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1

define adenomyosis

endometrial glands trapped in myometrium

2

adenomyosis
presentation
physical exam

female ^40 yo
dysmenorrhea w
heavy menstrual bleeding
progression to chronic pelvic pain

boggy tender uniformly enlarged uterus

3

define heavy menstrual bleeding

soaking a pad or
changing tampon q2h

4

synonymns for boggy

soft
flaccid

5

adenomyosis
dx
tx

pelvic us and/or mri initially
bx amd histopath definitively

ocp, levonorgestrel iud
hysterectomy if these unsuccessful

6

levonorgestrel moa

thickens cervical mucus against sperm
inhib ovulation
inhib fsh and lh
alters endometrium against implantation

7

bladder pain syndrom aka

interstitial cystitis

8

bladder pain syndrome

pain over anterior vaginal wall
discomfort w bladder filling
dysuria
urinary freq

9

is post coital bleeding from cervical cancer assoc w pain?

no
painless

10

fibroids aka

uterine leiomyomata

11

tf
depression often presents to pcp with physical complaints such ad headaches, aches and pains, insomnia, fatigue

t

12

explain weight loss in cancer

v po intake
systemic inflammation ~ hypercatabolism

CACS
cancer-related anorexia cachexia syndrome

13

treat CACS
cancer-related anorexia cachexia syndrome

progesterone analogue
(megestrol acetate)
if longer life expectancy

can consider corticosteroid if shorter expectancy (more SEs)

- stim apetite, weight gain, possibly assoc w some antiinflammation

14

tf
dronabinol tx CACS cancer-related anorexia cachexia

f
some clinical effectiveness for HIV cachexia

not cancer cachexia -- use megestrol acetate or corticosteroid if short expectancy

15

tf
nutritional education amd supplementation iv or po is effective for tx of cacs cancer-associated anorexia cachexia

f
not very effective.
megestrol acetate long expect (progesterone analogue)
or corticosteroids short expectancy (more SE's)

16

child refusal to speak in certain situations for more than a month, but normal interactions in other situations

selective mutism
a social anxiety disorder

17

at what age does stranger anxiety typically begin and end

6mos - 3yrs

18

tf
selective mutism does not need to be treated

f
treat early to avoid education and social impairment

19

sympx w blood loss of
100ml 20%
150ml 30%
200ml 40%

-orthostasis hr100+ rr20+ agitation cool
-hypotension hr120+ rr30+ confusion cool
-severe hypotension hr140+ rr40+ obtunded cold

20

hyper igM aka

cd40 ligamd deficiency

21

cd40 liganf deficiency aka

hyper igM

22

normal b cell count
high igM
low igGAE
dx

hyper igM
aka cd40 ligand deficiency

23

normal b cell count
low igMGAE
dx

common variable immunodeficiency

24

common variable immunodeficiency
b cell count
and ig quantities

normal b cell count
low igMGAE

25

job synndrome aka

hyper igE

26

hyper igE aka

job syndrome

27

normal b cell count
high igE but other igs normal
dx

hyper igE
job syndrome

28

nl b cell count
nl igMGE
low igA
dx

selective igA deficiency

29

low b cell count
low igMGAE
dx

x-linked agammaglobulinemia
aka
bruton agammaglobulinemia

30

how to calc b cell count from total lymphos and t lymphos

subtract that shit

31

bruton agammaglobulinemia
aka

x linked agammaglobulinemia

32

bruton x linked agammaglobulinemia
pathogenesis
sympx
tx

tk mut in b cells
failure of pre b lympho dev in bone marrow
so low circulating mature b lymphos
low igMGAE
maternal passive imm wanes 3-6 mos
recurrent severe / chronic sinopulmonary otitis media pna gi salmonella campylo infections
pe older kids underdev tonsils lns lymphoid tissue... but not normally very prominent anyway
ivig and ppx abx

33

presentation of cvid vs xla

common variable immunodef same but less severe sx after adolescence w dec serum ig's but norm b cell count

x linked (bruton) agammaglobulinemia severe recurrent sinopulm or gi infections in late infancy, low/absent ig's AND b cells

