Internal Medicine

Question 1

acute angle-closure glaucoma

Answer 1

symptoms: headache, ocular pain, nausea, decreased visual acuity
signs: conjunctival redness, corneal opacity, fixed/mid-dilated pupil
dx: tonometry (intraocular pressure) and goniscopy (measures corneal angle)
treatment
1. topical- multidrug (timolol, pilocarpine, apraclonidine)
2. systemic- acetazolamide (consider mannitol)
3. laser iridotomy

Question 2

what can lead to hepatorenal syndrome

Answer 2

risk factors: advanced cirrhosis with portal hypertension and edema
precipitating factors: reduced renal perfusion, GI bleed, vomiting, sepsis, excessive diuretic use, spontaneous bacterial peritonitis, reduced glomerular pressure and GFR possibly by NSAIDS (constrict afferent arteriole)

Question 3

what maneuvers increase parasympathetic tone to the heart

Answer 3

carotid sinus massage
cold water immersion or diving reflex
valsalva maneuver
eyeball pressure

Question 4

Chronic Lymphocytic Leukemia

Answer 4

Clinical

• lymphadenopathy and hepatosplenomegaly
• mild thrombocytopenia and anemia
• could be asymptomatic

Diagnostic

• severe lymphocytosis and smudge cells
• flow cytometry (clonality of mature B cells)

Prognostic

• median survival 10 years
• worse with: multiple chain lymphadenopathy, hepatosplenomegaly, thrombocytopenia, anemia

Complications

• infection
• autoimmune hemolytic anemia
• secondary malignancies (richter transformation)

Question 5

how to evaluate elevated alk phos

Answer 5

1. check GGT (if normal then its likely due to bone abnormality)
2. if elevated then its likely due to biliary problem so check RUQ ultrasound and anti-mitochondrial antibody
3. AMA+ or abnormal hepatic parenchyma on US do liver biopsy
4. dilated bile ducts do ERCP (endoscopic retrograde cholangiopancreatogram)
5. both normal then consider liver biopsy, ERCP, observation

Question 6

asymptomatic patient with elevated alk phos, normal AST and ALT, normal RUQ ultrasound, and positive anti-mitochondrial antibody assay, severe hypercholesterolemia
patient might have pruritus and fatigue

Answer 6

primary biliary cholangitis (previously, primary biliary cirrhosis)

• chronic progressive liver disease with cholestasis and autoimmune destruction of intrahepatic biliary ducts
• give patient ursodeoxycholic acid (hydrophilic bile acid)
• down the line most of these pts will need liver transplants
• complications: malabsorption of fat-soluble vitamins, metabolic bone diseases (osteoporosis/malacia), hepatocellular carcinoma

Question 7

kidney problem that causes persistent activation of the alternative complement pathway

Answer 7

membranoproliferative glomerulonephritis, type 2

-immunofluorescence will show C3

Question 8

patient with loss of motor and sensory function, loss of rectal tone, and urinary retention

Answer 8

acute spinal cord compression

-manage with emergency surgical consultation, neuroimaging, and possibly IV glucocorticoids

Question 9

what is the most common cause of ascites

Answer 9

liver cirrhosis/chronic liver disease

Question 10

next step for all patients who newly present with ascites

Answer 10

paracentesis is required to determine the cause

Question 11

main complications after MI

Answer 11

0-24hrs: arrhythmia
1-3days: fibrinous inflammatory pericarditis
3-14days: pseudoaneurysm of inferior wall, free wall rupture, papillary muscle rupture, septal/VSD rupture
2weeks-3months: Aneurysm in anterior wall, dressler syndrome/immune pericarditis

Question 12

intermittent claudication, diminished pulses, and abnormal (<1) ankle brachial index
-can be in one limb

Answer 12

Peripheral artery disease
-intermittent claudication = 20% 5-year risk of nonfatal MI and stroke AND 15-30% 5-year risk of death due to CV causes AND 1-2% critical limb ischemia with risk of limb amputation

-treat pt with statin and low-dose aspirin then start supervised exercise therapy

Question 13

nonpupil sparing cranial nerve 3 palsy is concerning for what

Answer 13

aneurysmal compression (get MR or CT angiography immediately)

• most commonly caused by microvascular ischemia
• associated with diabetes mellitus, hypertension, hyperlipidemia

Question 14

what are the nonosmotic reasons ADH can be stimulated for release

Answer 14

nausea
pain
physical/emotional stress
hypotension
hypovolemia 
hypoxia 
hypoglycemia

Question 15

localized pain and tenderness over the medial tibial condyle in a runner

Answer 15

pes anserinus pain syndrome

• associated with overuse
• risk factors: obesity, DM, knee osteoarthritis, angular deformity
• dx: clinical
• treatment: quad strength training and NSAIDs

Question 16

what does a third heart sound indicate

Answer 16

decompensated heart failure
-give dobutamine which stimulates myocardial contractility leading to improved ejection fraction, reduce LVESV, and symptomatic improvement

Question 17

most common skin malignancy in US

Answer 17

basal cell carcinoma

-slow growing papule with pearly rolled borders

Question 18

what is primary sclerosing cholangitis associated with

Answer 18

ulcerative colitis

Question 19

how to diagnose multiple sclerosis

Answer 19

• T2 MRI lesion disseminated in space and time

- oligoclonal IgG bands on CSF lumbar puncture

Question 20

patient with acute onset headache, sensation of the room spinning, nystagmus

Answer 20

stroke or hemorrhage affecting the cerebellum

Question 21

pt with flank pain and hematuria and palpable abdominal mass
-left scrotal varicoceles

Answer 21

renal cell carcinoma

-paraneoplastic syndromes: anemia/erythrocytosis, thrombocytosis, fever, hypercalcemia, cachexia

Question 22

aquagenic pruritus

Answer 22

polycythemia vera
-treat with phlebotomy

-one major complication is budd-chiari syndrome

Question 23

budd-chiari syndrome

Answer 23

hepatic venous outflow obstruction usually due to myeloproliferative disorders (PV), malignancy (hepatocellular carcinoma), OCP use/pregnancy

acute signs: jaundice, hepatic encephalopathy, variceal bleeding, prolonged INR/PTT, elevated transaminases

chronic signs: abdominal pain, hepatosplenomegaly, ascites, elevated bilirubin and transaminases

dx: abdominal doppler ultrasound showing decreased hepatic vein flow then investigate for underlying causative disorders

Question 24

single most important prognostic consideration for pts treatment with cancer

Answer 24

TNM staging, stage 4 is the worst

Question 25

good and bad prognostic factors in breast cancer

Answer 25

good ER+ PR+ bad overexpression of HER2/neu oncogene poorly differentiated tumors

Question 26

endemic locations of systemic mycoses

Answer 26

histo- mississippi and ohio river valleys blasto- eastern and central US and great lakes coccidio- southwestern US and california paracoccidio- latin america

Question 27

clinical features of blasto

Answer 27

lung- acute/chronic pneumonia skin- wart like lesions, violaceous nodules, skin ulcers bone- osteomyelitis genitourinary- prostatitis, epididimo-orchitis CNS- meningitis, epidural or brain abscesses

Question 28

what does an S4 mean?

Answer 28

-AKA atrial gallop indicates a stiff LV (the sound is atrial contraction and blood is hitting the stiffened LV) -restrictive cardiomyopathy -can be heard in acute phase of myocardial infarction OR -LV hypertrophy from prolonged hypertension

Question 29

acute lead toxicity vs chronic

Answer 29

GI: constipation Neuropsych: sensorimotor neuropathy, short-term memory loss Heme: microcytic anemia with basophilic stippling, hyperuricemia treat with chelation therapy with calcium disodium EDTA Chronic is the same but it can also lead to hypertension, nephropathy, hyperuricemia, and microcytic anemia

Question 30

pronator drift

Answer 30

both arms out and palms up then one arm drifts down and palm turns toward the floor sensitive and specific for upper motor neuron or pyramidal/corticospinal tract disease

Question 31

how to treat secondary raynaud phenomenon

Answer 31

first the patient should get tested for autoantibodies and inflammatory markers -CBC, metabolic panel, urinalysis, ANA antibody, rheumatoid factor, ESR, complement levels (C3 and C4) - evaluate and treat underlying disorder - CCB for persistent symptoms, aspirin for patients at risk for digital ulceration

Question 32

patient with AIDS, progressive blurred vision, floaters, yellow-white exudates adjacent to the fovea/retinal vessels

Answer 32

cytomegalovirus (CMV) retinitis - most common end-organ complication of CMV in pts with advanced AIDS - treat with valganciclovir and in severe cases intravitreal infections - pts should start on antiretroviral treatment to prevent recurrence and progression

Question 33

what ratio to look out for in prerenal acute kidney injury

Answer 33

BUN/creatinine ratio (>20:1)

Question 34

three most common causes of aortic stenosis

Answer 34

- senile calcific aortic stenosis - bicuspid aortic valve - rheumatic heart disease

Question 35

adverse effect of antithyroid drugs

Answer 35

agranulocytosis - methimazole: 1st trimester teratogen, cholestasis - propylthiouracil: hepatic failure, ANCA-associated vasculitis

Question 36

telogen effluvium

Answer 36

- acute, diffuse, noninflammatory hair loss - scalp and hair fibers appear normal - hair shafts easily pulled out (hair pull test) - triggers: severe illness, fever, surgery, pregnancy/childbirth, emotional distress, endocrine/nutritional disorders - management: address underlying cause, reassurance (self-limited)

Question 37

serum to ascites albumin gradient

Answer 37

>1.1 = portal hypertensive etiologies (cardiac ascites, cirrhosis) <1.1 = non-portal hypertensive etiologies (malignancy, pancreatitis, nephrotic syndrome, tuberculosis)

Question 38

dietary recommendations about pts with renal calculi

Answer 38

1. increased fluid intake 2. decreased sodium intake 3. normal dietary calcium intake

Question 39

urine cytology

Answer 39

checks for cancer cells in the pee

Question 40

patients with idiopathic isolated thrombocytopenia should be tested for what? -patient may also present with large platelets

Answer 40

they likely have ITP but you have to test them for hepatitis C and HIV before cause its kinda a diagnosis of exclusion -test for ITP with antinuclear antibody screen

Question 41

what can trigger distal symmetric polyneuropathy

Answer 41

- DM, long-standing HIV, uremia, toxicity - damage to distal sensory peripheral nerve axons - treat underlying cause cause and use pain management with gabapentin, tricyclic antidepressant, duloxetine, or capsaicin cream

Question 42

how to define high grade carotid stenosis

Answer 42

70-99% occlusion | -pts should be considered for carotid endarterectomy to reduce future stroke risk

Question 43

what is brain natriuretic peptide and what is it used for?

Answer 43

natriuretic hormone released from ventricular myocytes in pts with CHF in response to high ventricular filling pressures -elevated BNP has high sensitivity (>90%) for dx of CHF... levels of over 400 are diagnostic (below 100 has a high negative predictive value)

Question 44

hodgkin lymphoma

Answer 44

epidemiology: bimodal peak incidence (15-35 and over 60), associated with EBV in immunosuppressed pts clinically: painless lymphadenopathy, mediastinal mass, B symptoms (fever, sweats, weight loss), pruritus, labs: elevated LDH and eosinophilia testing: PET scan with 18-fluorodeoxyglucose dx: lymph node biopsy and reed-sternberg cells on histology

Question 45

supraventricular tachycardia

Answer 45

regular but narrow QRS duration < 120ms with rate of 160bpm | -any tachy above bundle of His

Question 46

paroxysmal supraventricular tachy

Answer 46

PSVTs are SVTs with abrupt onset and offset | -inclduing AVNRT, AVRT, atrial tachy, and junctional tachy

Question 47

most common cause of cor pulmonale in united states

Answer 47

COPD | -you will hear a third heart sound

Question 48

if youre looking at past records what two types of studies can you use and whats the difference?

Answer 48

retrospective cohort ---> (looks at risk factors first) review past records and look for + and - risk factors then compare incidence case control ---> find diseased and control cases (look at outcome first) then compare risk factor frequency

Question 49

worsened pain with alcohol and mediastinal mass

Answer 49

hodgkin lymphoma

Question 50

tophaceous gout

Answer 50

multiple white nodules in hands with history of painful arthritis in fingers and feet -uric acid crystals in joints --> enough urate crystals can form tophi tumors causing ulceration and chalky material

Question 51

how does a pt with pneumocystis pneumonia present?

Answer 51

HIV with CD4 count less than 200 - subacute dyspnea, fever, dry cough, elevated LDH, diffuse bilateral pulmonary infiltrates - dx with bronchoalveolar lavage

Question 52

how to treat pneumocystis pneumonia

Answer 52

TMP-SMX and add corticosteroids for pts with PaO2 <70, A-a gradient >35, or pulse ox <92% on room air to reduce risk of respiratory decompensation -dx with bronchoalveolar lavage

