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Flashcards in Mixed Step 2 Review Deck (335):
1

What is the most useful intervention to improve functional capacity and reduce claudication in peripheral artery disease (PAD) patients?

A supervised graded exercise program

Antiplatelet agents (aspirin, clopidogrel) do not consistently reduce claudication symptoms, but are indicated to reduce the risk of myocardial infarction, stroke, and cardiovascular mortality. Current guidelines also recommend high-intensity statin therapy for reducing cardiovascular risk in patients up to age 75 with clinically significant atherosclerotic cardiovascular disease. Other measures for treating PAD include smoking cessation, aggressive diabetes control, and blood pressure control.

1

All-trans retinoic acid is a crucial component of therapy for what condition?

Acute promyelocytic leukemia

The retinoic acid receptor is involved in the pathogenesis of this condition.

1

Any HIV-positive patient with bloody diarrhea and a normal stool examination should have a colonoscopy with biopsy to look for what?

Cytomegalovirus (CMV) colitis

CMV colitis is characterized by bloody diarrhea with abdominal pain. Colonoscopy shows multiple ulcers and mucosal erosions. Biopsy demonstrates characteristic cytomegalic cells with inclusion bodies.

1

What condition is characterized as generally asymptomatic in the initial stages, followed by a gradual loss of peripheral vision over a period of years, and eventual tunnel vision?

Open angle glaucoma

It is more common in African-Americans. Beta-blockers such as timolol eye drops are effective in the initial management of the patient. Laser trabeculoplasty is used as an adjunctive measure. If there is a continuous increase in intraocular pressure, surgical trabeculectomy is done.

1

What is the most common cause of blindness in industrialized countries?

Macular degeneration

The primary risk factor is age, although smoking can increase the risk as well.

1

A nail puncture wound in an adult resulting in osteomyelitis is most likely due to what pathogen?

Pseudomonas aeruginosa

Treatment is with oral or parenteral quinolones and aggressive surgical debridement.

1

What is the most effective treatment for malignant otitis externa?

Intravenous ciprofloxacin

1

What test is recommended prior to starting trastuzumab (herceptin) therapy?

Echocardiogram

Trastuzumab can be cardiotoxic so an echocardiogram is recommended before beginning treatment, both to establish a baseline should there be concern for cardiotoxicity in the future, but also to consider other treatments in patients with poor baseline heart function.

1

What is the U.S. Preventive Services Task Force (USPSTF) screening recommendation regarding chlamydial infection in women?

Screen all sexually active women age 24 years and younger, and screen other asymptomatic women at increased risk for this infection

Patients at increased risk include those with other sexually transmitted diseases and those with new or numerous partners.

1

Progressive blurring of central vision bilaterally (acute or insidious) with ophthalmoscopic exam revealing central scotoma and growth of abnormal vessels in the retinal space is indicative of what diagnosis?

Exudative macular degeneration

Sudden visual loss may occur if it is complicated by retinal detachment.

1

What are some key differences betwen rheumatoid arthritis and arthritis secondary to parvovirus B19?

  1. Rheumatoid arthritis: Morning stiffness >1 hour, joint swelling on exam, and symptoms for >6 weeks
  2. Parvovirus arthritis: Morning stiffness for 10-15 minutes, no joint swelling on exam, acute onset of symptoms

2

Any elderly patient with bone pain, renal failure, and hypercalcemia has what until proven otherwise?

Multiple myeloma

2

What condition is associated with rheumatoid arthritis and other autoimmune disorders and is characterized by a localized or patchy red eye with mild associated pain and discharge?

Episcleritis

It is usually self-limited and does not affect vision or involve the cornea.

2

What is the most common malignancy diagnosed in patients exposed to asbestos?

Bronchogenic carcinoma

Asbestos exposure increases the risk of pulmonary fibrosis and malignancy. Smoking acts synergistically with asbestos to further increase the risk of lung cancer. Asbestos is the only known risk factor for malignant pleural mesothelioma, however, bronchogenic carcinoma is more common in patients with asbestos exposure, especially smokers. Pleural mesothelioma typically presents as a unilateral pleural abnormality with a large pleural effusion on chest x-ray

2

What are the three best initial screening tests for patients with suspected adrenal insufficiency?

  1. Early-morning cortisol levels
  2. Adrenocorticotropic hormone (ACTH) levels
  3. Cosyntropin (ACTH analogue) stimulation test

An increase in serum cortisol levels >20ug/dL 30-60 minutes after the administration of 250ug cosyntropin virtually rules out primary adrenocortical insufficiency (Addison's disease).

 

3

What is expected to be seen in the bone marrow of a patient with multiple myeloma?

Overproliferation of plasma cells

Classical findings of multiple myeloma include lytic bone lesions, marrow plasmacytosis, and urine/serum monoclonal proteins (Bence Jones proteins).

3

What diagnosis should be suspected in an elderly patient with anemia, renal failure, and hypercalcemia?

Multiple myeloma

Serum immunoelectrophoresis demonstrates a characteristically abnormal M-spike. In most cases, this is due to IgG antibody production by the abnormal plasma cells.

3

A pseudo-allergic reaction to which medication causes persistent nasal blockage and episodes of bronchoconstriction?

Aspirin

Aspirin sensitivity syndrome is believed to involve 'pseudo-allergic reaction' that is an exaggerated release of vasoactive and inflammatory mediators in susceptible individuals. Aspirin is a cyclooxygenase 1 and 2 inhibitor, and as a result of its pharmacological action, arachidonate diverges from blocked COXs to a 5-lipoxygenase pathway. Accumulation of leukotrienes and changed prostaglandin/leukotriene balance triggers characteristic reactions (bronchoconstriction, polyp formation) in susceptible individuals. Leukotriene inhibitors are gaining popularity in the treatment of this condition. Other commonly used treatment modalities include topical corticosteroids and aspirin desensitization therapy.

3

Liver failure is a well-known side effect of which HIV medication/medication class?

Nevirapine (non-nucleoside reverse transcriptase inhibitor)

3

Anemia of chronic disease is due to what?

Erythropoietin deficiency

One must be careful to ensure adequate iron stores prior to erythropoietin replacement because the erythropoietin-induced surge in red blood cell production can precipitate an iron-deficient state.

3

All patients, including pregnant patients, with chronic hepatitis C should receive vaccinations against what (assuming they are not already immune)?

Hepatitis A and B

Both vaccinations are safe during pregnancy.

3

What is the likely cause of vertigo if the patient also has a sensation of ear fullness?

Meniere's disease

Meniere's disease is a disorder of unclear etiology in which there is an abnormal accumulation of endolymph within the inner ear. A lesion of the eighth cranial nerve can lead to central vertigo, but it would not cause a sensation of ear fullness.

4

What is the appropriate treatment for hoarding disorder?

Selective serotonin reuptake inhibitors and cognitive behavioral therapy

6

Low plasma osmolality (100-150mOsm/Kg) is diagnostic of what condition?

Syndrome of inappropriate diuretic hormone (SIADH) secretion

One of the causes of SIADH is NSAID therapy - NSAIDs potentiat the action of antidiuretic hormone.

6

The high-dose dexamethasone suppression test is used to differentiate between what two conditions?

Cushing's disease and ectopic ACTH production

Failure to suppress 24-hour urinary cortisol or serum cortisol levels by 50% of the basal cortisol level makes ectopic ACTH syndrome more likely than Cushing's disease. This phenomenon can be explained by the fact that ACTH secretion by the pituitary adenomas is only relatively resistant to negative feedback regulation by glucocorticoids, whereas most ectopic tumors that produce ACTH are completely resistant to feedback inhibition.

7

How do the affected joints in the hand differentiate osteoarthritis and rheumatoid arthritis?

Osteoarthritis primarily affects the distal interphalangeal joints and rheumatoid arthritis primarily affects the metacarpal phalangeal joints and the proximal interphalangeal joints

8

Increasing hat size, decreased hearing, and headaches are signs/symptoms indicative of what diagnosis?

Paget's disease

The primary defect in Paget's disease is abnormal bone remodeling. Initially, there is a localized excess of osteoclastic bone resorption, in which there are usually increased numbers of larger than normal osteoclasts at the involved sites. With progression of osteoclastic activity, activation of the osteoblasts and immature bone deposition occurs. Activation of the osteoclasts and osteoblasts leads to transformation of normal lamellar and woven bone into a chaotic "mosaic" pattern of irregularly juxtaposed pieces of lamellar bone, interspersed with woven bone. Patients will have an elevated alkaline phosphatase level. Bisphosphonates are the most common treatment for symptomatic Paget's disease.

8

Acute or subacute vision loss and an ophthalmoscopic exam revealing optic disk swelling, retinal hemorrhage, dilated veins, and cotton wool spots are all suggestive of what diagnosis?

Central retinal vein occlusion

Loss of vision is typically not quite as acute as the vision loss seen in patients with central retinal artery occlusion which is characterized by an ophthalmoscopic exam that shows pallor of the optic disk, a cherry red fovea, and boxcar segmentation of blood in the retinal veins.

10

What two actions can help minimize the risk of contrast-induced nephropathy?

  1. IV hydration with isotonic bicarbonate or normal saline
  2. Administration of acetylcysteine

11

What is the treatment of choice for complicated cystitis?

Fluoroquinolones (5-14 days)

Extended-spectrum antibiotics like ampicillin/gentamicin can be used for more severe cases.

11

What is the first step in the evaluation of a patient with primary amenorrhea (absence of menarche by age 15)?

Ultrasound of the abdomen

This is performed to determine whether Mullerian structures (ovaries, uterus, or vagina) are present or absent. Ultrasound is the preferred modality to assess the uterus and ovaries. If the uterus is present, serum FSH levels should be attained. If the uterus is absent, karyotype and serum testosterone should be attained.

12

In what condition other than hereditary spherocytosis might the peripheral blood smear show spherocytes?

Autoimmune hemolytic disease

The difference is that the family history will be negative and the coombs test will be positive in autoimmune hemolysis vs positive family history and negative coombs in spherocytosis.

13

How is the diagnosis of Granulomatosis with polyangiitis (Wegener's) made?

c-ANCA positivity and tissue biopsy.

14

Most cases of contact lens-associated keratitis is due to what?

Gram-negative organisms such as pseudomonas and serratia

Gram-positive organisms as well as certain fungi and amoebas can also be the cause.

15

Dysphagia/odynophagia, substernal burning pain, large linear ulcers in the distal esophagus, and intranuclear and intracytoplasmic inclusions on biopsy are characteristic of what diagnosis?

Cytomegalovirus esophagitis

Treatment is ganciclovir.

15

What is the most reliable indicator of metabolic recovery in patients with diabetic ketoacidosis?

Arterial pH or anion gap

15

Which condition classically affects new mothers who hold their infants with the thumb outstretched (abducted/extended) and presents with tenderness that can typically be elicited with direct palpation of the radial side of the wrist at the base of the hand?

De Quervain tenosynovitis

The condition is caused by inflammation of the abductor pollicis longus and extensor pollicis brevis tendons as the pass through a fibrous sheath at the radial styloid process. The adductor pollicis longus and extensor pollicis brevis tendons are affected; passive stretch of these tendons elicits pain.

16

How is babesiosis definitively diagnosed?

Giemsa-stained thick and thin blood smear

Laboratory studies may demonstrate intravascular hemolysis, anemia, thrombocytopenia, mild leukopenia, atypical lymphocytosis, elevated erythrocyte sedimentation rate, abnormal liver function tests, and decreased serum complement levels.

16

What is the first-line treatment for central diabetes insipidus (DI)

Desmopressin

A water deprivation test can distinguish between central and nephrogenic DI and also definitively exculde primary polydypsia. Administration of desmopressin after water deprivation can distinguish between central and nephrogenic DI. Patients with central DI increase their urine osmolality by at least 50% following the administration of desmopressin acetate tablets; patients with nephrogenic DI will not show much change.

17

An increased leukocyte alkaline phosphatase score is characteristic of what?

Leukemoid reaction

Chronic myeloid leukemia (CML) and leukemoid reaction are indistinguishable on a peripheral blood film. The sudden elevation in the total leukocyte count and marked increase of granulocyte precursors (left shift) suggest a serious infection with or without an underlying leukemic state. The leukocyte alkaline phosphatase (LAP) test plays a role in distinguishing these two conditions. The LAP score is usually decreased in CML; however, it may be increased in the presence of subsequent secondary infections. For this reason, the presence of the philadelphia chromosome should be determined in suspicious cases since this is diagnostic for CML.

