Medicine Flashcards
(176 cards)
1
Q
What is the treatment for anemia of chronic disease? (decreased TIBC and increased ferritin)
A
Address the underlying disorder (if RA then give methotrexate, ect).
2
Q
What are headaches, nausea/vomiting, an abducens nerve palsy, and umbilicated skin lesions in a patient with HIV suggestive of? (patient also has enlarged ventricles on head CT)
A
Cryptococcus meningioencephalitis. Next step is to perform LP with India ink stain. Head imaging may show enlarged ventricles from increased ICP (fungal components clogging arachnoid villi).
3
Q
What are the signs of acute closed angle glaucoma?
A
Sudden onset of decreased vision, visual halos/photophobia, unilateral headache, sever eye pain, and nausea/vomiting. Is a medical emergency.
4
Q
What is the medical management of closed angle glaucoma?
A
Agents that decrease IOP such as mannitol, acetazolamide, pilocarpine, or timolol. Avoid mydriatic agents (such as atropine, ect.) as pupillary dilation worsens the glaucoma.
5
Q
What agent is given for acute cocaine intoxication?
A
Benzodiazepines (if ACS present also give aspirin, nitroglycerin, and calcium channel blockers).
6
Q
What is a solid organ transplant patient who presents with dyspnea/dry cough, GI symptoms (abdominal pain, hematochezia, ect) suggestive of?
A
Tissue invasive CMV (causing pnemonitis, hepatitis, gastroenteritis, ect).
7
Q
What is a patient with brownish skin pigmentation, elevated fasting blood glucose, elevated LFT’s, and erectile dysfunction suggestive of?
A
Hereditary hemochromatosis (“bronze diabetes” and ED from hypogonadism). Increased risk of HCC and infections such as Listeria, Vibrio vulnificus, ect.
8
Q
In addition to IV benzos, what should be administered for status epilepticus?
A
A non-benzo anti-epileptic such as fosphenytoin to prevents seizures. Then head imaging can be performed.
9
Q
What defines aplastic anemia?
A
An acquired deficiency of pluripotent stem cells (pancytopenia with no splenomegaly or abnormal cells on peripheral smear).
10
Q
What cardiac dysfunction is seen with acromegaly?
A
Concentric myocardial hypertrophy. (asymmetric IV septum hypertrophy would be seen in hypertrophic cardiomyopathy but not myocardial hypertrophy due to other causes).
11
Q
What is the most likely cause of esophagitis in an HIV patient with odynophagia (pain with swallowing)?
A
Viral esophagitis. Candida esophagitis would have dysphagia but would not be painful (additionally there would be the presence of oral thrush which the patient did not have).
12
Q
What are the signs of high output heart failure?
A
Widened pulse pressure, strong peripheral arterial pulsation (e.g. brisk carotid upstroke), and a systolic flow murmur. LV hypertrophy is usually present with the point of maximal impulse displaced to the left.
13
Q
What should be suspected in a patient with signs of heart failure and a history of prior trauma (stab wound) to the thigh?
A
An AV fistula causing high-output heart failure.
14
Q
What is the management of severe Grave’s disease? (mild would be with anti-thyroid drugs)
A
A beta-blocker plus an anti-thyroid drug (propylthiouracil, methimazole) is given to stabilize the patient before definitive treatment (radioactive iodine or thyroidectomy).
15
Q
What would hyponatremia, hyperkalemia, and hypoglycemia in a patient with an upper lobe cavitary lesion on CXR suggest?
A
Addison’s/primary adrenal insufficiency secondary to disseminated TB. Would have a normal anion-gap metabolic acidosis.
16
Q
What are the signs and fundoscopic findings of a vitreous hemorrhage?
A
Sudden loss of vision and onset of floaters. Most commonly occurs in those with diabetic retinopathy. Fundoscopy shows loss of fundus details (difficulty visualizing the fundus) with floating debris and a dark red glow.
17
Q
What is proximal muscle weakness in the setting of hand and/or eyelid rash, normal DTR’s, and a lung mass indicative of?
A
Dermatomyositis.
18
Q
What does a right sided pleural effusion in a patient with ascites suggest?
A
Hepatic hydrothorax (transudative fluid movement through diaphragmatic defects).
19
Q
What is the empiric antibiotic regimen for patients with acute bacterial meningitis who are immunosuppressed? (i.e. organ transplant, ect).
A
Cefepime, vancomycin, and ampicillin (to cover for Listeria).
