facts Flashcards

Question

hodgkin lymphoma peak age clin presentation histo findings

Answer 1

* yound adult (30s) or \>60 * 40% have B sx (weight loss, night sweats, fevers) * most present for painless LAD (cervical + mediastinal), or a mediastinal mass found on CXR * hepatosplenomegaly * inc LDH * histo= giant cells w bilobed nuclei in germinal centers

Answer 2

sends radiotracer that will be taken up by cells with high metabolic activity = neoplastic cells BUT also includes the **brain**, **kidneys** (and thus **bladder**), and **liver** so these places will also light up even if no mets there

Answer 3

literally acute, within a day can happen present with balloon shape on echo = segmental mid- , apical, and basilar **hypokinesis**

Answer 4

= takes 6-72 hours after the inciting event to develop (while the inflammatory response develops) presents with diffuse, bilateral infiltrates

Answer 5

fractures of 3+ adjacent ribs in 2+ areas the groups of fractured ribs start moving paradoxically and will also injure the lung underneath =flail chest with increased work for breathing and dec oxygenation --\> respiratory failure --\> mechanical ventilation

Answer 6

* ERCP = suspected choledocolithiasis * MRCP= visualize the biliary and pancreatic ducts to asses for biliary obstruction or cholangiocarcinoma * HIDA scan= look for cholecystitis in suspected patients * best for viewing pancreas for CA or inflammation = **CT abd**

Answer 7

no! mild inc risk for small bowel cancer, but not even enough to screen for it

Answer 8

MC pathogens * \<3 months = s. aureus, Grp B strep, G- bacilli * \> 3 months= s. aureus, Grp A strep management * get an arthrocentesis to confirm dx and get a culture * AFTER getting culture, start empiric abx for that organism * bc of long term damage, need prompt surgical drainage to decompress and clear debris

Answer 9

inhibitor development: * the body begins to recognize the infusions as foreign material and makes Abs to the infusions * presents as breakthrough bleeds despite long standing control with treatment, or hemorrhage unresponsive to trx = inc PTT, n PT * trx for this= provide infusions of factors that bypass the need for factor 8 in the first place = recombinant factor 7, activated prothrombin complex (so you don't need factor 8 to make 10 to make thrombin)

Answer 10

psychotic sx, MC visual hallucinations and paranoid delusions =a *late stage sx* of PD, but risk increases when you add/replace carbidopa/levidopa with the dopamine agonists= **pramiprexole, ropinorole** **=**preferred trx= * FIRST dec carbidopa/levidopa dose * IF NO IMPROVE --\>low potency antipyschotics w minimal D antagonism = **queitiapine, clozapine, pimavanserin**

Answer 11

supracondylar humerus fracture falling on an outstretched arm brachial A with displaced bone (humeral shaft forward) * ulnar nerve is more distal

Answer 12

diabetic retinopathy

Answer 13

oligoclonal IgG bands on LP

Answer 14

alc hydroxyurea zidovudine chemo drugs

Answer 15

at wrist= 4th+5th digit numbness and parasthesias and *intrinsic* hand weakness = **clumsy** at elbow= ^^ plus **grip strength weakened** and weaker hand flexion

Answer 16

CMV retinopathy

Answer 17

recommend additional 6 months= continuation phase trx

Answer 18

intussussception

Answer 19

-persistant albuminuria and/or dec GFR AND 1+: * prolonged hx of DM dx \> 5 years * retinal neovascularization (diabetic retinopathy) bc they are both microvascular complications of DM and so are usually associated

Answer 20

the body surface amount only \<10% = SJS \>30%= TEN

Answer 21

vasomotor collapse secondary to adrenal hemorrhage in the setting of meningococcemia = adrenal gland failure presents w meningitis, purpura and petechiae, sudden hypotension--\> resp failure--\> 100% mortality

Answer 22

primary sclerosing cholangitis (90% pts have UC) MRCP= rapid and noninvasive--\> will show the beaded duct vs PBC associated w celiac ds, CREST, hashimoto

Answer 23

polio Hep A influenza (inactive HIP)

Answer 24

diptheria tetanus DT= dead toxin

Answer 25

measles mumps rubella varicella rotavirus (live motor= VRRMM)

Answer 26

Hep B H influenzae B HPV Pertussis Pneumococca Meningococcal

Answer 27

myeloproliferative disorders tumor lysis syndrome CKD

Answer 28

tear upwards--\> aortic regurge --\> backflow into lungs

Answer 29

--\> gestational HTN= \>140/\>90 **new onset HTN** at 20+ wks NO PROTEINURIA on 24 hour urine --\>pre-eclampsia= **HTN + proteinuria** / end organ damage --\>pre-eclampsia _w severe feature_s= * new onset HTN \>160/\>110 * OR HA/visual hanges / pulm edema * OR Cr\>1.1 * OR inc AST/ALT or plts\<100,000 * severe features = greater morbidity = eclampsia, abruptio placentae, fetal demise --\>eclampsia= **HTN + proteinuria + new- onset seizures** vs n renal changes = inc BUN, inc Cr * (bc of inc GFR + BM permeability) * nin preg = 0.4-0.8

Answer 30

MINORITY OF PTs ecg= prominent S lead 1, prominent Q lead 3, inverted T L3 * S1Q3T3 * afib is also associated w PE cxr= * hampton hump= lateral wedge * westmark sign= space of dec markings surrounded by normal markings * , palla's sign= prominent R descending pumonary A

Answer 31

* external bleeding * chest (can lose up 40% BV) * abd: up to entire BV, into perotineum * pelvis: up to entire BV, hidden in retroperitoneum * thigh: 1-2 L per thigh

Answer 32

-*brady*cardia and *flacid* paralysis and *hypo*tension (loss of sympathetic tone) or Cushing's Triad * HTN * bradycardia * irregular respiration

Answer 33

* succinylcholine should not be used w patients at risk for hyperkalemia = **extensive skeletal muscle injury,** **burn injury, disuse muscle atrophy, denervation syndromes** (i.e. stroke, Guillan-Barre, polynueropathy) * succinylcholine is a *depolarizing NMSK agent* can cause hyperkalemia, the above conditions will also cause inc K and **will upregulate Ach-R**. this leads to **inc risk of cardiac arrhythmias** w use of succinylcholine * instead use non-depolarizing NMSK agent= **vecuronium, rocuronium**

Answer 34

* presents with cyanosis at birth with a loud single S2 and a narrow mediastrinum (egg on a string CXR) (tachypnea and subcostal retractions) * treat with prostaglandins to keep open a PDA that is required to live

Answer 35

occurs from forced pulling or twisting of the arm **red flag for child abuse**

Answer 36

a coagulation inhibitor (rather than factor deficiency) MC = lupus anticoagulant, present in antiphospholipid antibody syndrome * APAB has inc PTT but *not PT* * associated w livedo reticularis, IBS, migrains

Answer 37

inc = thrombophilia

Answer 38

* malignant HTN presents in ppl geneticall predisposed who **are anesthetized w halothane or succinylcholine** * vs *_exertional heat stroke_*: exertion outside in heat, inc risk w obesity, dehydration, use of : anticholinergics, anti-psychotics, tricyclics postdural HA * post partum: after neuroaxial anesthesia (epidural) --\> occipital HA, worse w sitting or standing bc of CSF leak, but NO focal neuro signs * trx= epidermal patch

Answer 39

observation and PT: 80% of pts have spontaneous recovery within 3 months -if no improve in 3-9 months, can get surgery but its not necessarily curative

Answer 40

Rhematoid Arthritis

Answer 41

HOCM = LV wall thickening, MC in basal AV septum (asymmetric septal hypertrophy)' * systolic anterior motion of the mitral valve --\> anterior (abn) motion of mitral valve leaflets towards the IV septum --\> LVOT obstruction during systole --\> crescendo-decrescendo murmur increase * Valsalva * abdrupt standing * nitroglycerin decrease * sustained hand grip * squatting * passive leg raise

Answer 42

dec preload * dec LV volume = **inc murmur:** hypertrophic cardiomyopathy + mitral valve prolapse dec flow across stenotic valve= **dec murmur**: aortic stenosis

Answer 43

= inc afterload + BP * inc = aortic regurge, mitral regurge, VSD * dec= hypertrophic cardiomyopathy *and* aortic stenosis

Answer 44

* valsalva (dec flow across stenotic valve)= softer * squatting = no change * sudden standing (dec flow across stenotic valve)= softer * sustained handgrip (dec P gradient) = softer

Answer 45

* valsalva (dec LV volume) = louder * squatting (inc LV size) = softer * sudden standing (dec LV volume) =louder * sustained handgrip = no change

Answer 46

1. DASH diet 2. weight loss 3. aerobic excercise 4. dec Na 5. dec alc

Answer 47

atelectasis = impaired cough, shallow breathing

Answer 48

healthy kids: * probs NOT MRSA = nafcillin/oxacillin or cefazolin * probs IS MRSA = clindamycin / vancomycin sickle cell kids * clindamycin + ceftriaxone * or vancomycin + cefotaxime * (to cover MRSA + salmonella)

Answer 49

epiglottitis acute, due to narrow airway : need intubation

Answer 50

= aneurysm rupture (sudden onset, i.e. on toilet) CNIII= down and out, ptosis = MC CNII= unilat vision loss, bitemporal hemianopsia

Answer 51

get a serum TSH and US to check for suspicious anatomy (irregular margins, internal vasculature, microcalcifications) * if suspecting malignancy, get a FNA * if shows v aggressive, can do thryoidectomy in second trimester, otherwise wait until after pregnancy * just don't give radioactive iodine for imaging or trx bc that is teratogenic

Answer 52

to assess for cushing's sydnrome (inc cortisol) * sx= M weakness, fasical flushing, supraclavicular fat pads * = adrenal tumors or ACTH secreting pituitary tumors

Answer 53

cholangiocarcinoma * inc Alk phos \> inc AST/ALT * inc **CEA**, **CA 19-9**, n AFP * inc **direct bilrubin, GGT, ALP** * hx of *_PSC secondary to UC_*, or hx of *_fibrocystic liver ds_* * acholic stools, dark urine, pruritis, RUQ heaviness/mass, * hepatocellular carcinoma * inc AST/ALT \> inc ALK phs * n CEA, CA 19-9 , 50% have inc **AFP** * hx a*_lchoholism, chronic viral hepatitis_* * RUQ pain, cachexia

Answer 54

* spontaneous = tall, thin, young men vs. tension * small (\<2 cm) & stable = observe, O2 * large & stable = needle thoracostomy, chest tube * unstable = chest tube \> emergent needle decompression

Answer 55

adbominal perforation i.e. hx of GERD..postprandial, sudden worsening w lots of epigastric pain --\> perforated peptic ulcer * FIRST emergent surgical exploration to clear up secretions = dec mortality * THEN.. IV PPI, fluids, nasogastric suction

Answer 56

ALL * blast cells on blood smear (small nucleoli and scant cytoplasm) * children CLL * smudge cells (fragile lymphocytes) * ~70 yo burkitt * starry sky appearance * EBV pts

Answer 57

both have \<104T w sweating, N/V, HA, dizzy, tachycardia, hypotension exertional heat stroke = AMS heat exhaustion= no CNS dysfunction

Answer 58

Group B strep --\> can lead to sepsis w high mortality * low chance of transmission if mom is prophylaxis * but if C section and mom not given prophylaxis, she can still go home and give it to baby * listeria presents a lot like GBS but 1. GBS is more common 2. mom would have had flu like sx w listeria infection from food

Answer 59

bronchial carcinoid tumor presents w recurrent pnuemonia or hemoptysis

Answer 60

anterior MIs (affecting the LV) are more likely to lead to dilated cardiomyopathy (eccentric hypertrophy) via **neurohormonal signalling** of cardiac remodeling - one of the neurohormonal pathways = **RAAS** * trx w **ACE-I** post anterior-MI can help prevent dilated cardiomyopathy --\> ischemic heart disease --\> death

Answer 61

carbon monoxide cyanide * HA, vertigo, dizzy, N/V, tachy, hyperventalation (dec paCO2), inc LDH

Answer 62

diabetic ketoacidosis - type 1 DM in young pt (maybe they didn't know), DKA can be precipitated by low calorie/carb - insulin resistance= less K being taken up by cells bc usually insulin and K go in together =inc total body K even tho you are also increasing excretion via kidneys (hyperosmolarity)

Answer 63

* \>65 * \<65 if they have comorbid conditions that inc risk of pneumococcal infection = chronic liver/lung/heart disease, DM, smoking

Answer 64

-"irregular mass seperate from and superior to the testes" that does NOT transilluminate, worse with standing long persiods and valsalva, decreases w lying supine

Answer 65

pre-renal azotemia =AKI due to hypovolemia (i.e diuretic use that causes dec BP...)