17

Senile purpura usually presents with ecchymoses in elderly patients in areas exposed to repeated minor trauma (I.E. extensor surfaces of the hands and forearms) and is caused by what?

Age-related loss of elastic fibers in the perivascular connective tissue

Senile purpura is not dangerous and requires no further evaluation.

17

Positive VDRL, a tendency toward spontaneous abortions, thrombocytopenia, and a prolonged PTT are characteristics of what condition?

Antiphospholipid antibody syndrome (APS)

APS can promote arterial and venous thromboses and a resultant tendency toward spontaneous abortions. Pregnant patients should be started on low molecular weight heparin (LMWH) to reduce the risk to the current pregnancy.

17

What condition presents initially with impaired fine visual acuity and distortion of straight grid lines, making them appear curved?

Macular degeneration

The primary risk factor is age, although smoking can increase the risk as well.

18

What hormone is responsible for refeeding syndrome?

Insulin

Carbohydrate intake stimulates insulin activity, which in turn promotes cellular uptake of phosphorus, potassium, and magnesium. Clinical manifestations include arrhythmias and cardiopulmonary failure.

18

What is the initial treatment for warm autoimmune hemolytic anemia?

Prednisone in divided doses

Should prednisone prove ineffective, splenectomy is indicated.

18

How can rotator cuff tendonitis be differentiated from rotator cuff tear prior to obtaining an MRI?

Lidocaine injection

This will ameliorate the pain and weakness of rotator cuff tendonitis but does not improve the symptoms of a rotator cuff tear.

18

What is the most common cause of abnormal hemostasis in patients with chronic renal failure?

Platelet dysfunction due to uremic coagulopathy

PT, PTT, and platelet count are all normal, but bleeding time is prolonged. Desmopressin (DDAVP) is usually the treatment of choice, if needed. DDAVP increases the release of Factor VIII-Von Willebrand factor multimers from endothelial storage sites. Platelet transfusion is not indicated because the transfused platelets quickly become inactive.

18

What is the treatment of choice for syphillis in penicillin-allergic patients?

Doxycycline

14 day regimens are appropriate for primary and secondary syphillis, whereas a 28 day regimen is appropriate for latent syphilis. The exceptions are that tertiary syphilis in penicillin-allergic patients is treated with 14 days of ceftriaxone, and pregnant patients should undergo penicillin desensitization before being treated with penicillin.

19

Which germ cell tumor is characterized by increased serum beta-HCG?

Choriocarcinoma

Teratomas can be associated with elevations in serum alpha fetoprotein (AFP) or beta-HCG.

20

What diagnosis should be suspected in a patient with gradual loss of peripheral vision resulting in tunnel vision, and ophthalmoscopy showing pathologic cupping of the optic disc?

Open angle glaucoma

21

What multi-systemic inflammatory condition is characterized by recurrent oral ulcers, genital ulcers, and skin lesions, and is seen most commonly in the Turkish, Asian, and Middle Eastern population.

Behcet's syndrome

Common findings include anterior uveitis and erythema nodosum (painful and nodular skin lesions with areas of hyperpigmentation suggested by old, healed nodules).

21

Lactic acidosis is a well-known side effect of which HIV medication/medication class?

Nucleoside reverse transcriptase inhibitors

22

CREST syndrome refers to a constellation of findings including what?

  1. Calcinosis cutis
  2. Raynaud phenomenon
  3. Esophageal dysmotility
  4. Sclerodactyly
  5. Telangiectasias

Calcinosis cutis refers to localized dystrophic deposition of calcium in the skin and manifests as subcutaneous pink-to-white nodules typically on the upper extremities. These may ulcerate and drain a chalky material. Sclerodactyly decribes fibrosis of the skin of the fingers distal to the metacarpophalangeal joints resulting in a shiny appearance of the skin and flexion contractures and joint pain.  Telangiectasias manifest as "mat-like" patches commonly on the face and palms.

22

What is the first step to confirm the diagnosis of malignant melanoma?

Excisional biopsy that removes the entire lesion with narrow margins and depth through the subcutaneous fat

Excisional biopsy with narrow margins is preferred because this allows confirmation of the diagnosis as pigmented basal cell carcinomas and some seborrheic keratoses and atypical nevi can mimic melanoma clinically. Additionally, a complete excision allows determination of tumor depth, ulceration, presence of mitosis, regression, lymphatic and vascular involvement, and host response. Excision with wider margins is not recommended until the diagnosis is confirmed as it would be inappropriate to remove margins around a benign lesion, and because this may disrupt afferent cutaneous lymph flow and the ability to identify sentinel nodes.

23

What medication is effective in treating dermatitis herpetiformis (DH)?

Dapsone

Its unclear as to how Dapsone treats DH but it is thought to be the drug's anti-inflammatory and immunomodulatory effects. Pruritus improves and the lesions begin to heal within hours after starting Dapsone. Dapsone is an antiparasitic used in cases of malaria but it is also bacteriostatic and competitively inhibits bacterial or fungal dihydropteroate synthestase, preventing PABA conversion to folic acid and inhibiting growth.

23

What is the immediate treatment of choice for patients with symptomatic moderate (calcium 12-14mg/dL) or severe (calcium >14mg/dL) hypercalcemia?

Intravenous saline hydration

Saline hydration helps to restore intravascular volume and promote urinary calcium excretion. Calcitonin also reduces serum calcium concentration within 4-6 hours and should be administered along with saline hydration. Bisphosphonates are recommended for long-term management in addition to treatment of the underlying cause.

24

A tick bite in the Northeastern region of the United States in a patient with signs of hemolysis is suggestive of what diagnosis?

Babesiosis

The illness is caused by the parasite Babesia and is transmitted by the Ixodes tick. Following tick bite, the parasite enters the patient's red blood cells and causes hemolysis. Clinical manifestations vary from asymptomatic to hemolytic anemia associated with jaundice, hemoglobinuria, renal failure, and death. Rash is not a common feature. Definitive diagnosis can be made from a Giemsa-stained thick and thin blood smear. Laboratory studies may demonstrate intravascular hemolysis, anemia, thrombocytopenia, mild leukopenia, atypical lymphocytosis, elevated erythrocyte sedimentation rate, abnormal liver function tests, and decreased serum complement levels. The two most widely used drug regimens are quinine-clindamycin and atovaquone-azithromycin.

24

In the United States, what induration size on tuberculin skin testing is considered negative in healthy patients with a low likelihood of tuberculosis (TB) infection?

<15mm is considered negative

Induration >5mm is considered positive in HIV-positive patients or patients with recent contact with TB positive individual.

25

Hypertension, palpable bilateral abdominal masses, and microhematuria all point to what diagnosis?

Autosomal dominant polycystic kidney disease (ADPKD)

Intracranial berry aneurysm is a common complication, and is seen in 5-10% of the cases. Although such aneurysms are common and dangerous when coupled with hypertension, routine screening for intracranial aneurysms is not recommended. Other extra-renal complications of ADPKD include hepatic cysts (most common extrarenal manifestation of ADPKD), valvular heart disease (most often mitral valve prolapse and aortic regurgitation), colonic diverticula, and abdominal wall and inguinal hernia.

26

What is the treatment of choice for cellulitis with systemic signs?

Intravenous nafcillin or cefazolin

Oral dicloxacillin is used for the acute treatment of mild cellulitis without systemic signs.

26

Which immunologic blood transfusion reaction is characterized by the following?

  1. Occurs within 1 hour of transfusion
  2. Fever, flank pain, hemoglobinuria, renal failure and disseminated intravascular coagulation
  3. Positive direct coombs test, pink plasma
  4. Caused by ABO incompatibility

Acute hemolytic transfusion reaction

27

What is the most common etiologic agent in mucormycosis?

Rhizopus

Poorly controlled diabetes predisposes to this disease.

28

Methylene blue is the treatment for what?

Methemoglobinemia

This is seen in the setting of ingestion of certain drugs (I.E. Dapsone) or anesthetic agents. Methemoglobinemia manifests as cyanosis and respiratory depression as a result of impaired oxygen delivery to the tissues.

30

Fatty casts are characteristic of what renal diagnosis?

Nephrotic syndrome

31

Ear pain and a history of teeth grinding is suggestive of what diagnosis?

Temporomandibular joint (TMJ) dysfunction

The pain is often referred to the ear and is worsened with chewing.

32

Hemolytic anemia and venous thrombosis (particularly in the hepatic veins) is suggestive of what diagnosis?

Paroxysmal nocturnal hemoglobinuria (PNH)

Patients with PNH have a tendency towards venous thrombosis, particularly within the hepatic veins. Flow cytometry tests are commonly used to confirm the diagnosis by assessing for the presence of the CD55 and CD59 proteins on the surface of the red blood cells.

 

32

What antibodies are associated with acute and chronic hepatitis?

Anti-smooth muscle antibodies and anti-LKM antibodies

The highest titers are linked with chronic active hepatitis.

33

What medication should be considered in patients who have persistent claudication symptoms despite antiplatelet therapy and adequate supervised exercise programs?

Cilostazol

This is an antiplatelet medication. Percutaneous or surgical revascularization can also be considered in these patients.

34

Red blood cell casts are characteristic of what renal diagnosis?

Glomerulonephritis

34

Deficiency in B12 (cobalamin) or folate will result in increased levels of what compound?

Homocysteine

Both folate and cobalamin are involved in the conversion of homcysteine to methionine. Deficiency in either will result in elevated homocysteine levels. Cobalamin, unlike folic acid, is also involved in the conversion of methymalonyl-CoA to succinyl-CoA. Thus, cobalamin deficiency will yield increased concentrations of methylmalonic acid, whereas they will remain normal in folic acid deficiency.

35

What is the next step in diagnosis in a patient with a modified Wells score under 4 but a D-dimer test > 500 ng/mL?

CT pulmonary angiography

D-dimer is 95-97% sensitive for venous thromboembolism with a specificity of 45%. A negative D-dimer result therefore has a negative predictive value >95%, but a positive test has poor positive predictive value.

36

Which type-2 diabetes mellitus drug class induces weight loss?

GLP-1 agonists (Exenatide, liraglutide)

They also have a lower hypoglycemia risk, but they are associated with acute pancreatitis.

38

What is the treatment for fibromuscular dysplasia?

Percutaneous angioplasty with stent placement

38

In which regions of the world is chloroquine-resistant plasmodium falciparum particularly common?

  1. Sub-Saharan Africa
  2. The Amazon Basin
  3. Southern and Southeast Asia

In these areas, malaria prophylaxis is achieved by means of mefloquine, atovaquone-progruanil, or doxycyline. In areas of chloroquine-susceptible P. falciparum, chloroquine and hydroxychloroquine will suffice. Primaquine does not kill the schizont forms of P. falciparum and is used primarily in regions where P. ovale and P. vivax are the dominant malaria species (I.E. the Korean peninsula).

39

Low-grade fever, bloody nasal discharge, nasal congestion, and involvement of the eye with chemosis, proptosis, and diplopia are features of what condition?

Mucormycosis

Involved turbinates often become necrotic. Invasion of local tissues can lead to blindness, cavernous sinus thrombosis, and coma. If left untreated, mucormycosis can lead to death in days to weeks.

40

What presents with claudication-like symptoms with walking that remain there while standing still?

Lumbar spinal stenosis

The term "neuropathic claudication" is often used to describe lumbar stenosis. Unlike peripheral artery disease, the symptoms are positional and remain while standing still. Pain is relieved by flexion of the spine. Diagnosis is made based on clinical history and classic findings on spinal magnetic resonance imaging.

40

What does synovial fluid analysis typically show in acute gout monoarthritis?

Leukocytosis (50% neutrophils) and monosodium urate crystals

Monosodium urate crystals are needle-shaped and negatively birefringent under polarizing light.

40

What might cause the heterophile antibody test to be negative in a patient with infectious mononucleosis?

Test administered early in the illness

Heterophile antibodies are very sensitive and specific, but may be negative early in the illness.

41

What is the most important target in treating chronic myeloid leukemia?

Non-receptor tyrosine kinase

A reciprocal translocation of chromosomes 9 and 22 can form the Philadelphia chromosome containing the BCR/ABL fusion gene, which is a characteristic finding in chronic myeloid leukemia (CML). Tyrosine kinase inhibitors, which function by inhibiting the abnormal BCR/ABL gene, are a key component of treatment for CML.

