MKSAP Flashcards
(666 cards)
1
Q
Best initial antibiotic for an adult with acute otitis media.
A
Amoxicillin.
2
Q
Class of drugs is used to treat generalized anxiety disorder.
(Especially if insomnia is the chief complaint).
A
Selective serotonin reuptake inhibitors. SSRIs.
Don’t use benzodiazepines.
3
Q
If the triglycerides are between 200 mg/dl - 500 mg/dl then should they be started on lipid lowering drugs?
A
The first step into determine what their non- HDL cholesterol is:
Total cholesterol - (minus) HDL cholesterol = non-HDL cholesterol.
Goal for non-HDL cholesterol is = Goal LDL + (plus) 30 mg/dl.
Treatment should also be considered for people with a personal or family history of coronary artery disease regardless of non-HDL cholesterol.
4
Q
Empiric treatment for chronic cough. (defined as more than 8 weeks).
A
First generation antihistamine/decongestant combination.
5
Q
Most effective drug for smoking cessation.
And
Most effective smoking cessation therapy.
A
Verenicline.
(Chantix).
Contra-indicated in patients with history of major depression and suicidal ideation as the drug is associated with new-onset of these symptoms or exacerbation of these symptoms.
Most effective therapy is high dose nicotine patch in combination with another anti-smoking therapy e.g, nicotine replacement gum or spray.
6
Q
Manage recurrent falls in an elderly patient.
A
Measure 25-hydroxy-vitamin D level.
Vitamin D supplementation reduces falls and fractures by about 20% in the elderly.
7
Q
Treatment of chronic prostatitis/chronic pelvic pain syndrome.
A
Alpha-blockers.
e.g. terazosin, tamsulosin.
8
Q
Treatment for musculoskeletal neck pain.
A
NSAIDS and physical therapy.
9
Q
Symptoms of scleritis.
A
Deep, boring eye pain.
Erythema localized to sclera (no normal white sclera visible between blood vessels) that looks like raised erythematous lesions.
Watering and tearing of eye.
Decreased visual acuity.
10
Q
When to give herpes zoster vaccination.
A
Indicated in all patients over 60 years of age regardless of chicken pox history.
11
Q
Symptoms and initial step in management of olecranon bursitis.
A
Pain on flexion of elbow.
Aspiration of olecranon bursa.
12
Q
Oral lesion associated with smokeless tobacco use.
And
Oral lesion associated with HIV.
A
Leukoplakia.
And
Oral hairy leukoplakia.
13
Q
Causes of dizziness in geriatric patients.
A
Multifactorial - deficits in multiple sensory systems and medication side effects.
Treatment is by physical therapy.
14
Q
Treatment of advanced carpal tunnel syndrome.
A
Surgery - Carpal tunnel release.
15
Q
Features of rotator cuff tendinitis.
A
Overuse injury, subacromial tenderness, and impingement.
16
Q
Features of bicipital tendinitis.
A
Overuse injury, bicipital groove tenderness, anterior shoulder pain with resisted forearm supination or elbow flexion.
17
Q
Preventing pressure ulcers.
A
Specialized foam mattresses and overlays.
18
Q
Acute painless visual loss, pale fundus, cherry red spot on fovea.
A
Central retinal artery occlusion.
19
Q
Screening for hearing loss in the elderly.
A
Whispered voice test or hand held audioscopy. Do it even if the patient denies having hearing problems.
20
Q
Ottawa ankle rules - for ankle pain/sprain.
A
No imaging unless there is tenderness along the posterior edge of either malleolus, pain and bone tenderness in the midfoot, or the inability to bear weight.
21
Q
Treatment of urge incontinence.
A
Oxybutynin or tolterodine.
22
Q
Prevent attacks of allergic rhinitis.
A
Intranasal cromolyn sodium.
23
Q
Root-cause analysis.
A
Used by performance improvement team to investigate the multiple factors associated with patient care errors.
24
Q
Panic disorder treatment.
A
Cognitive-behavior therapy plus SSRI.
25
Management of abnormal uterine bleeding in perimenopausal woman.
Rule out endometrial hyperplasia or cancer with endometrial biopsy.
26
Systemic side effects of ophthalmic timolol.
Bronchospasm, bradycardia, lethargy, decreased libido and erectile dysfunction.
27
Test to order when evaluating benign prostatic hyperplasia.
Urinalysis.
28
Key points to ascertain in medical decision making.
Whether the patient understands the risks and benefits and why the patient is making the choices that he is making.
29
Therapy and duration for drug eluting stents.
Dual therapy with aspirin and clopidogrel uninterrupted for at least 12 months.
30
Prevent medication (opiate) related falls.
Standardized protocols for management of opiate medications - dosage and strength.
31
Manage ocular trauma.
Emergency ophthalmology consult and shield (metal or paper cup) for affected eye.
32
How to reduce surgical risk in ESRD patient.
Schedule dialysis one day before surgery.
33
Patient with depression and suicidal ideation willing to make a 'no harm contract'.
Urgent referral to psychiatric facility/mental health referral. (Even if they contract for safety). If they contract for safety than a psychiatrist is okay. If not then hospitalization is appropriate.
34
Treat grief response.
Patient's that meet criteria for major depression for two consecutive weeks, eight or more weeks after their loved ones' death are candidates for pharmacological therapy.
35
Yellow deposits on retina. Diagnosis?
Early age-related macular degeneration. Patients should be counseled to quit smoking.
36
Difference between binge-eating disorder and bulemia nervosa.
Bulemia: Binge-eating two or more times a week for three months with purging or compensatory behavior.
Binge-eating disorder: Binge eating two or more times a week for six months with feelings of disgust or guilt but no purging or compensatory behavior.
37
LDL goal for patients with zero or one cardiovascular risk factor.
Less than 160 mg/dl.
38
Increased glare and impaired blue-yellow color vision. Diagnosis?
Cataracts.
39
Treatment of acute non-specific lower back pain.
Acetominophen.
40
Complications of gastric bypass surgery.
Stomal stenosis, marginal ulcers or erosions can result in persistent nausea and vomiting. Do an upper endoscopy.
41
Active young women with anterior knee pain worse when going down steps.
Patellofemoral syndrome.
42
Treatment of bacterial vaginosis.
Metronidazole. No need to treat partner.
43
Pink, pearly nodules with telangiectases and sometimes flecks of melanin pigment.
Basal cell carcinoma.
44
Erythematous, excoriated papules, sometimes with punctum, along clothing lines in the setting of outdoor activity - caused by?
Chigger bites.
45
Affect of smoking on cutaneous lupus erythamatosus.
Smoking interferes with the anti-malarial drugs used to treat it thus making the cutaneous lesions worse.
46
Large, irregular lesion with uneven pigmentation. Diagnosis?
Lentigo Maligna (malignant melanoma in situ). Do a broad, shallow shave biopsy.
47
Diagnosis of uticarial vasculitis.
Uticarial plaques are fixed in position for more than 24 hours and commonly heal with bruising. Diagnosis is confirmed with a biopsy of the skin.
48
Diagnositic test of choice for non-healing or atypical appearing ulcers.
Skin biopsy.
49
Pustular erythrodermic flare in the setting of history of psoriasis.
Can happen days to weeks after treatment with systemic steroids.
50
Neurogenic pruritus.
Subacute, severe, generalized pruritus with secondary erosions in the absence of a primary dermatological lesion.
51
Rapidly growing, non-tender, firm nodules with depressed keratotic centers.
Keratoacanthoma.
52
Ocular cicatricial pemphigoid - first step?
Accurate diagnosis with biopsy.
53
Treatment of pyoderma gangrenosum.
Systemic corticosteroids.
54
Treatment of gram negative folliculitis as a complication of Acne vulgaris.
Isotretinoin.
55
Florinated topical corticosteroid (triamcinolone) use on facial skin.
Perioral dermatitis - no treatment.
56
Gold standard for diagnosis in allergic contact dermatitis.
Epicutaneous patch testing.
57
How do you take pressure off a neuropathic ulcer.
Contact casting.
58
Recurrent erythema multiforme.
Herpes simplex virus (90%).
59
Fever with onset of erythematous macules and plaques that progress to epidermal necrosis and sloughing.
Steven-Johnson syndrome.
60
Proximal white subungal onychomychosis. Underlying disease?
HIV
61
Treatment of mixed cryoglobulinemia in the setting of HCV infection.
Treat underlying infection with pegylated interferon alfa and ribavirin.
62
Persistent, scaling, eczematous, or ulcerated lesion involving the areola/nipple.
Paget's disease of the breast.
63
Indications for bi-ventricular pacemaker defibrillator.
NYHA class III or IV heart failure.
QRS greater than 120 msec.
Ejection fraction less than or equal to 35%.
64
Cardiopulmonary symptoms in patients with less than severe mitral regurgitation.
Indicative of some other disease process e.g. pulmomary, coronary artery disease or physical de-conditioning.
65
Heart failure symptoms, decreased exercise tolerance, conduction defects, syncope or cardiac arrest in heart transplant patients is indicative of...
Coronary artery disease.
66
Indications for low dose spironolactone in heart failure patients.
Mortality benefit of 35% in patients continuing to have class III or class IV heart failure symptoms despite beta-blockers and ACE inhibitors. Not indicated for class I or class II heart failure symptoms.
67
Indications for an ICD (implantable cardioverter-defibrillator).
Reduces risk of sudden death in people with NYHA class II or III heart failure symptoms and an ejection fraction of 35% or less (in either ischemic or non-ischemic cardiomyopathy).
68
Echocardiogram shows echogenic, globular, mobile mass attached to the atrial septum. What is it and what's the treatment?
Atrial myxoma. Treatment is cardiac surgery for resection of the mass.
69
Type of cardiomyopathy caused by iron over load and treatment.
Restrictive cardiomyopathy. Treat the underlying cause i.e. phlebotomy, and if not tolerated then iron chelation.
70
Treatment of medically refractory angina.
External enhanced counterpulsation (EECP) and spinal cord stimulation.
71
Treatment of recurrent atrial flutter.
Radioactive ablation. Flecainide is contraindicated as a single agent as it can lead to ventricular fibrillation.
72
Management of decompensated mitral stenosis in a pregnant woman.
Maximum medical management first with beta-blockers, diuretics and heparin/lovenox.
73
Treatment of recurrent pericarditis.
Colchicine.
74
Titration of dose of beta-blocker in coronary artery disease.
Beta-blocker should be titrated to acheive a resting heart rate of 55 - 60 beats/min; or 75% of the heart rate that produces angina with exertion.
75
Hemoglobin levels in Eisenmenger syndrome.
Usually between 18 - 20 mg/dl as it is a cyanotic heart disease. Relative anemia is treated with low dose iron; if less than 10 mg/dl (bleeding/surgery) then may need transfusion.
76
Pain on prolonged standing, better on sitting; ankle reflexes decreased, sometimes knee reflexes too...
Spinal canal stenosis.
77
Treatment of syncope in heart failure with low EF on medication.
ICD placement. No need to document arrhythmias if suspicion is high enough.
78
Management of idiopathic pericardial effusion persisting for more than three months.
Pericardiocentesis.
79
Imaging modality contraindicated if pacemaker or ICd present.
MRI.
80
Treatment of Dressler syndrome.
High dose aspirin.
81
Treatment of choice for pulmonary stenosis.
Pulmonary balloon valvuloplasty.
82
Intervention of choice in unstable angina and high pretest probability of coronary artery disease.
Coronary angiography.
83
Cardiac clearance in aortic stenosis.
Asymptomatic patients - proceed with surgery. Symptomatic patients - prophylatic aortic valve replacement.
84
Next step after echocardiogram to evaluate congenital cardiac disease in adults following surgery during childhood.
If cause of symptoms is not apparent on the echocardiogram then a cardiac MRI needs to be done.
85
Evaluation of frequent symptoms (palpitations) in patients with known diagnosis of paroxysmal atrial fibrillation.
If symptoms happen multiple times a day then 24-hour amubulatory monitoring can be done to see if the symptoms correlate with atrial fibrillation or with rapid ventricular response. This will help in tailoring therapy.
86
What should be used instead of beta-blockers in acute coronary syndrome if their are contraindications to beta-blockers?
Calcium channel blockers.
87
Syncope during activity and family history of early sudden death,
Congenital long QT syndrome.
88
Indications for endomyocardial biopsy.
1. New onset heart failure (< 2 weeks) with hemodynamic compromise.
2. New-onset heart failure (2 weeks to 3 months) with dilated left ventricle, new ventricular arrhythmias, Mobitz type II 2nd degree, or 3rd degree heart block, or failure to response to usual care in 1 - 2 weeks,
89
Indications of aortic valve replacement surgery in aortic regurgitation.
