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Flashcards in Random UWorld Deck (161):
1

treat HYPERNatremia

euvolemic
hypovolemic asymptomatic
hypovolemic symptomatic

how and why to limit rate of serum sodium correction

euvolemic - free water

hypovolemic asymptomatic - D5 (hypotonic)

hypovolemic symptomatic - .9% NS (isotonic) till euvolemic, then D5 (hypotonic)

Limit Na correction to .5mEq/dl/hr (12mEq/dl/24hr) -- or Risk CEREBRAL EDEMA

2

mechanism of Li induced nephrogenic diabetes inspidus

symptoms

treatment

ADH Resistence by Impairing Water Resorption in collecting duct

nocturia, polyuria, polydipsia, CNS symptoms when severe

discontinue lithium, if cannot - salt restriction and amiloride (select diuretic)

3

water deprivation test differentiates between...

central diabetes insipidus (low ADH from pituitary)

nephrogenic diabetes insipidus (ADH resistance in kidney - impaired water resorption)

primary polydipsia

4

Manage hypercalcemia

severe
moderate
mild

^14 or symptomatic - IVNS and Calcitonin acutely, Bisphosphonate long term (Zoledronic Acid, Pamidronate)

12-14 - only treat as above if symptomatic

v12 asymptomatic - no immediate treatment.... avoid thiazide diuretics (can use loop diuretics to secret calcium Only if volume up) avoid lithium, volume depletion, prolongued bed rest

5

why might an old lung cancer guy with PTHrp secreting tumor get an AKI

volume depleted via hypercalcemia-induced nephrogenic diabetes (trying to pee out the calcium)

6

why will fiail chest patient have decreased lung sounds in bases bilaterally

shallow breaths to avoid pain

7

treat flail chest

pain control
supplemental O2

if respiratory failure eg from edema/blood/pulmonary contusion - PPV Positive Pressure Ventilation... maybe with prophylactic chest tube to minimize risk of mechanical PPV causing tension pneumo

8

how to follow an AAA

ultrasound is all that is needed, very sn and sp and can measure and see thrombi

9

TF
abruptio placenta can cause extreme maternal pain

T

10

at 36 weeks gestarion, sudden extreme pain, vaginal bleeding, firm distended uterus, low fetal heart rate

diagnosis

abruptio placenta

11

Pain?

placenta previa vs abruptio placenta

no pain placenta previa usually, just painless bleeding

PAIN Abruptio Placenta, severe

12

interstitial cystitis
aka
assoc with
UA findings
treatment

aka painful bladder syndrome

assoc with anxiety, fibromyalgia, psche and pain syndromes

UA normal

treat with Behavioral Modification and Trigger Avoidance, Amitripyline, Analgesics for exacerbations

13

Criteria for home oxygen

general

if right heart failure or polycythemia?

generally if SpO2v88% or PaO2v55mmhg

if RHF or PCV (HC^55%) then SaO2v89% PaO2v59mmhg

(supplement to SpO2^90%)

14

what kind of diuretic can treat calcium kidney stones

thiazide diuretic
-hypercalcemia, hypocalcuria

(all others, loops, potassium sparing, increase urinary calcium excretion)

15

longstanding smoking and chronic productive cough with recent hemoptysis

chronic cough with daily production of copious mucopurulent sputum in setting of recurrent respiratory tract infections

diagnoses?

Chronic Bronchitis - smoking, chronic small productive cough with recent hemoptysis

Bronchiectasis - irreversible dilation and destruction of bronchi, chronic cough and impaired mucus clearance, history of recurrent URIs and copious mucupurulent sputum... can also cause hemoptysis

16

3 most common causes of hemoptysis in adults

pulmonary airway disease
-chronic bronchitis
-bronchogenic carcinoma
-bronchiectasis

17

define chronic bronchitis

most common cause

Chronic Productive Cough ^3months in 2 successive years

smoking most common cause

18

how can ruptured AAA cause hematuria

can rupture into retroperitoneum, cause aorto-caval fistula (aorta-IVC) backup of venous system, bleeding of bladder veios, hematuria

19

potential ECG changes with ruptured AAA

ischemic changes
eg ST Depressions

20

TF
Drug Fever is a common cause of fever 1-2 hours postop

F
Drug Fever 1-2 WEEKS postop -- more allergic picture with rash and eosinophilia