42

What diagnosis should be suspected when a patient with a significant smoking history presents with hypercalcemia and a hilar mass?

Squamous cell carcinoma of the lungs

Hypercalcemia usually resuts from the effects of parathyroid hormone-related protein (PTHrP), which is similar in nature to parathyroid hormone (PTH) in the receptor-binding area. By contrast, small cell carcinoma of the lungs usually causes other paraneoplastic syndromes such as ACTH production and SIADH.

 

42

What are the two most widely used drug regimens for babesiosis?

  1. Quinine-clindamycin
  2. Atovaquone-azithromycin

43

What is the treatment of choice for pregnant and lactating patients with early localized Lyme disease?

Amoxicillin

Erythema migrans and constitutional symptoms typically resolve within 3 weeks of therapy.

44

What presents with yellowish-white patches of retinal opacification and retinal hemorrhages in an AIDS patient with a CD4 count less than 50 cells/uL?

Cytomegalovirus (CMV) retinitis

Patients may be asymptomatic. In the initial stage, the eye is usually white and quiet. Treatment is ganciclovir or foscarnet.

46

What is an external hordeolum?

Common staphylococcal abscess of the eyelid

It is also known as a stye. It should be treated with warm compresses, but if it does not begin to resolve within 48 hours, incision and drainage is performed.

47

What is the first-line treatment for Ehrlichiosis?

Doxycycline

Chloramphenicol is a second-line treatment for ehrlichiosis and rocky mountain spotted fever. Ehrlichiosis is a tick-borne infection caused by Ehrlichia chaffeensis and Ehrlichia ewingii. These bacteria are carried by ticks, including the lone star tick found in the southeastern and south central United States. Ehrlichiosis is characterized by an acute febrile illness with malaise and altered mental status. Ehrlichiosis is not often associated with rash (

47

What condition commonly occurring in patients over 60 years of age is characterized by back pain radiating to the buttocks and thighs that interferes with walking and lumbar extension and is releived by lumbar flexion?

Degenerative central canal stenosis

Lumbar spinal stenosis is a degenerative condition where the spinal canal is narrowed, resulting in compression of one or more of the spinal roots. It most commonly results from a combination of two factors: enlarging osteophytes at the facet joints and hypertrophy of the ligamentum flavum. Most affected patients are over age 60. Patients experience back pain that radiates to the buttocks and thighs. Numbness and paresthesias may occur.

48

What is the greatest risk in completing homicide?

Access to firearms

50

What is the proper treatment for mild persistent asthma (symptoms >2 days/week but not daily, nighttime awakenings 3-4x/month, minor limitation on activities, and normal pulmonary function tests)?

PRN albuterol inhaler and inhaled corticosteroids

51

What are the differences between the presentation of primary HIV infection and infectious mononucleosis?

Rash and diarrhea are more common in primary HIV infection and tonsillar exudate in more common in infectious mononucleosis

53

Fibromuscular dysplasia (FMD) most commonly involves which 3 arteries?

  1. Renal artery
  2. Carotid artery
  3. Certebral arteries

FMD is a noninflammatory and nonatherosclerotic condition caused by abnormal cell development in the arterial wall that can lead to vessel stenosis, aneurysm, or dissection. It can involve any artery but these are the most common.

54

What are the 2 most severe consequences of methanol intoxication?

Vision loss and coma

Physical exam in methanol intoxication reveals optic disc hyperemia while laboratory studies reveal anion gap metabolic acidosis. An increased osmolar gap is often seen as well. Ethylene glycol and methanol poisoning share similarities. Both are sometimes ingested as a substitute for ethanol and both can cause anion gap metabolic acidosis and increased osmolar gap. Whereas methanol damages the eyes, ethylene glycol damages the kidneys.

55

What is the initial drug of choice for pain relief in mild to moderate osteoarthritis (OA)?

 

Acetaminophen

NSAIDs also have a proven efficacy in treating OA, however, gastrointestinal and renal side effects with long-term use make them second-line agents.

55

What is the treatment of choice for comedonal acne?

Topical retinoids

Comedonal acne is characterized by closed or open comedones on forehead, nose & chin. It may progress to inflammatory pustules or nodules.

56

How is bronchiectasis definitively diagnosed?

High-resolution computed tomography scan

56

What areas of the body are most affected by psoriasis?

The extensor surfaces (I.E. elbows, knees)

57

What diagnosis should be suspected in a patient presenting with mild diabetes mellitus or hyperglycemia with necrotic migratory erythema, diarrhea, anemia, and weight loss?

Glucagonoma

This is a rare pancreatic neuroendocrine tumor. The characteristic necrolytic migratory erythema (NME) usually presents as erythematous papules or plaques that coalesce to form a large, painful, and inflammatory blister and/or crusting with central clearing. NME commonly occurs in the perineum, extremities, and face. The normocytic and normochromic anemia may be due to anemia of chronic disease or glucagon's direct effect on erythropoiesis. The serum glucagon level >50pg/mL usually confirms the diagnosis in suspected patients.

58

What drug class is the mainstay of treatment for most patients with prolactinoma?

Dopamine-agonists (I.E. Bromocriptine or cabergoline)

Medical treatment not only results in normalization of prolactin levels, but leads to significant reduction in tumor size. Cabergoline is a new drug which has fewer side effects, and has been shown to be more effective than bromocriptine.

59

Acute bleeding in patients with liver failure is best treated with what?

Fresh frozen plasma

The liver synthesizes all the clotting factors except factor VIII. Chief among these are vitamin K dependent factors like factor II, VII, IX, and X.

60

What diagnosis should be suspected in a patient with acute onset of mild to moderate eye discomfort, photophobia, watery discharge, and diffuse or localized bulbar conjunctival injection?

Episcleritis

Episcleritis is an inflammation of the episcleral tissue between the conjunctiva and sclera. Episcleritic nodules may be present.

60

Of the bacterial pathogens known to cause secondary pneumonia complicating a viral upper respiratory infection, which bacteria is the only one associated with necrotizing bronchopneumonia resulting in pneumatoceoeles (cavities in the lung parenchyma filled with air)?

Staphylococcus aureus

Secondary bacterial pneumonias are most often due to Streptococcus pneumoniae, Staphylococcus aureus, or Haemophilus influenzae. Blood-streaked sputum and multiple midfield lung cavities on chest x-ray suggest an acute necrotizing pneumonia with secondary pneumatoceles.

62

What effect does increased extracellular pH levels (alkalosis) have on serum calcium levels?

Hypocalcemia

Alkalosis increases the affinity of serum albumin to calcium, thereby increasing the levels of albumin-bound calcium, and consequently decreasing the levels of ionized calcium. Ionized calcium is the only physiologically active form, which means that decreased levels of this form can result in clinical manifestations of hypocalcemia.

63

What are the two etiologies of severe, acute retinal necrosis associated with pain, keratitis, uveitis, and funoscopic findings of peripheral pale lesions and central retinal necrosis in HIV infected patients?

Herpes simplex virus (HSV) and Varicella Zoster virus (VZV)

64

Diabetic patients over the age of 40 years should be put on what medication regardless of lab values?

Statin

This is regardless of baseline lipid levels. Dose intensity can be selected based on overall risk of cardiac events.

65

Which cells are the principle source of testosterone in males?

Leydig cells

66

What is the most common cause of pneumonia in HIV patients?

Encapsulated bacteria, especially pneumococci like Streptococcus pneumoniae

67

Nongonococcal urethritis, asymmetric oligoarthritis, and conjunctivitis compose the triad of symptoms seen in which condition?

Reactive arthritis

This is a seronegative spondyloarthropathy. In addition to the classic triad, mucocutaneous lesions and enthesitis (achilles tendon pain) are common findings in reactive arthritis.

68

The vast majority of head and neck cancer is what cancer type?

Squamous cell carcinoma

Non-tender, firm, solitary lymph nodes in the head and neck are concerning for squamous cell carcinoma (particularly in older patients with a significant smoking history).

69

Patients with recurrent hypercalciuric renal stones should be treated with what?

  1. Increased fluid intake
  2. Sodium restriction
  3. Thiazide diuretic

Calcium restriction is not advised. The treatment of a first uncomplicated calcium stone is hydration and observation. Thiazide diuretics decrease urinary calcium excretion (primarily by inducing mild volume depletion, which leads to a compensatory rise in proximal reabsorption of sodium and calcium) and prevent the precipitation of calcium in the urine.

70

Erythema multiforme (dusky red, target shaped skin lesions) is an extrapulmonary manifestation that is characteristic of which etiology of atypical pneumonia?

Mycoplasma pneumonia

This is the most common cause of atypical pneumonia.

70

The effect of warfarin is increased by what?

  1. Acetaminophen
  2. Antibiotics/antifungals
  3. Amiodarone
  4. Cranberry juice, ginkgo biloba, vitamin E
  5. Omeprazole
  6. Thyroid hormone
  7. Selective serotonin reuptake inhibitors

71

What is the foundation of management of fibromyalgia?

Exercise

Additional measures include patient education and good sleep hygeine. Medications (I.E. duloxetine, tricyclic antidepressants) are reserved for patients who fail initial measures. Patients with fibromyalgia tend to have fairly normal physical examination except for point muscle tenderness in areas such as the mid trapezius, lateral epicondyle, costochondral junction in the chest, and greater trochanter.

73

What is the treatment for Mucormycosis?

Aggressive surgical debridement plus early systemic treatment with Amphtericin B

Amphotericin B is the only effective drug against Rhizopus.

73

Which antibiotics are associated with phototoxic drug reactions?

Tetracyclines (particularly Doxycyline)

These eruptions manifest as exaggerated sunburn reactions with erythema, edema, and vesicles over sun-exposed areas.

75

Low leukocyte alkaline phosphatase with leukocytosis is classic for what condition?

Chronic myelogenous leukemia (CML)

CML is characterized by leukocytosis, anemia, and increased number of mature granulocytic forms, such as segmented neutrophils and band forms on peripheral blood film. The disease is mostly seen after the age of 50 and presents with fatigue, malaise, low-grade fever, anorexia, weight loss and bone pains.

76

What condition associated with hepatitis C infection and often triggered by the ingestion of certain substances (I.E. ethanol, estrogens) is characterized by painless blisters, hypertrichosis, and hyperpigmentation?

Porphyria cutanea tarda

This is a condition that arises from the deficiency of uroporphyrinogen decarboxylase, an enxyme in the heme synthesis pathway. Elevated urinary porphyrin levels confirm the diagnosis. Phlebotomy or hydroxychloroquine may provide relief, as can interferon-alpha, in patients simultaneously infected with Hepatitis C virus.

78

What is the most common serious ocular complication of HIV-positive patients?

Cytomegalovirus retinitis

This is typically painless and fundoscopy shows fluffy or granular retinal lesions located near the retinal vessels and associated hemorrhages. It does not usually cause initial conjunctivitis or keratitis.

78

What is the treatment of choice for Nocardiosis?

Trimethoprim-sulfamethoxazole

Minocycline is the best oral alternative. The risk of nocardiosis in AIDS and transplant patients can be decreased by prophylasis with trimethoprim-sulfamethoxazole. Nocardiosis is an invasive disease caused by nocardia species, which are aerobic, gram-positive, partially acid-fast, branching rods. It is diagnosed by the presence of crooked, branching, beaded, gram-positive, and partially acid-fast filaments on microscopy.

79

Sodium thiosulfate is the antidote for what?

Cyanide poisoning

It is generally seen in the setting of fires or occupational exposure (I.E. mining, pesticides). Patients with cyanide poisoning have markedly elevated lactate levels (typically >10mEq/L).

81

What is the preferred screening test for HIV infection?

HIV serology by ELISA

This is because it is greater than 99.9% sensitive. Western blot is a confirmatory test for HIV infection, with a specificity that is greater than 99.99% when combined with ELISA.

82

Antinuclear antibodies and anti-topoisomerase-I antibodies would most likely be present in which condition?

Systemic sclerosis

This is a form of scleroderma with widespread organ involvement. GERD, right heart failure, and hypertension result from involvement of the esophagus, pulmonary arteries and kidneys, respectively.

83

What is the most common site of bleeding in hemophilia?

Joints

The joints account for up to 80% of bleeding events. Hemarthrosies can occur without significant trauma and are so characteristic in patients with hemophilia that they are almost diagnostic. Spontaneous bruising is less common in hemophilia than is hemarthrosis.

85

What is the most common cause of endocarditis following dental procedures?