34

22q11.2 deletion syndrome aka

digeorge syndrome

35

digeorge syndrome aka

22q11.1 deletion syndrome

36

classic triad digeorge

congenital heart defect
t cell deficiency
hypocalcemia

37

xla vs 22q11.2 keys

xlinkedbrutonagammaglob recur sinopilmonary gi inf late infancy no B cells no igs

digeorge recurrent bact fung inf no T cells

38

scid
presentation
labs

scid recurrant bact fung viral inf in infant, from t cell developmental impairment not stimulating b cells so low T AND B

39

transient hypogammoglobulinemia of infancy
pres
pathogenesis

milder recurrent sinopulm and gi inf in infancy
dec igg
variable igm
normal igA and b cells
normalizes typically 9-15mos old

40

sudden onset hypotention tachycardia and back pain hours post cardiac cath suggests

retroperitoneal hematoma due to bleeding from arterial access site

41

most common complications of cardiac cath

local at catheter insertion site:

bleeding, hematoma local or with retroperitoneal extension, arterial dissection, thrombosis, pseudoaneurysm, av fistula

42

most hemorrhage or hematoma formation occurs within __ hours of catheterization

within 12 hours

43

quad screen
trisomy 18
trisomy 21
neural tube or ab wall defect

18 - everything down

21 - BhCG and Inibin A up, MSAFP and Estriol down

NTD AWD - MSAFP up

44

quad screen is done when

2nd trimester 15-20 weeks

45

next step after failure of nsaids / ocps for endometriosis

laparoscopy

46

typical ultrasound finding of dermoid cyst / cystic teratoma

hyperechoic nodules and calcifications

47

adnexal mass due to ovarian stimulation by high B-hCG levels (e.g. molar pregnancy) that resolves after levels decline. Do not present outside pregnancy. On ultrasound, multiseptated bilateral cystic masses, No calcifications or hyperechoic nodules

Theca Lutein cyst

48

young female with known dermoid cyst presents down the line with unilateral lower quadrant abdominal pain -- tenderness to deep palpation and voluntary guarding... suspect __ not ___

Torsion - higher risk from mass

not rupture -- that would have peritoneal signs, INvoluntary guarding... and much more common with Simple Ovarian and Corpus Luteum cysts... dermoid cysts Don't typically rupture

49

Pelvic Pain in a patient with a Known Ovarian Mass should be suspected for ____ until proven otherwise

pelvic pain with known ovarian mass should be suspected for OVARIAN TORSION until proven otherwise

50

woman trying to conceive and attentive to... stuff... otherwise healthy notices 2 days clear vaginal discharge like uncooked egg white -- it is...

peri-ovulatory cervical mucus - increases close to ovulation for sperm facilitation, thickens afterward... some women notice as "vaginal discharge"

51

what does a passed cervical mucus plug look like and what was its function in pregnancy

brown red or yellowish thick mucus
typically shed before or during labor
barrier to ascending infection during pregnancy

52

icu pt on pressors with symmetric duskiness and coolness of all fingertips - explain, and what else at risk

ischemia from pressor (such as norepi) - induced vasospasm in already hypotensive pt

at risk for mesenteric ischemia and renal ischemia as well

53

what is SVC syndrome

Compression of SVC by e.g. lung cancer, thrombi, or fibrosing mediastinitis causing Upper Extremity Edema

54

fetal Position vs Presentation

Position - relationship of presenting part to maternal pelvis

Presentation - lowest/presenting part of fetus

55

arrest of 2nd stage of labor due to transverse lie of fetal head in pelvis... call this malposition or malpresentation?

MalPosition - relationship of presenting part to maternal pelvis

(malpresentation refers to lowest/presenting part of fetus, e.g. vertex, face, breech)

56

vertex, breech, face

refer to position or presentation?

presentation (lowest/presenting part of fetus)

(position is relationship of lowest part to pelvis)

57

optimal fetal position

what is risk of alternate positions with same presentation

occiput anterior (occipital bone forward toward pubis, face back toward coccyx -- facilitates cardinal movements of labor

cephalopelvic disproportion and arrest of labor a risk with occiput transversus or occiuput posterior

58

occiput anterior, posterior, transversus

refer to position or presentation?

