MKSAP 5

Question 1

50 y/o 2 hour episode of epigastric discomfort and dyspnea during exercise that is relieved by rest. Now pain free. Antacids give parital relief. No fever, chills, n/v, diaphoresis. Diagnosis?

Answer 1

ANGINA PECTORIS: Ischemic cardiac pain has predictable relation to exercise and relief with rest or nitroglycerin. Most patients with PUD do not have pain at diagnosis.

Question 2

Trreatment of right ventricular MI with hemodynamic abnormalities?

Answer 2

NORMAL SALINE INFUSION: RV contractility is reduced resulting in higher RV diastolic pressure, lower RV systolic pressure and reduced preload. Mecahnism is: Increases gradient of pressure from RA to LA to maintain filling of LV. Nitro and B-blocker are co

Question 3

Classic triad of right ventricular MI?

Answer 3

Hypotension, Clear lung fields, elevated estimated central venous pressure. Most predictive finding is ST-segment elevation on right-sided precordial lead V4R. Likely RCA

Question 4

Most common cause of marked bradycardia?

Answer 4

Third degree block - complete absence of conduction of atrial impulses to the ventricle.

Question 5

Mobitz type I second-degree AV block is characterized by:

Answer 5

Progressive prolongation of the PR interval until a dropped beat occurs. Intermittent failure of AV conduction

Question 6

Mobitz type II second degree block is characterized by:

Answer 6

regularly dropped beat, ie nonconducted P wave every second or thrid beat w/o progressive prolongation of the PR interval. PATHOLOGIC. 2:1. Anatomic site almost always below AV node, frequently associated with BBB

Question 7

Treatment of chronic stable angina.

Answer 7

TREAT CHRONIC STABLE ANGINA WITH WORSENING SYMPTOMS WITH INCREASED DOSAGE OF A BB. Use antianginal agents (BB, CCB, nitrates) and vascular-protective therapy (ASA, ACE, statins). Beta blocker dose should be titrated to achieve a resting HR of approximatel

Question 8

MOA and use of Ranolazine

Answer 8

Rx chronic stable angina. Only used in addition to baseline therapy with a BB, CCB, long-acting nitrate. Inhibits late phase of inward sodium channel (late I Na) in ischemic cardiac myocytes reduce intracellular sodium and reduces calcium influx via Na-Ca

Question 9

What physical exam findings would you look for if you suspect a PE?

Answer 9

Chest pain and dyspnia with asymmetric leg edema, elevated central venous pressure, tachypnea, tachycardia

Question 10

Exercise electrocardiographic stress testing is the primary approach to the diagnosis of:

Answer 10

CAD in patients who can exercise and have normal resting ECGs.

Question 11

Rx for chronic stable angina?

Answer 11

Aspirin (reduces risk of stroke, MI, SCD, vascular death by 33%), ACE (20% reduced mortality), Statins (25-30%) and maintain LDL <100 mg/dL for patients with CAD. Nitroglycerin. (Carvedilol, lisinopril, simvastatin, nitro.)

Question 12

Next step in patient with CAD that remains highly symptomatic despite optimal medical therapy

Answer 12

CORONARY ANGIOGRAPHY is indicated in patients with chronic stable angina who experience lifestyle-limiting angina despite optimal medical therapy.

Question 13

Presence of a new systolic murmur and respiratory distress several days after an acute MI

Answer 13

Ventricular septal rupture or mitral regugitation

Question 14

First degree AV block

Answer 14

PR > 0.2 sec, associated with soft S1, associated with acute reversible conditions ie inferior MI, RF, digitalis intoxicatin

Question 15

Clinical triad of hypotension, clear lung fields, and jugular venous distension.

Answer 15

RIGHT VENTRICULAR INFARCTION occurs in 20% of patients with an inferior wall STEMI. RIght sided ECG shows ST-elevation in leads V3R and V4R.

Question 16

Rx for right ventricular infarction

Answer 16

Restore blood flow to RV: Thrombolytic therapy, primary percutaneous coronary intervention, aggressive volume loading with IV NS, dopamine or dobutamine if hypotension persists.