Streptococcus mutans (and other Viridans group Streptococci)

87

What are the screening recommendations for pancreatic cancer?

No screening is recommended

No serologic or radiographic test has proven effective in screening for pancreatic cancer in asymptomatic adults.

88

What diagnosis should be suspected in patients 30-60 years old with telangiectasia over the cheeks, nose, and chin, with flushing of these areas precipitated by hot drinks, heat, emotion, and other causes of rapid body temperature changes.

Rosacea

Topical antibiotic such as metronidazole is the most frequently prescribed initial therapy.

89

What condition is characterized by hyperviscosity of the blood owing to the excess production of IgM?

Waldenstrom's macroglobulinemia

Two important diagnostic clues for this disorder are and IgM spike on electrophoresis, and hyperviscosity. Multiple myeloma may present with similar symptoms, but the involved immunoglobulins are usually either IgG or IgA.

90

A long-standing diabetic who presents with anorexia, nausea, vomiting, early satiety, postprandial fullness, and impaired glycemic control likely has what condition?

Diabetic gastroparesis (delayed gastric emptying)

This is one manifestation of diabetic autonomic neuropathy. Prokinetic agents (I.E. metoclopramide, erythromycin, cisapride) are useful in the management of symptoms.

91

The most classic description of what condition is that of "a curtain coming down over my eyes"?

Retinal detachment

It usually presents with sudden onset photopsia (the presence of percieved flashes of light) and floaters. Retinal detachment refers to separation of the layers of the retina. It usually occurs in people aged 40-70 years old. Usually, the inciting event occurs months before the retinal detachment. Myopia or trauma can cause retinal breaks, through which fluid seeps in and separates the retinal layers. Ophthalmoscopic examination reveals a grey, elevated retina. Laser therapy and cryotherapy are done to create permanent adhesions between the neurosensory retina, retinal pigment epithelium, and choroid.

91

What is the most common cause of ductopenia (loss of intrahepatic bile ducts) in adults?

Primary biliary cirrhosis

The exact underlying pathophysiology is unknown.

 

92

What initially presents as a painful swelling that progresses to a nodular rubbery lesion on the eyelid, without any discharge, redness, or other abnormalities?

Chalazion

This is a chronic granulomatous condition that develops when a meibomian gland becomes obstructed. Persistent or recurrent chalazion may be due to meibomian gland carcinoma (sebaceous carcinoma). Additionally, basal cell carcinoma frequently presents as a solitary nodule on the lid margin, and may initially be clinically difficult to distinguish from chalazions. Therefore, histopathologic examination is required to rule out malignancy.

92

Medullary thyroid cancer should always raise suspicion for what?

Multiple endocrine neoplasia (MEN) 2A and 2B

92

What is the initial therapy for treatment-naive hepatitis C virus (HCV) patients?

Peginterferon + ribavirin

Combination therapy has been shown to be more beneficial than monotherapy with either peginterferon or ribavirin. Patients with HCV genotype 1 also receive an additional protease inhibitor (telaprevir or boceprevir). HCV viral load is typically monitored during treatment to assess response.

93

What part of the axial skeleton is rheumatoid arthritis (RA) most likely to affect?

Cervical spine

RA does not affect the thoracic, lumbar, or sacral spine or sacroiliac joints. The thoracic spine has great stability and is rarely affected by arthritis, disc herniation, or other spinal disorders. The lumbar spine is the most common site of disc herniation and spinal stenosis. The sacroiliac joints are commonly affected in seronegative spondyloarthropathies.

94

Painless vision disruption with fundoscopy showing fluffy or granular retinal lesions located near the retinal vessels with associated hemorrhages is indicative of what diagnosis?

Cytomegalovirus (CMV) retinitis

95

Besides anticoagulants, what should be given to a hypercoagulable patient with elevated homocysteine levels?

Pyridoxine (B6)

Vitamin B6 lowers homocysteine levels by acting as a cofactor for the enzyme cystathionine beta-synthase, which metabolizes homocysteine into cystathionine, which goes on to become cysteine.

96

What is the treatment of choice for moderate inflammatory acne?

Topical retinoids + Benzoyl peroxide + topical antibiotics (I.E. erythromycin, clindamycin etc.)

Inflammatory acne is characterized by inflamed papules (

97

Which immunologic blood transfusion reaction is characterized by the following?

  1. Occurs within a few seconds to minutes of transfusion
  2. Rapid onset of shock, angioedema/urticaria, and respiratory distress
  3. Caused by recipient anti-IgA antibodies

Anaphylactic transfusion reaction

98

How can emphysema and chronic bronchitis be differentiated?

Diffusing capacity of the lung (DLCO)

DLCO is decreased in emphysema but normal in chronic bronchitis. DLCO is also decreased in interstitial lung disease. Forced expiratory volume in 1 second/forced vital capacity is decreased in COPD (both emphysema and chronic bronchitis), as apposed to normal in restrictive lung disease.

100

What is the appropriate management of a healthcare worker with exposure to HIV?

Draw blood for baseline HIV serology levels and immediately begin antiretroviral therapy with 2-3 drugs

101

Current guidelines recommend treating all confirmed or suspected cases of influenza within what time period and with what medications?

Treatment with oseltamivir or zanamivir within 48 hours of symptoms onset

101

What diagnosis should be considered in the differential diagnosis of any bone marrow transplant (BMT) recipient with both lung and intestinal involvement (I.E. pneumonitis and colitis)

Cytomegalovirus (CMV) pneumonitis

The median time of development of CMV pneumonitis after BMT is about 45 days (range of 2 weeks to 4 months). Typical chest x-ray findings include multifocal diffuse patchy infiltrates. Bronchoalveolar lavage is diagnostic in most cases. Other than pneumonitis, CMV infection in post-BMT patients also manifests as upper and lower gastrointestinal ulcers, bone marrow suppression, arthralgias, myalgias, and esophagitis.

102

What condition is characterized as a familial disorder of bilirubin glucuronidation in which the production of UDP glucuronyl transferases (enzymes that mediate glucuronidation of various substances) is reduced?

Gilbert syndrome

104

What is the first step in managing severe symptomatic hypercalcemia?

Vigorous hydration with intravenous normal saline

Bisphosphonates are the drugs of choice for long-term management of hypercalcemia of malignancy.

105

What diagnosis should be suspected in a patient (often a child) with an abrupt onset of fever, proptosis, restriction of extraocular movements, and swollen red eyelids?

Orbital cellulitis

105

Which species of malaria is not generally associated with cyclic fevers?

Plasmodium falciparum

Most of the malaria-related deaths are associated with P. falciparum, whereas P. vivax and P. ovale are responsible for several relapses. The typical presentation of P. falciparum consists of a cold phase characterized by chills and shivering, followed by a hot phase characterized by diaphoresis and resolution of fever. Anemia and splenomegaly are common findings.

107

What is the treatment of choice for mild cellulitis without systemic signs?

Oral dicloxacillin

Intravenous nafcillin or cefazolin is the treatment of choice for cellulitis with systemic signs.

107

What is the treatment of choice for unresponsive nodular (cystic acne)

Oral isotretinoin

Nodular acne is characterized by large (>5mm) nodules that can appear cystic. Nodules may merge to form sinus tracts with possible scarring.

 

108

What are the characteristics of type 1 heparin-induced thrombocytopenia?

  1. Non-immune-mediated
  2. Occurs 1-4 days after heparin
  3. Platelet count usually stays above 100,000/uL
  4. It is managed with observation, heparin can be continued as it usually self resolves

110

What antibodies are present in 90% of patients with primary biliary cirrhosis?

Anti-mitochondrial antibodies

This is a chronic liver disease characterized by autoimmune destruction of the intrahepatic bile ducts and cholestasis.

111

Which antibiotic is associated with tendinopathy and tendon rupture?

Fluoroquinolones

The achilles tendon is the most common. Patients can develop tendon pain within 24 hours with a median of 8 days after starting the drug.

113

Patients with pelvic inflammatory disease should also be screened for what?

HIV, syphilis, hepatitis B, and cervical cancer (pap smear)

When there is a history of intravenous drug abuse, hepatitis C serology should also be obtained.

115

What is the initial disease-modifying antirheumatic drug (DMARD) of choice in patients with rheumatoid arthritis?

Methotrexate

Methotrexate is a folate antimetabolite and the preferred initial DMARD in patients with moderate-to-severe rheumatoid arthritis due to its established efficacy and safety for long-term use.

116

What is the initial management of suspected spinal cord compression?

Intravenous glucocorticoids and magnetic resonance imaging.

118

What drug is approved for both treatment and prophylaxis of secondary amyloidosis?

Colchicine

Treatment, however, is usually directed at the underlying inflammatory disease.

120

The ACIP recommends that the pneumococcal vaccine be given to all healthy adults once at what age?

65 years old

Patients under the age of 65 with chronic medical conditions (chronic lung disease, chronic cardiovascular diseases, diabetes, chronic liver disease, chronic renal disease, asplenia, and immunosuppression) may be vaccinated once followed by a booster 5 years later.

121

Pancreatitis is a well-known side effect of which HIV medication/medication class?

Didanosine (nucleoside reverse transcriptase inhibitor)

122

What typically presents as an osteolytic lesion in the epiphyseal region of long bones with a "soap-bubble" appearance on radiograph?

Giant cell tumor of bone

This is a benign and locally aggressive skeletal neoplasm that usually presents with pain, swelling, and decreased range of joint motion at the involved site. Most commonly, the distal femur and proximal tibia are involved.

123

What are the criteria cutoffs for mild, moderate, and severe neutropenia?

  1. Mild: absolute neutrophil count < 1500 cells/uL
  2. Moderate: absolute neutrophil count <1000 cells/uL
  3. Severe: absolute neutrophil count < 500 cells/uL

Febrile neutropenia is defined as a single temperature of >101.3F or a sustained temperature >100.4F for >1 hour in a neutropenic patient. All 3 categories of neutropenic fever require antibiotics, but both moderate and severe neutropenic fever require hospitalization for intravenous antibiotics. Inpatient antibiotics include an anti-pseudomonal beta-lactam monotherapy (preferred). Vancomycin should be added in suspected line sepsis, hemodynamic instability, or skin infections. Antifungal therapy should be started after 4-7 days of persistent neutropenic fever or if there is evidence of invasive fungal infection.

124

What is the most common vaccine-preventable disease among travelers?

Hepatitis A

126

HIV patients with CD4 counts <50/microL require prophylaxis against what?

Mycobacterium avium complex (MAC)

Prophylaxis is with azithromycin or clarithromycin.

127

When is an INR of 2.5-3.5 preferred over an INR of 2.0-3.0 in patients on warfarin therapy?

Patients with prosthetic heart valves require an INR of 2.5-3.5

127

Which hypercoagulable disorder usually presents with unexplained superficial venous thrombosis at unusual sites such as the arms or chest area?

Trousseau's syndrome

This is a migratory superficial thrombophlebitis. The syndrome is usually diagnosed prior to (sometimes months to years before) or at the same time as an occult visceral malignancy. It is usually associated with cancer involving the pancreas (most common), lung, prostate, stomach, and colon as well as acute leukemias. Factors associated with higher risk of pancreatic cancer include increasing age and smoking. The tumor likely releases mucins that react with platelets to form platelet-rich microthrombi.

129

Painless loss of monocular vision is the usual presentation of what?

Central retinal artey occlusion

131

Both Celiac disease and crohn's disease can present with weight loss, abdominal pain, and oral ulcers but Celiac disease would not be associated with what?

Granulomatous inflammation

Granulomas can be seen pathologically in up to 30% of patients with Crohns's disease, and can confirm the diagnosis in the absence of granulomatous infections.

132

What should be offered to patients with newly diagnosed hepatitis C prior to treatment?

Liver biopsy

It offers the best clinical predictor of disease progression and helps assess likely response to treatment. It can also determine the stage of the disease, rule out other concomitant liver diseases (I.E. hemochromatosis), and guide treatment decisions (duration, surveillance).

133

What is the treatment for Torsades de points?

Cessation of any offending agents and initiation of magnesium sulfate

135

What diagnosis should be suspected in an asian patient with an insensate, hypopigmented patch of skin?

Leprosy

Diagnosis is made by demonstration of acid-fast bacilli on skin biopsy.

137

What size margins are required in the excision of a melanoma lesion that is < 1mm in depth

1 cm tumor free margin

This is associated with a 99% 5-year survival rate. Tumors great than 1mm in depth should have sentinel lymph node study.