1. Symptomatic patients.
2. Asymptomatic patients with bicuspid aortic valve and severe aortic regurgitation when the left ventricular end systolic diameter reaches 55 mm or the LVEF is less than 60%.
3. Equivocal symptoms - exercise induced increase in pulmonary systolic pressure more than 60 mmHg (or 25 mmHg over baseline) during treadmill stress echocardiography.
90
Progressive dyspnea and pulmonary hypertension.
Evaluate with VQ scan to rule out chronic thromboembolic disease.
91
Pregnancy and pulmonary artery hypertension.
Pregnancy is contraindicated in severe pulmonary artery hypertension even if the patient is asymptomatic. Estimated maternal mortality risk 30% - 50%. If unplanned pregnancy occurs then termination is recommended.
92
Pregnancy and anticoagulation in mechanical prothesthetic valves.
Warfarin use throughout pregnancy until near term provides the lowest risk for maternal complications/death in women with mechanical heart valves. Teratogenic risk less than 10% in first trimester if dose less than 5 mg/day. Low molecular weight heparin is very difficult to dose by weight during pregnancy.
93
Factors influencing BNP levels.
BNP levels are usually lower in obese people, even in the setting of acute heart failure, They can be higher in elderly, females, in renal failure, even if there is no volume overload.
94
Management of patient with cardiac sarcoidosis and syncope secondary to frequent PVCs and ventricular tachycardia episodes.
Placement of implantable cardiac defibrillator because these patients are risk of sudden cardiac death.
95
Treatment of reversible heart block secondary to Lyme disease (Lyme carditis).
Intravenous ceftriaxone.
96
Treatment of infrapoliteal symptomatic peripheral vascular disease.
Supervised exercise program.
| This can provide substantial symptomatic relief.
97
Hydralazine versus spironolactone in heart failure.
Hydralazine is added to the standard therapy of beta-blockers, ACEIs and diuretics in black patients.
Spironolactone is indicated in heart failure class III or IV in addition to standard therapy. Reduces mortality by 30%. Make sure potassium is not over 5 meq/L.
98
Indications for Milrinone.
Short term treatment of cardiogenic shock.
| It is a phosphodiesterase inhibitor and positive ionotropic agent.
99
Treatment of sick sinus syndrome with bradycardia and dizziness.
Pacemaker placement.
(Even if the bradycardia is a drug side effect if the patient still needs the drug e.g. rate control in atrial fibrillation.
100
Imaging studies that can diagnose aortic dissection.
1. Transesophageal echocardiogram.
2. Contrast-enhanced CT chest/abd.
3. Thoracic magnetic resonance angiography.
101
Pregnancy risk in repaired Tetralogy of Fallot.
Chance of offspring being born with congenital heart disease is about 50%.
102
Nonpharmacological treatment of atrial fibrillation with rapid ventricular response.
Atrioventricular nodal (junctional) ablation with pacemaker placement.
103
Common complication of repair of Tetralogy of Fallot.
Pulmonary and tricuspid valve regurgitation.
104
Management of patient with sedentary lifestyle, and severe asymptomatic mitral regurgitation.
An exercise stress echocardiography will need to be performed as the patient's exercise tolerance cannot be gauged by history as she has a sedentary lifestyle.
Exercise associated increase in pulmonary pressures of 25 mmHg over baseline should prompt surgical intervention.
105
Treatment of decompensated heart failure with volume overload and decreased cardiac output.
Intravenous inotropic agent e.g. dobutamine.
106
How to manage patient with prosthetic aortic valve and no history of thromboembolism on warfarin before elective surgery.
Stop warfarin 3 - 5 days before surgery. There is no need to use a heparin bridge in low risk patients.
107
Treatment of persistent asthma.
Defined as asthma attacks on 2 or more days a week or 2 more nights a month and is treated with inhaled corticosteroids with albuterol as needed.
108
Test of choice for acute exacerbation of idiopathic pulmonary fibrosis.
Bronchoscopy with a bronchoalveolar lavage to rule out opportunistic infections.
109
Define GOLD stage II COPD and treat it.
Defined as a postbronchodilator FEV1/FVC ratio of less than 70% and an FEV1 of less than 80% but more than 50%. Treatment is with long acting beta-2 agonists with albuterol as needed. Long acting anticholinergics can also be used.
110
Follow-up for 3 mm lung nodule found on chest CT.
If low risk for lung cancer then nodules less then 4 mm then no follow-up. If the patient is high risk then a follow-up CT is done at 12 months.
111
Generalized, flaccid weakness, with unexplained difficulty weaning from ventilator.
Intensive care unit acquired weakness.
112
Imaging to diagnose pulmonary embolism in a patient with a creatinine of 2 mg/dl.
Ventilation/perfusion scan.
113
Asthma like symptoms that do not respond to conventional asthma therapy.
Patient may have vocal cord dysfunction and needs a laryngoscopy.
114
Diagnosis of dermatomyositis with lung disease resembling idiopathic interstitial lung disease.
Electromyography and muscle biopsy.
115
Lymphocytic predominate pleural effusion, with high protein and LDH.
Likely a tuberculous pleural effusion.
116
Treatment of pulmonary embolism after delivery of baby.
Even if you suspect an amniotic fluid embolus you will still anti-coagulate the patient since you cannot differentiate and thrombus from an amniotic fluid embolus.
Subcutaneous unfractionated heparin, low molecular weight heparin or fondaparinux can be used.
117
Treatment and prevention of high altitude pulmonary edema.
Nifedipine.
118
Myasthenia gravis and mass of chest CT.
Thymoma. Thymomas are associated with paraneoplastic syndromes like myasthenia gravis.
119
Episodic chest discomfort and cough after upper respiratory tract infections with normal spirometry. Next step?
Suspect asthma if there are episodic symptoms and the patient is well with normal spirometry inbetween episodes. Methacholine challenge testing is performed.
120
Next step in management of 1.5 cm lung nodule that is non-enhancing (Hounsfield units < 15) on dynamic CT contrast study.
Non-enhancing lesions are likely to be benign so 3 month follow-up CT chest is appropriate.
121
Next step in patient failing extubation because of hypoxemic respiratory failure and what not to do.
Reintubate the patient.
| Non-invasive positive-pressure ventilation is potentially harmful in these patients.
122
Japanese patient who recently started smoking, who has hypoxemic respiratory failure after 1 - 2 weeks of fever and systemic symptoms.
Acute eosinophilic pneumonia.
123
A COPD patient on home oxygen wants to take a flight. Next step?
Hypoxia inhalation test to predict in-flight pO2 and development of cardiac events related to low oxygen levels.
124
Severe anterior chest pain during therapeutic thoracocentesis.
Diagnostic of unexpandable lung with development of significant negative intrapleural pressure. Treatment is by insertion of a thoracentesis needle or catheter to allow air entry and relieve pressure. An indwelling pleural catheter will allow for drainage which can be discontinued when chest pain develops.
125
Selection criteria for augmentation with alpha-1 antitrypsin intravenous augmentation therapy.
Most effective in patients with FEV1 35 - 60% of predicted and FEV1/FVC ratio of 30 - 65%.
1. Age at least 18 years.
2. Non-smoker or ex-smoker.
3. Likely adherence to protocol.
4. High risk phenotype (protease inhibitor Z). .
5. Plasme alpha-1 antitrypsin levels below 50 - 80 mg/dl.
6. Airflow obstruction with spirometry.
126
Improve survival in patients with severe sepsis and APACHE score of 25 or greater.
Activated protein C.
Platelets below 30,000 are a relative contraindication.
Mortality benefit not shown if APACHE score less than 25 or only one organ system involved.
127
Routes of epinephrine in anaphylaxis/anaphylactic shock.
Epinephrine can be given subcutaneously, intramuscularly or intravenously; depending on severity of symptoms.
128
Diagnosis in young woman with spontaneous pneumothorax and cystic changes seen on high resolution CT scan.
Lymphangioleiomyomatosis.
129
Management of pulmonary involvement in systemic sclerosis.
Minimal lung involvement (less than 20%) just requires periodic lung function testing and high resolution CT scans. Severe, but not moderate involvement may benefit from cyclophosphamide. FVC less than 70% of predicted is predictive of response to therapy.
130
If there is a lung nodule and a malignant appearing lymph node which one would you biopsy.
The lymph node because that would establish the stage as well, whereas biopsying the lung nodule would only establish the diagnosis and not the stage.
131
Management of complex parapneumonic pleural effusions with septations.
Initially try pleural fluid drainage with a chest tube or catheter, and then a trial of thrombolysis for the septations. If there is no response then a surgical consultation for VATS is warranted.
132
Caloric requirements of patients in the ICU.
Critically ill patients typically require 25 - 30 nonprotein kcal/kg/day and 1 - 1.5 protein kcal/kg/day.
Severely malnourished patients require 30 nonprotein kcal/kg/day and 1.5 protein kcal/kg/day.
133
In patients with hypoxemia and ARDS which ventilator setting should be changed?
The PEEP should be increased to recruit the collapsed and flooded alveoli.
134
Rewarming techniques in hypothermia.
Mild hypothermia: 93 - 97 F - passive and active rewarming techniques.
Moderate hypothermia: 86 - 93 F - active external rewarming by rewarming the trucal areas first.
Severe hypothermia: less than 86 F - active internal rewarming techniques.
135
Depressed consciousness and hypoventilation in a patient who has been receiving pain medications.
Think of opiod overdose and treat with intravenous naloxone.
136
Pulmonary hypertension and chronic progressive dyspnea in a patient with no parenchymal lung disease (or out of proportion disease).
Think of chronic thomboembolism; and go for a V/Q scan before doing a pulmonary catheterization.
137
Patient with fever who stopped taking her antiParkinsonian medications.
Neuroleptic malignant syndrome.
Causes:
1. Taking neuroleptic drugs.
2. Abrupt withdrawal of antiparkinsonian medications.
138
Treatment of idiopathic pulmonary fibrosis.
Lung transplant is the only therapy that improves survival.
139
Reduction of post-operative risk of pulmonary complications in COPD patients who smoke.
Incentive spirometry.
| If patient quits smoking two months before surgery then there is a decrease in pulmonary complications.
140
Moderate COPD with rising pCO2 and use of accessory muscles.
Initiate non-invasive positive pressure ventilation early. It can prevent the need for intubation.
141
Definitive therapy for chronic thromboembolic pulmonary hypertension.
Pulmonary thromboendarterectomy.
142
Common cause of difficulty weaning from ventilator.
Excessive ventilation.
143
Treatment for patient with homogenous emphysema with FEV1 less than 20% of predicted and DLCO less than 20%.
Lung transplantation.
| They have a median survival of 3 years. Lung transplant improves quality of life but not survival.
144
Treatment of severe pulmonary arterial hypertension.
Intravenous epoprostenol.
145
Evaluate lung nodules 1 - 2 cm in size.
Transthoracic needle aspiration of nodule will have a higher yield than bronchoscopy for nodules of this size.
146
Interstitial lung disease in the context of significant past or current smoking.
Respiratory bronchiolitis interstitial lung disease.
147
Can a patient with a normal RSBI but copious secretions be extubated?
No. Secretions must also improve.
148
Main influenza vaccine used in US.
Trivalent killed virus.
149
Can a patient with a normal RSBI but copious secretions be extubated?
No. Secretions must also improve.
150
Can a patient with a normal RSBI but copious secretions be extubated?
No. Secretions must also improve.
151
Main influenza vaccine used.
Trivalent killed virus.
152
Propofol infusion syndrome.
Primarily occurs in patients with acute neurological or inflammatory conditions complicated by severe sepsis or infection who are receiving catecholamines or corticosteroids in addition to propofol. Symptoms include heart failure, rhabdomyolysis, severe metabolic acidosis and renal failure associated with hyperkalemia.
153
Role of limiting exposure of allergens in asthma patients.
Limiting allergens as a main intervention in asthma is not very effective. It might be effective in allergic patients who also have difficult-to-control asthma,
154
How would you monitor the respiratory status of a patient with neuromuscular weakness.
Measuring serial vital capacity.
Patients with vital capacity under 15 - 20 ml/kg, who are unable to generate more than 30 cm H2O of negative inspiratory force, or those with declining values are at high risk of ventilatory failure requiring invasive mechanical ventilation.
155
Treatment of Helicobacter pylori after initial proton-pump inhibitor based triple therapy has failed to eradicate the infection.
Bismuth based quadruple therapy with a proton-pump inhibitor, bismuth subsalicylate, metronidazole and tetracycline.
The initial failure is most likely secondary to non-compliance or resistance to clarithromycin.
