All Questions 201-400 Flashcards
(200 cards)
1
Q
22yo F with abnormal Pap smear and no history of irregular menstrual, postcoital bleeding, or vaginal discharge.
A
Cervical carcinoma in situ.
2
Q
29yo Vietnames F with nausea, vaginal bleeding, dyspnea, and hemoptysis.
A
Choriocarcinoma. Can develop during normal pregnancy, s/p hydatidiform mole, or previous spontaneous abortion. Elevated hCG.
3
Q
45yo F with gross difference in size of her breasts with sensation of fullness but no pain. Exam reveals large, firm mass.
A
Cystosarcoma phyllodes. Less common benign tumor of breast. Mass tends to be mobile and is well circumscribed. Path = cystic spaces on cut section, producing recesses and longitudinal openings with ‘leaflike’ (phyllodes) appearance.
4
Q
25yo W with amenorrhea for 6 weeks and development of pelvic pain for 1 day.
A
Ectopic pregnancy. Risk factors = previous tubal surgery, tubal ligation, endometriosis, previous ectopic pregnancy, ovulation induction, pelvic inflammatory disease. Test of choice = hCG and ultrasound (can get transvaginal US if needed).
5
Q
60yo F with obesity presents with intermittent vaginal bleeding for three months. Has never had children.
A
Endometrial CA. Estrogen-dependent cancer. Rx: hysterectomy, radiation. Important to include in differential of postmenopausal bleeding.
6
Q
27yo with inability to conceive, painful intercourse, and painful menses.
A
Endometriosis = extrauterine endometrial tissue. Can be located in various locations with unique symptoms , most frequently bilateral ovaries = chocolate cysts.
7
Q
27yo F marathon runner with painful lump breast. Mammography reveals irregular mass with focal areas of calcification.
A
Fat necrosis. Indurated lesion with retraction of overylying skin. Unilateral localized process associated with trauma, breast biopsy, and radiation. Easy to confuse with CA… pain is the key distinguishing feature.
8
Q
25yo F with right breast lump that is small, encapsulated, and freely moveable.
A
Fibroadenoma. #1 benign breast tumor in young women; sometimes enlarges during pregnancy or normal menstrual cycles. Mammogram = “popcorn calcifications”.
9
Q
20yo F with chronic left lower quadrant pain and left adnexal mass on exam.
A
Follicular ovarian cyst. #1 cause of ovarian enlargement. Test = US to look for cyst. Rx: Follow-up ultrasound (many disappear spontaneously); laparoscopic removal if persistent.
10
Q
52yo nulliparous F with painles lump in breast. PE reveals fixed, hard, nontender mass with retraction of overlying skin and palpable ispilateral nodes.
A
Infiltrating ductal CA = #1 breast cancer. Risk = family hx, estrogen “exposure”, atypical hyperplasia, previous breast cancer. Fibrosis with induration = desmoplastic reaction. Rx = surgery, tamoxifen if E receptor positive.
11
Q
59yo F with pain and swelling in breast with erythematous overlying skin with peau d’orange appearance.
A
Inflammatory carcinoma of breast. Highly malignant with early and widespread metastases.
12
Q
39yo F with heavy and frequent periods, occasionally painful.
A
Leiomyoma. #1 tumor of uterus, most common tumor in women. Estrogen-dependent. US reveals multiple heterogenous masses, 95% intramural myometrium location, round, firm, well circumscribed.
13
Q
60yo F with foul-smelling, blood-tinged, purulent vaginal discharge. Tumor projecting from cervical os on speculum exam.
A
Leiomyosarcoma. CT = large complex mass in uterus. Biopsy = spindle-shaped cells with many mitotic cells. Rx: adriamycin, progestins, combination therapy. Aggressive malignant tumor of the myometrium, can arise from leiomyoma or de novo.
14
Q
56yo F with history of breast CA with pelvic mass identified on routine physical exam.
A
Ovarian carcinoma. Serous type most common, often bilateral and advanced at diagnosis. Elevated CA-125, psammoma bodies.
15
Q
68yo F with itchy, painless scaling and oozing of erythematous nipple.
A
Paget’s carcinoma. Characteristically a scally skin lesion of areola and nipple arising from ductal adenocarcinoma.
16
Q
35yo F with bloody nipple discharge originating from one of the duct openings.
A
Papilloma of the breast. Benign proliferation of ductal epithelial tissue. #1 cause of serous / bloody nipple discharge.
17
Q
88yo M with purpura over extensor aspect of both hands. CBC reveals not abnormality.
A
Senile purpura. Benign disease of elderly, characteristically extensor hand surfaces, forearms, and neck. Defect in collagen support of dermal cappillaries. No treatment available. Cosmetic consequence only.
18
Q
18yo M with small purple skin lesions following URI two weeks ago.
