, which is conducted by passively stretching the affected tendons by grasping the flexed thumb into the palm with the fingers, elicits pain.
37
what skin cancer is especially common in pts who have a hx of organ transplant and are on chronic immunosuppressive therapy?
Squamous cell carcinoma
| - these lesions often become keratinized (with a thickened, rough surface) or ulcerate with crusting and bleeding
38
how does vertebral osteomyelitis usually present?
PE usually shows exquisite focal tenderness on percussion at the posterior spinous process of the affected vertebra, increased muscle spasm in the contiguous area, and decreased range of motion in the back
leukocyte count may be normal, but ESR and CRP are usually markedly elevated
plan x-rays can be normal in the first few weeks so you should get an MRI
39
what are possible complications of primary biliary cholangitis?
malabsorption, fat-soluble vitamin deficiencies
metabolic bone dz (osteoporosis, osteomalacia**)
hepatocellular carcinoma
40
pt with multiple male sexual partners and weight loss. he has a mole he wants you to look at. it was originally a pink papule and has developed into a violet, enlarging macule. what is this lesion?
Kaposi sarcoma -- caused by HHV-8 (and HIV, coinfection)
41
what is the cause of the RUQ abdominal pain in pregnant pts with HELLP syndrome?
due to liver swelling with distension of the hepatic (Glisson's) capsule
-swelling may be caused by centrilobular necrosis, hematoma formation, or thrombi in the portal capillary system
42
name this lesion:
a common epidermal tumor seen in middle-aged/elder people. may be found anywhere except palms and soles. can vary in appearance form nearly flat macules to raised, wart-like lesions, and can be pink/white, brown, or black. velvety or greasy surface with well-demarcated border. often described as "stuck-on" in appearance. occasionally pruritic or tender. benign lesions.
Seborrheic keratosis
43
what is the empiric tx for immunocompromised (transplant recipients on immunosuppressants) pts suspected of having bacterial meningitis? what bugs are you covering for?
Vancomycin + cefepime + ampicillin
Cefepime (4th gen cephalosporin) covers the major organisms -- Strep pneumo, N meningitidis, GBS, Haemophilus -- as well as pseudomonas (gram neg rods)
Vanc covers cephalosporin-resistant pneumonococci
Ampicillin covers for Listeria
44
young kid has seizures, mental retardation, and a port wine stain along the territory of the trigeminal nerve. can develop glaucoma. Skull x-ray reveals gyriform intracranial calcifications that resemble a tramline. what is this?
Sturge-Weber syndrome
45
what is first-line maintenance pharmacotherapy for pts with bipolar disorder that had inadequate response to monotherapy and/or severe episodes (psychotic features, aggression, high risk of suicide, frequent episodes with marked impairment requiring hospitalization)?
Lithium or valproate combined with a 2nd gen antipsychotic (eg, quetiapine)
*antidepressants should generally be avoided in the maintenance tx of bipolar I disorder due to the risk of mood destabilization
46
In Guillain-Barre syndrome, neuromuscular respiratory failure is the most life-threatening complication. after dx of GBS, what is the most important next step in assessing the pts pulmonary function?
Serial Spirometry!
- measurement of FVC is the gold standard for assessing ventilation; a decline in FVC (especially < 20 ml/kg) indicates impending respiratory arrest requiring endotracheal intubation
*if spirometry is not readily available or is difficult in an unstable pt, then you can do peak flow meter testing (but this is less accurate)
47
pt has recurrent episodes of acute, severe right periorbital pain accompanied by autonomic manifestations (eg, ipsilateral miosis, lacrimation) but no vision changes. they often begin during sleep and occur multiple times. two years ago he had similar episodes daily for about a month. what is this? what can quickly improve his current condition?
Cluster headaches
100% oxygen by facemask is the most rapid-acting and effective abortive tx
(subcutaneous sumatriptan can also be used)
*as the attacks are short but severe, prophylactic meds (verapamil, lithium) are the key to management
48
what is the approach to treatment of ITP in kids vs adults?
Children:
- skin manifestations only = observation (regardless of platelet count)
- bleeding = IVIG or glucocorticoids
Adults:
- platelet count > 30,000 w/o bleeding = observation
- platelet count < 30,000 OR bleeding = IVIG or glucocorticoids
49
the anemia of chronic kidney disease is due to EPO deficiency. when starting EPO replacement therapy, what may be rapidly depleted and need supplementation?