156
Colorectal cancer screening in a patient with ulcerative colitis.
Colorectal cancer screening should be initiated 8 years after onset of disease (risk 1 - 2% per year after 8 years). Screening is done with colonoscopy 8 years after onset of disease and follow-up colonoscopy every 1 - 2 years thereafter.
157
If someone has MALT (Mucosa-associated lymphoid tissue) then what should you test for?
Helicobacter pylori.
158
First line treatment for diffuse esophageal spasm.
Proton-pump inhibitor.
It is usually caused by GERD so a trial of PPIs is recommended first.
159
In obscure GI bleeding - if the EGD and colonoscopy have previously been normal, what is the next step?
Repeat EGD.
| This identifies the source in a significant number of patients.
160
Alcoholic patient with chronic diarrhea, normal pancreatic enzymes, and fat in his stool. What is the diagnosis and treatment?
Chronic pancreatitis and pancreatic insufficiency.
| Pancreatic enzyme replacement (even if the serum levels are normal).
161
Alcoholic patient with chronic diarrhea, normal pancreatic enzymes, and fat in his stool. What is the diagnosis and treatment?
Chronic pancreatitis.
| Pancreatic enzyme replacement (even if the serum levels are normal).
162
Treatment of achalasia in the elderly or people with multiple co-morbidities.
Botulinum toxin injection is the treatment of choice in patients who are not candidates for surgical or endoscopic treatment.
163
Treatment of achalasia in the elderly or people with multiple co-morbidities.
Botulinum toxin injection is the treatment of choice in patients who are not candidates for surgical or endoscopic treatment.
164
Criteria of irritable bowel syndrome and initial management.
Recurrent abdominal pain or discomfort.
Marked change in bowel habits for at least 6 months.
Symptoms experienced at least 3 days a month for 3 months.
Two or more of the following:
1. Pain relieved by bowel movement.
2. Onset of pain related to change in frequency of stool.
3. Onset of pain related to change in appearance of stool.
Symptomatic treatment.
165
Treatment for eosinophilic esophagitis.
Topical (swalllowed) liquid corticosteroids.
166
How to proceed if you have a patient who might have Hereditary Nonpolyposis Colorectal Cancer in his family.
Refer for genetic counseling. Initial genetic testing should be under the guidance of a genetic counselor and the initial sample should be taken from a relative affected with cancer.
167
CT scan of abdomen: well-circumscribed lesion in liver with and an enhancing central scar.
Treatment?
Focal nodular hyperplasia.
| This is benign and just requires observation.
168
Treatment of acute, recurrent bleeding from H. pylori infected peptic ulcer that does not respond to endoscopic treatment.
Surgical treatment.
169
Imaging modalities of staging of gastric adenocarcinoma.
After diagnosis by EGD, initial staging is done by CT imaging, followed by pre-operative PET scan if the lesions on the CT scan are indeterminate.
170
Symptoms of achalasia with mass at the distal esophagus - management.
Psuedoachalasia.
| Endoscopic ultrasonography of the esophagus with needle biopsy to evaluate the mass.
171
How do you diagnose pancreatic cancer if a mass is not seen on CT scan.
Endoscopic ultrasonography.
172
Delayed gastric emptying after infectious gastroenteritis.
Post-viral gastroparesis.
173
Next step in evaluation of obscure GI bleeding after the patient has had two negative EGDs and a negative colonoscopy.
Wireless capsule endoscopy.
174
Management of fundic gland polyps.
No follow-up needed.
| No malignant potential.
175
If the liver function tests are abnormal after a liver transplantation in a Hepatitis C patient, what is the next step?
Liver biopsy to differentiate between recurrent hepatitis C infection and rejection.
176
Colon cancer screening in patients with a family history of colon cancer or adenomas.
Screening should be started at age 40 or at an age 10 years younger than the youngest affected family member, whichever comes first. Screening is done by colonoscopy 3 - 5 years.
177
How long can patients with acute hepatitis C remain seronegative? And what should you test for?
They can remain seronegative up to 8 weeks.
| Check HCV RNA.
178
Evaluation of younger patient with hematochezia and low risk for colon cancer.
Flexible sigmoidoscopy.
179
What is the most sensitive test for chronic pancreatitis?
Endoscopic reterograde cholangiopancreatography (ERCP).
180
Management of high grade dysplasia detected at screening colonoscopy in ulcerative colitis patients.
Total proctocolectomy.
181
Biopsy specimen from esophageal ulcer in immuno-suppressed patient shows intense inflammatory infiltrates with granulation tissue associated with occlusion body cells. Diagnosis?
Cytomegalovirus esophagitis.
182
What is the next step in evaluating a patient with a clinical diagnosis of pancreatitis?
Abdominal ultrasound to rule out gallstones.
183
Management of patients with abnormal liver enzymes and abnormal transferrin saturation.
Screen for hereditary hemochromatosis - mutations of the HFE gene.
Treatment with phlebotomy, or chelation if patient cannot tolerate phlebotomy (anemic).
184
Management and screening of a patient after resection of colon cancer.
Initial colonoscopy (pre- or post-operative) and then colonoscopy at 1 year, 3 years and 5 years.
CEA every 3 months post-operatively for 3 years.
CT scan at 1 year for 3 years.
History and physical exams every 3 - 6 months for 3 years and then every 6 months for the next 2 years.
185
Patient who just had bariatric surgery presenting with sudden shortness of breath, tachycardia and tachypnea.
Suspect pulmonary embolism.
| Infrequent early complication of bariatric surgery, but accounts for 50% of the deaths in these patients.
186
Treatment of a single focus hepatocellular carcinoma in a patient with decreased liver reserve (cirrhosis - decompensated or with complications).
Evaluation for a liver biopsy.
187
Persistently elevated liver enzymes in patients with metabolic disease should get...
Liver biopsy.
| To distinguish between non-alcoholic steatohepatitis and steatosis.
188
Persistently elevated liver enzymes in patients with metabolic disease should get...
Liver biopsy.
| To distinguish between non-alcoholic steatohepatitis and steatosis.
189
Persistently elevated liver enzymes in patients with metabolic disease should get...
Liver biopsy.
| To distinguish between non-alcoholic steatohepatitis and steatosis.
190
Left lower quadrant abdominal pain, fever, and elevated leukocyte count.
Diagnosis and best imaging modality?
Diverticulitis.
| CT Abd/Pelvis.
191
What kind of murmurs in asymptomatic patients needs a trans-thoracic echocardiogram?
1. Systolic murmurs grade 3/4 or higher in intensity.
2. Diastolic murmurs.
3. Continuous murmurs.
4. Holosystolic murmurs.
5. Late systolic murmurs.
6. Murmurs associated with ejection clicks.
7. Murmurs that radiate to neck or back.
192
Asymptomatic patient with non-radiating, systolic, 2/6 intensity murmur. Does he/she need an echocardiogram?
No.
193
What has the greatest effect on reducing mortality in coronary artery disease patients?
Smoking cessation.
194
Chest pain in cancer survivor with previous radiation therapy. Suspect?
Premature coronary artery disease.
195
Treatment of a type A (proximal) aortic intramural hematoma.
Emergency cardiothoracic surgery.
196
Treatment of a type B (descending aortic) intramural hematoma.
Intravenous beta-blockade followed by intravenous sodium nitroprusside to control blood pressure.
197
Pulmonary edema and low ejection fraction. Think of...
Congestive heart failure and give intravenous furosamide.
198
Fixed splitting of the S2, systolic pulmonary flow murmur, right ventricular or parasternal impulse and right sided cardiac chamber enlargement noted on chest radiograph.
Ostium secondum atrial septal defect.
199
What can high sensitivity C-reactive protein be useful for?
Reclassifying patients with an intermediate cardiovascular risk as either high or low risk.
200
Symptomatic bicuspid aortic valve and dilated aortic root. Treatment?
Aortic valve replacement and if aortic diameter is more than 45 mm then ascending aortic graft placement (aortic root surgery).
201
Dronedarone - effect on kidney.
May reduce creatinine clearance. However, does not reduce glomerular filteration rate or kidney function.
202
What do you give patients with high risk NSTEMIs in addition to heparin for anticoagulation?
Glycoprotein IIb/IIIa inhibitors.
203
What is the best anti-arrhythmic drug for atrial fibrillation in the setting of heart failure and structural heart disease?
Amiodarone.
204
What does the door to balloon need to be for primary percutaneous intervention?
90 minutes or less.
| If the transfer time is 90 min - that's too long.
205
How do you give mechanical hemodynamic support in cardiogenic shock.
Placement of an intra-aortic balloon pump. This will reduce afterload and increase cardiac output.
206
When do you need mechanical hemodynamic support in cardiogenic shock?
When cardiogenic shock does not improve with inotropic agents.
207
Management of patient with aortic mechanical valve without additional risk factors on warfarin who needs a surgery.
Discontinue warfarin 48 - 72 hours before the surgery and resume after the surgery as soon as hemostasis allows.
208
Preferred treatment of pulmonary valve stenosis.
Pulmonary balloon valvuloplasty.
209
The Reynold's risk score versus the Framingham risk assessment system.
The Reynolds risk score is a sex-specific cardiovascular risk assessment system that is more sensitive in predicting risk in women compared with the Framingham risk assessment system.
210
Treatment of wide-complex tachycardia with a history of coronary artery disease or cardiomyopathy.
Ventricular tachycardia.
| Treat with amiodarone.
211
Diagnosis?
Patient has clubbing, cyanosis, right ventricular hypertrophy and decreased pulmonary vascularity on chest radiograph.
Eisenmenger syndrome.
212
After ablation for atrial fibrillation what should be done about the anticoagulation?
All patients should continue warfarin for 2 - 3 months. After this the anti-coagulation is based on the CHADS2 score; as if the ablation never happened.
213
Treatment of patient with repaired Tetralogy of Fallot who developed pulmonary valve regurgitation, which leads to right heart enlargement, tricuspid valve regurgitation and atrial fibrillation.
Pulmonary valve replacement.
Tricuspid valve repair.
And a maze procedure.
214
Treatment of unstable angina in patients with contraindications to beta-blockers.
Diltiazem.
| First line therapy.
215
Which supraventricular tachycardias does adenosine terminate?
1. AV nodal re-entrant tachycardia.
| 2. AV reciprocating tachycardia.
216
Management of patient with chronic, severe mitral regurgitation and normal left ventricular systolic function, with new-onset atrial fibrillation.
Mitral valve repair surgery.
217
How long do you keep a patient on clopidogrel if they have unstable angina or an NSTEMI treated medically with no stent placed after cardiac catheterization?
For at least 1 month and ideally for 1 year.
218
Patient with chronic stable angina is symptomatic on optimal doses of beta-blockers, calcium channel blockers and nitrates. Next step?
Ranolazine.
219
What do you do with an ICD during surgery?
Turn off the shock therapy because the electrocautery will cause it to go off.
1. Packemaker dependent people: turn of shock function and change pacing function to asynchronous mode.
2. Non-pacemaker dependent people: Putting a magnet over the ICD will disable the shock feature.
220
STEMI with single vessel disease. Treatment?
Primary percutaneous coronary intervention.
221
What EKG change can haloperidol produce?
Prolonged QT increasing the risk for Torsades de pointes.
222
How do you assess for recurrent coarctation or aneurysm in patients with a repaired aortic coarctation?
CT or MRI of the heart.
223
When should patients admitted to the hospital for heart failure follow-up after discharge.
Physician appointment one week after discharge.
224
When would you not image someone with abdominal aortic aneurysm?
Not a surgical candidate because of multiple co-morbidities.
225
New-onset heart failure in patients with angina; or new-onset left ventricular dysfunction in the setting of a condition that may predispose to silent ischemia. Next step?
Coronary Angiography.
226
What vascular complications can occur after percutaneous coronary intervention and what study would you do?
Pseudoaneurysm or arteriovenous fistula.
| Duplex ultrasonography would differentiate between the two.
227
Management of a limb that has severe motor impairment, dense anesthesia and lack of Doppler vascular signals.
Acutely ischemic non-viable limb.
| Needs prompt amputation.
228
How do you monitor an infrequent arrhythmia?
Implantable loop recorder.
229
What are the indications of aortic value replacement in patients with severe aortic stenosis?
1. Symptomatic.
2. LVEF less than 50%.
3. Exercise results in hypotension or symptoms.
4. Rapid progression of stenosis.
5. Very severe stenosis (mean gradient > 60 mmHg)
230
Findings on echocardiography: Restrictive ventricular diastolic filling, severely dilated atria, and small- to normal-sized ventricular cavities. Diagnosis?
Restrictive cardiomyopathy.
231
What is myopericarditis?