A
ITP. Abrupt onset. Viral illnesses, drugs = thiazides, gold, carbamazepine, phenothiazines, quinine, rifampicin, valproate, sulphonamides, penicillins. Drug binds pltlt or drug binds plasma protein, forms immune complex, binds pltlt. Rx: steroids.
19
Q
Causes of purpura.
A
Senile, Osler-Weber-Rendu (hereditary haemorrhagic telangiectasia), giant cavernous hemangioma (can cause DIC), Ehler’s-Danlos, Marfan’s, HSP, scurvy, Cushing’s, steroid use, uremia, liver dx.
20
Q
64yo M with testicular swelling.
A
Lymphoma of testis. #1 testicular neoplasm in elderly.
21
Q
29yo M with painless lymph node in the axilla, normochromic, normocytic anemia, and elevated ESR. Next test?
A
Node biopsy. Hodgkin’s –> Reed-Sternberg. Non-Hodgkins’ –> spectrum small lymphocytic (low-grade) to large cell centroblastic (high grade). A2 staging; I=nodes 1 region II=2 regions, same side III=nodes both sides hemidiaphragm, IV=diffuse.
22
Q
45yo F with anemia, bone tenderness, and abdominal distension. Smear demonstrates blasts at all stages of maturation. Recent DVT.
A
CML. Philadelphia chromosome 22 bcr-abl translocation 9:22 (95% of cases). Complications = hyperviscosity (rx with leukophoresis).
23
Q
60yo F with diffuse lymph node enlargement and smear with increased lymphocytes, smudge cells.
A
CLL. Most common leukemia in US and Europe. Monoclonal transformation of B cells. Diagnosis = persistent lymphocytosis with increased lymphs. Warm antibody hemolytic anemia may result. No rx if asymptomatic.
24
Q
Causes of asplenia (anatomic or functional).
A
SLE, sickle cell, celiac, lymphoma, post-surgical. Risk of infection with S. pneumo, H. flu, N. meningitidis, malaria.
25
34yo M with facial plethora (redness), conjunctival suffusion, and splenomegaly.
Polycythemia. True or d/t excess EPO --> polycystic kidneys, renal CA / cysts, chronic glomerulonephritis, liver disease, hepatocellular CA, overian CA, bronchial CA. Hypoxia, lung disease, congenital heart disease, smoking. Enlarged retinal vessels.
26
P. vera
Hyperuricemia (rx with allopurinol), thrombotic events (less risk in secondary dx), 20% progress to myelofibrosis. Rx with phlebotomy. High incidence of HTN, itching, hepatomegaly, gout.
27
Causes of warm antibody autoimmune hemolytic anemia.
Lymphoma, leukemia (CLL), SLE, HIV. Causes spherocytes (also seen in congenital spherocytosis). Rx: prednisolone may induce remission; consider splenectomy.
28
Causes of cold antibody autoimmune hemolytic anemia.
Infectious mononucleosis, mycoplasma pneumonia, malaria, idiopathic (IgM paraprotein).
29
Cigar shaped erythrocytes.
Hereditary elliptocytosis. Usually asymptomatic.
30
Spherocytes on peripheral smear.
Perform osmotic fragility test. Spectrin defect = hereditary spherocytosis.
31
2yo with frontal bossing and "hair-on-end" appearance on skull x-ray. Has painful swelling of the fingers.
Sickle cell. Salmon-patch retinal hemmorhages. Homozygotes affected, heterozygotes asymptomatic until exposed to low O2 tension. Test with Hb electrophoresis and sickling test.
32
25yo black M develops painful joints and severe stomach pain one day into ski trip in the French Alps.
Sickle cell trait. Crisis at low O2 tensions.
33
Drug induced aplastic anemia.
Chloramphenicol, chlorpropamide, chlorpromazine, carbimazole, carbamazepine, gold salts, methotrexate, phenytoin.
34
Most common cause of iron deficiency anemia worldwide.
Hookworm.
35
58yo F with recurrent episodes of thrombophlebitis in the legs and arms.
Pancreatic CA. Thrombophlebitis may preceed diagnosis by many months.
36
64yo peanut farmer with jaundice, weight loss, and right upper quadrant pain.
Hepatocellular CA. Test for alpha-fetoprotein. Ultrasound / CT to evaluate.
37
Causes of cirrhosis.
Glycogen storage, Fanconi's, alpha-1-antitrypsin (neonatal hepatitis with cirrhosis in childhood), cardiac cirrhosis (late complication of R heart failure), methotrexate, hereditary hemorrhagic telangiectasias, ulcerative colitis and Crohn's.
38
17yo M with tremor, athetoid movements, and elevated LFTs.
Wilson's disease. Low ceruloplasmin. Kayer-Fleischer ring in cornea. Rx: penicillammine chelation therapy.
39
55yo F with pruritus and jaundice that progressed over 3 years.