Position - relationship of presenting part to maternal pelvis

(presentation is lowest/presenting part of fetus)

59

most common cause of arrest of 1st stage of labor and 2nd stage of labor

1st stage arrest - insufficient contractions

2nd stage arrest -- cephalopelvic disproportion

60

ominous possible explanation for decreased fetal movement despite normal fetal heart tone

benign explanation

central nervous system hypoxia

fetal sleep cycle

61

contraindications to contraction stress test

contraindications to labor
(placenta previa, prior myomectomy, etc)

62

normal Amnionic Fluid Volume on biophysical prophile

single pocket ^2x1cm

AFI ^5
(amnionic fluid index)

63

normal fetal Movements, Tone, and Breathing Movements on biophysical profile

3 or more general body movements

^1 flexion/extension of fetal limbs or spine

^1 breathing episode for ^30sec

64

a score of 0-4/10 on BPP biophysical profile suggests
you should

Fetal Hypoxia due to Placental Dysfunction
aka Placental Insufficiency

Deliver promptly to avoid fetal demise

65

when to stop pap testing

age 65 or hysterectomy
AND
no hx CIN2 or higher or immunocompromise or maybe smoking
3 consecutive negative Paps
OR
2 consecutive negative co-tests

66

TF
in patient with vulvovaginal atrophy and urinary incontinence the cause of both is estrogen deficiency

T
urinary incontinence because urethra has estrogen receptors and atrophies as well, losing tone

67

mechanism of urinary incontinence in vulvovaginal atrophy

estrogen deficiency
-urethral mucosa atrophies and loses tone

68

TF
postmenopausal woman with vulvogavinal atrophy and urinary incontinence... incontinence likely due to urethral hypermobility

F
estrogen deficiency
-urethral mucosa atrophies and loses tone without estrogen input

69

inheritance pattern of HOCM

mutated proteins

Autosomal Dominant

myocardial sarcomere contraction protein mutations

70

EKG changes in HOCM

LVH - tall R wave aVL, deep S wave V3

Repol changes in anterolateral leads I aVL V456

71

diagnostic test for pancreatic cancer according to jaundiced or not

jaundiced - Ultrasound - likely pancreatic head mass

not jaundiced - CT - body or tail tumor

72

when to start fertility investigation in couple trying to conceive

1 y mom v35yo

6 mo mom ^35yo

73

kussmaul sign

lack of decrease (or increase) in JVP during inspiration

74

ekg in PE

sinus tachy
or nonspecific ST changes or T wave changes, new RBBB, S1Q3T3 pattern (acute cor pulmonale)

75

ekg changes with fluconazole and moxifloxacin

QT prolongation
risk of Torsades

76

treat Torsades in hemodynamically stable vs unstable pt

unstable - immediate Defibrillation
stable - Magnesium IV

77

treat paroxysmal supraventricular tachycardia

Adenosine

78

use of Atropine for ekg abnorm

Atropine for Symptomatic Sinus Brady or AV Block

79

ekg changes with hyperkalemia

peaked T waves
P-R elongation
eventual widening of QRS
eventualll Sine Wave

80

woman with epigastric pain and right shoulder pain for 4 hours after eating a cheeseburger = classic....

biliary colic

81

"hollow organ contraction and outlet obstruction" in setting of epigastric pain and shoulder pain for 4 hours in a women after eating a cheeseburger refers to

biliary colic

82

TF
pain from fat necrosis from acute pancreatitis can resolve spontaneously after a few hours

F
not usually spontaneously resolving in a few hours.... think more biliary colic

83

biliary colic caused by contraction against obstructed cystic duct usually lasts less than __ hours

biliary colic lasts less than 6 hour usually

84

a PE might seem like a MI of what ventricle at first presentation

may seem like Right Ventricle MI

(PE causes backup into RV and RV dysfunction)... but more dyspnea and syncope with PE and more arrhythmia and bradycardia with RVMI

85

postmenopauseal bleeding, breast tenderness, and 10cm adnexal mass and thickened endometrial stripe on ultrasound -- next step CT or endometrial biopsy?

endometrial biopsy

estrogen secreting Granulosa Cell Tumor high risk for causing Endometrial Carcinoma... must rule out

CT to stage after that

86

cardioselective beta blockers (B1)

A-M

87

TF
metroprolol is a cardioselective beta blocker (B1)

T
A-M are cardioselective

88

FEV1
FEV1/FVC
FVC

obstructive vs restrictive lung disease (including obesity)