1-2 hour postop fever ddx is
-preop infection or trauma
-malignant hyperthermia
-medications side effect (eg to anesthesia... but this is NOT "Drug Fever"
-Febrile NonHemolytic Transfusion Reaction to Blood Products

21

Febrile NonHemolytic Transfusion Reaction

time to onset
cause
treat

1-6 Hours after transfusion

cytokine buildup in stored blood by residual leukocyte debris

stop transfusion, rule out other serious causes of fever (acute hemolytic ABO incompatability), antipyretics (avoid aspirin if thrombocytopenic)

22

appendicitis symptoms ^5 days with phlegmon with abscess that has walled off

manage

manage conservatively with abx and bowel rest, then Delayed Appendectomy weeks later

23

trauma to sphenoid bone will classically cause... epidural or subdural hematoma? how?

sphenoid trauma - Epidural Hematoma - tearing of Middle Meningeal Artery

24

sphenoid trauma, bruise, ipsilateral pupillary dilation

diagnosis?
mechanism of pupillary dilation?
how to treat when focal neurological deficits?

epidural hematoma

increased intracranial pressure
uncal herniation - CN III Palsy and Hemiparesis

if FNDs treat with Craniotomy to decrease ICP

25

brief unconsciousness, lucid interval, then worsening state again... what kind of dural hematoma

epidural hematoma

26

most common location of urethral injury with pelvic fracture, why

next step if suspected

what to do with urine leading up to urethral repair

Posterior Membranous urethra at bulbomembranous Junction (between prostate and penis) -- where less support and risk for tearing when bladder and prostate elevated in pelvic fracture

get Retrograde Urethrogram

temporary Suprapubic Catheter while awaiting Delayed repair when associated with pelvic fracture... don't foley because may damage urethra more, don't repair immediately unless anterior urethra without pelvic fracture... because must address pelvic fracture first...

27

acanthosis nigracans (thick velvety skin plaques) in PCOS indicates

insulin resistance (diabetes)

suggested by acanthosis nigracans thick velvety skin plaques

28

how does clomiphene citrate induce ovulation

Selectively Blocks Estrogen Receptors in Hypothalamus to Restore Pulsatile GnRH, normalize LH and FSH and LH SURGE

29

how could bromocriptine induce ovulation

Dopamine Agonist blocks HyperPROLACTINEMIA which was preventing ovulation

30

what is Cyclic Progesterone supplementation's role in the the treatment of PCOS

endometrial protection from uncontrolled anovulatory estrogen fueled proliferation

31

when are pregnant women screened for diabetes

and how, fasting glucose?

screen at 24-28 Weeks for Gestational Diabetes

Earlier IF HIGH RISK

screen with 1 Hour OGTT, more sensitive than fasting blood glucose

32

TF
if pregnant woman not flu-vaccinated, and it is flu season, the next best step is always Vaccinate with Inactive Virus

TRUE

Vaccinate in ANY TRIMESTER and IF BREAST FEEDING, NO CONTRAINDICATION to INACTIVE virus

...active vaccine contraindicated in pregnancy

33

44yo F with night sweats, insomina, irregular periods 6 mos, otherwise healthy -- no thyroid abnormality on exam

top 2 ddx?
next steps

still HyperThyrodism and Menopausal transition even with normal thyroid exam, a little early for Menopausal transition (usually ^45yo) but not very early...

so think TSH and FSH next... must rule out thyroid issue before concluding menopausal

34

pale enlarged turbinates, transverse nasal crease, and pharyngeal cobblestoning are suggestive of ___

treat with ___
less effective alternatives include...

pale enlarged turbinates, transverse nasal crease, and pharyngeal cobblestoning suggest ALLERGIC RHINITIS

treat with INTRANASAL CORTICOSTEROID

less effective alternatives include nonsedating oral antihistamines, cromolyn nasal sprays, leukotriene modifiers

35

TF
intranasal glucoccorticoids for allergic rhinitis cause rebound congestion (rhinitis medicamentosa)

