PANCE Topics to Review

Question 1

Hepatic encephalopathy treatment

Answer 1

D/c offending or precipitating agent (i.e. infection, GI bleed, sedative meds) and lower serum ammonia with nonabsorbable disaccharides (i.e. lactulose – helps acidify the colon, which facilitates absorption of ammonia and conversion to ammonium, which is excreted through feces)

Question 2

Dysphagia to solids suggests _______ versus dysphagia to solids AND liquids suggests _________

Answer 2

Mechanical obsturction (must get EGD to r/o tumor or obstructive mass); Motility disorder (consider esophageal manometry or barium swallow studies)

Question 3

T or F: dysphagia is a red flag symptom of GERD

Answer 3

True – can be a sign of esophageal cancer developing

Question 4

Treatment for bleeding due to heparin toxicity

Answer 4

Protamine sulfate (binds heparin and has no anticoagulant activity)

Question 5

Treatment for warfarin toxicity (aka bleeding)

Answer 5

Vitamin K – but this requires formation of new clotting factors and thus takes a while to work (FFP can be used in acute life threatening bleeds d/t warfarin)

Question 6

Measles rash is blanchable/non-blanchable, and timeline of development is ___________

Answer 6

Blanchable and nontender; start on face then spreads to the rest of the body after 3 days of conjunctivitis, coryza, and cough

Question 7

Murmur with nonejection click and varying in timing depending on position is characteristic of?

Answer 7

MVP

Question 8

Alcohol withdrawal presentation

Answer 8

Mild withdrawal (6-24 hours since last drink): anxiety, insomnia, tremors, diaphoresis, palpitations, GI upset, intact orientation
Seizures (12-48 hours): single or multiple generalized tonic-clonic seizures
Alcoholic hallucinosis (12-48 hours): can be visual, auditory or tactile; VS, intact orientation
Delirium tremens (48-96 hours): confusion, agitation, fever, tachycardia, HTN, diaphoresis, hallucinations

Question 9

Treatment of delirium tremens

Answer 9

Benzos and supportive management (ICU admission)

Question 10

Opiate withdrawal presentation

Answer 10

Timing dependent on specific opioid used

General sx: GI distress, myalgia, rhinorrhea, diaphoresis, mildly elevated VS

Question 11

PCKD presentation

Answer 11

Chronic fatigue and flank pain
Hematuria
HTN
Palpable flank masses (usually b/l but doesn’t have to be)
Element of CKD on labs

**usually asymptomatic until age 30-40
**extrarenal manifestations include cerebral aneurysms and liver cysts (hepatomegaly)

Question 12

STEMI treatment for patients that are not PCI candidiates

Answer 12

Fibrinolytics

Question 13

Urge incontinence presentation

Answer 13

Sudden urge to urinate followed by immediate loss of urine

Question 14

Urge incontinence management

Answer 14

First line = bladder training (Kegels, timed voiding) to help delay micturition

If refractory to LSM –> beta-adrenergic agonists (mirabegron) or antimuscarinics (oxybutynin); postmenopausal women with concurrent vaginal atrophy may benefit from vaginal estrogen

Question 15

T or F: all patients with DM aged 40 or older should be offered statin therapy

Answer 15

True regardless of baseline lipid levels (dose depends on ASCVD risk – < 10% can start with medium intensity, those with > 20% risk should be started on high intensity statin therapy)

Question 16

Ethylene glycol (toxic alcohol metabolized to glycolate – toxic to renal tubules) poisoning presentation

Answer 16

Acute onset of flank pain, gross hematuria, and oliguria + AGMA

Question 17

Causes of anion gap metabolic acidosis (AGMA)

Answer 17

MUDPILES

Methanol
Uremia
DKA
Propylene glycol/paraldehyde
Isoniazid/iron
Lactic acidosis
Ethylene glycol (antifreeze)
Salicylate (aspirin)

Question 18

Postop ileus definition, presentation and management

Answer 18

Delayed return of bowel function > 72 hours after surgery

Presentation: delayed passage of flatus, abdominal distension, vomiting, decreased BS

Diagnosis: abdominal XR (+) uniformly dilated bowel loops (vs discrete transition point in SBO)

Management: conservative (antiemetics, bowel rest, serial examinations) to ensure self resolution; avoid opiates!!

Question 19

Pharmacotherapy for patients with history of previous MI

Answer 19

Betablocker, high intensity statin, DAPT, ACEi/ARB

***EKG finding for previous MI = Q wave, T wave inversions

Question 20

Therapy of choice for preventing VTE in patients with nonvalvular afib

Answer 20

Heparin or TSOACs (i.e. rivaroxaban, dabigatran)

***warfarin preferred in patients with mitral stenosis, prosthetic heart valves, ESRD, and decompensated valvular disease; LMWH preferred in patients with malignancy

Question 21

Causes of hyperactive (“hot”) thyroid nodule on radioiodine uptake scintigraphy

Answer 21

Nodular pattern: Thyroid adenoma, multinodular goiter
Diffuse pattern: Graves

**Thyroid cancers typically have euthyroid levels and are “cold” on scintigraphy
**If left untreated, hyperthyroidism can lead to increased burn turnover rates and eventual osteoporosis, arrhythmias, cardiomyopathy

Question 22

Hyperthyroidism workup

Answer 22

1) Measure TSH, reflex T4
2) Evidence of primary hyperthyroidism – look for clinical signs of Graves, scintigrpahy if these are absent
Evidence of secondary hyperthyroidism (elevated TSH AND T4/T3) – pituitary MRI

Question 23

Esophageal varices management

Answer 23

• Placement of 2 large bore peripheral IVs, IVF administration
• In unresponsive, hemodynamically unstable or low GCS patients: endotracheal intubation to preserve airway
• Type and crossmatch if clinical suspicion for necessary blood transfusion
• EGD as early as possible after patient is stabilized (both diagnostic and therapeutic)

Question 24

Two year old developmental milestones

Answer 24

• Able to say 2 word phrases
• Vocabulary of 50 words
• Strangers able to understand at least half of what they are saying
• Able to run, throw a ball, and copy a straight line
• Stranger anxiety

Question 25

Varicocele increases risk of: A) Chronic epididmyitis B) Infertility C) Intestinal strangulation D) Testicular cancer E) Testicular torsion

Answer 25

B -- and testicular atrophy, can be treated with surgical venous ligation (indicated if signs of infertility or testicular atrophy on semen analysis) A -- arises d/t retrograde flow of urine into epididymis C -- complication of inguinal hernia D -- increased risk with cryptorchidism

Question 26

Red flag features of back pain that warrant further workup (most commonly imaging)

Answer 26

- Sudden onset of pain + spinal tenderness - h/o malignancy or recent infection - Constitutional symptoms (fever, unexplained WL) - Recent trauma - Significant or progressive neurologic deficits (bowel or bladder incontinence, LE weakness) - Persistent nocturnal pain ***emergent/initial MRI indicated for patients with significant neurologic deficits OR those with signs of infection

Question 27

Minimal change disease versus postinfectious GN presentation

Answer 27

Minimal change: heavy proteinuria (3+), more immediate symptom development, hypoalbuminemia, hyperlipidemia, oval fat bodies and hyaline casts (type of NEPHROTIC syndrome) > treat with EMPIRIC STEROIDS (response is usually immediate after first dose) Postinfectious GN: hematuria, HTN, periorbital edema, sx development 2-4 weeks after infection, RBC casts, AKI (MC streptococcal infection, type of NEPHRITIC syndrome -- minor proteinuria)

Question 28

Bulimia nervosa lab findings

Answer 28

Hypokalemic, hypochloremic metabolic alkalosis 2/2 vomiting

Question 29

Pulmonary hypertension auscultation findings

Answer 29

Pulmonic component of S2 louder than aortic + accentuated impulse at L sternal border d/t RV enlargement 2/2 increased pulmonary P (left sternal lift d/t R ventricular heave)

Question 30

T or F: you can see changes 2/2 pulmonary HTN on CXR

Answer 30

False

Question 31

STOP-Bang survey metrics for OSA

Answer 31

Snoring Tiredness (daytime somnolence) Observed apneas or choking/gasping Pressure elevated BMI > 35 Age > 50 Neck size > 17 in for M, > 16 in for F*** Gender (male)

Question 32

Analyzing STOP-BANG scoring to determine OSA workup

Answer 32

< 3 points = low risk, no need for further workup 3-4 points = intermediate risk, order PSG

Question 33

Methods to decrease habitual snoring not suspected to be 2/2 OSA

Answer 33

Decrease alcohol consumption before bed Smoking cessation WL

Question 34

XR findings of Ewing versus osteosarcoma

Answer 34

Ewing = moth eaten appearance of diaphysis described as poorly defined lytic lesion surrounded by concentric layers of bone (often a/w systemic findings) Osteosarcoma = proximal or middle of long bones involved, "sunburst" appearance

Question 35

Cannot miss diagnosis/cause of oculomotor nerve palsy

Answer 35

Enlarging intracranial aneurysm

Question 36

Open globe injury management after emergent optho consult is placed

Answer 36

Placement of eye shield to prevent development of intraocular HTN

Question 37

PJP on CXR

Answer 37

Diffuse interstitial infiltrates

Question 38

Presentation of stroke versus bell's palsy

Answer 38

Stroke SPARES the eyes/forehead -- treat with alteplase if last known well < 3-4 hours ago Bell's palsy INVOLVES the eyes/forehead (aka patients unable to lift/wrinkle when asked) -- treat with prednisone +/- antiherpes medication, can often be a/w a prodrome of auricular pain

Question 39

Esophageal SCC develops in the ______ esophagus versus esophageal adenocarcinoma develops in the ________ esophagus

Answer 39

Upper 2/3; lower 1/3 ***Esophageal SCC RF = smoking, alcohol use, intake of N-nitroso containing foods

Question 40

DIC lab findings

Answer 40

Decreased fibrinogen, thrombocytopenia, and prolonged PT/PTT and elevated bilirubin d/t microangiopathic hemolytic anemia Tx = resuscitate with FFP (contains all clotting factors) and pRBCs

Question 41

What organism causes malaria?

Answer 41

Plasmodium falciparum (identified on blood smear/culture as ring shaped trophozoites within RBCs) Treat with anti-malarials (i.e. chloroquine)

Question 42

SIRS criteria

Answer 42

2 out of 4 of the following: - HR > 90 - WBC > 12 OR < 4 - T > 100.4 OR < 96.8 - RR > 20

Question 43

HIV postexposure prophylaxis

Answer 43

- Most effective if treatment (tenofovir + emtricitabine + raltegravir) administered within 2 hours of exposure (window of treatment initiation is 72 hours) - Treatment taken for 28 days and decreases rate of seroconversion by 50%

Question 44

Lyme disease prophylaxis criteria

Answer 44

Must meet ALL of the following to get prophy with doxy 200 mg x1 dose: - Tick attached for at least 36 hours - Treatment given within 72 hours of removal - No contraindications to doxy (i.e. allergy, < 8 y/o)

Question 45

Initiation treatment regimen for newly HIV positive patients

Answer 45

Two nucleoside and nucleotide reverse transcriptase inhibitors + integrase strand transfer inhibitor

Question 46

Botulism presentation

Answer 46

Caused by clostridium botulinum (which can be consumed in canned foods): - Symmetric descending flaccid paralysis (cranial nerve palsies, dysphagia/slurred speech) - Muscle weakness, loss of DTRs ***particularly common in those who inject heroin ***treat with botulism antitoxin

Question 47

Botulism versus MG

Answer 47

Botulism = post infectious (greater risk with IV heroin use) inhibition of release of ACh resulting in flaccid paralysis MG = autoimmune disorder at postsynaptic junction of ACh receptors (decreases uptake) resulting in descending weakness

Question 48

Best way to prevent HSV transmission in heterosexual, immunocompetent, HSV-discordant couples

Answer 48

Chronic daily suppressive therapy (valacyclovir) b/c it reduces viral shedding (which can occur while asymptomatic)

Question 49

Disseminated gonococcal infection triad

Answer 49

Polyarthralgia Pustular rash (can be on the palms and soles) Tenosynovitis ***many patients have no GU symptoms and often times arthritis is purulent ***secondary syphilis also w/ rash and arthralgia but rash is maculopapular vs vesicular and pustular, and is symmetric

Question 50

Late neurosyphilis/tabes dorsalis findings

Answer 50

Argyll Roberston pupil (d/t spirochetal induced brain damage) - small, irregularly shaped pupils that fail to constrict to light Sensory ataxia, wide based gait, sharp/stabbing pains in extremities, absent DTRs, (+) Romberg ***almost like Parksinson disease but in a younger person

Question 51

Rabies presentation

Answer 51

1-3 months after animal bite: - Nonspecific prodrome (fever, malaise, sore throat) up to 1 week - Pain, tingling or numbness of bite wound (HIGHLY SUGGESTIVE) Followed by development of encephalopathic symptoms: - Liquid aversion/hydrophobia (ALSO HIGHLY SUGGESTIVE) - Aerophobia - Dysautonomia: hypersalivation and drooling, muscle contractions

Question 52

What patients are at risk for anaerobic pneumonia and how do they present?