Question 53

CREST syndrome

Answer 53

``` Calcinosis cutis Raynauds Esophageal dysmotility Sclerodactyly Telangiectasia ``` - anti-topoisomerase I antibodies - strongly associated with limited cutaneous systemic sclerosis - pulmonary arterial hypertension is associated with this

Question 54

wide, fixed splitting of S2

Answer 54

ASD

Question 55

systemic sclerosis

Answer 55

results from intimal hyperplasia of pulmonary arteries causing pulmonary hypertension

Question 56

painless loss of monocular vision

Answer 56

central retinal artery occlusion causing ischemia of inner retina -emergently treated with ocular massage and high-flow oxygen

Question 57

essential tremor

Answer 57

- action tremor - bilateral action tremor of hands, head is usually also involved, without leg involvement - possible isolated head tremor without dystonia - usually no other neurological signs - relieved with alcohol in many cases - treat with propranolol (first-line), primidone, or clonazepam

Question 58

pill-rolling resting tremor that starts on one hand and progresses to other extremities, jaw, face, tongue, and lips

Answer 58

parkinsons disease | -give anticholinergic --> trihexyphenidyl

Question 59

what improves mortality in pts with ARDS

Answer 59

lung protective strategies like low tidal volume ventilation (LTVV) -lower pulmonary pressures decreasing likelihood of overdistending alveoli

Question 60

acute respiratory distress syndrome

Answer 60

risk factors: infection, trauma, massive transfusion, acute pancreatitis pathophys: lung injury leading to fluid and cytokine leakage into alveoli with impaired gas exchange, decreased lung compliance, PHTN dx: new/worsening respiratory distress within 1 week of insult, bilateral lung opacities not due to CHF, hypoxemia with PaO2/FiO2 ratio < 300 management: mechanical ventilation (low TV, high PEEP, permissive hypercapnia)

Question 61

parvo virus rash in adults

Answer 61

nonspecific morbilliform exanthem

Question 62

postictal pH disturbance

Answer 62

anion gap metabolic acidosis after tonic-clonic seizure | -resolves without treatment within 90 minutes

Question 63

normal pressure hydrocephalus

Answer 63

symptoms: gait instability, cognitive dysfunction, urinary urgency/incontinence, depressed affect (frontal lobe compression), UMN signs in lower extremity dx: miller fisher (lumbar tap) test-- marked improvement of gait with spinal fluid removal, enlarged ventricles out of proportion to sulci and underlying brain atrophy on MRI treatment: ventriculoperitoneal shunting

Question 64

acute interstitial nephritis

Answer 64

causes: drugs (penicillins, TMP-SMX, cephalosporins, NSAIDs) 3 main clinical features: acute renal failure, maculopapular rash, fever.... also new drug exposure, arthralgias labs: urinary eosinophils, eosinophilia, inflammation, pyuria treat: discontinue offending drug, systemic glucocorticoids

Question 65

what pathology do you see in the brain of a pt with lewy body dementia?

Answer 65

eosinophilic intracytoplasmic inclusion | -a lot of alpha-synuclein protein

Question 66

widespread pain, fatigue, cognitive/mood disturbances

Answer 66

fibromyalgia foundation of management: exercise medications only really used for pts who fail initial measures ---> use amitryptilline

Question 67

unsteadiness, shock sensation in spine, atrophy/weakness in upper extremity, and increased tone/reflexes in lower extremities

Answer 67

spinal cord compression (myelopathy) in cervical spine -these pts usually have cervical spondylosis-- degenerative condition associated with spinal cord narrowing due to formation of osteophytes in lateral vertebral bodies and ossification of posterior longitudinal ligament/ligamentum flavum

Question 68

top 3 causes of the common cough

Answer 68

1. upper-airway cough syndrome (postnasal drip) --> give H1 blockers 2. asthma --> give anti-inflammatory meds 3. GERD --> give PPIs

Question 69

myasthenic crisis

Answer 69

causes: infection, surgery, pregnancy/childbirth, tapering of immunosuppressive drugs, meds (aminoglycosides, fluoroquinolones, and beta blockers) signs: increased generalized and oropharyngeal weakness, respiratory insufficiency/dyspnea treatment: intubation for deteriorating respiratory status, plasmapheresis or IVIG as well as corticosteroids

Question 70

2 most common causes of microcytic anemia

Answer 70

iron deficiency and thalassemia

Question 71

how to treat MS

Answer 71

IV glucocorticoids and use plasmapheresis if they dont respond to steroids

Question 72

how to treat alopicia areata

Answer 72

mild/moderate hair loss: topical intralesional corticosteroids severe hair loss: topical immunotherapy or oral corticosteroids

Question 73

explain the difference b/w spironolactone and epleronone

Answer 73

spironolactone: progesterone and androgen receptor antagonist that can cause decreased libido and gynecomastia epleronone: very selective mineralocorticoid antagonist with very low affinity for progesterone or androgen receptors so it has very few of the same side effects

Question 74

how to diagnose and treat carcinoid syndrome

Answer 74

- elevated 24-hour urinary excretion of 5-HIAA - CT/MRI of abdomen and pelvis to localize tumor - octreoscan to detect metastases - echocardiogram if symptoms of carcinoid heart disease are present) - clinical features: skin flushing, diarrhea, valvular lesions, bronchospasm, niacin deficiency - treat with octreotide before surgery and surgery for liver metastases

Question 75

how to treat for cyanide poisoning

Answer 75

hydroxycobalmin or sodium thiosulfate or with nitrates to induce methemoglobinemia

Question 76

mechanism of cyanide poisoning | -presents with altered mental status, lactic acidosis, seizures, and coma

Answer 76

cyanide binds to ferric iron in cytochrome oxidase a3 in mitochondrial ETC, blocking oxidative phosphorylation and promoting anaerobic metabolism --> causing lactic acidosis -can occur in pts treated with nitroprusside with higher doses, prolonged infusions, or renal impairment

Question 77

three major differences b/w actinomyces and nocardia and how to treat each

Answer 77

1. actinomyces = anaerobic / nocardia = aerobic 2. actinomyces is not acid-fast 3. actinomyces has sulfur granules treat actinomyces with penicillin treat nocardia with tmp-smx

Question 78

most common cause of hemoptysis in adults

Answer 78

pulmonary airway disease - chronic bronchitis - bronchogenic carcinoma - bronchiectasis

Question 79

bronchiectasis vs chronic bronchitis

Answer 79

both can cause hemoptysis bronchiectasis: irreversible dilation and destruction of bronchi, resulting in chronic cough and inadequate mucus clearance... associated with chronic respiratory tract infections and chronic cough with copious amounts of mucopurulent sputum chronic bronchitis: chronic cough for more than 3 months for 2 years... usually due to smoking

Question 80

MEN1 vs MEN2a vs MEN2b

Answer 80

MEN1 - pituitary adenoma - pancreatic/gastrointestinal tumors - parathyroid hyperplasia MEN2a - parathyroid hyperplasia - medullary thyroid carcinoma - pheochromocytoma MEN2b - medullary thyroid carcinoma - pheochromocytoma - mucosal neuroma - marfanoid habitus

Question 81

fluctuating, fatigable muscle weakness that worsens with repetitive motions and improves with rest - weakness with proximal muscles, ocular and bulbar muscles (ptosis) - causes of exacerbations: medications (abx, nmb agents, cardiac meds, mgso4, penicillamine, child birth, surgery, infection) - dx via ice pack test (bedside) or another highly specific test

Answer 81

myasthenia gravis | -dx via AChR-Ab (highly specific) or CT scan of chest showing thymoma

Question 82

what should be considered in a pt with molluscum contagiosum with widespread and/or facial lesions

Answer 82

HIV testing or some other reason for immunocompromise

Question 83

patient presents with dysphagia, chest/epigastric pain, reflux/vomiting, food impaction, associated atrophy - throwing up immediately after drinking a cup of water - refractory heart burn

Answer 83

eosinophilic esophagitis - chronic immune mediated esophageal inflammation - dx via endoscopy/esophageal biopsy (>15 eosinophils per high-power field) - treat with dietary restriction and possible topical glucocorticoids

Question 84

treatments for urgency incontinence

Answer 84

1. bladder training 2. pelvic floor exercises 3. antimuscarinic (oxybutinin) to decrease detrusor activity

Question 85

old lady presents with unilateral headache and jaw claudication

Answer 85

giant cell (temporal) arteritis - may lead to irreversible blindness due to ophthalmic artery occlusion - associated with polymyalgia rheumatica - increased ESR - treat with high dose corticosteroids to prevent blindness and then get temporal artery biopsy (will see focal granulomatous inflammation)

Question 86

UC vs Crohns

Answer 86

UC- mucosal inflammation and crypt abscesses (complication is colorectal cancer) Crohns- transmural inflammation, cobblestone mucosa, creeping fat (complication is fistulas)

Question 87

cough, hypercalcemia, hilar lymphadenopathy

Answer 87

sarcoidosis | -lungs follow restrictive pattern

Question 88

cluster analysis

Answer 88

grouping of different data points into similar categories | -randomization at group (not individual) level

Question 89

parallel study

Answer 89

randomizes 1 treatment to 1 group and another to a different group -usually just wanna see how the treatment works and nothing else is measured

Question 90

factorial design studies

Answer 90

randomization to 2 or more groups and studying 2 or more variables

Question 91

bartter syndrome hallmark finding

Answer 91

metabolic alkalosis with high urine chloride

Question 92

slowly expanding, circular, itchy rash with raised border and central clearing

Answer 92

tinea corporis | -treat with topical antifungals

Question 93

colonoscopy with melanosis coli- dark brown discoloration with pale patches of lymph follicles

Answer 93

laxative abuse | -these pts will usually have diarrhea in the middle of the night

Question 94

acute bronchitis

Answer 94

- preceding respiratory illness (90% viral) - cough for 5days -- 3weeks, possibly with sputum - absent systemic findings - wheezing or rhonchi, chest wall tenderness dx and treatment - only get CXR if pneumonia is suspected - symptomatic treatment, NSAIDs or bronchodilators - NO abx

Question 95

gynecomastia and small testes in a tall male pt struggling to conceive with his wife

Answer 95

Kleinfelters (XXY) -infertility due to testicular fibrosis with seminiferous tubule dysgenesis, azoospermia, hypogonadism, and elevated FSH and LH levels

Question 96

what is on your differential if you have a mediastinal shift

Answer 96

1. pleural effusion (away from effusion, if large) 2. pneumothorax (away from tension, toward spontaneous) 3. atelectasis (toward, if large)

Question 97

increased tactile fremitus

Answer 97

consolidation, like lobar pneumonia

Question 98

hyperresonance to percussion

Answer 98

pneumothorax

Question 99

carboxyhemoglobinemia

Answer 99

carbon monoxide poisoning - due to smoke inhalation - main symptom is headache... also nausea and dizziness - dx via arterial blood gas: carboxyhemoglobin level - treatment: high flow 100% O2 // use intubation and hyperbaric O2 if severe

Question 100

when to prophylatically treat HIV patient for and with what?

Answer 100

CD4 count < 200 -give TMP-SMX for pneumocystis jirovecii CD4 count < 150 -give itraconazole only if youre in an endemic area for Histo CD4 count < 100 -give TMP-SMX only if positive IgG antibody positive *give IVIG within 4 days of exposure to pts with exposure

Question 101

upper respiratory tract: perforation of nasal septum, chronic sinusitis, otitis media, mastoiditis, saddle-nose deformity lower respiratory tract: lung nodules/cavitation, hemoptysis, cough, dyspnea renal: hematuria, red cell casts, rapidly progressive GN skin: livedo reticularis, nonhealing ulcers

Answer 101

Granulomatosis with polyangitis (Wegeners) ``` DX ANCA, PR3, MPO, c-anca biopsy -skin (leukocytoclastic vasculitis) -kidney (pauci-immune GN) -lung (granulomatous vasculitis) ``` management: corticosteroids and immunomodulators

Question 102

what is likely associated with a transudative pleural effusion

Answer 102

- congestive heart failure - cirrhosis - nephrotic syndrome - peritoneal dialysis

Question 103

- common cause of red eye - localized/patchy distribution and generally mild associated pain and discharge - can be associated with rheumatoid arthritis and other autoimmune disorders

Answer 103

episcleritis | -usually self-limited and does not affect vision or involve the cornea

Question 104

- painful red eye with opacification and ulceration of cornea - similar to contact lens-associated keratitis - usually due to gram-negative (pseudomonas or serratia), but can also be positive

Answer 104

pseudomonas keratitis - medical emergency can lead to corneal perforation, scarring, and permanent vision loss - remove and discharge contact lens then use topical broad-spectrum antibiotics

Question 105

when to start statin therapy for lipid levels

Answer 105

primary prevention in pts with 10-year ASCVD risk > 7.5-10%

Question 106

what to look at when considering nonalcoholic fatty liver disease

Answer 106

pts usually only have hepatomegaly and... - steatohepatitis presents with AST/ALT ratio < 1 - treat with diet/exercise then consider bariatric surgery if BMI > 35

Question 107

methotrexate mechanism and adverse effects

Answer 107

- folate antimetabolite | - hepatotoxicity, stomatitis, cytopenias

Question 108

leflunomide mechanism of action and adverse effects

Answer 108

- pyrimidine synthesis inhibitor | - hepatotoxicity and cytopenias

Question 109

hydroxychloroquine mechanism of action and adverse effects

Answer 109

- TNF and IL-1 suppressor | - retinopathy

Question 110

sulfasalazine mechanism of action and adverse effects

Answer 110

- TNF and IL-1 suppressor | - hepatotoxicity, tomatitis, hemolytic anemia

Question 111

``` adalimumab certolizumab etanercept golimumab infliximab ``` -mechanism of action and adverse effects

Answer 111

- TNF inhibitors | - infection, demyelination, congestive heart failure, and malignancy

Question 112

patient with exertional dyspnea, pounding heart sensation (water hammer pulse)-- made worse when lying on left side, and widened pulse pressure

Answer 112

chronic aortic regurgitation

Question 113

if someone has low calcium what is the next step?

Answer 113

check magnesium levels - if its low or due to medication or due to recent blood transfusion then treat underlying cause, replete magnesium, and give IV calcium for severe symptoms - if magnesium is normal then measure serum PTH

Question 114

nonallergic (vasomotor) rhinitis

Answer 114

- usually has later age of onset - nasal congestion, rhinorrhea, sneezing, postnasal drainage - no obvious allergic trigger - perennial symptoms (may worsen with seasonal changes) - erythematous nasal mucosa - mild gets treated with intranasal antihistamine or glucocorticoids - moderate to severe gets treated with combination therapy

Question 115

when do you start antibiotic therapy for a pt with suggested infective endocarditis

Answer 115

3 separate blood cultures should be obtained from 3 different venipuncture sites -if pt has severe symptoms then get these 3 w/i 1 hour before beginning empiric abx therapy

Question 116

seborrheic dermatitis

Answer 116

dandruff and greasy-looking scaly rash involving nasolabial folds.. usually on face and scalp - associated with CNS disorders (parkinsons) and HIV - treat with topical antifungal agents

Question 117

AV nodal blocking agents

Answer 117

adenosine, beta blockers, calcium channel blockers (especially verapamil), and digoxin -not to be used in pts with a.fib cause it can promote conduction across accessory pathway and lead to degeneration of a.fib into v.fib

Question 118

when is lidocaine used for cardiac purposes

Answer 118

ventricular arrhythmias

Question 119

acute treatment of pts in a.fib in pts with WPW is aimed at prompt control of ventricular response and termination of a.fib...

Answer 119

hemodynamically unstable --> electrical cardioversion | hemodynamically stable --> IV procainamide or ibutilide

Question 120

proximal vs widespread muscle pain

Answer 120

proximal (polymyalgia rheumatica) --> pain and stiffness , often with fever, malaise, weight loss, NO WEAKNESS, women > 50, associated with giant cell (temporal) arteritis, bilateral, increased ESR/CRP/normal CK/normal strength testing, rapid response to low-dose corticosteroids *note that proximal can also be polymyositis/dermatomyositis ---> WEAKNESS widespread (fibromyalgia) --> women 20-50, chronic widespread musculoskeletal pain associated with tender points/stiffness/paresthesias, poor sleep, fatigue, cognitive disturbance, treat with regular exercise, antidepressants, neuropathic pain agents (tricyclic antidepressants)

Question 121

what is the heart murmur with aortic dissection

Answer 121

acute aortic regurgitation which leads to an early diastolic murmur

Question 122

- acute/aggressive - fever, nasal congestion, purulent nasal discharge, headache, sinus pain - necrotic invasion of palate, orbit, brain - dx via: sinus endoscopy with biopsy and culture

Answer 122

Rhino-orbital-cerebral mucormycosis treatment: surgical debridement, liposomal amphotericin B, eliminate risk factors (DM with ketoacidosis, hematologic malignancy, solid organ/stem cell transplant)

Question 123

acute intermittent porphyria vs porphyria cutanea tarda

Answer 123

AIP- porphobilinogen deaminase, 5Ps: painful abdomen/port-wine colored urine/polyneuropathy (proximal muscle weakness)/psych disturbances/precipitated by drugs alcohol or starvation, treat with hemin and glucose PCT- uropurphorinogen decarboxylase, blisters, bullae, scarring, hypo/hyperpigmentation on sun exposed areas, scarring and calcification similar to scleroderma, associated with hep C/HIV/alcohol/estrogen use/smoking, mildly elevated liver enzymes and iron overload, elevated plasma or urine porphyrin levels, treat with phlebotomy, sun avoidance, and antimalarials

Question 124

how to treat uric acid stones

Answer 124

oral potassium citrate

Question 125

when to no longer give HIV pts a live vaccine

Answer 125

CD4 count below 200

Question 126

curtain descending over visual field of the eye

Answer 126

amaurosis fugax/retinal detachment - painless rapid transient monocular vision loss - due to retinal ischemia from atherosclerotic emboli originating from ipsilateral carotid artery - pts with vascular factor should receive duplex ultrasound of neck

Question 127

how to treat lyme disease in pregnant women

Answer 127

- you cant give doxycycline cause shes pregnant and you dont want tooth/skeletal discoloration - give oral amoxicillin - if theres an allergy to that then give azithromycin

Question 128

how to treat secondary amyloidosis

Answer 128

colchicine for prevention and treatment | -diagnose with abdominal fat pad aspiration biopsy

Question 129

pt has subarachnoid hemorrhage, what are you concerned about and what can you give to prevent this

Answer 129

concerned about vasospasm leading to infarct | -give nimodipine to prevent this

Question 130

what characterizes lactose intolerance | -lactase is as a brush border enzyme

Answer 130

- positive hydrogen breath test - positive stool test for reducing substances - low stool pH - increased stool osmotic gap - no steatorrhea

Question 131

triggers: trauma, sprain, fracture, surgery clinical features: severe, regional, burning/stinging pain, vasomotor changes with altered skin temperature, tropic skin/hair/nail changes

Answer 131

Complex regional pain syndrome - dx mainly clinical but x-ray will show patchy demineralization and bone scintigraphy will show increased uptake in affected limb - treat with exercise/PT/OT and for meds you can use NSAIDs and antineuropathic meds (pregabalin and TCAs)

Question 132

enthesitis

Answer 132

inflammation and pain at sites of tendon and ligament attachment to bone -common finding in ankylosing spondylitis and other spondyloarthropathies

Question 133

methanol intoxication

Answer 133

epigastric discomfort, vomiting, blurred vision, vision loss, coma optic disc hyperemia anion gap metabolic acidosis (VERY low bicarb) increased osmolar gap

Question 134

ondansetron mechanism of action

Answer 134

serotonin antagonist used for chemo induced nausea and vomiting

Question 135

positive anti-U1 ribonucleoprotein antibody

Answer 135

mixed connective tissue disease - raynauds - hand/finger swelling - arthritis/synovitis - inflammatory myopathy

Question 136

shooting jaw pain treatment

Answer 136

trigeminal neuralgia | -treat with carbamazepine (can cause n/v and leukopenia/aplastic anemia)

Question 137

HIV patient with hematochezia

Answer 137

cytomegalovirus | -if they have this then they need to get an eye exam right away to rule out CMV retinitis

Question 138

corrected calcium level =

Answer 138

measured total calcium + 0.8 x (4 - serum albumin)

Question 139

- rheumatoid arthritis (severe erosive joint disease/deformity, rheumatoid nodules, vasculitis with skin lesions) - neutropenia - splenomegaly

Answer 139

Felty syndrome - anti-CCP and RF positive in > 90% of pts - markedly elevated ESR, often > 85 - peripheral smear and bone marrow biopsy to rule out other causes of neutropenia

Question 140

cardiovascular drugs that shouldnt be used in pts with hypertension management

Answer 140

beta-blockers due to the side effect of increased insulin resistance/impaired glucose control and increased weight gain

Question 141

immunocompromised pt gets indurated pustules and then punched out gangrene, what do you think of

Answer 141

ecthyma gangrenosum due to pseudomonas | -get blood cultures and give IV abx

Question 142

if a pt is aggressively treated for an asthma attack (with beta-2 agonists) what do you worry about

Answer 142

watch for muscle weakness/arrhythmias/EKG abnormalities likely due to hypokalemia -other common side effects are tremor, palpitations, and headache

Question 143

patient with history of asthma or chronic rhinosinusitis with nasal polyposis taking aspirin

Answer 143

aspirin-exacerbated respiratory disease - pseudoallergic reaction due to prostaglandin/leukotriene misbalance - treat by avoiding NSAIDs

Question 144

when to screen for osteoporosis with dual energy x-ray absorptiometry

Answer 144

all women >65 and younger women with equivalent risk of osteoporotic fracture

Question 145

TCA toxicity

Answer 145

Convulsions, Coma, Cardiotoxicity -give supportive treatment, monitor ECG, give sodium bicarb to prevent arrhythmia (sodium load alleviates depressant action of myocardial sodium channels), activated charcoal

Question 146

what is very important in the pathogenesis of MALT

Answer 146

H. pylori | -pts usually go into complete remission after abx use with quadruple therapy

Question 147

numbness or pain b/w the 3rd and 4th toes | clicking sensation when palpating space b/w 3rd and 4th toes while squeezing metatarsal joints

Answer 147

morton neuroma - mechanically induced neuropathic degeneration of interdigital nerves - symptoms worse with walking on hard surfaces and in high-heels or tight shoes

Question 148

differentials for thyrotoxicosis with normal or increased radioactive iodine uptake

Answer 148

graves toxic multinodular goiter toxic nodule

Question 149

painless thyroiditis

Answer 149

starts with hyperthyroid phase then you go to hypothyroid and you can give beta-blockers to help with the hyperthyroid phase symptoms

Question 150

tick from southeastern and south central united states

Answer 150

amblyomma/lone star tick - causes flu like illness, confusion, and rarely but sometimes a rash - leukopenia and thrombocytopenia - elevated liver enzymes and lactate dehydrogenase - dx via intracytoplasmic morulae in monocytes and PCR testing for E. chaffeensis and E. ewingii - treat with empiric doxycycline while awaiting confirmatory testing

Question 151

how to slow down the growth of varicies and bleeding due to liver pathology only given to those with already medium or large varicies

Answer 151

beta blockers

Question 152

octreotide

Answer 152

somatostatin agonist causing splanchnic vasoconstriction and stops variceal bleeding while its happening by inhibiting glucagon release

Question 153

pt with tinea that becomes widespread... what do you think

Answer 153

compromised immunity - diabetes mellitus - systemic glucocorticoids - HIV infection

Question 154

intermittent chest pain that radiates to interscapular area with difficulty swallowing liquids and solids during these episodes -can be precipitated by food or emotional stress

Answer 154

diffuse esophageal spasms - corckscrew pattern - esophageal manometry for dx - treat with calcium channel blockers (nitrates or tricyclics can be used if needed)

Question 155

dacryocystitis

Answer 155

- infection of lacrimal sac - inflammatory changes to the medial canthal of the eye - usually due to staph aureus

Question 156

patient with normal colonoscopy and painless GI bleeding

Answer 156

angiodysplasia - can be seen in pts with advanced renal disease and aortic stenosis - can be treated with cautery

Question 157

elevated BNP

Answer 157

patient likely in cardiac heart failure - increased heart filling pressures - audible third heart sound

Question 158

patient gets vascular procedure then has cutaneous findings (blue toes or livedo retularis), cerebral or intestinal ischemia, acute kidney injury, and hollenhorst plaques... what do you think of

Answer 158

atheroembolism (cholesterol embolism) - complication of cardiac catheterization and other vascular procedures - treat/prevent with statin therapy

Question 159

how to prevent anginal episodes and how does it work

Answer 159

beta-blockers | -decrease myocardial contractility and heart rate

Question 160

most common cause of sudden cardiac arrest in immediate post-infarction period in patients with acute myocardial infarction

Answer 160

reentrant ventricular arrhythmias (v. fib)

Question 161

hemoglobin goal for nonelderly pts and why

Answer 161

A1c = 7% -a more strict goal of 6.5% is associated with good microvascular outcomes (decreased retinopathy) but NOT good macrovascular outcomes (increased hypoglycemia and cardiovascular mortality)

Question 162

unexplained congestive heart failure, proteinuria, left ventricular hypertrophy without history of hypertension

Answer 162

amyloidosis | -the congestive heart failure is a restrictive cardiomyopathy

Question 163

acute respiratory distress syndrome

Answer 163

risk factors: infection, trauma, massive transfusion, acute pancreatitis pathophysiology: lung injury causes fluid and cytokine leakage into alveoli, impaired gas exchange, decreased lung compliance, PHTN diagnosis: new/worsening respiratory distress within 1 week of insult, bilateral lung opacities (pulmonary edema) NOT due to CHF or fluid overload, hypoxemia with PaO2/FiO2 ratio < 300mgHg management: mechanical ventilation (low TV, high PEEP, permissive hypercapnia)

Question 164

what is a normal urine albumin/creatinine ratio

Answer 164

less than 30

Question 165

how to diagnose sjogrens?