Answer 66

atopic dermatitis

Answer 67

dental caries pneumonia / other lower resp tract infections middle ear ds

Answer 68

the vaccine only has Hbs protein to have Hbc Ab you have to have had HBV +AntiHbc, +AntiHbs = previous resolved infection

Answer 69

perforated peptic ulcer (probs undx PUD) * DIFFUSE tenderness (peritonitis), positive guaiac points to PUD * get an upright Xray abd+chest --\> will show abd free air: emergent surgery * cholecysitits would have pain specifically in RUQ, no peritonitis, would NOT have a + stool test

Answer 70

inc Hgb, inc BUN + Cr w dry mucus membrane

Answer 71

LV hypertrophy * high voltage QRS complex * inverted T waves V5-V6 (lateral) * ST segment depression V5-V6 (lateral)

Answer 72

* NMS= generalized M rigidity * SS= hyperreflexia, myoclonus, tremor

Answer 73

renal vein thrombosis L gonadal V drains into L renal V so it will all back up and you get L sided engorged veins -due to underlying hypercoagubility (i.e. from nephropathy, RCC)

Answer 74

* urine albumin: creatinine ratio (will detect earlier, smaller changes in albumin clearance) * annual test in diabetics: starting at dx with Diabetes type 2 and 5 years post-dx with Diabetes type 1

Answer 75

gout inflammatory effusion with negative bifringent needles

Answer 76

PTHrP releasing tumors * **_squamous_** cell CA head, neck, lung, renal, bladder, ovarian, breast ACTH releasing tumors (inc melanin + cortisol) * *neuroendocrine tumors* : MC = small cell lung CA \> medullary thryoid CA, bronchial carcinoid tumor

Answer 77

positive nitrates and positive leukocyte esterase

Answer 78

* CASE STUDY= asseses a disease group (against control) to compare risk factor frequency * CROSS SECTIONAL STUDY= assesses risk factor group (against a control) to compare current disease prevalence * PROSPECTIVE STUDY= follows a risk factor group (against a control) to compare future disease prevalence

Answer 79

patients with carotid artery stenosis who * have a history of TIA/stroke from the effected carotid vessel within the last 6 months * AND have 70%+ stenosis = high grade stenosis

Answer 80

family history boys 5-8 NOT psych stuff SECONDARY enuresis= psych stuff or underlying medical condition first step = urinalyses * after, address behavioral concerns or underlying medial conditions

Answer 81

CP, dyspnea, hypoxia, unilat dec breath sounds * apical bleb rupture: spontaneously occurs in pts with hx COPD, lung ds = usually no tracheal deviation, only if large enough * lung atelectasis: preceded by insulting factor = aspiration, malignancy, pnuemonia (severe, w mucus plug) : associated with tracheal deviation

Answer 82

stone stuck in the ureter (can't sit still, referred pain down to groin, sudden onset..) - best = abd US - spiral CT abd/pelvis WITHOUT contrast

Answer 83

**CT of the CHEST, w IV contrast** will show injury to the subclavian vessels, as well as any possible lung /pleura injury (i.e. pneumothorax)

Answer 84

arterial / venous THROMBOSIS * (dec plts bc spleen attacks the Abs on the plts, but the Abs actually cause activation so inc thrombosis) * NOT bleeding probs * i.e. low molecular weight heparin = enoxaparin

Answer 85

x fibrillin 1 --\> marfan's x fibrillin 2 --\> congenital contractural arachnodactyly (tall, arachnodactyly, multiple contractures of large joints) x collagen --\> ehler's danlos

Answer 86

INFECTIOS MONO rash post amoxicillin= Hallmark

Answer 87

* AST= 2(ALT) (but less than 500) * inc GGT (enzyme found in hepatocytes) * inc ferritin (an acute phase reactant)

Answer 88

nocturnal bruxism = grinding their teeth at night, maybe don't even know it

Answer 89

* ASA use * uremia * advanced liver ds * cardiopulmonary bypass

Answer 90

_painful_ * HSV * haemophilus ducreyi (**chancroid**) _NO pain_ * syphillis (**chancre**) _BOTH PAINLESS AND THEN PAINFU_L Chlamydia serotype L1-L3 = **lymphogranuloma venereum** = first is painless and small so often missed, but then it comes back as a painful buboe

Answer 91

-dec **Vit B12**! -- due to **Ab against intrinsic factor** = no absorb Vit B12 in stomach ---Ab against intrinsic factor also injures parietal cells --\> chronic infl --\> inc risk of **gastric CA**

Answer 92

adequate anelgesia * pain from rib frx will lead to shallow breathing (small tidal volume) + atelectasis * --\> inc risk of pneumonia (rib frx typically heal w/o surgery (especially if nondisplaced : only do surgery if have flail chest, etc)

Answer 93

* early Lyme = erythema migrans * early Lyme in non-pregnant= doxycycline (can cause fetal tooth discoloration and skeletal deformities) * early Lyme in pregnancy-use amoxicillin * severe, late Lyme ds= sx like carditis, meningitis * should be treated with ceftriaxone which is *also safe to use in pregnant patients*

Answer 94

* OSTEOARTHRITIS * bouchard's nodes (PIP) and Heberden's nodes (DIP) * can present with pain in the 1st ICP (i.e. base of thumb) or distal IPJ (furthest joint) * NO FURTHER EXAM= OA is a clinical dx * an xray would show osteophytes and dec joint space but is NOT NECESSARY

Answer 95

* lose all brainstem reflexes, **DTRs intact bc they orginate in the spinal cord** and are not connected to the brainstem * no HR will not inc: atropine dec vagal tone--\> inc HR BUT in brain death there is no vagal tone to begin with so the HR won't change * no respiratory responses present = apnea test

Answer 96

renal US to assess for AKI (can also get urinealyses but US is key)

Answer 97

PCOS : is a result of hyperandrogen (inc T) dx of PCOS requires clinical/lab findings of increased T **and** hx of menstrual irregularity

Answer 98

neuronal functional disturbance, no structural intracranial injury

Answer 99

chiari 1 malformation (present in teen/YA) -inc risk of syringomyelia (compression from tonsils)

Answer 100

cerebral amyloid deposition

Answer 101

* dec amino acid metabolism * dec demethylation of tetrahydrofolate

Answer 102

wolf parkinson white- accessory AV pathway, most pts asx, might have intermittant palpitations w diaphoresis from an arrhythmia

Answer 103

\> 24 ounces of cows milk is too much --\> iron deficiency anemia * cows milk does not have a lot of iron in it, and excessive amounts replaces iron-rich food in the diet * iron from cow's milk has decreased bioavailability

Answer 104

* umbilical hernia * duodenal atresia: "double bubble" sign on imaging, polyhydramnios on US * hirschsprung

Answer 105

6-12 cm at midclavicular line

Answer 106

DIAGNOSTIC STEPS * 1st- check **fasting IGF-1** (insulin-like GF) * if elevated --\> 2nd **= oral glucose test to check for suppressed GH levels** * inadequate GH suppression --\> **brain MRI** * pituitary mass--\> resection * no pituitary mass--\> search for extra-pituitary sources of GH= ectopic, tumors

Answer 107

= thyroid cancer recurrence * thyroglobulin = precursor to T3/T4= * produced by normal thyroid OR **papillary/follicular** thyroid CA

Answer 108

those that affect renal function --\> lithium toxicityn * NSAIDs * ACE-I, ARBs * tetracyclines * metronidazole AE = * nephrogenic DI, chronic insterstitial nephritis * hypothyroid, hyperPTH * worsens physiologic tremor (resting, worse w stress (+posture held against gravity) * nonprogressive, symmetric, fine tremor at rest * weight gain * leukocytosis * acne, worse psoriasis, hair thinning * goiter in pregnancy, teratogenic = ebstein anomoly \*\*can cause dystonia: BUT dystonic tremor is a tremor associated w dystonic M contractions i.e. torticollis\*\*

Answer 109

having emigrated from an endemic area

Answer 110

**reye syndrome** = child given NSAID =l_iver damag_e _+ rapidly progressing encephalopathy_ * vomiting, lethargy, seizure, coma * no jaundice even w hepatic enzyme also have *dec glucose, inc PT/PTT/INR* * **trx= supportive**

Answer 111

chronic pulmonary aspergillosi * image shows a cavitary lesion in the upper lung with a fungus ball in it *

Answer 112

-LAD STEMI = inc risk for LV aneurysm --\> dec EF + inc stasis --\> LV thrombus formation --\> risk of emobilization --\> stroke OR acute limb ischemia

Answer 113

* respiratory distress syndrome develops within minutes to hours, often in preterm (associated w grunting, retractions, hypoxia) * trx= continuous positive airway pressure ventilation

Answer 114

angiodysplasia * often missed by colonoscopy bc of poor prep or was behind haustra * associated with renal ds or vWF ds (which is oft associated w aortic stenosis) * treatment is supportive: if have anemia, then cauterize the abn vessels

Answer 115

inc sample size = inc power (prob of rejecting a false H0) --\> dec type II error (prob of FAIL TO REJECT a false H0) --\> inc type I error (prob of rejecting a true H0) = inversely related to type II

Answer 116

these are plantar **hyperkeratotic** warts! (painful) HPV

Answer 117

(= non-drinker, w elevated liver enzymes and gallstones on imaging ) * once her sx and labs have resolved, --\> early laparoscopic cholecestectomy (for stable pts) * reduce risk of recurrance of gallstone pancreatitis

Answer 118

ethylene glycol poisoning (from anti-freeze) * calcium oxylate stones * high anion gap * will also have high serum osmolality = \>295 * complications = **acute** renal failure **_vs methanol poisoning = AMS and HAGMA but no crystals : complications --\> bilndness_**

Answer 119

* large fiber = predominantely negative sx * DCML * small fiber= predominantely positive sx * ALS

Answer 120

subdural hematoma = tearing of bridging veins -often in old people w generalized cerebral atrophy: often after a fall (TBI), inc risk w anticoagulation progressive confusion, weakness, unsteady gait

Answer 121

* infantile botulinism * werdning-hoffman = AR degen of anterior horn cells and CN motor nuclei

Answer 122

clozapine - agranulocytosis (aka neutropenia) - seizures - myocarditis

Answer 123

electrical alternans w short QRS

Answer 124

THYROID STORM - precipitated by acute injury or surgery (inc wbc, fever, inc CK...) - also precipirated by child birth, IV contrast

Answer 125

=COPD RHF caused by LHF/Congenital heart ds is NOT cor pulmonale Cor pulmonalie can also be caused by: interstitial lung ds, OSA, pulmonary vasc ds, chest wall disorders

Answer 126

peaked T waves, shortened QT or widened QRS complex P wave disappears,- conductive block assocated w ESRD

Answer 127

multiple myeloma =osteolytic "moth eating" lesions NOT JUST IN BACK, also long bones

Answer 128

* peripheral destruction (immune mediated) * SLE, Antiphospholipid Ab * TTP * DIC * splenic sequestration * portal HTN, hepatic V thromobosis * liver cirrhosis * sickle cell ds

Answer 129

=inc BUN/Cr, inc HCO3, dec K/H+ * **loop diuretics** = inc ALD and inc Na delivery to distal tubule to inc diuresis

Answer 130

* *systemic* vasodilation (NOT coronary) * dec preload, dec afterload * = dec LV wall stress aka dec myocardial O2 demand

Answer 131

1. upper-airway cough syndrome/ postnasal drip 1. aka nasal secretions 2. associated with chronic/multiple episode of rhinosinusitis (i.e. allergic rhinitis) 2. asthma 3. GERD

Answer 132

serum sicknless-like reaction

Answer 133

paralytic ileus

Answer 134

retroperitoneal hematome

Answer 135

=causes perotoneal stretching (so cameras can see) -perotoneal stretch receptors will trigger inc vagal tone --\> can cause **severe bradycardia and possible transient AV block** --\> maybe even asystole needs to be monitored by anesthesia -*_CO2 embolization_* is v **_rare_**, associate with CO2 pushed into an artery/vessel --\> end organ infarction/ hypotension/ obstructive shock

Answer 136

both have v high osmol gap with bicarb v low (oftn \< 6) = alc substitutes * ethylene glycol = renal damage, Ca oxylate stones * methanol = blindness, **optic disk hyperemia**

Answer 137

observe for 1st pacemaker for third degree, mobitz type 2

Answer 138

AA AMYLOIDOSIS = nephrotic syndrome

Answer 139

cardiac syncope * muscle jerking can be in lots of syncope bc of cerebral hypoperfusion * no prodrome preictal period rules out vasovagal or seizures to a high degree * cardiac syncope = * LV outlet obstruction (occurs with exertion) * v tach = no warning sx, either monomorphic or polymorphic * conduction impairment = preceding faint feeling, associated w ekg changes dx= ambulatory ECG

Answer 140

simple renal cyst= benign ; no treatment or follow up required

Answer 141

aortic stenosis most frequently * AS due to bicuspid valves usually presents 40s-50s BUT bicuspid valve is the MC cause of ***aortic regurge*** in the US * typically diagnosed in 30s-40s * decrescend, early diastrolic murmur @L sternal border w patient leaning forward and holding exhalation bicuspid aortic valve can also cause aortic root dilation which --\> causes aortic regurge

Answer 142

lung\> breast\> unknown \> melanoma\> colon * single: breast, colon, renal cell carcinoma * multiple: lung CA, malignant melanoma

Answer 143

hypomagnesemia dec Mg --\> inc K excretion by kidneys --\> **hypokalemia** (ROMK channels in kidney are regulated by Mg: v common ause of refractory hypoK is hypoMg) def Mg -\> induced PTH resistance --\> **hypocalcemia** hypoCa oftn refractory to trx unless also give Mg (phospohorous is n-low bc of depletion = vs other causes)

Answer 144

= suppression of RBC production by inflammatory cytokines =inflammatory ds like RA, SLE NOT like OA...

Answer 145

HYPOXIC BRAIN INJURY =hyperintensity of the globus pallidus bc it is very sensitive to hypoxic injury -also associated w hypoxic brain injury is diffuse cerebral edema (later) and the sx of AMS, confusion, seizures, lactic acidosis from peripheral tissue hypoxia

Answer 146

AS angina = w severe AS, w \<1 cm of valve area, often w a low pulse P

Answer 147

=GILBERT SYNDROME * mild jaundice with stress/illness/surgery/dehydration/vigorous excercise * -presents in kids/teens/ YA GILBERT is inc indirect bili with **normal hgb** * *vs g6pd= inc indirect bili w dec hgb*

Answer 148

acute mono-ocular painless vision loss= retinal A embolism oftn from ispi carotid A or cardioembolic (a. fib)

Answer 149

necrotizing (fasciitis) surgical infection

Answer 150

atenolol propranolol bupropion nasal decongestants

Answer 151

(false + PCP) ## Footnote - dextromethorphan - diphenhydramine, doxylamine - ketamine - tramadol - venlafaxine

Answer 152

allrgic = specific allergens (pollen, cats..) -nonallergic = no systemic sx, associated with the cold, season changes, etc.

