Medicine 2 Flashcards
(200 cards)
1
Q
Vesicular ear rash and facial droop or facial pain with vesicular eruption. Dx?
A
Herpes zoster oticus (Ramsay Hunt syndrome).
2
Q
Isolated damage (often penetrating) to one eye that is followed by a delayed (often weeks) reaction of blurred vision and other visual symptoms (floating spots, perilimbal flush, etc.) in the other eye. Dx?
A
Sympathetic ophthalmia. Damage to opposing eye leads to uncovering of hidden antigens that result in immunologic rxn in other eye, often anterior uveitis.
3
Q
Erysipelas and cellulitis differ in what way physically?
A
Cellulitis is deep in dermis and subQ fat, thus it appears flat with indistinct borders. Erysipelas appears raised, highly demarcated and erthematous as it involves the epidermis and superficial dermis.
4
Q
Define Number Needed to Treat.
A
NNT = 1/ARR; The number of people receiving a medicine that need to receive an Rx to prevent 1 additional adverse event. e.g. The population taking ASA vs those not have 1 less per 100 people taking the drug, then the NNT is 100.
5
Q
When can Relative risk and odds ratio be a good approximation of one another?
A
In a population with a low incidence of the disease in question.
6
Q
Progressive cellulitis of the submandibular space arising from a dental infxn. Dx?
A
Ludwig angina. Patients may develop local compression with systemic sx also. Infxn often anaerobic with gas-producing bacteria sometimes leaving crepitus. Rx: IV clinda or ampicillin/sulbactam
7
Q
MEN 1, 2, and 3 (2B) associated conditions?
A
- PPP: primary hyperparathyroidism, pituitary tumors, pancreatic tumors (esp. gastrinomas)
- PPM: parathyroid hyperplasia, pheochromocytoma, medullary thyroid cancer
- PMMM: Pheochromocytoma, medullary thyroid cancer, mucosal neuromas, marfanoid
8
Q
What are the leading causes of euvolemic hypernatremia and euvolemic hyponatremia?
A
DI and SIADH respectively.
9
Q
What lab values are expected in a female with recurrent miscarriage and VDRL+ and FTA-ABS negative testing?
A
Antiphospholipid antibody syndrome commonly presents with recurrent abortus and VDRL positivity in the absence of syphilitic disease (confirmed by FTA-ABS). Thrombocytopenia and prolonged PTT are common findings.
10
Q
Rx for antiphospholipid syndrome while currently pregnant to avoid loss?
A
ASA and LMWH. Not warfarin.
11
Q
What are ABCDE criteria for melanoma?
A
Asymmetric Borders jagged Color variability Diameter ≥6mm Evolution Also look for "ugly duckling" sign
12
Q
What is an empyema and what is the management?
A
Exudative pleural effusion that go untreated lead to bacteria in the pleural space (pus in pleural space). Rx: drain pleura (thoracentesis) and antibiotics. Often repeated draining is required.
13
Q
How are empyema and lung abscess different?
A
Empyema is in pleura space. Absvess is a cavity with air fluid level on Xray. Abscess is often caused by aspiration.
14
Q
Define pH, glucose, and WBCs in parapneumonic effusions (empyema) that are complicated or uncomplicated. Rx for each?
A
pH U≥7.2; C<7.2
Glucose U≥60; C<60
WBC U≤50,000; C>50,000
Rx: U = antibiotics; C = antibiotics and drainage (aka empyema)
15
Q
Colon Ca screening for ulcerative colitis?
A
8 years after Dx begin screening and q 1-2 yrs after that colonoscopy.
16
Q
Pt has recurrent kidney stones from childhood and positive family Hx also. Stones are radioopaque and hexagonal on urinalysis. Cyanide nitroprusside test screen is positive. Dx?
A
Cystinuria. Impaired AA transport especially cystine, lysine, arginine, and ornithine by brush borders of renal tubular/intestinal epithelium. Cystine is poorly soluble.
17
Q
Pearly flesh or pink-colored nodule with telangiectatic vessels on head or neck. Dx?
A
Basal cell carcinoma. Most common in population unless Pt is immunosuppressed, then SCC. BCC commonly causes neural invasion leading to neurological symptoms.
18
Q
Enlarging nodule in sun-exposed areas that appears thick and roughened. Ulceration with crusting and bleeding also present. Dx?
A
Squamous cell carcinoma. Most common in immunosuppressed, but less common in general pop. Tends to invade neurological tissue causing paresthesia, etc.
19
Q
Small cell cancer of lung commonly assoc. with which paraneoplastic syndromes?
A
ACTH (cushing) and SIADH
20
Q
Squamous cell cancer of lung commonly assc. with which paraneoplastic syndrome?
A
Parathyroid hormone-related protein release and hypercalcemia. Remember: sCa++mous cell cancer
21
Q
Antibody attachment in bullous vs vulgaris pemphigoid diseases?
A
B: Basement membrane
PV: Between epidermal keratinocytes (desmosomes - aka desmoglein 1 and 3)
22
Q
Under what level is Mycobacterium avium complex prophylaxis needed? What is prophylaxis?
A
CD4<50 and prophylaxis is Azithromycin
23
Q
Shingles pain onset time scale?