Obstructive
FEV1 v70%
FEV1/FVC v70%
FVC normal to decreased

Restrictive
FEV1 v80%
--Fev1/FVC ^70%
FVC v80%

89

TF
55yo with new asthma symptoms and asthma PFTs on metoprolol probably caused by metoprolol rather than adult-onset asthma

F
metoprolol is A-M cardioselective (B1)
rarely causes asthma symptoms

Adult Onset Asthma is a thing not that uncommon even though asthma typically diagnosed younger

90

worsening cough and wheezing in old guy preceded by refractory chronic rhinosinusitis with nasal polyposis could be due to what drug

aspirin
aspirin-exacerbated respiratory disease

91

2 key PFT findings diagnostic of asthma regardless of age

^12% increase FEV1 reversible obstruction with beta agonist

with normal diffusion capacity for carbon monoxide

92

elderly pt with "abdominal pain" limited to severe pain with brushing skin in a local area with negative TTP etc in setting of recent cancer treatment "chemo" likely attributable to ___

treat with ___ to accomplish ___

shingles, herpes zoster

even without rash, as pain may precede rash. often arises with severe physical stress (cancer treatment) or immunocompromise

treat with acyclovir valacyclovir or famciclovir to shorten duration and decrease risk of post-herpetic neuralgia

93

adult respiratory distress symptoms presents very similarly to ___ but lacking the history and risk factors that would make you think ___

similar to CHF
without hx and risk factors

94

renal effects of CHF

RAAS activation in response to decreased cardiac output, to increase contractility, peripheral vasoconstriction, and extracellular fluid volume

specifically
--- ATII constricts EFFERENT glomerular arteriol more than afferent arteriol, and stims SODIUM resorption in CORTICAL COLLECTING TUBULE and adrenal ALDOSTERONE secretion

95

pellagra is due to ___ and characterized by...
seen in populations...

pellagra is due to NIACIN deficiency (niacin from diet or synthesized endogenously from Tryptophan)

characterized by 3 Ds
-Dermatitis - sun-exposed, rough, scaly, hyperpigmented
-Diarrhea
-Dementia - neuronal degeneration... memory, affective symptoms, psychosis

CORN diets (tryptophan unabsorbable)
MALNUTRITION (alcoholism, illness)
CARCINOID syndrome (depletion of tryptophan)
HARTNUP disease (congenital tryptophan malabsorption)
ISONIAZID therapy (eg TB) can interfere with tryptophan metabolism

96

___ causes episodic not chronic abdominal pain, vomiting, diarrhea, often with neurologic agitation, paresthesias, confusion, may be triggered by isoniazid, with chronic transaminase elevation, more common in women than men

AIP
acute intermittent porphyria

97

_____ is characterized by erythematous scaly plaques affecting scalp face chest intertriginous areas, can be associated with dementia/Parkinsons, does not typically affect the hands does not typically cause GI symptoms

seborrheic dermatitis

98

skin findings with UC

erythema nodosum and pyoderma gangrenosum

99

presentation classic for aortic dissection -- diagnostic steps?

CT angio preferred if hemodynamically stable and normal creatinine

TEE (transesophageal echocardiogram) if Cr elevated Renal Insufficiency or hemodynamically Unstable

MR angio not preferred - contrast required and time-consuming in possibly emergent setting (type A aortic dissections are emergencies with mortality rates 1-2%/hour following onset

100

probable aortic dissection with Cr 2
why Cr elevated?
diagnostic test?

dissection may extend to renal arteries
(or CKD)

TEE transesophageal echocardiogram for dissection with renal disease (no contrast).... otherwise CT angio

101

50yo heavy alcohol user, smoker, with compensated CHF, no cad, MCV ^100, thrombocytopenia, AST:ALT^2:1

diagnosis

best treatment for heart
-ACEI/ARB? Smoking cessation? Alcohol cessation? Salt restriction?