Answer 153

normal pressure hydrocephalus * early disease my present w ONLY gait changes +/- flat affect, but no cognitive or incontinence * dx= ventriculomegaly and n opening pressure vs PD= shuffling or festinating (short, quick steps)

Answer 154

* alveolar hypoventilation = * **inc** PaCO2 * **n** A-a gradient * PE, atelectasis, pulmonary effusion/edema * **dec** PaCO2 * **inc** A-a gradient (aka **VQ mismatch**) n A-a mismatch= \<15

Answer 155

- assess the severity of brain injury - EVM = eye opening, verbal response, motor response - GCS = 0-15 * mild injury = 13-15 * moderate injury= 9-12 * severe injury = \<8

Answer 156

pancreatic pseudocyst = mature walled off pancreatic fluid collections (usually no necrosis or solid material) surrounded by **thick, fibrous capsule** and contains enzyme rich fluid, tissue, debris * can --\> amylase-rich fluid leaking into circulation and inc serum amylase * complications = spontaneous infection, duodenal or biliary obstruction, pseudaneurysm (*presents with embolism before drainage procedure*), pancreatic ascites, pleural effusion TRX * asx= expectant management (symptomatic therapy, NPO) * sx w abd pain/V/infection/pseudoaneurysm --\> endoscopic drainage

Answer 157

PORCELAIN gallbladder dx= cholecystitis * CXR= rim like calcifcation where the GB should be * CT= calcified rim wall w central, bile filled dark gb * the gallbladder irl is like bluis-grayish on the outside bc of the Ca deposition, and oftn filled w yellow, multifaceted gallstones * (US shows thick GB wall filled w sludge, and surrounded by fluid) trx= cholecystectomy * chronic cholecystitis has inc risk of GB adenocarcinoma

Answer 158

* balanced resuscitation= "damage control" * **limit** use of crystalloids (saline infusion) bc these will dilute coag factors --\> coagulopathy = inc bleed * replace the intravascular fluid with **blood products** = 1:1:1 ratio * maintain permissive hypotension (65 MAP) until hemorrhage is controlled danger of excessive fluid resuscitation with IV fluids = * hypothermia (room temp is colder than body) * acidosis (NAGMA, hyperchloremic) * inc mortality from lethal triad = hypothermia, acidosis, coagulopathy * inc risk of ARDS (dose dependent on amounts of fluid)

Answer 159

-secondary malignancy= solid organ (breast, lung) * associated w radiation * secondary malignanc is the MC cause of CA related death in those cured of a CA -CV ds = CAD, valve damage, PVD, cardiomyopathy * leading non-malignant cause of death in hodgkin lymphoma survivors * myocyte necrosis and fibrotic destruction associated w **anthracyclines (-doxorubicin, -rubicin**) --\> progress to overt HF * **trastazumab**= myocardial stunning/hybernation without destruction = asx LV systolic dysfunction, more likely to be reversible - pulmonary fibrosis/bronchiectasis (radiation) - hypothyoid (radiation) - neuropathy (chemo)

Answer 160

ARDS (due to associated pulmonary edema= intrapulmonary shunting as Nø inflammation fills the alveoli w proteinacious fluid) * inc PEEP= positive end expiratory pressure= opens up the flooded alveoli and recruits them for ventilation = inc the amoung of lung that is actually doing O2 transfusion * aka dec the intrapulmonary shunt effect * associated w increase risk of barotrauma so have to be careful massive pulmonary embolism severe R--\>L intracardiac shunt

Answer 161

amyloidosis ## Footnote psoriasis= chronic inflammatory disease nephrotic syndrome palpable kidneys= amyloid dep hepatomegaly = amyloid dep S4 = vetriculomegaly = amyloid depo

Answer 162

estrogen is produced by the ovaries so in TS--\> decreased estrogen * results in amenhorrhea and poor breast development * inc risk of osteoporosis and fractures (estrogen inhibits osteoclasts) trx includes giving TS teens estrogen to promote sexual maturation and dec risk of osteoporotic fractures

Answer 163

child is given ASA --\> liver toxicity and damage --\> **hyperammonemia** --\> buildup in CNS --\> cerebral edema --\> toxic metabolic encephalopathy = rapidly progressivve nausea, vomiting, lethargy, AMS/confusion

Answer 164

anorexia nervosa -even if purge, AN vs BN = BMI BMI\<18.5= AN

Answer 165

restrictive PFTS w dec DLCO

Answer 166

**anal fissure** (hx constipation) **food-protein induced allergic prococolitis** (n bowel movements: is associated w mom's diet if being breastfed, clinical dx--\> have mom cut out dairy + other foods till sx resolve) (things like intestinal obstruction or necrotizing enterocilitis would present with an ill pt + tender abd)

Answer 167

-clinical presentation of hypercortisol * 1st get: * 24 hour urinary cortisol excretion * **late night** salivary cortisol assay * low dose dexamethason suppression test * if two of these are abn = you have high cortisol: * then do a high dose dexamethasone suppression test to differentiate between ACTH dependent or independent * imaging to look for pituitary/ adrenal tumors, etc.

Answer 168

**n trx= IV abx and O2 supplement prn** - if the pt is in acute heart failure, oft secondary to aortic/mitral regurge * = acute SOB, bilat LE edema, pulm edema - extensin of infection (i.e. abscess, fistula, heart block) - IE is caused by a fungus or med- resistant pathogen - persistant bactermia after abx trx - persistent septic emboli

Answer 169

mesenteric ischemia dx= evidence of bowel infarction--\> go to OR : it pt stable/suspicious, get CT angio

Answer 170

narrow QRS + regular rhytym = paroxysmal SVT =in young pt (\<40) w normal heart, MC cause is **AV nodal reentrant tachy** * two distinct conduction pathways in the AV node = fast w long refractory and slow with short refractory

Answer 171

* abn electrical activity around ischemic scar tissue * or abn automaticity of the ventricular conduction sytem = associated with dilated cardiomyopathy

Answer 172

high methylmalonic acid = combalamin= Vit B12 "**_fol_**ate MTMA _falls_\* \***co**balamin= both up\*

Answer 173

posterior urethral injury get a retrograde urethrogram ASAP \*upward movement of bladder/prostate can cause urethral tearing, MC at bulbomembranous junction\* -other sx= inability to void,, perineal bruising

Answer 174

=near sightedness -SEVERE myopia is associated w inc risk of * macular degenration * retinal detachment

Answer 175

bell's palsy is paralysis of one side of the face, including the lower **and upper face** * also sudden onset = difficulty eating, drooping smile, trouble closing eye, foreheard involved *pupils equal and reactive though* * a stroke would not include the upper case as well bc of the different innervations bc \>50% of U&L face palsies are due to bell's and because the prognosis is so benign --\> = clinical diagnosis * further testing is NOT recommended in pts w classical presentation * may rule out other causes through H&P usually

Answer 176

MC opp infections= * CMV pnuemonia (bilat infiltrates, fever, acute onset) * pneumocystis pneumonia (bilat infiltrates, fever, indolent onset) * + invasive molds (Aspergillus) \*\*NEW ONSET PULMONARY INFILTRATES: have to rule out acute transplant rejection during the workup for infection (can be concurrent) --\> bronchoscopy, lung biopsy

Answer 177

**perforatd viscus** * \*hx of colon surgery --\>adhesions--\> SBO --\> perforation\* * - present w recent anorexia, AMS, pt cannot tolerate being upright, sx of peritonitis dx= clinical signs plus xray (CT w contrast if xray -) trx- immediate surgical exploration to repair

Answer 178

* cholesterol embolism * presents with livedo reticularis, ulcers/gangrene, **blue toe syndrome** due to peripheral shower emboli, kidney injury, stroke/olfactory hallucinations (due to cerebral emboli), **Hollenhurst plaques** (golden yellow spots in eye) * dx= eosinophilia, dec C3 * = emboli from atherosclerotic plaque in aorta * inc risk w HTN, hypercholesterol, DM * presents days-weeks after a cardiac/vascular surgery * trx= supportive

Answer 179

intraperitoneal perforation = surgical exploration

Answer 180

systemic sx assocaited with **sarcoidosis** * trx- glucocorticoids (asx pts are just followed) BILAT LAD = sarcoidosis or lymphoma * UNILAT fullness associated w TB (+/- lower lobe effusion / consolidatio**n, bronchial compression from hilar adenopathy**, and risk factors i.e. old, DM, nursing facility) * progress slowly over weeks, prsents as a sick pt w signs of pneumonia, but pneumonia trx is unaffective *

Answer 181

Pagets Ds =**MC cause of isolated alk phos (w n Ca)**

Answer 182

avoidant personality disorder = avoidance due to fear of criticism or rejection

Answer 183

SIADH (this was associated with a hilar mass = SCLC) trx= hypertonic saline + fluid restriction

Answer 184

sacroiliatis secondary to IBD (vs reactive arthritis which is after **infectious** diarrhea, more commonly associated w uveitis, urethritis, malaise, skin changes)

Answer 185

splenic laceration= MC injured organ of BLUNT abd trauma * duodenal rupture--\> free air * pancreatic transection --\> weeks later you would see a peripancreatic fluid collection (pseudocyst) on US

Answer 186

noncomplicated = colicky pain, V, abd distension * *partial* obstruction * bowel rest, and IV fluids complicated = no flatus of stool (obstipation), indicative of bowel ischemia or perforation * *complete obstruction* * urgent laparotomy to relieve obstruction

Answer 187

adrenal crisis

Answer 188

dx= focal nodular hyperplasia risk= young female on long term OCs trx= often an incidental finding : benign, rarely transform, no need to trx * vs: hepatic adenoma: also present in young females and associated with OC use, BUT no centripetal enhancement * vs HCC = rise in the setting of cirrhosis or viral hepatitis, associated with weight loss, systemic sx: ALSO enhances w contrast, but no central scar the whole thing will light up

Answer 189

tinea corporis * vs cutaneous lupus= also can cause annular plaques but are multiple and in sun exposed areas vs urticaria * acute/subacute itchy wheals, associated w edema

Answer 190

McCune Albright girls \<8, boys \<9

Answer 191

inc obesity --\> inc aromatization in adipose --\> inc estrogen --\> turns GnRH pulses to high frequency and short intervals --\> inc LH/FSH ratio abn LH/FSH ration --\> no LH surge right before menstruation --\> anovulation

Answer 192

disseminated gonococcal infection * vs lyme = monoarticular arthritis months or years after infection: target shaped lesions, NOT pustular

Answer 193

= \< 10th percentile * can be symmetric or asymmetric (big head, tiny body) complications = * polycythemia (hypoxia --\> inc EPO) * hypoxia * perinatal asphyxia * meconium aspiration * hypothermia * hypoglycemia * hypocalcemia

Answer 194

= due to parvovirus B19 * acute (\<2 weeks) w NORMOcytic anemia and DEC reticulocytes vs folate deficiency= MACROcytic, dec reticulocytes, develops over weeks

Answer 195

**trachoma**= from C. trichomatis ## Footnote - MC in children = follicular conjunctivitis and pannus (neovascularization) formation in cornea (thick) - repeated or chronic --\> scarring =MC cause blindness

Answer 196

**actinic keratosis** ## Footnote dry, scaly flat papules with an erythematous base, mostly seen in sunexposed areas =premalignant to SCC

Answer 197

**acrochordon** = skin tag = in areas of inc friction

Answer 198

seborrheic keratosis =ranges from brown macules to raised wart like lesons that can be pink, white, black, etc HALL= "stick on" appearance dx= clinical, if you get a biopsy would see basal cells, keratin containing cysts, and hyperkeratinosis trx= observation : if annoying, cryotherapy

Answer 199

both cause metabolic acidosis both associated with N/V/abd pain * iron= w kids \< 6 who took a bunch of iron pills/prenatal vitamins: can see tablets as "opacities" on iaging * ASA= early signs include tinnitus, cannot see tablets on imaging

Answer 200

prostate CA mets =osteoblastic mets!!! making bone = n-dec Ca, inc Ph -further eval to confirm = radionucliide bone scan, prostate biopsy, and PSA

Answer 201

ECT MDD w psychotic features trx * antidepressant + antipsychotic * or ECT * preferred in elderly patients who can't eat of drink, are psychotic, or suicidal * quicker onset of action

Answer 202

both associated with waterry diarrhea and flushing * VIPoma = inc VIP levels; associated w dec K, inc Ca (esp if in MEN1 with hyperPTH), hyperglycemia * MC in pancreatic tail * carcinoid = also associated with bronchospasms * MC in small intestine: carcinoid syndrome presents once the CA spreads to the liver

Answer 203

phenytoin (anticonvulsant)

Answer 204

AS * sx appear w severe AS, reaching/at \<1 cm of valve SA left * presents with exertional dyspnea/fatigue, presyncope (lightheaded)/syncope w exertion, exertional angina = SOB + discomfort * Chest **pain** is minimal to none * dx= echocardiogram * will show correlating LV dysfunction * will assess size, functional impact, and severity of the AS * treadmill stress test is CONTRA bc of complications = syncopy/death * trx= valve replacement vs CAD * sx present \>/= 70% stenosis * presents with retrosternal pain/pressure, can radiate to jaw/axilla/neck + dyspnea, palpitations, dizzy, restless/anxiety * +/- autonomic dx = diaphoresis, N/V, syncope * dx= treadmill stress test * will show the different A stenosis levels and Ms that are being affected * trx= nitros, CABG/stents

Answer 205

differentiate btwn DI and PP = water deprivation test * assesses change in urine osmolalilty 1. primary polydipsia, 1. hypothalamus 2. associated w psych hx 2. nephrogenic DI, 1. @renal collecting ducts not reacting to the ADH 2. chronic lithium, hyperCa, or aquaporin mutation 3. central DI 1. @hypothalamus or posterior pituitary, ADH deficiency 2. idiopathy, trauma/pituitary surgery, ischemic encephalopathy

Answer 206

lateral rectus M entrapment -trauma --\> sudden inc P--\> fracture of the weakest bone in the orbit = orbital floor/medial orbital wall = **blowout fracture** * = entrapping of the inferior rectus M --\> inability for ipsi eye to look up * req surgery * vs open globe injury = associated with markedly dec visual acuity + "flattening" of orbit on imaging

Answer 207

1. CNIII - oculomotor = inferior oblique M + orbital muscles 2. CN IV = trochlear = superior oblique M 3. CN III= occulomotor =inferior rectus M

Answer 208

ACE-I/ARBs Beta Blockers Mineralcorticoid R-Ant = spironolactone/eplerenone * in pts with HF with LV dysfunction

Answer 209

**pseudogout = calcium pyrophosphate crystals** rhomboid shaped, + bifringence, only 15-30 cells * often in knees and ankles (like urate gout) but can also be in large joints, and multiple at same time * associated with chronic inflammation and atherosclerosis, can present like RA/OA : MC \<65, occur in the setting of trauma/surgery, medical illness, overuse vs - gout = monosodium urate crystals * NO asosciated chondrocalcinosis * is v acute, v painful (vs pseudogout progresses over hours-days) * (-) bifringent, shows up to 50k cells * associated hyperurate (tumor lysis, drinkers, etc)

Answer 210

acute splenic sequestration: often presents in children =life-threatening complication of early sickle when RBCs become entrapped in spleen -trx= IV fluids and RBC transfusion (NOT whole blood even tho low plts there is no incr risk of bleed)

Answer 211

henoch schloen purpura =inc risk of intussusception, renal ds, scrotal pain and swelling trx= supportive: steroids if v sick

Answer 212

pancreatitis that is not caused by alc or gallstones is probably from inc triglycerides (i.e. pregnant pts - TGs inc 2-4x in third trimester, or pt w hx of hyprecholesterols, obesity, etc) **next best step = get lipid panel**

Answer 213

diabetic foot ulcers * peripheral neuropathy + peripheral vascular ds * plantar foot, often of metatarsal * often have dry, scaly skin (dec autonomic tone = dec sweat) venous stasis ulcers * incompetant venous valves * commonly near the ankle * surrounded by 'brawny skin discoloration' (hemosiderin depo)

Answer 214

fibromyalgia first -line = aerobic excercise, patient education, and improved sleep hygiene --\> no improve --\> 1st line= **TCA** amytriptiline = depression and also helps w pain * second line= duloxetine, pregabalin, milnacipran * NOT nsaids or steroids bc fibromyalgia is not inflammatory and won't respond

Answer 215

niacin =\> pellegra urine inc 5-HIAA

Answer 216

mulitple myeloma = old person w fatigue, normocytic anemia, inc Ca, and inc protein gap (total-albumin \>4) dx= serum protein electrophoresis showing IgM spike --\> confirm w bone biopsy= clonal plasma cell proliferation

Answer 217

membranous glomerulopathy : * MC in adults, but can be in kids from secondary cause * presents w subacute proteinuria, edema hypoalbumin/hyperlipid : w n BP and GFR next step is to check for related conditions, especially in children * hep B even though super rare!!!