138

What presents with the usual complaint of blurred vision following blunt trauma and is characterized on examination by central scotoma, retinal edema, hemorrhagic detachment of the macula, subretinal hemorrhage, and crescent-shaped streak concentric to the optic nerve?

Choroidal rupture

139

diabetic ulcers usually occur where?

The pressure points of the feet

Sensory, motor, or autonomic neuropathy can all contribute to the development of foot ulcer by decreasing pain sensation and perception of pressure causing muscle imbalance that can lead to anatomic deformities, and by impairing the microcirculation and the integrity of the skin.

139

What condition is characterized as a severe autosomal recessive disorder of bilirubin metabolism with severe jaundice, neurologic impairment due to kernicterus (bilirubin encephalopathy), and elevated indirect bilirubin levels (usually 20-25mg/dL but as high as 50mg/dL)?

Crigler-Najjar syndrome type 1

Liver enzymes and histology are normal. If intravenous phenobarbital is administered, the serum bilirubin remains unchanged. Liver transplant is the only curative option.

140

How are primary polydipsia and diabetes inispidus differentiated?

Primary polydipsia is characterized by dilute urine and hyponatremia, whereas diabetes insipidus (DI) is characterized by dilute urine and hypernatremia

DI can be central due to decreased antidiuretic hormone (ADH) release from the pituitary or nephrogenic due to normal ADH level but with renal ADH resistance.

141

What is the most accepted and recommended management for a H. pylori-positive patients with gastric mucosa-associated lymphoid tissue (MALT) lymphoma without any metastasis?

Antibiotic therapy (clarithromycin and amoxicillin)

Such lymphomas may regress after the eradication of H. pylori using antibiotic therapy. Chemotherapy typically plays a role in the management of patients with MALT lymphoma if eradication of H. pylori fails to produce regression of the lymphoma. Such therapeutic regimens usually include CHOP (cyclophosphamide, adriamycin, vincristine, and prednisone) or CHOP + Bleomycin.

143

What is the most common valvular abnormality detected in patients with infective endocarditis?

Mitral valve prolapse with coexisting mitral regurgitation

About 75% of patients with infective endocarditis have previously damaged heart valves, with mitral valvular disease being the most common.

145

What is characterized as a benign condition in which there is a defect of hepatic storage of conjugated bilirubin, resulting in its leakage into the plasmaand causing a chronic and mild hyperbilirubinemia of both unconjugated and conjugated forms without any suggestion of hemolysis?

Rotor syndrome

Liver function tests are normal and treatment is unnecessary.

145

Fever and sore throat in any patient taking antithyroid drugs suggests what diagnosis?

Agranulocytosis

It is caused by immune destruction of granulocytes, and most cases occur within 90 days of treatment. Antithyroid drugs should be stopped and white blood cell (WBC) count checked. Routine WBC count measurement in patients taking antithyroid drugs is not cost effective.

146

What is the treatment for deep vein thrombosis in a patient with contraindications to anticoagulation?

Inferior vena cava filter

This is to prevent pulmonary embolism.

146

Stevens-johnson syndrome is a well-known side effect of which HIV medication/medication class?

Non-nucleoside reverse transcriptase inhibitors

147

What benign lesion is described as a soft, yellow plaque that appears on the medial aspects of the eyelids bilaterally, and is characterized histologically by lipid-filled macrophages in the dermis?

Xanthelasma

Xanthelasmas and xanthomas are common cutaneous associations of primary biliary cirrhosis (PBC). PBC is a progressive autoimmune disease characterized by immune-mediated destruction of the intrahepatic bile ducts leading to bile stasis and cirrhosis.

148

Acute renal failure associated with arthralgia, rash, and white blood cell casts made mostly of eosinophils are indicative of what diagnosis?

Allergic interstitial nephritis

PABA analogue antibiotics (sulfonamides), penicillins, cephalosporins, rifampin, trimethoprim, NSAIDs, diuretics, phenytoin, allopurinol, and captopril are all potential causes.

149

Which anticoagulant is recommended to bridge to warfarin in a patient with severe renal insufficiency?

Unfractionated heparin

Reduced renal clearance increases anti-Xa activity levels and bleeding risk.

151

What is the treatment of choice for severe PCP pneumonia in an HIV-positive patient?

Trimethoprim-sulfamethoxazole (TMP-SMX) and steroids

TMP-SMX is the drug of choice, but the addition of steroids have been shown to decrease mortality in patients with severe PCP infection. Indications for steroid use in PCP include PaO2 <70mmHg on room air or an A-a gradient >35.

153

Sensorineural hearing loss that occurs with aging is referred to as what?

Presbycusis

It is usually first noticed in the 6th decade of life, and presents with high-frequency, bilateral hearing loss. Patients with presbycusis often have difficulty hearing in noisy, crowded environments.

154

What is the best treatment for frostbite?

Rapid re-warming with warm water

155

White blood cell casts are characteristic of what renal diagnosis?

Interstitial nephritis and pyelonephritis

156

Broad and waxy casts are characteristic of what renal diagnosis?

Chronic renal failure

157

Granulomatosis with polyangiitis (Wegener's) is a vasculitis affecting arteries of what size?

Small and medium-sized arteries

Patients present with a combination of glomerulonephritis and upper and lower respiratory tract disease. Diagnosis is made by c-ANCA positivity and tissue biopsy. Treament involves hight-dose corticosteriods and cytotoxic agents.

158

Ulcers of arterial insufficiency usually occur where?

Tips of the fingers

The poor blood supply prevents adequate healing.

160

What is the most common cause of nutritional folate deficiency in the United States?

Alcohol abuse

Alcohol abuse causes folate deficiency by impairing its enterohepatic cycle and inhibiting its absorption. Alcoholics can develop megaloblastic anemia within 5 to 10 weeks, as body stores of folate are limited.

161

What is the most reliable sign for spinal osteomyelitis?

Tenderness to gentle percussion over the spinous process of the involved vertebra

Fever and leukocytosis are unreliable findings but erythrocyte sedimentation rate is grossly elevated (>100mm/h).

162

Muddy brown casts are characteristic of what renal diagnosis?

Acute tubular necrosis

163

What organism should be considered in patients who have a subacute presentation of delayed-onset prosthetic joint infection?

Staphylococcus epidermidis

Staphylococcus aureus is the most common organism in early-onset infections.

163

What are the screening recommendations for colonoscopy in a patient with a family history of colon cancer?

Begin screening colonoscopies 10 years prior to the age the relative was diagnosed

Patients at average risk of developing colon cancer should begin screening at age 50 with fecal occult blood testing, flexible sigmoidoscopy, a combination of the twon, colonoscopy, or double-contrast barium enema.

164

What is the pathophysiologic mechanism underlying the non-productive cough seen in 5-20% of patients taking ACE inhibitors?

Accumulation of kinins and possible activation of the arachidonic acid pathway

Kinins are degraded by angiotensin-converting enzymes; therefore, they accumulate as a result of ACE inhibitor therapy. Another physiologic effect of ACE inhibitors is an increase in serum renin level, but this is not responsible for producing cough.

165

What toxicity presents with hyperthermia, mydriasis, delirium, urinary retention, decreased bowel sounds, and dry mouth?

Anticholinergic toxicity

167

What are the characteristics of type 2 heparin-induced thrombocytopenia?

  1. Immune-mediated
  2. Occurs 5-10 days after heparin (or
  3. Platelet count usually remains above 20,000/uL
  4. There is increased risk of thrombosis, necrotic skin lesions at heparin injection sites, acute systemic reactions
  5. Management is stopping heparin and using alternative anticoagulant to prevent thrombosis

168

What is the drug of choice for treating Hairy Cell Leukemia?

Cladribine (2-chlordeoxyadenosine)

It is a purine analog. It is toxic to bone marrow and its effects include neurological and kidney damage. Hairy cell leukemia is characterized by lymphocytes with fine, hair-like projections and a tartrate-resistant acid phosphatase (TRAP) stain. The bone marrow may become fibrotic; thus leading to dry taps.

170

Hypersensitivity syndrome is a well-known side effect of which HIV medication/medication class?

Abacavir (nucleoside reverse transcriptase inhibitor)

171

What is the most feared complication of a retropharyngeal abscess?

Spread of infection into the mediastinum

This can lead to acute necrotizing mediastinitis.

172

What is the initial empiric treatment for patients with suspected postnasal drip?

Oral first-generation antihistamine (I.E. Chlorpheniramine) or combined antihistamine-decongestant (I.E. brompheniramine and pseudophedrine)

173

Proximal muscle weakness in the setting of fatigue, anxiety, tremor, weight loss, and tachycardia is indicative of what diagnosis?

Hyperthyroidism

Up to 60-80% of untreated hyperthyroid patients can develop acute or chronic myopathy.  Acute thyrotoxic myopathy can present with more severe distal or proximal muscle weakness, but usually without bulbar or respiratory muscle involvement. Chronic thyrotoxic myopathy typically presents with more proximal muscle weakness weeks to months after onset of hyperthyroidism. Objective findings include possible muscle atrophy, high-frequency and low-amplitude tremor with movement (unlike resting tremor in parkinson's disease), and normal to increased deep-tendon reflexes with shortened relaxation phase. Treatment of hyperthyroidism usually improves the myopathy.

174

Which encapsulated gram-negative bacteria typically causes a pneumonia in the upper lobes, and grows mucoid colonies on sputum culture?

Klebsiella pneumonia

It produces jelly-like sputum with tissue necrosis and early abscess formation and a fulminant course. It is one of the most common organisms responsible for pneumonia in alcoholics and it accounts for most nosocomial pneumonias. It has a high mortality rate.

175

The following signs/symptoms are characteristic of what condition?

  1. Maculopapular rash on wrists and ankles that spreads to the trunk, extremities, palms, and soles around day 5 of illness
  2. Patient appears toxic with high fever, conjunctivitis, severe headache, and diffuse myalgias

Rocky mountain spotted fever (RMSF)

This is a rickettsial disease spread by ticks. It requires rapid initiation of antibiotics to prevent mortality.

176

What is the antibiotic regimen of choice for prophylaxis/treatment of infections caused by a human bite?

Amoxicillin-clavulanate

This is also the drug of choice for dog bites.

177

What condition is characterized by dendridiform corneal ulcers and a vesicular rash in the trigeminal distribution?

Herpes Zoster Ophthalmicus

 

179

Which two antibiotic classes are used to treat Legionella pneumonia?

Macrolide antibiotics and quinolones

180

Which germ cell tumor is accompanied by an increase in serum alpha fetoprotein (AFP)?

Yolk sac tumor (endodermal sinus tumor)

181

What is the main danger associated with creatine phosphokinase (CPK) levels >20,000U/L?

Acute renal tubular necrosis

This occurs due to myoglobinuria.

182

Vitamin D deficiency presents with what levels of calcium, phosphate, and parathyroid hormone?

Low calcium, low phosphate, and high parathyroid hormone

183

Chest x-ray findings of hilar adenopathy, with or without reticulonodular infiltrates, and biopsy of noncaseating granulomas is indicative of what diagnosis?

Sarcoidosis

For symptomatic disease, administration of systemic glucocorticoids is indicated.

184

Coarse facial features, arthralgias, uncontrolled hypertension, increased ring size, skin tags, and carpal tunnel syndrome are all symptoms consistent with what diagnosis?

Acromegaly

Elevated growth hormone in acromegaly stimulates hepatic insulin-like growth factor (IGF-1) secretion, which is responsible for most of the clinical features. Growth hormone levels can fluctuate in a diurnal pattern, whereas IGF-1 levels remain constant. Therefore, IGF-1 levels are the preferred single screening test for acromegaly.

185

What 4 medications can be used to reduce the intraocular pressure in patients with acute glaucoma?

  1. Mannitol
  2. Acetazolamide
  3. Timolol
  4. Pilocarpine

Narcotics are used to control the pain. Mydriatic drugs such as atropine should be avoided since dilation the pupil can worsen the glaucoma.

186

What are common in aging adults and described as small, red, cutaneous papules that do not regress spontaneously and typically increase in number with age?

Cherry hemangioma

Light microscopy of these lesions shows proliferation of capillaries and postcapillary venules in the papillary dermis.

187

What presents in a manner similar to other urinary tract infections, but with the addition of perineal pain, pronounced systemic symptoms (fever, chills, acute illness), and a tender, boggy prostate on examination?

