Medicine 3 Flashcards
(201 cards)
1
Q
Individuals who have received a blood transfusion before 1992 are at risk for what?
A
Hep C. They should be tested.
2
Q
In a patient with signs of infective aortic valve endocarditis and associated AV conduction block/syncope, suspicion of what is critical?
A
Perivalvular abscess. The infected valve can extend into adjacent tissues and compress the nodal tissues leading to block. 30-40% of IE patients have perivalvular abscess.
3
Q
A man presents with fatigue, dyspnea on exertion with edema and ascites. Liver border is 8cm and he has JVD>9cm. Xray shows scattered calcification on the left side of the heart. Echo shows enlarged atria with normal ventricle thickness and vent size, and EF of 65%. Dx?
A
Constrictive pericarditis. Thickened or calcified pericardium limits diastolic filling. Prior cardiac surgery is often the cause, but can be idiopathic. Radiation, TB, malignancy, or uremia also. Kussmaul sign (lack of JVP decrease on inspiration) or pericardial knock (middiastolic sound) are classic signs.
4
Q
Under what conditions are antithyroid drugs (PTU or methimazole) indicated?
A
Mild hyperthyroidism
Older age with limited life expectancy
Preparation for radioactive iodine/thyroidectomy (often accompanied by ß-blocker)
Pregnancy (PTU 1st line)
5
Q
Renal vein thrombosis (RVT) is commonly associated with nephrotic or nephritic syndrome? Why? Which condition within the syndrome?
A
RVT is most commonly associated with nephrotic syndrome as the loss of antithrombin III predisposes to thrombosis. However, within nephrotic syndrome, RVT is most commonly associated with membranous glomerulonephropathy, though RVT can happen in any of the nephrotic conditions.
6
Q
Aspirin intoxication leads to what acid/base derangement?
A
Mixed respiratory alkalosis and metabolic acidosis. The respiratory alkalosis is due to increased respiratory drive and the metabolic acidosis due to increased prodxn and decreased renal elimination of organic acids (lactic acid, ketoacids) leading to an increased anion gap.
7
Q
In a patient with normal pH, but PaCO2 of 25 and PaO2 of 100 and HCO3- of 14, what is the derangement? Use Winter’s formula to help decide.
A
PaCO2 = 1.5 (HCO3-) + 8+/-2
PaCO2 = 29 +/-2
The formula gives us what the PaCO2 should be if we had a purely metabolic acidosis. The PaCO2 is lower than that, thus, this is mixed metabolic acidosis and respiratory alkalosis. ASA toxicity is the most common cause of this kind of metabolic derangement.
8
Q
Classic signs of digoxin toxicity are?
A
NVD, decreased appetite, confusion, and weakness. Scotomata, blurry vision and xanthochromia are common too. Hypokalemia, caused by loop diuretics, often predispose patients on digoxin to toxicity.
9
Q
Central retinal artery occlusion Rx?
A
Emergently treated with an ocular massage and high flow O2.
10
Q
In a patient with mild weakness in whom a pronator drift is found, where is the likely lesion?
A
Pyramidal/corticospinal tract. An UMN lesion in these areas causes more weakness in supinators compared to the pronators of the upper limb and when the eyes are closed leaves proprioception to do the sensing. This leads to affected arm drifting downward and palms turning toward the floor.
11
Q
Patients with resting tremor, rigidity, bradykinesia, or choreiform movements typically have a lesion where?
A
Basal ganglia.
12
Q
Patients with ataxia, intention tremor, impaired dysdiadochokinesia (impaired alternating movements) have a lesion where?
A
Cerebellar dysfxn.
13
Q
Classic triad of Wernicke’s encephalopathy?
A
Encephalopathy
Ocular dysfxn (e.g. pupillary rxn delay)
Gait ataxia
*Due to thiamine deficiency.
14
Q
CML gene abnormality and Rx?
A
Abnormal BCR-ABL gene fusion t(9;22) leads to constitutively active tyrosine kinase. First line Rx is tyrosine kinase inhibitors (imatinib). Dramatic leukocytosis >100K with absolute basophilia and shift toward very early neutrophil precursors is typical.
15
Q
APML Rx?
A
APML is a subtype of AML and is typically treated with all-trans retinoic acid.
16
Q
A man with weakness, weight loss, hyponatremia, and hyperkalemia, with a low-normal cortisol level presents. Next steps?
A
ACTH stimulation test (cosyntropin - synthetic ACTH) given first to test if adrenals respond to ACTH. Then do 8am cortisol and plasma ACTH. Low cortisol level with high ACTH confirms primary adrenal insufficiency. High/high-normal cortisol rules out PAI.
17
Q
Best strategy for prevention of further liver damage in HCV positive patient?
A
Avoid EtOh, give HAV, HBV vaccines.
18
Q
A patient presenting with a mild type 1 rxn after taking a new medication (itchy, urticaria, but no wheezing) is managed how?
A
Antihistamines and discontinue drug
19
Q
Best analysis of HSV encephalitis?
A
PCR is gold std.
20
Q
In anaphylaxis, when are IM and IV epi indicated?
A
IM Epi is given initially. IV Epi is only given if the Pt has not responded to IM Epi.
21
Q
Pt with an MI undergoing revascularization via PCI who gets a drug-eluting stent requires what 6 drug therapy afterwards?
A
Dual antiplatelet Rx: ASA and P2y12 receptor blocker ("grel" drug e.g. clopedogrel). These are taken for 12 months.
Beta blocker
ACEI
Statin
Aldosterone antag.
22
Q
In a man newly diagnosed with liver cirrhosis, what potential life threats must be ruled out first?
A
Esophageal varices. M&M are 30-60% in cirrhotic patients, thus, a screening endoscope is required.
