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Question 1

Young woman presenting with adult-onset asthma, hemoptysis, fever and sensory abnormalities of the upper and lower extremity most concerning for
next step?

Answer 1

Eosinophilic granulomatosis with polyangiitis (Churgg-Strauss)
PAN – Palpable purpura, Asthma/sinusitis, Neurological symptoms (wrist drop, sensory)
Serum antineutrophil cytoplasmic autoantibody assay (p-ANCA)
MPO-ANCA
will see eosinophilia

adult onset asthma with eoosinophilia: churg strauss or allergic bronchopulmonary asperfillosis

Question 2

Elderly woman with many vaginal deliveries presenting with inability to void that resolves with catheterization and with physical exam most consistent with pelvic organ prolapse

Answer 2

urinary retention

Question 3

If a patient recently began treatment with methimazole/propylthiouracil and presents with fever and a sore throat, the next best step

Answer 3

get a CBC

agranulocytosis

Question 4

routine prenatal testing:

Answer 4

Routine testing at initial visit: HIV, Urine protein/culture, Chlamydia PCR, Rh(D) antibody screen, Hemoglobin/Hematocrit, Hepatitis B serum antigen, Rubella and varicella titers, Pap test (if indicated)

24-28 weeks: Rh(D) antibody screen, gestational diabetes screen, hemoglobin/hematocrit

35-37 weeks: Group B Strep culture

Question 5

Periodic sharp wave complexes on EEG
(2) Increased 14-3-3 CSF assay
(3) MRI findings on caudate nucleus and/or putamen

Answer 5

Creutzfeldt jakob
rapid progressive
startle reflex

Question 6

increased CSF beta amyloid

Answer 6

alzheimers (amyloid)

Question 7

increased methylmalonic acid

Answer 7

vitamine b-12 megaloblastic anemia + neuro sxms

Question 8

hypercalcemia, bone pain, anemia, kindey problems

Answer 8

multiple myeloma
serum protein electropheresis

Question 9

Young woman with lupus presenting with bleeding gums and petechiae/ecchymosis of extremities found to have mild anemia and pronounced thrombocytopenia most consistent with
next step?

Answer 9

Immune thrombocytopenia
TIP
1ST LINE: STEROIDS, ivIG

Patients with lupus tend to have pancytopenia, most commonly due to autoantibodies leading to immune-mediated destruction (particularly of platelets and leukocytes; multiple potential ways lupus can lead to anemia)

Immune thrombocytopenia classically leads to increased number of megakaryocytes on bone marrow biopsy and few platelets on peripheral smear

Question 10

Adolescent boy with recent viral illness presenting with fatigue and respiratory distress found on physical exam to have hypotension, lung crackles, and a new cardiac murmur most consistent with

Answer 10

myocarditis

Question 11

Adolescent boy with acute, unilateral testicular pain with physical exam demonstrating elevated right testicle with absent cremasteric reflex on the right with a negative Prehn’s sign (pain unrelieved with elevation) most consistent with

Answer 11

testicular torsion
genitofemoral nerve (travels within spermatic cord is affectred by torsion)
GO STRAIGHT TO OR
NEED PERFORM OCHIOPEXY ON BOTH TESTICLES

vs

testicular pain relieved with elevation –> Positive Prehn’s sign –> Epididymitis

Question 12

potential symptoms of sarcoidosis:

Answer 12

lupus pernio (subacute raised violacious facial lesions)
bell’s palsy
uvietis
erythema nodosum( also seen in IBD, TB, Behcets, fungal infections)

Question 13

Polymyositis/Dermatomyositis:

Polymyalgia rheumatica: Stiffness, associated with temporal arteritis

Answer 13

Inflammed with increased ESR and increased CK

increased ESR and normal CK

Question 14

Indications for electroconvulsive therapy in setting of depression:

Answer 14

(1) Refractory to standard treatment (2) Presence of psychotic features (3) Psychiatric emergency (pregnancy patient, refusal to eat/drink, imminent risk of suicide)