20
Q
What drug class can cause SIADH in the elderly?
A
SSRIs.
21
Q
Which Grave’s disease treatment can worsen the Grave’s ophthalmopathy?
A
Radioiodine ablation.
22
Q
What is the first line maintenance medication for stable angina and how dies it address stable angina?
A
Beta-blockers, their main effect is to decrease myocardial oxygen demand by reducing myocardial contractility and heart rate.
23
Q
What diabetic medication class is best for weight loss?
A
GLP-1 agonists (exenatide, liraglutide).
24
Q
How does thyrotoxicosis cause HTN?
A
Increases myocardial contractility, leading to an increase in systolic BP with a widened pulse pressure (can lead to high out-put heart failure).
25
What typically precedes vasovagal syncope?
A prodrome of nausea, diaphoresis, pallor, and light headedness. EKG immediately before syncope would show sinus bradycardia and sinus arrest.
26
What is typically seen in Alzheimer's patient's on MRI?
Temporal lobe atrophy.
27
What is seen with Grave's opthalmopathy?
Proptosis and impaired extraocular motion (impaired convergence and diplopia).
28
What compensatory mechanism allows for LV volume overload states (aortic regurgitation, ect) to initially be asymptomatic?
An increase in LV compliance (increased LV stretch leading to increased SV via Frank-Starling). Leads to eccentric hypertrophy.
29
What causes bloody diarrhea in an AIDS patient?
CMV (cryptosporidium would be watery diarrhea).
30
What is the management outline for hypernatremia?
First assess volume status. If euvolemic then oral water, if hypovolemic then assess if they are symptomatic or not. If not then use hypotonic fluid (5% dextrose) and if symptomatic then rehydrate with NS (0.9%) followed by hypotonic.
31
What are the best markers for assessing resolution of ketonemia in DKA?
The serum anion gap and direct assay of beta-hydroxybutyrate.
32
What does lower extremity pitting edema with a medial malleolus ulcer, a history of being worse at night, and no signs of CHF suggest?
Chronic venous insufficiency. Manage initially with leg elevation and compression stockings.
33
What are the exam findings for open angle glaucoma?
Cupping of the optic disc (from increased intraocular pressure) and loss of peripheral vision.
34
What is the initial empiric antibiotic for febrile neutropenia?
An anti-pseudomonal agent such as piperacillin-tazobactam, cefepime, ect. (Gram negative and gram positive coverage).
35
What is the most significant complication of untreated benign intracranial hypertension/pseudotumor cerebri?
Blindness (may need to perform an optic nerve sheath fenestration).
36
What does the development of hypotention and an urticarial rash after the insertion of a foley catheter suggest?
Anaphylaxis due to latex allergy (many foley catheters still contain latex).
37
What is the difference between a case control study and a retrospective cohort study?
Case control studies determine the outcome and look for associated risk factor, while a cohort study ascertain risk factor exposure and then determine the outcome.
38
What is the PCWP in PE?
Normal to low (since blocking the PA means less blood return to the LA). If PCWP is elevated then it is most likely MI.
39
What can be seen on examination with pulmonary hypertension (as can be caused by scleroderma)?
Right ventricular heave (impulse palpated immediately to the left of the sternum that suggests RV enlargement).
40
What is the initial presentation of cyanide toxicity? (i.e. patient with HTN emergency on nitroprusside drip)
AMS/confusion and seizures followed by coma.
41
What is the only anti-platelet that is effective in reducing the risk of early occurrence of ischemic stroke/TIA?
Aspirin. It should be given w/i 24 hours for all patient swith ischemic stroke. If patient is already on aspirin then add clopidegrel or dipyradamole.
42
Are heparins indicated in the management of ischemic stroke?
No, due to the risk of intracranial bleed (no enoxaparin and stroke). Use anti-platelet (aspirin).
43
What can be seen on imaging of pseudogout (CPPD crystal disease)?
Chondrocalcinosis (calcification of articular cartilage).
44
On EM what does dense deposits of C3 in the GBM in a patient with nephrotic range proteinuria and hematuria suggestive of?
Type 2 membranoproliferative glomerulonephritis (dense deposit disease). Due to persistent activation of the alternative complement pathyway caused by C3 nephritic factor.
45
What is the management of a myasthenic crisis? (i.e. patient with myasthenia gravis who develops respiratory failure,ect).