A
Pain may precede rash by several days during which physical exam would not reveal typical vesicular rash. However, pain would be in typical dermatomal distribution. .
24
Q
Abnormal ankle-brachial index?
A
Under 1. Suggestive of PAD. PAD and claudication have estimated 20% 5 year risk of nonfatal MI and stroke and 15-30% 5-year risk of death due to CV causes.
25
Rx for hepatic encephalopathy?
Lactulose or rifaximin
26
A 20-30s male with sudden onset thrombocytopenia and no other obvious Sx should be tested for what?
HIV and HepC. Thrombocytopenia may be initial presentation of HIV infxn.
27
What is cardiac index?
CI = CO/BSA; it is a measure of cardiac fxn and is reduced in CHF
28
How is Ca++ found the blood?
40-45% on albumin, 40-55% as free ions, and 5-15% bound to phosphate or other anions.
29
How does low albumin in the blood affect Ca++?
Hypoalbuminemia can reduce total blood calcium as albumin binds Ca++.
30
Corrected Ca++ based on serum albumin?
Corrected Ca++ = (measured Ca++) + 0.8*(4 - serum albumin); in other words, if albumin is higher or lower than 4, the corrected Ca++ is either lower or higher respectively.
31
Evaluation of hypercortisolism (Cushing syndrome) steps?
Two of following must be abnormal to establish Dx: Late-night salivary cortisol assay, 24-hour urine free cortisol measurement, and/or overnight low-dose dexamethasone suppression test. If hypercortisolism confirmed, ACTH levels measured to differentiate ACTH-dependent (Cushing disease, ectopic ACTH) from ACTH-independent (adrenal adenoma) causes.
32
What test differentiates CML from leukemoid rxn?
Leukocyte alkaline phosphatase score. In CML, the neutrophils are cytochemically and fxnly abnormal, so LAP score is low.
33
Most sensitive test for avascular necrosis of hip?
MRI, not Xray, though crescent sign on Xray is helpful in advanced disease.
34
Indications for primary and secondary preventive statin Rx?
Primary: Estimated 10-year risk of atherosclerotic CV disease (ASCVD) ≥7.5%
Secondary: Known ASCVD and LDL≥190 (suggestive of familial hypercholesterolemia)
35
Aside from antibiotics, what RFs are associated with C diff infxn?
Gastric acid suppression (omeprazole, etc.) alter microbiome.
Hospitalization.
Old age.
36
What is the null value of relative risk?
1.0. The outcome occurs with equal frequency in both groups studied and there is no association between the exposure and the outcome. If RR>1, then the outcome occurs more frequently in the exposed group. If RR<1, then the outcome occurs less in the exposed group. If a study has a 95% CI, then the RR must NOT be 1; it must not contain the null value. This means the p is under 0.05.
37
An obese Pt without COPD or any other pulmonary disease and chronic hypercapnia (>45) likely suffers from?
Obesity hypoventilation syndrome (aka Pickwickian Sx). BMI ≥30 and awake daytime hypercapnia (PaCO2>45) with no other possible cause likely has this.
38
Proper Rx for delerium un the elderly?
Haldol or atypical antipsychotics (quetiapine or risperidone). Benzos not typically used as they are not recommended.
39
Sclerotic, cortical lesion on Xray of bone with central nidus of lucency. Painful at night and unrelated to activity. NSAIDs relieve pain. Dx?
Osteoid osteoma.
40
Painful, swollen knee with decreased ROM. Osteolytic lesion present on Xray of distal epiphyseal region of long bone. Dx?
Giant cell tumor. Presents with painful Sx and soap-bubble appearance on Xray. Eipphyseal in appearance of long bones especially distal femur or proximal tibia at knee joint. Osteoclast giant cells appear as round-to-oval mononuclear cells on pathology. Surgery is Rx.
41
HA, confusion, amnesia, difficulty concentrating/multitasking, vertigo, mood issues, sleep problems, and anxiety after a brain injury are signs of?
Postconcussive syndrome. Usually resolve in weeks after TBI, but can last ≥6 months.
42
What effect does a CYP450 inhibitor have on Warfarin? Inducer?
Inhibitor: increases warfarin effect leading to bleeding
INducer: reduces warfarin effect leading to reduced efficacy (clotting)
43
A young Pt (20-30s) taking HCTZ for HTN develops hypokalemia on just a low dose of the drug requires what testing?
Plasma renin and aldosterone concentrations. Suspicion of hyperaldosteronism (and other 2° causes) should be raised when young age and hypertensive. The Pt here with hyperaldosteronism may not have spontaneous hypokalemia, but may develop it on a new diuretic for the first time.
44
Use of oral contraceptives in a female with breast cancer has a strong association with breast cancer, but not in those without a family Hx. What phenomenon is occurring here?
Effect modification. Only in a person with a family Hx of breast cancer do OCs increase breast cancer risk, yet in those without family Hx, the breast cancer risk would not be altered by OCs. This differs from a confounder in that the confounder, when removed, would show no change to the outcome of the disease.
45
Supplementation of what will reduce SE in methotrexate Rx?
Folic acid. MTX is an folate antimetabolite and the preferred initial DMARD in moderate to severe RA.