FALSE

that's nasal decongestant sprays (alpha antagonists?) that cause rebound congestion rhinitis medicamentosa

intranasal glucoccorticoids are first line for allergic rhinitis

36

genitopelvic pain / penetration disorder
aka
risks
features, key absent feature
treatment

aka vaginismus

risks - past trauma, abuse, lack of sexual knowledge

features - pain and anxiety re Penetration (not external genital tenderness) with no medical cause

treat - desensitization therapy, kegels

37

vulvodynia and pudendal neuralgia will produce pain/tenderness where

superficial vulva / external genitalia

38

watch out especially for concurrent use of these two drug classes when prescribing sildenafil

nitrates, alpha blockers

(risk combined hypotension)

39

manage suspected PE in 3 steps

1 - O2, IVMF
2 - assess for Contraindication to Anticoagulation - if CI, diagnostic testing

3 - if No CI, assess PE probability with Modified Wells Criteria
-3points if DVT or PE most likely dx
-1.5points if prior DVTPE, HR^100, or recent Surgery or Immobilization
-1point if Hemoptysis or Cancer
---^4 PE likely (and in distress), anticoagulate
---v4 PE unlikely, get diangostic testing

Basically, if PE most likely and patient in distress and no CI, skip diagnostics and anticoagulate... because huge in reducing mortality

40

postop CABG guy intubated in SICU with fever WBC RUQ tenderness... most likely dx?

even with no jaundice and normal LFTs?

diagnose
treat

ACALCULOUS CHOLECYSTITIS (F WBC RUQ pain with risk factors... yes jaundice and lft abnorms are less common... if Alk Phos elevated think more Cholangitis)

risk factors are severe trauma or recent surgery, critical ICU illness, prolonged fasting or TPN

RUQ US.... HIDA or CT if needed

antibiotics, cholecystostomy till clinically stable for cholecystectomy

41

Acute Acalculous Cholecystitis is acute inflammation of the gallbladder in the absense of gallstones most commonly seen in

acute acalculous cholecystitis most commonly seen in Hospitalize and Critically ill Patients

42

MVA guy with blow to lower abdomen and pelvis with chemical peritonitis... what part of GU system probably injured? Why? Mechanism?

Dome of bladder
adjacent to peritoneal cavity

sudden blow and increase in bladder pressure while full can cause rupture upward into peritoneal cavity and chemical peritonitis... lower pelvic bladder injuries urethral injuries and retroperitoneal structures etc not going to cause intraperitoneal leaks and peritonitis... more lower abdominal pain or back/flank pain

43

1st and 2nd line therapy for BPH

alpha blockers (terazosin, tamsulosin)
-1st line, fast onset, rapid relaxation of bladder neck and prostate smooth muscle

5-alpha reductase inhibitors (finasteride)
-2nd line, delayed effect,... take months to shrink prostate

44

normal post void residual in nonoperative patient

v12ml

45

TF
low PSA means less suspicion for BPH

Fish not really
PSA suggests prostate cancer... also BPH a little bit... but less...

46

when to get Urodynamic studies in general

when to get in setting of BPH

urodynamics to assess for Overactive Bladder, Neurogenic Bladder

get in BPH if FAILED Medical treatment or Atypically present v50yo

47

15yo 2 years post-manarche with irregular cycles, family history of PCOS but she has no ovarian cysts no hirsutism no obesity etc... positive bleed with progesterone challenge...

cause of irregular menstrual cycles probably PCOS or or just developing HPA axis? cause of each? Typical time to HPA normalization in newly menstruating female?

prob HPA immaturity (low GnRH secretion... so estrogen but not regular ovulation or progesterone so uterine buildup and positive bleed with progesterone challenge).... can take 1-4 YEARS TO NORMALIZE

anovulation in pcos from elevated androgens and LH... without other signs hpa immaturity is more likely

48

first 5 steps for suspected variceal hemorrhage in cirrhotic with hematemesis

f/u management

2 large bore IV catheters

Fluids
IV Octreotide
Abx

Endoscopic eval/therapy Urgently

f/u BB, band ligation, TIPS depending on control

49

megacolon/megaesophagus with cardiac disease in Latin American think...