Question 17

A ventricular septal defect following an ST-elevation MI results in what? How could you confirm?

Answer 17

Hypotension, respiratory distress, new systolic murmur, and a palpable thrill. occurs in 0.1% STEMI 2-7 days after MI. Echocardiography to confirm.

Question 18

Sinoatrial node dysfunction

Answer 18

ALso called sick sinus syndrome, Comprises a collectin of pathologic findings (sinus arrest, sinus exit block, sinus bradycardia) that result in bradycardia. CC: Dizziness, sinus bradycardia, rates between 40-50/min with 2 symptomatic sinus pauses of 3-5

Question 19

CHAD2 score

Answer 19

Congestive HF, Hypertension, Age >75, Diabetes, Stroke or TIA(2 points for stroke/TIA). Risk is 18%. Warfarin with target INR 2-3 reduces stroke risk by 62% compared to 19% on aspirin. Use warfarin if score 3+ or h/o stroke.

Question 20

How should you treat Atriall fibrillation.

Answer 20

METOPROLOL and WARFARIN: No survival advantige rate vs rhythm but for older patients (>70) rate associated with improved quality of life scores.

Question 21

Primary eligibility criterion for implantable cardioverter-defibrillator implantation for primary prevention of SCD in the setting of heart failure is:

Answer 21

LV EF <35%

Question 22

Peripartum cardiomyopathy

Answer 22

HF with LVEF <45% diagnosed between 3 months before and 6 months after delivery in the absence of an identifiable cause.

Question 23

Most appropriate diagnostic test forna patient with new-onset heart failure and angina? (Sx of typical angina substernal CP precipiated by exertion and relieved by rest) and exertional dyspnea, orthopnea (new-onset HF)

Answer 23

Evaluation with CARDIAC CATHETERIZATION and ANGIOGRAPHY if they are possible candidates for revascularization.

Question 24

Purpose of BNP?

Answer 24

Differentiating acute HF from noncardiac causes of dyspnea. If 500 pg/mL likely HF.

Question 25

Most appropriate diagnostic test for a patient with newly diagnosed or suspected heart failure?

Answer 25

ECHOCARDIOGRAM - to determine if failure is systolic vs diastolic and whether structureal or functional abnormalities may be causing (wall abnormalities, pericardial disease, valvular abnormality)

Question 26

Standard treatment for patients with New York Heart Association class III or IV heart failure.

Answer 26

ACE, BB, spironolactone (30% reduction in mortality with spironolacone)

Question 27

Maneuvers that increase the murmur of hypertrophic cardiomyopathy

Answer 27

Valsalva maneurver and squat-tostand: transiently decrease venous return, with septum and anterior mitral leaflet brought closer together. Turbulent flow and the murmur increase.

Question 28

How is blood glucose managed in hospitalized patients with diabetes?

Answer 28

A basal-bolus insulin regimen consisting of a long-acting insulin and a rapid acting insulin analogue before meals is recommended.

Question 29

How can you prevent hypoglycemia in a patient with DM?

Answer 29

Use one injection of basal Insulin GLARGINE and insulin LISPRO x 4 before each meal; basal and rapid-acting insulin analoges when dosed properly, reduce the risk of hypoglycemia.

Question 30

Optimal basal insulin that are peakless and have 24 hour duration of action?

Answer 30

Insulin GLARGINE (lantus) and insulin DETEMIR, NPH does not, administered twice daily, acting 12-18 hours peaking 4 to 8 hours.

Question 31

Ideal prandial insulins

Answer 31

Lispro, aspart, glulisine

Question 32

Onset, duration of glargine

Answer 32

Onset 3-4 hours, Duration 24 hours, given at bedtime

Question 33

Onset, duration of Human insulin lispro

Answer 33

15 minutes onset, 4 hours duration

Question 34

How do you diagnose DKA?

Answer 34

Serum glucose, electrolytes, ketones, and ABGs. BG <15 meq/L and positive serum or urine ketone concentrations.