46
Best way by which Rx efficacy for DKA is monitored?
Serum anion gap and ß-hydroxybutyrate levels. Anion gap returns to normal with disappearance of ketoacid anions.
47
What test is used to evaluate proximal small intestinal absorption in Celiac's disease?
D-xylose test. Testing absorption of sugar at proximal small intestine by evaluating for high content in urine. If poor absorption in intestines, then poor output in urine. Malabsorption due to enzyme deficiencies (pancreatitis, etc.) will have normal D-xylose absorption.
48
Invasive fungal infxn most commonly seen in poorly controlled DM (esp. DKA)? Rx?
Mucormycosis. Rx: surgical debridement, antifungal meds (amphotericin B), treat DKA.
49
Tumor in pancreas leading to facial flushing, watery, often tea colored stool, and muscle weakness/cramping, with low chloride levels?
VIPoma. Similar Sx to carcinoid syndrome, but located in pancreas. VIPoma syndrome is characterized by the symptoms described due to a secretory diarrhea. Most Carcinoid tumors are located in the small intestine and do not involve the pancreas.
50
Management of diffuse esophageal spasm?
Calcium channel blockers, nitrates, or TCAs. Presents with "corkscrew" pattern on esophagram.
51
Dx tool in suspected DVT?
Compression US should be done in moderate or high probability DVT. Low Wells score requires D-dimer
52
Sx of dementia with falls and incontinence, but neurological deficits on one side (e.g. hemiparesis or weakness) are less likely due to normal-pressure hydrocephalus and more likely due to what?
Vascular dementia. Also presents as stepwise with events that are correlated with decreases in fxn.
53
HIV Pt with CD4<100 complains of difficulty swallowing and substernal burning. Dx?
Esophagitis. Candida (MCC), HSV, CMV, and aphthous (noninfectious esophagitis) are common. in HIV Pts with CD4<100.
54
MCC of contact lens-associated keratitis?
Pseudomonas and Serratua or other gram-negatives are the most common. Some Gram + organisms can cause issues also.
55
Small or low risk skin lesions suspicious of cancer require what? High risk/cosmetically sensitive?
Skin biopsy for low risk. High risk requires Mohs micrographic surgery.
56
What type of complications are prevented with intensive glycemic control of DM2?
Microvascular complications (e.g. nephropathy, retinopathy, neuropathy, etc.). Studies have not shown that macrovascular complications (e.g. MI, stroke, etc.) were prevented by glycemic control management.
57
What medication class can be given in significant anticholinergic overdose?
Cholinesterase inhibitors (-stigmine). Dry as a bone, blind as a bat, hot as a hare, full as a flask (urinary retention), red as a beet, mad as a hatter.
58
What microscopic qualities differentiate Crohn's from UC?
Crohn's has noncaseating granulomas, UC does not.
59
Initial management of IBDs?
5-aminosalicylic acids and steroids. Maintenance therapy may involve azathioprine or antitumor necrosis factors.
60
What is the cutoff CD4+ count for receiving live vaccines in HIV?
200. If CD4 is under 200, then start antiretroviral therapy and give vax after CD4 count rises above 200.
61
What is the mechanism behind reduction of angina from nitrates?
Decreased left ventricular wall stress 2° to reduced systemic preload from peripheral vasodilation and then reduced wall stress and reduced myocardial oxygen demand. This is all from the Law of LaPlace where wall stress is proportional to pressure*radius/thickness.
62
Young active female with numbness and pain between 3rd/4th toes with a clicking sensation when palpating or squeezing the foot joints. Dx?
Morton neuroma. Common in runners. Is not a true neuroma, but a neuropathic degeneration of the interdigital nerves that causes numbness, aching, and burnign in the distal forefoot.
63
A patient with good fasting glycemic control (good numbers in the morning before eating), but poor A1C likely have what?
Postprandial hyperglycemia. Rx focused on controlling glucose without causing fasting hypoglycemia. Long-acting basal insulin and rapid -acting mealtime insulin may be needed to control postprandial glucose elevations.
64
MC extraskeletal complication of ankylosing spondylitis?
Anterior uveitis.
65
Three forms of calcium in serum?
Ionized (45%)
Albumin bound (40%)
Anion bound (15%)
These fluctuate based on pH. Extracellular pH rise causes H+ to leave albumin and Ca++ to bind. to it resulting in low ionized Ca++ and symptoms thereof.
66
A patient with an absolute neutrophil count below 1500/uL and a fever must be worked up for?
Neutropenic fever. This is a sign of an underlying infection without the ability to fight it off due to neutropenia. Initial Rx should include Zosyn (piper and tazo) to cover pseudomonas.
67
Young female athlete with pain with activity particularly using the stairs with more severe pain on compression of the patella on the femur. Dx?
Patellofemoral syndrome. Often due to overuse or trauma, the patellofemoral compression test elicits pain in the knee. Xray and MRI are usually normal and are unnecessary, unless all other tests are equivocal or fails to improve.
68
A rash with occult + bloody diarrhea and liver dysfxn (LFTs elevated) after bone marrow (or any organ) transplant is due to?
Gravft-versus-host disease. Caused by donor T-cells recognizing HLA-antigens on the host that results in cell-mediated immune rxn. Skin, liver, and intestines are the most classically affected organ systems.