Answer 52

Pts with chronic alcohol use or dysphagia Pres: FOUL SMELLING SPUTUM!!!

Question 53

Viral versus bacterial conjunctivitis

Answer 53

Viral = bilateral, thin, watery or clear discharge Bacterial = often starts unilateral, thick purulent eye discharge (reaccumulates minutes after wiping it away)

Question 54

Initial presentation of scarlet fever

Answer 54

Development of sx after strep pharyngitis infection > fever, malaise, abdominal pain, sore throat After 1-2 days: scarlet splotch rash on neck, armpits and groin then spreads to rest of the body (circumoral pallor) -- rash can sometimes be called "Pastia lines" (linear petechiae between skin creases)

Question 55

Bacteria a/w diarrhea w/ animal exposure

Answer 55

Campylobacter > bacterial diarrhea = INFLAMMATORY, so you will have elevated leuks and it appears BLOODY, watery

Question 56

"Facial twisting" on physical exam indicates

Answer 56

Facial nerve palsies -- consider Lyme, Bell's palsy, botulism, etc.

Question 57

Timeline of arthritis in Lyme disease

Answer 57

Early on: fever, fatigue, poylarticular, migratory arthralgias Late: polyarticular arthralgia turns into an acute, weight bearing monoarticular inflammatory arthritis (MC in the knee) w/ joint tap showing WBC of ~20,000 (Versus 50+ in septic arthritis)

Question 58

Cryptococcal meningitis big 4

Answer 58

Etiology: infection MC occurs at CD4 < 100 d/t inhalation of bird droppings or contaminated soil Presentation: - meningoencephalitis -- HA, malaise, fever, confusion - pneumonia sx (inf spreads from lungs to CNS, penetrates cerebral capillaries) Diagnostics: - CSF India ink stain (+) spherical yeast with thick polysaccharide capsule Tx: - amphotericin B and flucytosine (initially) - fluconazole (maintenance) after a few weeks of initial treatment

Question 59

T or F: both scabies and varicella can be vesicular/papular

Answer 59

T: but scabies usually is in interdigital spaces with excoriations versus varicella is diffuse

Question 60

Hepatitis C infection diagnostics

Answer 60

Initial = antibody testing Confirm = PCR > start antiviral agents once diagnosis is confirmed

Question 61

Anal pinworms treatment options

Answer 61

OTC = pyrantel pamoate Rx = albendazole or mebendazole

Question 62

Dengue fever presentation

Answer 62

First 3-5 days: fever, myalgias, retro-orbital pain/HA, bleeding complications (i.e. epistaxis) Followed by macular or maculopapular rash > this is when patients ender the critical stage of illness --> can lead to capillary leakage and edema, effusions, hypotension/shock, severe hemorrhage Can see TCP, leukopenia and elevated HCT on labs > supportive care

Question 63

What CD4 count puts you at risk for toxoplasmosis?

Answer 63

CD4 < 100 Presents as disoriented, focal neurologic deficits, multiple ring enhancing lesions on MRI!!!

Question 64

Toxoplasmosis prophylaxis

Answer 64

Bactrim (same as PJP) Transmitted through exposure to raw or undercooked meat, cat litter, or congenital transmission

Question 65

T or F: MAC causes CNS disease

Answer 65

False

Question 66

Congenital toxoplasmosis presentation

Answer 66

TRIAD: intracranial calcifications, chorioretinitis, micro or macrocephaly

Question 67

Cat scratch disease presentation and mgmt

Answer 67

Pres: regional tender lymphadenopathy, skin lesion (erythematous, papular or nodular) Mgmt: azithro (CSD can self resolve in 1-4 months but azithro helps decrease symptom length and severity)

Question 68

MMR vaccination

Answer 68

First dose at 12 months, second at 4-6 y/o

Question 69

Greasy, foul smelling stool + belching and flatulence is a/w

Answer 69

Giardia > protozoal infection, tx = tinidazole (other protozoan infections self resolve but giardia can persist for weeks if left untreated)

Question 70

Cellulitis MC etiologies

Answer 70

Non-purulent = beta hemolytic strep Purulent = staph aureus

Question 71

TST (PPD) threshold for treatment in patients with HIV

Answer 71

>/= 5 mm of induration ***r/o active disease with HPI and CXR (which would be + for cavitary lesions, infiltrate, lymphadenopathy) before starting latent TB treatment w/ 9 months isoniazid + pyridoxine to prevent neuropathy

Question 72

Tetanus method of diagnosis

Answer 72

Clinical -- titers can be drawn but take a while to come back and you want to administer tetanus immunoglobulin ASAP

Question 73

Acetaminophen overdose level and treatment

Answer 73

OD within 4 hours of ED arrival: Tylenol > 200 mg/kg in a single ingestion > administer activated charcoal for GI decontamination OD between 4-24 hours before ED arrival: draw acetaminophen levels to guide treatment Time to presentation unknown: GI decontamination should still be considered Give N-acetylcysteine if 4 hour tylenol levels > 150 to decrease risk of liver damage

Question 74

Malignancy caused by H pylori

Answer 74

MALT (mucosa associated lymphoid tissue lymphoma) > can increase risk of gastric cancer

Question 75

More severe form of impetigo in kids?

Answer 75

Bullous impetigo > vesicles enlarge and form flaccid bullae w clear yellow fluid that later becomes darker and more turbid > rupture and leave behind a brown crust

Question 76

Order of treatment for thyroid storm

Answer 76

1) Propranolol - decrease sympathetic hyperactivity and potential to decrease conversion of peripheral T4 (inactive) to T3 (active) 2) PTU (or MMI) - block thyroid hormone synthesis and peripheral T4 to T3 conversion 3) Potassium iodide - given one hour after PTU to prevent release of stored thyroid hormone 4) Dexamethasone - given d/t concern for adrenal insufficiency and ability to further decrease any peripheral T4 to T3 conversion

Question 77

Osteomyelitis treatment in a HDS patient with h/o SCD

Answer 77

Cefotaxime - covers staph and salmonella (MC pathogen in patients with SCD) Used in conjunction with vanco or clindamycin to get MRSA coverage

Question 78

24 y/o M with rectal pain x4 days that is exacerbated with movement, sitting and defecation. PE notable for swelling and erythema at the anal verge. Rectal exam shows induration that can be palpated through the rectal wall. Most likely diagnosis is... A) Anal fistula B) Internal hemorrhoid C) Perirectal abscess D) Pilonidal cyst

Answer 78

C -- characterized by pain and discomfort with bowel movements A -- presents with persistent, painless, malodorous discharge B -- tender, palpable mass w/ rectal bleeding D -- fluctuant mass located in superior gluteal cleft

Question 79

A 24-year-old man presents for a “cyst” on his neck that recently drained foul-smelling, white, clumpy material and is now slightly sore. A culture of the remaining expressed material returns three days later with no growth. What is the most likely diagnosis? A) Bacterial folliculitis B) Epidermal inclusion cyst C) Furuncle D) Molluscum contagiosum

Answer 79

B -- benign growths of upper portion of a hair follicle that MC develop on the face and trunk, hallmark sign = overlying pore or black comedone A -- many pustules a/w itching and burning in hirsute areas, not one discrete lesion C -- purulent drainage rather than the cheesy drainage seen with epidermal inclusion cyst D -- dome shaped w central umbilication, not confined to hirsute areas and typically don't have pus/debris

Question 80

Colles fracture mgmt

Answer 80

Emergent ortho surg consult in pts who present with acute neuropathy VS placement of sugar tong splint and ortho surg f/u if PE otherwise unremarkable

Question 81

Paronychia presentation

Answer 81

Localized nailfold infection -- Fluctuance at nail fold, pain and swelling of digit

Question 82

Differentiating cryptococcal meningitis versus toxoplasmosis in patients with HIV

Answer 82

Cryptococcal meningitis has associated skin findings/lesions and is preceded by pneumonia like symptoms whereas toxo is not, and crypotococcus infection typically localized to Southwest US

Question 83

MCC of hyperviscosity syndrome

Answer 83

Waldenstrom macroglobulinemia (abnormal synthesis of IgM paraproteins)

Question 84

Treatment mainstay for hemophilia B versus hemophilia A and VwD

Answer 84

Hemophilia B = factor IX concentrate Hemophilia A, vWD = desmopressin (also factor VIII concentrate for hemophilia A)

Question 85

Risk factors for solar/actinic purpura (sun induced damage to connective tissue, minor trauma leading to ecchymosis)

Answer 85

- Blood thinner use - Older age

Question 86

MC CNS tumor site in kids 1-10 years old

Answer 86

Cerebellum -- medulloblastoma, astrocytomas, and ependyomas

Question 87

AC joint separation treatment

Answer 87

Grade I or II - sling and ortho f/u Grade III and beyond - more likely to need surgical management

Question 88

First line treatment for balanitis

Answer 88

topical miconazole > can try oral fluconazole if patients are refractory

Question 89

Narcissistic personality disorder DSM criteria

Answer 89

Pervasive pattern of grandiosity, lack of empathy, and need for admiration ***also often sensitive to criticism and lack insight require to make psychotherapy effective

Question 90

Erythema nodosum pathophys/etiology

Answer 90

Development of painful red to purple (violaceous) subcutaneous nodules due to inflammatory reaction/hypersensitivity after exposure to infection (strep, drugs or systemic disease)

Question 91

What is an empyema

Answer 91

Collection of pus within the pleural space that can develop 2/2 pyogenic bacteria, fungi, parasites or mycobacteria invade

Question 92

Empyema diagnosis confirmed by...

Answer 92

Thoracentesis reveals presence of bacteria on gram stain of pleural fluid (fluid looks purulent and cloudy on gross inspection) Fluid analysis also shows decreased glucose level and leukocytosis

Question 93

Malignant otitis externa treatment of choice

Answer 93

IV cipro (better pseudomonas coverage than vanc)

Question 94

RSV infection typically treated with supportive care (mainstay = supplemental O2), but what can you give in patients with higher risk of complication 2/2 infection (i.e. immunocompromised)?

Answer 94

Ribavirin -- antiviral medication

Question 95

Air conduction > bone conduction with Rinne testing indicates what type of HL?

Answer 95

SNHL -- i.e. excessive noise exposure, cochlear or nerve damage

Question 96

Hill-Sachs lesion is a/w...

Answer 96

Anterior glenohumeral dislocation -- results in a fracture or defect of the posterolateral humeral head (think of the cram the pance photo where man named Antonio is holding an axe and a photo of a bank on top of a hill)

Question 97

MC presentation of Meckel diverticulum

Answer 97

Painless rectal bleeding (confirm dx with technetium scan)

Question 98

Lyme disease treatment in pregnancy

Answer 98

Amoxicillin (500 mg TID x14 days in early Lyme)

Question 99

MCC of toxic megacolon in patients with HIV

Answer 99

CMV

Question 100

Most sensitive imaging modality to r/o cerebral aneurysm?