Secure the airway/intubate and hold their acetylcholinesterase inhibitor (as agents such as pyridostigmine can increase bronchial secretions). Once stabilized perform plasmapharesis and give corticosteroids.
46
Is the PPV-23 a conjugate vaccine?
No, so it will induce a T-cell independent B cell response (as opposed to the PPV-13 which is conjugated and thus will induce a T cell dependent B cell response).
47
What are some signs of co-morbid GERD in an asthma patient?
Sore throat, morning hoarseness, cough worse only at night, and an increased need for rescue inhaler following meals. Justifies adding a PPI.
48
What does the rapid onset of hypotension and a harsh systolic murmur along the left sternal border in a patient with a recent MI suggest?
IV septum rupture.
49
What are the indications for home oxygen therapy in those with COPD?
PaO2 < 55 or pulse ox < 88% on room air.
50
What are the findings with supravalvular aortic stenosis? (Congenital LVOT obstruction from ascending aorta stenosis)
A systolic murmur in the right first intercostal space, a paplable thrill in the suprasternal notch, and a blood pressure difference between arms.
51
What is often associated with supravalvular aortic stenosis?
LV hypertrophy and coronary artery stenosis leading to exertional angina from increased myocardial O2 demand.
52
What are patients with a prior MI and an EF <30% at increased risk for?
Sudden cardiac death due to ventricular arrhythmia. Following a trial with optimal medical therapy (beta-blocker, ACEI, spironolactone), these patients should have primary prevention with an ICD (implantable cardioverter-defibrillator).
53
What types of vaccines should be avoided in those on TNF-alpha inhibitors (adalimumab, ect)?
Live attenuated.
54
What is the serum to ascites albumin gradient (SAAG) and what is it's significance?
SAAG (i.e. serum albumin - ascites albumin) determines if ascites is from portal hypertension (cirrhosis, CHF) or another cause. SAAG > 1.1 mean portal hypertension, while a SAAG of <1.1 suggests another cause.
55
What is the cutoff for neutrophil count in ascites fluid to determine peritonitis/infection?
250 (less then 250 neutrophils means no peritonitis).
56
What does a painful, red eye with corneal opacification and ulceration in a contact lens user suggest?
Contact-lens associated keratitis, which is most commonly caused by Pseudomonas.
57
What is the treatment for central retinal artery occlusion? (painless mono-ocular vision loss with diffuse ischemic retinal whitening and cherry red spots on fundoscopy)
Ocular massage and high flow O2. Intra-arterial thrombolytics may be used but not intravenous.
58
What effects can trimethorprim have on lab values?
TMP can cause hyperkalemia and an artificial increase in serum creatinine (through blockade of ENaC in the collecting tubule and glomerular reabsorbtion of creatinine respectively).
59
In addition to trimethorprim what other medications can cause hyperkalemia?
Non-selective beta-blockers, ACEI/ARBS/K+ sparing diuretics, digoxin, cyclosporine, heparin, NSAIDS, succinylcholine.
60
What is a potentially life-threatening complication of influenza in a young adult?
Secondary bacterial pneumonia with community acquired MRSA (causes a necrotizing pneumonia with hemoptysis and multilobular cavitary lesions).
61
What is the next best step for a patient with chronic headaches who develops a new type of headache? (ex unilateral headaches for years and now a new-onset severe bilateral headache).
Brain MRI. Remember that a new type of headache in a patient with chronic headaches is one of the red flags that warrants head imaging.
62
What is pain/redness in the medial canthal region suggestive of?
Dacrocystitis (inflammation of the lacrimal sac). Usually caused by S. aureus and responds to systemic antibiotic therapy.
63
Can cyclophosphamide cause bladder carcinoma?
Yes, in addition to hemorrhagic cyctitis due to accumulation of acrolein.
64
What does tight glycemic control reduce the risk of?
Microvascular complications (retinopathy, nephropathy, ect.) but not macrovascular complications (MI, stroke).
65
What is the next best step for a patient with chronic epigastric pain that is relieved by leaning forward, weight loss, and alcohol use?
CT of the abdomen to look for chronic pancreatitis (weight loss indicated malabsorption). Plus the pain with chronic pancreatitis usually relieves with leaning forward.
66
What is the initial work-up for a first time seizure in an adult?
Basic blood tests and a toxicology screen (drug test, ect). If those are normal then follow-up with neuroimaging and EEG.
67
What should a splenic infarct (LUQ pain and wedge shaped hypodensity on ultrasound) prompt evaluation for?