Question 35

How do you treat Hyperglycemic hyperosmolar syndrome?

Answer 35

Identify underlying precipitating illness and restore plasma volume with IV FLUIDS!

Question 36

Insulin used in DKA?

Answer 36

INSULIN DRIP

Question 37

LDL-cholesterol goal varies depending on these 5 major CV risk factors

Answer 37

Smoking, HTN, older age (men 45, women 55), Low HDL, family history of coronary artery disease (male 55, female 65)

Question 38

LDL-cholesterol goal for 0-1 risk factors

Answer 38

Below 160 mg/dL

Question 39

When is fibrate therapy indicated?

Answer 39

>200 mg/dL hypertiglyceridemia

Question 40

When do you start a statin in a patient with no CV risk factors?

Answer 40

If LDL-cholesterol was above 190 mg/dL, ideal range is 160-190 if 0 risk factors.

Question 41

LDL target in patients with DM

Answer 41

<100 mg/dL

Question 42

LDL target in patient with a previous MI

Answer 42

<100 mg/dL

Question 43

LDL goal in a patient with a TIA?

Answer 43

<100 mg/dL

Question 44

M/C Cause of hypothyroidism? Do you need to confirm diagnosis?

Answer 44

Hashimoto disease, confirmation with measurement of TPO antibody is not necessary

Question 45

Guidelines for evaluation of a thyroid nodule?

Answer 45

FNA for any nodule greater than 1 cm in diameter. Smaller nodules if cancer risk factors (male, h/o neck irradiation, fam hx esp medullary, rapid growth, hoarseness, extreme ages 60).

Question 46

Sensitivity of FNA

Answer 46

90-95% Cancer risk of a thyroid nodule is 5-10% with incidence of thyroid nodules 4-7%

Question 47

How should you manage hypothyroidism during pregnanacy? Why?

Answer 47

MONITOR TSH levels, standard T4 is not as accurate during pregnancy. Levothyroxine requirements may increase 30% to 50% during the first trimester of pregnancy. Estrogen increases TBG which binds free T4. Fetus depends on maternal thyroid hormone for firs

Question 48

How do you treat Graves disease?

Answer 48

ATENOLOL and METHIMAZOLE. Methimazole has fewer side effects and results in quicker achievement of the euthyroid state than does propylthiouracil in patients with hyperthyroidism.

Question 49

What is postpartum thyroiditis?

Answer 49

Occurs in 5% women within a few months of delivery, variant of painless thyroiditis; may have transient THYROTOXICOSIS (hyperthyroid), HYPOTHYROID or BOTH.

Question 50

75 year old admitted to ICU with sepsis associated with PNA, respiratory failure and hypotension. Corisol elevated, TSH low, T4 low-normal, T3 low. Diagnosis?

Answer 50

EUTHYROID SICK SYNDROME, next step is to allow the patient to recover for 4-8 weeks and then repeat the thyroid funciton tests.

Question 51

Patient with abdominal pain and CT revelaed incidentally discovered 1.4 cm left adrenal nodule with smooth borders and low attenuation. CMP normal, next diagnostic test?

Answer 51

PLASMA METANEPHRINE levels and OVERNIGHT DEXAMETHASONE suppression test. Hypersecretion of glucocorticoids and catecholamines, evaluate even in asymptomatic patients with incidentally discovered adrenal adenomas.

Question 52

What is the best screening test for primary hyperaldosteronism?

Answer 52

Ratio of serum aldosterone to plasma renin activity. ?20, especially if serum aldo is ?15 is consistent with a diagnosis of primary hyperaldosteronism

Question 53

Best way to diagnose pheo?

Answer 53

CT sensitivity 93-100% in detecting adrenal pheo and 90% in detecting extra-adrenal catecholamine-secreting paraganliomas.

Question 54

How do you treat adrenal insufficiency during stress?