Answer 100

MRA (angiogram) versus a CT in SAH

Question 101

Chalazion versus hordeolum

Answer 101

Chalazion = hard, focal swelling of upper or lower eyelid --> painless lump Hordeolum = bacterial infection MC at root of eyelash follicle, tender, swollen and erythematous

Question 102

Most sensitive DDH finding in infants < 3 months versus >3 months old?

Answer 102

< 3 months = positive Barlow > 3 months = limited hip abduction (less likely to have a positive Ortolani or Barlow at this age b/c hip joint has likely already stabilized)

Question 103

Mgmt of pinonidal cyst versus ischiorectal abscess

Answer 103

Pilonidal cyst = I&D in the ED Ischiorectal abscess = surgery for operative drainage

Question 104

G6PD PBS findings

Answer 104

Keratocytes, blister cells, Heinz bodies, and polychromatic macrocytes -- indicates oxidative hemolytic process

Question 105

Gold standard for diagnosis renal artery stenosis

Answer 105

Renal angiography

Question 106

Presentation of prepatellar bursitis versus patellar tendonitis

Answer 106

Prepatellar bursitis = space anterior to patella is painful Patellar tendonitis = anterior aspect of patellar tendon is painful (which is slightly inferior)

Question 107

What pathogen is required to develop Kaposi sarcoma?

Answer 107

HHV-8 ***Kaposi common in HIV patients but not required for disease development

Question 108

Is ALP elevated with uncomplicated cholecystitis?

Answer 108

Typically no, since obstruction is localized to the gallbladder only. Think about cholangitis or other complications if ALP is elevated but US/HIDA confirm cholecystitis

Question 109

Hemothorax management

Answer 109

Immediate placement of chest tube -- this is sufficient intervention if VS are stable and output is < 1500 mL If patient is showing signs of hypovolemic shock, persistent hemorrhage ( > 200 mL bloody output for > 2 hrs)OR immediate chest tube output is > 1500 mL --> emergency thoracotomy

Question 110

Which type of lung cancer is a/w hypercalcemia?

Answer 110

Squamous cell THINK: SCa2++mos cell carcinoma/scuamous cell caricnoma, 4 C's of SCC = cigarette smoking, calcium elevation, centrally located, cavitary lesions

Question 111

Risk factors for decreased surfactant production and subsequent dev of hyaline membrane disease/respiratory distress in newborn?

Answer 111

- Prematurity - Uncontrolled diabetes (hyperglycemia decreases cortisol effect leading to decreased surfactant production)

Question 112

Indications where you may want to give medications for flu treatment?

Answer 112

>/= 65 y/o H/o other chronic medical conditions

Question 113

V:Q scan interpretation when evaluating pregnant patients for a PE

Answer 113

High PE pretest probability + a high or low probability of PE on V:Q scan warrants further w/u with CTA Normal V:Q scan + high or low PE pretest probability = effectively rules out PE High probability V:Q scan effectively confirms presence of PE

Question 114

PE treatment of choice in pregnancy

Answer 114

Anticoagulate with LMWH or unfractionated heparin (warfarin CI in pregnancy)

Question 115

Patients with refractory HTN (3+ medications) and RF of obesity, daytime somnolence, should be screened for ____ with ____

Answer 115

OSA; PSG

Question 116

Preoperative recommendations for patients who smoke and are undergoing elective surgery

Answer 116

Smoking cessation ASAP, patients who stop smoking 4-8 weeks before surgery have significantly less pulmonary complications post-op

Question 117

Definition of solitary pulmonary nodule

Answer 117

- Rounded opacity - 3 cm = mass) - Surrounded by pulmonary parenchyma - No associated LN enlargement

Question 118

Workup of confirmed solitary pulmonary nodule on CXR or CT

Answer 118

- Confirm SPN on initial imaging - Look at size --> nodules < 0.6 cm likely benign and generally don't need follow up; nodules > 0.8 cm require additional management - Confirmed SPN > 0.8 cm --> assess pt's malignancy RF (tobacco use, family history of cancer, age, sex, location and appearance of nodule, i.e. calcifications, irregular or spiculated borders) - SPN > 0.8 cm + intermediate or high risk for malignancy > require tissue diagnosis with surgical excision - SPN > 0.8 cm + low risk of malignancy = repeat CT in 3 months

Question 119

Best test to distinguish COPD versus asthma

Answer 119

Spirometry before and after an inhaled bronchodilator ***cannot use subjective symptom relief to albuterol trial as a measurement

Question 120

What treatment decreases length of hospitalization stay for COPD exacerbtion?

Answer 120

Glucocorticoids (systemic) ***still continue prn albuterol and maintenance ipratropium

Question 121

Asbestosis CXR findings

Answer 121

Pleural thickening and bilateral basilar interstitial (aka ground glass) opacities > pleural plaques

Question 122

Asbestos exposure increases risk of developing which malignancies?

Answer 122

- Bronchogenic carcinoma (derived from bronchial epithelium) -- MC but less severe - Mesothelioma, malignancy of pleural lining -- more rare and more severe

Question 123

Chronic cough, focal consolidation or infiltration on imaging, and hilar adenopathy (often in middle or lower lobes) is most c/w

Answer 123

Tuberculosis > can look like PNA on imaging but cough will be unresponsive to antibiotics

Question 124

Pruritic "tapioca grain" appearing lesions (aka tiny fluid filled blisters) is most c/w....

Answer 124

Dyshidrotic eczema ***Tx: high potency topical steroids (i.e. clobetasol) and avoiding water to the area

Question 125

Pulmonary contusion presentation

Answer 125

H/o blunt thoracic trauma followed by immediate development of bruising > later development of dyspnea, tachycardia, hypoxia d/t underlying alveolar hemorrhage (can take up to 24h to accumulate) and edema

Question 126

Pulmonary contusion CXR findings

Answer 126

Initial CXR can be negative d/t delayed accumulation of blood from alveolar hemorrhage Positive findings: Nonlobular opacity on affected side

Question 127

T or F: blunting of costophrenic angle is c/w both hemothorax and pleural effusions

Answer 127

True

Question 128

Subcutaneous crepitus on PE c/w

Answer 128

Pneumothorax or other causes of increased air accumulation

Question 129

Secondary agents for exercise induced bronchoconstriction refractory to prn albuterol/SABA 5-15 min before exercise

Answer 129

Option 1: daily ICS (may be more beneficial in patients with uncontrolled underlying asthma) Option 2: leukotriene receptor antagonists (i.e. montelukast), have a more rapid effect than daily ICS

Question 130

At what age do you perform 5 back blows versus Heimlich for patients who are choking

Answer 130

< 1 y/o = alternating 5 back blows and 5 chest thrusts 1 y/o and above = Heimlich (abdominal thrusts)

Question 131

Congenital diaphragmatic hernia presentation

Answer 131

- S/sx c/w respiratory distress shortly after birth (i.e. nasal flaring, grunting, tachypnea, retractions) - Absent breath sounds on affected side - Barrel chest - Scaphoid abdomen - Imaging findings: intrathoracic bowel loops and displaced cardiac silhouette (pushed towards unaffected side)

Question 132

Flail chest presentation

Answer 132

- Fracture of >/= 3 adjacent ribs in >/= 2 locations create isolated chest wall segment that moves paradoxically in comparison to the remaining rib cage > leads to negative intrathoracic pressure and increased work of breathing - Essentially think respiratory distress + multiple rib fractures

Question 133

Pleural plaques on chest imaging are most c/w which pneumoconiosis?

Answer 133

Asbestosis or asbestos exposure through construction, insulation manufacturing

Question 134

Indication for combination therapy for asthma exacerbation

Answer 134

Moderate to severe presentation (PEF or FEV1 < 40%) - inhaled SABA (albuterol nebs) PLUS ipratropium > decreases risk of immediate hospitalization ***initial asthma exacerbation treatment = albuterol, ipratropium and corticosteroids

Question 135

Biopsy findings for TB versus sarcoid

Answer 135

Sarcoid = noncaseating granulomas TB = caseating granulomas, (+) acid fast bacilli

Question 136

Afib anticoagulant of choice

Answer 136

1st line = eliquis (apixaban) or another DOAC (rivaroxaban, dabigatran, etc.) Warfarin = last resort ***Determine need for anticoagulation with CHA2DS2-VASc score (start AC if >/= 2 in M, >/=3 in F)

Question 137

Aortic dissection CXR findings and management

Answer 137

CXR = widened mediastinum Mgmt = immediate surgical repair, lower BP primarily w esmolol, add sodium nitroprusside if SBP refractory to BBs (>/= 120), morphine for pain control

Question 138

Cardiac tamponade classic triad

Answer 138

JVD, muffled heart sounds, hypotension

Question 139

1st line treatment for asymptomatic LV systolic dysfunction to delay progression into CHF?

Answer 139

ACEi, then add a BB once suitable ACEi dose is established

Question 140

Classic ADR of MAO inhibitors (used for refractory HTN)?

Answer 140

Hypertensive crisis after consumption of tyramine rich foods > tyramine causes increased adrenergic effect

Question 141

Diagnosis and treatment of blunt thoracic aortic injury resulting in an incomplete tear?

Answer 141

Diagnostic gold standard = CTA Management = immediate surgical repair, proceed with immediate thoracotomy +/- TEE in OR if hemodynamically unstable

Question 142

When do you skip LSM as first line management for HTN and go straight to pharmacologic therapy?

Answer 142

If SBP persistently >/= 150 OR SBP >/= 90

Question 143

Cardiovascular changes in pregnancy

Answer 143

- Increased blood volume - Decreased peripheral vascular resistance (leads to increased cardiac output, SV and increased HR)

Question 144

Leaning forward increases intensity of _____ murmurs, L lateral decubitus increases intensity of _______ murmurs

Answer 144

Aortic; mitral

Question 145

Which valvulopathy has highest risk of developing emboli?

Answer 145

Mitral stenosis -- use CHADS-VASc to determine AC need, 1st line for valvulopathy + need for AC = warfarin

Question 146

Are systolic or diastolic murmurs more likely benign?

Answer 146

Systolic, diastolic murmurs are almost always pathologic and require further workup with an echo (TTE)

Question 147

Indications for pacemakers in terms of AV block

Answer 147

Mobitz II, (high likelihood of transitioning to 3rd degree AV block) 3rd degree AV block

Question 148

Presentation of syncope 2/2 cardiac arrhythmia

Answer 148

- No prodromal symptoms, sudden onset of syncope - Occurs while at rest/seated (aka no correlation to change in position) - Evidence of underlying structural heart disease (i.e. murmur on exam, previous MI) - Presence of frequent ectopic beats

Question 149

Best fluids to give for burn patients

Answer 149

LRs -- mimic bodily fluid composition

Question 150

Indication for upright tilt table testing to confirm vasovagal etiology of syncope?

Answer 150

Unclear etiology of syncope -- otherwise it is a clinical diagnosis

Question 151

Best way to definitively diagnose coarctation of the aorta

Answer 151

Echo (CXR not necessary for diagnosis)

Question 152

Distinguishing presentation of pheo versus hyperaldosteronism

Answer 152

Pheo = EPISODIC hypertension, panic attacks (tachycardia + palpitations), HA, diaphoresis Hyperaldo = CONSISTENT hypertension, hypokalemia, hypernatremia

Question 153

TCA overdose presentation

Answer 153

- Anticholinergic toxicity (midriasis, hyperthermia, flushed skin, hypoactive BS) > would NOT see these sx w/ wellbutrin overdose - New onset seizure - Mental status changes (delirium, sedation) - Hypotension - Tachycardia + prolonged QRS

Question 154

Newly diagnosed primary hypertension labs

Answer 154

GOAL: assess for any end organ damage and determine CVD risk - Lipid panel (Assess CVD risk) - UA (look for hematuria or proteinuria as complication of uncontrolled HTN) - CMP - EKG (look for LVH)

Question 155

Hyperkalemia EKG findings

Answer 155

Initial: peaked T waves Progressive worsening: diminished amplitude of P waves, prolonged PR and QRS intervals, and eventual QRS widening with a "sine" wave appearance

Question 156

Metabolic ADRs of thiazide diuretics

Answer 156

Hyponatremia: inhibits NaCl cotransporter in DCT Hypokalemia: compensatory rise in RAAS activation and aldosterone secretion due to lower BP Hypercalcemia: increased reabsorption in DCT Hyperglycemia, hypercholesterolemia: decreased insulin secretion and increased insulin resistance Hyperuricemia: increased reabsorption in PCT

Question 157

Sick sinus syndrome EKG findings

Answer 157

- Bradycardia with dropped P waves - Alternating bradycardia and tachycardia ***abnormality originates in SA node (located in upper R atrial wall)

Question 158

Ezetimibe MOA

Answer 158

Inhibits cholesterol absorption at the brush border of the small intestine Often used for patients who cannot tolerate statins due to myalgias, development of rhabdo, etc.