Primary biliary cirrhosis. Anti-mitochondrial Abs. Assoc. c Sjogren's, Raynaud's, thyroid dx, Addison's, RA, fibrosing alveolitis, dermatomyositis, scleroderma. Women 9:1, age 40-60. ERCP reveals normal intra/extrahepatic bile ducts. Gallstones common.
40
31yo M with jaundice, pruritus, and RUQ pain. Markedly elevated AP with slight elevation in AST and ALT.
Primary sclerosing cholangitis. ERCP shows patchy dilatation and stricturing of biliary tree. High risk of ulcerative colitis. Progresses to hepatic cirrhosis. Risk = ascending cholangitis. HLA B8, DR2, DR3.
41
30yo F with hypothyroidism and rheumatoid arthritis develops jaundice.
Autoimmune hepatitis. Type I = history or family history of autoimmune disease. Type 2 = anti-liver and kidney microsomal autoantibodies, occurs in younger children. Type 3/4 = soluble liver antigen, type 4 ill-defined similar clinical as type 1.
42
31yo F with morbilliform rash and jaundice. Recently seen by a neurolgist for epilepsy.
Drug-induced hepatitis. Phenytoin (anti-epilepsy).
43
25yo with eosinophilia, chronic cough, and distal small bowel obstruction.
Ascaris lumbricoides. Larvae migrate to lung, small bowel obstruction are complications.
44
29yo HIV + F with eosinophilia, liver, heart, and renal failure.
Strongyloidiasis. Can result in systemic invasion in IC'd pts.
45
23yo M former aid worker in Guatemala has resolving bloody diarrhea nd develops stricturing and mucosal damage to colon.
Entamoeba histolytica. Don’t confuse with inflammatory bowel disease.
46
Diarrhea: viral
Rotavirus, Norwalk, Adenovirus.
47
Diarrhea: bacterial toxin
E. coli (enterotoxigenic), Vibrio cholerae, Staph aureus, Clostridium perfringens, Clostridium difficile, Clostridium botulinum, Bacillus cereus.
48
Diarrhea: bacterial invasive
E. coli (enteroinvasive), Shigella, Salmonella, Yersinia enterocolitica, Vibrio parahemolyticus, Campylobacter jejuni.
49
Diarrhea: parasites
Giardia lamblia, Cryptosporidium parvum, Entamoeba histolytica.
50
Diarrhea: drugs
laxatives, antacids with magnesium
51
Diarrhea: food toxins
puffer-fish, ciguatoxin, scombroid
52
Diarrhea: chronic GI disorders
Ischemic colitis, malabsorption, irritable bowel, inflammatory bowel disease
53
Diarrhea: secretory
Vibrio cholera, campylobacter, E. coli, Salmonella.
54
Diarrhea with systemic illness
Salmonella typi (enteric fever with diarrhea as late symptom)
55
64yo with CAD deficiency develops diarrhea, vomiting, and vague abdominal pain that rapidly progresses to hematochezia and severe abdominal pain.
Acute mesenteric ischemia.
56
48yo M with recurrent abdominal pain after eating. Also has hypercholesterolemia.
Chronic mesenteric ischemia (intestinal angina).
57
53yo M with abdominal pain and diarrhea with blood. Plain abdominal film reveals "thumbprinting" pattern in the descending colon and narrowing of the colonic lumen.
Colonic ischemia. More common than mesenteric ischemia, typically affects splenic flexure and other watershed areas.
58
55yo F previously treated for carcinoma of cervix, now with nausea, vomiting, and rectal bleeding.
Radiation colitis. Intestinal ischemia may develop due to endarteritis obliterans. Sometimes pseudo-obstruction. Barium study = thickening of mucosal folds, narrowing of lumen. Symptoms due to rapid transit time and malabsorption.
59
38yo F with celiac disease with chronic diarrhea and weight loss. Has been strictly adhering to gluten-free diet.
Intestinal lymphoma. Increased risk in celiac disease.
60
19yo F with diarrhea and bullous skin eruption.
Dermatitis herpetiformis. Gluten senstive enteropathy (celiac disease) + bullous skin eruption. Both may respond to gluten-free diet.
61
8yo M with chronic diarrhea, steatorrhea, abdominal distention, and failure to thrive.
Celiac disease (Gluten-sensitive enteropathy). Adult presentation more vague with megaloblastic anemia, diarrhea, vague abdominal symptoms. Abs include endomysial, gliadin, and reticulin. IgA endomysial Ab with high sensitivity and specificity.
62
Diagnosis of celiac disease?
Biopsy! Flattening of vili. Definative diagnosis requires trial of gluten-free diet.
63
Causes of malabsorption.
Stomach: post-gastrectomy dumping, ZE, pernicious anemia. Hepatic/biliary: bil. obstr. / cholestasis. Pancreas: CF, pancreatitis, CA. Sm. bowel: celiac, crohn's, removal of sm. bowel, fistulae/blind loops, infection, radiation, lymphoma, drugs, whipple's.