Question 15

antidepressant for people who are not eating enough and who have trouble sleeping

Answer 15

mirtazapine

Question 16

A young girl who was started on a penicillin for strep pharyngitis 8 days ago presenting with fever, lymphadenopathy, urticaria, arthralgias and proteinuria most consistent with

Answer 16

SERUM SICKNESS type III hs
is mediated by deposition of antigen-antibody complexes –> to prevent future episodes we want to avoid giving patient “antigen” and therefore we should avoid penicillins

Serum sickness often triggered by certain drugs (antibiotics) or infections (hepatitis B)

Question 17

Young woman with poorly controlled type 2 diabetes currently admitted for pyelonephritis that is refractory to standard treatment (fluoroquinolone) with persistent fevers and costovertebral tenderness, concerning for

Answer 17

complicated pyelonephritis so workup
CT SCAN OF ABDOMEN

Persistent symptoms despite 48-72 hours of therapy (2) History of nephrolithiasis (3) Unusual urinary findings (gross hematuria) (4) Concern for complicated pyelonephritis (renal abscess, emphysematous pyelonephritis, septic shock)

Likely would want to wait on blood cultures before deciding to broaden coverage because quinolones should cover almost all causative pathogens in setting of pyelonephritis

Question 18

Young man with significant immunodeficiency admitted to ICU with septic shock and hypotension refractory to 4L of fluid showing early signs of volume overload (inspiratory crackles, non-collapsible IVC) start on:

Answer 18

SEPTIC shock: hypotension with fever
give Norepinephrine

vs

hydrocortosone in pt with adrenal insufficiency with just refractory hypotension

Question 19

Middle-aged woman with type 2 diabetes and hypertension recently started on lisinopril who presents with signs of volume overload (lower extremity edema, lung crackles, S3 gallop), worsening hypertension and a severely increased creatinine (1.2 –> 4.0)

Answer 19

acute kidney injury
especially if pt had bilateral renal artery sclerosis of fibromuscular dypslasia would worsen with ace-i causing aki (pre-renal –> ATN)

Question 20

wrist widening, frontal bossing, leg bowing, hypertrophy of costochondral joints (“rachitic rosary”)

Answer 20

Osteomalacia/Rickets –> Poorly mineralized bone often in setting of vitamin D deficiency or problems activating vitamin D (liver/renal disease)

Question 21

hearing loss, multiple fractures, and hyperflexible joints presenting with potential lower extremity fracture in setting of minor trauma,

Answer 21

AD - ↓ production of type I collagen
osteogenesis imperfecta: (1) Frequent fractures (2) Blue sclerae (due to ability to see underlying choroidal veins) (3) Conductive hearing loss (4) Short- normal stature (5) Dentinogenesis imperfecta (thin, greyish teeth) (6) Joint hypermobility

Question 22

Middle-aged man with ST-elevation MI complicated by extensive anterolateral akinesis who on day 5 of hospitalization develops bilateral lower extremity pain/paresthesias, cyanosis, hypotension, and weak upper extremity pulses with absent lower extremity pulses

Answer 22

aortic embolism

Occlusion at aortic bifurcation: bilateral acute limb ischemia (most common presentation)
Limb pain
Pallor or cyanosis
Absent pulse
Paresthesia and paralysis
Diagnostics
CT angiography (confirmatory test)
Treatment
embolectomy
Aortobifemoral bypass

Question 23

An elderly man with a significant smoking history presents with chronic shortness of breath and cough with physical exam consistent with hypoxemia, fine/dry crackles of both lungs and clubbing with chest x-ray showing scattered reticular opacities most consistent with

Answer 23

idiopathic pulmonary fibrosis
High-resolution CT scan of the chest

crackles: either pulmonary edema (HF exacerbations) or interstitial lung disease (IPF, Sarcoidosis)