CHAGAS disase
chronic protozoal disease cause by
TRYPANOSOMA CRUZI

50

2 primary manifestations of Chagas disease

demographic
bug

pathophys

Megacolon/Megaesophagus
Cardiac disease

Latin America
Trypanosoma Cruzi

destruction of Nerves to GI smooth muscle
Myocarditis from protozoal infection

51

general Diptheria symptoms

Upper Respiratory Tract symptoms with Diptheria

52

treat frostbite

rapid rewarming with Warm Water ~body temp

analgesia and wound care

Thrombolysis if severe/limb-threatening/amputation probable
(not for limited distal frostbite)

53

when is debridement indicated for frostbite

after rewarming and accurate survey of devitalized structures

54

for what diagnosis are CCBs nifedipine amlodipine indicated for cold fingers

Raynaud's

55

most common causes of Cirrhosis in the USA

viral Hepatitis B more than C
Alcoholism
NAFLD
Hemochromatosis

56

what are you looking for in family history of cirrhotic

hemochromatosis (bronze diabetes, cardiomyopathy, arthropathy)

57

pt with heart failure diagnosed 2 mos ago and treatment started now has chronic dry cough 1 month but no signs of heart failure, seems well controlled... likely cause of cough?

ACEI - angioedema, cough
prob started as 1st line for CHF
produces cough in 20% of patients

58

what CHF drug class should always be considered on the differential for chronic cough?

ACEI
bradykinin, agioedema, cough

59

old guy gross hematuria or microscopic hematuria with cancer risks with no evidence of glomerular disease or infection... next step

cystoscopy
(bladder cancer... think when painless hematuria)

60

TF
BPH can cause hematuria

T
BPH can cause hematuria
but must rule out bladder cancer before settle on BPH

61

management of inevitable abortion depends on __ and __

options include __ __ and __

patient preference and vital stability

options- Expectant, Misoprostol induction, Suction Curettage (indicated above others if infection or hemodynamic instability)

62

TF
Oxyctocin for medical abortion

F
few oxytocin receptors in fist/second trimesters

Misoprostol for medical abortion

63

hallmark LFTs of Ischemic Hepatic Injury (Shock Liver)

timecourse of abnormalities

Massively Elevated AST ALT
modest tbili and alk phos

spike within a day of insult
1-2 weeks to recovery after treated

64

TF
prostate cancer commonly mets to liver

FALSE
prostate mets to Pelvic Lymph Nodes and Bones

To Liver: Colon Cancer #1, also Lung and Breast

65

most common mets to liver

Colon #1

Lung and Breast

66

Mets to liver on CT

next diagnostic test

Colonoscopy

most common Mets to Liver: Colon #1, Lung and Breast

67

old guy with mets to liver, slightly enlarged prostate, most probable source of mets? Next test?

Colon Cancer #1 Mets to Liver
also Lung and Breast
get COLONOSCOPY

Prostate mets to Pelvic Lymph Nodes and Bones not liver

68

how does NSAID cause AKI

constricts afferent arteriole

69

cause of AKI in HepatoRenal Syndrome

treat

does it improve with volume resuscitation?

Cirrhosis, Portal HTN, SBP and GI Bleeding, SPLANCHNIC ARTERIAL DILATION and DECREASE IN OVERALL VASCULAR RESISTANCE..... RAAS Activation, Renal Vasoconstriction

treat - recover hepatic function by ABSTAINING from Alcohol, or TRANSPLANT... temporize to transplant with splanchnic vasoconstrictors - Midodrine, Octreotide, Norepiniephrine... Albumin.... maybe Dialysis

does not improve with volume resuscitation... not from hypovolemia

70

3 most common causes of ATN

and UA findings

Aminoglycosides
Iodinated Contrast Dye
Hypotension

Muddy Brown Granular Casts on UA

71

HepatoRenal Syndrome

does it improve with volume resuscitation?

why/why not?

No, HRS does not improve with volume resuscitation

because not due to hypovolemia... due to Splanchnic Arterial Dilation and Decrease in Overall Vascular Resistance

(Cirrhosis, Portal HTN, SBP and GI Bleeding, SPLANCHNIC ARTERIAL DILATION and DECREASE IN OVERALL VASCULAR RESISTANCE..... RAAS Activation, Renal Vasoconstriction)