69
Prophylaxis for varices in newly discovered cirrhosis?
Nonselective beta blocker. Propanolol or nadalol are recommended to decrease progression of medium to large sized carices and reduce RF for hemorrhage. They decrease adrenergic tone in mesenteric arterioles which cause unopposed alpha vasoconstriction and decreased portal venous flow.
70
What is the metric for a "reversible" airway obstruction in Asthma?
>12% increase in FEV1. In COPD, there may be a partially reversible obstruction, but >12% change in FEV1 is only found in asthma and is evidence of fully reversible cause (aka Asthma). Diffusion capacity is unaffected or high in asthma and is either normal or low in COPD.
71
What common side effect appears due to Ca++ channel blockers that may mimic CHF or liver disease?
Edema. This occurs due to the inability to dilate peripheral blood vessels. If PE/labs/imaging are all normal and the patient has edema, consider this effect.
72
What is the most reliable and predictive sign of opioid intoxication?
Decreased respiratory rate in the presence of AMS, hypothermia, and miosis (can be misleading if coingestions...).
73
Classic presentation of AML?
Fatigue and >1 cytopenia of the myeloid cells (anything but T, B, NK, Plasma cells).
74
Imaging for diagnostic differentiation of acute diverticulitis from other abdominal causes of pain?
CT scan with oral or IV contrast.
75
An elderly patient with anemia and a negative guiac test requires what despite the negative test?
Colonoscopy and endoscopy. MCC of anemia in elderly is GI bleed.
76
What complications can result from heat stroke (AMS, hyperthermia >105°, tachycardia)?
Rhabdo
Renal failure
ARDS
Coagulopathic bleeding (nose bleed, bruising, etc.)
77
What Rx prolongs survival in COPDers with chronic hypoxemia (plethoric face, elevated Hct, clubbing, etc.)?
Long-term supplemental O2 therapy.
78
Lewy body dementia Sx?
Cognitive fluctuations
Visual hallucinations
Parkinsonianism (late)
79
What qualities differentiate Parkinson disease from Lewy body dementia (DLB)?
Early cognitive fluctuation and hallucinations in DLB, whereas dementia occurs very late in Parkinson disease.
80
First-line Rx for idiopathic intracranial HTN (pseudotumor cerebri)?
Acetazolamide +/- furosemide. If this fails, optic nerve sheath decompression (prevents MC complication - blindness) or lumboperitoneal shunting is recommended.
81
What does a positive urine bilirubin assay tell us?
There is a buildup of conjugated bilirubin (water soluble form) in the urine meaning there is hepatic dysfxn, biliary obstrxn, or hepatic secretion issue.
82
A patient with deterioration of neurologic status 2 days after an ischemic stroke may be suffering from?
Hemorrhagic transformation. It is a common complication of ischemic stroke and those treated with thrombolytics. It requires noncontrast CT scan to evaluate for urgent surgical decompression.
83
Yellow-red papules on the arms/shoulders and body associated with upper abdominal pain radiating to the back are likely due to?
Hypertriglyceridemia. Acute pancreatitis can be caused by high TGs (often >1000) and may appear as eruptive xanthomas (erythematous to yellow) on the skin.
84
What CSF changes are expected in Guillain-Barre syndrome?
Albuminocytologic dissociation. Elevated CSF protein with a normal cell count.
85
CSF changes expected in bacterial CNS infxn?
Neutrophilic pleocytosis.
86
14-3-3 protein in the CSF indicates what neurodegenerative disease?
Creutzfeldt-Jakob disease.
87
Patients with suspected acute arterial occlusion and threat of limb receives what next step?
Anticoagulation with heparin. This is done even prior to imaging. Arterial Doppler or duplex US are done if suspicion must be confirmed. Ankle-brachial index is done as a screen only for PAD.
88
What is used as a thrombolytic in stroke Rx?
IV alteplase. Alteplase is a tissue plasminogen activator and must be given within 4.5 hours of symptom onset.
89
Patient loses loads of hair by just pulling gently on the hair (hair pull test) after pregnancy. Dx?
Telogen effluvium. Telogen refers to hair follicle and effluvium an unpleasant odor or occurrence. It is an acute, diffuse, noninflammatory hair loss that is self limited.
90
Elevation of what aspect of ventilation may improve mortality in ARDS?
PEEP elevation. Prevention of alveolar collapse is key to reducing the pathologic mechanism of ARDS and PEEP splints the airways, preventing this occurrence.
91
Preferred Rx for exertional heat stroke? Nonexertional (classic) heat stroke?
Rapid cooling preferably in ice water immersion for exertional. Nonexertional requires evaporative cooling rather than ice water as ice water immersion tends to increase M&M in most patients.
92
Antibodies associated with systemic sclerosis?
Anti-topoisomerase 1 (main one)
Anticentromere
Antinuclear antibody
93
When does a COPD Pt require O2 therapy?
1. Resting arterial O2 tension (PaO2) ≤55 or SpO2 ≤88%.
| 2. Signs of right HF, cor pulmonale, or Hct>55% with a PaO2<60 or SaO2 <90%.
94
Fever, leukocytosis, and LUQ abd. pain are triad for?