Question 159

Most effective LSM for managing HTN

Answer 159

Weight loss -- often 2/2 DASH diet and incorporating regular aerobic exercise

Question 160

T or F: BB, ACEi and aldosterone antagonists are first line in ADHF treatment

Answer 160

False -- useful for chronic HF mgmt, but can worsen hemodynamic deterioration in ADHF

Question 161

Treatment for PAD w/o any revascularization versus s/p revascularization

Answer 161

W/o revasc: antiplatelet therapy (aspirin OR clopidogrel) for symptomatic PAD to reduce risk of ischemic stroke, MI, cardiovascular death + statin therapy regardless of BL lipid levels S/p revasc: DAPT

Question 162

MCC of euvolemic hypotonic hyponatremia?

Answer 162

SIADH (can be d/t carbamazepine or other SSRIs)

Question 163

Cardiac output in hypogenic, distributive, obstructive and cardiogenic shock

Answer 163

Cardiogenic, hypovolemic, and obstructive = decrease CO Distributive = increase CO (compensatory due to decreased peripheral vascular resistance)

Question 164

Management of N/V in pregnancy

Answer 164

1) LSM (smaller, less frequent meals and avoided food triggers) 2) Vitamin B6 and doxylamine if refractory 3) Oral dopamine and serotonin antagonists 4) IVF and IV antiemetics 5) Hospitalization -- TPN or tube feeds

Question 165

Blunt abdominal trauma workup

Answer 165

If HDS: FAST > CT CAP if FAST is neg (b/c FAST can miss small or early internal bleeds) and clinical suspicion remains high; serial abdominal exams if clinical suspicion remains low

Question 166

MC complication of blunt abdominal trauma

Answer 166

Splenic rupture (which often causes rib fracture)

Question 167

Are internal or external hemorrhoids classically considered painless?

Answer 167

Internal = painless External = painful

Question 168

Hemolytic uremic syndrome classic presentation/triad

Answer 168

Hemolytic anemia, thrombocytopenia, and renal insufficiency (this is d/t shiga-toxin producing e. coli which primarily causes glomerular and vascular injury)

Question 169

Does salmonella usually cause bloody or non-bloody diarrhea?

Answer 169

Non-bloody, watery diarrhea

Question 170

Intussusception presentation and mgmt

Answer 170

Pres: episodic inconsolable crying (lying with legs drawn to abdomen), lower abdominal tenderness (usually R sided), sausage shaped abdominal mass, currant jelly stool in later stages Mgmt: air contrast enema = both diagnostic and therapeutic (if uncertain, can use US to look for disease, (+) target sign)

Question 171

Abdominal pain + non bloody diarrhea + leukocytosis + pseudomembranes (white-yellow plaques) on colonic mucosa of sigmoidoscopy is most c/w...

Answer 171

Pseudomembranous colitis, aka C. diff post antibiotic exposure

Question 172

IBS treatment

Answer 172

IBS-C: fiber supplementation IBS-D: antidiarrheals (i.e. loperamide)

Question 173

HCV testing interpretation

Answer 173

Screen with HCV antibodies > if positive, get PCR for HCV RNA If antibodies and PCR are positive = indicates chronic HCV infection, refer for treatment If antibodies + and PCR negative = resolved infection (15-40% of cases) or false positive antibody result

Question 174

Pancreatic cancer can cause referred pain to...

Answer 174

Thoracic spine (innervated by splanchnic T5-T11)

Question 175

Presentation of volvulus versus SBO

Answer 175

Volvulus = more insidious onset of generalized abdominal pain, elderly patient likely w underlying malignancy OR chronic constipation SBO = more acute onset of severe abdominal pain, can be seen in younger patients or patients with abdominal surgical history

Question 176

Evaluation of atypical glandular cells (AGC) on Pap

Answer 176

Can be d/t endometrial or cervical adenocarcinoma --> requires f/u colpo, endocervical curettage and endometrial biopsy

Question 177

Pres and treatment of irritant diaper dermatitis versus candida diaper dermatitis

Answer 177

Irritant = SPARES skin folds (i.e. inguinal creases), treat with zinc oxide paste Candida = involves skin folds, treat with nystatin cream

Question 178

Reye syndrome presentation

Answer 178

S/p aspirin use for a viral infection in children: - Encephalopathy (rapid onset) - Acute LFT elevation/hepatic dysfunction - Cerebral edema, increase ICP ***Tx = supportive care

Question 179

AV nicking, arteriolar narrowing, and cotton wool spots on fundoscopic exam indicate

Answer 179

Hypertensive retinopathy

Question 180

Indications to start a 2 drug antihypertensive regimen as first line therapy?

Answer 180

If SBP Is >/= 20 above goal or DBP >/= 10 above goal

Question 181

Secondary syphilis rash versus tinea versicolor

Answer 181

Secondary syphilis = generalized maculopapular rash, diffuse and typically on hands and soles Tinea versicolor = also maculopapular but typically more localized (hyper and hypopigmented lesions often worse during summer months > treat with topical selenium sulfide OR ketoconazole)

Question 182

Swelling iso PICC line placement is more indicative of superficial phlebitis or UE DVT?

Answer 182

UE DVT > but both often have pain and erythema, diagnose with duplex US

Question 183

Cannabinoid ingestion is more a/w tachycardia or bradycardia?

Answer 183

Tachycardia

Question 184

First line pharmacologic intervention for thromboembolism 2/2 afib?

Answer 184

Eliquis

Question 185

Ovarian cyst findings on US

Answer 185

Dermoid cyst (cystic teratoma): heterogenous composition w/ multiple thin, echogenic bands Follicular cyst: simple, small thin walled cyst (hypoechoic d/t being fluid filled) Theca lutein cyst: large, b/l cystic masses > arise from GTN and are therefore a/w elevated b-hCG levels

Question 186

Order of workup if c/f for SAH but cannot rule out meningitis (i.e. pt afebrile but with neck stiffness and pain)

Answer 186

Noncontrast CT brain BEFORE an LP to r/o SAH (more emergent problem) > LP if CT scan negative (+ xanthochromia more c/w SAH, elevated opening pressure, low glucose and elevated protein c/w bacterial meningitis)

Question 187

Physical exam finding very specific to tension pneumo in INFANTS

Answer 187

Bedside transillumination with increased brightness on affected side > indicates need for emergent thoracostomy

Question 188

Alopecia areata first line treatment

Answer 188

Intralesional or topical glucocorticoids

Question 189

Disseminated gonococcal infection (DGI) presentation

Answer 189

Classic triad: migratory asymmetric polyarthralgias, tenosynovitis, pustular skin lesions OR Purulent arthritis (MC knees, ankles, wrists)

Question 190

Fracture of 11th or 12th rib w/ subsequent anterior displacement can lead to...

Answer 190

Kidney laceration (traumatic) > requires an urgent surgery consult

Question 191

When does Babinski reflex disappear in normal development?

Answer 191

~12 months

Question 192

Presentation of constitutional growth delay versus hypogonadotrophic hypogonadism

Answer 192

Constitutional growth delay: short stature but normal growth velocity (4-6 cm/yr) + delayed bone age (versus short stature and normal bone age more c/w familial short stature) Hypogonadotrophic hypogonadism: anosmia + hypogonadotropic hypogonadism, cryptorchidism and micropenis common in affected males

Question 193

Initial evaluation of secondary amenorrhea

Answer 193

b-hCG, and if that is negative > prolactin, FSH/LH, TSH

Question 194

Is an anterior or posterior shoulder dislocation more a/w seizures?

Answer 194

Posterior (seizures and electrocution) > arm held in internal rotation and adduction

Question 195

Narcolepsy first line treatment

Answer 195

Modafinil (psychostimulant that helps with daytime sleepiness)

Question 196

Where does RMSF rash begin?

Answer 196

Distal extremities (INCLUDING palms and soles), then travels centrally

Question 197

Most effective form of emergency contraception

Answer 197

Copper IUD (can be placed up to 120 hours after intercourse), BUT it is CI in pts with active cervicitis/cervical inflammation or pelvic infection > can do levonorgestrel-only pill (aka plan B) as alternative as long as it is within 72 hours of intercourse

Question 198

First line treatment of rosacea

Answer 198

Mild: LSM -- avoid triggers (hot/spicy foods, alcohol, sun exposure) Papulopustular: Topical metronidazole

Question 199

Indications for open reduction and internal fixation

Answer 199

- Significant displacement - Open fractures - Neurovascular compromise

Question 200

Enthesitis is most a/w which rheumatologic disorder

Answer 200

Ankylosing spondylitis

Question 201

What is the figure 8 bandage used for?

Answer 201

Nondisplaced, midshaft clavicular fracture > manage conservatively with a sling and swathe or figure 8 bandage (expect full healing in 6 weeks for kids, 12 weeks for adults)

Question 202

Pencil in cup deformities a/w

Answer 202

Psoriatic arthritis

Question 203

Pinpoint pupils, decerebrate posturing is most c/w intracranial hemorrhage in ...

Answer 203

The pons (this is where the MCA lays)

Question 204

Coadministration of a triptan and ergots (anti-emetics) for abortive migraine therapy may result in

Answer 204

Prolonged vasoconstriction and subsequent MI and/or stroke

Question 205

Psychogenic seizures versus seizures neurologic in origin

Answer 205

Psychogenic = typically occur during wakefulness and have no postictal symptoms -- immediate return to baseline after the episode

Question 206

Presentation of stroke versus Bell's palsy

Answer 206

Stroke = acute onset of sx, spares the eyebrow/forehead movements (able to wrinkle forehead/raise brows) Bell's palsy = gradual onset, unable to move forehead/eyebrow, can have auricular prodromal symptoms (pain or sound distortion)

Question 207

Hemorrhagic stroke in young, otherwise healthy patients with a normal physical exam should be concerning for _____ as underlying etiology

Answer 207

Cocaine use > get urine tox to confirm

Question 208

Which TIA patients should be admitted to the hospital?

Answer 208

Those who present within 72 hours of symptom onset and have an ABCD2 score >/= 3 If ABCD2 score is < 3, obtain basic labs (CBC, CMP, EKG), echo, carotid imaging and brain MRI within 24-48 hours outpatient

Question 209

Acute dystonia etiology

Answer 209

Sustained, involuntary muscle contractions w/ abnormal posturing that commonly develop after exposure to dopamine antagonists

Question 210

Unilateral vs bilateral hilar enlargement on CXR

Answer 210

Unilateral = think malignancy or TB Bilateral = think sarcoidosis

Question 211

Test to check for hyper versus hypofunctioning endocrine disorders

Answer 211

Hyperfunctioning = suppression tests Hypofunction = stimulation tests

Question 212

Best test for confirming acromegaly/gigantism

Answer 212

IGF-1 (GH itself isn't very helpful to measure) > followed by growth hormone suppression test (OGTT) if IGF-1 is very elevated

Question 213

Causes of acquired DI

Answer 213

Lithium, CKD, genetic causes

Question 214

Positive test for nephrogenic DI with desmopression

Answer 214

Administration of desmopressin does not alter urine concentration

Question 215

MEN1

Answer 215

Pancreatic tumors, parathyroid involvement, anterior pituitaryM

Question 216

MEN 2A

Answer 216

Medullary thyroid cancer, pheochromocytoma, parathyroid

Question 217

MEN 2B

Answer 217

Medullary thyroid cancer, pheochromocytoma, Marfanoid habitus, neuromasG

Question 218

Good alternative for patients with true anaphylactic allergy to penicillins

Answer 218

Clindamycin

Question 219

Piptazo has good gram negative coverage PLUS also covers....