72

2 causes of AIN

and UA findings

Infection and some Antibiotics both cause AIN

White Cells and White Cell Casts on UA

73

causes of ATN vs AIN an UA differences

ATN - Aminoglycosides, Iodinated Contrast Dye, Hypotension...Muddy Brown Casts

AIN - Infections and certain Antibiotics... WBCs and WBC Casts

74

hearing loss with dull hypomobile tympanic membrane in AIDS patient

diagnosis
pathophys

Serous Otitis Media

HIV LYMPHADENOPATHY or OBSTRUCTING Lymphoma leads to NON-INFECTIOUS Middle Ear Effusion

75

___ is a demyelinating disease that can occur in patients with HIV/AIDS with CD4 count v___

PML Progressive Multifocal Leukoencephalopathy

is a demyelinating disease that can occur in HIV/AIDS pts with CD4 count v200

76

when to bronch a chronic cough

RARELY
only if foreign body suspected really

77

TF
asthma may present with chronic cough that is predominantly nocturnal

how does this knowledge inform your workup

T
so if already failed a 1st gen H1 blocker (not upper airway cough syndrome / postnasal drip,
already on a PPI (not GERD)
not on an ACEI
low suspicion of infection or cancer

consider PFTs

78

2, TWO major toxic products of combustion (fire) in closed spaces

treat one empirically
why

do they cause methemoglobinemia?

Cyanide - combustion of foam cotton paint silk Nitrogen Containing Polymers
-HydroxoCobalamin or Sodium ThioSulfate Antidotes (bind cyanide)
-Nitrites to Induce Methemoglobinemia (Fe3 which binds cyanide) IF NO ANTIDOTE AVAILABLE
-Respiratory support, Fluid support
----treat to avoid eg CARDIORESPIRATORY ARREST and PERMANENT NEUROLOGIC DISABILITY, no way to measure exposure so treat empirically

CO Carbon Monoxide #2

-Methemoglobinemia (oxidation of ferrous Fe2 to Ferric Fe3 in Hb which cannot bind oxygen causing a functional anemia) occurs after exposure to Oxidizing agents DAPSONE NITRATES topical/local ANESTHETICS.... NOT FIRE, NOT CO POISONING... that is carboxyhemoglobin... i think...

79

how does Cyanid toxicity, e.g. inhaled in house fire /combustion of nitrogen containing household polymers, cause Lactic Acidosis?

Cyanide Reduces Oxygen Utilization by Tissues

inhibits cytochrome oxidase a3 in mitochondrial electron transport chain by binding Ferric Fe3 preventing reduction to Ferrous Fe2 so NO ATP from Oxydative Phosphorylation so ANAEROBIC METABOLISM and LACTIC ACIDOSIS

80

TF
unilateral pleural effusion rules out CHF as the cause

F
usually bilateral in CHF but 10-30% unilateral

81

pH of

normal pleural fluid
transudative pleural effusion
exudative pleural effusion

normal - 7.6 (higher than serum)
transudate - 7.4-7.55 (serum plus)
exudate - 7.30-7.45 (serum minus)

82

what to think of high amylase in pleural fluid

think pancreatitis-associated effusion or esophageal rupture (saliva)

83

sympathetic ophthalmia
aka
is characterized by

aka "spared eye injury"

characterized by immune recognition (antibody or cell-mediated) of "hidden" antigens in one eye (the sympathetic eye) after a penetrating injury to the other eye

84

inflammation and breast inflammation/dimpling/pitting without fever is trying to point you to

peau d'orange INFLAMMATORY BREAST CANCER

(DIMPLING NOT typically seen with MASTITIS or INFECTION... THINK CANCER... ABSENCE OF FEVER should also make you think LESS MASTITIS/INFECTION and MORE CANCER)

workup is mammography, ultrasound, tissue biopsy

85

morbidly obese woman stopped breast feeding 2 mos ago now with 1 month of unilateral breast pain and inflamed dimpling/pitting no fever...

top diagnosis is
workup is

peau d'orange INFLAMMATORY BREAST CANCER

(DIMPLING NOT typically seen with MASTITIS or INFECTION... THINK CANCER... ABSENCE OF FEVER should also make you think LESS MASTITIS/INFECTION and MORE CANCER)

workup is mammography, ultrasound, tissue biopsy

86

what helps you differentiate between Mastitis, Infection, and Inflammatory Breast Cancer on patient presentation with painful breast

Mastitis/Infection - fever

Inflammatory Breast Cancer - peau d'orange dimpling/pitting

87

___ is a benign palpable breast mass most commonly found in young women -- estrogen-sensitive tumor typically firm and mobile with regular borders and spherical shape