Sickle cell disease or trait, hypercoagulable states, and embolic states (patient had normal Hgb but elevated reticulocytes and indirect bilirubin suggesting mild hemolysis secondary to sickle cell trait thus the answer was perform hemoglobin electrophoresis).
68
What is the next best step for confirmed myasthenia gravis?
Chest CT to look for a thymoma.
69
What is the cutoff for the PPD skin test?
15 mm
70
What is telogen effluvium?
An acute, diffuse, and non-inflammatory hair loss triggered by stressful events. Patients have widespread hair thinning but normal scalp and hair shafts and a hair pull test with >10% fibers. It is self-limiting.
71
What should be suspected in an elderly woman with T2DM who presents with epigastric pain associated with nausea and vomiting but who has a normal abdominal exam?
Atypical MI. The next best steps should be ECG.
72
Can adenoviral conjunctivitis be unilateral?
Yes. Suspect viral conjunctivitis in a person with unilateral red eye (with no purulent discharge), rhinorrhea, and a sore throat. Tx is cold or warm compresses. As with all viral URI be aware of a secondary bacterial infection developing.
73
What is the urine chloride in metabolic alkalosis due to vomiting?
It is low. (high urine chloride would be seen in hyperaldosteronism, current diuretic use, Bartter and Gitelman syndromes, ect).
74
What is the next best step for a hemodynamically stable patient with afib with RVR?
Rate control with a beta-blocker or non-dihydropyridine Ca2+ blocker.
75
What infection can mimic sarcoidosis? (bilateral hilar adenopathy, erythema nodosum, non-caseating granulomas on biopsy, ect)?
Histoplasmosis. If a patient initially looks like they have sarcoidosis but get worse after steroid administration it may be Histoplasmosis instead.
76
What does signs of thyrotoxicosis with a painless enlarged thyroid, decreased TSH, and decreased radioiodine uptake on thyroid scinigraphy suggest?
Painless thyroiditis.
77
What is the first step in diagnosis of suspected bronchiectasis?
High resolution CT of the chest.
78
What is the next best step for an AIDS patient with oral thrush and burning substernal pain?
Empiric fluconazole for Candida esophagitis (if there is oral thrush you can empirically assume that it is Candida esophagitis). If there is no oral thrush or treatment fails then do EGD with biopsy.
79
Can calcium supplements cause milk-alkali syndrome?
Yes (suspect osteoporosis vitamin supplements as a potential cause of hypercalcemia {polyuria, abdominal pain, constipation, ect}).
80
Are Baker's cysts common in osteoarthritis?
Yes. In a patient with knee pain, a fluctuant posterior knee mass, and non-inflammatory findings on synovial fluid analysis suspect osteoarthritis.
81
What do yellow-white exudates following retinal vessels on fundoscopic exam in an AIDS patient with decreased vision suggestive of?
CMV retinitis.
82
What is the treatment for subacute thyroiditis? (Neck pain and hyperthyroid symptoms such as systolic HTN following an URI)
Beta-blockers for control of thyrotoxicosis symptoms and NSAIDS for pain relief.
83
What are the signs of subclavian steal syndrome? (stenosis of the subclavian artery {such as atherosclerosis, ect} proximal to the vertebral artery).
BP difference between arms, signs of arm ischemia (pain, parasthesias, ect), signs of vertebrobasilar insufficiency (vertigo, ect), and a systolic bruit in the supraclavicular fossa on the affected side.
84
What does significant hypertension in the setting of primary hyperparathyroidism suggest?
Pheochromocytoma from MEN 2A (MPH - medullary thyrpid carcinoma, pheochromocytoma, and hyperplasia of parathyroid glands).
85
What are the hallmarks of secretory diarrhea?
Large stool volumes (> 1 L/Day), occurs even during fasting/sleep, and has a low stool osmotic gap (SOG < 50 mOsm/kg).
86
What are the colonoscopy guidelines for a patient with a first degree relative with colon cancer?
Colonoscopy at either age 40 or 10 years before the relative's age of diagnosis (whichever comes first). (ex. if someone's Dad was diagnosed with colon cancer at age 50 then they should receive a colonoscopy at age 40). Repeat every 5 years.
87
What is the most likely diagnosis for a patient with signs of decompensated HF (dyspnea, ect) who presents weeks/months after an MI and whose ECG shows persistent ST elevation in the same leads as the initial MI?