23
Q
In a known cirrhotic patient, how often must surveillance for HCC with AFP be done?
A
q 6 months alongside EGD for varices.
24
Q
Management of ascites prevention in cirrhosis?
A
Sodium restriction
Diuretics
Paracentesis
EtOH abstention
25
Pt presents with abd. pain, constipation, and forgetfullness. His sensation is decreased in the lower legs and he has a microcytic anemia. Wife reports he has been drinking moonshine distilled at home. Dx?
Acute lead toxicity due to soldered metal joints with lead. Classic symptoms here. Lead causes porphyria due to heme synth disruption. Basophilic stippling of RBCs can present on smear.
26
If alk phos elevation is isolated do what test to check origin?
GGT. GGT positivity means biliary origin.
27
Medical management of PBC?
Ursodeoxycholic acid. This drug prevents damage from hydrophobic bile acids and improves bile movement. It may improve survival in these patients.
28
Path of Heparin-induced thrombocytopenia?
Conformational change in platelet factor 4 surface protein acts as neoantigen. Antibodies form to this antigen and bind to platelets leading to aggregation, thrombocytopenia, and prothombotic state.
29
Classic signs of Heparin induced thrombocytopenia?
Skin necrosis at the abdominal injection site. Must stop all heparin products and start direct thrombin inhibitor (argatroban) or fondaparinux.
30
Black woman presenting with focal proliferative glomerulonephritis has low platelets. Why?
SLE causes an autoimmune-mediated destruction of WBCs, RBCs, and platelets that occurs peripherally.
31
Calcium oxalate crystals found in the urine with a high osmolar gap in a patient with hematuria, oliguria, flank pain, and a cranial nerve palsy ingested what?
Ethylene glycol. Fomepizole is Rx of choice to inhibit alcohol dehy.
Ethylene glycol is metabolized to oxalic acid (which leads to calcium binding and hypocalcemia as well as crystal formation) and glycolic acid (which causes renal tubulear injury.
32
Why are elderly more susceptible to orthostatic changes?
Senescence of baroreceptor response and defects in myocardial responsiveness to this reflex.
33
Intubated patient in the ICU presents with fever 5 days after surgery. He grimaces to RUQ palpation. He has leukocytosis. US reveals pericholecystic fluid and enlarged GB wall. Dx?
Acalculus cholecystitis. Surgical patients or Pts on prolonged NPO status or TPN are susceptible. Unexplained fever with RUQ mass and leukocytosis or abnormal LFTs may present.
34
A patient on TPN develops gallstones. Why?
Bile stasis predisposes to gallstones and bile sludging that lead to cholecystitis.
35
CLL and CML are different in the leukocyte count in that?
CLL has lymphocytosis. CML has elevated neutrophils.
36
Hairy cell leukemia presents with?
Splenomegaly and pancytopenia.
37
Hodgkin lymphoma often presents with what symptoms?
Painless lymphadenopathy, B symptoms, with a normal blood smear and CBC. Massive lymphocytosis is unlikely.
38
Shistocytosis is expected in what 3 medical conditions?
```
Microangiopathic hemolytic anemias:
DIC
HUS
TTP
Prosthetic valves do it also.
They all present with low haptoglobin, high LDH and bilirubin.
```
39
Impaired memory and attention, personality changes and ataxia with other motor symptoms in a person with longstanding HIV who is over 50 and poor compliance with their HAART likely has?
HIV-associated neurocognitive disorder (HAND) or progressive multifocal leukoencephalopathy (due to JC virus). Both occur in chronic HIV patients and have similar symptoms. An MRI would show diffuse intensity changes of the white matter in HAND, but PML would show spotty, focal and asymmetric lesions.
40
What is the fundamental difference between a cohort study and a case control study?
Cohorts start with a risk factor and try to link it to a disease. Case controls start with a disease and try to link it to a risk factor.
41
SE of levodopa plus carbidopa?
```
Hallucinations early
Dyskinesia late (5-10 yrs)
```
42
SE of trihexyphenidyl or benztropine?
Anticholinergics for Alzheimer's cause dry mouth, blurry vision, constipation, nausea, urinary retention.
43
Entacapone or tolcapone are used with what drugs? Why?
Used in combination with levodopa and carbidopa, these drugs inhibit COMT (which breaks down dopamine). They can cause dyskinesia, hallucinations, orthostatic hypotension, etc.
44
What percent FEV1 increase in asthma testing indicates reversibility?
>12% increase in FEV1 indicates asthma as it is reversible. COPD is not.
45
Female patient experiences pain with filling of her bladder that relieves with voiding. She has increased frequency/urgency and notes pain with sex. Dx?
Interstitial cystitis. Often PE reveals tenderness to anterior vaginal wall. Cervical motion tenderness is not elicited on exam as in PID. This condition is often associated with fibromyalgia or other psychiatric diseases.
46
Man who had tooth abscess has been taking extra tylenol for the pain. He drinks two shots of whiskey daily and has Hx of HTN and DM. LFTs are elevated (thousands), INR>1.5, and he has a flapping of his hands when outstretched. Dx?
Acute liver failure. For a Dx of ALF, one needs elevated LFTs, INR≥1.5, and hepatic encephalopathy.
47
Focal segmental glomerulosclerosis is associated with what disease?
HIV
48
Membranous nephropathy is associated with what diseases?
Adenocarcinoma of lung/breast, Hep B, SLE
49
Membranoproliferative glomerulonephritis is associated with what diseases?
Hep B and C
50
Minimal change disease can be associated with what disease?
Lymphoma
51
Pts with IgA nephropathy typically have what prior to presenting with Sx?