Alcoholic (dilated) Cardiomyopathy

STOP ALCOHOL improves or normalizes LV function over time

smoking contributes to CAD not CHF

Salt restritction, ACEI/ARB, BB, diuretics, possible aldosterone antagonists, digoxin etc all part of treatment per CHF but Alcohol Abstinence best for Alcoholic Dilated Cardiomiopathy

102

time to ARDS onset after clinical insult

v1wk

103

vent settings to treat ARDS

low TV, high PEEP, high FiO2

104

hypoxia with PaO2/FiO2 v300 suggests

how to calculat PaO2/FiO2

suggests ARDS

e.g. 60mmhg/1.0 = 60
(1.0 = 100% FiO2)
90mmhg/.1 = 900
90mmhg/.2 = 450
90mmhg/.3 = 300

105

TF
massive transfusion can cause ARDS

T

106

Pleural fluid analysis in Uncomplicated vs Complicated Parapneumonic effusion

sterile or bacteria?
free or loculated?
pH, glucose, WBC, protein
gram stain culture
treatment

Uncomplicated - sterile, free-flowing, pH^7.2, glucose^60, WBCv50, low protein, negative cultures, antibiotics

Complicated - bacterial invastion, loculated vs empyema, pHv7.2, glucosev60, WBC^50, high protein, negative cultures still (bacterial load there but low), antibiotics and drainage

107

difference between complicated parapneumonic effusion and empyema?

negative cultures vs gross pus or bacteria on gram stain

108

parapneumonic effusion with continued fever and pleuritic pain despite abx suggests...

Complicated parapneumonic effusion (persistent bacterial invasion but low enough for negative cultures)
or Empyema (gross pus / positive cultures)

requiring Drainage in addition to abx

109

quantify "low protein" in a transudative effusion

v3g/dl
(consider that normal serum total protein is 8)

110

the most frequent underlying arrhythmia responsible for sudden cardiac arrest in setting of acute MI

pathophys

Ventricular Fibrillation

Reentrant ventricular arrhythmia (predominant, If within 10 minutes of MI, from distorted conduction patterns)

abnormal automaticity if 10-60min post mi, less common

111

pt with variceal bleed with hematemesis hemodynamically unstable with altered mental status - being transfused... next step NG tube to decrease hematemesis?

INTUBATE - protect airway (AMS, hematemesis, aspiration risk, cannot protect airway)

once protected, can move on to NG suction to improve EGD visualization, EGD for sclerotherapy/banding... also do octreotide (SS analogue) to decrease GI blood flow in meantime

112

calculate cardiac index

cardiac output / body surface area
CO / BSA

113

underlying cause of ascending vs descending aortic aneurysms

ascending - cystic medial necrosis (elderly) connective tissue disorders (marfan, ehlers danlos)

descending - ATHEROSCLEROSIS htn hld smoking

114

TF
done diagnosing aortic aneurysm with a cxr?

F
could just be tortuous aorta... CT to confirm

115

pt with fever, chills, malaise, headache, myalgias, dry cough

mediastinal or hilar lymphadenopathy with focal reticulonodular or miliary infiltrates on cxr

granulomas with narrow-based budding yeasts on biopsy

dx and risk factor?
treatment?

Histoplasma Capsulatum

Bird/Bat droppings - CAVES, Ohio/Mississippi river valleys, Northeast

complete spontaneous resolution in weeks
Itraconazole or Amphotericin B if not

116

chest pain, cough, fatigue, fever

normal cxr or unilateral infiltrate with ipsilateral hilar LAD

spherules with endospores on biopsy

dx? risk?

Cocccidioidomycosis

Arizona

117

Mononucleosis-like lymphadenopathy, fevers, malaise in cat owner think...

toxoplasma gondii

118

fit preggy gymnast wants exercise advice

continue jogging, swimming, walking, stop gymnastics (as long as pregnancy uncomplicated by multiple gestation, placental concerns, heart or lung disease, prematurity concerns...)

(avoid contact sports, FALL RISK, scuba diving, hot yoga)

119

physical activity to avoid in healthy pregnancy

contact sports
fall risk
scuba diving
hot yoga

120

TF
bilateral wheezing can occur in acute PE

T
bronchoconstriction in response to hypoxia and infarction

121

most common cause of mitral regurge, e.g. in otherwise healthy middle-aged person in a developed country

Mitral Valve Prolapse
(Myxomatous Degeneration)
MVP most common cause of MR
in developed countries