Question 24

Serum antiglomerular basement membrane antibody assay

Answer 24

Goodpasture syndrome –> Young man with hemoptysis and hematuria

Question 25

Four main types of lacunar infarct (highly associated with poorly controlled hypertension):

Answer 25

(1) Pure motor stroke (2) Pure sensory stroke (3) Ataxia-hemiplegia syndrome (4) Dysarthria-clumsy hand syndrome

Question 26

Young primigravid woman at 21 weeks’ gestation who presents with acute shortness of breath, GI symptoms, headache, muscle aches, fever and chest x-ray with unilateral interstitial infiltrates most concerning for

Answer 26

influenza A virus (the flu) Muscle aches and GI symptoms very common in patients with influenza infection and often can help differentiate it from a rhinovirus infection or a bacterial pneumonia

Question 27

Young woman with chronic earplug use who presents with subacute unilateral ear itchiness with physical exam notable for ear pain with manipulation of pinna and an erythematous/edematous ear canal most consistent with

Answer 27

otitis externa ear pain with pulling pinna vs relief with pulling pinna -- otitis media otitis externa: acetic acid drops or floroquinolones

Question 28

Most cases of sinusitis are viral in origin, but you should be concerned for bacterial rhinosinusitis if at least 1 of the following 3 criteria are met

Answer 28

1) Persistent symptoms >10 days (2) Febrile illness for >3 days (3) Symptoms improve and then get worse Bacterial rhinosinusitis –> Treat with amoxicillin + Clavulonic acid (Augmentin) vs viral sinusitis is without fever and managed conservatively

Question 29

Adolescent boy with VACTERL presenting with subacute cough accompanied by expiratory stridor, forced vital capacity > slow vital capacity and a scooped-out flow-volume loop, all of which are associated with

Answer 29

tracheal collapse Scooped out flow-volume loop = Obstructive lung disease (problem getting air OUT of the lungs) VATER syndrome = VACTERL = Constellation of mesodermal anomalies leading to Vertebral defects, Anal defects, Cardiac defects, Tracheal or Esophageal anomalies (often fistula), Renal defects and Limb defects

Question 30

Indications for Fine-Needle biopsy:

Answer 30

thyroid nodule larger than 2cm or 1cm + u/s showed microcalcifications, irregular markings REGARDLESS ALWAYS DO U/S AND TSH/T3/T4 FIRST

Question 31

Baby born to mother with well-controlled HIV (viral load < 1000 copies/mL) VS poorly controlled

Answer 31

zidovudine only vs multidrug antitretroviral therapy

Question 32

Macroprolactinoma (>1 cm) or symptomatic microprolactinoma: vs larger than 3cm or continues to grow with dopamine agonist

Answer 32

cabergoline, bromocriptine transphenoidal surgery

Question 33

pseudoseizure (no post-ictal state, no tongue biting, no incontinence, occured after a negative emotional state0 next step?

Answer 33

VIDEO EEG monitoring

Question 34

Overweight patient with increased LH:FSH ratio (often >3:1)

Answer 34

PCOS

Question 35

post-menopause labs

Answer 35

increased FSH premature menopause: primary ovarian failure --> hx of radiation or smoking

Question 36

Young woman who was recently hospitalized for crushing chest pain resolving with nitroglycerin with ST-depressions on ECG and a clean cardiac catheterization who continues to have short unprovoked episodes of chest pain most consistent with

Answer 36

Prinzmetal’s angina should be treated with calcium channel blockers or nitrates

Question 37

MEN 1 –> 3 P’s –> Pituitary tumors, Parathyroid adenoma, Pancreatic tumor (Zollinger-Ellison, VIPomas, etc.) vs MEN 2A –> 2 P’s and 1 M –> Parathyroid adenoma, Pheochromocytoma, Medullary thyroid cancer MEN 2B –> 1 P and 2 M’s –> Pheochromocytoma, Medullary thyroid cancer, Mucosal neuromas