Answer 218

mild = euphoria, irritability, restlessness, anxiety, sleep disturbances severe (associated w high dose or prolonged use) = depression, hypomania or mania, psychosis, confusion trx= stop using the steroid

Answer 219

both associated w either H Pylori or NSAID use * duodenal: worse on an empty stomach (i.e. at night, wake up to eat bread to relieve pain) * gastric: worse after eating (possibly due to inc gastric acid release)

Answer 220

= for possible percutaneous nephrostomy or stent insertion * pts w urosepsis (fever and tachy) * anuria * AKI * refractory pain - pts who don't pass the stone within 4-5 weeks or have a stone \>10 mm ==\> outpatient urology eval - everyone else = hydration, pain meds, antiemetics

Answer 221

46XX = female with inc androgens + dec cortisol due to 21-hydroxylase deficiency

Answer 222

both = "bag of worms" (painless, coiled.. seperate from testes, no illuminate) * primary= L sided and dec w supine, inc w valsalva * adolscent or adult * due to compression of L renal V * secondary= R sided, size no change * prepubertal * due to compression of IVC from abd mass or from thrombus

Answer 223

= inhaled corticosteroid!! (sx for any inhaled steroid) **low dose** = thrush (oropharyngeal candida) **high dose** for **prolonged** period of time = adrenal suppression, cataracts, dec growth in children, interference w bone metabalism = osteoporosis, purpura

Answer 224

contra= quinidine or class three anti-arrhythmics - can exacerbate

Answer 225

acute cholangitis dx + trx = ERCP

Answer 226

* CMV * **periventricula**r calcifications and **micro**cephaly * bodily fluids of infected children (salive, urine) - gets to baby w placental transfer * \*\*can also present w diffuse petechiae, jaundice, and v small (\<10% H&W)\*\* * Toxo * diffuse **parenchymal** calcifications and hydocephalus ak**a macro**cephaly * cat feces, unwashed fruits/veggies, undercooked meat

Answer 227

24 hours = rebleed 3-10 days= cerebral vasospasm and infarction

Answer 228

DRE may be NORMAL

Answer 229

S3 = blood entering the LV splashing against the blood already in there bc of inc afterload also associated with severe mitral regurge (blowing and high pitched holosystolic murmur heard best at apex) as MR --\> LV dilation and HF

Answer 230

v/q mismatch secondary to alveolar consolidation

Answer 231

=systemic inflammation --\> lymphocytic and Mø infiltrate into cardiac tissue * inc risk CV ds if: fever\<14 days, late onset IVIG trx, \<1 yo **lymphocytic myocarditis** **--\>** LV outlet obstruction * peripheral edema, S3 gallop and pulmonary edema, LE edema, hepatomegaly * diaphoresis w feedings: irritable when awake, sleeping longer + more often * aka frank HF \*\*skin findings \*\* include: *peranal peeling and periungal desquamation*

Answer 232

strabisumus = eye deviation +/- asymmetric red reflexes * -get fundoscopic exam to rule out underlysing malignant cause * -cover test vs. optic neuritis which would present with painful vision loss, pain worse w movement, central scotoma (smudge/blurriness) that spreads, "washed out colors", * visual evoked potential test * swinging flashlight test= paradoxical dilation when you shine a light into the ipsi eye

Answer 233

primary sclerosing cholangitis * asosociated w men, often w ulcerative colitis * effects EXTRAhepatic ducts --\> associated w recurrent acute cholangitis (=RUQ, jaundice, fever, +/-AMS) primary bilary cholangitis * associated w women, NOT IBD * INTRAhepatic ducts--\> fatigue, pruritis, RUQ pain, hepatomegaly w dull lower margine, splenomegaly, xanthomas/xanthalemas

Answer 234

TTP plasma exchange and IV steroids potentially life threatening: urgent trx needed!

Answer 235

**aortic stenosis** = "weak and slow" carotid pulses (slow= delayed) =also associated w single S2, mid-late peaking systolic murmur best heard right 2nd IC radiating to carotids * =fixed outflow tract obstrucion, can present with progressive exertional fatigue --\< presyncope/syncope w exertion

Answer 236

**aortic regurge** ## Footnote "capillary pulsations" associated with the widened pulse pressure (high/low)

Answer 237

**coarctation of the aorta** - dec BF to LE = claudication (inc BP in UE, dec BP in LE) - continous murmur at L interscapular area is associated w turbulent flow across the coarctation or large collateral vessels * or "continous murmur heard throughout the thorax at multiple locations" * can be associated with erosions of the inferior costal surfaces

Answer 238

**shigella** * consider in local communities (day care) - spread through water, require low infectious dose to be contagious * associated with waterry diarrhea that turns bloody * associated w seizures esp in kids, either from ltye loss or from direct toxin effect on CNS * other complications = rectal prolapse (secondary to severe infl), bacteremia (= inc fatality), HUS

Answer 239

NSAIDS = diclofenac cephalosporins = ceftriaxone penicillins = piperacillin-tazobactam dx= direct coombs test * = IgG or anti-C3

Answer 240

lisch nodules!!

Answer 241

SAH : CT head is \>90% sensitive but if its abn you still need to get LP to rule out +LP= yellow-pink fluid bc of Hgb breakdown= xanthochromia * also high RBC count

Answer 242

ESR, CRP = normal worse at the end of the day

Answer 243

**chorioretinits**= inflammation and scarring of the retina and choroid * congenital toxo \>\> CMV * = a long term sequelae of chronic infection --\> can lead to permanent vision loss * late manifestation can be up to months later: can also present w seizure, intellectual disability , hepatosplenomegaly

Answer 244

* pyrimidal aka corticospinal tract (decussates at pyrimadal space in cervicomedullary junction = name?) * =UMN ds, associated w MS, etc. * =pronator drift test: outstretched arm pronate w eyes closed bc UMN ds is stronger on supinators * proprioception defects = DCML tract! in the posterior colums of SC or dorsal root ganglia * test= romberg test, lose balance w eyes closed * cerebellar dysfunction * presents w ataxia, tremor, impaired dysdiakokinesia * =pronator drift w UPWARD drift of arms w eyes closed, no UMN signs

Answer 245

try another high dose statin or a moderate dose statin -they can usually tolerate a diff statin moderate intensity statins with low risk of myopathy = pravastatin, pitavastatin, fluvastatin

Answer 246

**nodular** malignant melanoma

Answer 247

hereditary hemorrhagic telangiectasias * hereditary AVMs will present w sx early life (childhood epistaxis, now a 30 yo w hemoptysis) * AVMs associated w **bruits** + iron deficiency anemia vs GPA * GPA= necrotizing of small vessel vasculitis * renal-pulmonary * hemoptysis from alveolar hemorrhage = crackles and diffuse patchy infiltrates * crescenteric glomerulonephritis = microscopic hematura = focal, segmental * + nasal septal necrosis and destructive sinusitis

Answer 248

NPH = ventriculomegaly on CT; only need gait dysfunction (MC sx) to actually dx * **confirm dx** w **high volume lumbar puncture**: when gait improves with removal of CSF --\> confirms * can also get temporary lumbar drain and wait for gain to improve over days **definative trx**= ventricular shunt placement * diverts excess CSF into the abd or heart **vs** acetozolamide used for *_idiopathic intracranial htn_* = seen in young, obese women and associated w papilledema, HA, and vision changes

Answer 249

(those hand bones are n for a kiddo) - buckle fracture= associated w FOOSH in kids \<10yo * stable, incomplete frx trx= pain control and splint, heals in few weeks

Answer 250

* fat embolism * **_12-72 hours post injury_** * post-frx tachypnea + hypoxemia **associated w neuro changes and petechial rash,** * pulmonary contusion * **_within 24 hours of injury_** (blunt thoracic) * tachypnea, tachycardia, hypoxia w rales/dec breath sounds * CT chest (gold)= patchy alveolar infiltrates **not contained by anatomic borders** (*_diffuse) =_* ***ground glass opacities*** *adjacent to the trauma*

Answer 251

-often in 30s-40s w * reccurent flank pain +/- hematuria * hematuria = ruptured cysts * can be triggered by activities that require bending and exertion = yard work * HTN from renal ischemia

Answer 252

i.e. IBD =Ca-oxolate kidney stones

Answer 253

pheochromocytoma = chromaffin cells of the adrenal **medulla** * can cause the hx of intermittant HTN--\> catecholamines release triggered by anesthetic vs thryoid storm * not as acute; associated w inc T

Answer 254

SBO = dilated bowels w air fluid levels on imaging w hx of pain, obstipation, N/V * complicated = risk of impending ischemia, strangulation, necrosis * fever * hypotension, tachy (instability) * change in character of pain * sign metabolic acidosis = dec HCO3 * gaurding * leukocytosis * management= emergency surgical abd exploration * delay of surgery can lead to perforation

Answer 255

carpal tunnel = the MC mononeuroapathy associated w hemodialyses * due to dialyses related **amyloidosis** * inflammation stimulates b2 microglobulin formation * not filtered w dialyses, will MC deposit in carpal tunnel as amyloid * classically worse during dialyses sessions, more severe in the arm that access is through (L in this pt) * dx= clinical, tinnels and phalen *

Answer 256

subclavian steal syndrome

Answer 257

teen w parotitis following nonspecific prodrome. * in teens/YA, orchitis --\> impaired fertility * kids/adults --\> pancreatitis * aseptic meningitis is usually benign * sensorineural hearing loss that is usually transient but can cause permanent hearing loss

Answer 258

ipsi Horner w Harlequin sign (ipsi absent flushing) and a cervical spine mass in a child = neuroblastoma * MC extracranial solid tumor in children * MC in adrenal medullla or _sympathetic ganglia_ *_vs. astrocytoma or medulloblastoma_* = present w ataxia/cerebellar signs, *not* horner's

Answer 259

NONE ## Footnote \< 3 cm below the costal margin is normal in infants **\>3 cm** = neonatal hepatomegaly = congenital infection, cholestasis --\> hyperbilirubinemia

Answer 260

Beckwieth Weidmann =***_11p15-_***-\> * inappropriate growth w visceromegaly, **hemihypertrophy**, abd wall defects, and tumor growths * neonatal hypoglycemia and poor feed bc of macroglossia, macrosomia, omphalocele/umb hernia, midfacies hypoplasia w under-eye and earlobe creases, +/- cleft palate * dx= ***_INC insulin-like growth factor_*** * inc risk wilms tumor, hepatoblastoma, trx: * **_abd US_** =every 3 months until 4 yo * renal US from 4-8 yo q 3 mo

Answer 261

\< 20 yo = S. aures * MC in infants and young children * not as life threatening, though will also present w nasal flaring, tachypnea, barrel chest and diffuse wheezing and crackles bc CF \>20 yo = pseudomonas * can occur in infancy but MC in adults: associated w precipitous decline in health and mortality, so always treat for pseudomonas just in case but its not the MC

Answer 262

hirschsprung --MC presents w neonatal bilious emesis and tight rectum = longer section of aganglionic colon --shorter segment of aganglionic colon will present later in infancy or even childhood w chronic constipation, possibly growth failure/FTT * xray: proximal dilation of colon, distal narrowing due to no ganglion = obstruction * PE = distension, tight anal canal, squirt sign = release stool and gas w digital exam * next best step = get contrast enema, this will show the prox dilation and distal narrowing : * confirm w rectal suction biopsy

Answer 263

**volvulus**--\> unstable pt w peritonitis sx (abd is _firm, distended, tender_) = **emergent laparotmy** * n rectal exam w bilious emesis, abd distension, and _air fluid levels w dilated loops of bowel on xray_ * MC present w bilious emesis : * this pt likely has progressed to ischemia /necrosis --\> GI bleed, *shock* * this pt probably has perforation = perotinitis * NO DELAY laparatomy for further diagnostic imaging - need to untie bowels and revascularize

Answer 264

glucose 6 phosphate deficiency = **von gierke ds** : presents at 3-4 mo w hypoglycemia (seizures) and lactic acidosis etiology= dec glycogen --\> glucose conversion in liver (+kidneys, intestines) \*\*NOT G6PD = glucose 6 phostate *_dehydrogenase_* deficiency = teens w transient jaundice w stress\*\*

Answer 265

\>/= 13 yo with **no** **secondary sex characteristics** \>15 w secondary sex characteristics = \>Tanner Stage 1 axillary hair, breast development, pubic hair first US to check for uterus: then FSH levels * FSH low --\> TSH/prolactin * FSH high --\>karyotype * n FSH = imperforate hymen (red/purple bulge)

Answer 266

most cases of intussusception are idiopathic 25% = pathologic lead points = **meckel's diverticulum** (aka congenital malformation), **intestinal tumor, henoch schloen purpura, celiac ds, polyps**

Answer 267

rubella = rash from face down w low grade fever * +arthralgias in adolescents, esp Fs (vs mono= no rash, main sign is exudative pharyngitis)

Answer 268

gaucher = present anytime infancy, child, teen, YA, adult * bone pains, anemia+thrombocytopenia * delayed puberty * splenomegaly

Answer 269

**amiodarone, verapamil, quinidine, propafenone** direcly interferes w digoxin metabolism -- need to decrease digoxin dose by 25-50% when starting on these meds or else --\> digoxin toxicity * acute digoxin toxicity = mostly GI sx (N/V, anorexia) and possible weakness and confusion * chronic digoxin toxicity= significant neuro ( lethargy, fatigue, disorientation, weakness) and visual changes (everything loooks yellow, scotoma, blindness) diagnostic for digoxin toxicity * **atrial tachycardia w AV block** * atrial tach = from inc automaticity, typically around 200 (vs a flutter = 300) * AV block = inc vagal tone, can be any degree but almost never see type 2 mobitz