Acute bacterial prostatitis

Urine culture should be obtained to help direct antibiotic therapy. Empiric antibiotic therapy with trimethoprim-sulfamethoxazole or a fluoroquinolone should be started while awaiting culture results, and treatment should be continued for 4-6 weeks in most cases.

189

What antibiotics are effective therapeutic options in patients with nosocomial pneumonia due to a pseudomonas infection?

Cefepime or piperacillin-tazobactam

Aztreonam, ciprofloxacin, imipenem/cilastatin, tobramycin, gentamicin, and amikacin are other effective drugs.

190

Over 90% of cases of avascular necrosis of bone are due to what two causes?

Chronic corticosteroid use and chronic excessive alcohol ingestion

191

What disorder is characterized by macular depigmentation that involves the acral and peri-orifacial areas, and is caused by the autoimmune destruction of melanocytes?

Vitiligo

This is a specific form of leukoderma which usually peaks in persons aged 20-30 years. The depigmentation has a predilection for acral areas and around body orifices, and appears as pale whitish macules with hyperpigmented borders. The condition is slowly progressive, few experience spontaneous remission.

193

Isolated thrombocytopenia without anemia or leukopenia suggests what diagnosis?

Idiopathic thrombocytopenia purpura (ITP)

ITP is usually diagnosed after excluding other possible causes of thrombocytopenia based on history, physical examination, complete blood count, and peripheral blood smear. It is also important to rule out pseudothrombocytopenia due to platelet clumping by EDTA, abciximab administration, or inadequate anticoagulation of the blood sample. Thrombocytopenia may be the presenting finding in up to 5-10% of patients with chronic HIV infections. Therefore, all patients with presumed ITP should be tested for HIV and hepatitis C virus as platelet counts can be affected by treating the underlying disease.

195

Which immunologic blood transfusion reaction is characterized by the following?

  1. Occurs within 2-10 days after transfusion
  2. Mild fever and hemolytic anemia
  3. Positive direct coombs test, positive new antibody screen
  4. Caused by anamnestic antibody response

Delayed hemolytic transfusion reaction

196

What typically presents as sudden loss of vision and onset of floaters in a diabetic patient?

Vitreous hemorrhage

The most common cause is diabetic retinopathy. An important diagnostic clue is that the fundus is hard to visualize, and even if it is visualized, details may be obscured. For patients with underlying medical conditions, conservative treatment (I.E. upright position during sleep, which enhances settling of the hemorrhage) is recommended.

197

Patients with hemochromatosis are vulnerable to infection by which bacteria?

Listeria monocytogenes

Iron overload is also a risk factor for infection with Yersinia enterocoliticia and septicemia from vibrio vulnificus, both of which are iron-loving bacteria.

199

What is the preferred first-line drugs/drug class in treating fibromyalgia that does not respond to aerobic exercise and good sleep hygeine?

Tricyclic antidepressants (I.E. Amitriptyline)

Pregabalin, duloxetine, and milnacipran are alternate therapies approved for patients not responding to tricyclic antidepressants.

200

How can benzodiazepine overdose be differentiated from opioid overdose?

Benzodiazepine overdose lacks severe respiratory depression and lacks pupillary constriction

201

What presents with fever, myalgias, marked hypotension, and diffuse erythematous macular rash (erythroderma) that can progress to multiorgan involvement?

Toxic shock syndrome (TSS)

Approximately 50% of TSS cases are related to mestruation (tampon use); the remainder are nonmenstrual (I.E. surgical wound infections, sinusitis, septorhinoplasty).

203

What agent causes molluscum contagiosum?

Poxvirus

It is usually a self-limited infection and resolves spontaneously in immunocompetent individuals. Genital lesions should be treated to prevent sexual transmission. The best form of treatment is curettage or application of liquid nitrogen.

204

The modified Wells criteria are used to determine the pretest probability of what?

Pulmonary embolism (PE)

3 points

  • Clinical signs of deep venous thrombosis (DVT)
  • Alternate diagnosis less likely than PE

1.5 points

  • Previous PE of DVT
  • Heart rate > 100
  • Recent surgery (<4 weeks) or immobilization (>3 days)

1 point

  • Hemoptysis
  • Cancer

Total score for clinical probability

  • >4 = PE likely

204

Inflammatory myopathies (I.E. polymyositis and dermatomyositis) are best treated with what?

High dose corticosteroids

206

What diagnosis should always be considered in patients with an unexplained elevation of serum creatinine kinase concentration and myopathy?

Hypothyroidism

Hypothyroid myopathy presents with fatigue, myalgias, proximal muscle weakness, sluggish ankle reflexes, normal sedimentation rate, and elevated serum creatine kinase.

207

What diagnosis should be suspected in a patient with central scotoma, afferent pupillary defect, changes in color perception and decreased visual acuity?

Optic neuritis

207

Verrucous, papilliform lesions located in the anogenital region are called what?

Condyloma acuminata

There are three treatment options for condyloma acuminata:

  1. Chemical or physical agents: (I.E. trichloroacetic acid, 5-florouracil epinephrine gel, and podophyllin)
  2. Immune therapy: (I.E. imiquimod, interferon alpha)
  3. Surgery (I.E. cryosurgery, excisional procedures, laser treatment)

208

A history of slowly progressive unilateral visual loss and dyschromatopsia (decreased brightness sensation) are characteristic of what condition?

Optic glioma

This occurs in 15% of patients with neurofibromatosis type 1. Exophthalmos is sometimes present on physical examination.

209

What is the emergent treatment for central retinal artery occlusion?

Ocular massage and high-flow oxygen administration

211

What are the 3 preferred treatment options for uncomplicated cystitis?

Trimethoprim-Sulfamethoxazole (3 days)

Nitrofurantoin (5 days)

Fosfomycin (single dose)

Fluoroquinolones are also effective but are typically reserved for patients who cannot take the above options (I.E. sulfa allergy) or for settings with high local resistance rates.

212

The effect of warfarin is decreased by what?

  1. Rifampin
  2. Carbemazepine
  3. Oral contraceptives
  4. Ginseng
  5. St John's wort
  6. Green vegetables

214

Aside from history, how can asthma be differentiated from chronic obstructive pulmonary disease (COPD)?

Asthma responds to bronchodilators and has a normal diffusing capacity for carbon monoxide (DLCO)

DLCO is decreased in COPD, especially in emphysema.

216

What is the most frequently prescribed initial therapy for rosacea?

Topical metronidazole

217

The history of normal skin at birth, with gradual progression to dry scaly skin, is typical of what diagnosis?

Ichthyosis vulgaris

This condition can be hereditary or acquired. The skin is usually dry and rough with horny plates over the extensor surfaces of the limbs. The condition worsens in the winter.

219

What condition is characterized by diffuse telangiectasias, recurrent epistaxis (nose bleeds), oral lesions, and widespread arteriovenous malformations (AVMs)?

Hereditary telangiectasia (Osler-Weber-Rendu syndrome)

In Hereditary telangiectasia, AVMs tend to occur in the mucous membranes, skin, and gastrointestinal tract, but may also be present in the liver, brain, and lung. AVMs in the lungs can shunt blood from the right to the left side of the heart, causing chronic hypoxemia and a reactive polycythemia. Pulmonary AVMs can also present as massive, sometimes fatal, hemoptysis.

220

An adrenal mass in a woman with virilism is most likely caused by excess production of what hormone?

Dehydroepiandrosterone-sulfate (DHEA-S)

Women produce androgens such as androstenedione (AS), dehydroepiandrosterone (DHEA), testosterone (T),  and dehydroepiandrosterone sulfate (DHEA-S). AS, DHEA, and T are produced by the ovaries and adrenals, whereas DHEA-S is predominantly produced in the adrenal glands only.

222

What diagnosis should be suspected in a patient with a painful and red eye, blurring of vision, perilimbal injection, keratic precipitates (inflammatory cellular deposits seen on corneal endothelium), and corneal stromal edema?

Anterior uveitis

223

What 4 metabolic abnormalities are associated with tumor lysis syndrome?

  1. Hyperphosphatemia
  2. Hyperkalemia
  3. Hyperuricemia
  4. Hypocalcemia

Both potassium and phophate are intracellular ions, and the breakdown of cells release excess amounts of these. Released phosphate binds calcium and causes hypocalcemia. Hypocalcemia is also due to the release of intracellular products by cell lysis. Degradation of cellular proteins causes elevation of uric acid levels.

224

What happens to the positive predictive value (PPV) of a test for a disease as the prevalence of that disease in the population increases?

PPV increases

Negative predictive value decreases as prevalence increases.

225

What is the most common cause of primary adrenal insufficiency in developed countries?

Autoimmune adrenalitis

This is responsible for more than 80% of patients with primary adrenal cortical insufficiency.

226

What is the preferred treatment for most patients with Graves' disease?

Radioactive iodine therapy

Contraindications to radioactive therapy are pregnancy and very severe opththalmopathy. Antithyroid drugs are used primarily in the treatment of hyperthyroidism during pregnancy and in preparation for surgery or radioactive iodine therapy.

227

Which antibody is present in patients with primary biliary cirrhosis?

Anti-mitochondrial antibody

229

Crystal-induced nephropathy is a well-known side effect of which HIV medication/medication class?

Indinavir (protease inhibitor)

It is caused by the precipitation of the drug in the urine and obstruction of the urine flow. According to one study, 8% of the patients treated with indinavir had urologic symptoms, and about 20% had urinary crystals consisting of indinavir.

230

Hereditary spherocytosis (HS) most often occurs as a result of a genetic defect in what gene?

Ankyrin

This results in abnormal red blood cell scaffolding proteins. The spherocytes without this scaffolding are less deformable than normal red blood cells and are more prone to splenic sequestration. Spherocytes can be seen in other conditions, but they do not have the characteristic laboratory findings seen in HS. The peripheral smear shows spherocytes (multiple small, round, dense, and hyperchromic red blood cells without central pallor). HS is autosomal dominant in 75% of patients but can also be autosomal recessive or due to spontaneous mutation.

231

What is the screening test of choice for abdominal aortic aneurysm?

Abdominal ultrasound

This should be performed as a one-time evaluation in male active or former smokers aged 65-75 years.

233

What is the diagnostic approach to a patient suspected of having esophageal cancer?

Barium swallow followed by endoscopy and biopsy

PET scan is sometimes useful to determine the stage of the disease and whether surgery is possible.

234

What is the treatment of choice for nocardia asteroides?

Trimethoprim-sulfamethoxazole

236

What is the most prominent extraarticular manifestation of ankylosing spondylitis?

Anterior uveitis

It occurs in 25%-40% of patients.

237

What is the treatment of choice for severe inflammatory acne?

Topical retinoids + benzoyl peroxide + oral antibiotics

Inflammatory acne is characterized by inflamed papules (<5 mm), pustules, and erythema

239

What condition is characterized by ring-shaped scaly patches with central clearing and distinct borders?

Tinea corporis

Any species of dermatophyte may cause this condition, but Trichophyton rubrum is the most frequent culprit. The most predominant symptom is itching. The diagnosis is confirmed with microscopic examination using KOH, which should reveal the presence of hyphae. Topical treatment with 2% antifungal lotions and creams (I.E. Terbinafine), or systemic treatment with griseolfulvin (for extensive disease) offers good relief. Patients with extensive disease should be investigated for underlying disorders that cause immunosuppression.

241

Back pain after physical exertion, absence of radiation, presence of paravertebral tenderness, negative straight-leg raising test, and normal neurological examination are all suggestive of what diagnosis?

Lumbosacral strain

This is the most common cause of back pain. It is estimated that the lifetime risk of lumbosacral strain is close to 80%. Treatment includes NDSAIDs and early mobilization.

243

How often should patients with ulcerative colitis have surveillance colonoscopies?

Every 1-2 years

Guidelines state that patients should begin colonoscopy surveillance 8 years after the diagnosis.

244

What two modalities have been shown to decrease mortality in patients with COPD?

  1. Home oxygen therapy
  2. Smoking cessation

246

What is the appropriate treatment for acute deep vein thrombosis (DVT)?

Combination of warfarin and heparin for the first 5 days and then heparin may be discontinued if the patient's INR is therapeutic

Inferior vena cava filters may be used in patients with lower extremity DVTs where anticoagulation is contraindicated or has failed. Thrombolytics are indicated for patients with hemodynamically significant pulmonary emboli. They are not routinely used for patients with DVTs.

247

What is the most common type of primary lung cancer in both smokers and nonsmokers?