Answer 54

Stress-level dosage of CORTICOSTEROIDS (10-times the normal daily replacement dose, usually 100 mg IV divided into 3-4 doses) + normal saline. If dose of hydrocortisone is over 60 mg/day, fludrocortisone is nnecessary because adequate mineralocorticoid ac

Question 55

Insufficient vitamin D vs deficiency? Treatment?

Answer 55

<20 are defined as deficient. Loading dose of 50,000 IU q week x 10 weeks + 2000 IU daily.

Question 56

When should screening ofr osteoporosis begin?

Answer 56

65 years and older in women and 60-64 years old who are at increased risk for osteoporosis.

Question 57

Definition of osteoporosis?

Answer 57

presence of fragility fracture (fracture secondary to minor trauma, ie falling from standing position) or BMD T-score less than -2.5 in patients that have not experienced a fragility fracture. Osteopenia is between -1 and -2.5.

Question 58

Diagnostic test for nephrolithiasis?

Answer 58

NONCONTRAST HELICAL ABDOMINAL CT - reveals urinary tract obstruction with hydronephrosis and detects stones as small as 1mm and evaluates potential causes of abdominal pain and hematuria

Question 59

Define acute abdomen. Diagnostic test?

Answer 59

sudden and severe abdominal pain <24 hours. Rebound tenderness and severe diffuse abdominal pain suggest acute abdomen with peritonitis. SUPINE and UPRIGHT ABDOMINAL RADIOGRAPHS to look for air-fluid levels, suggestive of bowel obstruction, and free perit

Question 60

Severe sudden abdominal back pain and loss of consciousness

Answer 60

RUPTURE (AAA) often mistaken for renal colic

Question 61

Diagnostic criteria for IBS?

Answer 61

Rome III criteria (abdominal pain relieved by defecation and change in bowel habits. presence of 2 out of 3 symptoms during 12 month period) and do not have alarm indicators (old age, male, nocturnal awakenning, rectal bleeding, weight losss, family histo

Question 62

Best imaging modality to confirm suspected diverticulitis?

Answer 62

CONTRAST ENHANCED CT SCAN of ABDOMEN and PELVIS (Sensitivity 69-95% and specificity of 75%-100%) in acute diverticulitis. Also evaluates for complications ie perforation, abscess, obstruction, fistula.

Question 63

LLQ pain + Fever + Leukocytosis

Answer 63

Diverticulitis

Question 64

Lab to help diagnose hemolytic uremic syndrome

Answer 64

Peripheral blood smear, schistocytes with elevated reticulocyte count, elevated lactate dehydrogenase level.

Question 65

Acute radiation proctitis

Answer 65

occurs in patients receiving pelvic radiation, resulting in diarrhea and tenesmus within 6 weeks of therapy. Diagnose with FLEXIBLE SIGMOIDOSCOPY.

Question 66

Diarrhea 10-15 times daily, lower abdominal pain, cramping, fever, leukocytosis

Answer 66

CDI

Question 67

Lab findings that indicate cholestatic injury?

Answer 67

elevation of serum alkaline phosphatase and relatively minimal elevations of AST and ALT.

Question 68

Lab findings in hepatocellular injury

Answer 68

elevated aminotransferase levels with mildy elevated alkaline phosphatase concentration and direct bilirubin fraction.

Question 69

Incidental finding of indirect (unconjugated) hyperbilirubinemia in an asymptomatic patient with a normal Hb level and otherwise normal liver tests is indicative of this disease

Answer 69

Gilbert syndrome

Question 70

Classic findings in acute cholecystitis

Answer 70

Biliary colic, murphy sign, fever, leukocytosis, mild bilirubin and aminotransferase elevation, gallstones, pericholecystic fluid, thickening of the gallbladder wall on ultrasonography

Question 71

Charcot's triad

Answer 71

Fever, jaundice, RUQ abdominal pain and common bile duct obstruction. Start broad-spectrum antibiotics to cover aerobic and anaerobic gram-negative bacilli and enterococci immediately. ERCP with sphincterotomy should be performed to remove impacted stones

Question 72

Initial treatment of choice for gallstone pancreatitis

Answer 72

ERCP (Endoscopic retrograde cholangiopancreatography) with SPHINCTEROTOMY and STONE EXTRACTION

Question 73

What suggests gallstones as the cause of acute pancreatitis?