Fibroadenoma

is a benign palpable breast mass most commonly found in young women -- estrogen-sensitive tumor typically firm and mobile with regular borders and spherical shape

88

___ is a benign condition that typically presents with unilateral bloody nipple discharge and no other symptoms or skin changes

Intraductal Papilloma

is a benign condition that typically presents with unilateral bloody nipple discharge and no other symptoms or skin changes

89

treat laryngeal edema from food allergy eg sob in restaurant

epinephrine
systemic corticosteroids
antihistamines

90

empty gestational sac with yolk sac but no fetal pole and b-hCG 25,000 dropped to 24,000 with no change to ultrasound suggests...

missed abortion or molar pregnancy?

missed abortion - sac no fetus or fetus no heart rate with closed cervix, declining b-hCG

mole would be snowstorm appearance and b-hCG SUPER high like 100,000

91

adult single toxic dose of acetaminophen
peds toxic dose

first step in management

7.5g adult, 150mg peds
Activated Charcoal if v4 hours since ingestion,
measure Acetaminophen level

92

^3 mos fever weight loss fatigue cough hemoptysis or dyspnea

cavitary lung lesion with debris/fluid on CT with history of cavitary TB

think
pathophys
diagnose
treat

chronic pulmonary aspergillosis

aspergillus many of us are exposed to every day can get traction in underlying lung disease / prior cavitary TB especially or immunocompromise

diagnose with aspergillus IgG

treat with VoraconAZOLE and maybe CaspoFUNGIN

93

Actinomyces israelii is an anaerobic bacterium that usually causes infections where...

CervicoFacial infections from Actinomyces

94

fever fatigue weight loss
pulmonary disease with cavitary nodules
nasal/sinus/ear symptoms
renal insufficiency and active urine sediment

think

GPA Granulomatosis with Polyangiitis
(ENT Pulm Renal stuff...)

95

Amikacin belongs to this class of drugs that may be used to treat multi-drug resistant pyelo and can cause acute failure of this organ

Amikacin
Aminoglycoside
can cause ARF Acute Renal Failure (ATN not AIN)

96

what kind of renal failure does Nafcillin cause, is it used in MDR pyelo

Nafcillin, AIN
MSSA not MDR organisms

97

use Vanc to treat MDR pyelo?

probably not
Vanc for MRSA... MDR pyelo probably GNR

98

TF
Vanc can cause nephrotoxicity

T at HIGH DOSES

99

TF
Levofloxacin can cause renal toxicity

F
fluoroquinolones must be renally dosed but do not cause renal toxicity

100

Doxycycline 4 common uses

CAP
Lyme...other zoonotic infections...
Chlamydia
Acne

101

Azithromycin 4 common uses

CAP
Sinus Infections
Strep Pharyngitis
Chlamydia

102

Aminoglycosides are used to treat ___

monitor for __toxicity

Serious Gram Negative Infections

monitor for Nephrotoxicity (ATN)

103

TF
impaired lung expansion from pleural calcifications cause respiratory compromise in asbestosis patients

False
there are pleural calcifications but it is Pulmonary Fibrosis (Interstitial Lung Disease) that causes respiratory compromise

104

TF
xanthelasma and hyperlipidemia are consistent with PBC

T
don't ask me why

105

TF
PBC can cause hepatomegaly with high Alk Phos but normal ast alt

T

106

3 adverse effects of oxytocin

do they include uterine rupture

HypONatremia (oxytocin similar to ADHvasopressin)

HypOtenison

Uterine TachySystole - abnormally frequent contractions

(NOT uterine rupture really unless uterine abdnormalities, scars, multiple gestation, abnormal placentation)

107

what is Vasa Previa
how can it affect mom and fetus

Vasa Previa - fetal blood vessels (yes, the cord) cross the fetal membranes between teh fetus and the inernal cervical os... then loop back in a longer path outside the membranes to the placenta.... instead of normally taking a more direct route not near the cervix

PAINLESS antepartum hemorrhage for mom

but RAPID DETERIORATION of FETAL HEART TRACING... because hemorrhage is of fetal origin

108

placenta previa vs vasa previa -- painful or painless -- fetal heart tracing affected?