Acute pericarditis occurring together with myocardial injury unrelated to myocardial infarction that may lead to heart failure.
232
What stressor should be used in patients with severe reactive airway disease who require pharmalogical stressing?
Dobutamine.
233
What study can be used to confirm cardiac involvement in sarcoidosis?
Cardiac magnetic resonance imaging.
234
What is the initial test of choice when there is a moderate or high pretest probability of endocarditis?
Transesophageal Echocardiography.
235
Pleuritic chest pain, regional concave downward ST-segment elevation, regional or global left ventricular dysfunction but no obstructive coronary artery disease in the distribution of dysfunctional myocardium, and elevated cardiac biomarkers.
Myopericarditis.
236
How do you detect right to left intracardiac shunts on echocardiography?
An agitated saline contrast study.
237
What stress test is used in patients who are able to exercise but have baseline electrocardiographic abnormalities?
An exercise nuclear stress test.
238
If the ankle-brachial index is 1.4 or more; how will you establish the diagnosis of peripheral artery disease?.
Cannot be interpreted. Indicates non-compressible vessels.
| Measure great toe systolic pressure to establish diagnosis.
239
Management of patients with arrhythmogenic right ventricular cardiomyopathy/dysplasia who experienced a syncopal event.
Placement of an implantable cardioverter-defibrillator.
240
Which calcium channel blockers may precipitate heart failure due to their negative inotropic effects in patients with a history of systolic heart failure?
Diltiazem.
Nifedipine.
Verapamil.
241
What calcium channel blockers can be given in systolic heart failure patients to control blood pressure?
Amlodipine.
| Felodipine.
242
In a patient with peptic ulcers and arthritis, what is important to look for?
Review medication list to make sure the patient is not using too many NSAIDS.
243
Liver mass that is:
1. A hyperechoic lesion on ultrasonography.
2. Peripheral arterial enhancement on contrast enhanced CT scan with no central scar.
3. Hyperintensity on both T1- and T2-weighted images.
Hepatic adenoma.
244
Liver biopsy specimen shows sheets of hepatocytes with no bile ducts or Kupffer cells.
(CT shows peripheral arterial enhancement with no central scar).
Hepatic adenoma.
245
Liver biopsy shows sheets of hepatocytes with bile ducts and Kupffer cells.
(CTs shows peripheral arterial enhancement with a central scar).
Focal nodular hyperplasia.
246
Treatment of patient with Barrett esophagus and high-grade dysplasia.
Esophagectomy.
247
Treatment of gastric adenomatous polyps.
Endoscopic polypectomy (regardless of degree of dysplasia since they all have malignant potential).
248
A patient has a significant portion of his distal ilium and proximal colon resected.
What kind of diarrhea will he have and what is the treatment?
Secretory diarrhea because the bile salts will not be absorbed.
Treatment is with Cholesytramine.
249
Multiple patients affected within 2 - 5 days of being at the same event. The have abrupt onset of fever, headache, malaise, chest pain, sore throat, abdominal pain, myalgia, and a dry non-productive cough. Chest radiography shows consolidation.
Pneumonic tularemia.
| Suspect bioterrorism
250
Patient with history of transplant, presents with non-productive cough, decreased oxygen saturation and bilateral pulmonary infiltrates on chest radiography.
Diagnosis?
Pneumocystis jirovecii pneumonia.
251
AIDS patients with multiple, nonenhancing lesions in the white matter on MRI with no mass effect.
Progressive multifocal leukoencephalopathy (demyelinating disease).
252
Mild diabetic foot infections in patients without a history of chronic nonhealing ulcers or prior antibiotic use...
Which organisms would you direct antibiotic therapy against?
Aerobic gram positive cocci.
253
Skin and subcutaneous infections with chronic, purulent drainage, lack of convincing pathogen on routine culture, and association with implanted prosthetic devices.
Organisms?
Mycobacterium abscessus.
254
Treatment of Herpes simplex encephalitis.
Intravenous acyclovir for 14 - 21 days. If repeat PCR testing is negative at the end of treatment that is a better prognosis. If positive then acyclovir should be continued.
255
If Mycobacterium avium complex grows out of a culture after a patient has already been treated (and clinically improved) for community-aquired pneumonia then what will you do?
Not treat it.
| Can be contaminants or colonizers of sputum culture.
256
How do you treat Pseudallescheria boydii and Scedosporium apiospermum?
Sensitive to triazoles.
| Resistant to Amphotericin B.
257
How do you treat Pseudallescheria boydii and Scedosporium apiospermum?
Sensitive to triazoles.
| Resistant to Amphotericin B.
258
Box-shaped gram-positive bacilli causing pneumonia and how to treat it?
Inhalation anthrax.
Initial therapy includes a fluoroquinolone or doxycycline plus one or two additional agents (for example, penicillin, erythromycin, vancomycin, rifampin, or clindamycin.)
259
Which antiretroviral agent is contra-indicated in pregnancy?
Efavirenz.
| Pregnancy risk Category D.
260
What is the empiric treatment for a cerebrospinal fluid shunt infection?
Vancomycin with either Ceftazidime, Cefepime or Meropenem.
261
A patient has altered mental status, parkinsonism, tremors, myoclonus and poliomyelitis-like flaccid paralysis.
What's the diagnosis?
West Nile encephalitis.
262
What is the treatment of a penicillin allergic non-pregnant patient who has syphilis?
Doxycycline.
263
Drug of choice for pulmonary aspergillosis in immunosuppressed patients.
Voriconazole.
264
Standard outpatient management of non-pregnant women with pyelonephritis.
Oral floroquinolone.
265
Treatment of non-gonococcal urethritis.
Oral Azithromycin.
266
What do you do if an otherwise healthy person has been exposed to someone with chicken pox?
Serologic testing for varicella virus antibodies.
267
What is the treatment of 'hot tub lung' (hypersensitivity pneumonitis/ extrinsic allergic alveolitis)?
Systemic corticosteroids in severe cases.
268
What will you do in patient with Babesiosis who initially responded to clindamycin and quinine therapy but then failed to improve?
Begin Doxycycline.
Patients can have more the one tick-borne disease at a time as the tick can be doubly or triply infected with Borrelia burgdorferi (Lyme disease), Anaplasma phagocytophilum (ehrlichiosis) or Babesia (babesiosis).
269
What are the major criteria for requiring an ICU admission for community-acquired pneumonia?
1. Septic shock requiring vasopressors.
| 2. Acute respiratory failure requiring intubation and mechanical ventilation.
270
If the patient does not meet major criteria for an ICU admission for community-acquired pneumonia, but still has severe disease, what criteria would be used to admit him to the ICU.
Any 3 of the following should be present:
1. Respiratory rate above 30 breaths/min.
2. Arterial pO2/FiO2 ratio of less than or equal to 250.
3. Multilobar infiltrates.
4. Confusion or altered mental status.
5. BUN of 20 mg/dl or greater.
6. Leukocyte count of less than 4000/micL.
7. Platelet count less than 100,000/micL.
8. Core temperature less than 36 deg C (98.6 F).
9. Hypotension requiring aggressive fluid resuscitation.
271
Treatment for Plasmodium falciparum malarial infection.
Quinine combined with pyrimethamine-sulfadoxine, clindamycin, or doxycycline.
Atovaquone-proguanil can also be used.
272
Treatment of osteoporosis in chronic kidney disease.
Bisphosphonates are contra-indicated in chronic kidney disease with a GFR of less than 30.
Calcium supplementation is okay.
273
What renal disease can ifosfamide cause?
Proximal (type 2) renal tubular acidosis.
274
Treatment if bedbug bites.
Topical corticosteroids and oral anti-histamines provide symptomatic relief.
275
Treatment of a venous stasis ulcer.
Unna boot compression.
276
Treatment of allergic contact dermatitis on the face.
Low potency corticosteroid like hydrocortisone valerate.
277
Treatment of localized impetigo.
Topical mupirocin.
278
Waxy to verrucous papules ranging in color from flesh colored, to yeloow, to tan, or irregularly pigmented.
What are they?
Seborrheic keratoses.
279
Sudden onset of tender, erythematous nodules on the anterior legs associated with infections, systemic diseases, or adverse drug reactions, particularly to antibiotics, oral contraceptives and hormone therapy.
Diagnosis?
Erythema nodosum.
280
Management of lesions that persist for more than 24 hours and resolve with bruising.
Skin biopsy to evaluate for urticarial vasculitis.
281
Name a pregnancy category X drug used to treat acne and psoriasis.
Tazarotene.
282
Management of patient with suspected toxic epidermal necrolysis.
Urgent dermatology consultation for skin biopsy and confirmation of diagnosis, followed by admission to a burn/intensive care unit for supportive care.
283
Heliotrope rash and Gottron papules.
Dermatomyositis.
284
Hyperhidrosis and crateriform pitted lesions on pressure-bearing areas of the feet.
Pitted keratolysis.
285
Asymptomatic erythematous macules and small papules over the upper trunk, face, and proximal extremities, often accompanied by oral aphthae and non-specific symptoms such as fevers, malaise, fatigue, nausea and diarrhea.
Acute HIV seroconversion.
286
Flesh-colored smooth bumps that often appear in areas of trauma that result in autoinoculation.
Flat warts (verruca plana).
287
Patient with extremely dry hands with scaling, erythema, and fissuring on the dorsal hand surfaces and a history of atopic eczema.
Diagnosis?
Atopic hand dermatitis.
288
Small erythematous papules of papulovesicles associated with itching, burning, and prickling.
Diagnosis and treatment?
Miliaria.
| Cooling measures.
289
Juicy, bright red, well-demarcated plaques with a sharp cut-off separating normal and inflamed skin that appear on the neck, upper trunk, and extremities.
Diagnosis?
Sweet syndrome.
290
Drug eruption with acute onset of widespread skin and mucosal necrosis.
Diagnosis?
Toxic epidermal necrolysis.
291
How much topical medication is needed to cover the average 70 kg patient?
30 grams.
292
Which malignancy is associated with dermatomyositis?
Ovarian cancer.
293
What is the gold standard for diagnosis of allergic contact dermatitis?
Epicutaneous patch testing.
294
Deep, crawling, or tingling sensation on the forearms, shoulders, and upper back; no visible skin findings.
Diagnosis?
Brachioradial pruritus.
295
Treatment of tinea versicolor.
Ketoconazole shampoo and the imidazole or triazole creams are effective topically; and are preferred to systemic therapy as initial treatment.
296
What is the optimal diagnostic test for an autoimmune bullous disease?
Skin biopsy with direct immunofluorescence microscopy.
297
Risk of giving gadolinium contrast agents in chronic kidney disease.
Potential to cause nephrogenic systemic fibrosis.
298
White-reticulated network on the buccal mucosa; desquamative gingivitis; and chronic, painful erosions on the oral or vulvar mucosa.
Diagnosis?
Mucosal lichen planus.
299
List the most common causes of erythroderma.
1. Drug eruptions.
2. Psoriasis.
3. Atopic dermatitis.
4. Cutaneous T-cell lymphoma.
300
Red papules on the chest, flanks, and back that may become pruritic with heat and sweating.
Diagnosis?
Grover disease.
| Acantholytic dermatosis
301
Erythematous and hypopigmented, scarred, atrophic, discoid plaques with raised borders.
Diagnosis?
Chronic cutaneous (discoid) lupus erythematosus.
302
Intensely painful, angulated, retiform purpuric patches with area of black necrotic tissue that may form bullae, ulcerate, and leave a hard, firm eschar.
Diagnosis?
Calciphylaxis.
303
Treatment of superficial laceration wounds in elderly patients.
Apply a non-adherent dressing over plain petrolatum.
304
Papulosquamous eruption characterized by a single, pink, 2 - 4 cm, thin, oval-shaped plaque with a thin collarette of scale at the periphery (herald patch) followed by development of many smaller lesions days to weeks later.
Diagnosis and treatment?
Pityriasis rosea.
| No treatment.
305
Premalignant, erythematous, scaly macules that occur on sun-exposed areas of older persons with fair skin.
Diagnosis?
Actinic kerotoses.
| May develop into squamous cell carcinomas over time.
306
Treatment of acute urticaria.
Combination H1 - and H2 - antihistamines are the first-line therapy.
307
Management of spontaneous bacterial peritonitis in a patient with significant hepatic (bilirubin over 4 mg/dl) and kidney dysfunction (Serum creatinine over 1.5 mg/dl).
Concomitant use of antibiotics and intravenous albumin is associated with a survival benefit.
Usually intravenous cefotaxime or a similar third generation cephalosporin is the treatment of choice.
308
What are the indications for liver transplantation?