Answer 165

- decreased lacrimation - positive anti-Ro (SSA) and/or anti-La (SSB) - salivary gland (minor gland of lip) biopsy with focal lymphocytic sialoadenitis - classification: primary if no associated CTD, secondary if comorbid CTD (SLE, RA, scleroderma)

Question 166

describe early septic shock

Answer 166

hyperdynamic cardiovascular state that occurs in response to peripheral vasodilation with capillary leak and intravascular hypovolemia -leading to increased stroke volume, heart rate, and pulse pressure

Question 167

ptosis, diplopia, down and out gaze, normal pupillary gaze

Answer 167

Ischemic ocular motor palsy - damage to inner somatic nerve fibers while sparing the more peripheral parasympathetic fibers - commonly associated with poorly controlled diabetes

Question 168

- acute, peaks at 2 weeks --> starts with smudge in center of eye - monocular vision loss - eye pain with movement - "washed out" color vision - afferent pupillary defect *usually in young women, assocaited with MS, immune-mediated demyelination

Answer 168

Optic Neuritis dx ---> MRI of orbitis and brain treatment ---> IV corticosteroids 35% of cases recur

Question 169

psych history, fever, confusion, muscle rigidity, autonomic instability

Answer 169

neuroleptic malignant syndrome

Question 170

extrarenal features of autosomal dominant polycystic kidney disease

Answer 170

``` cerebral aneurysms hepatic and pancreatic cysts mitral valve prolapse and aortic regurgitation colonic diverticulosis ventral and inguinal hernias ``` *pts present with flank pain, hypertension, and polyuria

Question 171

why can mixing a lot of alcohol with cocaine cause muscle weakness?

Answer 171

even just a lot of alcohol at once can cause rhabdomyolysis

Question 172

idiopathic pulmonary fibrosis

Answer 172

- due to excessive collagen deposition in peri-alveolar tissues - decreased lung volumes with preserved or increased FEV1/FVC ratio - impaired gas exchange resulting in reduced diffusion capacity of carbon monoxide and increased A-a gradient

Question 173

work up for HIV associated diarrhea

Answer 173

sending stool for culture, ova/parasites, acid-fast stain, and c.diff antigen -CD4 count, chronicity, and presence of absence of colitis symptoms help narrow the differential

Question 174

criteria for initiating long term oxygen therapy in pts with COPD

Answer 174

1. resting PaO2 < 55mmHg or SaO2 < 88% on room air 2. PaO2 < 59mmHg or SaO2 < 89% in pts with cor pulmonale or hematocrit > 55% * dose should be titrated so that SaO2 is maintained at >90% during sleep, normal walking, and at rest - survival benefits of home oxygen therapy are significant when its used for > 15hrs/day

Question 175

who is at risk or a cholesterol emboli

Answer 175

pts with risk factors for aortic atherosclerosis (hypercholesterolemia, diabetes, PVD) who undergo cardiac catheterization or vascular procedure

Question 176

first line therapy for postmenopausal osteoporosis

Answer 176

bisphosphonates | -treatment is usually discontinued after 5 years due to risk of atypical fracture with prolonged use

Question 177

acute lower back pain while lifting a heavy object - lower extremity strength, sensation, and reflexes are intact and straight leg test is negative - mainly lumbar and paraspinal area pain

Answer 177

lumbosacral strain *if it were radiating pain down the leg then it would be herniated disc (straight leg test would be positive)

Question 178

most common cancer found in pts with asbestos exposure

Answer 178

bronchogenic carcinoma

Question 179

indication for statin therapy

Answer 179

primary prevention - LDL > 190 - age > 40 with DM - estimated 10-year risk 7.5-10% secondary prevention -established ASCVD (acute coronary syndrome, stable angina, arterial revascularization, stroke, TIA, PAD)

Question 180

patients with primary hypoaldosteronism are more prone to waht

Answer 180

diuretic-induced hypokalemia

Question 181

first step after any pt presents with hypertension and hypokalemia

Answer 181

likely hyperaldosteronism so the first step is to get a plasma renin and plasma aldosterone level

Question 182

meds for alzheimers mild to moderate --- moderate to severe ---

Answer 182

mtm --- donepezil, galantamine, and rivastigmine (cholinesterase inhibitors) mts --- memantine (NMDA receptor antagonist)

Question 183

what does S3 sound like and what does it mean

Answer 183

kentucky - increased filling pressure - mitral regurg - heart failure - dilated ventricles * can also be normal

Question 184

what does S4 sound like and what does it mean

Answer 184

tennessee - increased atrial pressure - ventricular hypertrophy and noncompliance

Question 185

decreased active and passive motion in arm with possible stiffness with normal x-ray findings

Answer 185

adhesive capsulitis (frozen shoulder)

Question 186

types of cancers associated with lynch syndrome

Answer 186

colorectal cancer endometrial carcinoma ovarian cancer

Question 187

familial adenomatous polyposis

Answer 187

colorectal cancer desmoids and osteomas brain tumors

Question 188

von hippel-lindau syndrome

Answer 188

hemangioblastomas clear cell renal carcinoma pheochromocytoma

Question 189

what happens when a pt has membranous nephropathy

Answer 189

urinary loss of several anticoagulant proteins resulting in hypercoagulability -associated with renal vein thrombosis

Question 190

other symptoms to reactive arthritis besides the main 3

Answer 190

mucocutaneous lesions enthesitis (where tendon hits bone is inflamed) asymmetric oligoarthritis NSAIDs are first line treatment

Question 191

what is more likely to occur after an acute MI of RCA and LAD

Answer 191

RCA- right ventricular failure, papillary muscle rupture RCA or LAD- interventricular septum rupture (pt presents with sudden cardiogenic shock) LAD- free wall rupture, left ventricular aneurysm

Question 192

pts with uncontrolled diabetes and opiate use disorder are at risk of what

Answer 192

Small Intestinal Bacterial Overgrowth (SIBO) - pts present with abdominal pain, bloating, flatulence, and watery diarrhea - dx with carbohydrate breath test - treat with oral antibiotics (rifaximin or neomycin)

Question 193

what are the chemotoxicities of drugs

Answer 193

``` cisplatin/carboplatin- ototoxic, nephrotoxic vincristine- peripheral neuropathy bleomycin/busulfan- pulmonary fibrosis doxorubicin/trastuzumab- cardiotoxic cyclophosphamide- hemorrhagic cystitis ```

Question 194

wilsons disease

Answer 194

- presents b/w 5-35 - liver disease - neuropsych problems (parkinsonism, dysarthria, choreoathetosis, ataxia, personality changes, depression) - low ceruloplasmin with high copper levels

Question 195

hemochromatosis

Answer 195

hyperpigmented diabetic person | -liver disease, arthropathy, cardiac enlargement

Question 196

adverse side effect of long term amiodarone use

Answer 196

pulmonary toxicity - progressive dyspnea - nonproductive cough - new reticular/ground-glass opacities on chest radiograph

Question 197

gout triggers

Answer 197

``` alcohol use surgery/trauma dehydration diet with lots of meat and fat and fructose certain medications (diuretics) ```

Question 198

how to diagnose tinea pedis

Answer 198

potassium hydroxide of skin scrapings

Question 199

first line for rheumatoid arthritis

Answer 199

disease modifying drug ---> methotrexate

Question 200

how to treat disseminated histoplasmosis

Answer 200

IV amphotericin B then after 1-2 weeks of clinical improvement switch them to oral itraconazole for > 1 year of maintenance therapy

Question 201

what can cause cyanide poisoning and what does it look like

Answer 201

etiologies: combustion of carbon/nitrogen compounds like wool or silk, industrial exposure like mining, and medications like sodium nitroprusside symptoms skin- flushing first then cyanosis cns- headache, altered mental status, seizures, coma cv- arrhythmia respiratory- tachypnea followed by depression and pulmonary edema gi- abdominal pain, nausea, vomiting renal- metabolic acidosis (from lactic acidosis) then renal failure

Question 202

how to treat foodborne c. botulism

Answer 202

- check for toxin in blood - supportive care - for anyone over age 1 also give passive immunity via horse-derived antitoxin

Question 203

when/how to treat cataracts

Answer 203

indicated when loss of vision affects daily life | lens extraction and artificial lens implantation

Question 204

convexed nail beds

Answer 204

nail clubbing due to hypoxia and possible lung pathology

Question 205

DHEAS is where..

Answer 205

if female pt has virilization and high testosterone with high DHEAS then you know its likely adrenal cause if DHEAS is normal then its likely ovarian tumor or something

Question 206

``` urine shows... what do think muddy brown granular casts? RBC casts? WBC casts? Fatty casts? Broad and waxy casts? ```

Answer 206

``` muddy brown- ATN RBC casts- glomerulonephritis WBC casts- interstitial nephritis and pyelonephritis Fatty casts- nephrotic syndrome broad waxy casts- chronic renal failure ```

Question 207

how to treat pericarditis after a pt has an MI vs viral pericarditis

Answer 207

called Dresslers syndrome and give NSAIDs -if youre treating viral pericarditis give NSAIDS + colchicine

Question 208

what should be on the differential if a pt has pica for ice/paper?

Answer 208

iron deficiency

Question 209

hereditary hemorrhagic telangectasias (osler weber rendau)

Answer 209

- autosomal dominant - telangectasias - recurrent epistaxis - widespread AV malformations with shunting

Question 210

which antihypertensive medication causes peripheral edema

Answer 210

CCB (ex: amlodipine) - due to peripheral dilation of precapillary vessels - adding ACE or ARB can help with these side effects

Question 211

ACA vs MCA infarct

Answer 211

ACA- contralateral somatosensory and motor deficit (predominantly in lower extremity), dyspraxia, emotional disturbance, urinary incontinence MCA- contralateral somatosensory and motor deficit of face, arm, and leg, conjugate eye deviation toward infarcted side

Question 212

unilateral neck pain that radiates to the shoulder/arm and sensory, motor, and reflex abnormalities in a dermatomal distribution

Answer 212

cervical radiculopathy due to underlying cervical spondylosis -spine imaging (MRI) shows abnormal facet joints, including the presence of sclerosis and osteophytes

Question 213

leukemoid reaction vs CML

Answer 213

LR - leukocyte count > 50,000 - severe infection - high LAP (leukocyte alk phos) score - more metamyelocytes than myelocytes (more mature) - no absolute basophilia CML - leukocyte count > 100,000 - BCR-ABL fusion - low LAP score - more myelocytes than metamyelocytes (less mature) - absolute basophilia

Question 214

how to diagnose cavernous sinus thrombosis

Answer 214

MRI

Question 215

antiphospholipid syndrome

Answer 215

- patients have lupus anticoagulant - prolonged PTT that stays prolonged even with a mixing study - higher risk of thromboembolism and recurrent miscarriages

Question 216

common triggers of drug induced acne

Answer 216

glucocorticoids, androgens immunomodulators anticonvulsants, antipsychotics antituberculosis drugs (isoniazid)

Question 217

delayed muscle relaxation after contraction

Answer 217

myotonic dystrophy (CTG repeat) - starts with facial and distal muscle weakness and myotonia - cataracts, testicular atrophy, and sleep disturbances are also common

Question 218

calcific uremic arteriolopathy (calciphylaxis)

Answer 218

pathophys: arteriolar and soft tissue calcification with local tissue ischemia and necrosis risk factors: ESRD (MAINLY SEEN IN THESE PTS), hypercalcemia, hyperphosphatemia, hyperparathyroidism, obesity, diabetes, oral anticoagulants clinical manifestations: painful nodules and ulcers, soft tissue calcification on imaging, skin biopsy includes arterial calcification/occlusion with subintimal fibrosis

Question 219

fatigue, weight loss, hypotension, and hyperpigmentation of the skin and mucous membranes

Answer 219

deficiency of mineralocorticoids, glucocorticoids, and androgens

Question 220

where is the most common place for lung cancer to spread to

Answer 220

brain | -presents with headache

Question 221

initial treatment of chronic venous insufficiency

Answer 221

conservative measures: leg elevation, exercise, compression therapy

Question 222

what is a major cause of isolated systolic hypertension

Answer 222

arterial stiffness or decreased elasticity

Question 223

metoclopramide and prochlorperazine

Answer 223

dopamine antagonists which can cause extrapyramidal symptoms such as acute dystonias, akathisia, and parkinsonism -metoclopramide is used as promotility

Question 224

if you get one of these 3 skin conditions what should you test for? 1. sudden-onset severe psoriasis 2. recurrent herpes zoster 3. disseminated molluscum contagiosum

Answer 224

HIV infection

Question 225

if pt gets severe seborrheic dermatitis, what do you look for?

Answer 225

HIV infection or parkinsons disease

Question 226

if pt gets explosive onset of multiple itchy seborrheic keratoses, what do you look for?

Answer 226

GI malignancy

Question 227

pt presents with pyoderma gangrenosum (painful pustules and nodules that ulcerate and grow- NOT INFECTIOUS), what do you look for?

Answer 227

IBD

Question 228

pt with asymptomatic hypercalcemia with normal labs and low urinary excretion

Answer 228

familial hypocalciuric hypercalcemia - benign autosomal dominant disorder cause by mutation of calcium sensing receptor (CaSR) - will also have higher-normal PTH - potential complications: pancreatitis and chondrocalcinosis

Question 229

headache, malaise, low-grade fever, incessant cough, and nonexudative pharyngitis chest x-ray shows interstitial infiltrate +/- serous pleural effusion

Answer 229

atypical mycoplasma pneumonia | -give empiric azithromycin

Question 230

how to manage hypercalcemia in each of these ranges 1. severe/symptomatic (> 14) 2. moderate (12-14) 3. mild/asymptomatic (< 12)

Answer 230

1. severe- short term: normal saline hydration + calcitonin and avoid loop diuretics unless pt also has fluid overload HF long term: bisphosphonates (zoledronic acid) 2. moderate- nothing immediate unless symptomatic then refer to severe 3. mild- nothing, just avoid diuretics/lithium and keep hydrated and avoid best rest

Question 231

what are the systematic effects of exertional heat stroke

Answer 231

seizures, ARDS, DIC, hepatic/renal failure

Question 232

pemphigus vulgaris vs bullous pemphigoid

Answer 232

PV - antibody against desmosomes (desmoglein 1 and 3) - oral lesions - separation of epidermis (+ Niklovkys sign) BP - antibody against hemidesmosomes - NO oral lesions - separation of epidermis and dermis junction (- Niklovkys sign)

Question 233

how to treat diabetic nephropathy (early sign is increased albuminuria)

Answer 233

ACEi or ARB

Question 234

chronic intermittent epigastric pain with symptoms of malabsorption and diabetes mellitus pain gets better with leaning forward

Answer 234

chronic pancreatitis - dx with abdominal CT - decreased fecal elastase is also diagnostic - use lipase levels in ACUTE PANCREATITIS

Question 235

why do NSAIDs make anaphylaxis worse?

Answer 235

resulting in nonimmunologic mast cell activation

Question 236

main causes (ranked) of acute pancreatitis

Answer 236

1. alcohol 2. gallstones 3. hypertriglyceridemia * others include medications (valproic acid, diuretics, azathioprine, metranidazole, tetracyclines), infections, and trauma

Question 237

what does an echo show in viral myocarditis

Answer 237

4-chamber dilation

Question 238

when do pick defibrillation vs cardioversion

Answer 238

fibrillation or tachycardia --> defibrillation | that + hemodynamic instability --> cardioversion

Question 239

diagnosis via renal biopsy showing lymphocytic infiltration of the intima

Answer 239

T-cell mediated acute renal allograft rejection | -treat with high-dose IV glucocorticosteroids

Question 240

patient with vision changes, headaches, vertigo, dizziness, ataxia, peripheral neuropathy, cryoglobulinemia, and/or renal insufficiency

Answer 240

waldenstrom macroglobulinemia (B-cell neoplasm) - associated with elevated monoclonal IgM - high IgM can cause hyperviscosity syndrome - dx requires serum protein electrophoresis and bone marrow biopsy

Question 241

``` patient with hypercalcemia, anemia, renal insufficiency, bone/back pain, protein gap (diff b/w total protein and albumin > 4) C- hyperCalcemia Renal involvement Anemia Bone lytic lesions and Back pain ```