122

pathophys of Mitral Valve Prolapse

myxomatous degeneration

123

why avoid spillage of mature cystic teratoma / dermoid cyst contents during laparascopic cystectomy

can cause chemical peritonitis

124

most common risk factors for aortic dissection

htn #1

marfan
cocain

125

pathogenesis of exercise-induced bronchoconstriction (athletic asthma)

treatment

mast cell degranulation triggered by passage of high volumes of dry cold air

SABA before exercise if a few times per week

can substitute ICS or AntiLeukotriene if exercise daily

126

most common cause of adult-onset diarrhea due to malabsorption presenting between age 20-40

lactose intolerance

127

30yo with chronic crampy abdominal pain bloating and watery diarrhea after meals likely has ___

Lactose Intolerance
(brush border enzyme deficiency)

128

normal function and location of intestinal lactase

process lactose into glucose and galactos on the Brush Border of the Duodenum

129

quality of diarrhea in Lactose Intolerance, why

mechanism of bloating

watery diarhea
-undigested lactose draws water into intestinal lumen and decreases transit time

colonic bacteria ferment lactose producing hydrogen gas

130

diagnose lactose intolerance

treat

diagnosed by resolution of symptoms with lactose-free diet
or lactose breath hydrogen test if above inconclusive

treat by avoiding lactose or supplementing lactase

131

acute onset watery diarrhea and low-grade fever and positive FOBT with PPI therapy think...

C Diff
-associated with PPI use
-FOBT often positive
-diarrhea is ACUTE with Low Grade FEVER

132

quality of diarrhea in Celiac

foul-smelling, greasy

133

escalating symptoms of magnesium toxicity

treatment

nausea flushing headache hyporreflexia
areflexia, hypocalcemia, somnolence
respiratory paralysis, cardiac arrest

stop mag
give IV calcium gluconate bolus

134

2 uses of mag sulfate in OB

prevention of eclamptic seizures

preterm delivery -- decreases risk of cerebral palsy in premies

135

magnesium excretion

how does that inform your OB practice

renal

so watch out if renal failure or increased Cr, check levels and signs of toxicity always

136

how does mag therapy cause hypocalcemia

mag temporarily suppresses PTH secretion

137

TF
LEEP and Cervical Laser Ablation increase risk of preterm delivery

Fish

knife conization definitely

LEEP maybe

Laser definitely not

138

this trumps all other risks for preterm delivery

history of preterm delivery

trumps multiple gestation, short cervicle lenth, cervical conization surgery, cigarette use, obesity, etc

139

OB risks associated with gastric bypass surgery

risk for preterm delivery?

anemia in pregnancy
cesarean delivery

Not a risk for preterm delivery

140

manage history of preterm delivery in currently pregnant mama

cervical length measurements by TVUS
progesterone administration
maybe cerclage placement if diagnosie cervical insufficiency

141

hypotensive chest trauma patient has normal/high PCWP that elevates with fluid bolus, don't think hemorrhage now think...
get...

think myocardial dysfunction, possible contusion

get an urgent echocardiogram

142

most common infective endocarditis organism

staph aureus

143

valve involvement in infective endocarditis

tricuspid more than aortic

144

fever cough chest pain in IV drug user with systolic murmur that increases with inspiration and scattered round lesions in the peripheral lung fields bilaterally think..

infective endocarditis with tricuspid involvement and septic emboli to lungs

145

describe paradoxical split S2

and 3 examples that cause it

reversed, A2 follows P2, with split increased during Expiration and decreased with inspiration

seen with Fixed Left Ventricular Outflow Obstruction
-Aortic Stenosis
-LBBB
Right Ventricular Paced Rhythm

146

TF
inadequate pregnancy weight gain, e.g. from hyperemesis gravidarum, can cause fetal growth restriction

T

147

congenital malformation caused by lymphatic system obstruction in the fetal neck

aka
association

aka Cystic Hygroma

assoc with Aneuploidy eg Turner Syndrome

148

RhD antii-D immunoglobulin is given in OB Only After...

only after delivery of baby an blood type checked (Rh pos baby to Rh neg mom), within 72 hours of delivery

149

can get a FAST for an altert and hemodynamically stable trauma pt.... what SBP indicates hemodynamically stablility?