64
Approach to malabsorption?
1. confirm impaired absorption (fecal fat, Schilling test) 2. Identify specific deficiencies (CBC, Fe, iron, folate, B12, PT/PTT, vit D 3. establish cause.
65
34yo M with severe recurrent peptic ulcer, diarrhea, and weight loss.
Zollinger-Ellison. Gastrin producing tumor associated with MENI (usually pancreatic). Diagnosis = high gastrin level and high basal secretion of acid.
66
Upper GI bleeding?
GUMBLEEDING = Gastritis, Ulcer, Mallory-Weiss, B, L, Esophagitis, Esophageal varices, angioDysplasia, Infection, N, GERD.
67
Common causes of lower GI bleeding?
hemorrhoids, anal fissure, inflammatory bowel, diverticulitis, carcinoma, intussusception.
68
Test for bacterial overgrowth?
glycochocolate breath test, based on deconjugation of radiolabeled bile acid and exhalation of labeled CO2.
69
GI utility of US and CT?
Liver, pancreas, and biliary tract.
70
GI utility of plain film?
Demonstrate dilatation (toxic megacolon), obstruction.
71
GI utility of angiography?
GI bleeding of obscure cause or suspected mesenteric ischemia.
72
Unusual causes of lower GI bleeding?
AV fistulae, hereditary-hemorrhagic-telangiectasias (Osler-Weber-Rendu), angiodysplasia, vasculitis, amyloidosis. Meckel's, blood disorders (hemophilia, thrombocytopenia), rupture of AAA into bowel.
73
Common causes of upper GI bleeding?
Duodenal ulcer > stomach erosions / gastritis > GERD > gastric ulcer > Mallory-Weiss > duodenal erosions > esophageal/gastric varices > stomach CA
74
Causes of sore tongue?
Systemic: folate/B12/Fe deficiency, collagen-vascular dx, diabetes. Local: smoking, fractured tooth/dentures/crowns, candidiasis, dry mouth.
75
Teeth and gums
Blue line at tooth/gum margin = lead; gingivae swollen and purplish = scurvy; hyperplastic gingivitis = phenytoin, cyclosporin, and calcium antagonists; yellow staining = tetracycline.
76
Apthous ulcers?
poor dental hygeine, gluten enteropathy, inflammatory bowel dx, Behcet's.
77
Enlarged tongue?
Acromegaly, myxoedema, amyloidosis, motor neuron disease.
78
71yo M smoker with progressive dysphagia.
Esophageal CA
79
25yo M with progressive dysphagia and no past medical history.
Esophageal ring. Occur at or near GE junction. Cause unknown.
80
31yo M with HIV and odynophagia.
Esophagitis due to candidia, herpes, or CMV.
81
H. pylori infection.
Association with duodenal ulcer (100%) > gastric (80%) > duodenitis/gastritis. Increased risk of gastric cancer and MALT lymphoma. Test: serology or urease breath test.
82
Gastritis causes?
Infectious = rotavirus, norwalk, E. coli, H. pylori. Drug/chemicals = aspirin and other NSAIDs, alcohol. Asymptomatic chronic = elderly persons often with H. pylori. Atrophic = autoimmune (positive parietal cell Abs) with pernicious anemia.
83
38yo F presents with melena and epigastric pain. Barium study revealed rugal hypertrophy.
Menetrier's disease (giant hypertrophic gastritis). Assoc. with protein-losing enteropathy.
84
GI disease with finger clubbing?
malabsorption, small intestinal disease, and cirrhosis.
85
Hormone:
Stimulation test and markers:
86
ACTH and GH
Insulin hypoglycemia test: GH, cortisol, blood glucose
87
ACTH and GH
Glucacon: GH, blood glucose
88
TSH
Thyrotropin releasing hormone: TSH, T3, T4, prolactin, GH
89
LH, FSH
Gonadotropin releasing hormone: FSH, LH, spermatogenesis, ovulation
90
GH
GHRH: GH
91
ACTH
CRH: ACTH, cortisol
92
ADH
Fluid deprivation:
93
11yo M with with color blindness, midline facial deformity, and anosmia.
Isolated gonadotropin deficiency = Kallman's syndrome. Prepubertal onset, hypogonadal hypogonadism.
94
28yo F with resolving meningitis develops polyuria.
Central diabetes insipidus. Most frequently associated with craniopharyngioma. Rarely with anterior pituitary disease. Test = water deprivation and measure urine osmolality.
95
43yo M with thick skin, broad nose, and prominent supraorbital and nuchal ridges.
Acromegaly. Uncommon. May occur in MEN1. Large spade-like hands. Enlargement of the tongue. Hoarse voice. Cardiomegaly, heart failure, and malignancy causes death. Tufting of terminal phalanges on x-ray.