Answer 241

possible multiple myeloma - plasma cell neoplasm which can cause hypogammaglobulinemia - will see rouleax formation on blood smear and clonal plasma proliferation in bone marrow

Question 242

patient with nausea, vomiting, constipation, polyuria, polydispsia, and neuropsychiatric symptoms lab findings: hypercalcemia, metabolic alkalosis, acute kidney injury, suppressed PTH

Answer 242

Milk-alkali syndrome - excessive intake of calcium and absorbable alkali (usually in the form of calcium carbonate) - renal vasoconstriction and decreased GFR - renal loss of sodium and water, reabsorption of bicarbonate treat with discontinuation of causative agent and isotonic saline followed by furosemide

Question 243

panacinar emphysema causing more lower lobe destruction leads to what possible diagnosis

Answer 243

alpha-1-antitrypsin deficiency

Question 244

erythema multiforme

Answer 244

acute inflammatory disorder of skin that causes targetoid lesions - if severe can affect oral mucosa - associated with infections like HSV as well as medications, malignancies, and connective tissue diseases

Question 245

what is ascorbic acid

Answer 245

vitamin c

Question 246

how does parvo b19 present in adults

Answer 246

multiple joints with arthralgias | -may present like RA but with normal ESR

Question 247

stenosis or occlusion of proximal subclavian artery

Answer 247

subclavian steal syndrome - reversal of blood flow in ipsilateral vertebral artery - may have symptoms of upper extremity ischemia (fatigue, paresthesias) or vertebrobasilar insufficiency (dizziness, ataxia, disequilibrium) that are worsened by upper extremity exercise

Question 248

atypical presentation of acute coronary syndrome

Answer 248

more common in women and patients with diabetes - chest pain - dyspnea - nausea - vomiting - epigastric pain

Question 249

euthyroid sick syndrome

Answer 249

- aka low T3 syndrome - any pt with acute/severe illness - fall in total and free T3 due to decreased peripheral conversion of T4 to T3 - normal T4 and TSH levels

Question 250

riedels thyroiditis

Answer 250

inflammatory disorder characterized by fibrosclerosis of the thyroid, surrounding tissues, and remote nonthyroid structures - subclinical or overt hypothyroidism may be seen - patients usually have a hard goiter

Question 251

subclinical hypothyroidism

Answer 251

elevated TSH with normal T4 | -T3 is usually normal until very late stages

Question 252

multiple system atrophy (Shy-Drager syndrome)

Answer 252

degenerative disease w/ 1. parkinsonism 2. autonomic dysfunction 3. widespread neurological signs

Question 253

familial dysautonomia (Riley-Day syndrome)

Answer 253

- AR, Ashkenazi jew population - present at birth with feeding problems and low muscle tone - gross dysfunction of autonomic nervous system (no tears) - severe orthostatic hypotension (severe hypertension to postural hypotension)

Question 254

dark/black hepatocytes on biopsy

Answer 254

dubin-johnson syndrome - defect in hepatic excretion of conjugated bilirubin - benign hereditary condition resulting in chronic or fluctuating hyperbilirubinemia and intermittent jaundice

Question 255

shooting eye pain headache and how to treat it

Answer 255

cluster headache - acutely: subq sumatriptan and 100% O2 - prophylaxis: verapamil

Question 256

tension headache and how to treat it

Answer 256

bilateral stead "band-like" pain - acutely: analgesics, NSAIDs, acetaminophen - prophylaxis: TCAs and behavioral therapy

Question 257

essential elements when evaluating brain death

Answer 257

1. evaluating cortical and brain stem functions 2. proving the irreversibility of brain activity loss -spinal cord may still function so deep tendon reflexes may occur

Question 258

behcet syndrome

Answer 258

multisystem inflammatory condition (mainly with recurrent oral and genital ulcers) epidemiology: young adults, turkish/middle eastern/asian clinical findings: recurrent painful aphthous ulcers, genital ulcers, uveitis, skin lesions (erythema nodosum, acniform lesions), thrombosis evaluation: pathergy- exaggerated skin ulceration with minor trauma (needlestick) biopsy- nonspecific vasculitis of different sized vessels

Question 259

major symptoms in a patient with sarcoidosis

Answer 259

significant respiratory symptoms

Question 260

commonly used drugs with photosensitivity reactions

Answer 260

abx- tetracyclines antipsychotics- chlorpromazine, prochlorperazine diuretics- furosemide, hydrochlorothiazide others- amiodarone, promethazine, piroxicam

Question 261

what can be assumed in a case-control study if the outcome is uncommon in the population

Answer 261

that the odds ratio is a close approximation of the relative risk (rare disease assumption)

Question 262

injury to nerve at elbow vs wrist?

Answer 262

elbow- decreased grip strength | wrist- numbness and paresthesia called clumsiness of medial hand

Question 263

to add anaerobic coverage for pneumonia what meds should you consider

Answer 263

metronidazole + amoxicillin amoxicillin + clavulanate clindamycin

Question 264

if pt has hypercalcemia and youve done the test twice to check then what do you look at...

Answer 264

measure PTH levels if HIGH (PTH-dependent) - primary hyperparathyroidism - familial hypocalciuric hypercalcemia - lithium if LOW (PTH-independent) - malignancy - vitamin D toxicity - granulomatous disease - drug induced (thiazides) - milk-alkali syndrome - thyrotoxicosis - vitamin A toxicity - immobilization

Question 265

grid lines appear wavy on visual test

Answer 265

macular degeneration

Question 266

when someone has a stroke of this area it can lead to sudden onset contralateral burning pain exacerbated by touch

Answer 266

thalamic pain syndrome | -thalamus

Question 267

beta blocker overdose treatment

Answer 267

first-line: IV fluids and atropine | if that doesnt work: glucagon

Question 268

tenosynovitis

Answer 268

inflammation of the tendon and its synovial sheath - usually in hands and wrists due to overuse or bite or puncture wound - pts have pain and tenderness along the tendon sheath, particularly with flexion and extension movements

Question 269

hypertension + high calcium

Answer 269

hyperparathyroidism - pts also have renal stones, abdominal pain, neuropsych symptoms - also LV hypertrophy, arrhythmias, vascular and valvular calcification

Question 270

what medications can trigger G6PD deficiency symptoms

Answer 270

infection or medications (dapsone, tmp-smx, nitrofurantoin, antimalarials)

Question 271

acute coronary syndrome due to unstable angina or NSTEMI... what do you give the patient?

Answer 271

antiplatelet, antithrombotic, beta-blockers, nitrates, high-intensity statins *note that no fibrinolytic therapy is used

Question 272

watery diarrhea (secretory) hypokalemia weakness and muscle cramps mass in pancreas

Answer 272

VIPoma - watery diarrhea with VIP level > 75 - abdominal CT or MRI to localize tumor in pancreatic tail usually

Question 273

flushing diarrhea bronchospasm mass in small intestine

Answer 273

carcinoid syndrome

Question 274

what are the risk factors and how to tell if a pt is likely to get another foot ulcer

Answer 274

risk factors: ****diabetic neuropathy**** most important, previous foot ulceration, vascular disease, foot deformity monofilament testing predicts risk of future foot ulcers

Question 275

what lab value is most important in patients with beta cell tumors (insulinoma)

Answer 275

elevated c-peptide levels and proinsulin levels > 5

Question 276

how to manage colonoscopy in pts with IBD with colonic involvement

Answer 276

- 8-10 year postdiagnosis (12-15 if only in left colon) | - repeat every 1-3 years

Question 277

when do you decide to intubate

Answer 277

pH < 7.1 | hemodynamic instability

Question 278

how to treat pts with CHADVASC score > 2

Answer 278

warfarin or specific oral anticoagulants (rivaroxiban, apixaban, dabigatran) -pts with score 0 need no therapy

Question 279

classic triad of spinal epidural abscess

Answer 279

1. fever 2. focal/severe back pain 3. neurologic findings (motor/sensory change, bowel/bladder dysfunction, paralysis) - dx via spinal MRI - treat with vanc + ceftriaxone along with spinal aspiration and decompression

Question 280

hepatic hydorthorax

Answer 280

- pts present with dyspnea, cough, pleuritic chest pain, and hypoxemia - due to liver cirrhosis - results in transudative pleural effusions and is thought to occur due to small defects in the diaphragm - more common on the right side due to a less muscular hemidiaphragm - dx involves documentation of the effusion and testing to occlude other causes - definitive treatment is liver transplant

Question 281

brief (< 1min) episodic vertigo triggered by head position changes (looking up)

Answer 281

BPPV -crystalline debris in semicircular canal -if pt had lightheadedness or syncope then it would be true vertigo due to some cardiac problem or something

Question 282

extraintestinal manifestations of IBD

Answer 282

arthritis (spondyloarthritis, sacroileitis, etc) eye (uveitis, episcleritis) skin (pyoderma gangrenosum) hepatobiliary disease (psc)

Question 283

fibromuscular dysplasia

Answer 283

- noninflammatory and nonatherosclerotic condition caused by abnormal cell development in the arterial wall - can lead to vessel stenosis, aneurysm, or dissection - can involve any artery but commonly the renal, carotid, and vertebral arteries - pts can present with resistant hypertension (if renal artery involvement) - headache, pulsatile tinnitus, and dizziness (if carotid or vertebral involvement) - dx with computed tomography angiography or duplex ultrasound - do f/u bp and creatinine every 3-4 months and renal ultrasound every 6-12 months

Question 284

what happens to the kidney in diabetic nephropathy and what do you see clinically

Answer 284

glomerular hyperfiltration, basement membrane thickening, and mesangial nodules (KW-nodules) -pt will present with persistent proteinuria and poorly controlled hypertension

Question 285

what type of study is best to determine the incidence of a disease

Answer 285

cohort study design - comparing incidence of disease in 2 populations (with and w/o a given risk factor) - allows for relative risk calculation

Question 286

how can you tell bells palsy from central nervous system problems?

Answer 286

- upper face receives input from bilateral motor cortices - CNS lesions typically cause unilateral facial weakness that spares the muscles of the forehead - bells palsy affects the entire side of the face

Question 287

how to differentiate AIHA and hereditary spherocytosis

Answer 287

AIHA- positive coombs test and negative family history HS- negative coombs test and positive family history blood smear of both can cause spherocytes with central pallor

Question 288

what to suspect when patient placed on ACEi or ARB then gets diffuse atherosclerosis, asymmetric kidney size, recurrent flash pulmonary edema, or elevated serum creatinine > 30% from baseline

Answer 288

renovascular hypertension | -continuous periumbilical bruit

Question 289

first-line treatments for uncomplicated cystitis then complicated cystitis

Answer 289

nitrofurantoin 5 days bactrim 3 days fosfomycin single dose if complicated... give floroquinolones 5-14 days

Question 290

fomepizole

Answer 290

competitive inhibitor of alcohol dehydrogenase | -used in ethylene glycol poisoning (associated with hypocalcemia and and calcium oxalate crystal deposition in kidneys)

Question 291

prolonged, profuse, and watery diarrhea after traveling (10-14 days)

Answer 291

think of something parasitic - cryptosporidium parvum (due to ingestion of contaminated water via drinking or swimming) - cyclospora - giardia *immunocompromised pts are at risk of chronic infection

Question 292

when should you NOT give a pt sildenafil (or another PDE-5 inhibitor)

Answer 292

when they are also taking an alpha-blocker (-zosin) or a nitrate because that can cause severe hypotension

Question 293

what is your main concern if patients hypercapnia gets to around 70-80

Answer 293

delirium, confusion, lethargy, and eventually coma (CO2 narcosis) or seizures -can test for this with arterial blood gas

Question 294

diabetic retinopathy patient with sudden loss of vision and onset of floaters

Answer 294

vitreous hemorrhage

Question 295

what meds improve long term survival of pts with LV systolic dysfunction

Answer 295

ACEi --> reduces cardiac remodeling and improves survival of pts with MI and low ejection fraction ARBs beta-blockers mineralocorticoid receptor antagonists *hydralazine and nitrates combo used in black patients

Question 296

theophylline toxicity

Answer 296

``` CNS stimulation (headache, insomnia, seizures) GI disturbances (nausea, vomiting) cardiac toxicity (arrhythmia) ``` -inhibits cytochrome oxidase by other meds, diet, or underlying disease due to the small therapeutic window

Question 297

how to test for/diagnose infectious mononucleosis (prolonged fever, fatigue, pharyngitis, and lymphadenopathy)

Answer 297

1. positive heterophile antibody test (monospot)- note that this is negative in 25% of patients early on 2. atypical lymphocytosis 3. transient hepatitis

Question 298

which CN controls corneal sensation

Answer 298

V1 of trigeminal nerve

Question 299

normocytic MCV, what do you think of?

Answer 299

look at reticulocyte count IF LOW - leukemia - aplastic anemia - anemia of chronic disease IF HIGH - hemorrhage - hemolysis - -spherocytosis - -G6PD deficiency - -autoimmune - -microangiopathic

Question 300

how to define asthma

Answer 300

reversible airway obstruction (> 12% increase in FEV1) | normal CO diffusion capacity

Question 301

what type of gait is seen in parkinsonism

Answer 301

hypokinetic/shuffling gait

Question 302

how to treat premature atrial complexes

Answer 302

only needed when symptoms cause distress or supraventricular tachycardia -precipitating factors ---> tobacco, alcohol, caffeine, stress

Question 303

when to give packed RBCs

Answer 303

less than 7 for stable patients | less than 9 for unstable patients

Question 304

what diabetic medication has positive effects on patients cardiac and weight-related problems

Answer 304

SGLT-2 inhibitors (-flozin) - blocks proximal tubule glucose reabsorption - causes increased urinary glucose excretion - less nephropathy, albuminuria, CV mortality/morbidity, and can help with weight loss - can put pts at risk for euglycemic ketoacidosis, increased risk of genitourinary infections - contraindicated in pts with T1DM, history of DKA, impaired renal function GLP-1 agonists do the same thing (-tide)

Question 305

how does acute colonic ischemia present

Answer 305

- due to hypoperfusion - affects watershed areas - presents with crampy, left-sided abdominal pain and overt hematochezia during or shortly after (<24hrs) episodes of hypotension

Question 306

pt in ICU and can cause occult or gross GI bleeding -risk factors: shock, sepsis, coagulopathy, mechanical ventilation, traumatic spinal cord/brain injury, burns, and high-dose corticosteroids

Answer 306

stress ulceration

Question 307

blepharospasm

Answer 307

- form of focal dystonia where eyelids (bilateral and symmetric) - bright lights may trigger muscle contraction -tx: botulinum toxin may be used for very bad cases otherwise just try to block bright lights for mild cases

Question 308

when are live vaccines contraindicated in pts with HIV

Answer 308

MMR, zoster, and varicella are contraindicated if CD4 count is < 200

Question 309

who should get the Hepatitis A vaccine

Answer 309

people at increased risk - men who have sex with men - travelers to areas of increased incidence - adults with chronic liver disease

Question 310

chikungunya fever

Answer 310

viral illness via aedes mosquito - flulike illness (3-7 day incubation period) - symmetric severe polyarthralgias - macular/maculopapular rash on limbs and trunk - peripheral edema - cervical lymphadenopathy - lymphopenia, thrombocytopenia, transaminitis - treat with supportive care (usually resolves in 7-10 days) - chronic arthralias/arthritis in 50% of pts that may require methotrexate

Question 311

tender, indurated, erythematous nodules on anterior legs | -usually after an infection, IBD, sarcoid, or certain meds (abx or OCPs)

Answer 311

erythema nodosum - septal panniculitis without vasculitis - spontaneous resolution (weeks) with residual hyperpigmentation

Question 312

serum sickness

Answer 312

- immune reaction against blood products or antigens from nonhuman species - fever, joint pain, urticarial or vasculitis like rash

Question 313

thrombotic thrombocytopenic purpura

Answer 313

PENTAD: petechial rash w/ fever, renal failure, abdominal pain, and neurological manifestations -decreased ADAMTS13 level, uncleaved vWF multimers causing platelet trapping and activation manage with plasma exchange, glucocorticoids, and rituximab

Question 314

HIV patient with multiple ring enhancing lesions on brain imaging

Answer 314

TMP-SMX couldve been used for prophylaxis

Question 315

primary adrenal insufficiency

Answer 315

due to: autoimmune, infection, metastatic infiltration clinical features: fatigue, weakness, anorexia/weight loss, n/v, abdominal pain, salt craving, postural hypotension, hyperpigmentation acute adrenal crisis --> confusion, hypotension, shock lab findings: hyponatremia, hyperkalemia, eosinophilia, low morning cortisol, high ACTH dx with cosyntropin stimulation testing treatment: glucocorticoids and mineralocorticoids

Question 316

what spinal problems are most likely in pts with degenerative joint disease

Answer 316

lumbar spinal stenosis - neuropathic claudication - worse when walking - pain relieved by spinal flexion - dx via spinal MRI

Question 317

how often should you screen lipids in average risk patients

Answer 317

every 5 years

Question 318

when to start steroids for pts with pneumocystis pneumonia

Answer 318

pulse ox < 92% PaO2 < 70 A-a gradient > 35 on room air -meant to reduce risk of worsened hypoxia with treatment initiation

Question 319

whatre two meds when used together that can cause rhabdo

Answer 319

statins and colchicine

Question 320

if patient has persistent bradycardia with one of the following then whats the next step? - hypotension/signs of shock - acute mental status changes - chest discomfort concerning for cardiac ischemia - acute heart failure

Answer 320

if none of those then just observe | if at least one of those then give IV atropine 0.5mg bolus and repeat every 3-5 mins up to 3.0mg max

Question 321

strep bovis

Answer 321

used to be strep gallolyticus

Question 322

strep sanguins

Answer 322

part of strep viridins family

Question 323

if someone has trigeminal neuralgia bilaterally what do you think?

Answer 323

they likely have MS (demyelination of nerve axon)

Question 324

how to treat sporotrichosis

Answer 324

itraconazole

Question 325

classic triad for pheochromocytoma

Answer 325

episodic headache sweating tachycardia * pts have resistent hypertension and unexplained increase in blood glucose with possible family history - check urine or plasma metanephrines

Question 326

myelofibrosis

Answer 326

collagen or reticulin deposition in bone marrow - presents with fatigue, fever, and hepatosplenomegaly from extramedullary hematopoiesis - peripheral blood cell counts may be either elevated or decreased

Question 327

causes of aplastic anemia

Answer 327

pathogenesis: bone marrow failure due to hematopoietic stem cell deficiency (CD34) -- can be acquired causes: autoimmune, infections (parvo, ebv), drugs (carbamazepine, chloramphenicol, sulfonamides), exposure to radiation or toxins (benzene, solvents) pancytopenia and hypocellular bone marrow with fat and stomal cells seen on biopsy, no splenomegaly seen

Question 328

triad of acute liver failure

Answer 328

``` elevated aminotransferases (often > 1000) hepatic encephalopathy (confusion/asterixis) synthetic liver dysfunction (increased INR) ``` *no cirrhosis or underlying liver disease - acetaminophen toxicity is a common cause due to build up of NAPQI - pts with this need to get a liver transplant (only 50% without the transplant with survive)

Question 329

what type of medication is chlorthalidone

Answer 329

thiazide diuretic - can cause hyperglycemia, increased LDL, increased triglycerides, and hyperuricemia - also hypo-everything except hypercalcemia - glucose intolerance is a side effect in pts with metabolic syndrome or diabetes mellitus

Question 330

you diagnose someone with alcoholic liver cirrhosis, next steps?