Ventricular aneurysm (due to fibrotic remodeling in the areas of ischemia hence persistence of ST elevation in the same leads). Confirm with echocardiogram.
88
What causes the pleuritic pain with a PE?
Pulmonary infarction.
89
What is the management for acute decompensated heart failure with pulmonary edema?
Supplemental oxygen, diuresis (furosemide, ect) and vasodilator therapy (nitroglycerin) if HTN is present. If hypotehnsion/shock is present then give vasoconstrictors (NE). Beta-blockers should be avoided due to potential worsening of acute heart failure.
90
What is presbycusis?
A sensorineural hearing loss that occurs with aging (typically shows in the 6th decade of life). Patients often complain of difficulty hearing in crowded/noisy places.
91
What are the exam findings in alcoholic cerebellar degeneration?
Abnormal heel-knee-shin testing and an inability to tandem walk but relatively spared limb function (normal finger-nose testing) (due to preferentially affected the vermis {truncal ataxia}).
92
Are blood cultures negative in disseminated gonoccocal infection?
Yes. Anyone with fever, polyarthralgia, and a pustular rash should receive NAAT testing for N. gonorrhea as well as synovial aspiration.
93
What does the pronator drift sign assess for?
Pyramidal/corticospinal tract disease (with an UE UMN lesion the supinator muscles are weaker than pronator which is why the patient pronates their hands with their eyes closed).
94
What do claw/hammer toe deformities suggest?
A potential underlying neuropathy.
95
What are the biggest risk factors for TB in the US?
Substance abuse and incarceration. TB should be on the differential for a person with hx of IV drug use and jail time who presents with constitutional symptoms (fever, weight loss) and a CXR showing diffuse bilateral reticulonodular pattern (disseminated/miliary TB).
96
What is a necessary component of the management of ARDS?
Preventing alveolar overdistension by having a low tidal volume ventilation. (initially put PEEP < 5 but in ARDS PEEP of up to 15-20 CM H20 may be necessary to provide adequate oxygenation).
97
At what 10 year ASCVD risk percentage should statin therapy be initiated?
>7.5% (initiate if under in diabetics)
98
What is the first line for exercise induced asthma in patient who do not exercise daily?
Albuterol 10-15 min before exercise. If patient exercises daily then inhaled corticosteroids and anti-leuokotriene agents (montelukast, ect) can be used.
99
What acid base disorder can be seen in CHF exacerbation (bibasilar crackles, ect)?
Respiratory alkalosis due to tachypnea.
100
What are some manifestations of Waldenstrom macroglobulinemia?
Peripheral neuropathy, headaches/dizziness, decreased visual acuity with tortuous retinal veins on fundoscopy, an elevated ESR, and a gamma gap (large difference between total serum protein and serum albumin).
101
What are the colonoscopy guidelines for patients with ulcerative colitis?
Initiate colonoscopy screening 8 years after the initial diagnosis and repeat every 1-2 years.
102
What is a potential complication of nitrofurantoin?
Acute pulmonary injury (most commonly a hypersensitivity pneumonitis). Patients have SOB, dry cough, fever, eosinophilia, and/or an erythematous rash 3-9 days after taking nitrofurantoin. CXR shows bilateral opacities and/or pleural effusion.
103
What eye field defect can be seen in a putaminal intracerebral hemorrhage?
Eye deviation to the side of the lesion due to involvement of afferents from the frontal eye fields (contralateral hemiparesis and ipsilateral eye deviation).
104
What is the most reliable and accurate indicator of opioid overdose?
Respiratory depression/bradypnea. Consider naloxone in intoxicated patients who have respiratory depression. (sign like miosis may be less reliable due to co-intoxication with stimulants, ect).
105
What are the signs of chronic arsenic poisoning?
Hypo/hyperpigmented skin lesions, hyperkeratosis, and peripheral neuropathy. Treat with dimercaprol.
106
Can SLE present with seizures?
Yes. It can also cause transverse myelitis.
107
What is the most likely diagnosis for a patient with aortic dissection who then develops pulmonary edema (orthopnea, dyspnea, ect)?
Aortic regurgitation. Cardiac tamponade wouldn't have signs of pulmonary edema due to the left heart being less affected than the right (JVD, ect).
108
Can nephritic syndrome cause JVD and pulmonary edema?
Yes, due to fluid overload from decreased GFR.
109
In addition to aortic stenosis what valvular defect can arise from a bicuspid aortic valve?