96
Elevation of prolactin level due to physiolgic cause?
Sleep, stress, nipple stimulation, coitus, pregnancy, suckling.
97
Most common cause of Cushing's syndrome?
ACTH overproduction by pituitary 60% > ectopic ACTH (15%) > adrenal adenoma (15%) > adrenal carcinoma (10%). Cushing's disease usually pituitary microadenoma (90%) more frequently in women.
98
48yo F with develops increasing pigmentation following bilateral adrenalectomy for Cushing's disease.
Nelson's syndrome. May follow adrenalectomy if ACTH production continues in excess.
99
Diagnosis of Cushing's syndrome.
Low dose 48hr dex suppression. Screening with overnight dex suppresion test or 24hr urinary free cortisol. If plasma ACTH is undetectable, usually adrenal tumor. Pituitary-dependent disease suppresses, whereas adrenal tumors and ectopic ACTH does not.
100
Ectopic ACTH tumors?
Bronchial carcinoma, carcinoid.
101
29yo F with SLE and history of DVTs develops increased skin pigmentation and profound hypekalemia.
Primary adrenal insufficiency. Antiphospholipid syndrome can destroy adrenal glands.
102
31yo M with fatigue, weight loss, GI disturbances, and dark spots on the inside of his cheeks.
Addison's disease. Autoimmmune or rarely TB, granulomatous disease, metastases. Other causes of adrenal insufficiency include withdrawal of steroid therapy, Waterhouse-Friderichsen, anticoagulant therapy. Hyponatremia, hyperkalemia, vitiligo.
103
Poor growth syndromes?
Rare congenital syndromes, nutritional/emotionald deprivation, GH deficiency (fat with immature facies and genitals), hypothyroidism, Cushing's. "Fat and short" likely endocrine. Turner's 45XO, and Noonan's (45XO/XY mosaic).
104
34yo F with short stature, large head, prominent forehead and disproportion of body and limbs.
Achondroplasia. Autosomal dominant. #1 short stature with abnormal proportions.
105
15yo F found on pelvic exam to have bilateral masses in the labia. LH levels is high.
Testicular feminization syndrome. XY male with X-linked deficiency of androgen receptors.
106
Newborn with ambiguous genitalia, clitoral hypertrophy, and partial fusion of labioscrotal folds.
Congenital adrenal hyperplasia. 21-hydroxylase defiency. Excess androgenic cortisol precursors.
107
18yo M with small firm testes, gynecomastia, and female distribution of body hair.
Klinefelter's. Infertile, may be unusually tall, 47XXY.
108
Common causes of amenorrhea?
Hyperprolactinemia, weight loss, anorexia nervosa, autoimmune associated ovarian failure (Addison's or other).
109
24yo obese F with menstrual irregularity, hirsutism, and acne.
Polycystic ovarian syndrome. Stein-Leventhal syndrome = obesity, amenorrhea, and hirsutism. DM2 develops in 40% by age 40. Labs = incr LH, +/- incr T, normal FSH, prolactin and TSH. Pelvic
110
61yo M with new onset atrial fibrillation, heart failure, and 20lb weight loss over 12 months.
Masked hyperthyroidism. Commonly due to toxic multinodular goiter. Lacks typical Grave's features.
111
44yo F with diffuse goiter, pretibial myxoedema, and tachycardia.
Grave's. IgG antibodies against TSH receptor = thyroid stimulating Abs (TSAb). Exopthalmos, lid lag, periorbital puffiness, increased lacrimation, conjunctival edema, ophthalmoplegia, loss of visual acuity.
112
53yo F with hyperlipidemia, puffy face, and coarse hair, and hair loss.
Hypothyroidism: Spontaneous atrophic, postsurgical, radioactive I, Hashimoto's (thyroid peroxidase and thyroglobulin Abs in 90%). Dry skin, coarse hair, facial edema, effusion, ascites, cardiac dilatation. Assoc c pernicious anemia and carpal tunnel.
113
Most common goitrous hypothyroidism?
Hashimoto's. Women >> Men. Older women > younger.
114
58yo F from central Africa with large goiter.
Endemic goiter. Can be euthyroid. Due to iodine deficiency.
115
73yo F with hypothermia and altered mental status and history of hypothyroidism.
Myxedema coma. marked by hypothermia, cardiac failure, altered MS, convulsion. Mortality 50%.
116
46yo M with painful itchy ear following family vacation to lake. Experiences pain when tragus is pressed during exam.
Otitis externa. Symptoms inlcude pain, pruritus, hearing loss, and fullness. Tragus = semicircular cartilage in front of ear canal. Staph and pseudomonas.
117
51yo diabetic M with painful itchy ear. Physical exam reveals inflammation and swelling of the pinna.