Answer 330

get upper GI to make sure they dont have esophageal varices to indicate strategies to prevent future hemorrhage -primary prophylaxis is either endoscopic variceal ligation or nonselective beta-blocker like nadolol

Question 331

what virus is progressive multifocal leukoencephalopathy associated with?

Answer 331

reactivation of JC virus

Question 332

erysipelas

Answer 332

skin infection of the upper dermis and superficial lymphatic system - most common caused by group A strep pyogenes - manifests with fever and chills, regional lymphadenitis, warm tender erythematous rash with raised sharply demarcated borders

Question 333

what type of urine is seen in DM vs DI

Answer 333

DM --> high urine osmolaltiy and high urine specific gravity (osmotic diuresis) DI --> low urine osmolality and low urine specific gravity (< 1.006), dilute urine

Question 334

diabetes insipidus

Answer 334

central- ADH deficiency | nephrogenic- ADH resistance (renal disease), can be due to longterm lithium use

Question 335

triad of aspirin-exacerbated respiratory disease

Answer 335

- asthma (often severe and presenting in adulthood) - bronchospasm or nasal congestion following ingestion of aspirin or NSAIDs - chronic rhinosinusitis with nasal polyposis

Question 336

why is norepi used as first line treatment for septic shock

Answer 336

acts on a1 and b1 receptors to cause vasoconstriction, increase MAP so that you can optimize blood flow to critical organs like the brain but as a result it decreases blood flow to distal digits

Question 337

what parts of the eye changes vision

Answer 337

cornea- astigmatism lens elasticity- near/far sightedness lens opacity- cataracts

Question 338

painless hematuria

Answer 338

think likely bladder cancer

Question 339

how to tell the difference b/w vasovagal syncope and orthostatic hypotension

Answer 339

vasovagal (aka neurocardiogenic)- starts with nausea, diaphoresis, and pallor before passing out (usually in response to stress)... bradycardia with sinus arrest orthostatic- usually when you go from lying or sitting to standing

Question 340

most common site of metastasis for colon cancer -patient will have abdominal pain, microcytic anemia, positive fecal occult blood, and hepatomegaly with a hard liver edge

Answer 340

goes to the liver - presents as RUQ pain, mildly elevated liver enzymes, firm hepatomegaly - confirm with CT

Question 341

vascular dementia

Answer 341

- stepwise decline - early executive dysfunction - cerebral infarction and/or deep white matter changes on neuroimaging

Question 342

upper motor neuron problems distal to the site of compression

Answer 342

spinal cord compression - weakness, hyperreflexia, and extensor plantar response - medical emergency and requires prompt diagnosis by spinal MRI

Question 343

patient with chondrocalcinosis, pseudogout, chronic arthropathy, diabetes, and liver disease

Answer 343

hereditary hemochromatosis

Question 344

patient with any of the following... -crush injury or prolonged immobilization -intense muscle activity (seizure, exertion) -drug/med toxicity (opioids, colchicine, statins) what do you think of?

Answer 344

clinical features: muscle pain, weakness, dark urine, blood on urinalysis and no RBCs on microscopy, increased serum K and PO4, decreased serum Ca, increased AST/ALT, acute kidney injury dx: serum creatinine kinase > 1000 management: aggressive IV fluid resuscitation, sodium bicarb in some cases

Question 345

patient has a history of difficulty initiating swallowing with cough, choking, or nasal regurgitation... next step?

Answer 345

likely oropharyngeal dysphagia- video fluoroscopic modified barium swallow if they dont have that hx then likely esophageal dysphagia... - if solids and liquids at onset --> motility disorder (do barium swallow followed by manometry) - if solids then liquids --> mechanical obstruction (either barium swallow or upper endoscopy)

Question 346

euvolemic hypotonic hyponatremia, what do you think of

Answer 346

SIADH - can be caused by carbamazepine, SSRIs, NSAIDs - is associated with small cell lung cancer - serum osmolality < 275 // urine osmolality > 100 // urine sodium > 40 - manage with fluid restriction +/- salt tablets and hypertonic 3% saline for severe hyponatremia

Question 347

risk factors for MS

Answer 347

- female, caucasian, HLA-DRB1 - environmental factors: location (US and Europe), colder climates - low vitamin D levels - smoking

Question 348

patients with long standing RA are at higher risk of what

Answer 348

amyloidosis

Question 349

what ligament can cause compression of the lateral femoral cutaneous nerve

Answer 349

inguinal ligament

Question 350

most common cause of elderly pt with anemia

Answer 350

GI blood loss | -endoscopy and colonoscopy

Question 351

first line treatment in pt with aortic dissection

Answer 351

IV beta blockers

Question 352

myasthenia gravis vs lambert-eaton

Answer 352

MG - autoantibodies to postsynaptic ACh receptor, ligand gated - ptosis, diplopia, weakness with respiratory muscles - worsens with muscle use - associated with: thymoma, thymic hyperplasia - AChEi reverses symptoms, so give pyridostigmine LE - autoantibodies to presynaptic Ca2+ channel leads to decreased ACh release, voltage gated - proximal muscle weakness (difficulty walking, risking in chair, combing hair), autonomic symptoms (dry mouth, impotence) - improves with muscle use - associated with: small cell lung cancer - AChEi have minimal effect

Question 353

triad of normal pressure hydrocephalus and what it makes the brain look like

Answer 353

wet, wobbly, wacky -urinary incontinence, gait dysfunction, dementia - also presents with UMN signs - neuroimaging/CT presents with large ventricles with normal sulci

Question 354

- patient with distinct P waves with > 3 different morphologeis - atrial rate > 100 - irregular rhythm

Answer 354

Multifocal atrial tachycardia - precipitated by acute respiratory illness with underlying lung disease - treatment directed at correcting underlying inciting disturbance

Question 355

most common cause of abnormal hemostasis in pt with chronic renal failure (uremic coagulopathy)

Answer 355

platelet dysfunction - all labs are normal but bleeding time is prolonged - DDAVP is treatment of choice (not platelet transfusion cause they quickly become inactive anyways)

Question 356

risk factors below are risk factors for what... - acyclovir - sulfonamides - methotrexate - ethylene glycol - protease inhibitors - uric acid (tumor lysis syndrome)

Answer 356

crystal-induced acute kidney injury - usually asymptomatic - aki < 7 days of starting drug - UA: hematuria, pyuria, and crystals - increased risk with volume depletion, CKD mangement - discontinuation of drug - volume repletion - loop diuretic

Question 357

most common cardiac problem in pts with lupus

Answer 357

pericarditis

Question 358

cardiac tamponade (Becks) triad

Answer 358

- hypotension - distended neck veins - muffled heart sounds *exaggerated shift of intraventricular septum toward left ventricle (reduces LV preload, SV, and CO)

Question 359

ototoxic medications

Answer 359

aminoglycosides cysplatin/carboplatin salicylates loop-diuretics

Question 360

patient with hyperviscosity syndrome (diplopia, tinnitus, headache, dilated/segmented funduscopic findings), neuropathy, and infiltrative disease (hepatosplenomegaly, anemia, thrombocytopenia)

Answer 360

waldenstorms macroglobulinemia | -lymphoplasmocytic neoplasm with excessive IgM, end-organ damage, and > 10% clonal lymphocytes by bone marrow biopsy

Question 361

how to treat prolactinoma

Answer 361

asymptomatic- no treatment | symptomatic- dopamine agonists (cabergoline, bromocriptine) or resection if > 3cm or still growing on treatment

Question 362

how to treat hyperosmolar hyperglycemic state

Answer 362

IV fluids with normal saline

Question 363

what should be the follow up for pts with syncope and possible structural heart disease

Answer 363

echocardiogram

Question 364

undiagnosed pleural effusion (excess quantity of fluid in the pleural space) is best evaluated how

Answer 364

thoracentesis - except in pts with clear-cut evidence of congestive heart failure - diagnostic can be done at bedside and provides decision making info (if exudative then you need to do more)

Question 365

patient with lung infiltrate, coughing up blood, and nothing found on gram stain... what should be on your differential

Answer 365

invasive aspergillosis - immunocompromised (neutropenia, steroids, HIV) - triad (fever, chest pain, hemoptysis) - pulmonary nodules with halo sign - positive cultures and cell wall biomarkers - give voriconazole +/- caspofungin chronic pulmonary aspergillosis - look above but for > 3 months and with likely tb or other cavitary lesion - cavitary lesion with possible fungus ball - positive IgG serology - resect, give voriconazole and embolize if severe hemoptysis

Question 366

first-line medication treatment for idiopathic intracranial hypertension

Answer 366

acetazolamide +/- furosemide | -optic nerve sheath decompression or lumboperitoneal shunting for pts refractory to medication

Question 367

costochondritis

Answer 367

musculoskeletal chest pain - tenderness of > 1 sternochondral joint - sharp, localized chest pain that is reproducible with palpation - treatment: reassurance and symptomatic pain management

Question 368

what is the likely etiology of the following back pain - insidious onset - symptoms > 3 months - relieved with exercise but not rest - nocturnal pain

Answer 368

inflammatory back pain - ankylosing spondylitis - dx with x-ray of sacroiliac joints

Question 369

what causes condyloma acuminata

Answer 369

anogenital warts caused by Human Papilloma Virus (HPV) | -associated with increased risk of squamous cell carcinoma

Question 370

normal blood pressure readings in clinic but elevated bp throughout the day and at night -pts have left ventricular hypertrophy

Answer 370

masked hypertension | -dx made by ambulatory bp monitoring in pts with clinical evidence of hypertension

Question 371

most common complication of influenza

Answer 371

secondary bacterial pneumonia due to staph aureus or strep pneumo - MRSA can cause multilobar cavitary infiltrates - if due to staph it can cause rapid-onset, severe, necrotizing pneumonia with high risk of death

Question 372

if someone has complications months after an MI what is on your differential

Answer 372

pericarditis or left ventricular aneurysm

Question 373

what underlying mechanism causes the following in pts with liver cirrhosis - gynecomastia - testicular atrophy - decreased body hair - spider angiomas - palmar erythema

Answer 373

hyperestrinism | -liver cant remove estrogens

Question 374

inheritance pattern of hypertrophic cardiomyopathy

Answer 374

AD

Question 375

initial evaluation of hypertension

Answer 375

identifying complications and comorbid conditions - serum chemistry panel (lipid panel, fasting serum glucose, hemoglobin A1c) - hemoglobin/hematocrit - urinalysis

Question 376

explain the difference b/w 13 and 23 valent pneumococcal vaccines

Answer 376

23: T-cell independent B-cell response (IgM) 13: T-cell dependent B-cell response (IgG)

Question 377

pt with dermatomyositis, what do you screen them for?

Answer 377

occult malignancy, they are at an increased risk

Question 378

what are patients at risk for with untreated hyperthyroidism

Answer 378

rapid bone loss and osteoporosis | -increased thyroid hormones leads to increased osteoclast bone resorption

Question 379

acute persistent vertigo that can last days - often follows viral syndrome - abnormal head thrust test