Adenocarcinoma

Adenocarcinoma accounts for most of the primary lung cancers in nonsmokers. It is usually located peripherally and may present as a solitary nodule, with or without symptoms. In contrast, squamous cell lung cancer is usually centrally located and often has some evidence of necrosis/cavitation. Stage at diagnosis is the most important prognostic factor, with survival determined primarily by resectability.

248

Which immunologic blood transfusion reaction is characterized by the following?

  1. Occurs within 1-6 hours of transfusion
  2. Fever and chills
  3. Caused by cytokine accumulation during blood storage

Febrile nonhemolytic transfusion reaction

This is the most common transfusion reaction.

249

Lymphocytosis and smudge cells seen on peripheral smear are characteristic features of what condition?

Chronic lymphocytic leukemia (CLL)

Flow cytometry can prove clonality of the abnormal lymphocytes and is generally used to confirm the diagnosis.

250

Psammoma bodies are the histopathological feature of which form of thyroid malignancy?

Papillary thyroid cancer

This is the most common thyroid malignancy. It is characterized by a slow, infiltrative local spread affecting other parts of the thyroid gland and regional lymph nodes. Fine needle aspiration biopsy typically reveals large cells with ground glass cytoplasm, and pale nuclei with inclusion bodies and central grooving.

251

What condition typically presents with symmetrical proximal muscle weakness and erythematous rash on the dorsum of the fingers (Gottrons's sign) and/or upper eyelids (heliotrope eruption)?

Dermatomyositis

This is an idiopathic inflammatory myopathy with immune-mediated muscle injury that can be due to a paraneoplastic syndrome in malignancy. It can also present with interstitial lung disease, esophageal dysmotility, raynaud's phenomenon, and polyarthritis.

253

Inhalation exposure to what causes a bitter almond odor?

Cyanide

It is highly lethal and toxicity presents with headache, vomiting, abdominal pain and flushed skin.

254

Which form of psychotherapy focuses on reducing automatic negative thoughts and avoidance behaviors that cause distress.

Cognitive-behavioral therapy

It is effective as monotherapy or in combination with medication for a wide range of psychiatric disorders.

255

What diagnosis should be suspected in a patient who presents with gastrointestinal complaints followed by the characteristic triad of periorbital edema, myositis, eosinophilia, as well as subungual splinter hemorrhages and conjunctival or retinal hemorrhages?

Trichinellosis (Also known as trichinosis)

This is a parasitic infection caused by the roundworm Trichinella. It is acquired by eating undercooked pork that contains encysted Trichinella larvae. The disease occurs in three phases. The initial phase occurs in the first week of infection when the larvae invade the intestinal wall. This phase manifests as abdominal pain, nausea, vomiting, and diarrhea. The second phase begins in the second week of infection. It reflects a local and systemic hypersensitivity reaction caused by larval migration, with features such as splinter hemorrhages, conjunctival and retinal hemorrhages, periorbital edema, and chemosis. As the larvae enter the patient's skeletal muscle during the third phase, muscle pain, tenderness, swelling, and weakness occur. Blood count usually shows eosinophilia.

257

A scaling skin plaque with central ulceration and a biopsy showing polygonal cells with atypical nuclei at all levels of the epidermis with zones of keratinization is indicative of what diagnosis?

Squamous cell carcinoma of the skin

258

What is the first-line treatment of inflammatory acne?

Topical retinoids and benzoyl peroxide

Topical retinoids are first-line for noninflammatory (comedonal) acne. Moderate and moderate-to-severe inflammatory acne benefits from the addition of topical antibiotics. Oral antibiotics and isotretinoin are usually reserved for severe or recalcitrant acne.

259

What is the preferred initial imaging modality for suspected gynecological tumors?

Pelvic ultrasound

It has a high sensitivity for diagnosing uterine fibroids and ovarian pathology.

260

What medication is generally used for symptomatic relief of a patient with hyperthyroidism until the underlying cause is identified and definitively treated?

Propranolol

Propranolol effectively relieves the tachycardia, tremor, sweating, and anxiety that occur with hyperthyroidism due to any cause.

261

What is characterized by pale, velvety pink or whitish, hypopigmented macules that do not tan and do not appear scaly, but scale on scraping?

Tinea versicolor

Topical treatment with selenium sulfide lotion and ketoconazole shampoo is recommended.

263

Which should be done first in a patient with suspected infective endocarditis?

Blood cultures or initiating antibiotic therapy

Blood cultures

It is recommended that a minimum of 3 blood cultures be obtained from separate venipuncture sites over a specified period prior to initiating antibiotic therapy. In patients with acute illness, all 3 blood cultures should be obtained over a 1-hour period before beginning empiric antibiotic therapy. Patients with stable subacute illness (I.E. general malaise with no fever) should have blood cultures obtained over several hours, and antibiotic therapy can be delayed until the blood culture results become available.

264

What condition commonly presents in young-to-middle-aged women with widespread pain, fatigue, and cognitive/mood disturbances, without any laboratory abnormalities?

Fibromyalgia

Polymyositis presents with symmetrical proximal muscle weakness, mild pain, and elevated muscle enzymes, however, there is usually less prominent hip or shoulder involvement than in fibromyalgia. Polymyalgia rheumatica almost always occurs in patients age >50, who develop pain and stiffness of the shoulders and pelvic girdle but do not have significant muscle tenderness. Erythrocyte sedimentation rate is usually significantly elevated in polymyalgia rheumatica.

265

Adrenal calcification in a patient with primary adrenal insufficiency is a typical feature of what etiology?

Adrenal tuberculosis

In the past, tuberculosis was the most common cause of primary adrenal insufficiency. Treatment of tuberculosis usually does not generally result in normalization of adrenal functions. Most patients require lifelong replacement with glucocorticoids and mineralocorticoids.

266

What is the treatment of choice for hepatic encephalopathy?

Lactulose, rifaximin, and laxatives

Lactulose is a non-absorbable disaccharide used for lowering serum ammonia. Colonic bacteria metabolize lactulose to short-chain fatty acids (I.E. lactic acid, acetic acid). This acidifies the colon to stimulate conversion of the absorbable ammonia to the nonabsorbable ammonium. Rifaximin is an antibiotic that can decrease the number of ammonia-producing bacteria in the colon. It is usually added to lactulose if the patient does not improve within 48 hours. Catharsis using any laxative may also be beneficial.

268

What is the first step in working up a thyroid nodule?

Clinical evaluation, TSH levels, and thyroid ultrasound

If suspicious, fine needle aspiration (FNA) is the next step. If not suspicious but TSH levels are normal or elevated, FNA is still the next step. If not suspicious and TSH is low, I-123 scintigraphy is the next step and cold nodules should undergo FNA while hot nodules can be treated as hyperthyroidism.

269

What diagnosis should be considered in a patient with mononucleosis-like symptoms, atypical lymphocytes on the blood smear, and a negative monospot test?

Cytomegalovirus (CMV) infection

Unlike Ebstein-Barr virus-associated mononucleosis, sore throat and lymphadenopathy are uncommon in CMV infection.

270

What are the 3 most common causes of secondary clubbing?

  1. Lung malignancy
  2. Cystic fibrosis
  3. Right-to-left cardiac shunts

Chronic obstructive pulmonary disease (COPD) alone does not cause digital clubbing, and presence of clubbing in patients with COPD should prompt a search for occult malignancy.

271

What 3 signs/symptoms differentiate Legionella pneumonia from other bacterial pneumonias?

  1. Prominent gastrointestinal symptoms
  2. Hyponatremia
  3. Liver function test abnormalities

272

An elderly patient with acute back pain, no obvious preceding trauma, and a normal neurological examination is suggestive of what diagnosis?

Compression fracture of the vertebrae

273

What toxicity presents with CNS depression, cardiac arrhythmias, hypotension, hyperthermia, flushing, dilated pupils, decreased bowel sounds and urinary retention?

Tricyclic antidepressant poisoning (TCA)

274

The urinary nitroprusside test is widely used as a qualitative screening procedure for what?

Cystinuria

This is an inherited group of disorders characterized by impaired amino acid transport causing recurrent renal stone formation. The problem lies with the defective transport of dibasic amino acids (cystine, lysine, arginine, and ornithine) by the brush borders of renal tubular and intestinal epithelial cells. Cystine is poorly soluble in water; this leads to the formation of hard, radioopaque renal stones. The characteristic stones are hard and radioopaque. Urinalysis shows typical hexagonal crystals.

275

A normal or increased FEV1/FVC ratio with a low vital capacity and a decreased DLCO is seen in what disease?

Restrictive lung disease

The DLCO is decreased with interstitial lung disease, whereas chest wall weakness or other neuromuscular disorders causing similar findings would not have a decreased DLCO.

277

Fatigue, painless oral ulcers, non-deforming arthritis, and hematologic abnormalities are common findings in what condition?

Systemic lupus erythematosus (SLE)

Arthritis affects 90% of patients with SLE and is often the presenting symptom. Lupus arthritis, like rheumatoid arthritis, most commonly affects the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints, but differs in that it is not deforming. Patients may also present with low-grade fever, weight loss, malar rash, serositis, and proteinuria.

278

In the acute setting, what is one of the primary treatments for stroke in a sickle cell patient?

Exchange transfusion

While this may not reverse changes from the initial vascular event, it helps to decrease the percentage of sickle cells in the bloodstream and makes an additional stroke less likely. Continuing the hydroxyurea should also help to decrease the percentage of sickle cells by increasing the proportion of fetal hemoglobin. Fibrinolytic therapy is unlikely to be effective since the stroke is likely secondary to sludging of sickle cells as opposed to a true thrombus.

279

What is believed to be the main mechanism of kidney damage in Systemic Lupus Erythematosus (SLE)?

Immune complex-mediated damage

Immune complexes circulate in the blood and are deposited in renal glomeruli causing their damage via several mechanisms. One of these mechanisms includes complement activation. That's why serum C3 levels are decreased in immune complex-mediated kidney diseases such as SLE and poststreptococcal glomerulonephritis.

281

Classically, the diagnosis of Wilson's disease is confirmed by what?

Low serum ceruloplasmin (particularly

Evaluation should include measurement of serum ceruloplasmin levels and slit lamp examination of the eyes to establish whether the Kayser-Fleischer rings are present.

282

What is the treatment for ethylene glycol intoxication?

Fomepizole or ethanol

These inhibit alcohol dehydrogenase. Sodium bicarbonate can be added to alleviate the acidosis, and hemodialysis can be used in severe acidosis and/or end-organ damage.

283

What can be done to prevent febrile nonhemolytic transfusion reactions from happening?

Leukoreduction of donor blood

This can also reduce the risk of Human leukocyte antigen (HLA) alloimmunization and cytomegalovirus transmission. When red cells and plasma are separated from whole blood, small amounts of residual plasma and/or leukocyte debris may remain in the red cell concentrate. During blood storage, these leukocytes release cytokines, which when transfused can cause transient fevers, chills, and malaise, without hemolysis. Leukoreduction involves reducing the number of transfused leukocytes through filtering or other methods such as saline washing, freezing, and deglycerolizing, or buffy coat removal. Premedication with antipyretics and antihistamines has not been shown to significantly reduce transfusion reactions.

285

Kaposi sarcoma in HIV patients is caused by what?

Human Herpesvirus 8 (HHV-8)

286

Vesicles and dendritic ulcers in the cornea are characteristic of what condition?

Herpes simplex keratitis

288

Genetic testing for multiple endocrine neoplasia type 2 (MEN2) involves searching for germline mutations in which gene?

RET proto-oncogene

MEN1

  1. Parathyroid adenoma (>90%)
  2. Pituitary tumors (10-20%)
  3. Enteropancreatic tumors (60-70%)

MEN 2A

  1. Medullary thyroid cancer (>90%)
  2. Pheochromocytoma (40-50%)
  3. Parathyroid hyperplasia (10-20%)

MEN 2B

  1. Medullary thyroid cancer
  2. Pheochromocytoma
  3. Other: Mucosal/intestinal neuromas & Marfanoid habitus

289

What is the first-line treatment for noninflammatory (comedonal) acne?

Topical retinoids

Inflammatory acne is treated with topical retinoids and benzoyl peroxide. Moderate-to-severe inflammatory acne benefits from the addition of topical antibiotics. Oral antibiotics and isotretinoin are usually reserved for severe or recalcitrant acne.

290

When did donated blood and organs start being routinely tested for hepatitis C?

1992

Patients who received blood transfusions before 1992 are at increased risk of heptitis C.