Answer 270

guillan barre * symmetric ascending motor weakness, paresthesias, numbness/pain, *only mild sensory loss*, dec/no DTRs, +autonomic dys (arrhythmia, ileus) --\> resp compromise: * +radicular pain = electric/shock like pain shooting down LEs * recent history of URI/GI ds OR recent dx of HIV * dx= **_LP_** : *_mri is often normal_ bc gb is a ds of peripheral nerves _(__{v severe, might see enhancement of anterior nerve roots or cauda equina}*₎ ; **_CSF cell counts and protein levels_** *_{(NOT pcr bc there will be NO virus in there, it is a peripheral N ds)}*; **_NERVE CONDUCTION STUDIES_** *_{bc ds is in peripheral Ns}* * trx= monitor, IVIG/plasmapharesis transverse myelitis * RAPID bilat motor weakness + sensory loss starting from a clear spinal location = severe, of all types + autonomic dys (incontinence) * NO rad pain * classical start w wk/flaccid --prog--\> UMN sx * dx= MRI = **_hypertense T2 signal of a spinal cord segment_** * trx=support and trx underlying cause; causes = , infection (herpes zoster), AI, vascular malformation

Answer 271

chronic dermatophyta infection of toenails MC= *trichophyton tubrum* first= terbanifine or itraconazole second= griseofulvin, fulcanazole

Answer 272

pulmonary embolism, tension pneumothorax * CVP reflects right atrial P = **HIGH** bc of the back up = \>10 * pulm A P = **high** bc of back up = \>40 * PCWP reflects *left atrial* pressure = **n to low** * also reflects L sided heart function, which is normal in PE/tension pneumo so the PCWP will be n (can be low bc of the shock and dec BF) vs: inc CVP, pum A pressure, and PCWP = left heart dysfunction that led to right heart dysfunction

Answer 273

_suspicious for PE_ * recently hospitalized + had surgery w prolonged *_immobilzation_* * ***_pleuritic CP_* (**worse w inspiration, leaning forward) * *inc troponin w no st change**s* = evidence of heart damage from PE and can be seen * **low grade fever, dyspnea, tachycardia, tachypnea,** w **unilat LE edema** and small **pleural effusion** **_next best step_**: when suspicious for PE= CT pulmonary angiography for high diagnostic accuracy * = modified wells criterion * if pt have renal imparement, morbid obesity, or contrast allergy = V/Q scan, but less accurate

Answer 274

**_get radioactive iodine_** * diffusely inc iodine takeup = **graves** * DEC iodine uptake * w DEC thyroglobulin = **exogenous** thyroid intake * w INC thyroglobulin =excess endogenous thryoid = **thyroiditis**

Answer 275

dx= uremic pericarditis * blood UREA nitrogen \>60, minority of DM nephropathy pts w uremia will develop * usually NOT associated w classic pericarditis ecg = diffuse ST elevations trx= DIALYSES ; will resolve sx and dec size of pericardial effusion **vs dressler syndrome**= pericarditis *_1-6 weeks_* after MI

Answer 276

somatostatin is triggered by postprandial gastric acid and FAs * essentially inhibits all gastric secretions and mobility, inhibits gallbladder contraction, inhibits pancreas exocrine function (secretin release, etc) * \*\*can also be used in emergent variceal hemorrhage/hemoptysis to stop bleeding and stabilize\*\* somatostatinoma = * classic triad = **glucose intolerance** (dec insulin secretion), **gallstones** (dec cholecystokinin= gb stasis), and **steatorrhea** (inhibit pancreastic exocrine)

Answer 277

=**hypertensive hemorrhage** - intraparenchymal hemorrhage that affects the small arteries seen in lacunar infarcts * progress over minutes to hours w the focal neuro signs --\> inc ICP (nausea, lethargy, etc) MC affected areas = _putamen (basal ganglia), cerebellar nuclei thalamasu, pons_ * **putaminal hemorrhage=** often includes the internal capsul right next to it * =contra hemiparesis and hemisensory loss, w deviated gaze to ipsi side of lesion * cerebellar hemorrhage = ataxia, occipital HA, dysmetria, N/V, dizzy

Answer 278

medial medullary syndrome = x branch of vertebral A or x anterior spinal A * contra paralysis UE+LE = x lateral corticospinal * contra loss of position = xDCML * tongue deviate upsi = x hypoglossal N

Answer 279

retinal detachment * grayish retina and retinal tearing, patient had flashing lights then a "curtain fell down", sluggish pupil * happens months after a trauma, i.e. surgery, bc fluid needs to seep in and seperate the layers * *vs choroid ruptre*= immediate blurry vision after ocular trauma w central scotoma, retinal edema, crescent-shaped streak, subretinal hemorrhages, and hemorrhage detachment of macula central retinal A occlusion * optic disk pallor, cherry red fovea, boxcar segmentation of retinal vessels

Answer 280

metabolic effects of thiazides are DOSE DEPENDENT so minimal doses will be able to help BP without these effects

Answer 281

this patient has **latent** TB = asx anergy reaction * next= trx for latent = 9 mo isoniazid +pyridoxine OR 12 weeks rifampin, pyridoxine, and high dose isoniazid CXR w infiltrates or LAD OR pt w sx (night sweats, cough, fever) = **active** TB

Answer 282

all conjunctivitis = conjunctival inflammation (granular appearance of tarsal conjunctiva) * bacterial = purulunt dc, high fever, * viral = **mc= adenovirus** (school, daycare, etc)= watery dc, low grade fever, systemic sx (sore throat, etc) * allergic = intermittant, triggered, shorter episodes * antihistamine drops / mast cell stabilizers = **olopatadine, azelastine**

Answer 283

COPD w resting SaO2 \<88% or PaO2 \<55% OR SaO2 \<89% / PaO2 \<59% w cor pulmonale, heart failure, or hematocrit \>55% sign when used \>15 hours a day

Answer 284

**mixed cryoglobulinemia** = immune complex deposition vasculitis associated w palpable purpura, joint pains, glomerulonephritis associated w Hep C; often Rheumatoid Factor is present, low complement bc of diffuse deposition

Answer 285

ideal is FiO2 \<60% w adequate oxygenation = PaO2 55-80 aka 88-90% PaO2 * when you first start the ventilation, FiO2 will be high * once the ABG shows adequate oxygenation, bring the FiO2 prolonged FiO2 \>60% is associated w inc risk of oxygen toxicity

Answer 286

**lichen planus** 5 Ps = PINK PRURITIC PAPULES w *wickham striae* = lacy white network of lines on top

Answer 287

breast CA associated w * FH of BRCA1/2 * abn estrogen:T ratio = **klinefelter, obesity, cirrhosis, marijuana** gynecomastia is often symmetric and has irregular borders

Answer 288

cerebral amyloid angiopathy * beta pleated amyloid sheets deposit in BVs of the brain --\> inc fragile --\> spontaneous rupture * = the same proteins that are found in Alzheimer's * MC in parietal lobe or occipital lob, spares deep brain * hematoma expansion ---\> inc ICP = confusion dizzy, HA, impaired consciousness, N/V * trx= reverse anticoag, control BP, normalize ICP central amyloid angiopathy = **MC** cause of **lobar intracranial hemorrhage** and second MC cause of intracranial hemorrhage (after HTN)

Answer 289

RCA associated w mobitz type II AV block, = 90% (inferior MI --\> sinus brady)

Answer 290

* ST elevation in I and avL = LEFT CIRCUMFLEX * ST depressions in I and avL = RIGHT CORONARY * changes in V1-V6 (all or some) =LAD

Answer 291

chronic irritant contact dermatitis

Answer 292

vit B12 deficiency = neuropsych changes, sensory ataxia, and +babinski

Answer 293

**a. fib** irregularly irregular R-R intervals, absence of organized P waves MC (and most important) comorbidity= chronic HTN * CAD is the cause seen in pt's w MI/ischemic HF

Answer 294

yes + life expectancy \<6 mo w terminal illness

Answer 295

a solid, firm, nontender testicular mass **is cancer until proven otherwise** =exam + US + markers * nontender, firm (ovoid) testicular mass within tunica albuginea * scrotal US = * solid hypoechoic lesion ~ seminoma * lesion w calcfications and cystic areas ~ nonseminoma germ cell tumor * markers * elevated serum AFP, beta hcG, Lactate dehydregenase * **seminomas** : _may have (rare) inc b-hcg but almost always have N AFP_ * **NSGCTs** :_inc AFP and b-hcg in ~85%_ * =yolk sac, choriocarcinoma, embryonal carcinoma, and mixed germ cell * RADICAL INGUINAL ORCHIECTOMY= confrims dx and is definative treatment * getting a biopsy or even FNA is *_dangerous bc incision of the scrotal skin promotes spreading CA to local inguinal LNs_*

Answer 296

anterior= 4Ts \*\*lymphomas (arise in LNs) can be in any compartment of the mediastinum

Answer 297

**=subauricular systolic bruit** = stenosis of internal carotid A * fibromuscular dysplasia = noninflammatory systemic vascular ds that causes arterial aneurysm, stenosis, dissection * MC= ICA + renal A \>\> vertenral, iliac, mesenteric

Answer 298

both benign breast disorders associated with bilateral, premenstrual breast pain * fibrocystic changes= associated w bilat nodules and masses * cyclic mastalgia = NO masses or nodules fibroadenoma = SINGLE mobile breast mass w premenstrual tenderness

Answer 299

skin= track marks associated w IV drug use murmur = TR =infective endocarditis w staph aureus, trx= empiric vancomycin

Answer 300

dec total IgG but n response to vaccines= transient hypogammaglobulinemia of infancy delayed inc in IgG

Answer 301

keratosis pilaris = keratin plugs of follicles * benign, MC on posterior upper arms * usually asx but may have small pustules or by itchy dx= clinical trx= (if necessary) emollients and topical keratolytics (urea, salicylic acid)

Answer 302

- prolonged antipsychotic use --\> abn movements * grimacing, lip smaking, tongue protrusion ; dystonic posture, foot tapping,, rocking, thrusting trx= * wean off if can (stable condition for few years) * move to less provoking antpsychotic (i.e. clozapine, queitiapine) * if can't: monoamine transporter 2 inhibitor (i.e.tetrabenazine, valbenazine) **vs acute dystonia** = * = painful m spasms (i.e. torticollis) hours to days after med * trx benztropine

Answer 303

hepatojugular reflex = reflection of a failing right atrium, that cannot adjust jugular venous pressure to the inc venous return (from holding pressure down on the abd) MC causes * constrictive pericarditis * right ventricular infarction * restrictive cardiomyopathy

Answer 304

primary CNS lymphoma

Answer 305

inabilitytopass nasogastrictube into stomach / inc resistance at end of esophageal pouch

Answer 306

squamous cell CA * vs basal cell (pearly, telangiectasias blled) = SCC has keratinzation **(thick rough** surface) or ulcerate w crusting and bleeding * oft associated w **nuero sx (numbness, paresthesias)** * risk= * sunlight, fair skin, chronic inflammation/scar site, hx radiation * especially common in people w **hx of transplant and on immunosuppressive therapy**

Answer 307

open angle glaucoma = * =insidious, pts may have no complaints until v advanced * associated w peripheral vision loss w intact visual acuity * typically associated w inc IOP, but not specific of sensitive * initial treatment = topical bimatoprost to dec aqueous humor volume and pressure

Answer 308

osteosarcoma!! * **sunburst** _or Codman's triange_ * inc Alk Phos, LDH : v high levels associated w worse prognosis * risk in boys 13-16, MC at metaphysis of long bones, * most important finding = tender, ST mass **vs ewing sarcome** * actually v rare, but also associated w adolescent males * 20% have systemic findings * **osteolytic lesion w perioseal reaction --\> onion skin**

Answer 309

osteoid osteoma **vs osteoblastoma** : peak 10-20 yo but usually in vertebrae w chronic pain NOT RESPONDANT to NSAIDS * also lesion in corticla bone w central lucency, but no sclerotic around * trx- surgery

Answer 310

giant cell tumor =locally destructive, MC benign =MC in post-puberty YA \> or old ppl w pagets **soap bubble** on xray: microscopy giant cells that look like osteoclasts interspersed w sheets of mononuclear stromal cells

Answer 311

cocaine = associated w ICH * MC subcorticol, like thalamus + higher risk of secondary intraventricular hemorrhage * suspect in someone \< 60 yo w stroke: and someone wihtout underlying HTN medical hx (MC cause of ICH) * suspect bc of other sympa sx: tachy, hyperthermia, mydriasis trx= manage HTN, normal ICP, prevent further bleeding, AND GET A URINE TOX for this pt who is young and no risk factors * in a patient **on anti-coag** get coag studies (bleed, PT, PTT) but not on every pt w ICH

Answer 312

SVT = narrow complex tachy = an unstable pt (hypotension, poor perfusion)--\> **immediate direct current cardioversion synchronization** (anelgesia and sedate if you have time) -if pt we stable, you could try adenosine or vagal maneuvers (like this pt's squatting)

Answer 313

+/- day time somnolence * may present as behavioral changes, irritability.. * daytime mouth breathing fine, able to eat without cough or gag * +/- nasal speech

Answer 314

an aortic dissection can spread up or down and result in any of these * vertebral A dissection * neck pain, ischemic stroke, HA * anterior spinal A dissection * (most likely at T10-T12 bc that's where BF is the lowest) * bladder paresis (retention), motor paresis LEs, loss of crude touch and pain (ALS), diminished reflexes initially * posterior spinal A dissection * loss of proprioception + vibration below level of the lesion, mild/minimal weakness

Answer 315

chi square = assess proportions of a categorized outcome correlation : +/-/no relationship that you could graph

Answer 316

neuroblastoma

Answer 317

first get a T and DHEA-S levels most likely cause for rapid hirsutism= tumor * inc T w n DHEA-S= probs ovarian tumor (more common) * inc DHEA-S = probs adrenal tumor

Answer 318

= widespread LAD (including epitrochlear) =widespread papular rash of whole body, including palms and soles =condyloma lata = raised grey genital papules =gray, ulcer like lesions in the mouth trx= IM penicillin G, f/u in 1-2 mo to confirm dec serology

Answer 319

SCC that arises within a burn wound (SCC is associated w UV light, but also from scars/wounds/inflamed skin, may have neuro pain)

Answer 320

* femoral N = * anterior thigh injury (MCV), anelgesia injection below the inguinal L, hip disclocation/hematoma, pelvic frx * = dec sensation of anterior thigh, dec patellar reflex, dec sensation of medial lower leg (branching saphenous N) : wk hip flexion and knee extension * obturator N * medial compartment of thigh; rare to be injured, usually through direct trauma * = wk hip adduction and dec sensation to medial thigh * common peroneal N * from fracture or compression at the proximal fibula * posterolateral leg and dorsal foot dec sensation, foot drop w weak eversion, dorsiflexion, and toe extension * tibial N * injury at popliteal fossa --\>wk plantarflexion (gastroc and soleus) * injury at medial ankle (under flexor retinaculum) --\> numbness and paresthesias in the sole and distal toes = tarsal tunnel syndrome