Splenic abscess. Sometimes get pleural effusion above spleen also and splenomegaly.
95
Syringomyelia is frequently associated with what other congenital deformity?
Arnold chiari type 1.
96
Thymoma is usually found in what part of the mediastinum?
Anterior mediastinum.
97
Bronchogenic cysts are located in what part of the mediastinum?
Middle mediastinum. Tracheal tumors, pericardial cysts, lymphoma, lymph node enlargement, and aortic aneurysms of the arch are located here also.
98
Neurogenic tumors in the thorax are found in what part of the chest?
Posterior mediastinum.
99
What screening is important before starting chemo with traztuzumab or anthracyclines (doxyrubicin)?
Echocardiography. Both can cause CHF by reduction in stroke volume. Anthracyclines are more toxic and less likely to be reversed.
100
Most malaria infested countries are chloroquine resistant. What alternatives are available for chemoprophylaxis?
Atovaquone-proguanil
Doxycycline
Mefloquine
101
What lab changes are expected in Paget's disease?
Serum Ca++ and PO4- are normal, alkaline phosphatase and urine hydroxyproline (breakdown of collagen) are elevated.
102
In moderate COPD exacerbation (≥2 cardinal symptoms, esp. increased sputum purulence) or mechanical ventilation requirement also require what medication class?
Antibiotics on top of the usual O2, bronchodilators, steroids, etc.
103
What is the MCC of bacterial meningitis?
Pneumococcal meningitis.
104
Does pneumococcal meningitis cause skin manifestations?
Not typically. Meningococcal meningitis presents with petechial rash and shock.
105
Anticentromere antibodies assoc. disease?
Limited cutaneous systemic sclerosis (CREST syndrome - calcinosis, raynauds, esophageal dismotility, sclerodactlyl, telangiectasia). Better prognosis than diffuse cutaneous.
106
Anti-Scl-70 (topoisomerase-1) antibodies assoc. disease?
Diffuse cutaneous systemic sclerosis.
107
Best scan of chest for looking for lung malignancy?
CT scan.
108
Empiric antibiotic Rx for IV drug use caused infective endocarditis in non-prosthetic valve?
Vancomycin. Staph aureus >50% of cases, but strep and enterococci are also common.
109
GI bleeding leads to elevated BUN/Cr ratio due to what process?
Increased urea prodxn (from intestinal breakdown of Hgb) and increased urea reabsorption (2° to hypovolemia) lead to high BUN.
110
If a test result is negative and the NPV is 96%, what is the probability the person is actually positive?
1 - NPV. Or in this case, 4%. Same rule applies for PPV.
111
Tests needed after initial diagnosis of HTN to check for 2° causes/RFs?
Urinalysis for hematuria and protein/Cr ratio
Chem7
Lipid profile
ECG baseline
112
Management of patient with myasthenic crisis?
Intubation, plasmapheresis or IVIG and steroids
113
Daily management of myasthenia gravis?
Pyridostigmine or other Acetylcholinesterase inhibitor
114
Prostatitis MCC? Rx?
E. Coli. TMP/SMX (acute only) or fluoroquinolones (chronic and acute).
115
A pleural effusion in the presence of cirrhosis is called?
Hepatic hydrothorax. It is a transudative pleural effusion where small defects in the diaphragm lead to movement of peritoneal fluid into the pleural space. Rx: restrict salt and give diuretics
116
VZV lays dormant in which ganglion of the head?
Trigeminal ganglion leading to Herpes zoster opthalmicus.
117
In sickle cell disease or trait, low specific gravity of urine and polyuria may indicate what?
Hyposthenuria. This is the lost ability to concentrate urine.
118
Anti-SM antibodies and anti-ANA assoc. with what disease?
Autoimmune hepatitis. Anti-smooth muscle abs and anti-nuclear antibodies are related to autoimmune hepatitis. Fluctuating hepatocellular injury (high TAs) are present without cholestasis.
119
Anti-mitochondrial antibodies are assoc. with what disease?
Primary biliary cholangitis. PBC presents in middle-aged women with cholestasis (high alk phos) due to autoimmune destrxn of intrahepatic bile ducts. Later, jaundice, hepatomegaly, steatorrhea, and portal HTN can develop.
120
Short-term and long-term management of hypercalcemia (>14mg/dL)?
Normal saline hydration plus calcitonin and bisphosphonates.
121
Drug that is given to stroke with no prior antiplatelet Rx?
Aspirin.
122
Drugs given if already on ASA rx?
Aspirin and dipridamole or clopidogrel.
123
Management of stroke within 3.5-4 hour window of onset and no contras?
IV alteplase (tissue plasminogen activator).
124
A patient with thrombocytopenia and thrombus progression 3 days after heparin therapy likely has what?
Type 2 heparin-induced thrombocytopenia (HIT). Heparin induces a conformational change to platelet factor 4 (PF4) that exposes a neoantigen. The immune system responds by forming IgG against the neoantigen causing platelet activation and thrombocytopenia as they are removed via spleen.
125
Mechanism of heparin?
Binds antithrombin that inactivates factor Xa, thus prolonging aPTT.
126
Light criteria definition?