Question 38

Nitroblue tetrazolium testing

Answer 38

Chronic granulomatous disease –> Increased risk of Catalase positive organisms, often presents with recurrent Staph skin infections

Question 39

Young woman with complicated pregnancy (polyhydramnios, gestational diabetes) who has artificial rupture of membranes followed by a prolonged deceleration (on order of minutes), concerning for

Answer 39

umbilical cord prolapse if pt has membrane rupture and then shortly after abnormal fetal heart tracings usually will see fetal bradycardia, variable deceleraitons and prolonged decelerations > 1min Risk factors for umbilical cord prolapse: Breech presentation, artificial rupture of membranes, polyhydramnios Management of umbilical cord prolapse: Elevate the fetal head and perform a C- section (NOT appropriate to replace the cord or to allow the patient to continue to labor)

Question 40

Young woman with complicated pregnancy (polyhydramnios, gestational diabetes) who has artificial rupture of membranes followed by a prolonged deceleration (on order of minutes), concerning for

Answer 40

umbilical cord prolapse if pt has membrane rupture and then shortly after abnormal fetal heart tracings usually will see fetal bradycardia, variable deceleraitons and prolonged decelerations > 1min Risk factors for umbilical cord prolapse: Breech presentation, artificial rupture of membranes, polyhydramnios Management of umbilical cord prolapse: Elevate the fetal head and perform a C- section (NOT appropriate to replace the cord or to allow the patient to continue to labor)

Question 41

early variable late decelations

Answer 41

Early deceleration –> Deceleration mirrors contraction –> **Sign of fetal head compression –> Benign finding** Variable deceleration –> Unassociated with contractions, steep/abrupt deceleration and recovery –> Sign of **umbilical cord compression **–> Most concerning if recurrent and with loss of variability Late deceleration –> Deceleration occurs following contraction (nadir does not mirror peak of contraction) –> **Uteroplacental insufficiency –**> Most concerning if recurrent and with loss of variability; often most ominous of the deceleration patterns

Question 42

IBD (crohsn and ulcerative colitis) other findings:

Answer 42

skin disease (pyoderma gangrnosum, erythema nodosum), joint disease (inflammatory arthritis), eye disease (uveitis) and oral ulcers

Question 43

crohns disease kidney stones:

Answer 43

Crohn’s disease is specifically associated with calcium oxalate kidney stones (terminal ileal disease –> Impaired fat absorption –> Intra-intestinal calcium binds to fat instead of oxalate –> More free oxalate absorbed from the gut

Question 44

post op patient with super high glucose levels d/t

Answer 44

Decreased uptake of glucose by insulin-sensitive tissues insulin resistance 2/2 to injury/stress

Question 45

Middle-aged woman with type 2 diabetes presenting with fever and a lower extremity lesion that is exquisitly tender, lacks sharp margins and has bullae with purplish discharge most consistent

Answer 45

with necrotizing fasciitis over cellulitis 2) 1) Pain out of proportion to examine (extreme pain > tenderness) (2) Rapid progression of symptoms (3) Severe systematic features (fever, chills, hypotension) (4) **Crepitus** or free air (5) **Bullae** (6) Purulent, cloudy discharge (7) **Violaceous** appearance of lesion (8) Paresthesia/Anesthesia at edge of lesion go directly to OR diabetic pts predisposed to necfas of perineal -- fournier gangrene

Question 46

pt working at a plant where inhaling chlorine gas what to do?

Answer 46

primary disease prevention: prevent it before it even occurs with vaccination, **wearing a respirator** second disease prevention: screening for disease and manage asymptomatic disease (monthly pulmonary function tests) tertiary disease prevention: treatment of disease (corticosteroid therapy)

Question 47

Middle-aged man without significant alcohol history presenting with abdominal pain radiating to the back and elevated amylase found to have a triglyceride level in the 1000’s, most consistent with pancreatitis due to hypertriglyceridemia tx?