Answer 321

ANTERIOR dislocation = inferior and medial vs posterior dislocation= same level/slightly higher, dec space between humeral head and acromion

Answer 322

EN= tender, nonpruritic, erythematous, violaceous lesions on bilat shins (or anywhere) * biopsy = septal panniculitis without vasculitis associated w **IBS (crohn \> UC)** **Hodgkin lymphoma** **sarcoidosis** **strep, endemic fungi** (blasto, histo, coccidoides), **viral mono** (EBV)

Answer 323

esophageal stricture GERD --\> barretts / esophageal stricture (can be both in same pt) dx= biopsy to rule out adenocarcinoma (esp if hx of barretts) trx= endoscopy

Answer 324

#1 = abx use - age \>65 - hospitaliztion = mc setting, especially v ill pts - gastric acid suppression = PPI use (alters the biome)

Answer 325

FELTY syndrome -long standing RA --\> develop av against neutrophil compnents and granulocye stimulating factor * associated w high levels of RF, CCP: most patients are HLA-DR4 positive * neutropenia (+/- dec WBCs) = recurrent bacterial infections, especially skin and sinuses

Answer 326

**anthracyclines (doxarubicin, -rubicin)** **trastuzumab** - used in HER2 + breast CA - check eck before starting, do echos are regular intervals and stop if sx HF or EF drops by 16% +

Answer 327

ototoxicity * platinum based chemo **cisplatin, carboplatin, "-platin"** --\> get baseline audiometry before starting osteoporosis * aromatase inhibitors **"anastrozole, letrozole"** --\> get bone density scans before starting venous thrombosis = **tamoxifen** reactivate latent TB = **TNF-alpha inhibitors** --\> get TB test before starting, used for trx of RA

Answer 328

shingles= herpes zoster reactivation =two adjacent dermatomes!, preceding neuritic sx =small papules that can become confluent and evolve into vesicles and bullae

Answer 329

PN must be given through central venous cathether when needed for \>48 hours bc of the high osmotic load... * **MC** complication = blood streat infection from the central line * inc risk w poor pt hygeine, inc severity of pt illness, and *duration* * **\>2 weeks** of PN --\> inc risk of cholestasis = cholelithiasis * other = * inc risk of *hyper*glycemia * refedding syndrome *if the pt is already malnurished*

Answer 330

reactive NST =2+ accels 15+ above baseline for 15+ sec i..e if a pt comes in with pretern contractions, closed service, and this NST --\> conitnue routine prenatal care, no need for additional monitoring

Answer 331

**BPP** or contraction stress test is used to assess the fetus' risk of hypxemia and fetal demise * use if the pt has an uncomplicated pregnancy but an NONreactive NST if have NONreactive NST --\> * perform **fetal scalp stimulation** to promote accels * if fetus moves, they were probs just asleep (n physiolical) * if fetus still don't move, a sign that it might be more pathologic (i.e. acidemia ) **umbilical A dopper** = assess growth restricted fetus on US (\<10% of estimated fetal weight) - oft present later in preg, 25+ wk * assess for placental insufficiency and progressive hypoxmia * inc intravascular flow resistance --\>dec perfusion and worsening fetal hypoxia --\> emergeny deliver fetal fibronectin * if mom is having preterm contractions, get fibronectin to estimate the probabilty of preterm delivery

Answer 332

1) viral illness --\> CP = probs **viral pericarditis** - MC cause = coxsackie * often presents as retrosternal pain that radiates to the L arm and shoulder (neck) * **--\> now** severely worsened probs from **cardiac tamponade** = severely dec CO * presents w pulsus peridoxus = large decrease in SBP on inspiration = cannot feel (already v soft aka thready) pulse on inspiration * echo= thickened pericardium w loculated pericardial effusion * = *acutely ill pt* = bacterial pericarditis 2) viral illness--\> **viral myocarditis** coxsackie, adenovirus, parvovirus B19 * acute decompensated heart failure secondary to viral myocarditis. not acutely ill but have CP * echo = dilated ventricular chambers and diffuse hypokinesis

Answer 333

get TB screening (PPD) and trx but NOT the vaccine MMR + varicella zoster = CONTRA * recombinant zoster vaccine can be given to non-varicella immunized PROPHYLAXIS * less than 200 = TMP-SMX for pnuemocystis (\<100 = protecc against toxo, also TMP-SMX) * NO * MAC coverage w azithromycin no longer rec bc of dec incidence * HSV (acyclovir) = only for **secondary** prophylaxis (prevent **re**currence of outbreak) * antifungals = against histo sometimes if CD4 \< 150 and live in ohio/mississippi river valley

Answer 334

SVC syndrome = MC cause= malignancy so trx is to treat the malignancy less common = fibrosing mediastinitis from TB or hiso

Answer 335

=posterior RULobe or upper LLL in supine pts * **elevation of head of bed 30-45 degrees, diet mod for ppl dysphagia** * high risk in pts w impaired consciousness +/- impaired cough reflex = post-CVA or post-intubation vs incentive spirometry + breathing excercises * for pts post thoracic, upper abd, or aortic surgery * for post-op pnumonia for extended stays

Answer 336

BP= * 40-60 yo * itchy (*not pain*), tense bullae w prodrome of eczema/urticaria-like rash * rarely involve mucosa PG = * \> 60 yo = AI ds * flaccid, painful *(no itchy)* , easily rupture and form erosions * almost always have mucosal (oral) involve trx both w steroids

Answer 337

tension pneumothorax ICD = implanted cardiac defibrillator * tension pneumothorax as a complication of cardiothoracic procedure = dyspnea in recovery until

Answer 338

**respiratory distress syndrome** (esp if preterm) , **preterm delivery, macrosomia**

Answer 339

young AA pts SLE= serositis (inflammation of the pleura associated w SLE and RA) = **pleural inflammation** +/- pleural effusion, **pericarditis, peritonitis** * associated w pancytopenia, and poly-arthritis vs sarcoid = hilar fullness (LAD) and reticular opacities * associated w erythema nodosum and uveitis

Answer 340

MC cause = **coxsackie B** in US * looks like HF (paroxysmal noctural dyspnea, SOB w exertion) * leads to **dilated cardiomyopath**y = displaced maximal impulse (below 4th), bibasilar crackles, pitting edema * vs restrictive cardiomyopathy = caused by sarcoid, amyloidosis, hemochromotosis

Answer 341

plaque psoriasis = erythematous plaques w silver white scale mostly on EXTENSOR surfaces * koebner phenomenon = at places of inc friction (lots of kneeling ==\> knee) * associated w nail pitting, onycholysis: conjunctivitis, uveitis trx= topical high dose steroids or Vit D derivative (calcipotriene)

Answer 342

**bacteremia** : circulating bac are not opsonized bc of functional asplenia, can present even with appropriate prophylacic trx (penicillin) sx= acute (sudden) onset fever, lethargy, hypotension, tachypnea, can rapidly progress to sepsis * scattered petechiae can be associated with any cause of DIC (including sepsis seondary to bacteremia) = sign of impending decomp MC cause in sickle = strep pneumo, Hib

Answer 343

lateral medulla = Wallenburg syndrome = posterior inferior cerebellar A don't pica ho(a)rse that can't chew midbrain - pons- medulla- SC

Answer 344

midshaft humerus frx radial N (sensation of dorsal hand, wrist and finger extensor strength, can cause wrist drop) (brachial A injury is way less common is associated w dec peripheral pulses)

Answer 345

ASD usually presents in teens/YA w * dec excercise tolerance w fatigue, dyspnea, * atrial arrhythmias (flutter, fib) * paradoxical emobilizaiton = stroke * cerebral abscess auscultations= inc R sided bloow flow from intracardiac L--\>R shunt

Answer 346

honey crusted papules/pustules = S. aureus OR GRP A STREP (pyogenes) trx * topical = mupirocin * extensive= cephalexin possible complication = post strep glomerulonephritis

Answer 347

myelodysplastic syndrome inc risk in old ppl, and **previous radiation or chemo** dx= BM biopsy

Answer 348

granulomatosis w polyangiitis (wegeners) * **necrotizing vasculitis** of small to med vessels * nonhealing skin lesions due to local necrosis + ischemia sx= ANCA positive * ENT invovement * lung nodules/ cavitation * glomerulonephritis * skin = levido reticularis, pyoderma gangrenosum (papule/pustule progresses to nonhealing painful ulcer)

Answer 349

**viral sx = no diagnostic test,** symptomatic trx exudates/high fever/petechiae/ edema * get rapid Ag test / strep culture

Answer 350

spinal epidural abscess classic triad = fever, focal back pain, neuro sx * labs = ESR inc (+/- leukocytosis) dx= MRI spine trx= broad spec abx = vancomycin + ceftriaxone and then urgent decompression

Answer 351

= 5+ min of nonstop seizure of 2+ seizures without return to baseline mental status between * common causes * tumor, structural abn * electrolye abn = hypoNa, hypoglycemia * meningitis * withdrawal (alc, benzo) * immediate management * first ABCs for an active seizure * concurrently, **IV benzo** to arrest seizure activity (IM midazolam if IV unavail) AND give IV antiepileptic to prevent recurrence = **fosphenytoin, phenytoin, levitiracetam, valproid acid** * THEN, once stable and not seizing, get MRI brain/ head CT * if still not norm consciousness, continuous EEG to make sure they aren't in nonconvulsive status

Answer 352

Pancoast tumor consider in an old person w smoking hx mc= small cell lung ca

Answer 353

Age 50-75 q2 years early in high risk = * 1 first or second degree relative w both breast and ovarian CA * 1 first degree relative w bilat breast CA * 2 first degree relatives w breast CA, one of which was before 50 yo

Answer 354

T**MN stage= tumor burden** = single best stage IV = worst prognosis * histo stage is also important * HER/neu indicates worse, ESR/PR expression indicates better

Answer 355

MC stone = calcium oxalate, = small, radiopaque * serum Ca levels can be normal; these stones can be precipitated in any normal patient with dehydration, excessive sodium in diet, obesity * some stones are Ca oxolate and Ca phosphate mixed but pure Ca-PO4 is v rare * urine= hematuria but no casts

Answer 356

hypothyroid is associated w amenorrhea * dec T4 -\> inc TRH from hypothalamus-\> pituitary inc TSH **and prolactin (galactorrhea)** -\> dec GnRH release from hypothalamus through negative feedback -\> dec FSH, LH --\> amenorrhea * vs prolactinoma = weight gain, skin changes, and other hypothyroid sx bc inc tsh will not have an effect but prolactin will VS weight loss, vision changes, etc. * both can be associated w HA

Answer 357

Hyper triglyceridemia probs from familial dyslipidemia * high TG~ palmar xanthoma and lipemic serum (fatty) * probs having episodes of acute pancreatitis after drinking Trx= fenofibrates (or other fabric acid derivatives)

Answer 358

roseola = human herpesvirus 6 * less than two yo * rash appears after fever breaks trx = supportive care

Answer 359

2+ blood but 0-5 RBCs, 1-2 WBCs pigmented casts (heme pigment) serum = CK \> 1000, inc K and PO4, dec Ca, inc inAST\>ALT

Answer 360

OCP = dec risk of endometrial and ovarian CA * chronic ovulation suppression * progrererone dec endometrial proliferation OCP = inc risk of cervical CA * hepati adenine (benign)

Answer 361

amaurosis fugax = an embolus!!

Answer 362

MC = S. aureus= acute, often no preceding sx bilat= adenovirus

Answer 363

craniopharyngioma MC in children, but 50% in \>20, esp 55-t5

Answer 364

both cause amenorrhea * functional hypothalamic amenorrhea * something disrupts the HPA axis = sign weight loss, caloric deficiency, strenuous excercise, chronic illness, stress * **DEC FSH levels** (probs in hypothalamus) * (-) progesterone withdrawal test bc dec estrogen in body * dec estrogen also --\> dec libido, vaginal dec rugation and dryness, infertility, stress fractures (Oporosis) * first line trx= behavioral (inc calories) +/- estrogen replacement * primary ovarian insuff * present w amenorrhea plus vasomotor sx i.e hot flashes * **INC total FSH** (probs in ovaries) * asherman syndrome * postpartum / intruterine surgery --\> amenorrhea w n FSH levels * due to intrauterine adhesions post-trauma * also associated w cyclic pelvic pain and recurrent pregnancy loss

Answer 365

dermpatophytes = annular lesions w raised, scaly borders +/- partial central clearing vs candida = budding yeasts w **pseudohyphae**

Answer 366

* who * often in elderly white ppl * inc risk w UV light, vasomotor dysfunction, may be inflammatory rxn to micoorgnanisms * 4 types * erythematotelengiectasias * facial flushing, telangiectasias, roughness, scaling, burning sensation * papulopustular * kinda looks like acne * ocular * involve corean, conjunctivae, and/or lids * feels like burning, fb sensation, recurrent chelazia (swelling of life), conjunctivitis, keratitis, corneal ulcers * phymatous * chronic irregular thickening of skin, oft of nose * trx= * mild= lid scrubs, **topical metronidazole/erythromyci**n, ocular lubricants * severe= systemic abx, topical ummunosuppresants (**steroids, cyclosporine)**

Answer 367

**50**% (will have hypertensive vasculopathy that --\>) **hemorrahge into basal ganglia** * this commonly leads to uncal herniation * = nonreactive ipsi pupil * +displace midbrain = dEcErEbrate CONTRA positioning, coma, resp compromise * basal ganglia hemorrhage = diffuse inc DTRs and babinski

Answer 368

post-partum endometritis = infection of uterine decidua broad spec abx= gentamicin + clindamycin

Answer 369

mycoplasma pneumonia * indolent, viral-like prodrome, oft w hemolytic anemia * bilat fluffy infiltrates trx= **azithromycin** or resp floroquinolone

Answer 370

absence seizures

Answer 371

depression narcolepsy

Answer 372

babies : 1-2 yo -recurrent sinus/ear infections : dry skin/eczema : thrombocytopenia (purpuric rash) trx= HSC transplant

Answer 373

asthma and CF

Answer 374

alport = x IV **collagen** * kidneys, ears, lens (eye), BVs (HTN) * Xlinked R

Answer 375

nasal polyps = chronic congestion, sensation of post-nasal drip bland tasting food ASA-exacerbated respiratory disease * asthma (oft in childhood) * resp reaction to ASA use (i.e naproxen) = bronchospasms (wheezing, often go to ED) or congestions * nasal polyps = bilat, grey glistening mucoid masses

