Internal Medicine: UWorld Flashcards

Question

An isolated, round, smooth-bordered, ring-enhancing intracranial lesion on contrast CT scan of the brain in an immunocompetent patient with a known extracranial bacterial infection is most likely what?

Answer 1

A brain abscess

Answer 2

Primary sclerosing cholangitis ## Footnote *It is frequently associated with ulcerative colitis. Laboratory studies usually show unexplained elevated liver function tests in a cholestatic pattern.*

Answer 3

Cancer antigen (CA) 19-9 ## Footnote *This has a sensitivity and specificity of 80-90%. The CA 19-9 can be elevated in patients with jaundice but no pancreatic cancer, however, which reduces its utility as a screening tool. Postoperative monitoring of pancreatic cancer with CA 19-9 may be helpful in evaluating the tumor response to chemotherapy.*

Answer 4

Multiple endocrine neoplasia (MEN) type 2 ## Footnote *MEN 2A is associated with medullary thyroid cancer, pheochromocytoma, and parathyroid hyperplasia. MEN 2B patients can develop medullary thyroid cancer, pheochromocytoma, marfanoid habitus, and intestinal or mucosal neuromas.*

Answer 5

Pulmonary thromboembolism * Hypotension usually only occurs with massive embolism. PE and right ventricular infarction can be differentiated as follows:* * Right ventricular MI: ST elevation on ECG* * PE: Sinus tachycardia, new onset right bundle branch block (RBBB) or S1Q3T3 on ECG*

Answer 6

Colonoscopy ## Footnote *The most common cause of iron deficiency anemia in an elderly patient is gastrointestinal blood loss.*

Answer 7

Recombinant erythropoietin ## Footnote *The major cause of anemia in patients with end stage renal disease is deficiency of erythropoietin.*

Answer 8

Potassium ## Footnote *Stored red blood cells gradually lose intracellular potassium to the surrounding solution. This mechanism has the potential to cause hyperkalemia.*

Answer 9

Acute pyelonephritis ## Footnote *Urinalysis shows bacteriuria and pyuria. Urine culture reveals greater than 10,000 colonies/mL.*

Answer 10

Patient repositioning every 2 hours

Answer 11

Nitroglycerin ## Footnote *It relieves the dyspnea and tachycardia associated with cardiogenic pulmonary edema by rapidly reducing preload. Several studies have suggested that it works quicker than morphine or loop diuretics. Nitroglycerin is not part of the long-term management for patients with heart failure but can be beneficial in acutely alleviating symptoms.*

Answer 12

The absorptive capacity of the proximal small intestine ## Footnote *Patients with proximal small intestinal mucosal disease (I.E. Celiac Sprue) cannot absorb the D-xylose in the intestine. As a result, the D-xylose does not reach the kidneys and is instead excreted in the feces. These patients typically have decreased urinary and serum D-xylose concentrations.*

Answer 13

Crohn's disease ## Footnote *This is not a feature of ulcerative colitis.*

Answer 14

1. Systemic Lupus Erythematosus, vasculitis, and certain cancers 2. Acute hemorrhagic cystitis, bladder carcinoma, sterility, and myelosuppression ## Footnote *(Hemorrhagic cystitis and bladder cancer are caused by a bladder-toxic metabolite of cyclophosphamide called acrolein)*

Answer 15

Emergent DC cardioversion

Answer 16

Diffuse esophageal spasm The esophagogram is frequently normal, although the classic corkscrew esophagus is seen occasionally.

Answer 17

Progression to fulminant hepatitis ## Footnote *A rise in Prothrombin time (PT) with a decrease in transaminase levels implies that very little functional tissue remains in the liver, which can happen rapidly in cases of fulminant hepatic failure. PT is considered the single most important test to assess the function of the liver because all clotting factors (except for factor VIII) are synthesized in the liver. When the liver is unable to create sufficient amounts of clotting factors, the PT is prolonged.*

Answer 18

Nephrotic syndrome ## Footnote *Nephrotic syndrome can result in alterations in lipid metabolism. This dyslipidemia puts affected patients at increased risk for accelerated athersclerosis. This atherosclerotic tendency, along with intrinsic hypercoagulability, places patients with nephrotic syndrome at risk for complications such as stroke and myocardial infarction.*

Answer 19

Henoch-Schonlein purpura ## Footnote *Serum complement levels are normal in this condition.*

Answer 20

Serum amylase and lipase levels

Answer 21

1. E. Coli 2. Klebsiella ## Footnote *Enteric organisms are the most common. Empiric therapy is generally with a 3rd generation cephalosporin.*

Answer 22

Nothing/Observation *PACs are benign and neither require any treatment or follow-up*

Answer 23

Tachyarrhythmia

Answer 24

1. Papillary necrosis 2. Chronic tubulointerstitial nephritis *Analgesic nephropathy is the most common form of drug-induced chronic renal failure. Polyuria and sterile pyuria (WBCs may also be seen) are early manifestations. Microscopic hematuria and renal colic may occur following sloughing of renal papilla. Hypertension, mild proteinuria, and impaired urinary concentration commonly occur as the disease advances. Patients with chronic analgesic abuse are also more likely to develop premature aging, atherosclerotic vascular disease, and urinary tract cancer.*

Answer 25

Octreotide ## Footnote *This is a long-acting analog of somatostatin that causes splanchinc vasoconstriction and reduced portal blood flow by inhibiting the release of glucagon.*

Answer 26

Lactose hydrogen breath test ## Footnote *The lactose tolerance test is cumbersome and time consuming. A positive hydrogen breath test is characterized by a rise in the measured breath hydrogen level after ingestion of lactose, thus indicating bacterial carbohydrate metabolism.*

Answer 27

The side effect is explained by prostaglanding-induced peripheral vasodilation and can be reduced by low-dose aspirin

Answer 28

Acetazolamide *It inhibits choroid plexus carbonic anhydrase and thus reduces CSF production and intracranial hypertension*

Answer 29

1. Most common: Allergic reaction (2% of patients) 2. Most serious: Agranulocytosis (0.3% of patients)

Answer 30

Ventricular arrhythmias and supraventricular tachycardias such as atrial fibrillation.

Answer 31

Chagas disease (Trypanosoma cruzi) *Megacolon/megaesophagus occur secondary to destruction of the nerves controlling the GI smooth muscle. The pathophysiology of Chagas heart disease is not well understood, but probably represents a prolonged myocarditis secondary to the protozoal infection*

Answer 32

Thoracentesis is the preliminary investigation of choice in the management of pleural effusion, except in patients with classic signs and symptoms of congestive heart failure, where a trial of diuretic is warranted *Bronchoscopy is a close alternative to thoracentesis, however, it requires sedation and is considered relatively invasive. It would be the next step if the pleural fluid cytology is non-diagnostic and the patient had a lung mass. If the pleural fluid cytology was positive for lung cancer, bronchoscopy is not necessary.*

Answer 33

Ischemic hepatic injury (shock liver) ## Footnote *The hallmark of ischemic hepatopathy is a rapid and massive increase in the transaminases with modest accompanying elevations in total bilirubin and alkaline phosphatase. In patients who survive the underlying cause of their hypotension, liver enzymes typically return to normal within one to two weeks.*

Answer 34

ADAMTS-13 ## Footnote *TTP is thought to be due to a deficiency of or autoantibody against a specific von Willebrand factor-cleaving protease called ADAMTS-13. This causes the accumulation of large von Willebrand factor multimers and platelet aggregation. Patients can develop fever, microangiopathic hemolytic anemia, thrombocytopenia with possible purpura, renal failure, and neurologic findings (I.E. headache, confusion). TTP does not usually decrease complement levels.*

Answer 35

Malignant hypertension (retinal hemorrhages, exudates, and/or papilledema) or hypertensive encephalopathy (cerebral edema)

Answer 36

Citrate ## Footnote *Citrate is an anticoagulant that is added to stored blood. Citrate chelates calcium and magnesium and may reduce their plasma levels, causing paresthesias.*

Answer 37

Hepatitis B vaccine + Hepatitis B immune globulin ## Footnote *This should be administered as soon as possible.*

Answer 38

Dihydropyridine calcium channel blockers *They cause peripheral vasodilation and reflex tachycardia*

Answer 39

P_aCO₂ = 1.5 (HCO₃^-) + 8 *Winter's formula can be used to calculate the expected PCO2 during respiratory compensation for a primary metabolic acidosis.*

Answer 40

Hepato-jugular reflex is positive in cardiac etiologies

Answer 41

Vancomycin, Ceftriaxone, and Ampicillin _**Vancomycin** + **Ceftriaxone** is ideal for community acquired bacterial meningitis in adults and children since it covers the three most frequent agents: Strep pneumo, H. Flu, and N. Meningitidis. **Ampicillin** is included in the empiric regimen to cover Listeria, which is important in patients over 55 y/o or those who are immunocompromised_

Answer 42

Rate control with a beta-blocker or a calcium channel blocker ## Footnote *Immediate synchronized electrical cardioversion is indicated in hemodynamically unstable patients with rapid atrial fibrillation*

Answer 43

Hashimoto's thyroiditis *Patients with this condition can be hypothyroid, euthyroid, or even hyperthyroid early in the disease process due to thyroid-stimulating antibodies or the release of thyroid hormones from inflammation.*

Answer 44

Alveolar and interstitial inflammation which causes areas of V/Q mismatch. This manifests as an increase in the alveolar-arterial oxygen gradient.

Answer 45

Increased renal sodium retention *This results from the activation of the renin-angiotensin-aldosterone system as a result of hypoperfusion secondary to decreased cardiac output*

Answer 46

Ciprofloxacin ## Footnote *It is unlikely that ampicillin will cover any organisms that Ciprofloxacin does not, but oral ampicillin is used to treat some cases of infectious diarrhea.*

Answer 47

Squatting decreases the vertical height of the blood column, and therefore will increase venous return to the heart *Recumbency and leg raising have the same effect*

Answer 48

Carcinoid syndrome ## Footnote *Carcinoid syndrome is a constellation of symptoms that are exhibited by patient with carcinoid tumors. Such carcinoid tumors may occur in the small intestine, colon, bronchial tubes, or appendix. These tumors secrete excessive amounts of the hormone serotonin, as well as other chemicals that cause the blood vessels to dilate. Patients typically manifest with the classic triad of flushing, diarrhea, and wheezing. Episodic flushing is the clinical hallmark of carcinoid syndrome, occuring in approximately 85% of patients.*

Answer 49

Increased hydrostatic pressure

Answer 50

Oral metronidazole ## Footnote *Because of its associated risks, cyst aspiration is not typically recommended unless the patient fails therapy. Surgical resection of a hepatic amebic abscess is not usually first-line treatment because it is associated with numerous risks. Surgical intervention may be indicated when the abscess has ruptured, eroded into adjacent structures, or caused extrahepatic complications, such as small bowel obstruction.*

Answer 51

Multiple Endocrine Neoplasia (MEN) type 2B

Answer 52

Pseudogout

Answer 53

Abdominal ultrasound *It has nearly 100% sensitivity and specificity for this condition.*

Answer 54

Autosomal recessive ## Footnote *This is a very rare disease characterized by significant unconjugated hyperbilirubinemia. Phototherapy or plasmapheresis are typically helpful in the short term, with liver transplant the only curative option.*

Answer 55

Ultrasonogram, which shows signs of acute cholecystitis and no gallstones; however, CT scan and HIDA scans are more sensitive and specific for the diagnosis.

