Mixed Step 2 Review Flashcards
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.
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.
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.
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.
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.
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.
What is the most effective treatment for malignant otitis externa?
Intravenous ciprofloxacin
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.
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.
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.
What are some key differences betwen rheumatoid arthritis and arthritis secondary to parvovirus B19?
- Rheumatoid arthritis: Morning stiffness _>_1 hour, joint swelling on exam, and symptoms for _>_6 weeks
- Parvovirus arthritis: Morning stiffness for 10-15 minutes, no joint swelling on exam, acute onset of symptoms
Any elderly patient with bone pain, renal failure, and hypercalcemia has what until proven otherwise?
Multiple myeloma
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.
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
What are the three best initial screening tests for patients with suspected adrenal insufficiency?
- Early-morning cortisol levels
- Adrenocorticotropic hormone (ACTH) levels
- 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).
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).
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.
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.
Liver failure is a well-known side effect of which HIV medication/medication class?
Nevirapine (non-nucleoside reverse transcriptase inhibitor)
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.
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.
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.
What is the appropriate treatment for hoarding disorder?
Selective serotonin reuptake inhibitors and cognitive behavioral therapy
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.
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.
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
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.
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.
What two actions can help minimize the risk of contrast-induced nephropathy?
- IV hydration with isotonic bicarbonate or normal saline
- Administration of acetylcysteine
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.
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.
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.
How is the diagnosis of Granulomatosis with polyangiitis (Wegener’s) made?
c-ANCA positivity and tissue biopsy.
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.
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.
What is the most reliable indicator of metabolic recovery in patients with diabetic ketoacidosis?
Arterial pH or anion gap
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.
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.
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.
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.
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.
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.
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.
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.
What is the initial treatment for warm autoimmune hemolytic anemia?
Prednisone in divided doses
Should prednisone prove ineffective, splenectomy is indicated.
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.
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.
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.
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.
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
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).
Lactic acidosis is a well-known side effect of which HIV medication/medication class?
Nucleoside reverse transcriptase inhibitors
CREST syndrome refers to a constellation of findings including what?
- Calcinosis cutis
- Raynaud phenomenon
- Esophageal dysmotility
- Sclerodactyly
- 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.
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.
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.
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.
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.
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.
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.
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.
Which immunologic blood transfusion reaction is characterized by the following?
- Occurs within 1 hour of transfusion
- Fever, flank pain, hemoglobinuria, renal failure and disseminated intravascular coagulation
- Positive direct coombs test, pink plasma
- Caused by ABO incompatibility
Acute hemolytic transfusion reaction
What is the most common etiologic agent in mucormycosis?
Rhizopus
Poorly controlled diabetes predisposes to this disease.
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.
Fatty casts are characteristic of what renal diagnosis?
Nephrotic syndrome
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.
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.
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.
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.
Red blood cell casts are characteristic of what renal diagnosis?
Glomerulonephritis
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.
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.
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.
What is the treatment for fibromuscular dysplasia?
Percutaneous angioplasty with stent placement
In which regions of the world is chloroquine-resistant plasmodium falciparum particularly common?
- Sub-Saharan Africa
- The Amazon Basin
- 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).
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.
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.
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.
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.
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.
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.
What are the two most widely used drug regimens for babesiosis?
- Quinine-clindamycin
- Atovaquone-azithromycin
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.
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.
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.
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 (
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.
What is the greatest risk in completing homicide?
Access to firearms
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
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
Fibromuscular dysplasia (FMD) most commonly involves which 3 arteries?
- Renal artery
- Carotid artery
- 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.
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.
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.
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.
How is bronchiectasis definitively diagnosed?
High-resolution computed tomography scan
What areas of the body are most affected by psoriasis?
The extensor surfaces (I.E. elbows, knees)
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.
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.
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.
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.
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.
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.
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)
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.
Which cells are the principle source of testosterone in males?
Leydig cells
What is the most common cause of pneumonia in HIV patients?
Encapsulated bacteria, especially pneumococci like Streptococcus pneumoniae
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.
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).
Patients with recurrent hypercalciuric renal stones should be treated with what?
- Increased fluid intake
- Sodium restriction
- 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.
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.
The effect of warfarin is increased by what?
- Acetaminophen
- Antibiotics/antifungals
- Amiodarone
- Cranberry juice, ginkgo biloba, vitamin E
- Omeprazole
- Thyroid hormone
- Selective serotonin reuptake inhibitors
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.
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.
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.
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.
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.
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.
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.
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).
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.
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.
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.
What is the most common cause of endocarditis following dental procedures?
Streptococcus mutans (and other Viridans group Streptococci)
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.
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.
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.
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.
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.
What is the most common cause of ductopenia (loss of intrahepatic bile ducts) in adults?
Primary biliary cirrhosis
The exact underlying pathophysiology is unknown.
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.
Medullary thyroid cancer should always raise suspicion for what?
Multiple endocrine neoplasia (MEN) 2A and 2B
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.
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.
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
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.