Answer 379

``` vestibular neuritis (labyrinthitis) -associated with unilateral hearing loss ```

Question 380

patient with painless lymphadenopathy and B symptoms

Answer 380

non-hodgkin lymphoma -pts with chronic autoimmune diseases are at increased risk due to chronic b-cell stimulation, immune dysregulation, and use of immunosuppressive medications if they have no B symptoms then consider follicular lymphoma which has an indolent course and presents with waxing and waning lymphadenopathy

Question 381

common medication that can cause iron deficiency anemia

Answer 381

NSAIDs because they can cause chronic blood loss from the GI tract

Question 382

male patient presents with severe LLQ pain radiating to groin, vomiting... what do you think of if abdominal exam is normal?

Answer 382

obstructive ureterolithiasis | -get ultrasound or non-contrast spiral CT

Question 383

if a patient has hyperplastic polyps on colonoscopy how often should they get checked

Answer 383

every 10 years like normal, those dont increase the risk of cancer -if it were adenomatous then it would require more frequent checks

Question 384

what do you see on ECG if someone has taken too much digoxin

Answer 384

- increased ectopy (adds extra heartbeat) and increased vagal tone - atrial tachycardia with AV block side effects: CV- life-threatening arrhythmias GI- anorexia, n/v, abdominal pain Neuro- fatigue, confusion, weakness, visual color changes

Question 385

how to workup a possible aortic dissection

Answer 385

if chest x-ray and ECG suggest something else then fix that - if they lead to likely aortic dissection then check serum creatinine and see if they have a contrast allergy - if they cant take contrast dye then do TEE - if they can take contrast dye then do one of these, whichever is available (TEE, chest CT with contrast, MRI only if non-emergent and pt can still lie still)

Question 386

if you have severe liver cirrhosis and systemic/renal hypoperfusion... what do you think of?

Answer 386

hepatorenal syndrome

Question 387

post-op complication of a Roux-en-Y gastric bypass

Answer 387

stomal (anastimotic) stenosis - nausea - postprandial vomiting - GERD - dysphagia Treatment: EDG is both diagnostic and treatment for these pts

Question 388

how to treat lichen planus

Answer 388

high potency glucocorticoids | -disorder is self-limited and usually resolves w/i 2 years

Question 389

ventilation is defined as a product of what two things

Answer 389

respiratory rate and tidal volume

Question 390

how long is a typical gout flare

Answer 390

abrupt onset with maximal symptoms within 12-24 hours

Question 391

patient with super rapidly progressive nonspecific infection, myalgias, and poor perfusion

Answer 391

early meningococcal infection | -dx with lumbar puncture

Question 392

what is a synthetic cathinone

Answer 392

bath salts (amphetamine analogues) - norepi, dopamine, serotoinin - agitation, combativeness, psychosis, delirium, myoclonus, seizures * you can tell its this because it can take days to a week o subside*

Question 393

what do leafy green vegetables and grapefruit do to warfarin

Answer 393

vegetables decrease warfarin | grapefruit increases warfarin (ginseng also does but much less)

Question 394

when you see that someone has a metabolic acidosis, next step?

Answer 394

calculate plasma anion gap

Question 395

how to diagnose perforated peptic ulcer

Answer 395

chest x-ray will allow you to see the perforation via subdiaphragmatic free air

Question 396

if pt has primary hyperthyroidism (low TSH and high free T4) but no signs of graves (goiter or ophthalmopathy) then...

Answer 396

radioactive iodine uptake and scan HIGH - diffuse pattern: graves - nodular pattern: toxic adenoma or multinodular goiter LOW then measure serum thyroglobulin - high: thyroiditis or iodide exposure - low: exogenous hormone

Question 397

if pt has high TSH and high free T4 and T3 then...

Answer 397

secondary hyperthyroidism | -do MRI of pituitary

Question 398

lung and kidney problems without a fever, what do you think of

Answer 398

anti-GBM disease (Goodpasture syndrome) kidney- nephritic proteinuria, acute renal failure, urine sediment with dysmorphic red cells and red cell casts pulm- shortness of breath, cough, hemoptysis caused by pulmonary hemorrhage -dx made via linear IgG seen on renal biopsy

Question 399

definition of status epilepticus

Answer 399

seizure lasting > 5 mins or > 2 seizures where the pt does NOT regain consciousness - usually due to pts with structural brain abnormality (tumor or stroke), metabolic abnormality (hyponatremia, hypoglycemia), infection (meningitis), or drug withdrawal (alcohol or benzo) - give lorazepam or diazepam to stop the seizure then give a non-benzo seizure med to prevent future seizures

Question 400

when is pituitary imaging indicated

Answer 400

elevated prolactin mass-effect symptoms very low testosterone levels disruptions in other pituitary hormone levels

Question 401

what is the most common adverse transfusion reaction

Answer 401

febrile nonhemolytic transfusion reaction - transient fever, chills, malaise - caused by release of cytokines from leukocytes in stored blood product - symptoms develop w/i 1-6hrs - leukoreduction of donor blood

Question 402

next step for a pt with torsades de pointes (TdP)

Answer 402

type of polymorphic v. tach usually due to QT prolongation - if pt is hemodynamically unstable then do immediate defibrillation - if pt is hemodynamically stable then give magnesium

Question 403

when to give pts adenosine

Answer 403

used for acute termination of paroxysmal supraventricular tachycardia

Question 404

how does clostridium tetani work

Answer 404

(toxin mediated) blocks release of inhibitory neurotransmitters glycine and GABA across synaptic cleft -leading to fever, painful muscle spasms, and trismus (lockjaw)

Question 405

empiric treatment for community-acquired pneumonia

Answer 405

OUTPATIENT healthy- macrolide or doxycycline comorbidities- fluoroquinolone or beta-lactam + macrolide GENERAL INPATIENT fluoroquinolone beta-lactam + macrolide ICU beta-lactam + macrolide beta-lactam + fluoroquinolone *you can give moxi or levo as a fluoroquinolone cause they are respiratory specific

Question 406

how to determine if a patient should be hospitalized

Answer 406

CURB-65 ``` Confusion Urea > 20 mg/dL Respirations > 30/min Blood pressure (systolic < 90 or diastolic < 60 mmHg) age over 65 ``` 1 point for each of the following 0- low mortality - outpt treatment 1-2- intermediate mortality - likely inpatient treatment 3-4- high mortality - urgent inpt admit, possible ICU if score > 4

Question 407

scleroderma renal crisis

Answer 407

presents with: acute renal failure, malignant htn, mild proteinuria, MAHA with schistocytes and thrombocytopenia

Question 408

rapidly progressive myelopathy - motor weakness - autonomic dysfunction (bowel/bladder incontinence/retention and sexual dysfunction) - sensory deficits with distinct sensory level

Answer 408

transverse myelitis -immune mediated disorder with infiltration of inflammatory cells into a segment of the spinal cord leading to cells death and demyelination

Question 409

tetanus prophylaxis rules

Answer 409

if they had the 3 vaccine series as a child - clean wound: give vaccine if been > 10 years - dirty wound: give vaccine if been > 5 years if they didnt have all 3 vaccines - clean wound: give vaccine only - dirty wound: give both vaccine and TIG

Question 410

what is diabetic gastroparesis

Answer 410

delayed gastric emptying | -pt presents with anorexia, n/v, early satiety, postprandial fullness, and impaired glycemic control

Question 411

how does mixed cryoglobulinemia present

Answer 411

fatigue, palpable purpura (that do not blanch with pressure), arthralgias, renal disease, peripheral neuropathies with positive rheumatoid factor, hypocomplementemia, elevated transaminases, and kidney injury -associated with Hep C, HIV, and SLE

Question 412

which medications interfere with digoxin metabolism

Answer 412

amiodarone, verapamil, quinidine, and propafenone - increases serum level of digoxin - if they need to be on one of these meds then decrease the digoxin dose by 25-50%

Question 413

causes of myoclonus (involuntary muscle contraction)

Answer 413

genetic disorder seizures medications prolonged hypoxia (usually occurs after cardiac arrest)

Question 414

Lance-adams syndrome

Answer 414

chronic form of posthypolxic myoclonus - presents days to weeks after initial insult once pt has regained consciousness - typically focal in nature and exacerbated by action leading pts to drop objects or fall

Question 415

giving a pt estrogen can cause what

Answer 415

increase in TBG, so if they are on thyroid replacement therapy then they will need more to make up for the extra TBG

Question 416

obese pt with increased hematocrit

Answer 416

likely has increase in EPO due to OSA - pt may also complain of erectile dysfunction and arterial hypertension - fat and tired patient with hypertension think OSA

Question 417

what acid-base disturbance do pts have in DKA

Answer 417

metabolic acidosis due to rapid accumulation of ketoacids (beta-hydroxybutarate and acetoacetate) -pH can be brought close to normal but never fully corrects

Question 418

patients gets admitted to hospital then 6-24hrs later has hallucinations of bugs on them

Answer 418

alcoholic hallucinations | give them a benzo

Question 419

if they give you total protein and albumin labs when what do you think of

Answer 419

subtract them and if its > 4 then they likely have a monoclonal gammopathy due to multiple myeloma -get serum protein electrophoresis

Question 420

complications of radioactive iodine treatments for graves disease

Answer 420

- permanent hypothyroidism - worsening ophthalmopathy - possible radiation side effects

Question 421

risks of surgery for graves disease

Answer 421

- permanent hypothyroidism - risk of recurrent laryngeal nerve damage - risk of hypoparathyroidism

Question 422

bacilliary angiomatosis

Answer 422

- occurs when an immunocompromised pt presents with bartonella (gram - bacillus) - bright red, firm, friable, exophytic nodules - systemic b symptoms - rarely includes organ involvement - give oral erythromycin or doxycycline

Question 423

how to treat papulopustular rosacea (super red face that gets worse after sun exposure)

Answer 423

first-line: topical metronidazole, azelaic acid, ivermectin | second-line: oral tetracyclines

Question 424

- pt under 50 - possible smoker - recurrent chest discomfort - -occurs at rest or during sleep - -spontaneous resolution in < 15mins

Answer 424

vasospastic angina - hyperactivity of coronary smooth muscle - dx by ambulatory ECG showing ST elevation and coronary angiography shows no CAD - prevent with CCB - abort with sublingual nitroglycerin

Question 425

if a pt has clostridum septicum/group D strep/strep bovis, what is your next step

Answer 425

colonoscopy cause theyre associated with colon cancer

Question 426

what vaccinations do you give to pts going to north africa

Answer 426

hep A hep B typhoid polio booster

Question 427

patient with severe onset thats the worst of their life and has neck stiffness, what do you think of

Answer 427

subarachnoid hemorrhage - thunderclap headache - get urgent noncontrast CT and if negative then get lumbar puncture (high RBC count that does not decrease with each tube collected)

Question 428

what do you see on peripheral blood smear for pts with CLL

Answer 428

leukocytosis mature lymphocytes smudge cells

Question 429

patient has a firm thyroid nodule with no other symptoms, next step?

Answer 429

get serum TSH and ultrasound - if normal or elevated TSH: consider fine needle aspiration given other findings - if low TSH: radioactive iodine scintigraphy - -if hypofunctional node then do FNA - -if hyperfunctional node then treat hyperthyroidism

Question 430

patient presents with some form of optic neuropathy, elevated intraocular pressure, abnormal (increased) cup/disc ratio

Answer 430

open-angle glaucoma - pts will eventually lose peripheral vision - vision loss is irreversible - first-line is topical prostaglandin (latanoprost, bimatoprost) --> acts by increasing drainage through aqueous humor through uveosclerar pathway - -if needed you can also topical beta blockers (timolol)

Question 431

HIV patient presents with headache, fever, and malaise that develops within a week or two - normal MRI - bilateral papilledema

Answer 431

cryptococcal meningitis LP findings - high opening pressure - low glucose, high protein - wbc < 50/uL w/ mononuclear predominance - transparent capsule seen with india ink stain - cryptococcal antigen positive - culture on sabouraud treatment - initial: amphotericin b with flucytosine - maintenance: fluconazole

Question 432

which medications cause acute angle glaucoma

Answer 432

can be due to anticholinergics for parkinson disease - pts present with sudden onset of severe eye pain, n/v, unilateral conjunctival injection, dilated pupil with poor light response - untreated can develop blindness within 2-5 years

Question 433

how does leprosy present and what do you do - due to mycobacterium leprae - primary developing world (asia, africa, south america) - due to respiratory droplets/nine-banded armadillo - low infectivity

Answer 433

clinically - macular, anesthetic skin lesions with raised borders - nodular, painful nearby nerves with loss of sensory/motor function diagnosis - full-thickness biopsy of skin lesion (active edge) - cannot be cultured treatment - dapsone + rifampin - add clofazimine if severe (multibacillary)

Question 434

patient has damage and vision loss in one eye then develops spots in their other eye... what do you think?

Answer 434

sympathetic ophthalmia - immunologic mechanism involving recognition of 'hidden' antigens because natural barriers are broken - can manifest as anterior uveitis, panuveitis, papillary edema, and even vision loss - autoantibodies and cell-mediated

Question 435

in a UTI what do nitrates mean and what do leukocyte esterases mean

Answer 435

nitrates- presence of enterobacteriaceae | leukocyte esterases- pyuria (pus in urine)

Question 436

when to use synthetic cannabinoids vs progesterone analogues to increase appetite in pts

Answer 436

synthetic cannabinoids- advanced HIV cachexia progesterone analogues- cancer related cachexia (megestrol acetate and medroxyprogesterone acetate)- can also use corticosteroids but they have worse side effects

Question 437

herpes zoster ophthalmicus vs herpes simplex keratitis

Answer 437

HZO- by vzv infection, in elderly, fever, malaise, burning, itching in periorbital region, vesicular rash in cutaneous region of V1 branch of trigeminal nerve. eye has conjunctivitis and dendriform corneal ulcers HSK- pain, photophobia, blurred vision, tearing, possible history of same thing in past, corneal vesicles and dendritic ulcers. can occur more in pts with excessive sun exposure, outdoor occupation, or immunodeficiency

Question 438

when to screen for abdominal aortic aneurysm

Answer 438

man age 65-75 ANY smoking history (even if they quit a while ago) -do 1 time abdominal duplex ultrasound

Question 439

differentiate the following 4 causes of diarrhea in HIV patient 1. severe watery diarrhea, low-grade fever, weight loss 2. watery diarrhea, cramping abd pain, weight loss, NO FEVER 3. watery diarrhea, weight loss, HIGH FEVER > 102.2 4. frequent small volume diarrhea, hematochezia, abd pain, low-grade fever, weight loss

Answer 439

1. cryptosporidium 2. mircosporidium/isosporidium 3. mycobacterium avium complex 4. CMV

Question 440

how to interpret relative risk

Answer 440

if over 1 is positive association | if less than 1 its negative association

Question 441

super high ESR, normocytic anemia, glomerulonephritis, fatigue, arthralgias, dyspnea, possible embolisms

Answer 441

infective endocarditis

Question 442

pts presents with fatigue/dyspnea upon exertion, peripheral edema/ascites, increased JVP, pericardial knock (mid-diastolic sound), pulsus paradoxus, kussmal breathing -nonspecific ECG

Answer 442

constrictive pericarditis | -pericardial thickening and calcification

Question 443

when do pts with aortic stenosis start to experience symptoms

Answer 443

when it becomes severe | -valve area < 1cm2

Question 444

most common type of megaloblastic anemia in pts with chronic alcoholism

Answer 444

folate deficiency

Question 445

patients presents with fall in blood pressure ( > 10 mmHg) during inspiration, what is this called and what does it mean

Answer 445

pulses paradoxus | -ddx: severe asthma, COPD, cardiac tamponade

Question 446

why do you have to worry when you give O2 to a COPD patient

Answer 446

- can worsen hypercapnia due to combo to increased dead space perfusion causing v-p mismatch and decreased affinity for oxyhemoglobin for CO2 and reduced alveolar ventilation - o2 sat goal is 90-93%

Question 447

what are pts with nephrotic syndrome at risk for

Answer 447

- atherosclerosis due to hyperlipidemia | - av thrombosis due to loss of antithrombin III --> also increases risk for MI and stroke

Question 448

what type of medication is escitalopram

Answer 448

ssri

Question 449

how to diagnose cushings

Answer 449

- 24hr urinary cortisol excretion - late-night salivary cortisol assay - low-dose dexamethasone suppression test if hypercortisolism is confirmed then check ACTH to see if its dependent (cushing, ectopic ACTH) or independent (adrenal adenoma)

Question 450

pt with alcoholic history - temp 100 - abdominal pain/tenderness - altered mental status - hypotension, hypothermia, paralytic ileus with severe infection

Answer 450

spontaneous bacterial pneumonitis - do paracentesis (PMNs > 250, positive culture, gram - like ecoli or klebsiella, protein < 1, SAAG > 1) - give empiric abx: third gen cephalosporin, then use fluoroquinolones for prophylaxis

Question 451

describe CMV retinitis

Answer 451

painless no keratitis or conjunctivitis fundoscopically you will see hemorrhages/fluffy or granular lesions around retinal vessels

Question 452

most common signs and symptoms of pulmonary embolism

Answer 452

``` dyspnea pleuritic chest pain tachypnea tachycardia *chest radiograph usually isnt but CAN be normal ```

Question 453

main opportunistic infections in solid organ transplant pts

Answer 453

pneumocystis and CMV | -pts with systemic illness affecting a ton of organs should get tested for CMV viremia

Question 454

what is present in a pt with aortic regurg

Answer 454

bounding pulses

Question 455

pts who just had an anterior STEMI are at high risk for what to form even after stent placement -what you think of if they present with acute limb ischemia

Answer 455

LV aneurysm formation especially when reperfusion therapy is unavailable or delayed - muscle then fails to contract and balloons up - this can lead to LV thrombus that can embolize all pts who present with ALI should undergo a transthoracic echo