A bicuspid aortic valve can cause aortic regurgitation (ear decrescendo diastolic murmur at the left sternal border). Suspect in a younger person with this murmur.
110
What is the treatment for uremic pericarditis? (pericarditis in the setting of a BUN >60)
Hemodialysis.
111
What is a potential cutaneous complication of systemic glucocorticoids?
Drug-induced acne (monomorphic papules/pustules without comedomes or scarring and which are most common on the upper back, shoulders, and upper arms).
112
What is the pathophysiology of sick sinus syndrome?
Degeneration and fibrosis of the SA node and cardiac conduction system.
113
What is the diagnosis for a nephrotic syndrome patient who suddenly develops abdominal pain, fever, and gross hematuria?
Renal vein thrombosis. Is a risk factor in all nephrotic syndromes but is most common in membranous nephropathy.
114
What is the most likely cause of frontal headaches worse at night with blurry vision that is made worse with leaning forward?
Increased intracranial pressure.
115
What is the first line tx for symptomatic premature ventricular contractions (PVCs)?
Increasing the dose of patient's beta-blocker or Ca2+ channel blocker (does not correct PVCs but helps symptoms). Amiodarone can be used for refractory cases.
116
Can the pain from shingles precede the rash?
Yes. Suspect shingles in a patient with burning abdominal pain that is sensitive to touch but has no signs of organ involvement (no diarrhea, nausea, ect). (especially consider in those who are immunosuppressed such as those on chemotherapy).
117
What is the treatment for uremic encephalopathy? (AMS and asterixis in the setting of extremely elevated BUN)
Hemodialysis.
118
What is a warning sign that an acute asthma exacerbation is heading towards respiratory failure?
A normal PaCO2 level. (Normally would have repsiratory alkalosis but a normal PaCO2 despite tachypnea suggests either respiratory ,muscle fatigue or air trapping).
119
What skin finding would be found in cholesterol emboli? (Hx of recent vascular procedure such as coronary stenting, ect)
Livedo reticularis (purple discoloration of the skin that blanches with pressure). Can also see eosinophilia.
120
What is the most likely diagnosis in a patient with hypertension, a potassium of 3.1, and undetectable plasma renin activity?
Primary hyperaldosteronism.
121
What abnormal heart sound can be heard early on in an acute MI?
An S4 (atrial gallop) due to LV stiffening induced by myocardial ischemia.
122
What is unthoff phenomenon?
Worsening or precipitation of multiple sclerosis symptoms upon exposure to high temperatures (such as moving to AZ in the summer, ect).
123
What is the most appropriate step in the evaluation of an unprovoked first time DVT?
Age appropriate malignancy screen (ex if patient is over 50 then a colonoscopy may be warranted, or a mammogram if female ect).
124
What is the management of caustic ingestion? (ex drinking NaOH drain cleaner)
CXR and abdominal plain films to evaluate for perforation. If perforation then do upper GI x-ray study with water soluble contrast. If no perforation then do EGD.
125
What is the pH cutoff for initiating sodium bicarb therapy?
<7.1. In most cases the risks of NaHcO3 (increased lactic acid, myocardial depression) outweigh the benefits if pH is above 7.1.
126
What should hematuria, polycythemia, and a left sided varicocele raise suspicion for?
RCC (do abdominal CT).
127
What does low testosterone in the setting of normal FSH/LH levels indicate?
Secondary/central hypogonadism (even if FSH/LH are normal they should be elevated in the setting of low testosterone so this still represents an abnormal hypothalamic-pituitary response). Do the appropriate work-up (obtain serum prolactin, ect).
128
What should be tested for in all patient who have an isolated thrombocytopenia?
HIV and HCV (especially HIV since thrombocytopenia can be a presenting sign).
129
What is the next step for suspected polymyalgia rheumatica? (Elevated ESR with proximal muscle stiffness {NOT weakness} in a patient over 50).
Low dose prednisone (10 - 20 mg). Although PMR may be associated with temporal arteritis a biopsy should only be done if there's signs of TA (jaw claudication, temporal headache, amaurosis fugax, ect).
130
What is the preferred imaging study for suspected aortic dissection (chest pain radiating to the back) in a patient with elevated creatinine? (would normally be CT angiogram)
Trans-esophageal echocardiography.