Cellulitis. Differentiate from otitis externa.
118
47yo HIV positive M with "boring" ear pain and long-standing ear infection that has not responded well to treatment.
Necrotizing external otitis. Occurs in ICd pts. Refer to otolaryngology.
119
28yo F with diffusely swollen and tender pinna.
Perichondirits. IV antibiotics, serious condition.
120
31yo M with circumscribed swellings in the external canal with tenderness on exam.
Furunculosis. Rx with topical ABs.
121
82yo M with pruritus of the external canal. Whitish exudate with black spots on exam.
External mycotica (otomycosis). Aspergillus niger causes black spots over white.
122
44yo construction worker with dizziness, tinitus, and conductive hearing loss in the right ear.
Cerumen impaction.
123
Complications of sinusitis?
Osteomyelitis, periorbital infections (pain with eye motion, ptosis, proptosis), cavernous sinus thrombophlebitis (CN III, IV, VI palsies), brain abscess, meningitis.
124
Persistent sinusitis?
Consider Wegener's granulomatosis, cystic fibrosis, Kartagener's, and TMJ syndrome. Need CT scan to rule out obstruction.
125
25yo F develops high fever, myalgias, rhinorrhea, and sore throat.
Common cold, due to: influenza virus, rhinovirus, coronavirus, adenovirus, parainfluenza. Rule out bacterial sinusitis, pharyngitis, and allergic rhinitis (history of itchy eyes, nose, and throat).
126
25yo F develops high fever, myalgias, and palpable tender neck nodes.
Bacterial pharyngitis. No cough or rhinorrhea. Tonsillar exudate may be present. Viral pharyngitis much more common (90%). Group A strep >> other strep, mycoplasma, chlamydia, and neisseria gonorrhea. Diptheria with grey-white pseudomembrane.
127
25yo F with itchy eyes, nose, and throat. Pale edematous nasal mucosa.
Allergic rhinitis. Seasonal or allergic pattern. Tearing. Mucosa is not erythematous.
128
25yo F with purulent nasal discharge, tender face, and toothache.
Bacterial sinusitis. Treat with amoxicillin.
129
Findings suggestive of Group A strep pharyngitis.
Recent exposure, history of infection in past yr, absence of cough, hoarseness, or rhinorrhea, temp > 101, tonsillar exudate, anterior cervical lymphadenopathy.
130
Causes of secondary hypertension (5% of all HTN, primary/essential HTN 95%)
Aortic coarctation, intrinsic renal dx, renal artery stenosis (young = fibromuscular, old = athero), primary hyperaldosteronism (suspect if hypokalemic and not on diuretic), Cushing's, Pheo,
131
1 anatomic, two renal, three adrenal, and four CENTs cause HTN.
CENTs = hyperCalcemia, Ethanol or Estrogen (oral contraceptives) most common causes, Neurologic disease = increased ICP, Thyrotoxicosis.
132
21yo F develops dramatic increase in creatinine after starting ACE inhibitor therapy for hypertension.
Consider renal artery stenosis!
133
31yo M with mental status changes and blood pressure of 225/124
Hypertensive emergency. Hypertensive urgency = systolic BP > 220. Hypertensive emergency = Urgency + End-organ damage: encephalopathy (ms changes), intracranial hemorrhage, aortic dissection, MI, unstable angina, hypertensive nephropathy.
134
HTN treatment: uncomplicated, DM1, CHF systolic, CHF diastolic, isolated systolic HTN, CAD or MI, BPH, pregnancy.
beta blocker or diuretic; ACE or diuretic; beta blocker, diuretic, or CCB; diuretic; beta blocker; prazosin; methyyldopa.
135
18yo M with painful swollen knee and ipsilateral leg lower leg edema.
Ruptured popliteal cyst.
136
54yo F with inguinal lymphadenopathy, pelvic symptoms, weight loss and bilateral lower extremity edema. Dry and scaly skin on feet.
Lymphedema.
137
43yo F with painless edema worse at the end of the day. Varicose veins present. Improves with elevation.
Chronic venous insufficiency.
138
54yo F with painful thighs and bilateral lower extremity edema following knee replacement surgery.
Bilateral DVTs.
139
45yo F with tachycardia, bilateral lower extremity edema, and tremor.
Pretibial myxedema (Grave's disease)
140
12yo M with leg length discrepancy since childhood and ipsilateral lower extremity edema.
Congenital venous malformation.
141
24yo F with SLE presents with bilateral lower extremity edema.
Nephrotic syndrome.
142
28yo M with taut, shiny skin and extreme sensitivity to touch of right leg. Edema in the right leg on exam.
Reflex sympathetic dystrophy.
143
43yo M with lots of tatoos develops peripheral edema and necrotic skin lesions.
HCV is associated with cryoglobulins and membranoproliferative glomerulonephropathy.