Answer 219

Pseudomonas

Question 220

Which 3rd gen cephalosprin crosses the BBB?

Answer 220

Ceftriaxone

Question 221

Augmentin is the PO version of...

Answer 221

Unasyn

Question 222

Antibiotic choice for any bite

Answer 222

Augmentin

Question 223

Erythromycin can cause what in babies if taken by pregnant patients

Answer 223

Pyloric stenosis

Question 224

FQ ADRs

Answer 224

- Tendonitis/tendon rupture - Increased risk of aortic aneurysm or dissection - Peripheral neuropathy - Hypo or hyperglycemia

Question 225

Go to for inpatient MRSA coverage

Answer 225

Vanc, linezolid (outpatient can do bactrim!!!, clinda, or doxy)

Question 226

Metronidazole never given on its own unless you are treating

Answer 226

Vaginitis (BV or trich)

Question 227

Infectious disease MC a/w cyclical fevers

Answer 227

Malaria

Question 228

What virus causes CMV infection?

Answer 228

HHV-5

Question 229

Wernicke encephalopathy triad

Answer 229

Ataxia, confusion, vision changes (MC nystagmus) ***treat with vitamin B1 infusion followed by IV glucose

Question 230

Major risk factors for C diff infection

Answer 230

Age > 65 Recent antibiotic use (clinda = big culprit) Gastric acid suppression

Question 231

Ischemic colitis versus chronic mesenteric ischemia presentation

Answer 231

Ischemic colitis = rapid onset of bloody diarrhea, tenesmus chronic mesenteric ischemia = slow onset, atherosclerosis induced, benign abdominal exam, no N/V

Question 232

Multinucleated giant cells on labs c/w

Answer 232

HSV

Question 233

Contraindications to TRT

Answer 233

- Prostate or breast cancer - Unstable HF - Polycythemia - Severe LUTS - Untreated OSA ***TRT really only indicated in men with s/sx of androgen deficiency, not just generalized sx

Question 234

Which anti-arrhythmic can cause thyroid dysfunction?

Answer 234

Amio d/t its iodine component -- can cause hyper or hypothyroidism and thus TFTs should be checked prior to starting and throughout therapy

Question 235

MC viral cause of dilated cardiomyopathy

Answer 235

Coxsackie virus

Question 236

Best SSRI for breastfeeding

Answer 236

Sertraline (also ok in pregnancy)

Question 237

How do you approach switching SSRIs when trialing treatment?

Answer 237

Want to try highest dose of SSRI before saying it does not work for patient Do not have to trial ALL SSRIs before switching to SNRIs

Question 238

Acute bronchitis sx + watery eyes and rhinorrhea, think...

Answer 238

Adenovirus

Question 239

Bullous myringitis is a/w

Answer 239

Mycoplasma pneumonia

Question 240

MCC pneumonia in kids

Answer 240

< 1 y/o = RSV > 1 y/o = viral causes

Question 241

Patients s/p splenectomy are at risk for infection by what organisms?

Answer 241

Encapsulated organisms: Yes, Some Killer Bacteria Have Pretty Nice Capsules Yersinia pestis Streptococcus pneumoniae Klebsiella pneumoniae Bacillus anthracis Haemophilus influenzae Pseudomonas aeruginosa Neisseria meningitidis Cryptococcus neoformans

Question 242

Pink frothy sputum and hypoxia a/w

Answer 242

Pulmonary edema (usually d/t ARDS)

Question 243

Horner's syndrome presentation

Answer 243

Ptosis, miosis, anhidrosis

Question 244

Most modifiable risk factor for cerebral aneurysms

Answer 244

Smoking ***biggest RF in GENERAL (including non-modifiable) = genetics

Question 245

GCS score indicative of need for intubation

Answer 245

< 8

Question 246

Basilar skull fracture presentation

Answer 246

Postauricular ecchymoses (Battle sign) Periorbital ecchymoses (raccoon eyes) CSF otorrhea/rhinorrhea Blood in EAC CN injury ***antibiotic prophy still not supported

Question 247

Alzheimer's is due to buildup of...

Answer 247

Amyloid plaques > leads to decreased acetylcholine release

Question 248

Brown sequard spinal cord injury

Answer 248

Damage to half of the spinal cord causes: - Loss of pain and temp sensation on contralateral segment 1-2 levels below the traumatic lesion - Loss of vibration/position, motor function on ipsilateral side at the level of the lesion - Ipsilateral spasticity

Question 249

Conus medullaris versus cauda equina

Answer 249

Presentation: - Conus medullaris: loss of bowel and bladder function, hyperreflexia (b/c this is a LMN lesion), + Babinski - Cauda equina: also loss of bowel and bladder function, saddle anesthesia, loss of DTRs, - Babinski (which is normal), and muscle strength depleted

Question 250

Positional HA that worsens with sitting or standing and improves with laying down is most likely d/t

Answer 250

Postdural puncture HA (i.e. after an epidural is placed)

Question 251

Headache prophylaxis

Answer 251

Cluster: Verapamil > lithium Mirgaine: propranolol, topiramate Tension: TCAs (i.e. nortriptyline, amitriptyline)

Question 252

18 y/o F on OCPs presents with reccurrent daily migraines (4x a month). She has no other chronic medical conditions. VS and PE are normal. Which of the following is the next best step in management? A) Begin SSRIs B) D/c OCPs C) Prescribe daily propranolol therapy D) Prescribe daily topiramate therapy E) Reassure and advise NSAIDs prn

Answer 252

B -- pts with migraines are at increased risk of stroke, especially if on OCPs, so these must be stopped IMMEDIATELY A -- SSRIs are not used for migraine tx C -- good for prophylaxis, which typically starts after pts have 5 or more migraines/month D -- 2nd line to propranolol as prophy E - inappropriate management of migraines

Question 253

T or F: propranolol is the only BB used as migraine prophylaxis

Answer 253

FALSE -- metoprolol also acceptable

Question 254

Innervation of perianal area (sensory)

Answer 254

S4 nerve root

Question 255

Sensory nerve root of dorsal surface of feet

Answer 255

L5

Question 256

Sensory nerve root of genitalia

Answer 256

S2 and S3

Question 257

Sensory nerve root of posterior thighs and calves

Answer 257

S1 and S2

Question 258

When is an EMG indicated in working up carpal tunnel?

Answer 258

If sx are refractory to splinting for 6 weeks

Question 259

What test is used to distinguish the etiology of ataxia?

Answer 259

Romberg -- if positive, indicates sensory ataxia (i.e. syphilis, B12 def, ADR of isoniazid). If negative (aka unsteady even when eyes are open), indicates cerebellar ataxia

Question 260

What aspect of the nerve does GBS damage?

Answer 260

Peripheral nerve fibers (immune mediated damage)

Question 261

Femoral nerve sensory and motor functions

Answer 261

Sensory: anterior thigh and medial leg Motor: knee extension and hip flexion

Question 262

Presentation of hip fracture

Answer 262

Shortened, abducted and externally rotated extremity

Question 263

Common manifestations of a FOOSH

Answer 263

- Scaphoid fracture - Colles fracture - Ulnar styloid fracture - Supracondylar humeral fracture - Posterior glenohumeral dislocation

Question 264

Physical exam findings of anterior shoulder dislocation versus AC joint subluxation

Answer 264

Anterior shoulder dislocation = flattening of deltoid, axillary fullness, weak abduction and loss of lateral shoulder sensation AC joint subluxation = downward force causes swelling and upward displacement of the clavicle

Question 265

Ganglion cyst management

Answer 265

Asymptomatic = observation Symptomatic = needle aspiration/drainage (recurrence post procedure is common, may require eventual surgical excision)

Question 266

What is gamekeeper's skier's thumb?

Answer 266

Avulsion fracture at the base of the proximal phalanx of the first digit

Question 267

Risk factors for developing Dupuytren's contracture (aka trigger finger)

Answer 267

- Diabetes mellitus!!! - Age > 50 - Male - Family history

Question 268

Potential complication of supracondylar fracture

Answer 268

- Compartment syndrome - Brachial artery injury - Median nerve injury

Question 269

Physical exam deficits seen with patellar tendon rupture

Answer 269

Unable to actively extend knee or maintain a straight leg during hip flexion High riding patella on PE and XR

Question 270

Physiologic genu valgum presentation (aka physiologic knock knees)

Answer 270

- Age 2-6: knees deviate towards midline - Normal height - No significant pain or difficulty ambulating - No medial thrust

Question 271

Ottawa ankle rules

Answer 271

XR ankle required IF: Pain at malleolar zone AND... - Tender at posterior margin/tip of medial malleolus, OR - Tender at posterior margin/tip of lateral malleolus, OR - Unable to bear weight 4 steps XR foot required IF: Pain at midfoot zone AND... - Tender at navicular bone, OR - Tender at the base of the 5th metatarsal, OR - Unable to bear weight 4 steps ***if these are cleared, then ok to proceed with bracing, low likelihood of fracture

Question 272

Signs of more pathologic causes of extremity pain versus growing pains

Answer 272

Red flags: - Unilateral or progressive pain - Joint involvement - Systemic sx (aka B sx) - Abnormal physical exam

Question 273

Casting for non-displaced, stable Jones fractures

Answer 273

Non-weight bearing short leg cast

Question 274

Complications of SALTER III and IV fractures

Answer 274

- Increased risk of growth arrest and subsequent limb length discrepancy - Premature OA - Decreased ROM

Question 275

+ cross body adduction test (passive adduction of arm over torso elicits pain over superior shoulder) indicates what

Answer 275

AC joint sprain

Question 276

Retrograde and anterograde amnesia with preserved remote, long term memory; confabulation, apathy and lack of insight iso chronic alcohol use disorder should make you think...

Answer 276

Korsakoff syndrome -- like Wernicke encephalopathy except due to prolonged thiamine deficiency iso alcohol use disorder

Question 277

Lab workup for first time seizure in an adult

Answer 277

Rule out metabolic and toxic etiologies: - CMP (hypoglycemia, lytes) - CBC - Urine tox - Urgent CT head to r/o life threatening bleeds or masses If initial eval is unremarkable > proceed with MRI of head

Question 278

MCC of bacterial meningitis

Answer 278

Strep pneumo

Question 279

What risk factor has the strongest association with both ischemic and hemorrhagic stroke?

Answer 279

HTN

Question 280

Congenital rubella presentation

Answer 280

Fetal death, preterm delivery, congenital defects

Question 281

Antibiotic coverage for "fight bite" a/w Boxer's fracture

Answer 281

Augmentin (cover for oral flora/anaerobes)

Question 282

What does a sail sign/fat pad on XR indicate?

Answer 282

Elbow effusion > most likely a radial head fracture but could also be distal humerus fracture

Question 283

MC location for herniated disc

Answer 283

L5-S1

Question 284

NEXUS criteria for C spine imaging

Answer 284

No CT required if... - Pt is alert - No LOC - No intoxication - No focal neuro deficits - No other distracting injuries - No midline spinal tenderness

Question 285

Pencil in cup deformities a/w

Answer 285

Psoriatic arthritis

Question 286

First line pharmacotherapy for fibromyalgias

Answer 286

TCAs ***NSAIDs are not useful!!!