SBP^90
is a sign of hemodynamic stability

150

woman with HTN COPD and OSA has swollen legs and varicose veins with medial ankle ulcer...

diagnosis
recommend treatment
if fail treatment

chronic venous insufficiency
(nothing to do with COPD OSA or HTN... risk factors are age, obesity, family history, pregnancy, sedentery, prior trauma)

elevate legs and compression stockings

if fail this, get venous duplex ultrasound to demonstrate venous reflux and confirm diagnosis

151

TF
diuretics for chronic venous insufficiency

F
will just dehydrate

-elevate legs and compression stockings

152

TF
smoking cessation for chronic venous insufficiency

F
no evidence that stopping helps, though it is known to be a risk factor

-elevate legs and compression stockings

153

symptoms on presentation of choriocarcinoma

first lab test

treatment

amenorrhea or abnormal uterine bleeding
pelvic pain / pressure uterine mass
mets to lung / vagina and assoc sx

elevated b-hCG is first lab

chemo is treatment

154

within 6 months of pregnancy, delivery, abortion, molar pregnancy, woman has episodes of vaginal bleeding, large uterus, and lung symptoms

suspect
get
treat

suspect choriocarcinoma (with mets to lungs)

get b-hCG

treat with chemo

155

most common site of choriocarcinoma mets

choriocarcinoma mets to lungs

156

when to deliver baby in preeclampsia with severe features vs without severe features

^34 wks severe features

^37 wks no severe features

mag and antihypertensives (Hydralazine, Labetalol, Nifedipine) till then

157

TF
alpha methyldopa to for blood pressure control in preeclampsia

F
alpha methyldopa for Chronic htn in pregnancy

conrtol Htn in Preeclampsia with IV HYDRALAZINE, IV LABETALOL, or PO NIFEDIPINE

158

how to choose antihypertensive med for preeclamptic preggy

avoid Labetalol if already bradycardic

avoid Nifedipine (PO) if emesis suggests po intolerance

Hydralazine IV... pretty ok...

159

why are ACEIs contraindicated in pregnancy

can cause

fetal growth restriction
renal failure
pulmonary hypoplasia
oligohydraminos
skeletal abnormalities

160

why is sodium nitroprusside generally a Last Resort for treatment of hypertension

Cyanide is a metabolic byproduct

161

predominant Mechanism responsible for rapid anginal pain relief from Nitrates like Nitroglycerin

decreased left ventricular Wall Stress
via venodilation, decreased preload, decreased end diastolic volume resulting in decreased myocardial oxygen demand...

*wall stress more so than decreased contractility from decreased preload, or coronary dilation

162

pt with amenorrhea and history of chemo... otherwise ROS pretty negative,

suspect
FSH LH PRL TSH levels?

suspect Ovarian Failure from Chemotherapy (targets rapidly dividing cells)

FSH LH up (lack of inhibition from estrogen)
PRL TSH normal

163

abdominal succussion splash

describe
diagnosis
further diagnostic workup

stethoscope over upper abdomen
rock patient at hips

GOO - retained gastric material ^3 hours after a meal will generate a splash sound in a hollow viscus filled with fluid and gas (most sensitive for GOO, but must follow up with workup below)

NGT suctioning, IVMF, Endoscopy to confirm dx

164

explain the muscle weakness side effect of albuterol, eg with newbs in treatment of asthma exacerbation

what else can result of this mechanism

first step if occurring

Beta2Agonists like Albuterol can drive K into cells, HypoKalemia, Muscle Weakness, Arrhythmias, EKG changes... also Tremor, Palpitations, Headache

first step BMP to assess K level

165

treat hypertriglyceridemia

150-500
vs
^1000

and what is initial goal of therapy when triglycerides ^1000

150-500 - lifestyle Weight Loss, Alcohol decrease, Exercise increase, High Dose Statin IF CAD or High Risk

^1000 (initial goal Prevent Pancreatitis)
-Fibrates, Fish Oil, Abstain from Alcohol

166

triglycerides 465 in CAD patient -- what to do other than start high dose statin?