2/3 of the following indicate exudate:
Pleural protein/serum protein >0.5; pleural fluid LDH/serum LDH >0.6; Pleural LDH > 0.7 (2/3rds) of upper limit of normal for serum LDH.
127
Pt with severe eye pain, dilation and poorly responsive pupil, HA, and maybe NV with a ESR of 35 likely has?
Acute angle-closure glaucoma. Narrowing of anterior chamber angle results in increased intraocular pressure. Temporal arteritis has similar presentation, but ESR is often >50.
128
Fxn of aldosterone in the DCT?
Aldosterone increases Na+ reabsorption, secretes potassium and hydrogen. Water absorption occurs with sodium, but after several days of water reabsorption, diuresis occurs and water and sodium decrease (aldosterone escape). This prevents edema and results in mild hypernatremia. Hypokalemia directly increases renal bicarb resorption also causing metabolic alkalosis.
129
What are renin, aldosterone, and bicarb in Conn's syndrome?
Renin is low due to elevated aldosterone and bicarb is high due to increased K+ wasting.
130
Initial test for acute stroke?
CT without contrast.
131
Confidence interval is wide when?
Sample size is smaller.
132
Power can be increased by increasing?
Sample size.
133
CI and power can be narrowed and increased respectively by?
Increasing sample size.
134
Glomerulonephritis (high BUN/Cr ratio, proteinuria, RBC casts) in the presence of low C3 with bad sunburn, but no malar rash?
SLE glomerulonephritis. Can present with photosensitive skin and thrombocytopenia and low C3. Post strep glomerulonephritis can present similarly, but photosensitivity and low platelets is not common.
135
Pain anterior to the knee (directly over knee) that is common in jobs requiring kneeling. Dx?
Prepatellar bursitis or "housemaid's knee".
136
Anterior dislocation of the shoulder commonly occur in what position? Risk nerve is at risk?
Externally rotated and abducted arm. Axillary nerve at risk (teres minor and deltoid).
137
Nerve at risk in humeral mid-shaft Fx and improperly fitted crutches?
Radial nerve.
138
Nerve at risk in medial epicondyle of humerus Fx?
Ulnar nerve. Damage results in "claw hand".
139
Succinylcholine brings risk of hyperkalemia and arrhythmia due to what conditions?
Skeletal muscle injury, stroke, Guillain-Barre, polyneuropathy, etc. This is due to the upregulation of ACh receptors on postsynaptic cells that causes massive K+ efflux during Succinylcholine admin. In these cases, a nondepolarizing neuromuscular blocking agent should be safe (vec or rocuronium) as they do not affect post-synapse ligand-gated ion channels.
140
What are the preferred anticoagulants in ESRD?
Unfractionated heparin followed by warfarin
141
What anticoagulants are contraindicated in ESRD?
Low molecular weight heparin (e.g. enoxaparin) and rivaroxaban are not recommended for use in ESRD as they are metabolized by the kidney. Thus, they can result in bleeding. Unfractionated heparin and warfarin are not contraindicated in ESRD.
142
Trihexyphenidyl is used to treat tremors in what condition?
Parkinson's. Trihexyphenidyl has anticholinergic qualities.
143
Primidone is used to treat what kind of tremors?
Essential tremors.
144
Propanolol is used as a first-line agent for what kind of tremors?
Essential. Clozapine and clonazepam are also treatments, but 2nd line.
145
First line therapy for fibromyalgia?
Exercise and aerobic conditioning.
146
Management of variceal hemorrhage if bleeding continues despite treatment?
Balloon tamponade or repeat endoscopy. TIPS or shunt surgery is a last resort.
147
What is Beck's triad?
Tamponade leads to: Hypotension
Distended neck veins
Muffled heart tones
Note: Shift of the interventricular septum toward the left ventricular cavity reduces left ventricular preload, SV, and CO.
148
Cough, micturation, or defecation lead to what kind of syncope?
Situational
149
Aortic stenosis, HCM, anomalous coronary arteries lead to syncope when?
With exertion or exercise
150
Signs of congenital long QT syndrome are?
Family Hx of sudden death
Elevated QT interval
Syncope with triggers (exercise, startle, sleep)
151
Metabolic syndrome criteria?
Insulin resistance is central to the syndrome.
Must have 3 of the following:
Abdominal obesity(waist>40in in men, or >35in in women)
Fasting glucose>100
BP>130/80
TGs>150
HDL<40(men) or <50(women)
152
Acute kidney injury can lead to a non-anion gap metabolic acidosis due to?
Impaired H+ excretion, ammonia generation, or bicarbonate reabsorption.
153
Classic features of septic arthritis?
Hot, swollen joint, decreased ROM, fever, elevated ESR and CRP, synovial fluid contains>50K leukocytes
154
Initial Rx for septic arthritis?
Gram+ cocci: Vanco
Gram- rod: 3rd gen ceph
Negative microscopy: vanco (and 3rd gen ceph if immunocomp)
155
What features differ between Cushing syndrome from PCO?
Cushing only: Skin (dermal) atrophy, muscle weakness, easy bruising
Both: Obesity, irregular menses, hyperandrogenism
156
Most common site of ulnar nerve entrapment?
Elbow in the medial epicondylar groove.