Answer 56

IV diuretics *They provide symptomatic benefits to patients with decompensated heart failure*

Answer 57

Renal artery stenosis *Associated with a continuous periumbilical murmur on physical exam*.

Answer 58

A congenitally bicuspid aortic valve.

Answer 59

1. Larger aneurysm diameter 2. Current cigarette smoking

Answer 60

1. Barium swallow 2. Manometry 3. Endoscopy ## Footnote *Barium swallow is performed when achalasia is suspected and classically shows "bird-beak" narrowing at the gastroesophageal junction. The diagnosis is then confirmed with manometry which shows elevated resting lower esophageal sphincter (LES) pressure, incomplete LES relaxation after swallowing, and/or absence of peristalsis in the esophageal body. Before treatment is begun, endoscopy should be performed to rule out gastroesophageal malignancy.*

Answer 61

Cystoscopy ## Footnote *Other indications for cystoscopy include recurrent urinary tract infections, obstructive symptoms with suspicion for stricture or stone, irritative symptoms without urinary infection, and abnormal bladder imaging or urine cytology.*

Answer 62

IV epinephrine

Answer 63

Dubin-Johnson Syndrome ## Footnote *Normal individuals have urinary coproporphyrin composed primarily (80%) of coproporphyrin III.*

Answer 64

Chronic mesenteric ischemia due to occlusion (atherosclerosis) of visceral arteries (abdominal angina)

Answer 65

IV fluids and avoidance of preload reducing medications such as nitrates and diuretics *These patients are preload dependent and dropping preload can be catastrophic*

Answer 66

1. Beck's Triad 2. Cardiac Tamponade

Answer 67

1. Infection with Enterohemorrhagic E. Coli (EHEC) 2. Shigella, Slamonella, and Campylobacter

Answer 68

Diabetic nephropathy ## Footnote *Diabetic nephropathy is characterized by increased extracellular matrix, basement membrane thickening, mesangial expansion, and fibrosis.*

Answer 69

1. Sudden onset abdominal pain 2. Fever 3. Hematuria

Answer 70

Normal saline *Hypotonic fluids can be started when the intravascular volume improves.*

Answer 71

Hereditary hemochromatosis *Abnormal iron deposition in various organs, leading to multisystem end-organ damage*.

Answer 72

Trigeminal neuralgia

Answer 73

Acute epididymitis ## Footnote *Acute epididymitis in younger patients is usually caused by sexually transmitted organisms such as C. Trachomatis or N. gonorrhea. In older men it is usually non-sexually transmitted and is caused by gram-negative rods.*

Answer 74

Right ventricular infarct

Answer 75

Cryoprecipitate ## Footnote *Cryoprecipitate contains fibrinogen.*

Answer 76

Polyarteritis nodosa (PAN) ## Footnote *Patients can present with systemic symptoms (I.E. fever, malaise, and weight loss), neuropathy, arthralgias or myalgias, cutaneous findings (I.E. livedo reticularis), or renal disease.*

Answer 77

1. Confusion following episode of loss of consciousness 2. Bitten tongue after episode 3. Sore muscles after episode

Answer 78

Manometry ## Footnote *Spontaneous pain (that resolves with nitroglycerin) and odynophagia for cold and hot food are suggestive of DES. Esophageal manometry should reveal repetitive, non-peristaltic, high amplitude contractions, either spontaneously or after ergovine stimulation. Nitrates (and other calcium channel blockers) reduce pain because they relax not only the myocytes in the vessels, but also all others, including those in the esophagus.*

Answer 79

Ethambutol and Hydroxychloroquine

Answer 80

Granulomatosis with polyangiitis (Wegener's Granulomatosis)

Answer 81

Genetic defect (I.E. Deficiencies of Protein C, Protein S, or Antithrombin III) ## Footnote *In an elderly patient, this would be more suggestive of a primary malignancy.*

Answer 82

Decrease FiO2 to relatively non-toxic values ( \<60%) *Positive End Expiratory Pressure (PEEP) can be increased as needed to maintain adequate oxygenation after the FiO2 is lowered*. *Mechanical ventilation improves oxygenation by providing an increased fraction of inspired oxygen (FiO2) and by providing PEEP to prevent alveolar collapse. In the hospital setting, the arterial pO2 provides an important measure of oxygenation. It is influenced mainly by the FiO2 and PEEP level. The arterial pCO2, a measure of ventilation, is affected mainly by the respiratory rate and tidal volume. Patients are often provided a high FiO2 (\>80%) initially in mechanical ventilation, pending the results of the first blood gas analysis.*

Answer 83

_\>_10g/L (or hematocrit _\>_30%)

Answer 84

Beta-blockers *They reduce myocardial oxygen demand by decreasing heart rate and myocardial contractility. Beta-blockers should be avoided in patients with hypotension or bradycardia. Calcium-channel blockers or long-acting nitrates are used if beta blockers are contraindicated.*

Answer 85

MEN type I ## Footnote *MEN I is characterized by parathyroid tumors, pituitary tumors, and pancreatic tumors. Zollinger-Ellison Syndrome (gastrinoma) is the most common type of pancreatic endocrine tumor seen in MEN I.*

Answer 86

**Ursodeoxycholic acid**, which slows disease progression and relieves symptoms. Methotrexate and Colchicine have also been shown to be moderately beneficial. Cholestyramine forms a nonabsorbable complex with bile acids in the small intestine, reducing pruritis and hypercholesterolemia seen in PBC patients but it has no affect on the underlying condition or survival rates

Answer 87

Entamoeba histolytica *The primary infection is in the colon leading to bloody diarrhea; however, the ameba may be transported to the liver by portal circulation thus leading to an amebic liver abscess.* *Amebic liver abscesses are generally single and are located usually in the right lobe. An abscess on the superior surface of liver can cause a pleuritic-like type of pain and radiation to the shoulder.* *The diagnosis can be made by stool examination for trophozoites, serology, and liver imaging.*

Answer 88

Staph Aureus

Answer 89

Tricuspid regurgitation

Answer 90

Intravenous benzodiazepines *By reducing sympathetic outflow, benzodiazepines reduce anxiety and agitation, improve blood pressure and heart rate, and alleviate cardiovascular symptoms. Aspirin retards thrombus formation;nitrates and calcium channel blockers, being vasodilators, are beneficial for the cocaine-induced coronary artery vasoconstriction. Beta-blockers, however, should not be used in patients with cocaine-induced myocardial ischemia or infarction as their use can cause unopposed alpha adrenergic stimulation and worsen coronary vasoconstriction.*

Answer 91

Vasoactive peptide adenoma (VIPoma) ## Footnote *VIPomas are cancerous tumors that affect cells in the pancreas that produce vasoactive intestinal peptide (VIP). The cause is not known. VIPomas are diagnosed most commonly at age 50 years or so. Women are more likely to be affected than men. High levels of VIP in the blood is diagnostic. A CT scan or MRI is ordered to determine the location of the tumor.*

Answer 92

Glucose-6-phosphate dehydrogenase (G6PD) deficiency ## Footnote *Heinz bodies are characteristically seen on the peripheral blood smear. G6PD is an enzyme involved in creating NADPH, a cofactor required to create glutathione and prevent the oxidation of hemoglobin. Without G6PD, hemoglobin becomes oxidized and denatures into Heinz bodies. The denatured hemoglobin disrupts red blood cell membranes and causes hemolysis.*

Answer 93

Gastric ulcer

Answer 94

1. Focal segmental glomerulosclerosis 2. Minimal change disease 3. Membranous nephropathy 4. Diabetes 5. Primary amyloidosis 6. IgA nephropathy ## Footnote *In no specific order.*

Answer 95

Plasma BNP *BNP \> 100pg/mL is diagnostic of CHF with a predictive accuracy of 83%. BNP is released from the cardiac ventricles in response to volume overload.*

Answer 96

Nutritional (I.E. poor diet or alcoholism) ## Footnote *Folic acid deficiency can be caused by some drugs; these drugs can impair the absorption of folic acid (I.E. phenytoin) or antagonize its physiologic effects (I.E. methotrexate, trimethoprim).*

Answer 97

Atrial arrhythmias *Side effects include diarrhea, tinnitus, _QT prolongation_, torsades de pointes, hemolytic anemia and thrombocytopenia*

Answer 98

Abdominal ultrasound ## Footnote *If the ultrasound is nondiagnostic or difficult to interpret and there is high clinical suspicion for common bile duct disease, endoscopic ultrasound/endoscopic retrograde cholangiopancreatography (ERCP) may be performed to better visualize the gallbladder and biliary tree.*

Answer 99

Myocarditis *Viral infection, especially with Coxsackie B virus, is the most common cause.*

Answer 100

Cryptosporidium parvum ## Footnote *A modified acid-fast stain showing oocysts in the stool is very suggestive of an infection with cryptosporidium parvum. This organism can cause severe diarrheal disease in both immunocompetent and immunocompromised individuals. HIV-infected patients with a more preserved CD4 count tend to have a self-limiting illness, whereas AIDS patients with CD4 counts \< 180 cells/mm3 tend to have a more persistent clinical course. Isospora belli is also suggested by the presence of acid-fast oocysts, but infections with Isospora belli are not as common as Cryptosporidium in the United States.*

Answer 101

When CD4 count is \>200/micro-L and there is no history or evidence of an AIDS-defining illness