Question 456

explain malaria prophylaxis

Answer 456

``` note: choloroquine resistance is common use one of these for > 2 weeks before travel and continue for 4 weeks after you get back atovaquone-proquanil doxycycline mefloquine ```

Question 457

prolonged PR with normal QRS

Answer 457

first degree AV block - just do observation - get electrophys testing if they also have prolonged QRS

Question 458

how does arsenic poisoning present

Answer 458

mechanism: binds to sulfhydryl groups, disrupts cellular respiration and gluconeogenesis sources: pesticides/insecticides, contaminated water from wells, pressure-treated wood clinically acute- garlic breath, vomiting, watery diarrhea, QTc prolongation chronic- hypo/hyperpigmentation, hyperkeratosis, stocking-glove neuropathy treatment: dimercaprol or DMSA

Question 459

where is TBG produced

Answer 459

by the liver so pts with liver failure have normal TSH and high T3 and T4

Question 460

what is the problem if the pt had a stroke and now has one sided hemineglect

Answer 460

parietal lobe of the nondominant side | -responsible for spatial organization

Question 461

if pt has bloody diarrhea what do you think of

Answer 461

e.coli shigella campylobacter

Question 462

truncal coordination impaired

Answer 462

likely cerebellar problem

Question 463

how to reverse warfarin

Answer 463

IV vitamin K and prothrombin complex concentrate (contains factors 2, 7, 9, 10)

Question 464

tranexamic acid

Answer 464

antifibrinolytic that can help with heavy menstrual bleeding and prevent excessive blood loss during surgery

Question 465

explain the following terms: 1. breast cyst 2. fibrocystic changes 3. fibroadenoma 4. fat necrosis

Answer 465

1. solitary, well-circumscribed, mobile mass +/- tenderness 2. multiple, diffuse nodulocystic masses with cyclic premenstrual tenderness 3. solitary, well-circumscribed, mobile mass with cyclic premenstrual tenderness 4. post trauma/surgery, firm, irregular mass +/- ecchymosis, skin/nipple retraction

Question 466

most common form of drug-induced chronic renal failure

Answer 466

analgesic nephropathy -most common pathologies: papillary necrosis and chronic tubulointerstitial nephritis *patients with chronic analgesic abuse are more likely to develop premature aging, atherosclerotic vascular disease, and urinary tract cancer

Question 467

when to use the following tests Chi-squred ANOVA

Answer 467

chi-squred: compares proportions and uses categorical data | ANOVA: used to compare means of 3 or more variables

Question 468

how does riluzole work

Answer 468

glutamate inhibitor approved for ALS

Question 469

what is included in initial workup for pt with suspected dementia

Answer 469

neuropsych: montreal cognitive assessment labs: CBC, CMP, TSH, vitamin B12 neuroimaging: MRI or CT scan if pt has specific risk factors then you can do the following labs: folate, syphilis, vitamin D

Question 470

patient presents with sensory ataxia, lancinating/stabbing pains, neurogenic urinary incontinence, and small irregular pupils that poorly constrict to light but constrict normally with accomodation

Answer 470

those are argyll robinson pupils and pt has tabes dorsalis (neurosyphilis) --> develops more rapidly in HIV pts - syphilitic damage to dorsal sensory roots and damage to dorsal columns - give IV penicillin

Question 471

3 main categories of diabetic retinopathy

Answer 471

*leading cause of blindness in USA 1. background or simple retinopathy: consists of microaneurysms, hemorrhages, exudates, and retinal edema 2. pre-proliferative retinopathy: with cotton wool spots 3. proliferative or malignant retinopathy: consists of newly formed vessels *argon laser photocoagulation is preformed for proliferative complications

Question 472

diabetic sensory polyneuropathy... how do you know its small vs large fibers

Answer 472

small fibers cause positive symptoms ---> pain, paresthesia, allodynia large fibers cause negative symptoms ---> numbness, loss of proprioception and vibration sense, diminished ankle reflex

Question 473

expected lab abnormalities in pts with pagets

Answer 473

high alk phos and urine hydroxyproline due to increased bone turnover serum calcium and phosphorous are normal as long as there are no other complications

Question 474

how to reduce recurrent MI and cardiovascular death in pts after heart attack

Answer 474

dual antiplatelet therapy ---> aspirin + P2y12 receptor blocker

Question 475

how does thyrotoxicosis cause increased sensitivity to catecholamines

Answer 475

due to increased expression of beta-1-adrenergic receptors as well as changes in proteins controlling post beta-1-adrenergic receptor activity

Question 476

pt (age 50-70) presents with slowly progressive dyspnea, dry cough, and fine crackles

Answer 476

idiopathic pulmonary fibrosis

Question 477

what organs are most affected in GVHD

Answer 477

skin, liver, intestines

Question 478

what diabetes med is known to help with weight loss and have shown mortality benefits in pts with cardiovascular disease

Answer 478

GLP-1 agonists

Question 479

sodium levels can indicate what about heart failure

Answer 479

severity and its an independent predictor of adverse clinical outcomes -more hyponatremic = more severe heart failure

Question 480

pt is an obese woman presenting with headache, vision changes (blurriness and diplopia), CN 6 palsy, papilledema

Answer 480

idiopathic intracranial hypertension | -dx confirmed by lumbar puncture with elevated opening pressure and normal cell counts

Question 481

how does tympanic membrane fibrosis present

Answer 481

asymptomatic, usually an incidental finding on ear exam due to otitis media or barotrauma

Question 482

what can cause cochlea ossification and how does it present

Answer 482

- due to severe otosclerosis, meningitis, temporal bone fracture - presents with permanent high frequency hearing loss

Question 483

how to treat acute DVT/pulmonary embolism

Answer 483

oral Xa inhibitors or warfarin (if they are currently on one then give the other one) - Xa inhibitors work w/i 2-4 hours - warfarin works w/i 5-7 days and with warfarin you need to give some form of heparin for 5ish days

Question 484

how to approach wide-complex tachycardia

Answer 484

if its ventricular tachycardia - if pt is stable give IV amiodarone - if pt is not stable (hypotension, altered mental status, respiratory distress) give synchronized cardioversion if its an SVT with aberrancy - if pt is stable do carotid massage, rate control, treat - if pt is unstable give cardioversion

Question 485

HIV pt with infective endocarditis in pt with IVDU, what is the most common bug

Answer 485

staph aureus

Question 486

what are patients with heparin induced thrombocytopenia at increased risk of

Answer 486

arterial and venous clots | -need to be on alternate forms of anticoagulation

Question 487

what do you have to watch for in a pt with an acute asthma exacerbation that means they are getting worse

Answer 487

they should have a respiratory alkalosis (due to hyperventilation) but if their pH and PCO2 starts to normalize then they are no longer able to compensate anymore and that is suggestive for impending respiratory collapse

Question 488

side effect of hyperparathyroidism

Answer 488

pseudogout (CPPD)

Question 489

pt presents with psych symptoms, cognitive impairment, and chorea

Answer 489

huntingtons - AD, CAG trinucleotide repeat - preferential atrophy of caudate and putamen (neostriatum)

Question 490

when to think of secretory diarrhea

Answer 490

due to toxins, hormones, congenital disorders, or after bowel resection/cholycystectomy due to bile acids reaching bowel -pt has low stool osmotic gap (< 50) and nighttime awakenings *osmotic diarrhea will present after ingestion of a causative source

Question 491

what D-dimer level excludes PE

Answer 491

< 500 -if its more than do a CT pulmonary angiography

Question 492

what type of bias occurs when you dont have follow up from pts in a study

Answer 492

attrition bias --> a subset of selection bias

Question 493

epidermolysis bullosa

Answer 493

- group of inherited disorders characterized by epithelial fragility (mutations in epidermal/dermal proteins in basement membranes) - bullae, erosions, ulcers on palms, soles, oral - triggered by minor trauma - dx via biopsy with immunofluorescence microscopy and genetic testing - treatment is supportive

Question 494

main symptoms for strep pneumo meningitis

Answer 494

headache fever (> 100.4) nuchal rigidity altered mental status

Question 495

how to treat tinea versicolor

Answer 495

give topical selenium sulfide or ketoconazole or terbinafine - fungal skin infection with hyper/hypo/salmon-pigmented macules on upper trunk and extremities - more common in summer months

Question 496

if someone is given heparin for DVT but then they have heparin induced thrombocytopenia and the DVT gets worse what is happening

Answer 496

heparin platelet factor 4 + antibody immune complex causes 2 things - splenic sequestration and thrombus formation causing thrombocytopenia - platelet activation --> making thrombus symptoms worse due to platelet aggregation and procoagulant microparticle release

Question 497

underlying pathology to a lacunar stroke and major risk factors

Answer 497

microatheroma formation and lipohyalinosis leading to thrombotic small-vessel vasculitis major risk factors - hypertension - hyperlipidemia - diabetes - smoking

Question 498

uremic pericarditis

Answer 498

BUN > 60 + symptoms of pericarditis

Question 499

adverse effect of TMP

Answer 499

Treats Marrow Poorly - megaloblastic anemia - leukopenia - granulocytopenia * may be avoided with leucovorin (folinic acid)

Question 500

patient presents with progressive peripheral edema, elevated JVP, hepatomegaly, and ascites -possible etiologies: idiopathic or viral pericarditis, cardiac surgery or radiation therapy, tuberculous pericarditis in endemic areas

Answer 500

Constrictive Pericarditis - complication of mediastinal irradiation and an important cause of right heart failure - other findings include: hepatojugular reflux, kussmauls sign (increase or no change in JVP on inspiration), and pericardial knock (mid-diastolic sound)

Question 501

echocardiograph on patients with viral myocarditis

Answer 501

dilated ventricles with diffuse hypokinesis

Question 502

why is there increased incidence of orthostatic hypotension in elderly

Answer 502

progressively decreasing baroreceptor sensitivity and defects in myocardial response to this reflex

Question 503

what is recommended for infants with MEN2B

Answer 503

thyroidectomy cause of possible medullary thyroid cancer

Question 504

patient with transient chest pain who smokes and randomly gets transient ST elevation as well

Answer 504

vasospastic/prinzmetal/variant angina - smoking is a risk factor - triggers are cocaine, alcohol, and triptans - prevention: CCB and smoking cessation - abortive: nitrates

Question 505

hammer and claw toe deformities

Answer 505

- reflect imbalance in strength and flexibility b/w flexor and extensor muscle groups - sign of diabetic peripheral neuropathy

Question 506

discoid lupus erythematosus (chronic cutaneous lupus)

Answer 506

scaly, erythematous plaques, leading to atrophy, hypopigmentation, and scarring -most commonly affects sun-exposed areas of the head and neck

Question 507

necrobiosis lipoidica

Answer 507

confluent annular lesions with yellowish-brown hue, dilated blood vessels, and epidermal atrophy -typically affects pretibial skin and is most common in pts with DM

Question 508

where does porphyria cutanea tarda usually occur

Answer 508

blistering and skin fragility in sun-exposed areas | FACE AND DORSUM OF HANDS

Question 509

how to manage COPD exacerbation

Answer 509

- target O2 = 88-92% - bronchodilators - glucocorticoids - abx if 2 cardinal symptoms - oseltamivir if influenza - NPPV if vent failure - trach if NPPV failed or contraindicated

Question 510

what do cannon A waves represent - jugular venous pulsation waveform - regular, wide complex tachycardia

Answer 510

- occurs due to right atrial contraction against closed tricuspid valve (atrioventricular dissociation) - right atrial hemodynamics throughout the cardiac cycle

Question 511

what urine osmolality should lead you to think of diabetes insipidus

Answer 511

urine osmolality < 300 serum osmolality will be increased

Question 512

patient clearly has pyelonephritis, when do you get a CT

Answer 512

if they show no clinical improvement within first 48-72 hours on treatment, have a history of nephrolithiasis, or have unusual urinary findings (gross hematuria or thoughts of a stone)

Question 513

patient has lingering cough and wheezing after a viral prodrome

Answer 513

acute bronchitis - give NSAIDs and/or bronchodilators - NO abx

Question 514

patient presents with burning or itching of the lids, discharge (could lead to crusty eyes in the morning), and foreign body sensation in the eye

Answer 514

blepharitis -common contributors: seborrheic dermatitis, rosacea, allergic disorders, bacterial infection, viral infection, and demodex mite infestation

Question 515

normal distribution standard deviations

Answer 515

1 sd: 68% 2 sd: 95% 3 sd: 99.7%

Question 516

at what glucose level are you worried about hyperosmolar hyperglycemic state symptoms

Answer 516

> 600 (but usually its over 1000)

Question 517

when would a celiac patient have a negative anti-tissue transglutaminase

Answer 517

if they have a concurrent selective IgA deficiency -confirm with biopsy: villous atrophy

Question 518

what non diabetes drugs can cause hypoglycemia

Answer 518

quinolones quinine beta-blockers

Question 519

how to treat SIADH

Answer 519

fluid restriction (< 800mL/day) or salt tablets for asymptomatic or mildly symptomatic patients

Question 520

how to treat subacute thyroiditis

Answer 520

- same as de quervian (painful) - usually after URI - hyper then hypothyroid then normal once inflammation goes away - treat symptomatically with beta-blockers with NSAIDs

Question 521

patient gets CT with contrast then gets high fever, tachy, n/v, hypertension, agitation... what do you think of

Answer 521

possible thyrotoxicosis from thyroid storm triggered by contrast in CT

Question 522

patient with pericarditis within 2-4 days after MI...

Answer 522

peri-infarction pericarditis | -best prevented by early coronary reperfusion to minimize myocardial necrosis

Question 523

what pathology to think of in hyperpigmented patients

Answer 523

look at symptoms too but it could be due to increased pituitary release of ACTH and melanocyte-stimulating hormone (they are made with the same larger precursor molecule)

Question 524

how to test for obstructive sleep apnea

Answer 524

nocturnal polysomnography

Question 525

what are some of the clinical symptoms of tuberculous meningitis

Answer 525

possible cranial nerve palsy and stroke due to inflammation and exudative pressure

Question 526

most common cause of constrictive pericarditis in developing countries and what are the expected findings

Answer 526

TB -nonspecific afib, low voltage QRS complexes, pericardial thickening and calcifications, and JVP tracing showing prominent x and y descents

Question 527

when to consider surgery in pts with infective endocarditis

Answer 527

- stroke - significant valve dysfunction - persistent/difficult to treat infection - recurrent embolism

Question 528

what does an increased gamma gap (total protein - albumin) mean

Answer 528

high levels of autoantibodies

Question 529

patient with heart failure has acute kidney injury, what do you think of

Answer 529

cardiorenal syndrome - elevated central venous pressure leading to reduction in renal perfusion - decreased renal perfusion due to reduced cardiac output plays a small role as well

Question 530

dyshidrotic eczema

Answer 530

aka acute palmoplantar eczema - recurrent, acute episodes with deep-seated pruitic vesicles and bullae at hands and feet - complications can be desquamation, chronic dermatitis, secondary infection - treat with topical emollients and super high potency topical corticosteroids

Question 531

someone with both upper and lower motor neuron degeneration signs with widespread fibrillations and positive sharp waves (reflecting spontaneous depolarization) on electrophysiologic studies

Answer 531

ALS - progressive, fatal neurodegeneration disease - UMN: corticospinal neurons in primary motor cortex - LMN: cranial nerves, anterior horn cells

Question 532

female with recurrent rectal pain unrelated to anything and randomly occurs for up to 30 minutes at a time with no pain b/w episodes and normal physical exam/labs

Answer 532

proctalgia fugax - spastic contraction of anal sphincter due to pudendal nerve compression - manage with reassurance and possibly nitroglycerin cream +/- biofeedback therapy for refractory symptoms

Question 533

If someone has high-altitude illness, what do you do | -the body's first response will be to hyperventilate

Answer 533

give acetazolamide - prevents and treats it by increasing renal HCO3- excretion to reduce blood pH and alleviate central chemoreceptor inhibition of hypoxic ventilatory response - increases the ventilatory ceiling placed by the chemoreceptors

Question 534

how to treat syphilis pt with severe penicillin allergy

Answer 534

give doxycycline for all stages except if they have cardiovascular problems or gummas then give ceftriaxone -give penicillin G IV for neurosyphilis and desensitize them if they are allergic

Question 535

when to be concerned about giving PEEP to a pt

Answer 535

patients with any sort of underlying lung disease (ARDS, pneumonia, or obstructive airway diseases) are more likely to have barotrauma cause the lung is already messed up Possible complications: alveolar damage, pneumothorax, and hypotension

Question 536

elderly pt with bradycardia presenting with fatigue, dyspnea, dizziness, syncope, afib, palpitations

Answer 536

Sick Sinus Syndrome - most commonly due to degeneration of sinus node and replacement with fibrous tissue - ECG will show sinus brady, pauses, and dropped P waves - treat with pacemaker and possible rate-controlling meds if tachyarrhythmias

Question 537

patient with skin that kinda looks like less severe (no bleeding with picking of skin) atopic dermatitis/eczema but its more diffuse

Answer 537

ichthyosis vulgaris - chronic inherited skin disorder characterized by diffuse dermal scaling - caused by mutations in filaggrin gene and much worse in homozygotes - treat with emollients, keratolysis, and topical retinoids

Question 538

most common cause of spontaneous lobar hemorrhage in elderly

Answer 538

cerebral amyloid angiopathy - due to beta-amyloid deposition in walls of small to medium sized cerebral arteries - associated with Alzheimers

Question 539

what is the next best step after confirming likely cholestasis

Answer 539

anti-AMA | -to test for primary biliary cholangitis

Question 540

whipple disease

Answer 540

- rare multisystem illness due to infectious Trophyrma whippelii - GI: abdominal pain, weight loss, diarrhea, malabsorption, distension, flatulance, steatorrhea - extra-intestinal problems: migratory polyarthropathy, chronic cough, myocardial/valvular involvement - later stages include: dementia, supranuclear ophthalmoplegia, myoclonus, intermittent low-grade fever, pigmentation, lymphadenopathy -PAS POSITIVE IN LAMINA PROPRIA OF SMALL INTESTINE IS CLASSIC BIOPSY FINDING

Question 541

how to treat hyperkalemia

Answer 541

rapid calcium gluconate

Question 542

possible stroke pt, what is the FIRST TEST you do

Answer 542

head CT without contrast to look for hemorrhage - you can do MRI but its more expensive, takes longer, and is less available - if normal you can do a CT angiography of head and neck

Question 543

physostigmine

Answer 543

cholinesterase inhibitor

Question 544

most reliable and predictive sign of opioid intoxication

Answer 544

decreased respiratory rate

Question 545

preferred imaging modality in pt with possible multiple sclerosis

Answer 545

MRI T2-weighted

Question 546

what do you think of when you see anemia with reticulocytosis

Answer 546

acute bleeding or hemolysis | -make sure to also look at iron and B12 levels

Question 547

what hemolytic disease is associated with CLL

Answer 547

warm autoimmune hemolytic anemia

Question 548

what class of immunosuppressants are used after solid organ transplants and what are the side effects

Answer 548

tacrolimus and cyclosporine --> calcineurin inhibitors -adverse effects: nephrotoxic (hyperkalemia, hyperuricemia, increased gout), hypertension, neurotoxicity (tremor), glucose intolerance (needing more insulin), gingival hypertrophy, hirsutism, alopecia, and some GI disturbances

Question 549

key value to confirm primary polydipsia or malnutrition (beer drinkers potomania)

Answer 549

urine sodium < 100 mOsm/kg

Question 550

which electrolyte abnormality coincides with poor oral intake and hypokalemia

Answer 550

hypomagnesemia

Question 551

what should be on your differential if you see a pt with low hemoglobin and MCV and with a low reticulocyte count

Answer 551

anemia of chronic disease | something in the bone marrow disrupting a proper response

Question 552

what is Conn's syndrome

Answer 552

primary hyperaldosteronism (adrenal mass) - secretes aldosterone so you'll have a low renin and high aldosterone - this also causes a metabolic alkalosis

Question 553

complication of sjogrens syndrome that causes metabolic acidosis

Answer 553

renal tubular acidosis

Question 554

electrical alternans with sinus tachycardia, what do you think of

Answer 554

specific sign for pericardial effusion (can start from pericarditis) - can confirm with echo - if pt has hemodynamic instability/cardiac tamponade or it seems bad then do emergency pericardiocentesis

Question 555

common cause of stroke in young patients

Answer 555

internal carotid artery dissection - causes unilateral headache/neck pain/transient vision loss with ptosis and miosis along with focal weakness - dx with CT angiography - tx with thombolysis or antiplatelet therapy/anticoagulation

Question 556

initial criteria for extubation | -first they should undergo spontaneous breathing trial to help confirm candidacy for successful extubation

Answer 556

- pH > 7.25 - adequate oxygenation on minimal support (FiO2 < 40% and PEEP < 5) - intact inspiratory effort and sufficient mental alertness to protect the airway

Question 557

amiloride

Answer 557

potassium-sparing diuretic

Question 558

hypertrophic osteoarthopathy

Answer 558

digital clubbing along with painful joint enlargement

Question 559

pseudotumor cereri

Answer 559

idiopathic intracranial hypertension common in obese women < 45 and presents with headache, transient vision symptoms, and pulsatile tinnitus -also papilledema, and 6th nerve palsy

Question 560

patient has recent T2DM diagnosis then has weight loss, necrolytic migratory erythema (erythematous papules that coalesce to form large indurated plaques with central clearing), hyperglycemia, anemia, and diarrhea/anorexia/abdominal pain

Answer 560

Glucagonoma - pancreatic neuroendocrine tumor characterized by unregulated release of glucagon - necrolytic migratory erythema due to amino acid deficiency (painful/pruritic papules that end up having central clearing) - serum glucagon > 500 confirms dx - abdominal imaging can localize tumor and evaluate for mets

Question 561

patient who is either pregnant, obese, has DM, wears tight clothes/belts, or does abdominal straining movements has localized pain and paresthesia in the lateral thigh

Answer 561

Meralgia Paresthetica - caused by compression of the lateral femoral cutaneous nerve where it passes under the inguinal ligament into the thigh - NO weakness cause nerve has no motor fibers - conservative treatment by avoiding tight garments and weight loss

Question 562

patient with internuclear ophthalmoplegia (disorder of horizontal gaze)... what is damaged?

Answer 562

medial longitudinal fasciculus (MLF) -this is what happens in pts with MS (bilateral) or can indicate a lacunar stroke in pontine artery distribution if unilateral

Question 563

pt tests positive for neisseria gonorrhoeae, what else should you test for

Answer 563

chlamydia HIV syphilis Hep B

Question 564

what is miller fisher syndrome

Answer 564

variant of Guillain-Barre syndrome - group of immune-mediated polyneuropathies caused by molecular mimicry - characterized by ophthalmoplegia, ataxia, areflexia, strength often preserved - high associated with anti-GQ1b antibody

Question 565

what can be the cause of a pt having JUST bells palsy

Answer 565

thought to be reactivation of herpes simplex virus - give glucocorticoids (prednisone) - acyclovir or valacylovir may also help

Question 566

what are the HACEK organisms

Answer 566

- Haemophilus aphrophilus - Aggregatibacter actinomycetmcomitans - Cardiobacterium hominis - Eikenella corrodens (usually due to poor dentition/periodontal infection) - Kingella Kingae *these make up 3% of infective endocarditis cases

Question 567

side effect of aminoglycoside medications (gentamicin)

Answer 567

hearing loss, imbalance, sensation of objects moving (oscillopsia) -treat by discontinuing drug immediately

Question 568

inflammatory back pain in pt < 40 that could be chronic or insidious in onset and might get worse or better with activity -positive spinal tenderness

Answer 568

ankylosing spondylitis - treat with exercise, NSAIDs, COX-2 inhibitors - if those dont work then try TNF inhibitors or anti-IL-17 antibodies

Question 569

when pt places hand on top of head and their arm/neck symptoms get better what is this dx and tx of?

Answer 569

cervical radiculopathy -if symptoms get worse when bringing arm up think of thoracic outlet syndrome

Question 570

torticollis in adults

Answer 570

focal dystonia of sternocleidomastoid muscle (sustained muscle contraction resulting in twisting, repetitive movements, or abnormal postures) -can be idiopathic but is very often medication related

Question 571

athetosis

Answer 571

slow, writhing movements affecting hands and feet | -think of huntingtons when you hear this

Question 572

hemiballismus

Answer 572

unilateral violent arm flinging caused by damange to contralateral subthalamic nucleus -disruptive and self limited usually

Question 573

classic triad for disseminated gonococcal infection

Answer 573

1. polyarthralgia 2. tenosynovitis 3. painless vesiculopustular skin lesions

Question 574

what is amiodarone and what are its side effects

Answer 574

class 3 antiarrhythmic- K channel blocker - increase AP duration, ERP, and QT interval - side effects: pulm fibrosis, hepatotoxic, hypo/hyperthyroidism, corneal deposits, blue/grey skin, neurologic effects, constipation, cv effects like bradycardia/heart block/heart failure - check PFT, LFT, and TFT when using this drug

Question 575

D-xylose test

Answer 575

its a monosaccharide that can be absorbed in proximal small intestine and is excreted in the urine -if they dont pee a lot out then you know they have an absorption problem/some intestinal problem

Question 576

square envelope shaped crystals

Answer 576

ethylene glycol poisoning

Question 577

if patient gets a partial or total gastrectomy what is the FIRST thing on your differential

Answer 577

vitamin B12 deficiency due to intrinsic factor losses - vitamin B12 is necessary for purine synthesis (so DNA synthesis will also be impaired) - results in ineffective erythropoiesis presenting as megaloblastic anemia

Question 578

what is one of the most common risk factors for lower extremity cellulitis

Answer 578

tinea pedis | -causing fissures, erosions, and ulceration that allow bacterial entry into the tissue

Question 579

transverse myelitis

Answer 579

- immune mediated destruction. of the spinal cord (can be post-infectious) - bilateral motor weakness that can become spastic - unlike G-B it has a DISTINCT sensory level - autonomic dysfunction with bowel/bladder dysfunction - dx with MRI (no compression lesion) and Lumbar puncture will show increased WBCs and IgG index - treat with high dose IV steroids and plasmapheresis

Question 580

normal looking colon but then you end up with biopsy showing mononuclear infiltrate within lamina propria and subepithelial collagen band

Answer 580

microscopic colitis

Question 581

what to be concerned about if a pt with chronic pancreatitis or pancreatic resection is having hypoglycemic episodes?

Answer 581

-they might be having a glucagon deficiency cause they lost glucagon-secreting alpha cells as well

Question 582

what medical therapy to you use for ascites management in cirrhosis

Answer 582

medical therapy - spironolactone and furosemide - alcohol abstinence and sodium restriction - avoid ACE inhibitors, ARBs, and NSAIDs if refractory - large-volume paracentesis - transjugular intrahepatic portosystemic shunt

Question 583

first-line treatment for shingles for postherpetic neuralgia

Answer 583

this is the pain from shingles after the rash is already gone -give anticonvulsants like gabapentin or tricyclic antidepressants like amitriptyline

Question 584

pt is on phenytoin or they tell you they have a seizure disorder thats being treated -and pt has megaloblastic anemia

Answer 584

THINK FOLIC ACID DEFICIENCY -pt will also have gingival overgrowth/hyperplasia -if pt on phenytoin PUT THEM ON FOLATE AS WELL

Question 585

patient presents with hypopituitarism/hypogonadism and a large liver... what do you think of

Answer 585

hereditary hemochromatosis

Question 586

three common causes of esophagitis in pts with HIV

Answer 586

1. candida (white lesions) 2. HSV (round lesions with multinucleated giant cells) 3. CMV (linear uclcers with intranuclear/cytoplasmic inclusions)

Question 587

hypothyroidism most common pathology

Answer 587

antithyroid peroxidase antibodies with high titers and over hypothyroidism with increased risk of miscarriages

Question 588

normal values for ejection fraction

Answer 588