150-500 - lifestyle Weight Loss, Alcohol decrease, Exercise increase, High Dose Statin IF CAD or High Risk

^1000 (initial goal Prevent Pancreatitis)
-Fibrates, Fish Oil, Abstain from Alcohol

167

most effective pharmacologic therapy for lowering triglyceride levels

when to use it

Fibrates most effective for lowering triglycerides

use for SEVERE Hypertriglyceridemia ^1000 -- otherwise risky for myopathy and statins more effective by evidence so statins first-line for most CAD and moderate triglyceridemia

168

75yo DM and HTN, with cupping of optic disk on exam, loss of peripheral / tunneling of vision, why?

treat

OPEN Angle Glaucoma - cupping of optic disk

BB (Timolol) eye drops initial mgmt
Laser Trabeculoplasty as adjunct
Trabeculotomy if refractory

169

presentation of open vs closed angle glaucoma

Open - gradual loss of peripheral vision / tunneling, cupping of optic disk

Closed - Sudden onset Blurred Vision, Severe eye Pain, Nausea, Vomiting, Red eye with Hazy Cornea and Fixed Dilated Pupil

170

20yo with atypical chest pain and short systolic murmur at the apex that shortens with squatting... diagnosis?

MVP mirtal valve prolapse

squat, increase venous return... larger LV volume, delayed prolapse? per UWorld... thinking.... better stretched... less distance to prolapse....

MVP gets SOFTER with squat
MR gets LOUDER with squat

171

which gets louder with squatting and which gets softer MR vs MVP

MR gets LOUDER with squat
(more LV volume to regurge)

MVP gets SOFTER with squat
(more LV stretch, tighter chordae... less distance to flick back)

172

1st and 2nd most common Murmurs caused by Rheumatic Heart Disease

RHD
MS Mitral Stenosis #1
MR Mitral Regurge way less often

173

3 things to do in order for eeclampsia

give mag

give anihtn (hydralazine labetalol nifedipine

deliver baby

174

4 risk settings for ARDS

vent settings to treat with

how to avoid mortality

infection
trauma
massive transfusion
acute pancreatitis

treat with Mechanical Ventilation
-LOW TV, high PEEP, Permissive HyperCapnia

AVOID alveolar OVERDISTENSION (barotrauma) (low TV)
GOAL SpO2 ^88%

175

Pt put on vent for ARDS

what is the MOST important treatment strategy to avoid mortality?

Avoid Alveolar OverDistension (barotrauma) (low TV)
GOAL SpO2 ^88%

176

most common causes of Malignant pleural effusions

lung carcinoma
breast carcinoma
lymphoma

177

top 4 ddx for hypokalemia with alkalosis and normotension

how does urine chloride help you differentiate

surreptitious vomiting - low urine chloride

diuretic abuse
Bartter syndrome (renal protein mutation)
Gitelman's syndrome (renal protein mutation)
(all high urine chloride)

178

what kind of acid/base disturbance in chronic diarreha

metabolic ACIDOSIS
from loss of bicarb in stool

179

How can COPD exacerbation lead to seizure

and how can over-supplementation of oxygen contribute? Guidelines for use?

Seizure by HYPERCAPNIA (causes brain metabolite signaling changes) and reflex cerebral VasoDILATION

use Oxygen Cautiously with Goal SpO2 90-93% or PaO2 60-70mmHg
Too Much can Worsen HyperCapnia by:

-Loss of Hypoxic pulmonary Vasoconstriction and worsening V/Q mismatch.. increased deadspace perfusion
-Decreased CO2 reuptake because more O2 saturation
-Suppressed Hypoxic Respiratory Drive

180

Goal SpO2 and PaO2 in oxygen supplementation for COPD exacerbation

In COPD exacerbation, use Oxygen Cautiously

with Goal SpO2 90-93% or PaO2 60-70mmHg
Too Much can Worsen HyperCapnia by:

-Loss of Hypoxic pulmonary Vasoconstriction and worsening V/Q mismatch.. increased deadspace perfusion
-Decreased CO2 reuptake because more O2 saturation
-Suppressed Hypoxic Respiratory Drive

181

how can Zollinger-Ellison syndrome cause impaired fat absorption?

Gastrin producin tumor
high Acid
Impaired Pancreatic Enzyme Activation by duodenal base and Injury to the Mucosal Brush Border

182

workup of Zollinger-Ellison Syndrome

Gastrin level ^1000
Gastric pH v4

Endoscopy for ulcers (duodenal and maybe jejunal)

CT MRI SomatoStatin Receptor Scintigraphy to ID Pancreatic tumors (tumor often located in pancreas) and Mets

once confirmed, screen for MEN1 with PTH, Ca, PRL levels