Answer 102

Coarctation of the aorta

Answer 103

The splenic flexure ## Footnote *This is because it is supplied by end arteries. The splenic flexure is a "watershed" line between the territory of the superior and inferior mesenteric arteries. There are two watershed zones in the colon: The splenic flexure, which is supplied by narrow terminal branches of the inferior mesenteric artery, and the recto-sigmoid junction, which is supplied by narrow terminal branches of the inferior mesenteric artery. These two watershed areas are most vulnerable to ischemia during systemic hypotension.*

Answer 104

_Mild-moderate:_ 1. WBC \< 15,000 2. Creatinine \< 1.5x baseline _Severe:_ 1. WBC _\>_ 15,000 2. Creatinine \> 1.5x baseline

Answer 105

Massive pulmonary embolism *Jugular venous distension and right bundle branch block are indicative of right heart strain and in the setting of hypotension, the diagnosis of massive PE is highly likely*

Answer 106

Pancreatic cancer ## Footnote *Most (60-70%) of pancreatic cancers originate in the head of the pancreas.*

Answer 107

Membranoproliferative glomerulonephritis

Answer 108

An accessory conduction pathway like in Wolf-Parkinson-White syndrome

Answer 109

1. **ACE inhibitors** reduce afterload and are used to treat acute heart failure 2. **Beta-blockers** are contraindicated because they decrease myocardial contractility and exacerbate the already decreased ejection fraction

Answer 110

The pulmonary veins *Cardiac tissue (myocardial sleeves) extend into the pulmonary veins and normally functions like a sphincter during atrial systole. This tissue has different electrical properties than the surrounding atrial myoctes and is prone to ectopic electrical foci and/or aberrant conduction which can initiate atrial fibrillation*

Answer 111

Decreased elasticity of the arterial wall ## Footnote *ISH should always be treated due to its associateion with an increased risk for cardiovascular events. Initial treatment involves monotherapy with a low dose thiazide, an ACE inhibitor, or a long-acting calcium channel blocker*

Answer 112

Wilson's disease ## Footnote *The presence of low serum ceruloplasmin and increased urinary copper excretion or Kayser-Fleischer rings confirms the diagnosis.*

Answer 113

Cisplatin and Carboplatin

Answer 114

1. Age \> 50 2. Crepitus 3. Bony enlargement 4. Bony tenderness 5. Lack of warmth 6. Minimal or no morning stiffness If patient meets 3 or more criteria, the specificity for OA is 69% and the sensitivity is 95%

Answer 115

Contrast esophagram ## Footnote *This will clearly show the diverticulum.*

Answer 116

Clindamycin

Answer 117

Ulcerative colitis

Answer 118

Inactivation of pancreatic enzymes ## Footnote *Malabsorption may occur in patients with Zollinger-Ellison syndrome.*

Answer 119

Focal Segmental Glomerulosclerosis

Answer 120

Spectrin *This is the protein that provides scaffolding for red blood cells.* *This is an autosomal dominant disorder.*

Answer 121

Hepatocellular carcinoma

Answer 122

Emergent High-dose Prednisone to prevent vision loss while a temporal artery biopsy is performed to confirm diagnosis of Temporal (Giant cell) Arteritis

Answer 123

C1 esterase inhibitor deficiency, dysfunction, or destruction. A defect or deficiency of C1 inhibitor leads to elecated levels of the edema-producing factors of C2b and bradykinin. *The most common cause of acquired isolated angioedema is ACE inhibitor use.*

Answer 124

1. ACE inhibitors 2. ARBs 3. Beta-blockers 4. Spironolactone *Digoxin and Furosemide can reduce CHF symptoms and hopitalizations but they do not improve survival*

Answer 125

Primary malignancy *In a younger patient, it would be more suggestive of a genetic defect (I.E. Deficiencies in Protein C, Protein S, or Antithrombin III)*.

Answer 126

Autosomal dominant ## Footnote *It results from a disorder of spectrin, the protein that provides scaffolding for red blood cells.*

Answer 127

In the urethra ## Footnote *Such as in urethritis.*

Answer 128

1. Renal failure 2. Hepatic failure 3. Sepsis

Answer 129

Hepatitis C ## Footnote *It presents with immune complex deposition in small blood vessels, leading to endothelial injury, inflammation, and end-organ damage. The immune complexes are IgM antibodies (similar to rheumatoid factor) that form complexes with IgG and anti-hepatitis C virus antibodies, hepatitis C virus RNA, and complement. Low complement levels, increased rheumatoid factor, increased liver transaminases, serum cryoglobulins, and kidney/skin biopsy can confirm the diagnosis.*

Answer 130

Cardiovascular disease ## Footnote *It accounts for approximately 50% of all deaths in this population. Cardiovascular disease is also the most common cause of death in renal transplant patients. Infection is also a common cause of death in dialysis patients, accounting for approximately 15-20% of deaths, and is most commonly related to vascular access (line sepsis).*

Answer 131

Cigarette smoking ## Footnote *Other risk factors include occupational exposures (I.E. painters, metal workers), chronic cystitis, iatrogenic causes (I.E. Cyclophosphamide), and pelvic radiation exposure.*

Answer 132

Thiazide diuretics and beta-blockers because of their effect in reducing cardiovascular mortality and their cost effectiveness

Answer 133

Chlamydial urethritis ## Footnote *Dysuria and urinary frequency can occur. Urinalysis reveals absent bacteriuria. Urine culture shows less than 100 colonies/mL. Gonococcal urethritis is less common than chlamydial urethritis. The urethral discharge in gonococcal urethritis is purulent (rather than mucopurulent), and gram stain usually reveals the causative organisms.*

Answer 134

A bradyarrhythmia (typically bundle branch block) *Prolonged PR intervals are also often associated with bradyarrhythmias*

Answer 135

Cerebellar hemorrhage *Early diagnosis is essential since urgent decompression may be life-saving. If left untreated, stupor or coma may ensue due to brainstem compression*

Answer 136

Angiography or a doppler ultrasound

Answer 137

Transthoracic doppler echocardiography *Midsystolic soft murmurs (Grade I & II out of VI) in an asymptomatic young patient are usually benign and need no further work-up*

Answer 138

Wenckebach or Mobitz type I heart block (A type of second-degree AV block) ## Footnote *It is a benign arrhythmia and is transient. Unless the patient is symptomatic, it requires no treatment.*

Answer 139

Rapid bone loss *Direct effects of the thyroid hormones on the bone cells eventually lead to increased osteoclastic bone resorption*

Answer 140

Gram-negative rods (I.E. Escherichia coli) Acute epididymitis is characterized by fever, painful enlargement of the testes, and irritative voiding symptoms. It can be either sexually transmitted or non-sexually transmitted. Sexually transmitted acute epididymitis is more common in adults and is associated with urethritis, which causes pain at the tip of the penis and urethral discharge. Non-sexually transmitted acute epididymitis occurs in older persons and is usually associated with a urinary tract infection.

Answer 141

Ephysematous cholecystitis ## Footnote *This is a form of acute cholecystitis that arises due to secondary infection of the gallbladder wall with gas-forming bacteria (I.E. clostridium, Escherichia, staphylococcus, streptococcus, pseudomonas, and klebsiella).*

Answer 142

The Putamen *Accounts for 35% of hypertensive hemorrhages. The internal capsule that lies adjacent to the putamen is almost always involved, thereby leading to hemiparesis. The eyes deviate away from the paralytic side*

Answer 143

Crystalluria with renal tubular obstruction ## Footnote *Nephrotoxicity is a well-known side effect of acyclovir therapy. Acyclovir is poorly soluble in urine and easily precipitates in renal tubules causing obstruction and acute renal failure. Crystalluria with renal tubular obstruction usually occurs during administration of large parenteral doses of acyclovir; inadequate hydration is a predisposing factor. Oliguria with elevated creatinine and BUN are typical for acute renal failure.*

Answer 144

Prothrombin time (PT) ## Footnote *All clotting factors (except for factor VIII) are synthesized in the liver. When the liver is unable to create sufficient amounts of clotting factors, the PT is prolonged.*

Answer 145

Renal function ## Footnote *Aminoglycosides are antibiotics used to treat serious gram-negative infections. They are potentially nephrotoxic.*

Answer 146

Conn's Syndrome (Primary hyperaldosteronism)

Answer 147

Abdominal computed tomography (CT) *This helps differentiate it from other causes of abdominal pain (I.E. Colon cancer and kidney infection)*.

Answer 148

Measles *Koplick spots are suggestive*

Answer 149

1. diarrhea 2. Leukopenia 3. Hepatotoxicity ## Footnote *The side effects are dose-related. Azothioprine is a purine analog that is enzymatically converted to 6-mercaptopurine. It acts primarily by inhibiting purine synthesis.*

Answer 150

non-selective Beta-blockers and aspirin *Nonselective beta-blockers such as propranolol should be avoided because Beta-2 receptor inhibition can lead to worsened coronary vasospasm. Aspirin should be avoided because it causes prostacyclin inhibition, which can promote vasospasm*

Answer 151

CT scan of the abdomen because it can differentiate between calcium stones (radioopaque) and uric acid stones (radiolucent)

Answer 152

1. Dietary modification (I.E. High-fiber diet and large amounts of fluids) 2. Stool softener 3. Local anesthetic ## Footnote *The local anesthetic relieves the local spasm, and the stool softener creates soft, bulky, atraumatic stools that disrupt the vicious cycle of constipation and fissure development. This treatment also allows the fissure to heal in approximately 50% of patients.*

Answer 153

Coronary steal phenomenon

Answer 154

1. Radioactive iodine ablation: Preferred modality of tx in USA 2. Antithyroid drug therapy 3. Thyroidectomy

Answer 155

Upper endoscopy

Answer 156

Endometrial carcinoma ## Footnote *This develops in up to 43% of females in affected families.*

Answer 157

Zinc deficiency ## Footnote *Zinc deficiency may result from chronic total parenteral nutrition or malabsorption. Zinc deficiency in children may also cause growth retardation. Zinc is an essential mineral, and is found in animal protein, whole grains, beans and nuts. It is digested primarily in the jejunum.*

Answer 158

Dihydropyridine Ca-channel antagonists like amlodipine *This is due to them dilating peripheral blood vessels and not due to an allergic reaction.*

Answer 159

Diabetic nephropathy ## Footnote *The pathologic hallmark is nodular glomerulosclerosis but diffuse glomerulosclerosis is more common.*

Answer 160

Calcium oxalate ## Footnote *Calcium oxalate crystals are envelope-shaped, and can be seen on microscopic examination of urine. Small bowel disease, surgical resection, or chronic diarrhea can lead to malabsorption of fatty acids and bile salts; this predisposes to the formation of calcium oxalate stones. Fat malabsorption leads to the increased absorption of oxalic acid because the unabsorbed fatty acids chelate calcium, making oxalic acid free for absorption.*