Answer 73

Presence of stones in the gallbladder, dilated bile duct, elevated aminotransferase levels (656)

Question 74

2 most common causes of peptic ulcer disease

Answer 74

NSAIDS and H. pylori account for 90% of cases.

Question 75

Drugs most commonly associated with dyspepsia

Answer 75

NSAIDS

Question 76

Functional dyspepsia

Answer 76

chronic or recurrent discomfort in the epigastrium with no organic cause determined. Empiric trial of a PPI is indicated for ulcer-like functional dyspepsia

Question 77

Patient >60 yo, left lower quadrant pain, urgent defecation, and red or maroon rectal bleeding that does not require transfusion.

Answer 77

COLONIC ISCHEMIA

Question 78

Most likely sources of painless lower GI bleeding

Answer 78

Diverticulosis and vascular ectasia

Question 79

Most appropriate screening strategy for hepatocellular carcinoma?

Answer 79

Liver ultrasonography.

Question 80

Diagnostic triad of primary biliary cirrhosis

Answer 80

Cholestatic liver profile, positive antimitochondrial antibody titers, alkaline phosphate is usually elevated 10 times above normal. Hypergamaglobulinemia, mild hyperbilirubinemia

Question 81

M/C symptoms of primary sclerosing cholangitis

Answer 81

Pruritis and fatigue. Association with Ulcerative colitis and marked elevations in alkaline phosphatase

Question 82

Interpretatino of ascitic fluid analysis showing a serum-to-ascites albumin gradient greater than 1.1 g/dL

Answer 82

Ascites caused by chronic liver disease, cirrhosis, right-sided heart failure, and Budd-Chiari syndrome

Question 83

First-line therapy for induction and maintenance of remission in mild to moderate UC is which treatment?

Answer 83

MESALAMINE or another 5-Aminosalicylate agent

Question 84

65 year old woman evaluated for 6 month history of watery, nonbloody diarrhea; 3-20 bowel movements a day. Abdominal cramps and bloating. Colonoscopy is normal.

Answer 84

MICROSCOPIC COLITIS: Collagenous coltis usually in 6th decade of life, women > men; Lymphocytic colitis - average age is 7th decade of life. Both characterized by chronic watery diarrhea without bleeding; diagnosis made with HISTOLOGIC examination of colo

Question 85

As the prevalence of disease decreases, what values change?

Answer 85

as prevalence is less, PPV is reduced and NPV increases.

Question 86

How do you calculate the PPV?

Answer 86

PPV= TP / (TP + FP)

Question 87

What is a likelihood ratio (LR) of a test?

Answer 87

proportion of patients with disease who test positive divided by the proportion of patients without disease who test positive; TP/FP (numerator is sensitivity, denominator is FP) Can be used to approximate the probability of disease after a test is perfor

Question 88

Positive likelihood ratios of 2, 5, and 10 increase the probability of disease by which amount?

Answer 88

15%, 30%, and 45% respectively

Question 89

Using a receiver operating characteristic curve, which test is most accurate?

Answer 89

Best overall accuracy for each of its cut points will have the largest area under the ROC curve.

Question 90

Screening for AAA?

Answer 90

One-time screening for AAA with ULTRASONOGRAPHY recommended for all men aged 65-75 years who have ever smoked.

Question 91

Recommendation for pneumococcal vaccine

Answer 91

Once at age 65 every 5 years and for younger patients who are active smokers or who have COPD, asthma, and other disorders that increase their risk for invasive pneumococcal disease.

Question 92

Zoster vaccine indication?

Answer 92

all patients age 60 years and older without contraindications, regardless of history of prior varicella infection. Live attentuated zoster vaccine in reduces incidence of zoster by 51% and postherpetic neuralgia by 67%. Prevents zoster more ages 60-69 but

Question 93

When is Tetanus booster indicated?