1. Acute liver failure.
2. Hepatic decompensation due to chronic liver disease (manifested by the complications of ascites, hepatic encephalopathy, jaundice, or portal hypertension-related bleeding). The chronic liver disease can be secondary to Hepatitis C, NASH, alcoholic liver disease, etc.
3. Primary liver cancer.
4. Inborn errors of metabolism.
309
Colon cancer screening for ulcerative colitis patients.
Patients with ulcerative colitis with disease extending beyond the rectum should undergo routine surveillance colonoscopy with biopsies every 1 to 2 years beginning 8 to 10 years after diagnosis.
310
Does reversal of coagulopathy need to be done if a patient needs an EGD or a colonoscopy because of a GI bleed?
Only if the INR is supratherapeutic i.e. above 3.
311
What is the next step following resolution of acute diverticulitis?
Colonoscopy - to rule out other disorders that may mimic diverticulitis such as adenocarcinoma or Crohn disease.
312
Management of patient with hematochezia, syncope secondary to blood loss and NSAID use.
Upper endoscopy as the clinical picture suggests brisk upper GI blood losses.
313
What is the most effective treatment for patients with recently diagnosed moderately to severely active Crohn disease?
Anti -tumor necrosis factor therapy like infliximab, with or without an immunomodulator such as azathiioprine or 6-mercaptopurine.
314
Under what conditions are systemic corticosteroids contraindicated in alcoholic hepatitis patients?
1. Gastrointestinal bleeding.
2. Renal failure.
3. Active infection such as spontaneous bacterial peritonitis.
315
What pharmacological therapy would you use in patients with severe alcoholic hepatitis (Maddrey discriminate function score more than or equal to 32) if corticosteroids were contra-indicated?
Pentoxifylline.
316
Patient has angioectasias associated with aortic stenosis.
| What is the name of the syndrome and what is the treatment for preventing gastrointestinal bleeding?
Heyde syndrome.
| Aortic valve replacement reduces the risk of gastrointestinal bleeding.
317
A patient with hereditary polyposis syndromes such as familial adenomatous polyposis or Peutz-Jeghers syndrome undergoes complete colectomy.
What surveillance does the patient need?
Upper endoscopy.
| Long term endoscopic surveillance of the duodenum to screen for development of ampullary adenocarcinoma.
318
How long does a patient with a high risk peptic ulcer i.e. active bleeding or a visible vessel in an ulcer base, need to be observed in the hospital?
At least 72 hours after endoscopic therapy.
319
What is a common infectious cause of nephropathy with transplanted kidneys?
Polyomavirus BK virus.
320
Treatment of acyclovir resistant genital herpes.
Foscarnet.
321
How long after successful treatment of early Lyme disease does the patient remain seropositive?
At least months after treatment. Further antibiotics are not required.
322
Name some drugs that increase cyclosporine levels.
1. Voriconazole.
2. Diltiazem.
3. Ofloxacin.
323
Most sensitive and specific test for diagnosing herpes simplex encephalitis.
Cerebrospinal fluid polymerase chain reaction.
324
Which patients with Pneumocystis jirovecii pneumonia need to be treated with corticosteroids in addition to trimethoprim-sulfamethoxazole?
1. Arterial pO2 less than 70 mmHg, or
2. Alveolar-arterial oxygen gradient of greater than 35 mmHg,
Adjunctive therapy should be given within the first 72 hours.
325
What is the first step in the diagnosis of a patient suspected of having variant Creutzfeldt-Jacob disease?
Tonsillar biopsy.
326
Patients who develop secondary community-acquired pneumonia after influenza need to be covered for what additional bacteria?
MRSA.
327
What is the treatment of cat bites in patients with severe penicillin allergies?
Ciprofloxacin and clindamycin.
328
What infection control measures should be initiated immediately for patients suspected of having pulmonary tuberculosis?
Airborne Precautions.
329
If the serum-ascites albumin gradient value is 1.1 g/dl or greater with total ascites protein greater than 2.5 g/dl then what conditions in that indicative of?
Cardiac disease:
1. Heart failure.
2. Constrictive pericarditis.
330
What diagnosis would you suspect in patients with dyspnea, cirrhosis, and a pO2 less than 70 mmHg?
Hepatopulmonary syndrome.
331
Management of patients with small (less than 2 cm) type I gastric carcinoid tumors.
Initial endoscopic removal.
| Followed with endoscopic surveillance every 6 - 12 months for at least 3 years after the initial removal.
332
Treatment of autoimmune pancreatitis.
Corticosteroids.
333
Painless jaundice in the context of a diffusely enlarged pancreas with a narrowed pancreatic duct.
Diagnosis?
Autoimmune pancreatitis.
334
Management of patients with Barrett esophagus and high-grade dysplasia.
Endoscopic mucosal resection and ablative therapy.
335
Management of short-bowel syndrome after bowel resection.
Acid suppression therapy.
| There is hypersecretion in the post-operative period.
336
Guidelines for screening for colon cancer when there is a history of family cancer.
At age 40 years. Or 10 years younger than the youngest family member with colon cancer. Whichever comes first.
337
Therapy for constipation-predominant irritable bowel syndrome when symptoms persist despite the use of fiber and standard laxatives.
Lubiprostone.
338
Hepatic venous outflow tract obstruction.
| Diagnosis?
Budd-Chairi syndrome.
339
Next step after diagnosing esophageal adenocarcinoma by EGD and biopsy.
Staging with CT/PET and endoscopic ultrasonography.
340
Most common cause of a stool osmotic gap that may occur transiently after a self-limited gastroenteritis.
Lactose malabsorption.
341
Treatment of confirmed GERD that is refractory to proton pump inhibitor therapy.
Fundoplication.
342
Treatment of complex fistula resulting from perianal Crohn disease after surgical therapy.
Infliximab.
343
Patient presents with diarrhea, bloating, or weight loss; vitamin B12 deficiency or an elevated serum folate level may be present.
Diagnosis?
Small intestinal bacterial overgrowth.
344
Immune-tolerant hepatitis B virus infection monitoring.
Monitor hepatic aminotransferases every 3 - 6 months.
345
Treatment of suspected hepatorenal syndrome.
Volume expansion with intravenous albumin.
346
Which test for Helicobacter pylori is not affected by recent gastrointestinal bleeding or use of proton pump inhibitors?
Helicobacter pylori serology.
347
What test provides the best sensitivity for actively bleeding lesions from an obscure gastrointestinal source?
Nuclear scintigraphy.
348
Management of patients hereditary hemochromatosis who are older than 40 years or have a serum ferritin level greater than 1000 ng/mL.
Liver biopsy because these patients are at increased risk for cirrhosis.
349
Effortless regurgitation of undigested food and re-swallowing of the contents.
Diagnosis?
Rumination syndrome.
350
Dilatation of the bile duct without evidence of an obstructing lesion.
Diagnosis?
Biliary cyst.
351
Management of a polyp larger than 10 mm in the gallbladder.
Surgical resection of the gallbladder, as there is a 45% - 67% likelihood of cancer.
352
How do you diagnose acute acalculus cholecystitis?
Abdominal ultrasound.
| It shows significant gallbladder wall thickening and/or distention.
353
What is the first step in management of suspected eosinophilic esophagitis?
Exclusion of GERD by either ambulatory pH study or a 6 week trial of high dose proton pump inhibitor.
354
What is the next step in a patient, younger then 40 years of age, who is found to have numerous gastric fundic gland polyps?
Colonoscopy.
| For evaluation of signs of possible familial adenomatous polyposis.
355
What is the preferred next diagnostic test in severely ill patients with hypotension and sepsis and a high suspicion for acute cholangitis with or without confirmatory imaging stuides?
ERCP.
| Endoscopic Reterograde Cholangiopancreatography
356
What is the first line therapy for achalsia?
Surgical release of lower esophageal sphincter by laparoscopic myotomy.
357
Which disease should be considered in all patients presenting with iron deficiency anemia after routine upper endoscopy and colonoscopy fail to reveal a source of gastrointestinal blood loss?
Celiac disease.
358
Abnormally thickened subepithelial collagen band in the lamina propria on colonic biopsies.
Diagnosis and treatment?
Microscopic colitis - collagenous.
Usually caused by drugs (lansoprazole, NSAIDS, sertraline, ranitidine, ticlopidine, and acarbose), so stop offending agent.
359
Treatment for opioid-induced constipation.
Methylnaltrexone.
360
What is the next step when there is concern for malignancy as a cause of psuedoachalasia?
Upper endoscopy.
| This will rule out any mechanical cause for obstruction.
361
What should be done if the bowel preparation is inadequate for a screening colonoscopy.
It should be repeatedly promptly.
362
If a patient is suspected of having tuberculosis what initial infection control precautions should be implemented?
Air-borne precautions.
363
Immunocompetent patient in Arizona, California, New Mexico, or west Texas, northern Mexico, with acute or subacute pneumonia, with or without pleural effusions or empyema, with possible late sequelae that present as pulmonary nodules or cavitary disease.
Diagnosis?
Coccidioidomycosis.
364
Treatment of recurrent Clostridium difficile previously treated with metronidazole,
Oral vancomycin for 10 - 14 days followed by tapering or pulsing doses of vancomycin over a 4 - 6 week period.
365
Management of spinal abscess with neurological changes of less than 24 - 36 hours duration.
Emergent laminectomy.
366
How can you confirm HSV encephalitis in a patient with compatible radiologic and clinical findings whose initial CSF is negative?
Repeat HSV PCR on new CSF sample 3 - 7 days after initiation of treatment.
367
Fever, headache, painful, ulcerated genital lesions.
| Diagnosis?
Primary genital herpes simplex viral infection.
368
In addition to antibiotics; how would you manage subdural empyema?
Craniotomy and drainage.
369
Treatment of trichomonal vaginitis.
Single 2 gram dose of oral metronidazole.
370
Which systemic disease has non-specific cutaneous involvement in HIV/AIDS patients?
Cryptococcosis.
371
Treatment of severe community acquired pneumonia in a penicillin allergic patient.
Fluoroquinolone and aztreonam.
372
Which test is specific and sensitive for Aspergillus in a tissue sample?
Polymerase Chain Reaction.
373
What screening tests should be performed in patients with recurrent neisserial infections?
Total hemolytic complement (CH50) measurement.
374
What is the most common mold to cause pulmonary disease in neutropenic patients?
Aspergillus.
375
A crusted, ulcerated papule and regional lymphadenopathy after recent return from Africa.
Organism?
Rickettsia africae
376
What prophylaxis is given for HIV if a person has had a 'severe exposure' needle stick injury?
Post-exposure prophylaxis with three or more anti-retroviral agents.
377
Treatment of mild community-acquired pneumonia in an ambulatory outpatient with no co-morbidities.
Macrolides.
| Azithromycin or Clarithromycin.
378
What should you suspect if a patient has multiple sinus infections?
Common variable immunodeficiency.
379
How do you test for common variable immunodeficiency?
Quantitative immunglobulin assay.
380
How long does a tick need to be attached for the transmission of Lyme disease?
More than 36 hours.
381
Management of a patient who develops a small, erythematous patch at the site where a tick has just been embedded?
Reassurance.
| The erythematous patch is local irritation and not the erythema migrans of Lyme disease.
382
What kind of precautions and mask are needed if a patient is suspected of having meningococcal meningitis?
Droplet precautions.
| Face mask.
383
What is the best test for diagnosing West Nile virus encephalitis?
CSF IgM antibody assay.
384
A patient has fever, lethargy and flaccid paralysis of lower extremities. He notes multiple mosquito bites and a dead bird on his balcony.
Diagnosis?
West Nile virus encephalitis.
385
What is the prophylaxis for the close contacts of a patient with smallpox?
Vaccinia vaccination.
386
Patient with fever, headache, diffuse body aches, abdominal pain, severe malaise, mouth sores, painful rash starting in trunk and progressing to arms and legs - hard papular lesions.
Diagnosis?
Smallpox
387
What kind of vancomycin level monitoring do patients need if there creatinine is stable and their infection is not severe?
None.
388
What is the best perimenstrual prophylaxis for menstrual related migraines?
Mefenamic acid.
389
What is the most common cause of peripheral neuropathy associated with only pain and sensory loss?
Diabetes mellitus and impaired glucose tolerance.
390
What is worsening of neurologic status of a multiple sclerosis patient in the presence of an underlying infection or medication called?
And how to you treat it?
Pseudorelapse.
| By treating the underlying cause.
391
What is the best perimenstrual prophylaxis for menstrual related migraines?
Mefenamic acid.
392
What is the most common cause of peripheral neuropathy associated with only pain and sensory loss?
Diabetes mellitus and impaired glucose tolerance.