Answer 161

1. Back pain accompanied by low-grade fever and elevated ESR. 2. Physical exam may demonstrate local tenderness on percussion over the affected vertebrae and paravertebral muscular spasm. *High-grade fever and chills are uncommon*

Answer 162

The anterior wall of the left ventricle as well as the anterior 2/3rds of the septum *Occlusion most commonly causes ST-segment elevation in V1-V4*

Answer 163

Disk prolapse ## Footnote *A large midline disk herniation can cause nerve root injury known as cauda equina syndrome, a condition characterized by bladder atony with overflow incontinence, bilateral sciatica, saddle anesthesia and loss of anal sphincter tone.*

Answer 164

1. Use non-ionic contrast agent 2. Adequate intravenous hydration 3. Acetylcysteine ## Footnote *These all decrease the incidence of nephropathy.*

Answer 165

Radical Orchiectomy: Removal of testis + associated cord

Answer 166

Coarctation of the aorta (Check bilateral blood pressure)

Answer 167

1. Weight loss (in obese patients): 5-20mmHg reduction 2. Physical activity: 4-9mmHg reduction 3. Salt restriction: 2-8mmHg reduction 4. Reduction of alcohol intake: 2-4mmHg reduction

Answer 168

Laxative abuse *This dark brown discoloration is known as melanosis coli.* *Melanosis coli is not characteristic for celiac disease, infectious diarrhea, or non-hodgkin's lymphoma*

Answer 169

Complex ventricular arrhythmia *Acute ischemia creates heterogeneity of conduction in the myocardium. Areas of partial block of conduction are frequently formed that predispose the patient to reentrant arrhythmias. Ventricular fibrillation is a typical example of reentrant arrhythmia. Decline in mortality of patients hopitalized with acute coronary syndromes is largely attributable to the effective detection and treatment of reentrant ventricular arrhythmias.*

Answer 170

Men age \> 50 years old with Symptoms for \> 5 years or Cancer risk factors or Alarm symptoms (melena, persistent vomiting, hematemesis, weight loss, anemia, dysphagia/odynophagia) *If the patient meets any of these criteria, an endoscopy should be performed. In the absence of any of these criteria, a once daily proton pump inhibitor can be tried for 2 months.*

Answer 171

A1AT is established by measurement of the serum A1AT level, followed by confirmatory genetic testing ## Footnote *A1AT is coded for by a single, highly pleomorphic gene on chromosome 14.*

Answer 172

Abdominal ultrasound

Answer 173

Atrial septal defect

Answer 174

Intravenous steroids ## Footnote *Biopsy of the transplant will show heavy lymphocyte infiltration and vascular involvement with swelling of the intima.*

Answer 175

Bullous pemphigoid

Answer 176

Multiple Sclerosis

Answer 177

They decrease the extracellular concentration of potassium by driving the potassium into the cell.

Answer 178

Subclavian artery stenosis

Answer 179

Diagnostic peritoneal lavage (DPL) ## Footnote *If aspiration of 10 mL of peritoneal flluid shows blood, intraperitoneal injury is likely. If no gross blood is obtained, peritoneal cavity lavage with normal saline is performed and the effluent is sent to the laboratory for analysis (red blood cell count). A positive DPL should be followed by an exploratory laparotomy. A negative DPL should be followed by stabilization, and in the absence of signs of extra-abdominal hemorrhage, CT of the abdomen.*

Answer 180

Hypomagnesemia

Answer 181

IV Ceftazidime + Vancomycin ## Footnote * These drugs cover pseudomonas and Staph Aureus respectively*

Answer 182

Dorsal root ganglia

Answer 183

Young and middle-aged women who have a lengthy history of oral contraceptive usage *Hepatic adenomas may also be seen in association with anabolic androgen use, glycogen storage disease, pregnancy, and diabetes*

Answer 184

Hypertensive encephalopathy

Answer 185

Chemical peritonitis due to a perforated peptic ulcer ## Footnote *Upright chest and/or abdominal radiographs typically reveal free air under the diaphram.*

Answer 186

3rd generation cephalosporin

Answer 187

1. Sodium and water restriction 2. Spironolactone 3. Loop diuretic (not more than 1 L/day of diuresis) 4. Frequent abdominal paracentesis (2-4 L/day as long as the renal function is okay) ## Footnote *The treatment of ascites starts with Na⁺ and water restriction (2 L/day). Diuretic therapy, if needed is typically started with spironolactone. When the maximal dose of spironolactone fails to improve the patient's status, giving a loop diuretic (I.E. Furosemide) is recommended. Aggressive diuresis (\> 1 L/day) is not recommended due to the risk of hepato-renal syndrome.*

Answer 188

Prostate or bladder

Answer 189

Intermittent catheterization

Answer 190

Afterload reduction with vasodilators like nifedipine or ACE inhibitors *For aortic regurgitation so severe as to cause symptoms, valve replacement is generally recommended.*

Answer 191

1. Duodenal ulcers usually improve with food 2. Gastric ulcers tend to worsen with food ## Footnote *Melena and abdominal pain are most likely due to peptic ulcer disease. The diagnosis is made by upper endoscopy.*

Answer 192

Cystic medial necrosis or connective tissue disorders *The #1 risk factor for aortic dissection is still hypertension*

Answer 193

Carbamazepine

Answer 194

Newer antipneumococcal quinolones, like levofloxacin or mosifloxacin

Answer 195

Cardiogenic shock *Once pump failure occurs in cardiogenic shock, blood backs into the lungs, causing increased pulmonary capillary wedge pressure. Systemic vascular resistance is typically increased to maintain adequate tissue perfusion pressure. The lower tissue perfusion signals the tissue to extract more oxygen from the blood, which decreases mixed venous oxygen saturation. All of this manifests clinically as depressed mental status, dyspnea, decreased urinary output, and cool extremities*

Answer 196

1. Hyperglycemia 2. Increased LDL cholesterol 3. Plasma triglycerides

Answer 197

Glomerular hyperfiltration ## Footnote *It is also the major pathophysiologic mechanism of glomerular injury in these patients. It creates intraglomerular hypertension leading to progressive glomerular damage and renal function loss. The effectiveness of Angiotensin converting enzyme (ACE) inhibitors in diabetic nephropathy is related to their ability to reduce intraglomerular hypertension and, thereby, decrease glomerular damage. Thickening of the glomerular basement membrane is the first change that can be quantitated. This is followed by mesangial expansion. Nodular sclerosis is superimposed later and is specific for diabetic nephropathy.*

Answer 198

1. Hemorrhages are seen as hyperdense areas 2. Infarcts are seen as hypodense parenchymal areas

Answer 199

Aortic stenosis *Pulsus parvus and tardus refers to a carotid pulse that is slow and late*

Answer 200

Iron deficiency anemia ## Footnote *This often occurs through chronic blood loss from the gastrointestinal tract.*

Answer 201

Conjugated hyperbilirubinemia ## Footnote *Unconjugated bilirubin is highly insoluble in water and is tightly bound to albumin. When bound, this unconjugated bilirubin cannot be filtered by the glomerulus and is therefore not excreted in the urine. Dubin-Johnson syndrome and Rotor syndrome are inheritable forms of conjugated hyperbilirubinemia.*

Answer 202

Atracurium

Answer 203

Acetazolamide

Answer 204

Secretin stimulation test ## Footnote *Secretin stimulates the release of gastrin by gastrinoma cells. Normal gastric G cells are inhibited by secretin; thus, the administration of secretin should not cause a rise in serum gastrin concentrations in patients with other causes of hypergastrinemia. The calcium infusion study is usually reserved for patients with gastric acid hypersecretion who are strongly suspected of having gastrinoma despite a negative secretin test. Calcium infusion can lead to an increase in serum gastrin levels in patients with gastrinoma.*

Answer 205

Pericardial effusion

Answer 206

Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) ## Footnote *The presence of fragmented cells in the peripheral smear suggests microangiopathic hemolytic anemia (MAHA), a characteristic finding in TTP-HUS.*

Answer 207

Diffuse esophageal spasm ## Footnote *Barium swallow may reveal a "corkscrew" esophagus. The treatment is supportive with antispasmodics, dietary modulation and psychiatric counseling.*

Answer 208

Herpangina (typically occurs in children)

Answer 209

The vaccine contains capsular polysaccharides of the 23 most prevalent types of pneumococcus. Whereas peptides get presented to T-cells by macrophages and B-cells, polysaccharides cannot be presented to T-cells. Thus, polysaccharide vaccines yield a B-cell only (T-cell independent) response.

Answer 210

Ventricular arrhythmias *High doses can cause confusion, seizures and respiratory depression*.

Answer 211

Pericardial effusion *Most commonly idiopathic (thought to be due to a viral illness) but can also be due to malignancy, post- MI, uremia, autoimmune diseases, and hypothyroidism. Large pericardial effusions typically appear on chest x-ray as an enlarged and globular-appearing cardiac shadow.*

Answer 212

Alpha-1 Antitrypsin (A1AT) deficiency ## Footnote *This is a serum protein that is primarily produced in the liver and inhibits several different proteolytic enzymes. It is also an acute-phase reactant that plays a significant role in inflammatory states.*

Answer 213

Tuberculosis

Answer 214

Intravenous broad-spectrum antibiotic (ceftriaxone), metronidazole, and drainage

Answer 215

Deficiency of erythropoietin ## Footnote *This is a normocytic, normochromic anemia. The treatment of choice is recombinant erythropoietin, which is started if the hemoglobin is*

Answer 216

Increased myocardial oxygen demand

Answer 217

Pontine hemorrhage *Accounts for 5-12% of hypertensive intraparenchymal hemorrhages*

Answer 218

Rhabdomyolysis which frequently leads to acute renal failure

Answer 219

Progressively decreasing baroreceptor sensitivity and defects in the myocardial response to this reflex

Answer 220

1. Botulinum toxin injection into the lower esophageal sphincter (LES) 2. Nitrates or calcium channel blockers 3. Pneumatic dilatation 4. Surgical myotomy ## Footnote *Nitrates and calcium channel blockers relax the smooth muscles of the lower esophageal sphincter and have been used as medical therapy with variable success rates.*

Answer 221

Autosomal recessive ## Footnote *Most often identified in younger individuals aged 5-40 years. The genetic mutations associated with Wilson's disease hinder copper metabolism by reducing the formation and secretion of ceruloplasmin and by decreasing the secretion of copper into the biliary system.*