Iron!
-EPO stimulates production of more RBCs, and causes a surge in iron usage, which can rapidly deplete the body's irons stores, leading to a microcytic anemia
50
what drug is considered first-line tx for chemotherapy-induced nausea? (and what type of drug is it?)
Ondansetron -- a Serotonin (5HT) receptor antagonist that targets the 5HT3 receptor
51
how does serum sickness-like reaction (a type III hypersensitivity reaction) usually present? what drugs commonly cause it?
Fever, urticaria, and polyarthralgia with no mucosal involvement
typically occurs 1-2 weeks after administration of a beta-lactam (eg, penicillin, amoxicillin, cefaclor) or TMP-SMX
52
what do you see in pts with nonalcoholic fatty liver disease (NAFLD) that can lead to the diagnosis?
most pts have hepatomegaly, and mild elevations in AST and ALT, with AST/ALT ratio < 1.
Dx is often made based on lab findings and imaging -- US shows a hyperechoic texture
absence of other causes of secondary hepatic fat accumulation (eg, alcohol)
it is most common in pts with obesity and diabetes
53
pts with carcinoid syndrome are at risk of developing what vitamin deficiency?
Niacin deficiency
- carcinoid cells cause increased production of serotonin from tryptophan (required for niacin synthesis), resulting in niacin deficiency (ie, Pellagra = dermatitis, diarrhea, and dementia)
54
pt is found to have an acute aortic dissection of the ascending aorta. they suddenly develop worsening chest pain, increasing shortness of breath and does not want to lie flat, hypotension, and pulmonary edema. What is the cause of their SOB?
aortic valve insufficiency
- retrograde extension of the intimal tear can involve the aortic valve and cause acute aortic regurg (early descrescendo diastolic murmur)
*pts with cardiac tamponade present w/ hypotension, pulsus paradoxus, elevated JVP, and cardiogenic shock with CLEAR lung fields
55
what drug is most often implicated in drug-induced acne? how does this acne differ from acne vulgaris?
systemic glucocorticoids
drug-induced acne is characterized by monomorphic papules w/o associated comedones, cysts, or nodules -- it commonly involves the upper back, shoulders, and upper arms and can be seen in any age group
improves rapidly on discontinuation of the offending agent
56
what type of shock has LOW cardiac index, and HIGH PCWP?
cardiogenic shock
decreased myocardial contractility leads to a low cardiac index and resulting hypotension and reflexive tachycardia
57
a systolic-diastolic abdominal bruit indicates what?
Renal artery stenosis!
**most common correctable cause of secondary HTN
58
what do innocent, or physiologic murmurs in children sound like?
innocent cardiac murmurs result from normal blood flow through a structurally normal heart.
maneuvers that decrease venous return to the heart (Standing, Valsalva maneuvers) typically REDUCE the intensity of innocent murmurs.
benign murmurs are also early or mid-systolic in timing.
no workup is indicated.
59
a female has normal internal genitalia, external virilization (clitoromegaly), and undetectable serum estrogen levels. no breast development but normal public and axillary hair. serum FSH, LH, testosterone, and adrostenedione concentration are high. US shows multiple ovarian cysts. what is this?
Aromatase deficiency
- testosterones can't be converted to estrone/estradiol in adipose tissue or the ovaries
- first manifests in utero -- the placenta can't convert androgens to estrogens, which leads to a transient masculinization of the mother that resolves after delivery
60
what is the most common adverse reaction that occurs within 1-6 hours of blood transfusion? what action could prevent this reaction?
Febrile nonhemolytic transfusion reaction
the use of Leukoreduced blood products
- this involves reducing the number of transfused leukocytes through filtering or other methods
61
child age 3-4 months old presents with hypoglycemia and resultant seizures and lactic acidosis. other lab findings include hyperuricemia and hyperlipidemia. PE shows a doll-like face with rounded cheeks, thin extremities, short stature, and a protuberant abdomen due to hepatomegaly. What does this child have a deficiency of/what is the dz name?
Glucose-6-phosphatase deficiency (type I glycogen storage disease, von Gierke disease)
- results in impaired conversion of glycogen to glucose, leading to glycogen accumulation in affected organs (liver, kidneys, intestinal mucosa)
62
what anticoagulant do you use in pts with severe renal insufficiency (estimated GFR < 30)? and what is contraindicated?