131
What is the test of choice for suspected CLL? (elderly patient with severe lymphocytosis, hepatosplenomegaly, and lymphadenopathy)
Flow cytometry (LN biopsy is not indicated for CLL). Remember that additional findings for CLL are infection (patient had pneumonia), hemolytic anemia, and secondary malignancies (Richter transformation).
132
What factors require an EGD in the evaluation of typical GERD symptoms? (burning substernal chest pain after eating, ect) (normally would do an empiric PPI trial and f/u if refractory)
Alarm symptoms (dysphagia, weight loss, anemia, recurrent vomiting) or men age > 50 with symptoms for > 5 years and cancer risk factors (smoking, ect).
133
What is the most likely diagnosis in a chemotherapy patient who develops fever and non-tender, gangrenous macules and pustules?
Ecthyma gangrenosum (Pseudomonas infection, do blood cultures for gram-negative bacteremia).
134
How can cardiac tamponade be distinguished from a massive PE? (signs of right heart failure such as JVD and hypotension, ect).
Massive PE would have hypoxemia (also patient had colon cancer, i.e. hypercoagulable state).
135
What are the risk factors that warrant anti-viral medication sin the management of influenza?
Age >65, chronic medical conditions, and pregnancy. Everyone else can be managed symptomatically.
136
What imaging results are seen in acute cholangitis? (Charcot's triad of fever, RUQ pain, and jaundice).
Dilation of the intrahepatic and common bile duct.
137
Can PE cause pleural effusion?
Yes. Suspect PE in an immobilized patient with tachypnea, tachycardia, pleuritic chest pain, ect and evidence of a small pleural effusion on CXR.
138
What is the tx for actinimycetes?
Penicillin.
139
Can irritant contact dematitis have vesicles?
Yes.
140
What tests are used in the initial evaluation of Cushing's?
Late night salivary cortisol assay, 24 hour urine free cortisol measurement, and an overnight low-dose dexamethsaone suppression test.
141
What are the signs of Ehrliciosis? (tick borne illness in the southeastern and south central USA).
An acute febrile illness with AMS, leukopenia/thrombocytopenia, and elevated transaminases/LDH. Unlike lyme or rocky mountain spotted fever there is usually no rash.
142
What is the treatment for Guillain Barre syndrome?
IVIG or plasmapharesis.
143
In addition to the elderly what age group can develop otosclerosis? (conductive hearing loss i.e. BC>AC in the affected ear).
Adults in their 20-30's.
144
How do vagal maneuvers affect AVNRT?
They slow conduction at the AV node (while it also slows down SA conduction the reentrant pathway in AVNRT does not involve the SA node).
145
What is the most common cause of gross lower GI bleeding?
Diverticulosis (typically painless and bright red blood per rectum, ect).
146
Is acetaminophen a CYP inhibitor or inducer?
It is a CYP inhibitor (i.e. increases warfarin effect, ect).
147
What is a potential presenting complaint of Sjogren's?
Dysphagia secondary to decreased salivation (i.e. dysphagia with dry food like crackers and relieved with water).
148
What is the most likely diagnosis in a patient who has abdominal pain/diarrhea which resolves and then one week later develops periorbital edema, myositis, and eosinophilia?
Trichinellosis (initial abdominal pain/diarrhea from the larvae intestinal phase and then the triad of periorbital edema, myositis, and eosinophilia from the muscle stage). (Remember these stages because the question stem did not mention eating undercooked meat).
149
What is the calculation for risk?
people with disease and exposed to risk factor/total # people with risk factor exposure
150
What are the signs/symptoms of pill esophagitis?
Sudden onset retro-sternal pain with odynophagia. EGD shows deep ulceration with normal surrounding mucosa.
151
What does insulin resistance do in regards to lipolysis?
Increases lipolysis which releases free fatty acids (FFA) which go to the liver and participate in NAFLD pathogenesis.
152
What does straight grid lines appearing curved on ocular exam suggest?
Macular degeneration (can be unilateral).
153
What is the best initial step for a suspected disc herniation?
NSAIDs/Acetaminophen (most cases of lumbosacral radiculopathy will spontaneously resolve).
154
What are the risk factors that require a PPV23 before age 65?
Heart or lung disease, diabetes, smoking, and chronic liver disease.
155
What is the first step for severe hypercalcemia?
IV hydration and calcitonin.
156
What is the initial treatment for frostbite?
Rapid reheating in warm water. (note though that rewarming shouldn't be done if there is a risk of re-freezing the tissue (ex. on the field)).
157
If after 2 days/48 hours a hospitalized pyelonephritis patient shows improvement what is the next best step?