Answer 376

daiphragmatic rupture: associated w hx of blunt trauma --\> tear/avulsion of L\>R diaphragm (liver protecc) some pts (esp kids) have not have sx until **months to years later** CXR= lung compression, mediastinal shift, bowel looks in thoracic cavity * delayed dx --\> inc risk hernia formation/ bowel strangulation & ischemia * further testing = **CT chest+abd =** more definitive and diagnostic * trx= emergent surgery

Answer 377

acute interstitial nephritis * associated abx allergy, days-weeks later vs post-infectious glomerulonephritis * after *strep throat or skin infection, 1-2 weeks later* * RBC casts and mild proteinuia * no associated rash, usually has HTN and periorbital edema

Answer 378

inc thrombotic risk for 6-12 mo post stent placement, until fully endothelialized non-adeherance

Answer 379

E Coli= 75% = smooth, enlarged, tender prostate trx= flouroquinolone = ciprofloxacin for 6 weeks

Answer 380

wilson's ds = inc copper (dec ceruloplasmin) * hepatomegaly * neuro (tremor, jerking, parkinson-like, gait abn, tremor) * psych (depression, apathy, personality changes, psychosis) hemochromatosis * golden diabetes * liver ds, hyperpigmentation, DM, arthropathy, cardiac enlargement

Answer 381

PE w/o SF = **37** weeks * get pre-eclampsia (protienuria+inc BP at \> 37 weeks= deliver them now) PE w SF= \>**34** weeks w **even one severe feature--\> deliver now** * severe features = * Cr \> 1.1/2x baseline * pulmonary edema * signs of organ compromise = Cr, HA * plts \< 100k * SBP 160+ / DBP 110+ * AST/ALT \> 2x ULN * trx severe range HTN= **IV labetolol, IV hydralazine** * seziure prophylaxis = **magnesium sulfate**

Answer 382

@36-38 weeks intrapartum IV penicillin G indicated if * labor @ \<37 weeks * prolonged rupture of membranes 18+ hours * at any point in this gestations mom had GBS UTI or bacteremia, even if it was treated * intrapartum fever * prior infant w early onset GBS

Answer 383

RCA * papillar M rupture or RV failure LAD * LV aneurysm or free wall rupture (IV septum rupture is either) * acute= RV fail * subacute= papillar M rupture of IV septum rupture or free wall rupture * mo = LV aneurysm * deep Q waves and persistant STE in I, avL, V2-V5

Answer 384

hormonal IUD dec menstrualbleeding!! contra to both = acute pelvic infection hormonal contra= acute liver ds, breast CA copper contra= wilson's ds, copper allergy, *heavy menstrual bleeding*

Answer 385

can cause preterm labor, low birth weight, and tachycardia on FHT * associated w nulliparity and asx acteriuria, as well as \<20yo and DM med probs = ARDS, hypothermia

Answer 386

hx acute otitis media --\> now have pain directly posterior to air, purulent exudate external ear and bulding TM, the external ear may be posteriorly displaced

Answer 387

cervical CA, *an AIDS defining illness*

Answer 388

chronic hypoparathyroidism dec Ca + inc PH Ca-Ph product \> 55 = inc risk of ST calcification * Ca= 57.72 * BG calcification is a common association w chronic low PTH, now pt has EPS * other complications = nephrocalcinosis and cataracts

Answer 389

postpartum hemorrhage due to retailed placenta * = placenta retained longer than 30 min postpartum vs DIC = would not be clots, would be bleeding from mucosal surfaces and IV lines vs uterine inversion = from pulling too hard on placenta, presents w PPH and a visible mass protruding from cervix/vagina vs uterine rupture = intense abd pain and **antepartum** rupture and palpable fetal parts (freaky hand crawling out uterus tear)

Answer 390

zidovudine NNRI

Answer 391

listeria monocytogenes meningitis -from unpasteurized milk (NOT LEGIONELLA)

Answer 392

= hypersensitivity rxn to **allopurinol, phenytoin, or carbamezapine** **_D_**rugs **_R_**ash (morbiliform) **_E_**osinophilia **_S_**ystemic **_S_**x vs Dressler syndrome = post-MI pericarditis

Answer 393

MDS = (pan)cytopenias w insuff reticulocytes * associated w hypogranular Nøs w dec lobulation * may transform into CML\>CLL CML/CLL = inc in lymphoblasts/myeloblasts = inc in leukocytes, oft associated w hepatosplenomegaly

Answer 394

myometrium proliferation = uterine fibroids * inc heavy menses and irregularly shaped uterus * get a sonogram endometrium proliferation * endometrial hyperplasia = prelim to endometrial CA = inc menstrual bleeding but regular shape * endometrial polyp = inc intermensrtual spotting, regular shape * \> 45 yo and risk for endometrial hyperplasa --\> get endometrial biopsy * consider in younger than 45 if risk factors present or other trx has failed

Answer 395

WM= IgM ----trx= plasmapharesis MM = IgG, IgA, light chains

Answer 396

= single cavitary lesion with air fluid level --\> ML squamous cell carcinoma most in center, but up to 40% peripheral associated w long term smoking

Answer 397

MD = **d**irect hernia is **m**edial to vessels indirect = IN the INguinal canal

Answer 398

sialodenosis * = bilat, painless enlargement of salivary glands (no fluctuate or change : gradual enlargment) * = overaccumulation of secratory granules in acinar cells * associated **alcoholics,** (protein) **malnutrition, bulimia** * or from fatty infiltration of the gland * **DM, chronic liver disease** _vs. pleomorphic adenoma_ = * benign tumor= unilat, painless enlargment of parotid gland * can usually palpate and distinct mass within the gland _vs. sialolithiasis_ = * salivary gland stones = block drainage of duct * = fluctuating, painful, and associated w eating

Answer 399

kids 1-12 yo **-parinaud syndrome** = down and out, retracted eyes, light-near dissociation **-obstructive hydrocephalus** - papilledema, V, --\> progress to ataxia

Answer 400

-unilat painful, "red eye" w tearing, photophobia, and dec visual acuity * mostly idiopathic, but can be associated w lupus, IBD, herpes, toxo, akylosing spondylitis * PE= ciliary flush, red eye, pupillary constriction, "hazy" aqueous humor

Answer 401

blastomyces dermatitides -blasto = pulm, skin, bone, prostate, CNS

Answer 402

both have= * bitemporal hemianopsia * can cause inc ICP craniopharyngioma * age = 5-14 & 50-75 * causes endocrinopathies bc of compression of pituitary stalk * **calcified or cystic** ***_supra_***sellar mass pituitary adenoma * peal = 35-60 yo * can be secratory (prolactin MC --\> galactorrhea + amenorrhea) or nonsecratory = present only if get v big with mass effect + hypopituitary * NOT calcifed on imaging, is an ***_intra_***sellar mass (MRI sella w IV contrast= gold)

Answer 403

MR : the papillary Ms are pulled out bc of dilation --\> stretched chordae tendinae --\> dilated mitral valve --\> regurge * the murmur can fix / improve once any decompensation is treated bc dec LV end-diastolic V --\> not as much stretching --\> papillary Ms can return to their optimal position **vs. hypertrophic cardiomyopathy** = dynamic LV outflow obstruction = crescendo-decrescendo murmur * inc w dec LV preload

Answer 404

probs MEN2A/MEN2B -thyroid nodule w inc calcitonin --\> medullary thryoid CA * her mom had thyroid CA which means it was probs inherited * mom died during surgery ~ HTN crisis secondary to pheochromocytoma, happends during procedures next best step = * genetic testing for RET mutations * plasma fractioned metanephrine levels

Answer 405

interstiital lung ds * hx of ischemic heart ds w dry cough and exertional dyspnea * dry crackles = **inspiratory** **velcro crackles** dx= **high resolution CT** = way better at picking up interstitial changes + full PFTs \*\*gerd would not explain the velcro crackles or dyspnea * tho chronic GERD can cause idiopathic pulmonary fibrosis = ILD * still get the high resolution CT to dx that tho

Answer 406

bradyarrythmia secondary to AV block / conduction abn bc its episodic nature, the HR may be normal at presentation

Answer 407

turner syndrome: \>50% have **lymphatic network dysgenesis** * =**non** pittting edema from accumulation of protein rich fluid * severe ; can lead to **hygroma** --\> or hydrops fetalis

Answer 408

laryngeal papillomas =HPV 6+11 benign but can cause lots of complcations: mainstay of trx=surgical debridement

Answer 409

PTSD --\> depression and suicidality sexual assualt --\> depression and suicidality, fibromyalgia * + STDs, pelvic pain, functional GI disorders, cervical CA (may be due to avoiding pelvic exams)

Answer 410

SAD PUCKER supreadrenal :: aorta/IVC :: duodenum ^{2nd and 3rd} ^segments:: pancreas ^except^tail :: Ureter :: Colon ^{ascending and descending} :: Kidneys :: esophagus :: rectum

Answer 411

**orbital cellulitis** - MC cause is bacterial sinusitis, esp if nearby can have direct spread of Strep/Staph - less likely but common = dental abscess *_on the same side, in the maxillary teeth (near sinus/orbit)_* \*\*NOT from molar teeth\* **vs. ds spread from molar infections** --\> Ludwig Angina * rapidly progressive infection of the submandibular space * systemic sx (fever, chills, malaise) * local sx= **drooling, muffled voice, mouth pain, dysphagia, airway compromise,** displaced tongue bc floor of mouth is elevated * trx= IV ampicillin-sulbactam / IV clindaymycin

Answer 412

DRUG INDUCED LUPUS =athralgias + serositis (pleuritis/percarditis) + systemic sx MC causes = hydralazine, penicillamine, procainamide * also isoniazid, infliximab, minocycline

Answer 413

conversion disorder psychogenic pseudosyncope: associated w * v long episodes of LOC (i.e. 20 min-hrs: vs 1-2 min n) * pt remembering sx/events that occured during the episode (i.e. remembering her head throbbing after she had slid down) = rules out true syncope * no objective findings (vs syncope associated w abn vitals, diaphoresis, pallor) vs cataplexy = loss of M tone that looks like syncope associated w strong emotions in **pts w narcolepsy**

Answer 414

dec ACTH--\> dec cortisol --\> (loss of inhibition of ADH) --\> **SIADH--\> dec Na** \*\*adrenal glad is still functioning= RAAS+ALD still functioning --\> **n K**\*\*

Answer 415

chronic bronchitis * 3+ productive cough within 2 consecutive years * +/- hemoptysis * leading cause= smoking bronchiectasis * chronic cough w hx of recurrent respiratory tract infections and copious mucopurulent sputum production * +/- hemoptysis * irreversible dilationg and destruction of bronchi --\> chronic cough and inadequate mucus clearance

Answer 416

aka = "what is the accuracy of the test" -how many people who test (+) are (+) **and** who test (-) are (-) * sensitivity = how many actual + will test + * specificity = how many actual - will test - =(true positives + true negatives) / total 1. they give prevalence**_, assume 100 peopl_**e : 30 actual (+) + 70 actual (-) 2. TP= sensitivity \* actual (+) = 0.9 \* 30 = 27 3. TN = specificty \* actual (-) = 0.8 \* 70 = 56 4. accuracy = (27+56) / 100 = ***_83%_***

Answer 417

plantar fasciitis * (-) squeeze test, +/- heel spurs, worse pain w dorsiflexion of toes :: pain at plantar aspect of heel and hindfoot * oft worst when stand after long period of sitting, and then after long periods of excericse * associated w overuse, and lots of barefoot acitibity calcaneal stress fracture * positive squeeze test * after starting high impact excercise program, like new athletes and military recruits

Answer 418

sphincter of odi dysfunction : mimics gb obstruction w inc labs and sx * can follow any inflammatory process (surgery, pancreatitis, etc) * = dyskinesia and stenosis of sphincter --\> bile retention * opioids cause sphincter contraction and can worsen/precipitate sx gold standard for dx =SOD manometry * vs: biliary gastritis = x pyloric sphincter after gastric surgery

Answer 419

flash pulmonar edema : presents as sudden onset SOB and inability to lie flat, JVD but no LE edema and normal ejection fraction * trx w diuretics and the episode resolves - in a pt w hx of CAD, severe HTN, and recurrent pulmonary flash edema --\> **renal a stenosis** * unilat RAS --\> the unaffected kidney can compensate for the inc RAAS--\> hyperALD aka Cr is normal * in bilat --\> can lead to CKD

Answer 420

post-obstructive diuresis = the urine build up is enough to overcome the obstruction -urine outflow tract obstruction, probs renal stone (esp w flank pain)

Answer 421

diaphragm injury --\> diaphragmatic hernia

Answer 422

osmotic diarrhea * high SOG, \>125 * happens after large meals * due to presence of osmotically active solute = lactulose, ascites, polyethylene glycol secratory diarrhea * low SOG, \<50 * can happen during fasting, i.e. nocturnal * due to toxins (vibrio), hormons (VIPoma), CF,

Answer 423

sturge weber = port wine stain, leptomeningeal capillary, venous malformations, + **glaucoma** * anterior chamber angle abn * confirm= tanometry which will find inc IOP

Answer 424

granulomatosis w polyangiitis = wegener ## Footnote = **URT (nose, ears, sinuses)** + **LRT** (lungs) + _arthralgias/arthriti_s + _systemic_ sx + **rapidly progressive GN** dx= quantitative serum Abs = cANCA

Answer 425

porphyria cutanea tarda = associated w Hep C * enzyme x in early porphyrin metabolsim --\> abd pain and neuropsych sx * enzyme x later in metabolism --\> photosensitivity w blisters on the hands and hyperpigmentation on sun exposed areas vs cryoglobulinemia * also associated w Hep C * but presents w palpable purpure, arthralgias, and glomerulonephritis

Answer 426

femoral A access is MC way to do cardiac cath * oft --\> local femoral A complications = inguinal/groin pain after the procedure = **AVM, pseudoaneurysm, or hematoma** AVM = continous murmur, +/- palpable thrill, NO palpable mass pseudoaneurysm = bulging, pulsatile mass, systolic murmur hematoma = +/- mass, no murmur

Answer 427

NSAID induced kidney injury * this dehydrated pt was given an NSAID = COX inhibitor * the kidney responds to volume depletion w inc COX --\> afferent A dilation * inhib COX --\> vasoconstriction in the setting of volume depletion --\> kidney injury

Answer 428

neurogenic arthropathy, most likely secondary to diabetic neuropathy * chronic dec sensation and change in weight bearing --\> mechanical changes * associated w osteophyts and dec joint space (kinda like OA), but with gross deformity, inc bony fragmentation and deformity, and dec bone mass

Answer 429

MC - 1. lung malignancy 2. cystic fibrosis 3. right to left cardiac shunts \*\*hypoxemia in COPD does not lead to clubbing