Unfractionated heparin!! --it is more convenient to monitor its therapeutic level via aPTT
LMWH (enoxaparin), fondaparinux, and rivaroxaban are all contraindicated in CKD bc reduced renal clearance increases anti-Xa activity levels and bleeding risk.
63
how do you distinguish exogenous/factitious thyrotoxicosis from endogenous thyroid hormone release in hyperthyroid pts with low radioactive iodine uptake?
in exogenous thyroid hormone intake, serum THYROGLOBULIN IS LOW
64
hard, unilateral, non-tender lymph node in the submandibular/cervical region in an old smoker, what is the most likely diagnosis?
Squamous cell carcinoma (this is the vast majority)
65
pt gets a fishbone stuck in her throat (or other type of penetrating trauma to the posterior pharynx) and develops neck pain, odynophagia, and fever. What is this? and what is a dangerous possible complication?
retropharyngeal abscess
extension through the alar fascia into the "danger space" can transmit infection into the posterior mediastinum and result in Acute Necrotizing Mediastinitis.
66
why do newborn girls with Turner syndrome sometimes have carpal and pedal edema?
this is congenital lymphedema, which occurs due to abnormal development of the lymphatic system
(also why fluid accumulates in the webbed neck)
67
what is the most common cause of sudden cardiac arrest in the immediate post-infarct period in pts with acute myocardial infarction?
reentrant ventricular arrhythmias (eg, V fib)
68
pts with nephrotic syndrome are at high risk for developing what?
Hypercoagulability
-due to increased urinary loss of antithrombin 3, altered levels of protein C and S, increased platelet aggregation, hyperfibrinogenemia due to increased hepatic synthesis, and impaired fibrinolysis.
69
pt has cough for > 5 days productive of yellow sputum with occasional blood streaks. she has malaise, nasal congestion, and sore throat. she is afebrile. on exam the oropharynx is clear, and scattered b/l wheezes and crackles that clear with coughing are heard on chest auscultation. CXR reveals clear lung fields. what does she have? what caused it? what is next step?
Acute bronchitis, usually caused by a viral URI
the illness is self-limiting, and only symptomatic tx is indicated
*the absence of fever and consolidation on CXR make pneumonia unlikely, therefore no further workup is necessary
70
what is Mittelschmerz?
when normal ovulation causes pain in the middle of the menstrual cycle (days 10-14_
pt experiences discomfort when rupture of the follicle releases the egg
71
pt presents with recurrent sinusitis and otitis. He has ulcerations in his auditory canal. He has scant yellow nasal discharge occasionally mixed with blood. He has fatigue. he's anemic and has very mild leukocytosis. UA shows signs of glomerulonephritis. What's the best next step in managment? and what is this?
need to get Qualitative serum Autoantibodies (serum ANCA) bc this guy has Granulomatosis with Polyangiitis! (formerly Wegener granulomatosis)
*lower respiratory tract involvement may not clearly be seen in the question stem..... (cool) but may cause dyspnea, cough, and hemoptysis
72
In pts with severe aortic stenosis, what additional finding will they have on PE besides diminished and delayed carotid pulses, and mid-systolic murmur that is best heard over the right upper sternal border?
Soft and Single second heart sound (S2)
- thickening and calcification of the aortic leaflets leads to reduced mobility and causes a soft S2, as S2 is mainly due to sudden aortic valve closure (A2)
- also as a result of the reduced mobility, A2 is delayed and occurs at the same time as pulmonic valve closure (P2), leading to a single S2
73
What clinical features do pts with Hemophilia A or B present with? also how is it inherited?
delayed/prolonged bleeding after mild trauma or procedure
- Hemarthrosis (bleeding into joint), hemophilic arthropathy
- IM hematomas
- GI/GU tract bleeding
*x-linked recessive, so usually males
74
women age >/= 35 are at an increased risk of fetal aneuploidy (trisomy 21, etc). what test should they be offered after 10 weeks gestation?
cell-free fetal DNA testing (cffDNA) of materal plasma
- normal results are reassuring
- abnormal results can be confirmed by fetal karyotyping via chorionic villus sampling (first trimester, 10-13 wks) or amniocentesis (2nd trimester, 15-20 wks)
75
are ACL or MCL tears associated with significant hemarthrosis (aspiration yields grossly bloody joint fluid)?