Upper resp infxn
52
Patient presents with abdominal pain, constipation, and polyuria/polydipsia. She started over-the-counter supplementation for osteoporosis about 3 months ago. She has dry mucous membranes. Dx?
Milk-alkali syndrome. Excessive intake of calcium (hypercalcemia) and absorbable alkalis leads to renal vasoconstriction and decreased GFR, renal loss of sodium, water, and resultant bicarbonate reabsorption causes metabolic abnormalities. Thiazides, ACEIs, and NSAIDs can increase the risk. AKI, metabolic acidosis, low mag and phosphate can occur.
53
What factors affect PPV and NPV?
Pre-test probability (i.e. RFs [age, family hx, etc])
Risk group (e.g. condom use, many partners, etc.)
Prevalence is directly related to pre-test probability, which affects PPV/NPV.
54
3 MCC of PTH-independent hypercalcemia?
Malignancy
Vitamin D tox
Extrarenal activation of vitamin D (sarcoid)
55
What psych drug can lead to hypercalcemia?
Lithium.
56
Pleural effusions presents with what kind of breath sounds?
Decreased due to insulation around the lung. Poor transfer of sound to fluid from air. Tactile fremitus is also decreased.
57
Consolidation presents with what breath sounds?
Increased breath sounds with crackles or egophony. Tactile fremitus is increased.
58
Pt experiences respiratory distress and cardiogenic pulmonary edema within 6 hours after transfusion. Dx?
Transfusion related acute lung injury. Due to anti-leukocyte antibodies.
59
Shock, urticaria, and wheezing minutes after a transfusion. Dx?
Anaphylaxis. Due to anti-IgA antibodies in transfused blood.
60
What test is used for lactose intolerance?
Lactose hydrogen breath test. A rise in the measured breath hydrogen level after lactose ingestion indicates increased bacterial carbohydrate metabolism.
61
First line drug for fibromyalgia?
TCAs, but only after they fail to improve after aerobic exercise and sleep hygiene management.
62
18yo black man presents with splenomegaly and mild scleral icterus. Hgb is 8, MCV 90, MCHC normal, reticulocytes 10%, platelets and leukocytes WNL. He had a URI recently and took amoxicillin. No prior Hx. Dx?
Autoimmune hemolytic anemia (AIHA). Fatigue/dyspnea following respiratory infxn treated with amoxicillin has splenomegaly and anemia with reticulocytosis suggests warm agglutinin AIHA, possibly due to antibiotics. A positive direct Coombs test is typical as the test identifies autoantibodies or complement bound to RBC surfaces. Typical Rx: steroids.
63
What is chlorpheniramine MOA?
H1 blocker.
64
Chronic cough (>8 wks) most commonly caused by what 3 conditions?
Upper-airway cough syndrome (postnasal drip) - Dx confirmed via improvement with histamine blockers
Asthma
GERD
65
What dietary recommendations are in place to prevent renal calculi?
Increase fluid intake
Decreased sodium intake (increased sodium intake enhances Ca++ excretion into tubules due to Na/Ca coupling mechanisms in thick ascending loop)
Normal dietary calcium intake
66
MCC of osteomalacia (maybe asymptomatic, or present with bone pain, weakness/cramping, trouble walking/waddling)?
Vitamin D deficiency. Often PTH increases as a result leading to normal Ca++ and often low phosphate lvls. Pseudofractures and concave appearing (codfish) vertebral bodies occur.
67
Common causes of Vitamin D deficiency?
Malabsorption (Crohn's), intestinal bypass, celiac sprue, liver and kidney disease
68
Molluscum contagiosum appears widespread in a patient. What must be considered as a potential cause?
Impaired cellular immunity (HIV). Prolonged courses of the virus or very large lesions/widespread lesions suggest the patient cannot defend against it, which is normally not an issue in the healthy Pt.
69
If pneumocystic pneumonia is suspected (immunocompromised with bilateral, diffuse interstitial infiltrates), then what must be done to Dx?
Culture from secretions, or if this does not reveal a source, do broncheolar lavage.
70
In a study, what does latency period mean when gathering data on an exposure?
While infectious diseases have a short latency period usually, some diseases (cancer, heart disease) have longer ones before manifestation occur. In studies, time must pass on a drug or with an exposure before a significant result is seen. Statins require a long period of time (~1yr) before a significant protective advantage takes place.
71
Female patient with muscle weakness lately has diplopia on two occasions and ptosis of the right eye. On occasion she has trouble speaking (bulbar muscle weakness) and weakness in her neck muscles. She notes trouble brushing her hair. Dx? Where is the pathology?
Myasthenia gravis, thus, autoantibodies against ACh receptors on the motor end plate are present. Muscle weakness presenting as extraocular (diplopia/ptosis) or bulbar (dysarthria) in nature and fluctuating fatigability are classic. Also symmetric proximal neck weakness is typical of MG.
72
Young female presents with orthostatic hypotension has hypovolemia, hypokalemia, hyponatremia, and hypochloremia. Her urine sodium and potassium are elevated. Likely Dx?
Diuretic abuse. Woman has salt wasting (determined by urine electrolyte content) despite being dehydrated.
73
Young female presents with orthostatic hypotension has hypovolemia, hypokalemia, hyponatremia, and hypochloremia. Her urine sodium and potassium are very low. Likely Dx?
Self-induced vomiting. Woman has salt-retention (determined by urine electrolytes) as would be appropriate.
74
If K+ is hard to correct despite multiple K+ administrations, what is the issue most likely?
Hypomagnesemia. It can lead to refractory hypokalemia due to removal of inhibition of renal K+ excretion.
75
The serum-to-ascites albumin gradient helps to determine what?
The origin of the ascites in question. If ≥1.1g/dL then it indicates portal HTN (cirrhosis, or CHF), if below 1.1g/dL, then likely not (malignancy, pancreatitis, nephrotic syndrome, TB).