Answer 222

1. Tubular adenoma 2. Tubulovillous adenoma: As the villous component increases, the risk of malignancy increases 3. Villous adenomas: These are most commonly sessile and 3 times more likely than tubular adenomas for malignant transformation ## Footnote *Hyperplastic polyps are the most common non-neoplastic polyps in the colon. These arise from hyperplastic mucosal proliferation.*

Answer 223

Bone marrow suppression ## Footnote *Mycophenolate is a reversible inhibitor of inosine monophosphate dehydrogenase (IMPDH), which is the rate-limiting enzyme in de novo purine synthesis.*

Answer 224

Hemochromatosis ## Footnote *Bilirubin and alkaline phosphatase levels are usually normal or mildly elevated without clinically obvious jaundice.*

Answer 225

Spontaneous bacterial peritonitis (SBP) ## Footnote *Ascitic fluid with polymorphonuclear leukocytes _\>_250/uL and positive peritoneal fluid culture confirm the diagnosis. The serum-ascites albumin gradient (SAAG) is the serum albumin minus ascites albumin. SAAG _\>_ 1.1g/dL indicates portal hypertension as the cause of ascites and makes SBP more likely.*

Answer 226

Barium esophagram *Upper endoscopy can be performed next, if the barium esophagram is inconclusive or negative*

Answer 227

Compression ultrasonography. *The decision to anticoagulate is not made based on the history and physical exam alone, but rather the results of non-invasive testing. If a DVT is detected, anitcoagulation with Heparin is initiated.*

Answer 228

Septic shock *Peripheral vasodilation usually causes less blood to return to the heart*

Answer 229

Acute angle closure glaucoma

Answer 230

Autosomal recessive ## Footnote *It occurs due to a mutated human hemochromatosis protein (HFE) gene that leads to increased intestinal iron absorption.*

Answer 231

Cigarette smoking

Answer 232

Atherosclerosis ## Footnote *Risk factors include hypertension, hypercholesterolemia, and smoking.*

Answer 233

Kidney or ureters

Answer 234

Ipratropium + Albuterol nebulizer + systemic steroids. The most commonly used parenteral steroid is methylprednisolone.

Answer 235

Hypocalcemia

Answer 236

\>65 years of age

Answer 237

ACE inhibitors because beta-blockers and thiazides may exacerbate hyperglycemia.

Answer 238

40% of circulating serum calcium is bound to proteins. Albumin is responsible for 90% of protein binding of the serum calcium. Therefore, decreased albumin levels will be associated with decreased total serum calcium

Answer 239

Rotor syndrome ## Footnote *Liver function tests are normal. Pigmented granules are not seen in the hepatocytes of individuals with Rotor syndrome (Whereas Black liver is seen in Dubin-Johnson Syndrome).*

Answer 240

1. IgA nephropathy 2. Lupus nephritis 3. Thin basement membrane disease 4. Membranoproliferative glomerulonephritis 5. Rapidly progressive glomerulonephritis 6. Post-streptococcal glomerulonephritis ## Footnote *In no particular order.*

Answer 241

Sickle cell trait

Answer 242

1. A prolonged constant PR interval (\>0.2 seconds) 2. It is a completely benign arrhythmia that requires no treatment

Answer 243

Liver biopsy ## Footnote *Liver biopsy that demonstrates a quantitative hepatic copper level \>250 mcg/gram dry weight. More commonly, diagnosis is confirmed by the presence of low serum ceruloplasmin (particularly \<20mg/dL) in conjunction with increased urinary copper excretion or Kayser-Fleischer rings.*

Answer 244

Aortic aneurysm due to involvement of the branches of the aorta *For this reason, patients should be followed with serial chest x-rays.*

Answer 245

Ulcerative colitis (UC) ## Footnote *These are all extraintestinal manifestations of UC. Severe complications include toxic megacolon and colon cancer. Routine surveillance with yearly colonoscopies is recommended for patients with UC beginning 8-10 years after diagnosis for prevention and/or early detection of colon cancer.*

Answer 246

Peptic stricture ## Footnote *Asymmetric narrowing of the esophageal lumen would be more concerning for adenocarcinoma.*

Answer 247

Low-dose prednisone

Answer 248

Lactose intolerance ## Footnote *Currently, the lactose hydrogen breath test has largely replaced the lactose tolerance test. Lactase is a brush border enzyme that hydrolyzes lactose. Its concentration declines steadily as one ages into adulthood, especially in people of non-European ancestry. Lactose intolerance is most commonly seen in Asian-Americans (90%). Patients typically manifest with osmotic diarrhea, abdominal cramps, bloating and flatulence after ingestion of milk products. The stool pH is acidic in lactase deficiency due to the fermentation products.*

Answer 249

Establish vascular access with two large bore intravenous needles or a central line.

Answer 250

Multiple Endocrine Neoplasia (MEN) type I ## Footnote *Parathyroid adenoma (\>90%), pituitary tumors (10-20%), enteropancreatic tumors (60-70%).*

Answer 251

**Carotid endarterectomy** (CEA) ***Carotid angioplasty with stenting** (CAS) is an alternative for patients with high surgical risk, poor 5-year predicted survival, or a lesion not amenable to surgery.* ***ASA + Statin** is the indicated therapy in patients with lesions less than 50%*

Answer 252

Transesophageal echocardiography *The sensitivity and specificity of the MRI, CT, and transesophageal echocardiography in diagnosing aortic dissection exceeds 90%. The transesophageal echocardiography is usually preferred to an MRI because the latter is time-consuming*.

Answer 253

Hydatid cyst ## Footnote *Hydatid cysts are caused by Echinococcus granulosus/ Humans contract the infection from the close and intimate contacts with dogs, which are the definitive host in the life cycle of E. Granulosis. it can cause a unilocular cystic lesion in any organs including liver, lung, muscle, and bones.*

Answer 254

A combination of cyclophosphamide and steroids

Answer 255

Folic acid deficiency ## Footnote *Folic acid is heat sensitive, so cooked foods are typically lacking. In the setting of dietary deficiency, folic acid stores can become depleted within 4-5 months, leading to decreased red blood cell production and macrocytic anemia.*

Answer 256

Glucagonoma

Answer 257

Calcium gluconate ## Footnote *The patient should immediately be given intravenous calcium gluconate, which acts within minutes to antagonize the effects of hyperkalemia on the cell membranes of the heart. The effects of calcium gluconate are short-lived and further treatment with agents such as insulin and/or sodium polystyrene sulfonate will eventually be necessary as well to reduce the serum concentration of potassium.*

Answer 258

Muscle injury ## Footnote *CPK levels should be checked in any patient on a statin who presents with myalgias. If highly elevated, the first step is to discontinue the statin. Muscle injury due to statins can progress to rhabdomyolysis with renal failure*

Answer 259

Intravenous atropine * Atropine provides an immediate increase in the heart rate by decreasing vagal input.* * Transcutaneous pacing is the next step after atropine, as it provides a sustained increase in heart rate. At that point, the identification and reversal of the underlying etiology of the sinus bradycardia is essential. Permanent pacemakers may be required in those individuals with chronic symptomatic sinus bradycardia*

Answer 260

1. Stool studies 2. Oral metronidazole ## Footnote *Severe colitis usually requires oral vancomycin with or without IV metronidazole or a possible switch to intracolonic vancomycin.*

Answer 261

Intravenous Amiodarone is usually preferred over other antiarrhythmics

Answer 262

Bare metal stent: 30 days Drug eluting stent: 1 year *This has been shown to help prevent subacute stent thrombosis.*

Answer 263

Calcium channel blockers (i.e. Nimodipine)

Answer 264

Hepatitis A and Hepatitis B ## Footnote *Vaccinations should be administered unless the patient is already immune.*

Answer 265

High-dose penicillin for 6-12 weeks

Answer 266

Ultrasound or computed tomography (CT) to search for any underlying pathologies or complications.

Answer 267

Minimal change disease (lymphocyte dysregulation and cytokine production may play a role)

Answer 268

Hypertrophic cardiomyopathy

Answer 269

Posterior or anterior anal verge

Answer 270

Paroxysmal supraventricular tachycardias (PSVTs) * The mechanism of PSVT is often due to formation of a supraventricular re-entry circuit, most commonly within the AV node (AVNRT). AVNRT results from a reentrant circuit formed by two separate conducting pathways (one fast and the other slow) within the AV node* * Another common cause of PSVT is atrioventricular reentry tachycardia (AVRT). Here, it is caused by a bypass tract separate from the normal conduction system that connects the atria and ventricular tissue. The most common example of AVRT is Wolff-Parkinson-White (WPW) pre-excitation syndrome, which predisposes to PSVTs since the accessory pathway (eg, bundle of Kent) provides a potential limb for reentrant loop formation.*

Answer 271

Viral gastroenteritis usually results in vomiting in addition to diarrhea

Answer 272

Increase dietary fiber intake ## Footnote *Bowel rest and antibiotics are administered to patients with uncomplicated diverticulitis. Diverticulosis is differentiated from diverticulitis by the absence of fever, leukocytosis, or other signs of peritoneal inflammation.*

Answer 273

Inflammatory Bowel Disease (IBD) ## Footnote *In patients with IBD and worsening symptoms accompanied by signs of sepsis, toxic megacolon should be considered and an abdominal radiograph ordered to confirm the diagnosis.*

Answer 274

Septic shock

Answer 275

Non-contrast head CT, which is critical for guiding further management

Answer 276

Hyponatremia indicates severe CHF *Water retention and the associated reduction in the plasma sodium concentration parallel the severity of the heart disease; they reflect the degree of neurohumoral activation in patients with heart failure. Low serum sodium level is associated with high levels of renin, aldosterones, vasopressin, and norepinephrine. As a result, a patient's survival is significantly reduced if the serum sodium level is below 137mg/dL.*

Answer 277

Unrecognized bowel ischemia *This would be particularly likely in a patient with acute abdominal pain and nausea accompanied by hypoactive bowel sounds and abdominal tenderness on physical exam.*

Answer 278

Tricyclic antidepressants (TCA) *TCAs can worsen urinary symptoms and orthostatic hypotension. Gabapentin is an alternative for these patients. NSAIDs can also be used but are contraindicated in patients with renal dysfunction.*

Answer 279

Expeditious pacemaker placement *This is because the rhythm can degenerate into ventricular tachycardia or ventricular fibrillation*