ACL tears!!
| -also have rapid onset of pain, "popping" sensation at the time of injury, and joint instability
76
what is aspiration pneumonitis? how does it present?
```
lung parenchyma inflammation due to aspiration of gastric acid with direct tissue injury.
presents HOURS after aspiration event -- ranges form no sxs to nonproductive cough, decreased O2, respiratory distress
CXR infiltrates (one or both lower lobes) resolve w/o antibiotics
```
77
a 3 month old child comes to the doctor because of lethargy, poor feeding and pallor. Labs show he has a macrocytic anemia (no hypersegmented neutrophils), low reticulocyte count, and congenital anomalies such as short stature, webbed neck, cleft lip, shielded chest and triphalangeal thumbs. what is this?
Diamond-Blackfan syndrome (aka congenital hypoplastic anemia)
electrophoresis reveals elevated fetal Hbg levels
Therapy is mainly corticosteroids
78
what medication used in the tx of symptomatic Parkinson disease can cause acute angle-closure glaucoma? what other classes of medication can also cause this?
Trihexyphenidyl! --an anticholinergic --these meds cause mydriasis, which may precipitate acute angle-closure glaucoma
other meds = decongestants and antiemetics
79
pt with a hx of HTN and poorly controlled DM presents with sudden onset double vision, ptosis, "down-and-out" gaze, and a normal pupillary response. What is this and what caused it?
Ischemic oculomotor (CN III) palsy -- commonly associated w/ poorly controlled DM
- The inner somatic nerve fibers responsible for innervating the levator muscle (ptosis) and 4 EOMs ("down-and-out-gaze") are farther from the blood supply and thus more susceptible to ischemic injury
- the superficial parasympathetic fibers responsible for control of pupil dilation are closer to the blood supply and less affected by ischemia (preserved pupillary response)
80
what kind of abortion is this?
finds = US last week showed an intrauterine gestational sac with a yolk sac but no fetal pole (eg, no embryo) (some early pregnancies can present w/o a fetal pole and viability is determined w/ repeat US and serial beta-hCGs), todays US is unchanged, closed cervix, decreasing beta-hCG, scant amount of brown vaginal discharge.
Missed abortion
- pregnancy loss at <20 wks gestation prior to expulsion of gestational tissue
- closed cervical os, no/minimal vaginal bleeding, no fetal cardiac activity or empty sac
81
what antiemetic drugs can cause extrapyramidal symptoms (such as acute dystonia, parkinsonism, or akathisia)?
antiemetics that are dopamine antagonists, such as METOCLOPRAMIDE, prochlorperazine, and promethazine
Tx = discontinue the med + give an anticholinergic med (benztropine) or diphenhydramine
82
when you have a high suspicion for TTP, what test is crucial in confirming the dx? and how do you tx it?
PERIPHERAL BLOOD SMEAR!! (shows signs of intravascular hemolysis --schistocytes, helmet cells, triangle cells)
TTP must be treated emergently with plasma exchange
83
an old man has lower urinary tract symptoms, such as urinary frequency, nocturia, and hesitancy, that are most likely due to BPH. but... what other test should you still do next to help you r/o other causes?
Urinalysis
| -will evaluate for hematuria (eg, bladder cancer, kidney stones) and infx
84
pt with a smoking hx and recurrent episodes of pneumonia. what is the next step in evaluation?
CT scan of the chest
| -better sensitivity than CXR for detecting lung malignancy, especially in the presence of alveolar infiltrates
85
prior to initiating trastuzumab, a monoclonal Ab used in the tx of HER2-positive breast carcinoma, what should patients be evaluated for?
baseline assessment of cardiac function by ECHO!!
-trastuzumab is known to have the adverse effect of cardiotoxicity, which usually manifests as an asymptomatic decline in left ventricular ejection fraction
86
what are the laboratory findings typically seen in hereditary spherocytosis?
elevated mean cell hemoglobin concentration (MCHC) due to membrane loss and RBC dehydration
elevated RBC distribution due to the various forms (eg, reticulocytes, spherocytes, normal RBCs) in the peripheral smear
reticulocytosis
normal/slightly low MCV
87
what kind of drug is Mirtazapine and what are its main side effects?
atypical anti-depressant
| can cause sedation and increased appetite/wt gain (so good in depressed pts with insomnia and decreased appetite!)