291

Which screening test is most important for patients taking hydroxychloroquine?

Eye examination

The most serious side effect of hydroxychloroquine is retinopathy. Corneal damage can also occur. Eye examinations every 6 months are the only form of routine screening required with hydroxychloroquine therapy.

292

What are the respective time courses of IgA nephropathy and postinfectious glomerulonephritis with respect to preceding illness?

  1. IgA nephropathy occurs within 5 days of upper respiratory tract infection
  2. Postinfectious glomerulonephritis occurs 10-20 days after streptococcal throat or skin infections

Serum C3 complement levels are low in postinfectious glomerulonephritis but normal in IgA nephropathy.

293

What is the treatment for Legoinnaire's disease?

Macrolides (I.E. Azithromycin) or newer generation fluoroquinolones (I.E. levofloxacin)

294

Which malignancy causes the majority of cases of malignancy-associated syndromes?

Small cell lung cancer

It can cause syndrome of inappropriate anti-diuretic hormone, ectopic adrenocorticotropic hormone production, and Lambert-Eaton syndrome.

295

What is the acute management of chronic obstructive pulmonary disease (COPD) exacerbations?

Short-acting bronchodilators, glucocorticoids, and antibiotics

Patients with continued symptoms despite medical management should be considered for noninvasive positive-pressure ventilation (NPPV). Endotracheal intubation with mechanical ventilation is recommended for patients who fail a 2-hour trial of NPPV.

296

Inflammatory symmetric arthritis that resolves within two months is due to what?

Viral infection

Causative agents include parvovirus, hepatitis, HIV, mumps, and rubella. Positive rheumatoid factor and a weakly positive ANA are not surprising findings in viral arthritis.

297

What is the most common cause of glomerulonephritis in adults and usually presents as a patient with recurrent episodes of gross hematuria, usually within 5 days after an upper respiratory tract infection?

IgA nephropathy

IgA nephropathy is differentiated from postinfectious glomerulonephritis based on earlier onset of upper respiratory tract infection-related glomerulonephritis and normal serum complement levels. Kidney biopsy can also help differentiate these 2 processes.

298

What is the treatment of choice for mild inflammatory acne?

Topical retinoids + Benzoyl peroxide

299

The development of atrioventricular block in a patient with infective endocarditis should raise suspicion for what?

Perivalvular abscess extending into the adjacent cardiac conduction tissues

300

Pallor of the optic disc, a cherry red fovea, and boxcar segmentation of blood in the retinal veins on ophthalmoscopic examination is characteristic of what condition?

Central retinal artery occlusion

It is characterized by a sudden painless loss of vision in one eye.

301

A fall in total and free T3 levels with normal T4 and TSH levels is characteristic of what condition?

Sick euthyroid syndrome

Any patient with an acute, severe illness may have abnormal thyroid function tests and the most common thyroid hormone pattern in such patients is a fall in total and free T3 without a change in T4 or TSH.

302

What is the most common cause of death in patients with acromegaly?

Congestive cardiac failure

This accounts for 38-62% of deaths. High levels of growth hormone (GH) lead to excessive production of insulin-like growth factor 1 (IGF-1). IGF-1 excess leads to the excessive growth of bone and soft tissues. Direct and indirect effects of GH excess (via IGF-I) also contribute to cardiovascular manifestations. Patients have an increased incidence of coronary heart disease, cardiomyopathy, arrhythmias, left ventricular hypertrophy, and diastolic dysfunction. Other causes of death include respiratory (0-25%) and malignancy (9-25%).

303

What complication of a chronic inflammatory condition results in extracellular tissue deposition of fibrils into tissues and organs and can lead to multi-organ dysfunction?

Secondary amyloidosis

Treatment is usually directed at the underlying inflammatory disease, but colchicine has been approved for both prophylaxis and treatment of secondary amyloidosis.

304

Which immunologic blood transfusion reaction is characterized by the following?

  1. Occurs within 6 hours of transfusion
  2. Respiratory distress and signs of noncardiogenic pulmonary edema
  3. Caused by donor anti-leukocyte antibodies

Transfusion-related acute lung injury

305

Decreased thyroid-stimulating hormone, elevated free T3 and T4, diffusely decreased radioiodine uptake (RAIU), and low serum thyroglobulin all suggest what diagnosis?

Factitious thyrotoxicosis

This results from ingestion of exogenous thyroid hormone. Patients present with signs and symptoms of thyrotoxicosis, but without goiter or exophthalmos.

306

The combination of bradycardia, AV block, hypotension, and diffuse wheezing is indicative of what diagnosis?

Beta-blocker overdose

Intoxication of calcium channel blockers, digoxin, and cholinergic agents would cause some of these symptoms, but wheezing is indicative of beta-blocker toxicity. Atropine and IV fluids are the first line of therapy, and if they do not completely reverse the cardiac symptoms, glucagon should be administered.

307

What is the treatment for tinea versicolor?

Topical selenium sulfide lotion and ketoconazole shampoo

308

Absent CD55 on red blood cell membranes is characteristic of which condition?

Paroxysmal nocturnal hemoglobinuria

The CD55 molecule is a part of complement regulatory proteins used to protect the cell from destruction by the complement system.

309

What is the drug-class of choice for treating and preventing chemotherapy-induced nausea and vomiting?

Serotonin 5HT3 receptor antagonists

Ondansetron is a commonly used medication in this group. These medications can be used to manage acute emesis but are also useful as prophylaxis. Corticosteroids are sometimes combined with 5HT3 antagonists for better prophylaxis against chemotherapy-induced vomiting. Compared with many other medications, the side effects of 5HT3 receptor antagonists are usually less severe and less frequent. Antidopamine agents such as metoclopramide and prochlorperazine may be used to treat nausea and vomiting, but they are not as effective as 5HT3 antagonists in the setting of recent chemotherapy.

310

What is described as a sharply demarcated, erythematous, edematous, tender skin lesion with raised borders?

Erysipelas

This is a specific type of cellulitis characterized by inflammation of the superficial dermis, thereby producing prominent swelling. The onset of illness is abrupt, and there are usually systemic signs, including fever and chills. The legs are the most frequently-involved site. The most likely causative organism is group A beta-hemolytic streptococcus (Strep. pyogenes).

311

What condition is characterized as a milder autosomal recessive disorder of bilirubin metabolism with lower serum bilirubin levels (<20 mg/dL)?

Crigler-Najjar syndrome type 2

Liver enzymes and histology are normal. If intravenous phenobarbital is administered, the serum bilirubin is reduced. Treatment is often unnecessary in milder cases, though periodic administration of phenobarbital or clofibrate can reduce serum bilirubin levels if necessary.

312

What is thought to be primarily responsible for the pathogenesis of carpal tunnel syndrome?

Deposition of mucopolysaccharide protein complexes within the perineurium and endoneurium of the median nerve and in the tendons and synovial sheath that causes direct pressure on the median nerve within the carpal tunnel

313

What effect does hypothyroidism have on serum lipids and sodium?

It causes hyperlipidemia and hyponatremia

314

What condition occurs in elderly patients with poorly controlled diabetes and presents with ear pain, drainage, and granulation tissue within the ear canal on otoscopic exam?

Malignant otitis externa

This is a potentially serious infection of the external ear that is usually caused by pseudomonas aeruginosa. Intravenous ciprofloxacin is the most effective treatment.

315

Which antibodies are present in more than 90% of patients with Hashimoto's thyroiditis?

Anti-thyroid peroxidase antibody and Anti-thyroglobulin antibody

316

What is characterized as a filamentous, aerobic, gram-positive, soil bacterium that is partially acid-fast?

Nocardia asteroides

It causes pulmonary or disseminated disease in immunocompromised hosts. Treatment of choice is trimethoprim-sulfamethoxazole.

317

What are the 4 components of treating chronic obstructive pulmonary disease (COPD) exacerbations?

  1. Supplemental oxygen (target oxygen saturation 88%-92%)
  2. Inhaled bronchodilators (beta-2 agonists and anticholinergics)
  3. Antibiotics
  4. Systemic glucocorticoids

318

How does central retinal artery occlusion (CRAO) present?

Sudden painless loss of monocular vision

Fundoscopy reveals diffuse ischemic retinal whitening and cherry red spots (typical but not specific for CRAO).

319

What is Light's criteria used for?

Light's criteria is used to differentiate between exudative and transudative effusions

Effusion is exudative if any of the following are true:

  1. Fluid protein/serum protein ration > 0.5
  2. Fluid LDH/serum LDH > 0.6
  3. Pleural fluid LDH is greater than 2/3 the upper limits of normal serum LDH

320

What is the most rapid and sensitive test to diagnose disseminated histoplasmosis in immunocompromised patients?

Urine or serum assay for Histoplasma antigen

322

What is the only intervention which has been conclusively shown to reduce the decline in glomerular filtration rate once azotemia develops due to diabetic nephropathy?

Intensive blood pressure control

For diabetic patients, the goal blood pressure is <130/80 mmHg.

323

Which mucocutaneous blistering disease is characterized by flaccid bullae and intercellular IgG deposits in the epidermis?

Pemphigus vulgaris

Autoantibodies are formed against desmoglein (an adhesion molecule). By contrast, bullous pemphigoid is a benign pruritic disease that is characterized by tense blisters, as opposed to the flaccid blisters in pemphigus vulgaris, and immunofluorescence microscopy shows IgG and C3 deposits in the dermal-epidermal junction. Furthermore, pemphigus vulgaris is aften associated with lesions in the oral mucosa, whereas oral lesions are very rare in bullous pemphigoid.

324

What diagnosis should be considered when an African American patient presents with insidious-onset dyspnea and dry cough, skin symptoms (protean manifestations, most commonly erythema nodosum), and eye symptoms (uveitis), but an absence of constitutional symptoms?

Sarcoidosis

This is a systemic granulomatous disease of unknown etiology that affects multiple organ systems including the lungs, skin, eyes, liver, kidney and/or heart.

325

Ear pain and drainage and granulation tissue in the ear canal of an elderly patient with poorly controlled diabetes is suggestive of what diagnosis?

Malignant otitis externa

This is caused by pseudomonas aeruginosa. Progression of the infection can lead to osteomyelitis of the skull base and destruction of the facial nerve.

326

Which two drugs have become the preferred therapies for treating chronic hepatitis B patients with acute liver failure or clinical cirrhosis and high serum hepatitis B virus DNA?

Entecavir and tenofovir

Entecavir can be used in decompensated cirrhosis; lower rate of drug resistance than lamivudine. Tenofovir is the most potent drug with limited drug resistance. It is the preferred drug in countries where it is approved. Entecavir and tenofovir have become preferred therapies due to lower drug resistance and ability to be used in decompensated cirrhosis. Interferon is also available but usually for younger patients with compensated liver disease; short-term treatment. Lamivudine has a diminished role due to higher drug resistance. It may have a role in HIV patients.

327

What is the single most important risk factor for developing squamous cell carcinoma of the skin?

Sun exposure

328

What is the standard of practice in the management of solitary brain metastasis with stable extracranial disease?

Surgical resection followed by whole brain radiation

Multiple brain metastases are best treated with palliative whole brain radiation.

330

Which immunologic blood transfusion reaction is characterized by the following?

  1. Occurs within 2-3 hours of transfusion
  2. Urticaria, flushing, angioedema and pruritus
  3. Caused by recipient IgE antibodies and mast cell activation

Urticarial/allergic transfusion reaction

331

What is the best proven method of improving long-term survival of patients with COPD?

Long-term supplemental oxygen therapy

Criteria for therapy include PaO255%), or evidence of cor pulmonale.

332

What medication is used as prophylaxis against mycobacterium avium intracellulare (MAC) when a patient's CD4 count drops below 50?

Azithromycin

333

What is the preferred antifungal treatment for histoplasmosis?

Itraconazole

Patients with mild to moderate disease may be treated with itraconazole alone. Those with more severe disease should be treated initially with intravenous liposomal amphotericin B for 2 weeks followed by itraconazole for 1 year.

334

Dysphagia/odynophagia, multiple, small, and well circumscribed ulcers with a round/ovoid "volcano-like" appearance, and eosinophilic intranuclear inclusions is characteristic of what diagnosis?

Herpes esophagitis

Treatment is acyclovir.

335

What are the 3 most common side-effects of recombinant erythropoeitin therapy?

  1. Hypertension (30% of patients)
  2. Headaches (15% of patients)
  3. Flu-like symptoms (5% of patients)