76
What is Stemmer sign?
A positive Stemmer sign is an inability to lift the skin on the dorsum of the second toe and is highly specific for lymphedema.
77
Unilateral edema of the lower extremity is more likely to be lymphedema or venous insufficiency?
Unilateral edema is typical of lymphedema whereas bilateral edema would be more typical of venous insufficiency.
78
Eosinophilia with SOB, cough, fever, diffuse lung opacities on Xray and an Hx of nitrofurantoin may indicate?
Hypersensitivity pneumonitis in short-term use, or interstitial lung disease in long-term use.
79
Proper management shown to reduce decline in GFR in diabetic nephropathy?
Intensive BP control (targeting 140/90). The diabetic that moves from micro to macroproteinuria (>300mg/hr) and an accompanied progressive decline in GFR is typical of DM nephropathy.
80
Nonseminomatous germ cell tumor markers?
AFP and ß-hCG. Seminomatous and nonseminotamous germ cell tumors have ß-hCG elevations.
81
Seminomatous germ cell tumor markers?
ß-hCG only. Nonseminomatous germ cell tumors have AFP elevations also.
82
A germ cell tumor found in the anterior mediastinum of a young male is not found in the testicle via US. Why?
Most germ cell tumors found in the anterior mediastinum are primary tumors, not metastatic. Look for primary in testicle via US, but likely not to find one.
83
Pica is a behavior that develops out of a deficiency for what?
Iron. Look for chronic bleed, etc.
84
RFs for DVT?
Acquired: immibilization, surgery, malignancy, meds
Inherited: factor V, prothrombin gene mutation, protein C deficiency.
85
In prolactinoma, the prolactin levels are often over?
200ng/mL. This is consistent with a microprolactinoma <1.5cm. In a 2cm prolactinoma, prolactin is often >1000ng/mL.
86
TSH levels in a micro vs macroadenoma?
Micro: TSH usually normal as the size of the tumor has not compressed enough to eliminate secretion.
Macro: TSH usually low as tumor size interrupts secretion (TRH interruption) and also secretes alpha subunit that disrupts negative feedback.
87
Best Dx tool for C. diff?
Stool toxin testing.
88
40s female presents with difficulty exercising due to dyspnea on exertion. She has crackles on inspiration and difficulty eating as "food gets stuck". Endoscope reveals mild hyperemia of distal esophagus and manometry shows lack of peristalsis in lower 2/3rd of esophagus w/ decreased tone in cardiac sphincter. Dx?
Systemic sclerosis. Progressive tissue fibrosis results in ulcers on hands, digital ulcers, and calcinosis cutis. She has esophageal dysmotility and dysphagia also and likely interstitial lung disease. Other Sx include HTN, renal crisis, myocardial fibrosis and pericarditis or effusion.
89
Woman has leg edema that worsens in the evening and throughout the day in the presence of 2cm JVP and some expiratory wheezes. BMI is 32 and she smoked for 30 years and has CPAP use at home. Dx?
Venous insufficiency. Leg swelling that worsens throughout the day in the absence of right sided heart congestion or pulm HTN likely suffers from venous HTN due to valve incompetence. Skin ulcers on the medial aspect of the lower leg and brawny skin changes (lipodermatosclerosis) are typical.
90
Men with HTN and a smoking Hx between what ages need screening for AAA?
65-75 yrs. One-time abdominal US is acceptable. Do not screen in men who have never smoked.
91
In a person with sold organ transplant, what prophylaxis is needed?
Oral TMP-SMX for Pneumocystis pneumonia prophylaxis. Often ganciclovir or valganciclovir are given for CMV prophylaxis.
92
In the case that a patient is competent to make decisions, but their health condition is a risk to public health (e.g. TB or menigococcal meningitis) is the doctor legally allowed to hospitalize the Pt. against their wishes?
Yes. Any threat to public health is an acceptable time to limit liberties until the risk is diminished.
93
What are the typical characteristics of glomerular hematuria?
Hematuria can be gross or microscopic, and can be caused by glomerular (nephrotic) or non-glomerular (stone, cancer, etc.) diseases. Typical glomerular diseases present with proteinuria and dysmorphic RBCs or RBC casts. Non-glomerular do not have proteinuria and have normal appearing RBCs.
94
The majority of cases of rupture of left ventricular free wall are after what kind of MI?
5-14 days post anterior MI. The type of MI is, therefore, important to consider when thinking of sequelae days after an MI.
95
Papillary muscle rupture is typical how many days after MI?
Acutely or 3-5days post MI (usually RCA) presenting with acute MR and cardiogenic shock Sx.
96
Interventricular septum rupture occurs how long after MI typically?
Acutely or 3-5 days post MI (usually LAD or RCA).
97
A patient with thrombocytopenia and thrombosis with recent heparin anticoagulation should be suspected for?
Heparin-induced thrombocytopenia. Markedly elevated aPTT suggests unfractionated heparin use.
98
Pt. presents with thrombocytopenia after 1 day of unfractionated heparin use. Dx?
Type 1 HIT occurs within 2 days of heparin initiation. A nonimmune direct effect of heparin on platelet activation presents within early on after heparin exposure. Platelet count will normalize with continued heparin therapy and no clinical consequences occur.
99
Pt. presents with thrombocytopenia and thrombosis with 5 days of unfractionated heparin initiation. Dx?
Type 2 HIT starts within 5-10 days of heparin therapy. It is more serious than type 1 due to antibody formation against platelet factor 4 (PF4) that leads to platelet aggregation, throbocytopenia, and thrombosis (arterial/venous).
100
What state causes an exacerbation of digoxin side effects?