157
S. aureus commonly infects people with what recent infection?
Recent viral influenza. Mostly affects ages>65, but MRSA affects young people leading to progressive, necrotizing pneumonia with high fever, productive cough, often hemoptysis, leukopenia, and multilobar cavitary infiltrates.
158
On a left skewed bell curve, where do mean, median, and mode sit?
From left to right, mean (average), median (middle, splits high/low data in half), and mode (peak or most common number of group).
159
If an outlier occurs in statistical data, what is most effected?
Mean>>median or mode
160
Valley fever presenting with community-acquired pneumonia (fever, CP, productive cough, lobar infiltrate) and arthralgias, erythema nodosum, or erythema multiforme is caused by?
Coccidioides species. Commonly associated with desert regions in the SW US. Presents about 7-14 days after innoculation.
161
How do each of the following affect kidney stone formation: furosemide, HCTZ, potassium citrate?
F: Enhance urinary Ca++ excretion (hypercalciuria) resulting in higher stone risk.
H: Reduces Ca++ excretion due to hypercalciuric stones.
PC: Potassium citrate alkalinizes the urine resulting in higher solubility of uric acid stones.
162
Which kidney stones are radiolucent?
Uric acid stones
| Xanthine stones
163
Condition in young females (15-50) that commonly leads to HTN?
Fibromuscular dysplasia. Noninflammatory, nonatherosclerotic condition due to abnormal development of arterial wall that leads to stenosis, aneurysm, or dissxn of the renal, carotid, and vertebral arteries (among others). Sclerosis of the renal artery results in seconary hyperaldosteronism.
164
Dx of choice for fibromuscular dysplasia?
CT angio of the abodmen or duplex US.
165
In a patient with a solitary lung nodule, what steps are to be taken to work it up?
1. Do CXR
2. Check previous Xray to compare
3. If stable, no further study. If unstable, do CT.
4. Benign? Serial CT. Suspicious? Biopsy (if indeterminate only). Resect.
166
Timeframe for papillary muscle rupture, interventricular septum rupture, free wall rupture, or LV aneurysm after MI?
Papillary muscle rupture: Acute or 3-5 days
IV septure rupture: Acute or 3-5 days
Free wall rupture: 5 days to 2 wks
LV aneurysm: Up to months
167
Medical management of renal artery stenosis?
ACEI or ARBs. Even in bilateral RAS, elevation of serum Cr is acceptable to <30%.
168
Arthritis, uveitis, episcleritis, erythema nodosum, and primary sclerosing cholangitis are the most common extraintestinal manifestations of?
Ulcerative colitis.
169
First line Rx for vitiligo?
Corticosteroids, topical or systemic.
170
Man presents with progressive dyspnea over 20 years, digital clubbing, and bibasilar end-inspiratory crackles on lung auscultation. He has an Hx of working in the insulation business for 40 years. Dx?
Asbestosis. Onset ~20years post exposure. Restrictive lung pattern with progressive dyspnea over many months is typical. Pleural plaque formation (large plaques on peripheral of chest Xray/CT) are the hallmark.
171
A serum BNP under what number helps to rule out suspected CHF exacerbation with associated symptoms?
100pg/mL
172
How many night time awakenings occur due to intermittent asthma, mild persistent, moderate persistent, or severe persistent asthma?
I: ≤2x per month
Mild: 3-4x/mo
Mod:>1x/wk, nut not nightly
Sev: 4-7x/wk
173
What is the frequency of exacerbations in intermittent, mild, moderate, or severe persistent asthma?
I: ≤2days/wk
Mild: >2days/wk
Mod: Daily
Severe: Throughout the day
174
Name the steps in asthma management from 1-6.
1. SABA PRN
2. Low-dose ICS
3. Low-dose ICS + LABA or medium ICS dose
4. Medium dose ICS + LABA
5. High-dose ICS + LABA and consider omaliumab for allergies
6. High dose ICS + LABA + oral steroid and consider omalizumab
* Steps 1-4 coincide with each level of asthma in a stepwise fashion. Severe can do step 4 or 5 depending in severity.
175
Diagnostic requirements for acute liver failure?
Liver injury: ALT, AST often>1000
Signs of hepatic encephalopathy
Synthetic liver dysfxn (INR>1.5)
176
A man with cirrhosis and ascites accompanied by fever and lethargy with diffuse abdominal pain with guarding requires what for Dx?
Paracentesis. Spontaneous bacterial peritonitis can present subtly and should be considered in cirrhotic patients with ascites and fever and AMS. Paracentesis with positive culture and neutrophils ≥250 are positive results.
177
QRS interval >100 msec in setting of TCA overdose is an indication for what Rx?
Sodium bicarbonate. The sodium load will alleviate the depressant action on myocardial sodium channels.
178
A man presents with loss of sensation on the right face and left body, right facial droop with complaints of vertigo and nystagmus. Dx?
Wallenberg syndrome due to lateral medullary infarct. Occurs due to occlusion of the posterior inferior cerebellar or vertebral artery.
179
What is the correlation coefficient (r)?
Correlation coefficient assess a linear relationship between 2 variables. The null value is 0, meaning no association and the sign of the value indicates either a positive or negative association. The closer to either 1 or -1, the stronger the association. e.g. HDL level and carotid intima-media thickness have a r value of -0.25. Thus, as HDL increases, the carotid intima-media thickness decreases.