Question 287

Anticentromere and anti-topo isomerase (aka anti scl 70) association

Answer 287

Centromere = CREST syndrome, limited scleroderma Topoisomerase = diffuse scleroderma

Question 288

Arrhythmia associated with late stage Lyme disease

Answer 288

AV blocks (usually 2nd degree)

Question 289

Definition of VT storm

Answer 289

3 or more episodes of VT in 24 hours

Question 290

Indication for DAPT in CAD/CHD patients

Answer 290

Patients s/p PCI ACS patients Usually started on aspirin + Plavix

Question 291

First line therapy to reduce anginal episodes and improve exercise tolerance for CHD

Answer 291

Beta blockers

Question 292

ACS medical therapy

Answer 292

- 325 mg chewed aspirin STAT - 0.4 mg nitro q5 min x3 doses (assess BP and pain to decide if there is a need for IV nitro) - Beta blockers: oral or IV - Statins: initiate high dose statin as early as possible (atorvastatin 80 mg, rosuvastatin 40 mg) - AVOID MORPHINE - DAPT (aspirin + P2Y12 inhibitor -- Plavix, Ticagrelor) - Anticoagulant: started ASAP after diagnosis (UFH, enoxaparin, or bilvarudin)

Question 293

Jones criteria for acute rheumatic fever

Answer 293

Need 2 major or 1 major and 1 minor: Major: polyarthritis, syndenham chorea, subcutaneous nodules, carditis, erythema marginatum Minor: elevated ESR/CRP, fever, arthralgias, prolonged PR on EKG

Question 294

Criteria for elective aortic aneurysm repair

Answer 294

> 5.5 cm OR > 1 cm growth/year

Question 295

Ideal lipid panel goals

Answer 295

Total cholesterol < 200 TG < 150 LDL < 100 HDL > 40 (M), > 50 (F)

Question 296

Niacin used for...

Answer 296

Raising HDLs Classic ADRs: flushing/hot flashes, pruritus

Question 297

Cotreatment guidelines for chlamydia and gonorrhea

Answer 297

If chlamydia has not been excluded in someone + for gonorrhea > treat for both! ***treat partners, and no sex for 7 days after therapy

Question 298

Absolute CI to OCPs

Answer 298

- H/o clots - Smoker > 35 y/o - Known or suspected pregnancy - Coronary occlusion - Congenital hyperlipidemia

Question 299

Presentation of neurogenic claudication versus cardiovascular claudication

Answer 299

Neurogenic (aka related to spinal stenosis): - Posture dependent pain - Worsened pain with lumbar extension - Pain relief with lumbar flexion - LE numbness and tingling - LE weakness - LBP - Dx: MRI spine Cardiovascular: - Exertionally dependent - Pain relieved with rest but not with bending forward while walking - LE cramping/tightness - No significant LE weakness - Possible buttock, thigh, calf, or foot pain - Decreased pulses, cool extremities, pallor w/ leg elevation - DX: ABI

Question 300

Unique characteristics of perioral dermatitis

Answer 300

- SPARES the vermilion border and does NOT respond to steroids, PO or topical (versus all other types of dermatitis are responsive to steroids)

Question 301

Plummer vinson syndrome

Answer 301

IDA, dysphagia, esophageal web

Question 302

Does folate or B12 deficiency cause neuro sx?

Answer 302

B12

Question 303

Lobar involvement of centriacinar versus panacinar emphysema

Answer 303

Centriacinar = upper lobes (tobacco-related emphysema) Panacinar = lower lobes (alpha 1 antitrypsin)

Question 304

Post-op atelectasis prevention strategies

Answer 304

Postoperative deep breathing exercises (i.e. incentive spirometry)

Question 305

Ramsay Hunt syndrome presentation

Answer 305

Ipsilateral facial paralysis, ear pain and vesicles in auditory canal and/or auricle

Question 306

When would a chest tube be indicated for pleural effusion treatment?

Answer 306

If paracentesis fluid eval shows + gram staining > indicates development of empyema which requires CT drainage

Question 307

Indications for antibiotic therapy in COPD exacerbation

Answer 307

- Moderate to severe exacerbation (increased sputum purulence) - Mechanical ventilation requirement **mainstay of therapy = glucocorticoids, supplemental O2, bronchodialtors

Question 308

Ototoxic medications

Answer 308

- High dose aspirin - NSAIDs - Aminoglycosides - Loop diuretics - Quinine - Chemotherapy agents

Question 309

Vestibular neuritis is like labyrinthitis but without ______

Answer 309

Hearing loss

Question 310

Is minimal change disease nephritic or nephrotic?

Answer 310

MC cause of nephrotic syndrome in kids

Question 311

Patients who take chronic opioids and have a high pain tolerance are at risk for what acid-base disturbance?

Answer 311

Respiratory alkalosis 2/2 hyperventilation w/ inadequate pain control

Question 312

Clinical presentation of compartment syndrome

Answer 312

- Pain on passive ROM - Paresthesias (early on) - Rapidly increasing and tense swelling - Pain out of proportion to injury (SEVERE PAIN) - Less common: decreased sensation, motor weakness, paralysis, decreased distal pulses

Question 313

Growing pain presentation

Answer 313

NONPROGRESIVE, episodic b/l leg pain that occurs during the evening or at night w/ a normal PE

Question 314

Best way to utilize FRAX score?

Answer 314

Used in patients with osteopenia to predict probability of 10-year fracture risk > start antiresorptive therapy in patients with >/= 3% chance of hip fracture, or >/= 20% chance of major osteoporotic fracture

Question 315

Labs for statin myopathy

Answer 315

Normal ESR, elevated CK

Question 316

sJIA clinical presentation

Answer 316

- Chronic oligoarthritis - Daily fevers (quotidian) - Rash (pink macular rash that worsens during the day) - Hepatosplenomegaly, lymphadenopathy - Labs: leukocytosis, thrombocytosis, elevated inflammatory markers ***no fever or rash in poly or oligoarticular JIA

Question 317

Paget's disease of the bone imaging findings

Answer 317

Lytic lesions, thickening of cortical and trabecular bone, and bony deformities

Question 318

Tophi findings /description on XR

Answer 318

Soft tissue mass and bone erosions with overhanging edges of cortical bone

Question 319

Presentation of neuropathic ulcers (versus arterial)

Answer 319

Located on weight bearing surfaces (plantar), lack of pain

Question 320

Drug induced SLE presentation

Answer 320

Like SLE but without renal or CNS involvement (will have positive anti-histone antibodies) ***common drugs = procainamide, hydralazine, isoniazid (THINK: HIP)

Question 321

Oligoarticular JIA complications

Answer 321

Uveitis > regular ophtho screening exams

Question 322

Fluid of choice for rhabdo treatment

Answer 322

0.9% NS (want to avoid hypotonic solutions d/t risk of hyponatremia, and 0.45% NS with 5% dextrose is rapdily metabolized to become effectively hypotonic)

Question 323

Indication for checking serum FSH, TSH in patients with vasomotor menopause symptoms

Answer 323

Vasomotor sx + age need to evaluate for other causes of amenorrhea such as primary ovarian insufficiency, hyperthyroidism

Question 324

Tubo-ovarian abscess description on US

Answer 324

Multiloculated adnexal mass with thick walls and internal debris

Question 325

Presentation of rectocele versus posterior subserosal uterine leiomyoma

Answer 325

Both with disrupted bowel habits (i.e. constipation, tenesmus) but subserosal leiomyomas are a/w UTERINE ENLARGEMENT

Question 326

LFT abnormality a/w hyperemesis gravidarum

Answer 326

Minor aminotransferase elevations (plus hypochloremic metabolic alkalosis)

Question 327

Live vaccines CI in pregnancy

Answer 327

MMR, varicella, intranasal influenza, HPV

Question 328

Mgmt of preX with severe features

Answer 328

Maternal risks outweigh benefits at 34 weeks GA > admit for IV mag, antihypertensive therapy (IV labetalol or nifedipine) and induction PreX with SF < 34 weeks can undergo expectant mgmt while admitted

Question 329

What is Asherman syndrome?

Answer 329

Formation of intrauterine adhesions following intrauterine surgery d/t complete or partial endometrial ablation > becomes a structural cause of amenorrhea (dx and tx with hysteroscopy, which can lyse any adhesions)

Question 330

Absolute CIs to combinced OCPs?

Answer 330

- Age >/= 35 + smkoing - Migraine with aura - <3 weeks postpartum - H/o stroke, thromboembolic disease - H/o antiphospholipid syndrome - Breast cancer - HTN >/= 160/100

Question 331

First line treatment for cholestasis of pregnancy

Answer 331

Ursodeoxycholic acid + delivery at 37 weeks GA

Question 332

Considerations for MTX vetrsus surgical mgmt of ectopic pregnancy

Answer 332

Hemodynamic instability, hCG > 5000, or not an MTX candidate (liver/renal/pulmonary disease, poor adherence, immunodeficiency) = surgical mgmt Can otherwise be managed with MTX with serial hCG measurements to ensure it is declining appropriately

Question 333

When is TIPS (transjugular intrahepatic portosystemic shunting) performed?

Answer 333

If ascites is refractory to medical therapy (diuretics, paracentesis) OR ongoing variceal bleeding

Question 334

T or F: MASLD is a risk factor for development of acute hepatitis

Answer 334

FALSE -- MASLD is an indolent process, more at risk for cirrhosis versus acute hepatitis

Question 335

Which of the following would most likely lead to a decrease in both liver inflammation and portal pressure in the setting of acute decompensated cirrhosis? A) ACEi B) BBs C) Complete abstinence from alcohol D) Diuretic therapy E) Large volume paracentesis

Answer 335

C A -- should be avoided in cirrhosis patients b/c they prevent RAAS activation for compensation of hypotension B -- used to prevent bleeding in patients with KNOWN varices, but should be avoided in pts with unknown variceal status D and E-- improve ascites but don't help with inflammation

Question 336

Most sensitive and specific test for diagnosing HSV?

Answer 336

Viral PCR assay (viral culture of active lesions can be used but not as sensitive)

Question 337

Clinical manifestations of typhoid

Answer 337

Week 1: rising fever, bacteremia, relative bradycardia Week 2: abdominal pain, rose spots (salmon colored macules) on trunk Week 3: hepatosplenomegaly, intestinal bleeding and perforation

Question 338

Grouped, shallow ulcers (can be vesicular or pustular) with an erythematous base should make you think

Answer 338

HSV

Question 339

Hallmark features of TORCH infections

Answer 339

Toxoplasmosis: chorioretinitis, micro or macrocephaly, diffuse intracranial calcifications Other (Syphilis): rhinorrhea, skeletal anomalies, desquamating rash on palms and soles Rubella: cataracts, heart defects(PDA), SNHL CMV (MC worldwide): SNHL, microcephaly, periventricular calcifications HSV: vesicular/ulcerative rash ***nonspecific findings of TORCH infections include fever, jaundice, blueberry muffin rash

Question 340

When is prophylactic augmentin indicated for animal bites?

Answer 340

- Bite on hands and/or feet - Bite near bone or joints, lymphatics or blood vessels - Bites requiring surgical repair - Bites that are deep and penetrating

Question 341

Prophylaxis indications for neisseria meningitidis

Answer 341

Prophylactic rifampin in: - Household members - roommates or intimate partners - Childcare center workers - People with direct exposure - Person seated next to affected person for >/=8 hours

Question 342

How long does a tick have to be attached before transmission of Lyme disease occurs?

Answer 342

At least 48-72 hours ***attachment for < 36 hours = no prophylaxis required

Question 343

Infectious gastroenteritis symptoms + positive peripheral eosinophilia on CBC = ???

Answer 343

Intestinal helminth infection > treat with oral albendazole

Question 344

What classes of diabetes medications are most a/w weight gain

Answer 344

Sulfonylureas Insulin TZDs THINK: if you SIT, you will get fat

Question 345

What medication most commonly causes SIADH?