Answer 280

Metronidazole ## Footnote *This is for suspected giardiasis. If the patient had instead travelled to a different location (like the Rocky Mountains) the answer is the same: Giardiasis*

Answer 281

Hemodynamic support Octreotide Endoscopic therapy Prophylactic antibiotics

Answer 282

Whipple's disease ## Footnote *This is a rare, multi-systemic illness that is caused by the bacillus Tropheryma whippelii. It is most commonly seen in white men in the fourth-to-sixth decades of life, and often presents with weight loss.*

Answer 283

Achalasia ## Footnote *Achalasia is an idiopathic esophageal motility disorder that causes loss of peristalsis in the distal esophagus and prevents lower esophageal sphincter (LES) relaxation during swallowing. Barium swallow usually shows a dilated esophagus with distal narrowing, and manometry shows lower esophageal sphincter abnormalities. Esophageal malignancy at the esophageal-gastric junction can mimic achalasia and should be excluded with endoscopy before starting treatment for achalasia.*

Answer 284

1. Hydration 2. Alkalinization of urine 3. Low-purine diet ## Footnote *Since uric acid stones are highly soluble in alkaline urine, alkalinization of the urine to pH \>6.5 with oral potassium bicarbonate or potassium citrate is indicated.*

Answer 285

Increased capillary permeability

Answer 286

1. Pleural effusion 2. Acute respiratory distress syndrome 3. Ileus 4. Renal Failure ## Footnote *These complications are often due to activated pancreatic enzyme (I.E. Phospholipase, trypsin) and cytokines (I.E. tumor necrosis factor) that are released from the inflamed pancreas into the circulation and cause inflammation in other parts of the body.*

Answer 287

Abdominal radiograph ## Footnote *The presentation is suggestive of toxic megacolon. An abdominal X-ray should be ordered to confirm this diagnosis.*

Answer 288

Sustained hand grip leads to an increase in systemic vascular resistance and increased afterload

Answer 289

Arteriovenous fistula (AVF) *Shunting of a large amount of blood through the fistula decreases systemic vascular resistance, increases cardiac preload, and increases cardiac output.*

Answer 290

Cardiomyopathy ## Footnote *Selenium deficiency, like zinc deficiency, may result from chronic total parenteral nutrition.*

Answer 291

1. Radioopaque 2. Radiolucent

Answer 292

1. Polyarthralgia 2. tenosynovitis (pain along tendon sheaths) 3. Painless vesicopustular skin lesions

Answer 293

Ulcerative colitis

Answer 294

Immediate DC cardioversion *DC cardioversion has a higher success rate than Amiodarone and Quinidine and is less likely to induce an arrhythmia. The success of cardioversion in a patient with recent-onset a-fib is approximately 90%.*

Answer 295

Gastrointestinal blood loss ## Footnote *The next step in evaluation would be a colonoscopy. A single negative occult blood test does not exclude the possibility of gastrointestinal bleeding.*

Answer 296

Alport's syndrome ## Footnote *This is a familial disorder which usually presents in childhood as recurrent gross hematuria and proteinuria. Sensorineural deafness usually occurs. Electron microscopy findings include alternating areas of thinned and thickened capillary loops with splitting of the glomerular basement membrane (GBM).*

Answer 297

1. IV fluids, antibiotics, and bowel rest 2. IV corticosteroids are the drugs of choice for IBD-induced toxic megacolon 3. Emergency surgery (subtotal colectomy with end-ileostomy is the procedure of choice) may be required if the colitis does not resolve

Answer 298

Dysfunction of the labyrinth, as in benign paroxysmal positional vertigo (BPPV) 30% of BPPV cases occur after head trauma but typically no precipitating causes are found.

Answer 299

Complete surgical removal ## Footnote *It can result in a permanent cure if it is possible to remove the tumor entirely. The mainstay of treatment for advanced carcinoid tumors that cannot be removed surgically is octreotide injection.*

Answer 300

Focused Assessment with Sonography for Trauma (FAST) examination ## Footnote *This assessment is done to rapidly detect the presence of intra-abdominal organ injury or hemoperitoneum. A positive test would be followed by an exploratory laparotomy. An inconclusive test would be followed by a diagnostic peritoneal lavage. A negative test in the absence of signs of extra-abdominal hemorrhage would be followed by a CT of the abdomen after the patient was hemodynamically stable.*

Answer 301

1. Transesophageal echocardiography 2. CT chest with contrast

Answer 302

Esophageal dysmotility ## Footnote *This is associated with scleroderma.*

Answer 303

Thyroid lymphoma

Answer 304

Inferior wall MI

Answer 305

1. Propylthiouracil (PTU) 2. Methimazole (MMI) *Aproximately 30-40% of patients treated with antithyroid drugs for 1 year go into permanent remission*

Answer 306

MRI of the spine *Bone scan has similar sensitivity to MRI in the diagnosis of vertebral osteomyelitis but it has inferior specificity*

Answer 307

1. Alpha 1-blockers (doxazosin or tamsulosin are usually preferred) 2. 5-alpha reductase inhibitors (Finasteride) ## Footnote *Alpha 1-blockers alone or in combination with 5-alpha reductase inhibitors are first-line for symptomatic relief. Surgery may be required for patients with severe symptoms (I.E. bladder outlet obstruction or recurrent urinary tract infections) or failing medical therapy.*

Answer 308

Membranous glomerulonephritis (often seen in patients with carcinomas of the lung, stomach, breast, and colon)

Answer 309

TPN causes gallbladder stasis and predisposes to gallstone formation and bile sludging

Answer 310

Acute aortic dissection

Answer 311

1. Development of hemodynamic instability 2. Failure to improve after initial conservative measures 3. Development of signs of strangulation ## Footnote *Most small bowel obstruction patients can be managed initially with conservative measures, including complete bowel rest, decompression with nasogastric tube placement, pain control, fluid resuscitation, and correction of metabolic derangements. Patients who do not improve with conservative measures and/or develop symptoms or signs of strangulation should be referred for urgent surgical intervention.*

Answer 312

pH and PaCO₂ ## Footnote *The HCO₃^- can be calculated from these values using the Henderson-Hasselbach equation. The PO2 gives information about a patient's oxygenation status. The urinary pH can give information about renal handling of acids and bases, but it can not be used to determine a patient's serum acid-base status with the same clarity that pH, HCO₃^- and PaCO₂ can.*

Answer 313

Propranolol

Answer 314

Vagal maneuvers and medications that decrease conduction through the AV node

Answer 315

5% permethrin cream which is applied from the neck down and left overnight. Repeat in 14 days if live mites are still present. *Low-potency steroids can be added to treat the dermatitis*

Answer 316

Calcium ## Footnote *It has an unclear underlying mechanism but is likely due to increased osteoclastic bone resorption. The risk is increased in patients with pre-existing high bone turnover (I.E. younger individuals or older individuals with Paget's disease). Hypercalcemia occurs within days of immobilization of these individuals.*

Answer 317

1. Constipation 2. Fatigue 3. Excessive urination

Answer 318

Uninterrupted cardiopulmonary resuscitation along with vasopressor therapy to maintain adequate cerebral and coronary perfusion *Potentially reversible causes of PEA should also be investigated. Defibrillation or synchronized cardioversion has no role in the management of these patients*

Answer 319

Autosomal dominant

Answer 320

Prazosin and Trazodone

Answer 321

No additional therapy is indicated ## Footnote *These patients are at low risk of systemic embolization (CHADS2 score of 0).*

Answer 322

1. Nausea 2. Vomiting 3. Abdominal pain 4. Diarrhea 5. Restlessness 6. Arthralgias 7. Myalgias

Answer 323

Anoscopy/proctoscopy ## Footnote *Office based anoscopy/proctoscopy are simple maneuvers that have a high yield and do not require bowel preparation. Anoscopy has higher sensitivity for diagnosing hemorrhoids than flexible endoscopy.*

Answer 324

Cyclosporine ## Footnote *Cyclosporine is a commonly used immunosuppressant. It acts by inhibiting the transcription of interleukin-2 and several other cytokines, mainly the T-helper lymphocytes. Tacrolimus has similar toxicities, except for hirsutism and gum hypertrophy.*

Answer 325

Impairment of daily functioning

Answer 326

Cardiac Tamponade

Answer 327

This is called Pulsus paradoxus and is most commonly seen in cardiac tamponade but can also be seen in asthma and COPD ## Footnote * Cardiac tamponade: During inspiration, increased systemic venous return to the right heart causes the interventricular septum to shift into the left ventricular cavity, reducing left ventricular end diastolic volume. This leads to decreased stroke volume and reduced systolic BP* * Asthma/COPD: Normally, there is a small variation in intrathoracic pressure with respiration, which drops 2-5mmHg below atmospheric pressure during inspiration. In patients with COPD/asthma, the drop in intrathoracic pressure upon inspiration is exaggerated up to 40mmHg. This negative pressure causes pooling of blood in the pulmonary vasculature, decreasing left ventricular preload.*

Answer 328

Diffuse esophageal spasm

Answer 329

Surgical resection under the cover of albendazole.

Answer 330

Symmetrical distal polyneuropathy

Answer 331

It decreases venous return and thus decreases preload *Standing from a crouched position has the same effect*

Answer 332

Upper endoscopy

Answer 333

Surgical embolectomy or intra-arterial fibrinolysis/mechanical embolectomy via interventional radiology *While intravenous infusion of a fibrinolytic agent is an option for STEMI patients, patients with acute limb ischemia typically are treated with direct intra-arterial, not intravenous, administration of a fibrinolytic agent on the clot using an angiographic catheter*

Answer 334

Neurocardiogenic (vasovagal) syncope.

Answer 335

MEN type 2B ## Footnote *MEN 2B patients can develop medullary thyroid cancer, pheochromocytoma, marfanoid habitus, and intestinal or mucosal neuromas.*

Answer 336

Beta-blocker *Type-A dissections involve the ascending aorta and are treated with medical therapy and surgery. Type-B dissections involve only the descending aorta and are usually treated with medical therapy alone.*

Answer 337

Left ventricular aneurysm *Papillary muscle rupture causes mitral regurg following an MI but this occurs 2-7 days post MI and is not associated with persistent ST-segment elevation on ECG*.