``` normal = above 55 boarderline = 50-55 decreased = less than 50 ```

Question 589

heart failure with preserved ejection fraction

Answer 589

diastolic dysfunction

Question 590

MULTIPLE ring enhancing lesions (dont think of this if there is just one)

Answer 590

toxoplasma gondii

Question 591

antibiotic therapy for pts with infective endocarditis

Answer 591

DO NOT USE ORAL FOR IE (pick IV answer) - look at susceptibilities and if penicillin then... - IV aqueous penicillin G (every 4-6hrs or continuous) or IV ceftriaxone (once daily) for 4 weeks

Question 592

bilateral abdominal masses in 30-40 year old with hypertension

Answer 592

ADPKD | -get ultrasound to see multiple renal cysts

Question 593

how does HIV-nephropathy present

Answer 593

heavy proteinuria, rapidly progressive renal failure, and edema -most common in pts of sub-Saharan African descent with advanced HIV infection

Question 594

immediate postprandial epigastric pain (intestinal angina), food aversion, and weight loss

Answer 594

chronic mesenteric ischemia - due to atherosclerosis of mesenteric arteries - get CT angiography (preferred), or doppler ultrasound - smoking and dyslipidemia are risk factors

Question 595

patient on chronic metformin therapy, what do you think of after >5 years of treatment

Answer 595

about 30% of these pts will develop vitamin B12 deficiency

Question 596

if a pt clearly has HIV but they also have cryptococcal meningoencephalitis how do you treat them

Answer 596

- treat cryptococcus first with amphotericin B and flucytosine followed by fluconazole for consolidation and maintenance therapy - then at least 2 weeks later you can consider HIV treatment and HAART

Question 597

what to think of if a pt has a medullary thyroid cancer and a family history of it...

Answer 597

MEN 2A or 2B | -look for a pheochromocytoma by looking for plasma fractionated metanephrine assay

Question 598

how to approach a pt with febrile neutropenia (especially if they are getting chemotherapy)

Answer 598

- these pts are at a higher risk of overwhelming bacterial infection due to absent or blunted PMN-mediated inflammatory response - usually infection caused by bacterial infection (pseudomonas) - treat empirically for pseudomonas

Question 599

person with chronic, poorly localized anterior knee pain (usually young women)

Answer 599

patellofemoral pain syndrome - pain with isometric contraction of the quadriceps - treatment: strengthening quads and hip abductors

Question 600

ototoxic medications

Answer 600

aminoglycosides loop diuretics carbo and cis-platin

Question 601

metabolic syndrome criteria

Answer 601

1. abdominal obesity (waist >40in in men and >35in in women) 2. fasting glucose >100-110 3. blood pressure > 130/80 4. Triglycerides > 150 5. HDL cholesterol <40 men <50 women

Question 602

why would someone on high-dose niacin get itchy

Answer 602

prostaglandin-related reaction causing vasodilation -also histamine gets released as well -can be reduced by aspirin

Question 603

- woman over 40 - pelvic mass, ascites, or abdominal pain - thyroid gland not enlarged

Answer 603

struma ovarii | very rare cause of thyrotoxicosis due to production of thyroid hormone by ovarian teratoma

Question 604

how to distinguish b.w graves disease and painless thyroiditis

Answer 604

both have hyperthyroidism and suppressed TSH -at this point you need to get a thyroid radioiodine scintigraphy painless thyroiditis --> decreased radioiodine uptake suggesting the release of preformed thyroid hormone graves --> hyperthyroidism due to increased synthesis of thyroid hormone

Question 605

what medications can cause male secondary hypogonadism (low libido, ED, low testosterone, low or normal LH)

Answer 605

opioids, glucocorticoids, exogenous androgens (withdrawal phase) -opioids suppress GnRH and LH secretion leading to reduced Leydig cell testosterone synthesis

Question 606

most common cause of primary adrenal insufficiency in developed countries

Answer 606

autoimmune adrenalitis

Question 607

how to differentiate primary adrenal insufficiency vs central adrenal insufficiency

Answer 607

PAI have hyperpigmentation and hyperkalemia

Question 608

what drugs can cause vitamin D deficiency

Answer 608

phenytoin, carbamazepine, and rifampin | -via p450 system in liver which degrades vitamin D to inactive metabolites

Question 609

how to tell the difference b/w decreased PTH and decreased vitamin D intake

Answer 609

serum phosphorous is low in vitamin D deficiency

Question 610

what serum prolactin level is diagnostic for. aprolactinoma

Answer 610

> 200

Question 611

transient foot drop and sensory changes over dorsal foot and lateral shin

Answer 611

common fibular neuropathy | -impaired ankle dorsiflexion and great toe extension with preserved plantar flexion and reflexes

Question 612

what is the one word to associate with each of these polymyalgia rheumatica fibromyalgia polymyositis

Answer 612

PR- stiffness fibromyalgia- pain polymyositis- weakness

Question 613

how does seborrheic keratosis work

Answer 613

- benign epidermal tumor - tan/brown/black round lesion with stuck-on appearance - dx made on clinical appearance only

Question 614

- pt over 60 | - back pain radiating to thighs worse with lumbar extension and persists while standing still

Answer 614

lumbar spinal stenosis

Question 615

what do you think of if you see multiple erythema migrans

Answer 615

erythema migrans- ring of red with dot in the middle if someone has multiple this is pathognomonic for early disseminated lyme disease -treat with doxycycline

Question 616

when to look for secondary causes of hypertension

Answer 616

resistant htn - >3 antihypertensive agents rom different classes - <30 years old - neither obese nor black pt

Question 617

when and why is leucovorin given

Answer 617

given to pts recieving methotrexate or another folic acid antagonist -prevents adverse events from damage to rapidly dividing cells in the GI system and liver

Question 618

if pt is about to get chemotherapy what do you do to prevent renal injury

Answer 618

give lots of NS to avoid tumor lysis syndrome which can cause precipitation of uric acid and calcium-phosphate -NS will flush out the kidneys

Question 619

when antivenom is indicated after a snake bite

Answer 619

- unstable vital signs (hypotension, tachypnea) - rapidly progressing changes in wound - abnormal coagulation studies *only give for these reasons due to risk of life-threatening allergic reaction

Question 620

if a pt with pyelo has been hospitalized what do you do if they are feeling better after 2 days

Answer 620

switch them to an oral abx if susceptible and send them home

Question 621

how to deal with a.fib with rapid ventricular response in hemodynamically stable pt

Answer 621

rate control with beta blockers or CCB

Question 622

pt has chronic cough and lung infections, what do you dx with

Answer 622

chest CT with high resolution to see bronchial dilation, lack of airway tapering, and bronchial wall thickening

Question 623

pt has chronic cough and lung infections, what do you dx with

Answer 623

chest CT with high resolution

Question 624

how to treat ankylosing spondylitis

Answer 624

start with nonpharm options like exercise and PT then try NSAIDs and COX-2 inhibitors then if that doesnt work try TNF-alpha inhibitors and anti-IL-17 antibodies (secukinumab)

Question 625

manifestations of tumor lysis syndrome

Answer 625

electrolytes: increased Ph, K, uric acid // decreased calcium AKI: due to acid,calcium phosporous stones cardiac arrhythmias

Question 626

what commonly used medication should be discontinued if a pt becomes acutely ill with renal/liver failure or sepsis

Answer 626

metformin due to the increased risk of lactic acidosis

Question 627

what commonly used medication should be discontinued if a pt becomes acutely ill with renal/liver failure or sepsis

Answer 627

metformin due to the increased risk of lactic acidosis

Question 628

what antibiotics do you have to be concerned about due to nephrotoxicity

Answer 628

aminoglycosides | -amikacin

Question 629

how to treat trigeminal neuralgia

Answer 629

carbamazepine

Question 630

pt with subacture gi symptoms (diarrhea, nausea, cramps) and systemic manifestations (fever, weight loss, night sweats), lymphadenopathy, and transient rash

Answer 630

acute HIV infection - usually causes a mono-like syndrome - oral ulcerations and transient rash

Question 631

pt with subacture gi symptoms (diarrhea, nausea, cramps) and systemic manifestations (fever, weight loss, night sweats), lymphadenopathy, and traniet rash

Answer 631

acute HIV infection

Question 632

what to think of if a pt has hyperkalemia and low bicarb

Answer 632

Renal tubular acidosis | -think of metabolic acidosis nonanion gap

Question 633

pt overdoses on something that causes tinnitus, fever, tachypnea, nausea, gi irrtation.. what do you think of

Answer 633

aspirin overdose -primary respiratory alkalosis followed by.... -primary anion gap metabolic acidosis

Question 634

what to be concerned about when a pt has one or more blood transfusions or packed red blood cells over 24 hours

Answer 634

pt presents with low calcium may develop elevated plasma levels of citrate (a substance added to stored blood) -citrate chelates calcium and magnesium and may reduce their plasma levels causing parethesias

Question 635

how to manage caustic ingestion

Answer 635

- secure ABCs - decontamination to remove clothes, chemicals, and irrigate exposed skin - chest x-ray if respiratory symptoms - endoscopy within 24hrs

Question 636

patient with infective endocarditis then develops AV block

Answer 636

perivalvular abscess

Question 637

if pt has muscle weakness and diplopia randomly then what should you think of

Answer 637

myasthenia gravis - great with AChE inhibitors (pyridostigmine) with/out immunotherapy - thymectomy

Question 638

how to deal with a recurrent tinea cruris infection

Answer 638

suggests reexposure to external source or autoinfection from concurrent dermatophyte infection elsewhere (search the body for it) and treat everywhere with topical antifungals like miconazole or tolnaftate

Question 639

what is essential for renal excretion of bicarb

Answer 639

chloride is essential and will be low in serum and urine if the pt is vomiting a lot or has diuretic overuse

Question 640

how to manage guillain-barre syndrome

Answer 640

- monitoring of autonomic and respiratory infection | - IVIG or plasmapheresis

Question 641

what do you see on imaging of pts with tuberculous meningitis

Answer 641

basilar meningeal enhancement, hydrocephalus, and stroke due to vasculitis -risk increases with immunocompromise

Question 642

patient with erythema nodosum (red/pink bumps on legs that kinda look like mosquito bites) -subcutaneous nodules

Answer 642

check for sarcoidosis with CXR

Question 643

how to treat lichen planus

Answer 643

associated with hep C, ACEi, beta blockers, hydroxychloroquine, and thiazides

Question 644

meniere disease

Answer 644

disorder of inner ear with increased volume/pressure of endolymph - recurrent episodes lasting 20 minutes to 3 hours - sensorineural hearing loss - tinnitus and feeling of fullness in the ear

Question 645

what do target cells mean on blood smear

Answer 645

HbC disease Anemia Liver disease Thalassemia

Question 646

what antiarrhythmic drug can cause pulmonary toxicity after longterm use

Answer 646

amiodarone - chronic interstitial pneumonitis (cough, fever, dyspnea, pulmonary infiltrates,) * most common*

Question 647

pt presents with HTN, tachycardia, dilated pupils, and chest pain

Answer 647

cocaine use - chest pain is due to coronary vasocontriction --> treat with benzos - psychomotor agitation and seizures as well

Question 648

up to 90% of pts with REM sleep behavior disorder develop what -characterized by dream reenactment

Answer 648

alpha-synuclein neurodegenerative disorders - parkinsons - dementia with lewy body - multiple system atrophy

Question 649

how to empirically treat native-valve endocarditis

Answer 649

geared toward MRSA, strep, and enterococci | -use Vancomycin

Question 650

what to lookout for in pts taking isoniazid

Answer 650

associated with hepatotoxicity so check LFTs -can look like viral hepatitis with aminotransferases >10x upper limit of normal or it can be mild and self limiting

Question 651

macrocytic anemia with thrombocytopena/leukopenia, and glossitis (smooth shiny tongue)

Answer 651

vitamin B12 deficiency - leading cause is pernicious anemia (antibodies against intrinsic factor) - glossitis is due to impaired replication of GI epithelium

Question 652

what medication should be given upon discharge of a pt with an asthma exacerbation

Answer 652

give albuterol and prednisone | -prednisone will help prevent relapse of symptoms

Question 653

besides blindness whats another complication (less commonly seen) in pts with giant cell arteritis

Answer 653

aortic aneurysm due to large vessel involvement

Question 654

EEG findings show sharp, triphasic, synchronous discharges... what do you think

Answer 654

prion disease aka creutzfeldt-jakob disease - pts will also have rapidly progressive dementia and myoclonus - most pts die within a year of onset

Question 655

pt presents with weakness and numbness (maybe upper and lower motor neuron problems) and possible bowel or bladder dysfunction but there is nothing found on imaging besides increased T2 signal in cervical spinal cord

Answer 655

idiopathic transverse myelitis - lumbar puncture shows increased WBCs and IgG index - treat first line with high dose IV steroids and then plasmapheresis if needed

Question 656

what will you see on imaging of a pt with acute cholangitis

Answer 656

dilation of the intrahepatic and common bile ducts

Question 657

fever, back pain, FOCAL spinal tenderness

Answer 657

vertebral osteomyelitis | -get blood cultures and inflammatory markers (ESR and CRP)

Question 658

progressive sensory loss in distal symmetric stocking and glove distribution... what to think of if it occurs acutely

Answer 658

toxin or medication mediated - metronidazole - fluoroquinolones - chemo - toxicity: alcohol abuse or heavy metal exposure

Question 659

pt with anemia related to chronic kidney disease what do you do

Answer 659

give erythropoietin - htn is a common side effect when they receive large doses - these pts need close bp monitoring

Question 660

vaccinatio for yellow fever is recommended prior to travel to central Africa but who should not get this live attenuated vaccine and should get a waiver instead?

Answer 660

- allergy to vaccine components (eggs) - AIDS CD4<200, immunodeficiency (like a thymus disorder), recent stem cell transplant - immunosuppressive therapy (TNFantagonist, high dose steroids)

Question 661

what is the routine for meningitis vaccines

Answer 661

11-12: primary vaccination 16: booster

Question 662

what ends up killing most people with ALS

Answer 662

respiratory failure - inspiratory muscle (diaphragm) atrophy and weakness - expiratory weakness so an ineffective cough to clear out lungs/bronchi - bulbar muscle weakness leading to dysphagia and chronic aspiration Note: it kinda looks like obstructive sleep apnea so you can treat it will noninvasive positive-pressure ventilation

Question 663

if someones ferritin level is over 1000 what do you do | -may also have hepatomegaly, elevated liver transaminases, and transferrin saturation

Answer 663

they probs have hereditary hemochromatosis and you wanna do a phlebotomy asap

Question 664

increased levels of homocysteine indicate what

Answer 664

its a highly reactive amino acid and increased levels predispose to venous thrombosis and atherosclerosis likely due to vascular damage -give pyridoxine (B6) to these pts

Question 665

narrow-complex tachycardia

Answer 665

supraventricular tachycardia | -if pt has this and is hemodynamically unstable then do synchronized cardioversion

Question 666

rounded swelling at the posterior elbow with a fluctuant mass on palpation

Answer 666

olecranon bursitis - can be due to chronic overuse/microtrauma - just rest and use NSAIDs

Question 667

overuse of crystalloids and the "lethal triad"

Answer 667

hypothermia, acidosis, coagulopathy