Answer 430

exophthalmos = graves ds * = lymphocytic and mø infiltration of ocular Ms --\> orbital tissue expansion * sx = exophthalmos as well as eye irritation, gritty feeling, pain w eye movement, diplopia, redness, photophobia, and tearing

Answer 431

kernicterus = inc bilirubin neurotoxicity * chronic in this baby that hasn't been checked and followed * often idiopathic : this bb had cephalohematoma, w resorbption = inc indirect bili = in risk of kernicerus * sx= chorea like movements, sensorineural hearing loss, developmental delay, upward gaze palsy

Answer 432

herpangina= coxackie A * grey vesicles/ulcers on palate, uvula, tonsils * +fever, pharyngitis * 1-7 yo; ate summer, early fall VS HSV1 herpetic gingivostomatitis * clusters of vesicles on tongue, lips, buccal mucose * + fever, pharyngitis, erythematous gingiva * 6 mo-5 yo

Answer 433

n Ca, abn labs due to dec albumin proteinuria --\> dec albumin most Ca is bound to albumin so shows as low on tests * correct Ca= measured Ca + 0.8 \* 4(measured albumin)

Answer 434

senile purpura = loss of elastic fibers in the perivascualr connective tissue * _= *old people or middle aged w lots of UV exposure* ="solar" / "actinic" purpura_ * _inc risk w use of anticoag, NSAIDs, or steroids_ * minor abrasions that usually only stretch skin in younger people willcause rupture of superficial BVs --\> extrasavation of blood --\> ecchymosis * vulnerable areas= hands and forearms * **hemosiderin depo can lead to residual brownish discoloration** even once purpura resolve not dangerous no follow up required: just require more careful woud care of minor lacerations in elderly

Answer 435

Wernicke Encephalopathy= x Vit B1 ataxia + encephalopathy + oculomotor dys * oculomotor = horizontal nystagmus, x lateral move alc overuse + chronic malnutrition (bowel resection, anorexia) * chronic malnutrition pts given IV fluids (aka dextrose) can suddenly develop wernicke bc the inc glucose depletes the remaining thiamine

Answer 436

routine testing w initial diagnosis dementia =CBC, Vit B12, TSH, CMP =CT/MRI brain =neuropysch testing (montreal cog assessment, n= 26+)

Answer 437

niemann-pick ds= sphingomylenase defiency * areflexia tay sacchs ds= beta hexosaminidase deficiency * hyperreflexia

Answer 438

* inc risk of renal issues, MC = painless hematuria (sickling in renal medulla) * hyposthenuria (presents as nocturia/polyuria) * inc UTIs (esp in preg)

Answer 439

hx of viral+bac+fungal (esp hx of candida or pneumocystis) and FTT (20th percentile) = combined B and T cell disorders * just T cell would not have otitis media (bac) this patient has telangiectasias on the eyes = ataxia & telangiectasia **dec B cells, dec T cells, dec IgA**

Answer 440

slipped capital femoral epiphysis --\> get a bilat hip xray "when pt stands w feet together, R foot points outwards and L foot points straight ahead" * v specific sign * reflects the dec IR and ABDuction other causes of trendelenburg = dev dysplasia of hip, avascular necrosis --\> both also require bilat hip xrays

Answer 441

get blood cultures from 3 dif IV sites * if high risk/v ill: give empiric abx AFTER cultures * if low risk/low sx : wait for cultures to give abx get transesophageal/transthoracic echo AFTER cultures

Answer 442

bladder CA =friable new BV bleed = hematuria throughout micturition (tumor of bladder *_neck_* = terminal micturition) * urine cytology has v low sensitivity so lack of abn cells/epithelial cells CANNOT rule out bladder CA next step = cystoscopy +CT urography (visualize kidneys and eval for mets)

Answer 443

crack lung = alveolar hemorrhage from smoking crack cocaine

Answer 444

acute hemolytic transfusion reaction ABO incompatability = MC cause

Answer 445

autoimmune atrophic gastritis =inc risk for gastric adenocarcinoma and neuroendocrine tumors --\> screen in pts w AAG

Answer 446

wood's lamp = tinea capitis **KOH =** tiniea corpus, tinea **pedis** = septal hyphae * tinea = hyperkaratotic lesions * so flaky skin, may fall off when take off sock; PE= excoriations and erythema on

Answer 447

soy is a complete protein source, contains all essential amino acids

Answer 448

CHF * crackles +/- mild, occasional wheezing, dec sounds over bases (~ pulm edema) * hypoxia, hypocapnia, respiratory alkalosis COPD * diffuse wheezing, NO crackles, * respiratory acidosis with hypercapnia

Answer 449

+ forward bending test --\> get x-ray to measure cobb angle - cobb angle 10-30 = follow q 6mo - cobb angle 30-40 = thoracolumbar spinal brace - cobb angle 40-50+ and severe = consider surgery

Answer 450

sigmoid volvulus = coffee bean sign * trx= therapeutic flexible sigmoidoscopy * if peritonitis/perforation = emergency sigmoid colectomy VS SBO * multiple air fluid levels (Attached) * = decompression and bowel rest

Answer 451

CT angiogram of the chest \*\*D dimer if v unlikely to have PE, bc it can rule it out then * but a wells score \> 4 , negative Ddimer cannot rule out

Answer 452

sick sinus syndrome * MC= age related degeneration of the cardiac conduction system = fibrosis of the sinus node atrial arrythmias = * a fib (palpitaitons) * paroxysmal bradycardia - tachycardia = brady alternating w SVT trx= pacemaker vs; abn automaticity of atrial myocytes = a fib (MC from pulm Vs ) = no sinus brady or sinus pauses vs: aberrant conduction pathway = WPW= paroxysmal tachy but no brady

Answer 453

first time unprovoked seizure in an adult CT brain w contrast * quick and effectve in ED outpatient / non-emergent * MRI bc more sensitive to lots of etiologies that can cause seizure

Answer 454

**triple bubble sign** and gas in colon associated w cocaine or tobacco in pregnancy,

Answer 455

menisceal tear

Answer 456

=DEC CO2 (BLOW IT ALL OFF) = resp alkalosis, dec CO2 * MC cause post-op = **atelectasis =** hypoxemia (mild, ~70), may be localized findings but dec breath soundes + dense opacities how to dec pulm complciations post-op * control underlying lung ds before * quit smoking ***_4-5 weeks_*** before * deep breathing excerices **(atelectasis)** * pain control post-op (**bronchospams)** * incetive spirometry for pneumonia (**pnuemonia)** **NOT** -pre/periop steroids or albuterol -

Answer 457

classic= pt w parkinsonian sx that has autonomic sx TRIAD = parkinsonian + autonomic dys + widespread neuro sx

Answer 458

bullous (L) = S. aureus * will have crusting w rupture of flaccid bullae, but less likely to be honey crusted nonbullous (R)= S. aureus or S. pyogenes * honey crusted lesions

Answer 459

CNIII palsy * two etiologies = ischemia vs motor * pupil sparing = ischemia (para fibers outside the bundle) * pupil dilation = compression from outside * = aneurysm until proven otherwise * get MR angiography or CT angiography

Answer 460

shoulder pain --\> pancoast tumor (invade into adjacent structures) * fungi/pneumonia would NOT cause the shoulder/arm pain bc they don't invade the nearby structures

Answer 461

= all HF sx (edema, dyspnea on exertion, orthopnea) but EF 65%+ 1. CAD + risk factors 2. ^^risk i.e DM 3. long standing HTN 4. ***obesity and sedentary lifestyle***

Answer 462

POLYARTERITIS NODOSA = vasculitis that *does not include lungs* * renal i.e infarction * GI i.e. mesenteric ischemia * derm i.e. livedo reticularis * neuro i.e. mononeuritis multiplex

Answer 463

CECAL VOLVULUS (CT is more sensitive for cecal) * trx= emergency laparotomy and rest * NOT detorsion vs sigmoid

Answer 464

* transudatve ~ systemic factors = hypoalbumin, inc hydrostatic P * exudative ~ inflammation normal pleural fluid = pH 7.0 transudative= 7.4-7.55 exudative = 7.3-7.45 * pH \< 7.3 = associated w inc acid (empyema) or dec H efflux (tumor, pleural fibrosis, pleuritis)

Answer 465

post injury heterotopic bone formation

Answer 466

tuberous sclerosis * angiofibromas of malar region * subependymal tumors * cardiac rhabdomyomas * renal angiomyolipomas

Answer 467

tinea versicolor = malassezia furfur / malassezia globus *not dermatophytes*

Answer 468

cysteine stones -associated with amino acid transport dysfunctions

Answer 469

ecthyema gangrenosum * MC = pseudomonas _(G-) skin infection : still get culture bc other G- orgs * RAPID development (12-18 hours), one of the MC skin infections in immunocomp * cutaneous/mucous membrane\> **punched out gangrenous** ulcers in LESS THAN A DAY pyoderma gangrenosum * neutrophilic inflammation; * associated with IBD and arthropaties * develop rapidly, begin as *_cutaneous_* papules and nodules --\> painful, **purulent** ulcers with **violaceous borders** * **uncommon** to have fever

Answer 470

dec GABA and atrophy of caudate nucleus and putamen

Answer 471

18+ =antisocial personality disorder \< 18 = conduct disorder less severe, against authority only = oppositional defiant

Answer 472

- painless vaginal bleeding w ROM or contractions - abn FHT (bradycardia, sinusoidal pattern) * sinusoidal pattern ~ fetal anemia , ominous sign - fetal exsangiunation + demise - can be dx on US at 18-20 weeks =cesarean at 34-35 weeks * or emergency cesarean if they present w ROM/contractions w bleeding and abn FHT

Answer 473

* *first degree=** only vaginal mucosa and perineal skin * *second degree =** ^ + bulbocavernosus M and perineal body * *third degree:** ^ + external anal sphincter, internal anal sphincter * *fourth degree =** ^ + rectal mucosa

Answer 474

oligohydramnios = AFI \< 5cm * risk : preeclampsia, abruptio placentae, uteroplacental insufficiency, renal anomalies, NSAIDs * complications : meconium aspiration, preterm delivery, umbilical cord compression polyhydramnios - AFI \>= 24 cm * risk= esophageal/duodenal atresia, anencephaly, multiple gestation, congenital infection, DM * complications : fetal malposition, umbilical cord prolapse, preterm labor, PPROM * presents as uterine size larger than dates, dyspnea from insufficient maternal lung expansion bc enlarged uterus

Answer 475

**hypercapnia is normal in late pregnancy** from direct stimulation of progesterone on central respiratory center * late preg - chronic resp acid

Answer 476

hyperemesis gravidarum * can present w orthostatic HTN * severe vomiting —\> lose HCl —\> metabolic alkalosis * vs severe diarrhea = nonunion gap metabolic acidosis from losing HCO3 * labs= ketonuria, hypochloremic metabolic alkalosis, hypokalemia, hemoconconcentration * trx= admission, antiemetics, IV fluids CAN CAUSE WERNICKE ENCEPHALOPATHY * encephalopathy (dec memory), gait ataxia, nystagmus/ abducens palsy, posture ataxia

Answer 477

inc maternal serum AFP = * open neural tube defects (anencephaly, open spina bifida), * ventral wall defects (omphalocele, gastroschiasis), * multiple gestation dec AFP= * aneuploidies (trisomy 18/ 21) * DOWNS

Answer 478

RUQ pain = biliary colic, can radiate to back * preg inc risk from inc estrogen levels —\> inc cholesterol excretion into bile AND inc progesterone —\> dec gallbladder motility and emptying as gallstone form and get too big —\> intermittently obstruct the cystic duct when the gallbladder contracts (i.e fatty meals) * confirm w RUQ US to show stones or sludge * most cases resolve w supportive care (pain control) * cholecystectomy usually delated until postpartum

Answer 479

cause = HPV 16+18 risk = smoking, **vuvlar lichen sclerosis,** immunodefciency, prior cervical ca, vulvar/cervical intraepithelial neoplase sx= POST MENOPAUSAL vulvar irritation/pain, erythematous friable plaque, intermittant bleeding + dyspareunia

Answer 480

* clinical= * age 50-60, * vulvar pain/pruritis, dyspareunia, **erosive variant=**MC * erosive, glazed lesions w white borders (wickham striae * , vaginal involvement +/ stenosis, associated **oral ulcers** * serosanguinous vaginal discharge, stenosis of vaginal introitus : lace like reticular erosions on gingiva and palate that cause ulcers and plaques * PAINFUL **papulosquamous variant** = * small, pruritic papule w purple hue * dx= vulvar punch biopsy bc lichen plants may present similar to vulvar cancer * first line trx= **high potency topical corticosteroids**

Answer 481

infant: * normal internal genitalia, external virilization (clitoromegaly), **undetectable serum estrogen levels** * in utero will cause transient masculinization of mom that resolves after delivery * can have either 46XX or 46XY older child * delayed puberty, * tall w weight gain and fatty liver + osteoporosis, * **undetectable estrogen levels,** * *no breast development,* * **high levels of FSH+LH** that result in polycystic ovaries (multiple cysts visible on US) * **vs turner**= low estrogen AND T w high FSH/LH * aromatase deficiency has low E but HIGH T

Answer 482

be suspicious for endometrial CA * age\<45 w abnormal uterine bleeding = LOW RISK, just start on combination contraception * \< 45 yo and fails contraception management --\> endometrial biopsy = GOLD STANDARD * post-menopausal can get US but biopsy is best biopsy shows * endometrial hyperplasia --\> contraceptive therapy or hysterectomy * endometrial CA --\> hysterectomy

Answer 483

leiomyomata uteri (fibroids) * common cause of _heavy menstrual bleeding_ = proliferation of sm M within myometrium can cause **irregular uterine enlargement (**no pain, maybe heavy) endometriosis * c_yclic bleeding_ of ectopic endometrial glands * present w _*pelvic pain*, heavy bleeding_, **irregularly enlarged uterus** adenomyosis = * proliferation of endometrial glands inside myometrium * **bulky tender uterus** that is **uniformly enlarged**

Answer 484

granulosa cell tumor * precocious puberty, adnexal mass * inc estrogen and inhibin * US= complex ovarian mass * histo = rosettes

Answer 485

sx= pelvic pressure, dyspareunia, urinary retention, urinary incontinence, constipation, fecal incontinence trx= weight loss and pelvic muscle training * refractory = pessary, surgery

Answer 486

neonatal lupus: sx = cardiac or cutaneous * rash periorbital or scalp * AV block at ~ 18-24 weeks ; due to *_irreversible_* injury to the AV node * **fetal heart tracings in utero = bradycardia \<110** * may also cause hydrops fetalis due to prolonged heart block and cardiomyopathy

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