Hypokalemia and hypomagnesemia. Loop diuretics in combination with digoxin commonly cause this issue.
101
Typical joint fluid characteristics in noninflammatory conditions (e.g. OA)?
Appearance: Clear
WBCs: 200 - 2000
PMNs: ~25%
102
Typical joint fluid characteristics in inflammatory conditions (e.g. crystals, RA)?
Appears: translucent/opaque
WBCs: 2,000-100,000
PMNs: Often >50%
103
Typical joint fluid characteristics in septic joint?
Appears: opaque
WBCs: 50,000 - 150,000
PMNs: >80-90%
104
Typical joint fluid charactersitics in a normal joint?
Appears: clear
WBCs: <200
PMNs: <25%
105
Hypothyroidism is typically accompanied by what metabolic abnormalities?
Hypercholesterolemia due to decreased LDL surface receptors and/or decreased LDL receptor activity. HyperTGs can occur also alongside hypercholesterolemia due to low LPL activity. Hyponatremia, asymptomatic CK and transaminase elevations can occur also.
106
60 year old female with gnawing abd. pain radiating to back, worse at night, with eating, and lying supine. She notes weight loss recently. She has Hx of chronic pancreatitis and smoking Hx. What scan does she need?
If obstructive jaundice present: US best test as the cancer is in the pancreatic head. Alk phos and bilirubin are elevated.
If non-obstructive (nonjaundiced), CT is needed to search for cancer in the body and tail of the pancreas.
CA19-9 is not a diagnostic tool for finding newly diagnosed pancreatic cancer. Smoking and chronic pancreatitis are RFs for pancreatic cancer.
107
Initial management for pulm HTN due to LV systolic or diastolic HF?
Loop diuretic and ACEI.
108
Low FEV1/FVC ratio association w/ disease?
Obstructive disease. If DLCO decreased, then COPD. If DLCO normal/increased, then asthma.
109
Normal/High FEV1/FVC ratio association w/ disease?
Restrictive disease. If DLCO down, then interstitial lung disease. If not, then chest wall muscle weakness.
110
What two medications commonly used in CHF do NOT provide a survival benefit?
Loop diuretics and digoxin.
111
What medications inhibit the absorption of folic acid?
Phenytoin, primidone, and phenobarbitol all lead to megaloblastic anemia due to folic acid malabsorption.
112
What medications inhibit the effects of folate leading to folate deficiency?
Methotrexate (inhibits dihydrofolate reductase) and trimethoprim. Leucovorin (folinic acid) are indicated to reverse the chemotherapeutic anti-folate effects in methotrexate.
113
Metoclopramide is used for what?
Dopamine antagonist used for antiemetic. Can cause dystonias, akathisia, parkinsonianism.
114
Prochlorperazine and promethazine are used for what?
Dopamine antagonists are used for antiemetic effects. Can cause dystonia, parkinsonianism, and akathisia (restlessness, cannot stop moving).
115
Lamotrigine is an anticonvulsant used to treat what psychiatric disorder?
Bipolar disorder. It causes Stevens-Johnson syndrome.
116
Why might an old guy on antihistamines (eg diphenhydramine) not be able to pee?
Urinary retention due to anticholintergic Fx of drug.
117
What organism is weakly acid fast? Which is strongly acid fast?
Weak: Nocardia
Strong: Mycobacterium TB
118
Which medication class is used in a diabetic who desires to control sugar and lose weight?
Glucagon-like peptide-1 agonists (exenatide and liraglutide). SE include pancreatitis, but are less likely to cause hypoglycemia than sulfonylureas.
119
What medication class is used if metformin Rx fails?
Sulfonylureas.
120
SE of Sulfonylureas?
Hypoglycemia and weight gain.
121
What medication class is used if metformin and sulfonylurea Rx fails?
Pioglitazone (Thiazolidinediones or TZDs). SE include weight gain, edema, CHF, bone Fx, bladder cancer. Can be used in renal insufficiency.
122
Main SE of metformin?
Lactic acidosis.
123
What two antihyperglycemics can be used in renal insufficiency?
Pioglitazone (TZDs) and DPP-IV inhibitors (sitagliptins).
124
What is the MCC of nutritional folate deficiency in the US?
Folate deficiency. This would present as megaloblastic anemia. Folate deficiency is the MCC of megaloblastic anemia in chronic alcoholics.
125
What is the MCC of megaloblastic anemia in alcoholics?
Folate deficiency.
126
What are the two important causes of hypoglycemia in non-diabetic patients with elevated insulin levels (elevated c-peptide, insulin level, and proinsulin levels)?
Insulinoma (ß-cell tumor)
| Surreptitious use of insulin or a sulfonylurea (increases endogeneous insulin secretion)
127
A patient presenting with a necrotic rash that shifts positioning and elevated glucose levels must be checked for?
Glucagonoma. Necrotic migratory erythema and elevated glucose levels are classic.
128
Woman presents with fatigue, malaise, weakness, and weight loss with nausea, abd. pain, and diarrhea. She has vitiligo. Labs reveal hyperkalemia. Dx?
Primary adrenal insufficiency or Addison's disease. GI symptoms present in >90% of cases and though pigmentation increases can present, so can vitiligo due to autoimmune issues (as can be the case in autoimmune adrenalitis). Hyponatremia is the most common electrolyte issue in PAI (~90% cases). Compensatory release of ADH due to hypotension (from lack of aldosterone) results in dulitional hyponatremia.
129
Pneumocystis pneumonia infxn Rx?
TMP-SMX and corticosteroids (steroids decrease mortality in severe cases of PCP likely due to reducing inflammation from dying organisms.)
130
When is an HIV Pt. at risk of PCP?
When CD4+ <200.
131
A woman presenting with idiopathic intracranial hypertension may present with the absence of what on MRI of brain?