393
What is worsening of neurologic status of a multiple sclerosis patient in the presence of an underlying infection or medication called?
And how to you treat it?
Pseudorelapse.
| By treating the underlying cause.
394
What predicts the risk of a recurrence after a single, unprovoked seizure?
1. If the event was a partial seizure.
2. If the patient has Todd paralysis (transient or unilateral weakness after partial seizure).
3. Status epilepticus on presentation.
4. Age greater than 65 years.
5. Abnormal findings on neurologic examination.
395
A patient has progressive proximal upper and lower limb weakness, autonomic symptoms (dry eyes/mouth, erectile dysfunction), and absent deep tendon reflexes.
What is the diagnosis?
Lambert-Eaton myasthenic syndrome.
396
What is the best diagnostic test for Lambert-Eaton myasthenic syndrome?
Measurement of voltage gated P/Q type calcium channel antibody test.
397
What should you do in a patient with trigeminal neuralgia who's under 40 years of age?
MRI brain.
Look for secondary causes such as multiple sclerosis, posterior fossa tumors and vascular or aneurysmal compression of the trigeminal nerve.
398
What class of antibiotics is contraindicated in myasthenia gravis?
Fluoroquinolones.
399
Patient presents with progressive weakness involving limbs, bulbar muscles and respiratory muscles. Reflexes are absent.
What is the diagnosis and treatment?
Myasthenic crisis.
| Treat with plasma exchange.
400
Chronic or subacute progressive myelopathy with episodes of more rapid, stepwise clinical deterioration.
What diagnosis should be suspected?
Spinal dural arteriovenous fistula.
401
How would you manage small, asymptomatic meningiomas in the elderly?
Serial imaging i.e. MRI brain.
402
Recurrent, moderately severe headaches, that have some additional features like nausea are most often what kind of headache?
Migraine.
403
A patient has progressive extremity weakness, parasthesias and areflexia.
Diagnosis?
Guillian-Barre syndrome.
404
What is the most appropriate next diagnostic test when a patient is suspected of having Guillian-Barre syndrome?
Electromyography (EMG).
405
For a patient on warfarin to be eligible for intravenous rTPA within the 3 hour window of symptom onset for stroke; what does the INR need to be?
1.7 or less.
406
A patient has progressive neurological symptoms that involve the autonomic system, extrapyramidal system and cerebellum.
What's the diagnosis?
Multiple system atrophy.
407
What is the next step in evaluating patients who remain unresponsive after resolution of clinical status epilepticus?
Continuous EEG monitoring to distinguish between post-ictal start and nonconvulsive status epilepticus.
408
Treatment of an acute dystonic reaction.
Benztropine.
409
Treatment of acute carotid dissection.
Intravenous heparin.
410
Acute unilateral headache with Horner's syndrome (ptosis and anisocoria).
Diagnosis?
Acute carotid dissection.
411
If you suspect a subarachnoid hemorrhage secondary to a ruptured aneurysm but the initial CT head is negative. What is the next step?
Lumbar puncture for CSF.
412
History of myoclonic and generalized tonic-clonic seizures on awakening with onset in adolescence.
Diagnosis?
Juvenile myoclonic epilepsy.
413
How long does juvenile myoclonic epilepsy need to be treated?
Lifelong anti-epileptic therapy.
| Risk of recurrence in 75% - 100% of patients
414
What is the treatment of multiple sclerosis related fatigue?
Amantadine.
415
How do you treat migraines during pregnancy that do not respond to simple analgesia?
Metoclopramide.
416
Adult patient with a few minutes of altered consciousness, oral automatisms, speech impairment and post-ictal confusion.
Diagnosis?
Complex partial seizure.
417
Treatment of progressive multiple sclerosis.
Physical therapy.
418
Unilateral headache, with rhinorrhea and lacrimation that occurs about 10 times a day and each episode lasts about 15 minutes.
Diagnosis?
Paroxysmal hemicrania.
419
What are first line medications for essential tremor?
1. Propranolol.
2. Primidone.
3. Gabapentin.
4. Topiramate.
420
Patient with progressive myelopathy and mild anemia; what should be measured?
1. Vitamin B12 level. (Deficiency)
2. Copper. (Deficiency)
3. Zinc. (Excess impairs copper absorption)
421
Treatment of symptomatic, severe (>70%) internal carotid artery stenosis in patients who are not candidates for carotid endarterectomy because of high surgical risk or difficult anatomy.
Carotid angioplasty and stenting.
422
What is the treatment for paroxysmal hemicrania?
Indomethacin.
423
What can provoke seizures in patients with juvenile myoclonic epilepsy?
1. Alcohol.
2. Sleep deprivation.
3. Exposure to flickering lights.
424
If the brain MRI of a patient with a first-ever event of symptomatic inflammatory demyelination shows lesions consistent with demyelination then what is the risk of developing multiple sclerosis in the future?
90% in 10 - 15 years time.
425
What class of drugs is first line for status epilepticus?
Benzodiazepines.
426
Solitary mass situated in deep white matter with minimal edema.
Next step in management?
Stereotactic brain biopsy to rule out lymphoma.
427
Obese, female patient with progressive daily headache with pulsatile tinnitus and transient visual obscurations.
Diagnosis?
Idiopathic intracranial hypertension.
428
Treatment of idiopathic intracranial hypertension.
Acetazolamide.
429
Development of compulsive behaviors i.e. excessive gambling, shopping, hypersexuality, are a potential side effect of which class of medications?
Dopamine agonists.
430
What anti-epileptic regimens have been associated with the highest rate of congenital malformations?
1. Valproic acid.
| 2. Polytherapy.
431
What should the blood pressure be maintained at after rTPA treatment for an ischemic stroke?
Less than 180/105 mmHg.
432
What should you do if a women on oral contraceptive pills has a migraine with aura?
Stop the oral contraceptive pills.
433
Severe demyelinating disease of the CNS that is similar to but separate from multiple sclerosis and involves optic nerves and spinal cord with relative sparing of the brain.
Neuromyelitis optica.
434
What test do you do to diagnose neuromyelitis optica?
Serum neuromyelitis optica (NMO)-IgG Autoantibody test.
435
What is the next step in patients with disabling partial seizures that have not responded to treatment with two appropriate anti-convulsant drugs?
Referral for epilepsy surgery evaluation.
436
What is the most imminent danger after a subarachnoid hemorrhage?
Rebleeding.
437
Which drug is first line for migraine prophylaxis and is associated with weight loss?
Topiramate.
438
Which two auto-immune diseases can present with chorea?
1. Anti-phosphoipid antibody syndrome.
| 2. Systemic lupus erythematosus.
439
Is it okay to use -triptans in breast-feeding mothers?
Yes.
440
Subacute, progressive neuropathy, characterized by severe, initially unilateral, lower leg pain and weakness
Diabetic lumbosacral radiculoplexus neuropathy.
441
What does menstrual flow on progestin withdrawal challenge when evaluating secondary amenorrhea indicate?
Patent outflow tract with no anatomical obstructions and relatively normal estrogen production.
442
What drug class needs to be given to normalize GH and IGF-1 levels after resection of pituitary tumors in patients who are not cured by the surgery?
Somatostatin analogues.
443
What test should be done next in a patient with elevated C-peptide and insulin levels along with low blood glucose levels?
Measurement of serum levels of sulfonylureas.
444
Perioperative treatment of pheochromocytoma for a patient who is not in hypertensive crisis.
Alpha-blockers initiated outpatient e.g. prazosin, terazosin, or doxazoxin.
445
What happens to macroprolactinomas during pregnancy?
They can enlarge during pregnancy.
446
What disease includes endocrinopathies such as diabetes mellitus, adrenal insufficiency and hypogonadotrophic hypogonadism?
Hemochromatosis.
447
What test do you do to diagnose hemochromatosis?
Transferrin saturation measurement.
448
Endocrine disease with tumors of the pituitary, parathyroid and pancreatic islet cells.
Multiple endocrine neoplasia type 1.
449
What type of hypothalmic disease is a thickened pituitary stalk associated with diabetes insipidus indicative of?
Infiltrative diseases of the hypothalmus:
1. Sarcoidosis.
2. Langerhans cell histiocytosis.
450
What is the treatment of myxedema coma?
1. Intravenous levothyroxine.
2. Intravenous hydrocortisone.
3. Empiric antibiotics.
451
What happens to the PSA in men treated with testosterone for hypogonadism?
They initially have low levels of PSA, that gradually increase with testosterone therapy and stabilize in 6 months.
452
What is the next step if a patient's PSA levels continue to rise 6 months after initiating testosterone therapy for hypogonadism?
Stop testosterone therapy and evaluate for prostate cancer with a prostate biopsy.
453
What class of drugs are used to treat patients with Paget's disease of the bone?
Bisphosphonates.
454
Diagnosis in man with low FSH, LH and testosterone levels and chronic narcotic use.
Opioid induced secondary hypogonadism.
455
First step in emergency management of hypercalcemia.
Aggressive fluid resuscitation with normal saline.
456
Next step in an obese patient who snores and has decreased libido because of decreased testosterone.
Sleep study.
457
Treatment of hypogonadotrophic hypogonadism in patients with sleep apnea.
Continuous positive airway pressure can reverse the hypogonadism.
458
Treatment of Graves disease in patients with mild Graves ophthalmopathy who are allergic to anti-thyroidal medications.
Prednisone followed by radioactive iodine ablation.
459
Which test best assesses the body's vitamin D stores?
25-hydroxy-vitamin D level.
460
In a patient with hyperparathyroidism what other level do you need to make decisions in addition to the the parathyroid hormone and calcium levels?
25-hydroxy-vitamin D level.
461
A patient has orthostatic hypotension, absent normal variation of the heart rate with breathing, resting tachycardia, early satiety and diabetes.
Diagnosis?
Cardiovascular neuropathy secondary to diabetes.
462
Next step when someone is found to have diabetic cardiovascular neuropathy?
Exercise stress test to rule out silent ischemia.
463
Treatment of sick patients with adrenal insufficiency.
Stress dose corticosteroids.
464
Young woman who exercises a lot presenting with irregular periods, infertility and decreased FSH levels.
Diagnosis?
Functional hypothalamic amenorrhea.
465
Next step in evaluation of frequent urinary tract infections in a patient with diabetic autonomic neuropathy.
Post-void urinary residual volumes to evaluate for neurogenic bladder.
466
What is the most suggestive feature of atypical parkinsonism syndrome?
Absence of a response to levodopa.
467
What blood pressure is associated with increased risk of recurrent stroke?
Greater than 140/80 mmHg.
468
Management of an athlete with a grade 3 concussion (brief - seconds, or prolonged - minutes, loss of consciousness) with no neurological abnormalities.
Prohibited from returning to competition until they are asymptomatic for one week.
469
Name some anti-epileptic drugs appropriate for women of child bearing age who are trying to conceive.
Carbamazepine.
Oxcarbazepine.
Lamotrigine.
Levetiracetam.
470
Patient with upper motor and lower motor signs and no other neurological pathology.
Diagnosis?
Amyotrophic lateral sclerosis.
471
Which medications are indicated for reduction of blood pressure after rTPA administration for an acute ischemic stroke?
1. Nicardipine.
| 2. Labetalol.
472
Which test would you order to diagnose Lambert-Eaton myasthenic syndrome?
Nerve conduction studies.
473
Management of patient with brief episode of unconsciousness (vasovagal or cardiogenic syncope) with jerking seizure like movements after which patient is back to normal.
This is convulsive syncope and just requires reassurance.
474
What test is preferred when compression of the spinal cord is suspected?
MRI.
475
A patient with headache, fever and encephalopathy with an MRI showing simultaneous demyelination in multiple regions of the central nervous system.
Diagnosis?
Acute disseminated encephalomyelitis.
476
Treatment of tension-type headache.
NASIDS like Ibuprofen and Naproxen.
477
What needs to be done if a patient on lamotrigine starts taking oral contraceptive pills?
Dose of lamotrigine needs to be increased.
478
Next step in a patient who has had headaches in the past but now has headaches that are different from the previous headaches.
MRI brain.
479
Treatment of incapacitating wearing-off motor fluctuations and dyskinesia in patients with Parkinson disease.
Deep brain stimulation.
480
Does compression of the spinal cord by an epidural hematoma respond to intravenous corticosteroids?
No.
| There is no inflammatory disease and it is an acute compressive lesion.
481
A patient with delusions of imposters; believing that important and familiar persons in their lives have been replaced by fraudulent doubles.
Diagnosis?
Capgras syndrome.
482
What antibodies are present in myasthenia gravis?
1. Antibodies against the acetylcholine receptors.
| 2. Antibodies against muscle specific tyrosine kinase (MuSK) receptors.