144
45yo F with recurrent infections, nonhealing leg ulcers, history of RA, and splenomegaly on examination.
Felty's syndrome.
145
Calcinosis, Raynaud's, Esophageal dysmotility, Sclerodactyly, Telangiectasias.
CREST
146
45yo F with history of PBC with skin thickening of the fingers and difficulty swallowing.
CREST. Associated with PBC and primary pulmonary hypertension.
147
Causes of chronic cough
Postnasal drip > GERD > asthma. Also cigarette use +/- COPD. Less common causes include bronchiectasis, CHF, ACE-I, post-pertussis cough, malignancy, chronic infection usually c systemic symptoms, and psychogenic cough.
148
Headache and jaw claudication.
Giant cell arteritis. Diagnosis with biopsy, start steroid rx immediately. Large vessel vasculitis.
149
26yo Asian F with finger ischemia and arm claudication.
Takayasu's arteritis. "Pulseless disease". Diagnosis with aortic arch angiogram.
150
32yo M with skin ulceration, hematuria, abdominal pain after eating, joint pain, and right hand weakness.
Polyarteritis nodosa (PAN). Necrotizing vasculitis of small and medium muscular arteries. 1/3 associated with HBV, also with HCV. No pulmonary findings!
151
35yo M with shortness of breath, fever, maculopapular rash, palpable purpura, and cutaneous nodules. CBC reveals eosinophilia.
Churg-Strauss. Granulomatous reaction in medium sized vessels.
152
28yo M with recurrent sinusitis, hematuria, and hemoptysis. Has had recurrent fevers, weight loss and arthralgias.
Waegener's granulomatosis. C-ANCA positive vasculitis of small arteries. Upper and lower respiratory infections.
153
Drug causing palpable purpura.
Hypersensitivity vasculitis.
154
45yo M with abdominal pain, swollen joints, purpuric rash, and hematuria following URI four days ago.
Henoch Schonlein Purpura. Definition = IgA nephropathy plus abdominal pain, join pain, and purpura.
155
24yo F with history microscopic hematuria and microalbuminuria, now with gross hematuria following URI.
IgA nephropathy
156
34yo M with hemoptysis and hematuria.
Goodpasture's syndrome. Anti-glomerular basement membrane antibody. (Anti-GBM).
157
50yo M with CLL presents with blurry vision, finger ischemia, headache, and lethargy.
Monoclonal cryoglobulinemia. Rx with plasmapheresis.
158
60yo M with history of IVDA now with arthralgia, purpura, glomerulonephritis, and neuropathy.
Mixed cryoglobulinemia. Result of immune complex deposition. Associated with HCV, lupus, and RA.
159
35yo M with one year progressive dyspnea. Oxygen saturation drops with ambulation.
Idiopathic pulmonary fibrosis or PCP pneumonia. Hallmark of interstitial lung disease.
160
Dermatomyositis patients have increased risk of what?
Malignancy: colon, lung, breast, and prostate.
161
Causes of wheezing
CARES: Cardiac asthma (CHF), Churg-Strauss, Allergic bronchopulmonary aspergillosis, Reflux esophagitis (GERD), Exposures (irritants, meds), Embolism, Sinusitis, Strongyloides.
162
Causes of obstructive lung disease?
Asthma, COPD, bronchiectasis, cystic fibrosis.
163
Causes of restrictive lung disease?
Pleural fibrosis, Interstitial (idiopathic, fungal infection: histoplasmosis, sarcoid), neuromuscular (myasthenia gravis, myopathy, Guillain-Barre), alveolar edema or inflammation, BOOP, pleural effusion, kyphoscoliosis, pregnancy, obesity.
164
What causes most cases of acute bronchitis?
Viral > atypical bacteria (Mycopl, Chlamydia, Legionella) > typical bacteria rarely (s. pneumo, h. flu, morexella) > allergic. Acute onset of cough and sputum production s hx of chronic pulm dx and no evidence of pneumonia or sinusitis. No Abs needed.
165
Most common immunodeficiency?
Selective IgA deficiency. Caused by anti-IgA IgG. Recurrent sinopulmonary infections.
166
Low IgA, IgG, and IgM. Normal numbers of B cells. Pts 15-30yrs old.
Common variable immunodeficiency. Associated with autoimmune disease and lymphoid malignancies.
167
Recurrent pyogenic infections of skin and lower respiratory tract. Pruritus, coarse facies, keratotic nails.
Job's syndrome. Hyper-IgE. Autosomal recessive. Abscess, empyema, staph. aureus.
168
Thrombocytopenia, eczema, and recurrent infections.
Wiscott-Aldrich. Depressed cell-mediated immunity, high IgA.
169
Low set ears, opportunistic and viral infections, severly sick after live viral vaccine, hypokalemia and hypocalcemia.
DiGeorge syndrome. Congenital immunodeficiency with no thyroid or parathyroid. 3rd and 4th pharyngeal pouch.