Answer 93

Tetanus booster vaccination can be omitted in patients who received a tetanus booster within the past 5 years and in patients with clean minor wounds who have received vaccination within the past 10 years. Otherwise, give tetanus-diphtheria toxoid and ace

Question 94

When do you need to give tetanus immune globulin?

Answer 94

Patients who have not completed primary series of tetanus immunizations or in patients with unclear immunization history.

Question 95

When should HPV vaccine be given?

Answer 95

HPV quadrivalent vaccine series given to all girls/women ages 9 through 26, women should get regular pap smears even after receiving b/c 30% of cervical cancers not prevented by vaccine.

Question 96

Screening tests for colon cancer?

Answer 96

Annual home stool testing, colonoscopy every 10 years, flexible sigmoidoscopy every 5 years toegether with high-sensitivity fecal occult blood testing every 3 years.

Question 97

Definition orthostatic hypotension?

Answer 97

Systolic drop of 20 mm Hg or 10 mm Hg diastolic within 3 minutes of standing.

Question 98

When should you suspect VT as a cause of syncope?

Answer 98

Advanced systolic HF and underlying ischemic heart disease.

Question 99

Presentation of vasovagal syncope?

Answer 99

prodromal symptoms of nausea, lightheadedness, diaphoresis (all highly sensitive if lasting longer than 10 seconds.Brief myoclonic jerking after losing consciousness is not unusual after vasovagal syncope.

Question 100

What is the gold standard for diagnosis of an arrhythmic cause of syncope?

Answer 100

Documentation of a rhythm disturbance at the time of symptom occurence. IMPLANTABLE LOOP RECORDER has been shown to have the greatest diagnostic yield and cost-effectiveness for evaluation of infrequent syncope.

Question 101

Next step in management if patient doesn't respond to antidepressant?

Answer 101

STAR*D trial found that 25% with major depression who did not respond to initial antidepressant achieved remission when another agent was substituted. If no response to full-dose therapy at 6 weeks, SWITCH!

Question 102

Next step in management if patient has suicidal ideation and a plan?

Answer 102

URGENTLY referred to a pschiatrist or hospitalized for psychiatric assessment.

Question 103

Patient with tachycardia, HTN, hyperthermia, mydriasis, agitation, psychosis? What is the intoxication and treatment?

Answer 103

COCAINE intoxication; treatment is sedation with a benzodiazepine, lorazepam IV or intramuscularly. Diazepam

Question 104

What is the pharmacological approach to managing alcohol dependence in the short term and also decreases frequency of relapse?

Answer 104

NALTREXONE, an opioid receptor antagonist, has been shown to be effective in short term treatment of alcohol dependence as well as decreasing frequency of relapse. Studies using disulfiram have been inconclusive on its effect in enhancing abstinence.

Question 105

Treatment for lumbar spinal stenosis

Answer 105

SURGERY! Refer after a minimum of 3 months to 2 years of failed nonsurgical interventions

Question 106

Management of vertebral osteomyelitis?

Answer 106

Back or neck pain gradually worsens over weeks/months, fever present in 50%, leukocytossis is typically absent but ESR is usually >100 mm/h. Disseminated hematogenously adjacent vertebral bodies. Culture blood (positive in 75%). MRI is PREFERRED IMAGING m

Question 107

In patients who do not smoke, do not take an ACE inhibitor, and have normal cest radiograph, what is most likely cause of cough?

Answer 107

UACS, asthma, or GERD are responsible for 99% of cases of chronic cough.

Question 108

Empiric treatment of chronic cough (>8 weeks duration) in a nonsmoking patient not taking an ACE inhibitor who has a normal chest radiograph?

Answer 108

Rx Upper airway cough syndrome (UACS, previously postnasal drip) with an ANTIHISTAMINE/DECONGESTANT combination.

Question 109

Most common causes of hemoptysis in ambulatory patients? Next step?