88
what is Sheehan syndrome and how does it present clinically?
Sheehan syndrome (postpartum hypopituitarism) = rare but severe complication of massive obstetric hemorrhage and hypovolemic shock causing ischemic infarction and necrosis of the ANTERIOR PITUITARY (FLAT PiG)
Symptoms of hypopituitarism (due to decreased levels of the FLAT PiG hormones) include:
-Lactation failure
-amenorrhea
-loss of sexual hair
-anorexia/wt loss
-lethargy
-hyponatremia
*postpartum hemorrhage can also cause iron-deficiency anemia
89
what is the most sensitive finding on x-ray for blunt aortic injury (like after an MVC or fall from > 10 feet)?
Widening of the Mediastinum
* deviation of the trachea, NG tube to the right, or depression of the left mainstem bronchus may also be seen
* anxiety, tachycardia, and HTN are common clinical signs/sxs
90
you have a pt >55 in whom you are concerned for esophageal cancer (sxs of burning CP, long-standing GERD, smoking hx, dysphagia -solid food) and he also has alarm sxs (weight loss, gross or occult bleeding, early satiety). what test should you get next?
Upper GI endoscopy
91
in late-onset (nonclassic) congenital adrenal hyperplasia caused by 21-hydroxylase deficiency, what signs and sxs do you see (in boys)?
```
advanced bone age, coarse axillary and pubic hair, severe cystic acne, and normal testicular volume for age
NORMAL electrolytes (in late-onset CAH)
this is a type of gonadotropin-independent (peripheral) precocious puberty, so LH level are low at baseline and do not increase after stimulation with GnRH agonist
```
92
what is aplastic crisis? how does it typically present in pts with sickle cell/what is the most common cause?
aplastic crisis is an acute drop in hemoglobin accompanied by a Low reticulocyte count (<1%) without splenomegaly
in pts with sickle cell, the anemia is typically severe (<6 g/dL) and presents with pallor, weakness, and fatigue as well as a functional systolic murmur due to hyperdynamic blood flow
The most common cause is Parvovirus B19, which infects erythrocyte precursors
93
pregnant woman (2nd or 3rd trimester) presents with intense, intolerable generalized pruritus, that is especially significant on the palms and soles and worsens at night. Serum total bile acids are increased. LFTs sometimes show elevated T bili and D bili (Alk phos is elevated in normal pregnancy), and serum aminotransferases may be really high. what is this?
Intrahepatic cholestasis of pregnancy
Tx is based on symptom relief, and pruritis resolves in the wks following delivery
Ursodeoxycholic acid is commonly prescribed to increase bile flow and relieve itching
94
what is first-line therapy for alleviating symptoms and improving exercise tolerance in pts with stable angina? what is the MOA by which these meds works?
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beta blockers (metoprolol, atenolol) are recommended as first-line therapy for controlling anginal sxs and improving exercise tolerance
**they Reduce myocardial oxygen demand through a Decrease in Heart rate and DECREASE in Myocardial contractility!
(nondihydropyridine CCBs [verapamil, diltiazem] tx angina through primarily the same mechanism, and are an alternative to beta blockers)
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95
how do you tx parkinsonism associated with antipsychotic use?
Benztropine or amantadine (when antipsychotic dose reduction is not feasible)
96
what is chlorpheniramine and how does it work?
Chlorpheniramine is a specific H1 antihistaminic receptor blocker
it reduces the action of histamine on H1 receptors, decreasing the allergic response
it also exhibits anti-inflammatory effects by blocking histamine release from mast cells and limiting the secretory response to inflammatory cytokines (eliminating nasal discharge and cough)
97
Headaches that are new or differ in character from prior, that are present on awakening, and that are associated with frequent n/v as well as blurry vision are concerning for a pathological cause. what should be done next in evaluation?
MRI of the brain
98
What are symptoms of hypokalemia? and what will an ECG show?
symptoms depend on severity, and may include weakness, fatigue, and muscle cramps
severe hypokalemia (< 2.5) may have flaccid paralysis, hyporeflexia, tetany, rhabdo, and arrhythmias
ECG will show BROAD FLAT T WAVES, U waves, ST depression, and premature ventricular beats