Empty sella. Occurs in about 70% of cases, but is not diagnostic.
132
Head CT/MRI findings of a butterfly lesion with central necrosis and heterogenous and serpiginous (wavy) contrast enhancement is typical of what?
Glioblastoma multiforme. Contrast enhancement is typical of high-grade astrocytoma. Low grade does not have contrast enhancement.
133
In Tylenol OD, charcoal administration should be done in how many hours?
4 or less. After giving charcoal, check acetaminophen levels. Give N-acetylcysteine and monitor for liver injury.
134
What is the cause of osteomalacia?
Defective mineralization of organic bone matrix.
135
45yo female complains of fatigue, weakness, and diffuse bone pain. She has celiac sprue, but is poorly compliant with her diet. Calcium is 9. Phosphate is low and PTH is high as is alk phos. Dx?
Osteomalacia due to malabsorption of Ca++. Without enough Ca++, osteoid matrix mineralization is impaired. Elevated alk phos results due to increased breakdown of bone and PTH is elevated to increase Ca++ concentration. Phosphorous is low due to PTH. Vitamin D is low also due to malabsorption. Symmetric pseudofractures are classic on Xray (Looser zones).
136
MC malignancy diagnosed in patients with asbestos exposure?
First is bronchogenic carcinoma. Second is mesothelioma.
137
Plumber with smoking Hx presents with bilateral lower lung plaques on Xray. Dx?
Bronchogenic carcinoma (BC). The synergism between smoking and asbestos leads to BC and often presents as bibasilar plaques on Xray. Clubbing, crackles, and honeycombing are common due to interstitial fibrosis.
138
Plumber who never smoked presents with unilateral lower lung plaque with large pleural effusion on Xray. Dx?
Malignant pleural mesothelioma. Lack of smoking Hx and unilateral lesion with large pleural effusion on Xray is classic.
139
MG presents typically when in men vs women?
Women: 2nd -3rd decade
Men: 6th -8th decade
140
A man presents with ptosis and trouble speaking after surgery. An ice pack is placed on his eyes that provides relief of the Sx. Dx?
Myasthenia gravis. Proximal muscle weakness with bulbar Sx (trouble speaking) and extraocular Sx (ptosis, diplopia) are typical. Edrophonium can be diagnostic or placing an ice pack on the eyelids for several minutes can lead to relief of ptosis due to decreased ACh breakdown at the NMJ. Testing includes ACh receptor antibody testing.
141
Young man presents with mild hypercalcemia on testing. PTH is high-normal and urinary calcium excretion is low. Dx?
Familial hypocalciuric hypercalcemia. Mutation of the calcium-sensing receptor (CaSR) leads to high Ca++ levels that do not appropriately suppress PTH secretion. i.e. Higher Ca++ levels are required to suppress PTH secretion resulting in slightly high or inappropriately normal PTH.
142
A patient with Hgb of 8.9 and BP of 80/55 and pulse of 110 presents to the ER. He has Hx of unstable angina and bloody diarrhea. First step in management?
Packed RBC infusion. Pts. with Hgb<9 and unstable with acute coronary syndrome Hx or active bleeding and hypovolemia are treated before the usual threshold of Hgb<7.
143
Untreated hyperthyroid patients are at increased risk for what?
Rapid bone loss and osteoporosis due to osteoclast activation.
144
Pt presents with >3months Hx of weight loss, cough, hemoptysis, and fatigue. He has prior Hx of TB that has resolved. Imaging shows an apical cavitary lesion which shifts with position. Dx?
Chronic pulmonary aspergillosis. Aspergillosis does not have to present with an aspergilloma, but does present with a cavitary lesion. The Pt. has prior lung disease/damage (like prior TB). TB like symptoms present. Serology would be positive for Aspergillus IgG. Immunocompetent individuals clear aspergillus quickly.
145
A man presents with IE due to Eikenella corrodens. What likely comorbidity is associated with this bacteria?
Poor dentition and/or periodontal disease. Dental procedures often precipitate the gram-negative infxn by E. corrodens.
146
Pt. presents with fatigue and weight gain. He has generalized edema. Liver is 5cm below costal margin in palpation. US of kidneys shows bilateral enlargement. Urinalysis shows 4+ proteinuria. Previous Hx unremarkable. Renal biopsy shows?
Glomerular deposits only visible with special stains (Congo red) seen as apple-green birefringence under polarized light. This is classic for amyloidosis. RA is the MCC of AA amyloidosis in the US. This patient has nephrotic syndrome and organomegaly due to deposits in kidneys and liver.
147
MCC of AL amyloidosis?
Multiple myeloma.
148
MCC of AA amyloidosis?
RA.
149
SE of cylosporine and tacrolimus?
Both: hyperkalemia, HTN, tremor
*Cyclosporine also has hirsutism and gum hypertrophy. Though the MOA of both drugs is the same (calcineurin-inhibitors), the SE are different.
150
SE of azathioprine?
Purine analog that is converted to 6-mercaptopurine (inhibits purine synth) leads to leukopenia and hepatotoxicity.
151
SE of mycophenolate?
Bone marrow suppression. This drug reversibly inhibits inosine monophosphate dehydrogenase (the rate limiting enzyme in de novo purine synth).
152
In patients with IE, initiation of what class of drugs significantly prevents risk of septic cardioembolism and must be initiated right away?
IV antibiotics.
153
Early use of what drug reduces stroke risk due to atherosclerotic thrombosis?
ASA. Heparin, on the other hand, is associated with increased risk of symptomatic intracranial hemorrhage.
154
Prolonged, profuse, and watery traveler's diarrhea is often due to?