Answer 345

Carbamazepine

Question 346

Historical findings of familial short stature

Answer 346

Height

Question 347

AMS, volume depletion, and polyuria iso T2DM should raise flags for

Answer 347

HHS ***tx = volume resuscitation with isotonic saline, AVOID correction of hyperkalemia as these patients are truly potassium deficient but show hyperK on labs due to compensation

Question 348

Cushing syndrome versus disease

Answer 348

Syndrome = excess cortisol production from adrenal itself, excess exogenous steroid use Disease = excess cortisol 2/2 pituitary adenoma Pres: - Central obesity - Proximal muscle weakness - Skin atrophy and wide, purple striae - HTN - Insulin resistance - Skin hyperpigmentation and androgenetic symptoms if ACTH in excess - Depression, anxiety

Question 349

Iodine uptake for thyroiditis

Answer 349

Diminished b/c hyperthyroidism in thyroiditis is 2/2 destruction of the gland and susbequent release of prestored hormone

Question 350

Labs to check for recurrent medullary thyroid cancer s/p thyroidectomy

Answer 350

Serum calcitonin (also checked at diagnosis to correlate risk of metastasis) b/c MTC arises from calcitonin-secreting parafollicular C cells

Question 351

Acromegaly treatment options

Answer 351

Surgical removal of pituitary adenoma if applicable Somatostatin analogues (octreotide) or growth hormone receptor antagonists (pegvisomant)

Question 352

hyperpigmentation and androgenetic symptoms in patients with Cushing symptoms is more c/w ACTH independent/dependent Cushing's

Answer 352

ACTH dependent -- ACTH acts on melanocytes and increases androgen activity

Question 353

When do you correct hyponatremia with hypertonic saline versus fluid restriction?

Answer 353

In severe cases where hyponatremia has led to cerebral edema (i.e. results in focal neuro deficits, tonic-clonic seizures) > requires more urgent treatment d/t risk of brainstem herniation

Question 354

Reidel thyroiditis etiology and presentation

Answer 354

Etiology: chronic fibrosis of thyroid leading to slowly progressive thyroid enlargement Pres: compressive sx with enlargement -- hoarseness, dysphagia, and a painless, hard and fixed thyroid nodule

Question 355

Subacute thyroiditis treatment

Answer 355

Symptomatic relief: - In hyperthyroid phase: beta blockers, NSAIDs - In hypothyroid phase: supplementation

Question 356

Fluids used in DKA treatment

Answer 356

NS (0.9%) + regular insulin for the first 1-2 hours to restore intravascular volume, then switch to 0.45%

Question 357

Cardiac complications of acromegaly

Answer 357

LVH, diastolic dysfunction, and possible HF

Question 358

Why do we avoid PTU after 1st trimester of pregnancy?

Answer 358

Maternal hepatotoxicity (MMI has teratogenic affects in 1st tri, including aplawsia cutis, esophageal atresia, and facial anomalies)

Question 359

Process of reversing anticoagulation in patients on warfarin who need urgent procedures

Answer 359

1) D/c warfarin immediately 2) Start prothrombin complex concentrate (contains vitamin K codependent factors) > this is more effective than FFP 3) IV vitamin K for synthesis of new vitamin K dependent clotting factors (II, VII, IX, X)

Question 360

How do you confirm and stage Hodgkin's lymphoma?

Answer 360

Confirm w/ tissue from excisional lymph node biopsy Stage with PET of CAP

Question 361

Is B12 or folate deficiency more a/w neuro sx + macrocytic anemia?

Answer 361

B12

Question 362

Chronic alcoholism causes deficiency in B12/folate quicker

Answer 362

Folate

Question 363

Helmet cells (aka schistocytes) on PBS should make you think of...

Answer 363

Traumatic microangiopathic hemolysis (i.e. DIC, HUS, TTP)

Question 364

Does vWF impact PT or PTT?

Answer 364

PTT -- factor VIII part of the intrinsic clotting cascade (extrinsic is just III, VII)

Question 365

Diagnosis of acute drop in hemoglobin, low retic count and no splenomegaly in a patient with SCD

Answer 365

Aplastic crisis (sudden halt in erythropoiesis), Mc d/t parvovirus B19

Question 366

+ terminal deoxynucleotidyl transferase on analysis of blasts from a peripheral smear

Answer 366

Indicates the blasts are lymphocytes > think ALL

Question 367

How do platelet counts in ITP compare to vWF?

Answer 367

ITP has severely low platelets, vWF with normal or mildly decreased TCP (and these patients usually have family history of bleeding)

Question 368

Classic hereditary hemochromatosis triad

Answer 368

Cirrhosis Skin hyperpigmentation Diabetes mellitus THINK: "bronze diabetes" ***can also see arthropathy, cardiac disease (conduction disorders, HF)

Question 369

Argatroban and dabigatraban MOA

Answer 369

Direct thrombin inhibitors

Question 370

Graham Steell murmur is...

Answer 370

Pulmonary regurg

Question 371

Preferred pharmacologic agent for rhythm conversion in HDS monomorphic v tach

Answer 371

Amiodarone IV

Question 372

ACLS treatment algorithm of adult tachycardia with a pulse

Answer 372

Sinus tach - treat underlying cause Hemodynamic instability present - synchornized cardioversion Widened QRS - if yes, pharmacologic conversion of vtach if HDS, defibrillate if pulsess v tach or v fib; if no, convert afib/aflutter or pSVT as appropriate (i.e. rate control with diltiazem, adenosine respectively)

Question 373

When do you use cilostazol for PAD?

Answer 373

Continued claudication even after being put on statins and aspirin

Question 374

QT prolonging agents

Answer 374

Anti-emetics FQs SSRIs (esp citalopram) TCAs Antipsychotics Diuretics d/t electrolyte imbalances

Question 375

SIDS risk factors

Answer 375

Maternal smoking Sleep positioning - avoid side and prone sleeping

Question 376

EOM innervation

Answer 376

Superior oblique = trochlear Lateral rectus = abducens Everything else = oculomotor THINK: SO4 LR6

Question 377

Superior oblique ocular muscle causes what movement of the eye?

Answer 377

Internal rotation and depression

Question 378

Temporal lobe blood supply

Answer 378

MCA

Question 379

Manifestations of MCA infarct/ischemia

Answer 379

Speech difficulties UE weakness Hemineglect and homonymous hemianopsia

Question 380

Hallmark of myasthenia gravis symptoms

Answer 380

Fluctuating and fatigable proximal weakness that WORSENS LATER IN THE DAY (myasthenia gravis LOVES resting) Sx include: ptosis, diplopia, dysphagia, dysarthria

Question 381

Treatment of myasthenia crisis

Answer 381

IVIG and plasma exchange (help neutralize acetylcholine receptor autoantibodies)

Question 382

Are nerve conduction studies helpful in diagnosing cervical radiculopathy?

Answer 382

No, b/c origin of symptoms is proximal to DRG so nothing will show up on EMG > diagnose with MRI cervical spine

Question 383

MS causes sensory/motor dysfunction

Answer 383

BOTH -- autoimmune demyelinating disease of both the CNS and PNS > diagnose with MRI brain (+ multiple ovoid, subcortical white matter lesions in CNS)

Question 384

MMSE score concerning for dementia

Question 385

At what age do you add ampicillin for empiric listeria coverage iso meningitis?

Answer 385

> 50 y/o

Question 386

Tool used to determine need for pediatric head imaging s/p trauma

Answer 386

PECARN rules < 2 y/o: image if AMS, LOC, severe MOI, nonfrontal scalp hematoma, palpable skull fracture 2 and older: image if AMS, LOC, severe MOI, vomiting, severe HA, basilar skull fracture Imagine with CT noncontrast of head Alternative option to observe for 4-6 hours if mental status is normal and there are no signs of basilar fracture

Question 387

What nerve is responsible for the jaw jerk reflex

Answer 387

Trigeminal

Question 388

Where is the most common location for lung cancer to metastasize to?

Answer 388

Brain

Question 389

Clinical features of lacunar infarct

Answer 389

Contralateral: - Pure hemiparesis (MC) - Pure sensory loss - Ataxic hemiparesis

Question 390

Open globe injury management

Answer 390

IV abx eye shielding CT eye to assess for intraocular FBs emergent ophtho consult for surgical repair!!! (this needs to be done FIRST before any of the above)

Question 391

Recommendation for visual acuity screening

Answer 391

Every child aged 3-5 should have at least one vision screen (can lead to permanent vision loss if left untreated by age 7-8)

Question 392

Painful vision loss + mid-dilated pupil nonreactive to light should make you think

Answer 392

Acute angle closure glaucoma

Question 393

Meds to AVOID during acute angle closure glaucoma

Answer 393

Anticholinergics (including atropine, ipratropium) Pseudoephedrine containing products ***these all cause midriasis which can worsen intraocular pressure

Question 394

Differentiating episcleritis versus anterior uveitis

Answer 394

Anterior uveitis more painful, episcleritis more a/w erythema and tearing, no vision impairment

Question 395

Hordeolum treatment

Answer 395

Warm compresses, symptom management ***topical antibiotics cannot penetrate the abscess/stye, I&D if no improvement after 2 weeks

Question 396

Pterygium versus pinguecula

Answer 396

Pterygium = triangular fibrous overgrowth over iris Pinguecula = fibrous deposit, spherical, limited to sclera/conjunctiva

Question 397

CSF rhinorrhea presentation, workup and management

Answer 397

Clear, watery, unilateral rhinorrhea with a salty or metallic taste Workup: CSF-specific protein testing (beta-2 transferrin, beta-trace protein), imaging with intrathecal contrast, and endoscopy Management: bed rest, head of bed elevation, avoidance of straining > lumbar drain placement and surgical repair

Question 398

Oral leukoplakia risk factors

Answer 398

Tobacco Alcohol ***need biopsy to confirm diagnosis, treatment is d/c tobacco and alcohol use, +/- surgical excision

Question 399

Most likely diagnosis if pt presents with unilateral, purulent, malodorous discharge

Answer 399

Nasal foreign body insertion > confirm diagnosis (after suctioning nasal secretions) by proper visualization of the posterior nasal cavity , can remove object with positive nasal pressure (sneezing) or mechanical extraction

Question 400

Do you performen cerumen removal in asymptomatic patients?

Answer 400

No, no harm in cerumen impaction if it is not disrupting their hearing abilities (if symptomatic, can do irrigation, cerumenolytics and/or manual disimpaction with a curette

Question 401

Weber and Rinne interpretations

Answer 401

Weber: lateralize to affected ear = CHL; lateralize to unaffected ear = SNHL Rinne: AC > BC signals normal conduction or SNHL, BC > AC shows CHL

Question 402

At what age should you consider testing for alpha 1 antitrypsin deficiency in patients with emphysema?

Question 403

TB precautions upon admission?

Answer 403

Airborne precautions before confirmatory TB testing

Question 404

Do you need to get a CXR for acute bronchitis?

Answer 404

No, unless clinical sus for pneumonia is high. Otherwise supportive care empirically with OTC expectorants, inhaled bronchodilators (ICS, albuterol)

Question 405

MC complication of bronchiolitis

Answer 405

Apnea and resp failure (esp if pt is < 2 months old)

Question 406

Pneumococcal vaccine recommendations

Answer 406

PCV20 one time for otherwise healthy adults >/= 65 y/o (one time dose) PCV15 followed by PCV23 OR PCV20 alone for adults > 65 who are current smokers or have other chronic medical conditions (COPD, DM, etc.)

Question 407

Initial evaluation of chronic cough (>4 weeks) in kids who are otherwise asymptomatic

Answer 407

Start with SPIROMETRY -- looking for evidence of obstruction If no evidence of obstruction -- follow with CXR

Question 408

Breathing sounds heard with epiglottitis

Answer 408

Inspiratory stridor (like croup)

Question 409

Squamous and small cell lung cancer associations

Answer 409

Squamous = sCuamous cell (hyperCalcemia, centrally located, cavitary lesions, cigarettes biggest RF) Small cell lung cancer = SCLC Smoking is #1 risk factor Chemo responsive Lambert Eaton syndrome Centrally located

Question 410

Tracheal deviation in tension pneumo versus atelectasis

Answer 410

Tension pneumo = tracheal shift to CONTRALATERAL side Atelectasis = tracheal shift to IPSILATERAL side

Question 411

Best method of rotavirus infection prevention

Answer 411

Routine vaccination (the R in B DR HIP)

Question 412

What does retrosternal crunching with each heartbeat indicate (aka Hamman sign)?