Answer 47

statins are the best lipid-lowering agent, with one key exception being the setting of hypertriglyceridemia-associated pancreatitis which should be treated with a **fibrate** because they lead to the most profound drop in triglyceride levels

Question 48

Middle-aged man with smoking history and likely COPD given baseline history presents in respiratory distress with significant hypoxemia despite mechanical ventilation with x-ray findings of diffuse bilateral alveolar infiltrates most concerning for

Answer 48

ARDS high PEEP with low TV **ADD/increase PEEP**

Question 49

nose bleeds, telangiectasias and, most concerning, AV fistulas (high-output heart failure)

Answer 49

Hereditary hemorrhagic telangiectasia

Question 50

Middle-aged woman with a 2-month history of fatigue and abdominal pain found to have anemia and a moderately differentiated adenocarcinoma in the ascending colon most consistent with right-sided colon cancer next step?

Answer 50

Righ hemicolectomy (dont just take out the lesion but surgically remove half of it)

Question 51

SBP cirrhosis PMH>250 TX?

Answer 51

3rd gen cephalosporin cefotax ceftri some cirrhosis pt can recieve flouroquinolones for prophylaxis also should get a EGD for esopahgeal varices ppx low temperature fever means that they are not fighting infection hard enough, aka low immune sxm, aka THIS IS BAD

Question 52

antiepileptics (phenobarbital and carbamazepine) + weak bones

Answer 52

induce p450 and increase metabolism of vitamin D (osteomalacia/rickets/ vit d deficiency) carbamazepine also causes folate deficiency

Question 53

primary amenorrhea:

Answer 53

girls who have not had secondary sexual changes (breast development mounds form, thelarche some pubic hair pubarche) by 13 or who have not had menarche by 15

Question 54

pleural fluid:

Answer 54

Light’s criteria (If at least 1 of the following conditions are true, then the effusion is exudative): (1) Pleural fluid protein: Serum protein ratio > 0.5 /// (2) Pleural fluid LDH: Serum LDH ratio > 0.6 /// (3) Pleural fluid LDH > 2/3 upper limit of normal serum LDH (often ~200) EXudative effusions are **due to increased vascular permeability** often in the setting of inflammation (cancer **increased protein or LDH in fluid**, infection, autoimmune) and you can remember that they have fluid and EXtra substances (protein, cells, LDH, etc.) Transudative effusions are often due to** increased hydrostatic pressure** (volume overload due to CHF exacerbation, CKD, etc.) or **decreased oncotic pressure** (nephrotic syndrome, malnutrition, etc.) Empyema (walled off, purulent fluid collection secondary to infection) –> **decreased glucose concentration** (bacteria eat sugar), increased segmented neutrophil count

Question 55

First step in primary amenorrhea work-up:

Answer 55

Determine if uterus is present (physical exam, imaging) because if it is ABSENT then the patient either has Mullerian agenesis (XX, normal breast and pubic/axillary hair development) or Androgen Insensitivity Syndrome (XY, absent pubic/axillary hair with normal breast development)

Question 56

Second step in primary amenorrhea work-up:

Answer 56

primary amenorrhea AND has a uterus FSH LEVELS: low fsh --> pituitary/hypothalamus is dysfunctional (prolactinoma, hypothyroidism, functional hypothalamic amenorrhea) normal fSH: FUNCTIONal defect: imperforated hymen elevated fsh:ovaries are dysfunctional (turners, primary ovarian failure)

Question 56

Second step in primary amenorrhea work-up:

Answer 56

primary amenorrhea AND has a uterus FSH LEVELS: low fsh --> pituitary/hypothalamus is dysfunctional (prolactinoma, hypothyroidism, functional hypothalamic amenorrhea) normal fSH: FUNCTIONal defect: imperforated hymen elevated fsh:ovaries are dysfunctional (turners, primary ovarian failure)

Question 57

hereditary spherocytosis coombs ( )

Answer 57

negative vs hemolytic anemia is +