170
5yo M without tonsils, recurrent URIs and skin infections, and asymmetric arthritis.
Bruton's congenital agammaglobulinemia.
171
Recurrent staph and strep infections in albino child.
Chediak-Higashi.
172
34yo M with slow onset of cough and pleuritic chest pain several days following resolution of URI.
Pneumococcal pneumonia. Usually abrupt presentation occurs insidiously following viral respiratory tract infection.
173
57yo M with COPD develops pleuritic CP and worsening cough.
H. flu pneumonia.
174
88yo F develops cough, fever, and pleuritic CP.
S. aureus pneumonia. Seen in ICd and nursing home pts.
175
54yo alcoholic presents with productive cough, fever, and lobar consolidation on CXR.
Aerobic GNR pneumonia.
176
19yo F with mild pneumonia and hemolytic anemia.
Mycoplasma. Prominent extrapulmonary symptoms including: erythema multiforme, myocarditis, erythema nodosum, bullous myringitis, neurological abnormalities.
177
23yo M with mild pneumonia and hoarseness with severe pharyngitis.
C. pneumoniae. Distinguishing feature = hoarseness with severe pharyngitis.
178
Atypical pneumonias?
Legionella, Moraxella, Chlamydia, Mycoplasma.
179
Pneumonia requiring hospital admission?
Two or more lobes, increased A-a gradient or tachypnea, mental status changes, vulnerable patient, homeless patient, very high/low white count.
180
45yo M with pedal edema, nocturia, and morning headache.
Sleep apnea. Symptoms include snoring, daytime hypersomnolence, morning headache, impotence, nocturia or enuresis, pedal edema, exercise fatigue. Exclude hypothyroidism and acromegaly.
181
Abdominal Pain due to metabolic / systemic disorders: Puking My Very BAD LUNCH
Porphyria, Mediterranean fever, Vasculitis, Black widow, Addison's / Angioedema, DKA, Lead, Uremia, Neurogenic (diabetes, syphillis, spinal nerve impingement), hyperCalcemia, Herpes zoster.
182
Abdominal pain: RUQ
liver, gallblader
183
Abdominal pain: Epigastric
stomach, pancreas, duodenum, abdominal aorta
184
Abdominal pain: LUQ
spleen
185
Abdominal pain: lower quadrants
appendix, intestine, ovary, fallopian tubes, testes, kidney, ureters
186
Abdominal pain: periumbilical
small intestine, appendix, abdominal aorta
187
Abdominal pain: suprapubic
bladder, uterus, ovaries, fallopian tubes
188
Causes of secretory diarrhea that persists despite fasting?
Thyrotoxicosis, carcinoid syndrome, colon cancer, colonic polyps, durgs.
189
Drugs causing diarrhea?
Colchicine, Mg-containing antacids, antibiotics, theophylline, lactulose, laxatives.
190
Causes of osmotic diarrhea?
Drugs, pancreatic insufficiency, celiac disease, lactose/fructose intolerance, laxatives.
191
Causes of exudative diarrhea?
(Protein, blood, mucus) Stools with leukocytes and blood. Causes include: Lymphoma, Whipple's disease, collagenous colitis, IBD, ischemic colitis.
192
Intestinal motility disorders associated with?
IBS, DM, narcotic use, systemic sclerosis, fecal impaction, surgery (post-gastrectomy dumping, post-vagotomy syndrome).
193
Causes of malabsorption?
Radiation enteritis, bacterial overgrowth, enteric fistula, ileal resection, short bowel syndrome.
194
Diarrheas associated with immunodeficiency?
Isospora belli, Microsporidia, Cryptosporidium parvum, Giardia lamblia, Strongyloides stercoralis, Entameba histolytica, Mycobacterium-avium-intracellulare complex, Clostridium difficile, CMV.
195
What accounts for 50% of cases of diarrhea referred to gastroenterologists?
Functional diarrhea. No organic cause.
196
34yo M presents with low back pain worse with rest and bloody diarrhea.
Crohn's disease.
197
67yo M with CAD and familial hypercholesterolemia presents with bloody diarrhea.
Ischemic bowel.
198
31yo F with diarrhea, weight loss, and skin rash.
Celiac disease with dermatitis herpetiformis.
199
Anion gap metabolic acidosis?
MUDPILES: Methanol, Uremia, Diabetic ketoacidosis, Paraldehyde, Iron/INH, Lactic acidosis, Ethylene glycol, Salicylates.
200
Causes of constipation?
Neoplasia, strictures, adhesion/rectoceles, drugs (tricyclics, opiates, neuroleptics, antihistamines, CCBs, iron supplements, antacids without Mg), DM, hypothyroid, hypokalemia, hypomagnesemia, uremia, neurologic disorders, IBS, amyloid, scleroderma.