Answer 338

Aldosterone secretion is relatively preserved in such patients because ACTH has a very modest effect on its secretion. ## Footnote *Glucocoritcoids suppress corticotropin-releasing hormone (CRH) secretion from the hypothalamus and also block the action of CRH on the anterior pituitary to release ACTH. ACTH acts on the adrenal cortex and is responsible for the secretion of cortisol and androgen from the zona fasciculata and zona reticularis, respectively. ACTH has a very mosdest stimulatory effect on aldosterone secretion from the zona glomerulosa of the adrenal cortex. Due to the differential effect of ACTH on the adrenal cortex, aldosterone levels are relatively normal with deficiency of ACTH in central adrenal insufficiency.*

Answer 339

Dark granular pigment of hepatocytes in Dubin-Johnson syndrome ## Footnote *Dubin-Johnson and Rotor syndrome are two familial disorders of hepatic bile secretion that results in conjugated hyperbilirubinemia. A dark granular pigment is present in the hepatocytes of patients with Dubin-Johnson syndrome, but is not seen in association with Rotor syndrome.*

Answer 340

Amyloidosis *In amyloidosis, extracellular deposition of excess proteins results in organ dysfuction. Deposition of amyloid fibrils in the kidney can result in proteinuria. Binding of amyloid fibrils to the liver can inhibit the synthesis of coagulation factors, resulting in increased bruisability. In the heart, amyloid deposition leads to restrictive cardiomyopathy with thickened ventricular walls and diastolic dysfunction. Systolic function is relatively well preserved, and ventricular dimensions remain unchanged.*

Answer 341

Removal of patient's clothes (which may be contaminated with pesticides) and washing of the skin to prevent further transcutaneous absorption.

Answer 342

1. Nausea 2. Vomiting 3. Decreased appetite 4. Confusion 5. Weakness 6. Visual symptoms such as scomata, blurry vision with changes in color, or even blindness

Answer 343

ACE inhibitors *Angioedema caused by ACE inhibitors can occur anytime during treatment, not just within the first few weeks of starting the medication*

Answer 344

Zenker's diverticulum ## Footnote *A contrast esophagram is the test of choice for confirming the diagnosis. Treatment is generally surgical.*

Answer 345

Octreotide injection ## Footnote *In many cases, this anti-hormone drug inhibits and sometimes reverses the growth of the tumors.*

Answer 346

Mesenteric ischemia

Answer 347

Celiac disease ## Footnote *IgA anti-endomysial and anti-tissue transglutaminase antibodies are highly predictive of celiac disease but may be absent if there is concurrent selective IgA deficiency (which is common in celiac disease).*

Answer 348

Oropharyngeal thrush

Answer 349

Mixed essential cryoglobulinemia ## Footnote *Most patients also have hepatitis C*

Answer 350

Gastrointestinal system ## Footnote *This includes anorexia, nausea, and vomiting.*

Answer 351

Hypoxemia-induced increases in erythropoietin production ## Footnote *Treatment of OSA causes the polycythemia to improve.*

Answer 352

Plasmapheresis ## Footnote *Goodpasture's syndrome is caused by circulating anti-glomerular basement membrane antibodies. Early removal of these antibodies by emergency plasmapheresis is imperative in order to minimize the extent of kidney damage. Emergency plasmapheresis improves the prognosis of patients.*

Answer 353

Colonoscopy ## Footnote *Routine surveillance with yearly colonoscopies is recommended for patients with UC beginning 8-10 years after diagnosis for prevention and/or early detection of colon cancer.*

Answer 354

Malignant hypertension

Answer 355

Polycythemia vera ## Footnote *In polycythemia vera, the concentrations of all blood cell lines are increased.*

Answer 356

Replace catheter ## Footnote *Empiric antifungal agents are generally unnecessary.*

Answer 357

Renal artery stenosis

Answer 358

Calcium channel blockers and/or nitrates *They prevent coronary vasospasm*

Answer 359

Atrial and ventricular arrhythmias *Potential side effects include nausea, drug-induced lupus, agranulocytosis, and _QT prolongation._*

Answer 360

Bacterial cystitis ## Footnote *Mucopurulent cervical discharge is not found. Urine culture shows colonies in excess of 1000/mL.*

Answer 361

Pancreatic or biliary cancer ## Footnote *Likely etiologies include pancreatic adenocarcinoma or cholangiocarcinoma. The next step in evaluation would be abdominal imaging (ultrasound or Computed tomography), with consideration for endoscopic retrograde cholangiopancreatography (ERCP) if initial imaging is nondiagnostic.*

Answer 362

Radiation therapy ## Footnote *Etidronate disodium and other bisphosphonates may be useful in patients with bony metastasis as it reduces bone resorption. It is useful in controlling chronic pain from bony metastasis, but its onset of action in alleviating acute bone pain is not as rapid as radiation therapy.*

Answer 363

Elapsed time to effective resuscitation *This includes effective CPR, prompt rhythm analysis, and early defibrillation for patients found to be in ventricular fibrillation. Ventricular fibrillation almost never terminates spontaneously and early rhythm analysis and defibrillation are the only effective means to reestablish perfusing cardiac rhythm and improve patient survival*

Answer 364

Gastroesophageal reflux (GERD)

Answer 365

Defibrillation *Time to defibrillation is strongly correlated with survival*

Answer 366

Vasospasm with symptomatic ischemia/infarction

Answer 367

Phlebotomy

Answer 368

Aortic stenosis

Answer 369

1. Salt restriction and diuretics 2. Transjugular intrahepatic portosystemic shunt (TIPS) for refractory disease ## Footnote *Hepatic hydrothorax is a cause of transudative pleural effusions in patients with cirrhosis who have no underlying cardiac or pulmonary disease to account for development of such an effusion. Hepatic hydrothorax usually results in a right-sided pleural effusion. Initial treatment is usually with salt restriction and diuretics. TIPS placement is considered in patients with refractory hepatic hydrothorax.*

Answer 370

Hypokalemia

Answer 371

Amyloidosis ## Footnote *A history of rheumatoid arthritis, enlarged kidneys, and hepatomegaly should raise suspicion for amyloidosis. The typical findings on renal biopsy in such a patient are amyloid deposits that show apple-green birefringence under polarized light after staining with Congo red. Extracellular amyloid fibrils demonstrated on electron microscopy are also typical.*

Answer 372

IgA nephropathy

Answer 373

They are cation-exchange resins that act in the GI tract by promoting the exchange of Na for K, and thereby increasing the ecretion of K+

Answer 374

HLA-B27-associated arthropathies and is particularly prominent in ankylosing spondylitis where it often manifests with heel pain due to tenderness at the insertion of the achilles tendon.

Answer 375

1. Analgesics 2. Intravenous fluids 3. Nothing by mouth ## Footnote *Acute pancreatitis is one of numerous conditions that cause an acute abdomen. It is managed conservatively, as most attacks are self-limiting and subside in 4-7 days with conservative treatment. This treatment regimen should include analgesics for pain (with meperidine or fentanyl favored over morphine), intravenous fluids to maintain intravascular volume, and no oral alimentation as a means of avoiding further pancreatic inflammation.*

Answer 376

Falsely prolonged PTT

Answer 377

Chelation of calcium by citrate ## Footnote *Citrate is a substance that is added to stored blood. It chelates calcium and magnesium and may reduce their plasma levels, causing paresthesias*

Answer 378

_Symptoms_ 1. Progressive dyspnea on exertion 2. Orthopnea 3. Hemoptysis _Signs_ 1. Left atrial enlargement 2. Elevation of left main bronchus on CXR (secondary to left atrial enlargement) 3. Persistent cough/hoarse voice (secondary to left atrial enlargement compressing recurrent laryngeal nerve) 4. Loud 1st heart sound 5. Opening snap after S2 best heard at apex 6. Low-pitched diastolic rumble best heard at apex

Answer 379

Diffuse esophageal spasm *Since the spasms occur in episodes, positive manometric findings may be intermittent, thus making diagnosis difficult.* *The esophagogram is frequently normal, although the classic corkscrew esophagus is seen occasionally.*

Answer 380

Posteroseptal MIs due to solitary blood supply of the posterior medial papillary muscle *Though less common, it can occur with anterolateral MIs as well*

Answer 381

The right coronary artery via the AV nodal artery ## Footnote *RCA occlusion can cause AV block and inferior MI. Thus, Inferior MI is most commonly associated with sinus bradycardia due to increased vagal tone in the first 24 hours after infarction and decreased RCA blood supply to the sinoatrial node*

Answer 382

Hypocalcemia

Answer 383

Atrial arrhythmias *It can cause nausea, anorexia, AV block, and ventricular and supraventricular arrhythmias.*

Answer 384

Hepatorenal syndrome (HRS) ## Footnote *This is one of the most dangerous complications of end-stage liver disease, occurring in up to 10% of patients with cirrhosis. It is thought to result from renal vasoconstriction in response to decreased total renal blood flow and vasodilatory substance synthesis. There are 2 subtypes of HRS. Type 1 is rapidly progressive; most patients die within 10 weeks without treatment. Type 2 progresses more slowly, with an average survival of 3-6 months. The most common causes of death are infection and hemorrhage. Unfortunately, no medication has consistently proven beneficial in HRS and the mortality for these patients placed on dialysis is very high. Liver transplantation is the only intervention with estalished benefit.*

Answer 385

Sodium Bicarb reverses the prolongation of the QRS interval by increasing the extracellular sodium concentration

Answer 386

Hepatitis B vaccine ## Footnote *Patients with risk factors for hepatitis B virus should be vaccinated, which is especially important in patients already infected with hepatitis C virus who are continuing their high-risk behaviors.*

Answer 387

Diabetes Insipidus *The normal reaction to plasma hyperosmolality is the production of maximally concentrated urine. This is seen in psychogenic polydipsia*

Answer 388

Age-dependent idiopathic sclerocalcific changes *These changes are common and usually have minimal hemodynamic significance, but sometimes may be severe.*

Answer 389

Observation with repeat chemistry panel after 2 hours ## Footnote *Post-ictal lactic acidosis is transient and typically resolves within 60-90 minutes. Repeat chemistry is done to see if the acidosis has resolved on its own. If it has not resolved, it is best to look for other potential causes of metabolic acidosis.*

Answer 390

Toxic megacolon *An abdominal radiograph should be ordered to confirm the diagnosis. The most widely used criteria to clinically diagnose toxic megacolon includes radiographic evidence of colonic distension* *_plus at least three of the following_:* 1. *Fever \>38C* 2. *Heart rate \> 120 beats/minute* 3. *Neutrophilic leukocytosis \> 10,500/mL* 4. *Anemia* *_Plus at least one of the following_:* 1. *Volume depletion* 2. *Altered sensorium* 3. *Electrolyte disturbances* 4. *Hypotension*

Answer 391

Maneuvers to increase vagal tone followed by adenosine and AV nodal blockers

Answer 392

Spontaneous bacterial peritonitis ## Footnote *Paracentesis is the test of choice, with a positive ascites fluid culture and polymorphonuclear leukocyte level \> 250/mm³ being the main criteria for making the diagnosis.*

Answer 393

Brain abscess secondary to maxillary sinusitis. Anaerobic streptococci (60-70%) and Bacteriodes species (20-40%) are the organisms most commonly responsible.