Answer 109

Infection (bronchitis/PNA), malignancy. CHEST RADIOGRAPH; patients at high risk for lung cacner should be referred for CHEST CT and fiberoptic bronchoscopy even if the chest radiograph is normal.

Question 110

When should antibiotics be used in a COPD exacerbation?

Answer 110

At least 2 of the following: Increased sputum PURULENCE (change in sputum color), increased sputum VOLUME, or indreased DYSPNEA

Question 111

Best pharmacological approach to smoking cessation?

Answer 111

Best drug is VARENICLINE: Bupropion and nortriptyline appear equally effective to nicotine replacement therapy (double odds of quitting compared to placebo) but bupropion has 1 in 1000 risk of seizures and VARENICLINE increases odds to quit at 12 weeks by

Question 112

When is surgical treatment for obesity indicated?

Answer 112

BMI >35 and serious obesity-related medical comorbidities or BMI of 40+ without comorbidities in whom attempts at weight loss including drug therapy were unsuccessful.

Question 113

Cause of persistent n/v occuring within the first few months after gastric bypass surgery?

Answer 113

STOMAL STENOSIS - undergo upper endoscopy to rule out.

Question 114

Drugs that may cause weight loss in an elderly patient?

Answer 114

anticholinergic, antiparkinson agents, digoxin, iron and potassium supplements, aspirin, NSAIDs, opiates, bupropion and fluoxetine, thyroid hormone supplementation, metformin and exenatide.

Question 115

How can you treat heavy menstrual bleeding?

Answer 115

ORAL MEDROXYPROGESTERONE ACETATE for 10 to 21 days. If orthostatic or dizzy from blood loss, IV estrogen are 70% effective in stopping bleeding entirely.

Question 116

How do you evaluate secondary amenorrhea?

Answer 116

PROGESTIN withdrawal challange. Menstrual flow on progestin withdrawal indicates normal estrogen production and patent outflow tract, which limits the df dx of secondary amenorrhea to chronic anovulation with estrogen present

Question 117

Evaluation of abnormal uterine bleeding?

Answer 117

Pelvic examination, Pap smear, urine pregancny test, cultures for gonorrhea and Chlamydia, CBC, thyroid, glucose, prolactin, coagulation. ENDOMETRIAL BIOPSY is appropriate to rule out endometrial cancer or hyperplasia in patients older than 35 years with

Question 118

Treatment for cystic and pustular acne?

Answer 118

ORAL ABX. Use oral isotretinoin for cystic and pustular acne that is unresponsive to abx.

Question 119

How do you evaluate new-onset urinary incontinence?

Answer 119

DIAPERS: Drugs, Infection, Atrophic vaginitis, Psychological (depression, delerium, dementia), Endocrine (hyperglycemia, hypercalcemia), restricted mobility, stool impaction.

Question 120

How do you test for hearing impairment?

Answer 120

WHISPERED-VOICE test or the handheld AUIDOSCOPY, even if they deny having a hearing problem.

Question 121

Treatment for an 85 yo with blood pressure of 186/70

Answer 121

Chlorthalidone - Treat HTN in an elderly patient with HCTZ: Low dose diuretic therapy is appropriate in older patients with HTN because they are more likely to be salt sensitive.

Question 122

Target BP goal for DM and kidney disease

Answer 122

DM 130/80, kidney 125/75 with urine protein-creatitinine ratio > 1 mg/mg.

Question 123

Sudden severe headaches, diaphoresis, palpitations

Answer 123

94% sensitivity and 91% specificity for pheochromocytoma in hypertensive patients. Absence of all 3 Sx reliably excludes pheo.

Question 124

Treatment for Stage 2 hypertension or blood pressure greater than 20 mm Hg systolic or 10 mm Hg diastolic above target.

Answer 124

TWO-DRUG THERAPY: Low dose HCTZ and ACE inhibitor (lisinopril); BB no longer used as first line for HTN because they do not prevent stroke. Thiazide diuretics are superior to alpha blockers, ACE, CCB in reducing cardiovascular and kideny risk in patients