180
A young woman presents with the inability to track objects. As she abducts the eyes, the left or right eye does not adduct to the abducting side. Dx?
Internuclear ophthalmoplegia due to MS. Damage to the medial longitudinal fasciculus leads to an inability to coordinate abducting/adducting eye movements due to lack of communication between CN3 and CN6 (abducens).
181
What hormone deficiency separates primary from secondary adrenal insufficiency?
Primary adrenal insufficiency presents with decreased aldosterone as well as low cortisol and sex hormones. Secondary has a normal aldosterone prodxn as aldosterone is primarily controlled by the RAS and not pituitary hormones (ACTH, FSH/H) as are cortisol and sex hormones.
182
Typical primary adrenal insufficiency symptoms?
Hyperpigmentation
Hyperkalemia
Hyponatremia
Hypotension
183
A man presents with signs of pneumonia and elevated BUN/Cr>20. Prior Hx of diabetes for which he is taking metformin. Why must the metformin be DCed?
In any patient with increased risk of lactic acidosis (renal failure, liver failure, sepsis), metformin must be discontinued.
184
Treatment of Guillain Barre?
IV IG or plasmapheresis.
185
A patient presents with progressive ascending paralysis that began acutely (hours ago). He was recently on a hiking trip with friends and he notes the paralysis is more pronounced in one leg than the other. Dx?
Tick-borne paralysis. This presents as described with differences in the level of paralysis in one side over the other. Guillain barre is not so acute in onset (days-months). Removal of the tick in tick-borne paralysis will remove the neurotoxin source and result in complete recovery in days.
186
Methimazole and PTU side effects?
Agranulocytosis for both. PTU causes hepatic failure also.
187
Positive hepatojugular reflux with sustained JVP>3cm may indicate what conditions?
Most commonly constrictive pericarditis, right ventricular infarction, or restrictive cardiomyopathy.
188
A vaccine with polysaccharides only (23-valent pneumococcal polysaccharide vaccine) vs one with conjugate proteins (13-valent pneumococcal conjugate vaccine) result in what immune responses leading to immunity?
Polysaccharide only: result in T-cell-independent B-cell response because T-cells do not respond to carbohydrates, only proteins
Polysaccharide/protein conjugate: induces a T-cell-dependent B-cell response secondary to the protein attachment that results in better immunogenicity due to formation of higher-affinity antibodies and memory cells. These conjugate vaccines are more effective in children under 2 and the elderly, hence their use in these populations.
189
A patient with signs of dehydration (dry mucus membranes, mild tachycardia etc.) with a BUN/Cr ratio >20 likely has what?
Prerenal acute kidney injury.
190
If hyperbilirubinemia with normal AST, ALT, alk phos. Differential?
Dubin-johnson or Rotors
191
If hyperbilirubinemia with predominantly elevated alk phos. Differential?
Cholestasis of pregnancy, malignancy, cholangiocarcinoma, PBC, PSC, choledocholithiasis
192
If hyperbilirubinemia with predominantly elevated AST, ALT. Differential?
Viral, toxin, autoimmune, ischemic, alcoholic hepatitis, hemochromatosis.
193
Amiodarone can cause side effects in what systems?
Cardiac: bradycardia, heart block, QT prolonged
Pulmonary: Chronic interstitial pneumonitis
Endocrine: Hypo/hyperthyroid
Gi/hepatic: hepatitis
Ocular: Corneal microdeposits, optic neuropathy
Derm: blue-gray skin
Neuro: neuropathy
194
Pt on suicide attempt presents with bradycardia, AV block, and hypotension. Lungs are wheezy. Treatment?
Beta blocker OD treated with glucagon.
195
A female with known SLE presents with difficulty breathing, fever, and dry cough. CXR shows diffuse interstitial infiltrates throughout. She takes prednisone and cyclophosphamide. Dx?
Pneumocystis jirovecii pneumonia (PCP). Occurs in severely immunocompromised patients. Appears similarly to interstitial fibrosis on CXR and presentation, but fibrosis occurs less acutely (months) and does not present with fever as does PCP.
196
A young woman with chronic nonbloody diarrhea and dark patches in her colon on colonoscopy. Dx?
Laxative abuse. Melanosis coli are dark brown discolorations in the lymph follicles of the colon secondary to laxative use. They will fade over time.
197
An older man with swelling and redness of his knee has labs on his synovial fluid that show a few rhomboid-shaped crystals. What signs accompany this disease?
Chrondocalcinosis and possibly an inflammatory effusion (15K-30K cells/mm3). Calcification of the meniscus or another structure in the knee would be common in pseudogout and would show up on an Xray. Calcium pyrophosphate crystal arthritis (rhomboid shaped, +birefringence) presents as mono/oligoarticular arthritis most often in the knees.
198
Patients with gonorrhea are at high risk of getting what other STDs?
Chlamydia, HIV, syphilis, and hep B
199
ABx for gonorrhea/chlamydia infxn?
Azithromycin and ceftriaxone.
200
Patients with unsafe sexual practices (MSM, unprotected sex) require evaluation for what illnesses?
HIV and Hep B in particular.