Answer 412

Air within the precordium > can be related to a full thickness esophageal tear

Question 413

Pathophysiology of pain behind McBurney's point?

Answer 413

Irritation of parietal peritoneum

Question 414

Exclusively breastfeeding puts infants at risk for what vitamin deficiency?

Answer 414

Vitamin D

Question 415

What GI disorders can TCAs be used for?

Answer 415

Second line treatment for IBS

Question 416

Scleroderma features

Answer 416

Skin: telangiectasias, sclerodactyly, digital ulcers, calcinosis cutis Extremities: arthralgias, myalgias, contractures GI: esophageal dysmotility, dysphagia, GERD Pulm: dyspnea, dry cough Vascular: Raynaud's CREST = limited scleroderma (a/w anti-crestomere antibodies)

Question 417

Achalasia findings on manometry

Answer 417

Aperistalsis in distal esophagus, increased LES pressure and incomplete relaxation (inappropriate contraction leads to bird's beak appearance)

Question 418

Vegan diet puts you at risk for what deficiencies

Answer 418

Calcium and vitamin D are the main ones!!! this is b/c we get most of this through dairy consumption ***Can also see vitamin B12 deficiency

Question 419

Chronic pancreatitis pres and diagnosis

Answer 419

Pres: steatorrhea (oily stools difficult to flush), diabetes, and pancreatic calcifications Diagnostics: abdominal CT to confirm

Question 420

Next step in GERD mgmt if pt unresponsive to daily PPI therapy

Answer 420

Increase to BID, if sx still refractory after 4-8 weeks of BID PPI, obtain esophageal pH monitoring and impedance testing

Question 421

Indication for urgent surgical ex lap of SBO mgmt

Answer 421

If signs of perforation > free air under diaphragm, acute abdomen on PE (rigid, distended, tympanic)

Question 422

Treatment for the 4 types of EPS

Answer 422

1) Acute dystonia -- oculary gyrocrisis, torticollis: treat with anticholinergics to increase dopamine (benadryl, benztropine) 2) Akathasia -- true restlessness of extremities, can't sit still: treat with a beta blocker 3) Pseudoparkinsonism -- looks just like true Parkinson disease with trademark rigidity, slow movements: treat with anticholinergics to increase dopamine (benadryl, benztropine) 4) Tardive dyskinesia -- repetitive, uncontrolled lip or tongue smacking: treat by discontinuing causative antipsychotic, +/- clozapine afterwards

Question 423

How to interpret C peptide levels

Answer 423

Reflects the activity of insulin production by the pancreas > if low, more c/w T1DM or exogenous insulin administration; if elevated, more c/w T2DM or insulin resistance

Question 424

Key differentiation of panic disorder from other anxiety disorders (i.e. social anxiety disorder)

Answer 424

Panic disorder will have some panic attacks that are UNEXPECTED and will always result in a persistent worry about future attacks

Question 425

DIG FAST symptoms

Answer 425

Manic episode (BPD I) = 7 or more days of elevated or irritable mood + increased E AND 3 or more of the following DIG FAST symptoms: Distractibility Impulsivity, risky behavior Grandiosity Flight of ideas/racing thoughts Activity levels increased/psychomotor agitation Sleep need is decreased Talkativeness/pressured speech

Question 426

Timeline for postpartum blues versus depression

Answer 426

Blues: up to 14 days after delivery PPD: onset usually 4-6 weeks after delivery > start treatment with SSRI at this point if sx persist

Question 427

VS in benzo overose

Answer 427

Often normal (severe cases can cause respiratory depression) ***pres more a/w CNS depression, slurred speech and ataxia

Question 428

Benzo versus opioid overdose presentation

Answer 428

Benzo: normal VS, slurred speech and ataxia Opioid: hypoactive BS, miosis, hypoventilation

Question 429

MDD pres in kids versus adults

Answer 429

MDD in adults: more characterized with anhedonia, depressed mood MDD in kids: more a/w irritability, annoyance and argumentative nature PLUS social withdrawal, declining academic performance, etc.

Question 430

Do you need confirmation of abuse from individual interviews or social work consult if pt has already disclosed potentially abusive information?

Answer 430

No, the disclosure from the patient is enough > next step is to call CPS

Question 431

Cocaine abuse presentation

Answer 431

Irritability Anxiety Mood swings Panic attacks Grandiosity Impaired judgement Psychotic symptoms Lowkey like bipolar/narcissist personality disorder but will also have abnormal VS and PE (dilated pupils, hypertension and tachycardia due to sympathetic activation)

Question 432

Withdrawal from what substance can mimic depressive episodes?

Answer 432

Cocaine (no longer getting the stimulant effect -- increased appetite, slowing of movements, fatigued, sleeping more often)

Question 433

Difference in distinguishing preoccupation with perfectionism in narcissistic personality disorders versus OCPD

Answer 433

Narcissistic = motivated by need for praise and admiration (grandiosity) OCPD = motivated by control and orderliness

Question 434

Buproprion ADRs

Answer 434

Lowers seizure threshold > CN in patients with bulimia and anorexia nervosa, epilepsy

Question 435

SIG E CAPS symptoms and MDD criteria

Answer 435

At least 5 SIG E CAPS symptoms over a 2 week period + depressed mood/anhedonia Sleep disturbance Interest loss Guilt (Worthlessness) Energy levels decreased Cognition or concentration difficulties Appetite increased or decreased Psychomotor slowing or agitation Suicidal ideation

Question 436

Diff between REM sleep behavior disorder and other sleep disorders

Answer 436

Recurrent episodes of arousal during sleep, but is fully alert upon awakening

Question 437

Delusional disorder criteria

Answer 437

>/= 1 delusion with no other psychotic symptoms, does not impact daily functioning or relationships significantly

Question 438

2 most common drugs a/w AIN

Answer 438

Amoxicillin, chronic NSAIDs

Question 439

Biggest RF for recurrent cystitis in kids

Answer 439

Functional constipation

Question 440

Bladder cancer presentation

Answer 440

Painless hematuria, s/sx c/w hydronephrosis, flank pain, voiding symptoms (urgency, frequency, dysuria)

Question 441

Finasteride and tamsulosin medication class

Answer 441

Finasteride = 5 alpha reductase inhibitor (inhibit conversion of testosterone to DHT, which prevents prostate enlargement) Tamsulosin = alpha adrenergic agonist (helps with vasodilation but does not impact prostate volume significantly)

Question 442

Nonseminoma germ cell tumor labs

Answer 442

Elevated AFP and LDH

Question 443

Bacteria responsible for producing basic kidney stones

Answer 443

Proteus (increases pH)

Question 444

Gram negative intracellular diplococci

Answer 444

Gonorrhea

Question 445

Description of Lyme arthritis

Answer 445

Migratory polyarthralgias over weeks-months transitions to monoarticular arthritis and is a/w fatigue and malaise

Question 446

Is RhoGam given to Rh negative or positive women? and when do you give it?

Answer 446

Negative because if their baby is Rh positive, exposure to the baby can cause development of harmful antibodies for the next pregnancy Give RhoGam after spontaneous PREGNANCY RELATED bleeding (i.e. previa, placental abruption, threatened abortion)

Question 447

Rash description in toxic shock

Answer 447

Palms and soles involved, diffuse and sunburn-like (also a/w rapid onset hypotension and organ dysfunction)

Question 448

Vascular dementia presentation

Answer 448

ABRUPT onset of executive dysfunction (organizing, planning) and focal neurologic deficits (decreased strength and sensation)

Question 449

Cholera diarrhea description

Answer 449

Rice water diarrhea -- very watery with bits of mucus ***cholera causative agent = vibrio cholerae

Question 450

Past MI EKG findings and subsequent management

Answer 450

Inverted T waves Q waves (wider QRS complex) Mgmt: DAPT, statin, beta blocker, ACEi/ARB

Question 451

Basic preoperative clearance labs for patient with DM

Answer 451

EKG, A1C, SCr and blood glucose

Question 452

Treatment of amphetamine/stimulant intoxication

Answer 452

Lorazepam

Question 453

Treatment of acute abnormal uterine bleeding

Answer 453

Assuming HDS: start with OCPs with high dose estrogen Hemodynamically unstable: fluid repletion, uterine tamponade --> can then proceed to curettage, IV estrogen, uterine artery ablation, hysterectomy if refractory

Question 454

Is cervical insufficiency a/w vaginal bleeding?

Answer 454

Typically no

Question 455

Contraindication to IUDs

Answer 455

Irregular menstrual bleeding (b/c this can be worsened with IUD insertion)

Question 456

Intraamniotic infection characteristics for diagnosis

Answer 456

Maternal fever d/t an otherwise unclear source of infection PLUS: - Maternal or fetal tachycardia - Purulent amniotic fluid - Leukocytosis

Question 457

Leriche syndrome triad

Answer 457

- Erectile dysfunction - Thigh, hip, and buttock claudication b/l - Absent or diminished femoral pulses ***increased risk in M who have atherosclerosis and/or are smokers

Question 458

Wet mount for a patient with abnormal white discharge and absence of clue cells or flagellated protozoa is c/w

Answer 458

Chlamydia or gonorrhea infection

Question 459

Cushing appearing extremely itchy rash in pregnancy and how do you treat it?

Answer 459

Rash = polymorphic eruption of pregnancy Tx = topical corticosteroids

Question 460

Catatonia etiology, presentation, and treatment

Answer 460

Etiology: most commonly arises in patients on mood stabilizers for BPD, can also be seen with antipsychotics Pres: immobility, mutism, negativism, echolalia Tx: benzos

Question 461

Best method to diagnose Zencker's

Answer 461

Barium swallow

Question 462

Which forms of contraception can worsen pre-existing HTN?

Answer 462

COCPs and estrogen-progestin vaginal ring due to estrogen induced angiotensin synthesis

Question 463

What skin cancer can arise from chronic wounds (burns, ulcers, etc.)?

Answer 463

Squamous cell carcinoma

Question 464

Treatment of crabs

Answer 464

Crabs = genital lice > treat with topical permethrin

Question 465

Potential red flag etiology of acanthosis nigricans

Answer 465

Gastric adenocarcinoma (look for glossitis + B sx)

Question 466

Complication of untreated vesicoureteral reflux (VUR)

Answer 466

Renal inflammatory response leading to ischemia and subsequent renal scar formation (would cause an intrinsic AKI, ?eventual CKD) ***no a/w glomerular disease

Question 467

Specific phobia first line treatment

Answer 467

Exposure therapy

Question 468

Dendritic uptake on flourescein staining w eye symptoms alone versus with vesicular rash w/ a dermtomal distribution on the face

Answer 468

Alone = think herpes keratitis W/ associated facial rash = think Ramsay Hunt syndrome, varicella zoster infection

Question 469

Ptosis that improves with ice pack is a/w

Answer 469

Myasthenia gravis

Question 470

Best immediate management for refractory, acute suicidal ideation

Answer 470

ECT

Question 471

Achalasia affects the distal esophagus or the LES?

Answer 471

LES > distal esophagus narrowing more c/w esophageal stricture (GERD = RF)

Question 472

How does blood impact fetal fibronectin results?

Answer 472

Causes false positive -- get TVUS instead first (looking for previa or abruption)

Question 473

Criteria for and management of active phase arrest of labor

Answer 473

Criteria: no change in >/= 6 hours with inadequate contractions OR no change in >/= 4 hours with adequate contractions

Question 474

Treatment of acute NSTEMI or UA

Answer 474

Anticoagulate: unfractionated heparin, Lovenox, etc. Antiplatelet therapy: DAPT BBs, nitrates, statin ***thrombolytics not indicated in UA or NSTEMI

PANCE Review (3 decks)

• PANCE Topics to Review
• Screening/Preventative Health Topics
• Derm