Parasitic pathogens like Cryptosporidium parvum. HIV patients are at risk for chronic infxn, while immunocompetent clear the infxn in 10 - 14 days.
155
Stronglyoides stercoralis helminth infxn Sx?
Mild skin, GI, and pulmonary symptoms that presents over the course of years. Diarrhea and abdominal pain are typical, but profuse watery diarrhea is not.
156
What is the biggest predictor of stent thrombosis after PCI and stent placement?
Premature discontinuation of antiplatelet therapy. ASA and a P2Y12 receptor blocker (-grels) are recommended to reduce stent thrombosis risk.
157
What substance in the blood is elevated in B12 (cobalamin) deficiency and not folate deficiency?
Methylmalonic acid. Cobalamin is involved in conversion of methylmalonyl-CoA to succinyl-CoA. Without it, Methylmalonyl-CoA (methylmalonic acid) is elevated.
158
What substance is elevated in B12 and/or folate deficiency?
Homocysteine. Both are required to convert homocysteine to methionine.
159
Pt IV drug use and holosystolic murmur that increases with inspiration has what valvular lesion?
Tricuspid regurgitation. Increased intensity of murmur with inspiration has a 100% sensitivity and 88% specificity in differentiating right from left sided systolic murmurs from all others.
160
Young female ballet dancer has pain localized to the anterior knee, especially when the patella is compressed into the leg. Climbing up and down stairs is particularly painful. Gait is normal and no visible deformity is noted. Dx?
Patellofemoral pain syndrome. Usually due to malalignment of patella or overuse, the Rx is quadriceps strengthening exercises. Patellofemoral compression test can reproduce the pain by pushing the patella into the femur.
161
Woman presents with fever, cough, and lower lobe consolidation. She has leukocytosis and crackles in lower lobe on right. She has Hx of sinusitis that was slow to respond to ABx and Hx of bloody diarrhea 6 months ago. Quantitative measurement of serum Ig levels reveal low IgG, IgA and IgM. Dx?
Common variable immunodeficiency. Impaired B cell differentiation and hypogammaglobulinemia are the cause leading to susceptibility to bacterial infxns leading to respiratory infxn (S. pneumoniae) as well as GI infxn (salmonella, campylobacter). Quantitative measurement of Ig levels and reduced/absent immune response to vaccination are diagnostic.
162
Esophageal dysphagia including both solids and liquids at onset is likely due to?
Motility disorder. This requires Barium swallow followed by manometry.
163
Dysphagia that progresses from solids to liquids is classic sign of?
Mechanical obstruction (cancer, etc.). If Hx of radiation, caustic injury, stricture, or cancer surgery, then do barium swallow with endoscopy, but if not just do upper endoscopy.
164
Management of stable patient with A.fib. and RVR?
Diltiazem. Rate control is used to manage these patients.
165
Management of rapid, regular narrow complex in stable patient?
Adenosine or carotid massage or vagal maneuvers first. A. fib. is not treated with adenosine.
166
Addison's disease metabolic derangement?
Non-anion gap metabolic acidosis due to retention of H+. Retention of K+ and loss of Na+ due to low aldosterone results.
167
Common infectious causes of primary adrenal insufficiency?
TB, HIV, and disseminated fungal infxn. Meningococcemia can lead to hemorrhage of adrenal also.
168
Primary antianginal effect of nitrates?
Systemic vasodilation leads to lower preload and lower left EDV that reduces wall stress/myocardial O2 demand.
169
Under what time frame are antivirals given for influenza patients?
Must be given within 48 hours of symptom onset.
170
20yo man presents with tremor of 3 days and mild difficulty speaking. He has ataxic gait and occasional jerky, rapid contractions. Labs unremarkable except elevated ASA and ALT. Dx?
Wilson disease. Classically presents with neuropsychiatric Sx like parkinsonianism, dysarthria, choreoathetosis, ataxia, personallity changes, and depression. Corneal buildup and basal ganglia are classically effected. Buildup of copper due to AR mutation in ATP7B gene and leakage from damaged hepatocytes. Usually presents in 5-35yo.
171
Chronic vomiting can lead to what acid/base derangement?
Metabolic alkalosis (MA). Loss of HCl and generation of new acid in the stomach requires bicarbonate production into the blood. This is called the generational phase of MA. Hypovolemia that results prevents the normal kidney from excreting excess bicarb in the urine. This maintains the derangement and is called the maintenance phase. RAAS exacerbates this issue due to K+ and H+ secretion and Na+ and HCO3- retention. Usually, this responds to NaCl admin (saline responsive MA).
172
Rx in pregnant female with early local Lyme disease?
Amoxicillin.
173
Rx in nonpregnant female with early local Lyme disease?
Doxycycline.
174
Rx in nonpregnant female with late Lyme disease?
Ceftriaxone or cefotaxime. "Late Lyme" meaning meningitis, encephalopathy, or carditis.
175
Type 2 diabetic presents with anorexia, nausea, vomiting, and early satiety. He notes fullness after meals and poor control of his blood sugars (40-400 throughout record). What medications may be helpful in managing this Pt?
Metoclopramide, erythromycin, cisapride. These meds help treat gastroparesis (NV, early satiety, anorexia, postprandial fullness) due to diabetic autonomic neuropathy of the GI tract. Delayed emptying of the stomach can result in hypoglycemic episodes because of insulin administration. These drugs are prokinetic.
176
Kidney stones of what size will pass spontaneously typically?
Under 5mm.
177
Pt presents with right hemiplegia, right hemisensory loss, and leftward deviation of the eyes and a BP of 174/102. Dx?
Basal ganglia hemorrhage. Basal ganglia hemorrhage often due to high BP and involvement of adjacent internal capsule leads to ipsilateral hemiplegia and hemisensory loss, but contralateral eye deviation (look toward the lesion aka conjugate gaze deviation).