483
What is the next step after diagnosing myasthenia gravis?
Chest CT to rule out thymoma or thymic hyperplasia.
484
A patient presents with limbic encephalitis, with subacute memory disturbance, personality change, psychosis, encephalopathy, possible seizures, and oral dyskinesia, after a flu-like prodrome.
Diagnosis?
Anti-NMDA receptor encephalitis.
485
Deep vein thrombosis prophylaxis in a patient admitted for an intracerebral hemorrhage a few days ago.
Low-dose low-molecular-weight or unfractionated heparin is recommended in patients at high risk for VTE by hospital day 4.
486
What is the treatment of multiple sclerosis-related fatigue?
1. Amantadine.
| 2. Modafinil.
487
Which anti-epileptic drugs used for migraine prophylaxis carry an increased risk of kidney stone formation?
1. Topiramate.
| 2. Zonisamide.
488
What test should be done in a patient suspected of having normal pressure hydrocephalus?
Brain MRI.
489
Patient with gait impairment, urinary incontinence and cognitive change.
Diagnosis?
Normal pressure hydrocephalus.
490
What is the most important thing to do to reduce recurrent stroke risk in a patient who had an acute ischemic stroke caused by high grade carotid stenosis?
Carotid endarterectomy.
491
Patient develops headache, fatigue, sleep disturbances, difficulties with concentration and memory after being hit of the head.
Diagnosis?
Postconcussion syndrome.
492
Next step in a patient with embolic appearing stroke on MRI, patient foramen ovale and no evidence of atrial fibrillation on telemetry.
Prolonged cardiac monitoring.
493
Treatment of migraines without aura that do not respond to NSAIDS.
Triptans.
494
Test for diagnosing Asherman syndrome.
Transvaginal pelvic ultrasonography.
495
Management of non-functioning thyroid nodules greater than 1 - 1.5 cm.
Fine needle aspiration biopsy.
496
Treatment of women with prolactinomas and amenorrhea who are not desirous of pregnancy.
Oral contraceptives to replace the estrogen.
497
When does NPH peak?
4 - 10 hours.
498
Alternative treatment of postmenopausal osteoporosis in patients who are intolerant to oral bisphosphonates because of exacerbation of GERD symptoms.
Intravenous zoledronate once yearly.
499
First step in treatment of pituitary tumor apoplexy.
Intravenous stress dose hydrocortisone.
500
Treatment of primary hyperaldosteronism caused by bilateral adrenal gland hyperplasia.
Spironolactone (non-selective).
| Eplerenone (selective).
501
How do you differentiate between thyroiditis and exogenous thyroid hormone use.
Measuring ESR and thyroglobulin levels.
| In thyroiditis they are high and in exogenous thyroid hormone use they are low.
502
What type of diuretics are more effective for blood pressure control in renal impairment?
Loop diuretics.
503
What test is done when a patient's symptoms and biochemical testing is consistent with a pheochromocytoma but no adrenal mass is seen on CT/MRI?
MIBG (metaiodobenzylguanidine) scan.
504
Which test is most important to do first when evaluating possible hypopituitarism in patients with head trauma?
Morning 8 am serum cortisol level.
505
What type of diuretics are more effective for blood pressure control in renal impairment?
Loop diuretics.
506
What test is done when a patient's symptoms and biochemical testing is consistent with a pheochromocytoma but no adrenal mass is seen on CT/MRI?
MIBG (metaiodobenzylguanidine) scan.
507
Which test is most important to do first when evaluating possible hypopituitarism in patients with head trauma?
Morning 8 am serum cortisol level.
508
What do you check if total testosterone levels are indeterminate in a man suspected of having hypogonadism?
Serum free testosterone level.
509
Treatment of thrombotic microangiopathy associated with antiphospholipid antibody syndrome.
Anticoagulation therapy with heparin followed by warfarin.
510
What infectious disease should be excluded in all patients with new-onset psoriasis or psoriatic arthritis or those who experience sudden exacerbations of mild psoriasis?
HIV
511
When is a colchicine an effective treatment for acute gout?
Within 24 hours of symptom onset.
512
What is the treatment of Churg-Strauss syndrome?
Methylprednisolone plus cyclophosphamide.
513
All patients with an acute monarthritis should be presumed to have what?
Septic arthritis.
514
Next step in cases of refractory dermatomyositis on prednisone.
Age and sex appropriate malignancy screening.
515
Next step when adequate disease control is not achieved in rheumatoid arthritis with one DMARD e.g. methotrexate.
Addition of a biological agent i.e. tumor necrosis factor a inhibitor e.g. etanercept.
516
Next step when adequate disease control is not achieved in rheumatoid arthritis with one DMARD e.g. methotrexate.
Addition of a biological agent i.e. tumor necrosis factor a inhibitor e.g. etanercept.
517
Can a tumor necrosis factor a inhibitor i.e. infliximab cause drug induced lupus?
Yes.
518
A patient with a rash characterized by sharply marginated, red-to-pink indurated, round or oval lesions with adherent scale involving the face, scalp, and ear canals accompanied by follicular plugging. Scarring on the scalp may cause patchy alopecia.
Diagnosis?
Discoid Lupus.
519
If a patient with aggressive rheumatoid arthritis is on a DMARD, prednisone and has been started on a tumor necrosis factor a inhibitor but is still not responding, then what is the next step?
Switch the tumor necrosis factor a inhibitor to another drug in the same class.
520
What does gout characteristically look like on a radiograph?
Bony asymmetric erosions with over-hanging edges.
521
What is the treatment of central nervous system lupus?
Methylprednisolone and cyclophosphamide.
522
Treatment of proliferative lupus nephritis once remission has been achieved with cyclophosphamide.
Switch to mycophenolate mofetil or azathioprine.
523
Being post-partum increases the risk for which type of arthritis?
Rheumatoid arthritis.
524
Treatment of early rheumatoid arthritis in patients who drink alcohol.
Hydroxychloroquine or Sulfasalazine.
525
If a patient develops osteoarthritis-like signs and symptoms in metacarpophalangeal then what is the likely cause?
```
Secondary Osteoarthritis.
Causes:
1. Trauma.
2. Previous inflammatory arthritis.
3. Metabolic Disorders e.g. hemachromatosis or chondrocalcinosis.
```
526
How long does morning stiffness have to last in rheumatoid arthritis for it to be considered active inflammatory disease?
More than 1 hour.
527
How long does morning stiffness have to last in rheumatoid arthritis for it to be considered active inflammatory disease?
More than 1 hour.
528
How long does morning stiffness have to last in rheumatoid arthritis for it to be considered active inflammatory disease?
More than 1 hour.
529
Patient of scleroderma with acute onset of hypertension, renal insufficiency and microangiopathic hemolytic anemia.
Diagnosis?
Scleroderma renal crisis.
530
What is the treatment of psoriatic arthritis?
Methotrexate.
531
Which antibodies are present in mixed connective tissue disease?
Antiribonucleoprotein antibodies.
532
How can you differentiate between rheumatoid arthritis and hepatitis C associated arthritis?
Anti-cyclic citrullinated peptide antibodies are more specific for rheumatoid arthritis.
533
Treatment of asymptomatic extra-cranial carotid artery stenosis.
Aspirin and Statin.
534
Treatment of multiple sclerosis related spasticity.
Tizanidine.
Baclofen.
Cyclobenzaprine.
535
What should be instituted in a medically stable patient after a stroke?
Early rehabilitation.
536
Next step after if a patient reports metal cloudiness and dizziness 4 days after head trauma.
CT head without contrast.
| Rule out subdural hematoma.
537
Treatment of mixed connective tissue disease.
Prednisone.
538
In patients with diffuse cutaneous systemic sclerosis and renal insufficiency?
Scleroderma renal crisis.
539
Effect of itraconazole on statins.
Inhibits breakdown resulting in higher levels and increased toxicity.
540
Treatment of menstrual cycle related migraines.
Prophylaxis with any of the following:
1. Topiramate.
2. Propranolol.
3. Timolol.
4. Amytriptyline.
5. Divalproex sodium.
6. Injectable onabotuliniumtoxinA.
541
Patient presenting with dementia, Parkinsonism and eye movement abnormalities.
What is the diagnosis?
Progressive supranuclear palsy.
542
Treatment of lupus nephritis.
High dose corticosteroids.
543
Where should stroke patients ideally be admitted?
Inpatient stroke unit.
544
Treatment of asymptomatic extra-cranial carotid artery stenosis.
Aspirin and Statin.
545
Treatment of multiple sclerosis related spasticity.
Tizanidine.
Baclofen.
Cyclobenzaprine.
546
What should be instituted in a medically stable patient after a stroke?
Early rehabilitation.
547
Next step after if a patient reports metal cloudiness and dizziness 4 days after head trauma.
CT head without contrast.
| Rule out subdural hematoma.
548
What is the appropriate drug to treat acute migraine with aura?
Sumatriptan.
549
What is the most common neurologic presentation of Wilson's disease?
Parkinsonism.
550
Effect of itraconazole on statins.
Inhibits breakdown resulting in higher levels and increased toxicity.
551
Treatment of menstrual cycle related migraines.
Prophylaxis with any of the following:
1. Topiramate.
2. Propranolol.
3. Timolol.
4. Amytriptyline.
5. Divalproex sodium.
6. Injectable onabotuliniumtoxinA.
552
Patient presenting with dementia, Parkinsonism and eye movement abnormalities.
What is the diagnosis?
Progressive supranuclear palsy.
553
What diagnostic possibilities exist in relatively younger patients with rapidly progressive dementias?
Creutzfeldt-Jakob disease (prions).
| Paraneoplastic syndrome.
554
Where should stroke patients ideally be admitted?
Inpatient stroke unit.
555
What is the most important adverse effect of Natalizumab?
Risk of CNS infection with JC virus, resulting in progressive multifocal leukoencephalopathy (PML).
556
A patient with Parkinson's disease on medication develops punding (compulsive repetitive complex behavior that serves no apparent purpose).
What is the most likely cause?
Medication related.
| Ropinirole.
557
What is the first line anti-epileptic drug in Asian patients?
Levetiracetam.
If the Asian patient has the HLA-B*1502 allele then there is a risk of developing Steven-Johnson syndrome with many of the other anti-epileptic drugs.
558
What is the first step in management in all patients suspected of having had a TIA?
Admit to hospital.
559
Patient with diabetes presenting with thigh pain that progresses to weakness and numbness over weeks to months.
Diagnosis?
Diabetic amyotrophy.
560
Next step in a patient presenting with an acute lumbar plexopathy and pain on hip extension after trauma.
CT Abdomen to rule out iliopsoas hematoma.
561
What nutritional deficiency can cause myelopathy localized to the posterior columns and bilateral corticospinal tracts?
Copper.
562
What the most common lung manifestation of systemic sclerosis?
Pulmonary artery hypertension.
563
Patient with inflammatory myopathy with acute or subacute onset and is characterized by fever; fatigue; Raynaud phenomenon; synovitis; interstitial lung disease; and scaly, rough, dry, darkened, cracked horizontal lines that develop on the palmar and lateral aspects of the fingers, with anti-Jo-1 antibodies positive.
Antisynthetase syndrome
564
What is an effective steroid-sparing drug in the treatment of polymyalgia rheumatica?
Methotrexate.
565
Next step in a patient with persistent elevated creatnine kinase despite discontinuation of statin.
MRI of proximal thigh muscles to assess for inflammation.
566
Approximately one third of patients with SLE and abdominal pain have mesenteric vasculitis.
True or false?
True.
567
Can patients with mixed connective tissue disease get pancytopenia?
Yes.
568
In patients with diffuse cutaneous systemic sclerosis and renal insufficiency?
Renal scleroderma crisis.
569
What is the treatment of mild cutaneous and joint manifestations of SLE?
Hydroxychloroquine.
570
What should you suspect in a patient with dermatomyositis who develops progressive muscle weakness despite decreasing creatinine kinase levels.
Corticosteroid-induced myopathy secondary to prednisone treatment.
571
What should you do if a patient on a tumor necrosis factor a inhibitor e.g. etanercept develops cancer?
Discontinue it.
572
How would you preserve fertility in a woman being treated with cyclophosphamide?
Leuprolide acetate injections.
573
How would you establish a diagnosis of ankylosing spondylitis?
MRI of the sacroiliac joints.
574
Treatment of early rheumatoid arthritis in patients who regularly consume alcohol.
Hydroxychloroquine.
575
Which drug can be continued in SLE patients who get pregnant to prevent lupus flares?
Hydroxychloroquine.