Answer 394

An Echo *This is necessary to rule out a thrombus in the left ventricle*

Answer 395

Cricopharyngeal muscle ## Footnote *Motor dysfunction and incoordination are responsible for the problem.*

Answer 396

Anterior MI

Answer 397

Proteus species

Answer 398

Nonselective beta blockers (I.E. Propranolol, nadolol) ## Footnote *Prophylactic treatment with nonselective beta blockers is recommended to reduce the likelihood of progression to large varices and the risk of variceal hemorrhage. The mechanism involves decreased adrenergic tone in mesenteric arterioles that results in unopposed alpha-mediated vasoconstriction and decreased portal venous flow. Endoscopic variceal ligation can be used as an alternate primary preventive therapy in patients with contraindications to beta blocker therapy.*

Answer 399

Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) ## Footnote *TTP-HUS is fatal in 80% of cases if appropriate therapy is not promptly instituted, so a high degree of clinical suspicion is necessary. Plasmapheresis (plasma exchange) is the treatment of choice and should be started as soon as possible. Plasmapheresis removes the offending autoantibodies and repletes the deficienct enzyme.*

Answer 400

It increases due to reduced diffusing capacity and V/Q mismatch. *In restrictive lung diseases, the total lung capacity, functional residual capacity, and residual volume are all reduced. Flow volumes are also reduced but the ratio of FEV1/FVC is either normal or increased*

Answer 401

Intravenous adenosine

Answer 402

Cardioversion or antiarrhythmics like procainamide *AV nodal blockers like beta-blockers, calcium channel blockers, digoxin, and adenosine should be avoided because they can cause increased conductance through the accessory pathway*

Answer 403

Folic acid deficiency ## Footnote *In SCD, folate deficiency can occur due to increased red blood cell turnover and increased consumption of folate in the bone marrow. Daily folic acid supplementation is recommended in all SCD patients to correct the underlying folate deficiency.*

Answer 404

Anticoagulation (warfarin or novel agents) or antiplatelet therapy (aspirin). Anticoagulation is preferred.

Answer 405

1. Decreased dietary protein and oxalate 2. Decreased sodium intake 3. Increased fluid intake 4. Increased dietary calcium

Answer 406

**IV fluid resuscitation** to increase the RV stroke volume and enhance left ventricular filling. **Nitrates are contraindicated**

Answer 407

Hypercalcemia ## Footnote *Symptoms are more likely to occur when serum calcium \>12mg/dL.*

Answer 408

Chlamydia and Gonococcus

Answer 409

NSAIDs *Anticoagulation should be avoided to prevent the development of a hemorrhagic pericardial effusion*

Answer 410

Hypovolemic shock

Answer 411

Ethylene glycol poisoning

Answer 412

Beta-blockers (works by promoting diastolic relaxation) *A cardiac acting calcium channel blocker such as diltiazem can be used in patients that cannot tolerate a beta-blocker*.

Answer 413

Fasting serum gastrin levels ## Footnote *A serum gastrin value \> 1000pg/mL is diagnostic of the disorder. In addition, measurement of gastric pH levels on a single specimen is important to exclude the possibility of secondary hypergastrinemia due to achlorhydria. Patients with non-diagnostic fasting serum gastrin levels should have a secretin stimulation test done.*

Answer 414

Echocardiogram

Answer 415

The brainstem

Answer 416

Angiodysplasia (arteriovenous malformation) of the gastrointestinal tract ## Footnote *They are usually seen in patients age \>60 years and can occur throughout the gastrointestinal tract including colon, small intestine, and stomach.*

Answer 417

Coxsackievirus B

Answer 418

Surgical treatment including excision, and frequently cricopharyngeal myotomy

Answer 419

1. Hyperkalemic patients should recieve IV fluids and insulin, and once potassium levels drop below 4.5mEq/L, they should start recieving K⁺ too 2. Normo or hypokalemic patients should recieve K+ right away with IV fluids and insulin *(Remember that hyperkalemic, normokalemic, and hypokalemic patients all have reduced total body potassium due to extracellular shift and subsequent gastrointestinal loss)*

Answer 420

Atrial tacchycardia with AV block *Since it is rare for ectopy and AV block to occur simultaneously, when they do, the combination is fairly specific for digitalis toxicity*

Answer 421

X-linked recessive ## Footnote *More common in African-American men.*

Answer 422

SAAG _\>_ 1.1 g/dL *The SAAG is used to distinguish between portal hypertension and other causes of ascites. The SAAG is calculated by subtracting the ascites albumen concentration from the serum albumin concentration.* *A difference of 1.1 g/dl or greater is 95% accurate in diagnosing a transudative process consistent with portal hypertension.*

Answer 423

1. Acyclovir 2. Valacyclovir 3. Famciclovir

Answer 424

\>5 mm within 48-72 hours of intradermal injection of 5 tuberculin units

Answer 425

High protein diet ## Footnote *This is associated with mainly calcium stones.*

Answer 426

Increased BUN/creatinine ratio ## Footnote *This occurs due to the breakdown of hemoglobin in the gastrointestinal tract with resultant urea absorption. Systemic steroids can also increase the BUN/creatinine ratio.*

Answer 427

Retroperitoneal hematoma

Answer 428

Collapsing focal and segmental glomerulosclerosis ## Footnote *Another name for this disease is HIV-related nephropathy. Typical presentation of focal segmental glomerulosclerosis includes nephrotic range proteinuria, azotemia, and normal sized kidneys. It is interesting to note that focal segmental glomerulosclerosis can be manifested even if all the markers of HIV (CD4 count, viral load) are normal. For an unknown reason, the disease is more prevalent among blacks than among other ethnic groups.*

Answer 429

Fever, rash, arthralgias, peripheral eosinophilia, hematuria, sterile pyuria and eosinophiluria, WBC casts in urine but rarely RBC casts.

Answer 430

Congestive heart failure *Elevated BNP levels and an audible S3 are both signs of increased cardiac filling pressures.*

Answer 431

1. Leg elevation 2. Compression stockings 3. Intermittent pneumatic compression dressings

Answer 432

Two-sample t-test

Answer 433

Duodenal ulcer

Answer 434

Alcohol hepatitis ## Footnote *Fatty liver (steatosis), alcoholic hepatitis, and early fibrosis of the liver can be reversible with the cessation of alcohol intake. True cirrhosis (with regenerative nodules) is irreversible, regardless of alcohol abstinence.*

Answer 435

Multiple Endocrine Neoplasia (MEN) type 2A ## Footnote *Medullary thyroid cancer (\>90%), Pheochromocytoma (40-50%), Parathyroid hyperplasia (10-20%).*

Answer 436

Acute bacterial cholangitis

Answer 437

1. Copper chelators like d-penicillamine or trientine 2. Oral Zinc ## Footnote *Treatment must be adhered to for the patient's lifetime and focuses on removing accumulated copper in the tissues and preventing re-accumulation. First line medications include copper chelators. Oral zinc is also recommended as it prevents copper absorption. Liver transplantation may be the only option for those with fulminant hepatic failure or decompensated liver disease that does not respond to pharmacotherapy.*

Answer 438

1. Acute onset 2. Lack of inflammatory markers 3. Resolution within two months

Answer 439

Uric acid stones ## Footnote *These are radiolucent stones, but they can be seen on ultrasound and computed tomography (CT) scans. Alkalinization of urine to pH \>6.5 with oral potassium bicarbonate or potassium citrate is the treatment of choice.*

Answer 440

Chronic lymphocytic leukemia

Answer 441

1. Hyponatremia 2. Hypokalemia 3. Hypercalcemia

Answer 442

Young female smokers *Chest pain usually occurs in the middle of the night, and episodes are associated with transient ST elevations on ECG*

Answer 443

Membranous glomerulonephritis

Answer 444

Isoniazid + Pyridioxine for 9 months (pyridoxine is to prevent neuropathy caused by Isoniazid)

Answer 445

Achalasia ## Footnote *Esophageal malignancy at the esophageal-gastric junction can mimic achalasia and should be excluded with endoscopy before starting treatment for achalasia.*

Answer 446

Zollinger-Ellison syndrome

Answer 447

CK-MB *It typically returns to normal levels within 1-2 days, whereas troponin T takes up to 10 days to return to normal after an MI, making elevations difficult to interpret in this sort of scenario.*

Answer 448

Hemodialysis

Answer 449

5 day course of Azithromycin

Answer 450

Membranoproliferative glomerulonephritis (MPGN) type 2 ## Footnote *Dense intramembranous deposits that stain for C3 is a characteristic microscopic finding for MPGN type 2 (also called dense deposit disease). This condition is unique among glomerulopathies, because it is caused by IgG antibodies (termed C3 nephritis factor) directed against C3 convertase of the alternative complement pathway. The antibodies reacting with C3 convertase lead to persistent complement activation and kidney damage. MPGN type I is the most common by far and is caused by immune complexes depositing in the kidney. MPGN type 3 is very rare, and is characterized by a mixture of subepithelial deposits and the typical pathological findings of type 1 disease.*

Answer 451

Anticholinergic drugs such as Benztropine

Answer 452

Septal hypertrophy and systolic anterior motion (SAM) of the mitral valve

Answer 453

Absent or decreased achilles tendon reflex can be a normal finding in elderly patients

Answer 454

Multiple endocrine neoplasia (MEN) type I ## Footnote *It is due to a single mutation of the MEN I tumor suppressor gene on chromosome 11. MEN I typically causes a predisposition to parathyroid, pituitary, and pancreatic tumors.*

Answer 455

Beta-blocker

Answer 456

1. They cause an increase in neutrophils by increasing the bone marrow release and mobilizing the marginated neutrophil pool 2. They cause a decrease in Eosinophils 3. They cause a decrease in lymphocytes

Answer 457

Crohn's Disease

Answer 458

Right coronary artery (80% of cases) *Left circumflex occlusion would be the cause in 20% of cases*

Internal Medicine: UWorld Flashcards

(486 cards)