178
An elderly patient presents with contralateral hemisensory loss due to hemorrhage in the parietal lobe. What is the likely cause of this hemorrhage?
Amyloid angiopathy. Amyloid deposition is the MCC of lobar hemorrhages in the elderly. Occipital hemorrhage might cause homonymous hemianopsia.
179
Pt presents with coma and pinpoint pupils. When they awaken, they are completely paralyzed. Dx?
Pontine hemorrhage.
180
Relative time to deficiency in folate vs B12?
Folate: months
B12: years
181
Most effective lifestyle modifications for reducing BP in newly Dx stage 1 HTN?
Losing weight in obese Pts. Otherwise, the DASH diet, limiting alcohol, and exercise are recommended. Smokers do have a higher risk of CV disease, but quitting smoking has minimal effect on HTN itself.
182
What is pseudoachalasia?
Narrowing of the distal esophagus not due to denervation, but rather malignancy. Endoscope should be able to differentiate b/t achalasia and pseudoachalasia as in achalasia the mucosa is normal and not cancerous, and the endoscope is easily moved through the sphincter, unlike malignancy.
183
Where are small cell and squamous cell lung carcinomas located?
Centrally.
184
Where are adenocarcinoma and large cell carcinomas of the lung located?
Peripherally.
185
MC lung cancer in smokers? Nonsmokers?
Adenocarcinoma for both.
186
What types of lung cancer are less common in nonsmokers?
Squamous, large, and small cell. The risk for all 3 is increased in smokers.
187
Centrally located lung tumor with necrosis and cavitation. Dx?
Squamous cell carcinoma. Necrosis and cavitation is typical of squamous, but not other lung tumors.
188
Centrally located lung tumor with necrosis and cavitation. Dx?
Squamous cell carcinoma. Necrosis and cavitation is typical of squamous, but not other lung tumors.
189
A female with lymphoma is being Rx with bleomycin, doxorubicin, and vincristine. She has DMII and HTN. On exam she has bilateral weakness on dorsiflexion of the feet and loss of pain/temp affecting both toes. Knee jerk reflex normal but ankle reflex absent. Dx?
Chemotherapy-induced peripheral neuropathy. Presents as symmetric, distal, sensory neuropathy that spreads in stocking-glove pattern. Typical agents are platinum-based (cisplatin, taxanes (paclitaxel), and Vinca alkaloids (vincristine).
190
Man presenting with pelvic pain for 4 months and urinary urgency as well as pain with ejaculation. PSA is 2ng/mL (normal under 3.5) and urinalysis has no RBCs, but many WBCs. Dx?
Chronic prostatitis (aka chronic pelvic pain syndrome). The cause is unknown and it is a Dx of exclusion. Typical symptoms are irritative voiding symptoms (frequency, urgency, hesitancy), perineal pain/genital pain, and pain or blood with ejaculation are typical. ABx, alpha blockers, and 5-alpha-reductase inhibitors for Rx.
191
Wide pulse pressure, water hammer pulse, LV enlargement, discomfort in the left lateral decubitus position (pounding heart and increased awareness of heartbeat) are all typical of?
Aortic regurgitation.
192
What is the MCC of hemostasis in chronic renal failure?
Platelet dysfxn. Bleeding time is prolonged. Rx is DDAVP as it increases release of FactorVIII:vWF multimers from endothelium. Platelet transfusion does nothing as platelets become affected also.
193
The anemia in lymphoproliferative disorders is due to?
Bone marrow infiltration with cancerous cells. Anemia can be due to decreased RBC prodxn/destrxn or frank blood loss, but obviously prodxn is an issue here.
194
45yo man presents with palpable, painless, nonpruritic, nonblanching, purple lesions on his legs. He has progressive fatigue, weakness, joint pains for months. He is afebrile with BP 147/91, HR 84. LFTs are 80 and 90. Cr is 2. Hct is slightly low. C3 is low. C4 is very low. Rh is positive. HIV negative. ANA negative. Urinalysis shows blood, protein, and dysmorphic RBCs. Dx?
Mixed cryoglobinemia. Immune complex deposition in small-medium size vessels leads to endothelial/end organ damage. Typical symptoms are listed. Renal disease, neuropathies, liver involvement are common. Palpable purpura that is nonblanching is classic. Usually associated with SLE and HCV, thus, on presentation this should be tested for. Consequently, HBV and HIV should be tested for also.
195
What is rheumatoid factor?
IgM antibodies against IgG aka IgM anti-IgG antibodies.
196
Significance of palpable vs nonpalpable purpura?
Palpable purpura: inflammatory reaction taking place in vasculature (aka vasculitis) results in elevation of skin.
Nonpalpable purpura: represents extravasation of blood from vessel (essentially small bruising tiny ecchymoses)
197
Dx for toxic megacolon?
Typically presents with bloody diarrhea and systemic findings. Plain Xray showing total or segmental nonobstructive colonic dilation with ≥3 of the following: fever>38 (100.4), pulse >120, WBC >10,500, and anemia. It is associated with UC, C diff, ischemia, volvulus, diverticulitis, etc.
198
Rx for toxic megacolon?
Steroids, NG decomp, ABx, and fluids. Subtotal colectomy with end-ileostomy required if colotis does not resolve.
199
In pulmonology, what is the plateau pressure and what maneuver measures it?
Plateau pressure = elastic pressure + PEEP
| Calculate by performing the end-inspiratory hold maneuver.
200
What maneuver is used to calculate PEEP?
End-expiratory hold maneuver, unlike plateau pressure, which is calculated with end-inspiratory hold maneuver.
201
Is screening for bladder cancer recommended?
No. Not even in patients who are at risk.