576
Patient with fever, subacute migratory polyarthralgia, arthritis, tenosynovitis and pustular or vesiculopustular lesions on the distal extremities. No organisms seen on Gram stain.
Diagnosis?
Disseminated gonococcal infection.
577
Patient with fever, arthralgia, myalgia, fatigue, and weight loss. Also elevated acute phase reactants, normocytic, normochromic anemia and vascular insufficiency.
Diagnosis?
Takayasu arteritis.
578
Management of patients with a PPD of 5 mm or more who need to be started on a tumor necrosis factor a inhibitor.
Isoniazid.
579
Treatment of Ankylosing Spondylitis.
Tumor necrosis factor a inhibitors e.g. etanercept.
580
A patient with chronic monoarticular arthritis with pain on weight bearing and during the night in the absence of morning stiffness, warmth, erythema, or an inflammatory synovial fluid leukocyte count.
Diagnosis?
Avascular necrosis.
581
Patient with chronic widespread musculoskeletal pain above and below the waist of at least 3 months’ duration with fatigue and difficulty sleeping.
Diagnosis?
Fibromyalgia.
582
If the skin biopsy shows leukocytoclastic vasculitis accompanied by perivascular IgA deposition, what is the diagnosis?
Henoch-Schonlein Purpura.
583
Treatment of kidney stones less than 5 mm in size.
Analgesics and intravenous fluids.
| Stones smaller than 5 mm usually pass spontaneously.
584
Management of a patient with a blood pressure reading of 136/86 mmHg in a clinic.
Pre-hypertension range.
| Lifestyle modification.
585
What type of renal tubular acidosis to patients with multiple myeloma typically develop?
Proximal (type 2) renal tubular acidosis.
586
If a patient has a normal anion gap metabolic acidosis, hypokalemia, and an intact ability to lower the urine pH, what is the diagnosis?
Proximal (type 2) renal tubular acidosis.
587
What is the next step in an ESRD patient requiring dialysis who has a complex cyst or mass on renal ultrasound?
Abdominal CT with iodinated contrast to rule out renal cell carcinoma.
588
What type of glomerulonephritis is associated with Hodgekin's lymphoma?
Minimal change disease.
589
What is the diagnosis in a young pregnant patient with an elevated creatinine, proteinuria and hypertension?
Chronic kidney disease.
590
A patient with HIV, increased serum creatinine level accompanied by hypocomplementemia and dysmorphic erythrocytes and erythrocyte casts seen on urinalysis.
Diagnosis?
Immune complex–mediated glomerular nephritis.
591
A patient with chronic kidney disease, osteopenia, fracture, and bone pain accompanied by a serum parathyroid hormone level below 100 pg/mL (100 ng/L) and a normal alkaline phosphatase level.
Diagnosis?
Adynamic bone disease.
592
Subepithelial deposition of immune complexes on electron microscopy of a kidney biopsy specimen.
Diagnosis?
Membranous nephropathy.
593
Treatment of membranous nephropathy.
ACEI.
594
How would you decrease the risk of recurrent uric acid stones?
Alkalinize the urine with potassium citrate.
595
How would you differentiate between cerebral salt wasting and syndrome of inappropriate antidiuretic hormone secretion?
In cerebral salt wasting there is evidence of hypovolemia e.g. orthostatic hypotension; whereas in SIADH the patient is euvolemic.
596
Treatment of IgA nephropathy.
Pulse methylprednisolone.
597
How often do you screen for microalbuminuria in diabetic patients?
Annually.
598
Next step if screening microalbuminuria is abnormal in diabetic patients.
It needs to be repeated twice in the next 6 months; and if two out of three samples are abnormal then microalbuminuria is confirmed.
599
What is the next step if an apparently healthy adult has decreased creatinine clearance and the 24 hour sample also shows decreased creatinine clearance?
Repeat the timed (24 hour) urine collection as the sample was probably under-collected.
600
What is the gold standard for diagnosing renovascular hypertension?
Intra-arterial digital subtraction angiography.
601
Management of an asymptomatic patient with Autosomal Dominant Polycystic Kidney Disease, with no hypertension or proteinuria.
Home blood pressure measurement every month.
| Urinalysis every 6 months to check for proteinuria.
602
Next step in patient with nonglomerular hematuria with an extensive smoking history.
Kidney ultrasonography and cystoscopy.
603
What would be the next test you would do when evaluating a patient found to have an elevated creatinine?
Spot urine albumin-creatinine ratio.
604
What are the cut-off values for transferrin saturation and serum ferritin level that are diagnostic of iron deficiency in predialysis patients with CKD?
A transferrin saturation below 20% and a serum ferritin level below 100 ng/mL (100 µg/L).
605
A patient has hypercalcemia, anemia, renal insufficiency and proximal (type 2) renal tubular acidosis.
Diagnosis?
Multiple myeloma.
606
A patient with nausea, vomiting, and anorexia accompanied by relatively low blood pressure in the absence of edema or urine sediment abnormalities, with chronic kidney disease and a FeNa of 4%.
Diagnosis?
Pre-renal azotemia.
607
What class of drugs is more likely to benefit an older patient with hypertension who is already on a beta blocker?
Low dose diuretic because older patients are more salt sensitive.
608
A patient with hyperphosphatemia, hypocalcemia, and elevated serum parathyroid hormone and alkaline phosphatase levels in the setting of renal disease.
Diagnosis?
Secondary hyperparathyroidism.
609
How do you reduce formation of calcium kidney stones?
Increased fluid intake and high calcium diet.
610
Next step in a patient with nephrotic syndrome?
Kidney biopsy to determine the cause.
611
Name an antibiotic that interacts with tacrolimus causing acute renal failure in kidney transplant patients.
Erythromycin.
612
What medication should you add to the regimen of a patient with resistant hypertension who is already on three anti-hypertensives?
Spironolactone.
613
Diagnostic test for polyarteritis nodosa.
Angiography of the renal arteries.
614
Patient with significant hypertension, kidney insufficiency, and renal vasculitis associated with proteinuria and hematuria.
Diagnosis?
Polyarteritis nodosa.
615
Treatment of staghorn calculi.
Percutaneous nephrolithotomy.
616
What type of nephrotic syndrome can occur soon after kidney transplantation?
Focal segmental glomerulosclerosis.
617
A patient has idiopathic thrombocytopenic purpura that is refractory to steroids and he refuses a splenectomy. How would you immediately raise his platelet levels?
Intravenous immunoglobulin.
618
What is the treatment of CML?
Imatinib.
619
A patient has pancytopenia, hemolytic anemia, and thrombosis.
Likely diagnosis?
Paroxysmal nocturnal hemoglobinuria (PNH)
620
What diagnostic test is appropriate for paroxysmal nocturnal hemoglobinuria?
Flow cytometry.
621
Treatment of 5q- syndrome.
Lenalidomide.
622
Preoperative treatment for a patient with factor IX deficiency.
No pre-operative treatment required.
623
What is the next step in a patient with erythrocytosis and elevated erythropoietin levels?
Ultrasonography of the abdomen to rule out renal cell carcinoma (erythpoietin secreting in 1 - 5%).
624
Secondary prevention for strokes in sickle cell anemia patients.
Aspirin and hyper-transfusion (transfusing erythrocytes monthly).
625
Secondary prevention for strokes in sickle cell anemia patients.
Aspirin and hyper-transfusion (transfusing erythrocytes monthly).
626
What is the risk of thrombosis in a patient with a mitral mechanical valve - low, medium or high?
High.
627
How do you treat a patient with essential thrombocytopenia who is to undergo surgery?
Preoperatively: Platelet apheresis.
| Post-operatively: Hydroxyurea.
628
Treatment of thrombocytopenic purpura.
Plasma exchange.
629
A patient has a hemoglobin S level that is greater than 60%, with an elevated hemoglobin A2 level and mild microcytosis.
Diagnosis?
S-beta+ thalassemia.
630
What would you check to measure a patient's risk for recurrent deep venous thrombosis after first episode of deep venous thrombosis?
D-dimer.
631
A patient with splenomegaly, normocytic anemia, circulating eryhthroblasts, and myeloid precursors, teardrop cells, and bone marrow fibrosis.
Diagnosis?
Myelofibrosis.
632
The patient has hypercalcemia, diffuse osteopenia, anemia, leukopenia, renal insufficiency, and a history of encapsulated organism–related pneumonia.
Diagnosis?
Multiple myeloma.
633
Right sided heart failure in a patient with sickle cell disease.
Diagnosis?
Pulmonary hypertension.
634
What is the difference between relative polycythemia and secondary polycythemia?
Relative polycythemia is because of volume contraction whereas secondary polycythemia is driven by an underlying disease process like COPD.
635
What is the difference between relative polycythemia and secondary polycythemia?
Relative polycythemia is because of volume contraction whereas secondary polycythemia is driven by an underlying disease process.
636
How do you reduce the risk of preganancy loss in patients with anti-phospholipid syndrome?
Heparin and aspirin.
637
What immunosuppressant drugs can cause microangiopathic hemolytic anemia?
Tacrolimus.
| Cyclosporine.
638
If there is a low suspicion of DVT what should you do to rule it out?
D-dimer.
639
How long does the low molecular weight heparin need to be continued in the initial treatment of a deep venous thrombosis?
Minimum 5 day and until the INR is more than or equal to 2 on 2 occasions 24 hours apart.
640
What is the next step after favorable high dose chemotherapy in multiple myeloma patients?
Autologous stem cell transplantation.
641
Treatment of a patient with refractory immune (idiopathic) thrombocytopenia and no splenomegaly that has failed therapy with prednisone, intravenous immune globulin, and rituximab.
Thrombopoietin receptor agonists:
1. Romiplostim
2. Eltrombopag
642
Treatment of a patient with refractory immune (idiopathic) thrombocytopenia and no splenomegaly that has failed therapy with prednisone, intravenous immune globulin, and rituximab.
Thrombopoietin receptor agonists:
1. Romiplostim
2. Eltrombopag
643
What test is needed for the optimal systemic treatment of breast cancer?
Assay for expression of esotrogen and progesterone receptors.
644
What's the treatment of locally advanced gastric cancer?
Chemotherapy, radiation therapy and surgical resection.
645
Treatment of stage II follicular lymphoma?
Cyclophosphamide, vincristine and prednisone with rituximab.
646
Treatment of early-stage, diffuse, large B-cell non-Hodgkin lymphoma.
Cyclophosphamide, doxorubicin, vincristine, and prednisone with rituximab (R-CHOP) for three cycles followed by involved-field radiation therapy.
647
Study to diagnose superior sulcus tumor.
CT of the chest.
648
Managment of completely resected ovarian cancer of low malignant potential without invasive implants.
Close observation and monitoring.
649
Treatment of an isolated hepatic metastasis in a patient previously treated for colon cancer.
Surgical resection.
650
Treatment of lytic bone metastases.
Intravenous bisphosphonates, e.g. zoledronic acid.
651
Best hormonal therapy for metastatic breast cancer in post-menopausal women.
Aromatase inhibitor, e.g. anastrozole.
652
What do you screen for in patients of multiple endocrine neoplasia type 2A?
RET mutation.
653
Management of extensive stage small cell lung cancer.
Cisplatin and etoposide.
654
Treatment of HER2 positive early stage breast cancer.
Adjuvant chemotherapy and trastuzumab.
655
Post-operative management of stage III colon cancer.
Adjuvant chemotherapy with an oxaliplatin based regimen.
656
Treatment of papillary thyroid cancer.
Total thyroidectomy followed by radioiodine-131.
657
Testicular mass with elevated alpha fetoprotein.
| Diagnosis?
Non-seminoma.
658
Next step in limited stage small cell lung cancer following chemotherapy and local radiation to the lung tumor.
Prophylactic cranial irradiation.
659
Back pain, muscle weakness and loss of bowel or bladder control. Next step?
MRI thoracolumbar spine to diagnose a spinal cord compression.
660
Possible cause of recurrent infections in a patient with CLL (IgG measured at 500 mg/dl).
Hypogammaglobinemia.
661
Treatment of hypogammaglobinemia in CLL.
Intravenous immune globulin.
662
Post-op treatment of stage 1 grade 1 ovarian cancer.
Greater than 90% survival rate without post-operative chemotherapy.
663
What's the most likely cancer if there is axillary lymph node metastasis and no detectable primary tumor?
Breast cancer.
664
What malignancy is associated with Sjogren's syndrome?
Lymphoma.
665
What should you suspect in a patient with chest pain and shortness of breath who has a history of breast cancer status post chemotherapy and radiotherapy and is taking tamoxifen?
Thromboembolic disease.
666
Difficulty opening mouth in a cancer patient who is using bisphosphonates.
Osteonecrosis of the jaw.