Switch from IV antibiotics to culture determined oral antibiotics (ex if culture shows it is TMP-SMX sensitive switch to oral TMP-SMX).
158
Does enoxaparin prolong the aPTT?
No. A person with HIT and a prolonged aPTT was likely given unfractionated heparin.
159
What characterizes herpes simplex keratitis?
Corneal vesicles and dendritic ulcers.
160
What is a factorial study design?
One in which there are two or more experimental interventions each with two or more variables that are studied independently.
161
What is effect modification?
When an external variable positively or negatively impacts the effect of a risk factor on the disease of interest. Can be confused with confounding but unlike confounding there is still a statistically significant risk-outcome association. For both stratified analysis elucidates the correlation.
162
What does a patient with fever, exudative pharyngitis, cervical lymphadenopathy, and hemolytic anemia (jaundice, ect) suggest?
Infectious mononucleosis complicated by autoimmune hemolytic anemia. (initially put malaria but that would have cyclical fever and wouldn't have an exudative pharyngitis).
163
What is the next best step for management of acute liver failure? (triad of elevated transaminases, hepatic encephalopathy, and synthetic dysfunction/prolonged PT with INR >1.5)
Liver transplant.
164
After supportive care is given (O2, ect) what is the next best step for management of suspected PE with no contraindications to anti-coagulation?
IV heparin infusion (if no contraindications to anti-coagulation is present then do anti-coagulation before diagnostic studies like CT angiogram).
165
What is the next best step for a pregnant woman with hx of miscarriage who has elevated TSH but normal T4?
Check anti-TPO antibody titers and start on levothyroxine. Anti-TPO antibodies can cause miscarriage and even if seemingly euthyroid (subclinical hypothyroidism) an elevated TSH in a pregnant woman should prompt evaluation and treatment.
166
What is the most likely diagnosis in a patient with a viral URI who then develops cough with purulent looking blood streaked sputum and crackles/wheezes on auscultation but has a normal CXR?
Most likely acute bronchitis (sputum and blood is due to epithelial sloughing and not a sign of bacterial infection). Treatment is symptomatic only (no antibiotics).
167
What is the most likely diagnosis for a pure motor stroke (muscle weakness but no sensory loss) in a patient with HTN and a normal head CT?
A lacunar infarct in the internal capsule (microatheroma and small vessel lipohyalinosis). Often not appreciated on non-contrast CT initially due to their small size.
168
How can emphysema and chronic bronchitis be differentiated in terms of DLCO findings?
DLCO will be decreased in emphysema (less surface area for diffusion) while DLCO is normal in chronic bronchitis.
169
Does renal artery stenosis cause flank pain or urinary symptoms?
No. In a patient with one kidney (hx of nephrectomy) flank pain and urinary symptoms are more likely to be due to a renal calculi.
170
What is the gold standard for diagnosing T2DM in PCOS patients?
Oral glucose test (more sensitive than A1c, ect).
171
What is the next best step in management of a patient with altered level of consciousness and ongoing hematemesis? (after two large bore IV's have been placed for fluid resuscitation).
Endotracheal intubation (remember the ABCs!!!!! Airway, breathing, circulation)
172
What are the imaging results for invasive pulmonary aspergillosis?
Nodules with surrounding ground glass opacities (halo sign) on chest CT. Initially put reactivation TB due to it being an upper lobe lesion but the ground glass opacities would not be associated with TB.
173
How long do the demyelinating plaques in multiple sclerosis last?
Days to weeks. Therefore sudden onset arm weakness/ect. that resolves in under 24 hours in a MS patient with vascular risk factors (hyperlipidemia, ect) is more likely a TIA than an MS attack (give statin and aspirin).
174
What are the signs of acute phenytoin toxicity?
Horizontal nystagmus, ataxia, dysmetria (abnormal finger-nose), slurred speech, and nausea/vomiting.
175
Asides from malabsorption and hepatocellular carcinoma, what is primary biliary cholangitis a risk factor for?
Metabolic bone disease (osteomalacia or osteoporosis).
176
What should be suspected in a cocaine user found passed out on the floor who then regains consciousness but is confused afterwards?
Seizure (cocaine is a potential cause of seizures, always think of loss of consciousness with awakening but confusion (i.e. post-ictal state) as a potential seizure). In the question's case it lead to rhabdomyolysis (hyperkalemia and elevated CPK) which led to AKI.