placenta previa - painless, no FHT effect

vasa previa - painless, FHT distressed (big fetal blood loss)

109

pain with placental abruption?

umm YES distended and TENDER UTERUS with abruption

110

diagnose vaginal lesion suspicious for vaginal cancer

biopsy that shit

111

SCC vs Clear Cell Adenocarcinoma of the Vagina

age
risk factor
location
diagnose

SCC ^60yo Smoking HPV upper Posterior vagina

Clear Cell Adenocarcinoma in utero Diethylstilbesterol v20yo upper Anterior vagina

biopsy both

112

why is vaginal breech delivery bad

what do you recommend instead

vaginal breech bad because higher fetal Asphyxia and Trauma

prefer External Cephalic Version or breech C-section

113

what is internal podalic version of fetus

breech eg butt first.. reach in and deliver feet first

114

presentation of Benign Intraductal Papilloma vs Infiltrating Ductal Carcinoma

unilateral Bloody nipple discharge Without mass or lymphadenopathy
- benign intraductal papilloma

pathologic nipple discharge but Mass and Lymphadenopathy
- infinltrating ductal carcinoma

115

other symptoms to look for when trying to attribute seizure to hypoglycemia

Hanger - anxiety, tremor, cognitive impairment, diaphoresis

116

why can S3 be normal in young folk and athletes

from splash into large left ventricle.... fast depol and relaxation causes suck-splash?

otherwise think chf...

117

TF
Lupus flare during pregnancy is a thing

T
Increased Risk of Lupus Flare in Pregnancy and Postpartum

causes obstetrical complications such as preeclampsia, premature birth, c-section, growth restriction, fetal demise

118

signs of Lupus Flare as cause of pregnancy proteinuria rather than preeclampsia

lupus stuff: associated joint pain, malar rash, bloody casts in urine, decreased complement levels, incraesed ANA titers

119

Hemolytic Uremic Syndrome presents with ___ ___ and ___ most often due to ___

Hemolytic Uremic Syndrome presents with Renal Injury, Thrombocytopenia and MAHA Microangiopathic Hemolytic Anemia most often due to Shiga Toxin producing E.Coli

120

TF
hepatitis and panlobular mononuclear infiltration with hepatic cell necrosis on biopsy is consistnent with Isoniazid side effect eg in the treatment of pulmonary TB

what other drugs also do this

T
this is what Isoniazid-Induced Hepatic Cell Injury looks like....
Idiosyncratic Liver Injury with Histological Features Similar to Viral Hepatitis

Isoniazid, Halothane, phenytoin, alpha methyl dopa....

just watch out for hepatic stuff after starting drugs...

121

how often to screen healthy 70yo lady with

mammogram
lipid panel
blood pressure
DEXA scan

in old lady

mammo q2 age 50-74
lipid panel... no just q5 for men over 35 and women at high risk over 45

BP q2
DEXA for osteoporosis at least once over 65

122

treat VTach

IV Amio of stable
Cardioversion if unstable or severely syptomatic

123

carotid sinus massage useful for what arrhythmia

PSVT
paroxysmal supraventricular tachycardia
(narrow complex)

124

digoxin for what arrhythmia

afib aflut atach

125

pt diagnosed previously with chronic bronchitis but seeming more like bronchiectasis now (less smoking with little production and viral exacerbations, more difficulty clearing tons of mucus with bacterial infections and sinus congestion...)

workup?

high resolution chest CT #1 best test for bronchiectasis

Immunoglobulin quantification

CF testing, sputum culture

PFTs

126

chronic bonchitis vs bronchiectasis

smoking
sputum production
viral vs bacterial
antibiotics

chronic bronchitis - smoking, small sputum, viral exacerbations

bronchiectasis - copious sputum production, bacterial exacerbations, antibiotics

127

"linear atelectasis" on cxr suggests...

bronchiectasis

128

cxr linear atelectasis, dilated and thickened airways, irregular peripheral opacities

hrct bronchial dilation, lack of airway tapering, bronchial wall thickening

diagnosis?
pathogenesis
obstructive?

bronchiectasis
airway/bronchial dilation from recurrent infection, inflamation, tissue damage from bacterial infections with impaired clearance
yes, obstructive

129

most common cause of Massive lower GI bleed

hemorrhiods?

diagnose
treat

Diverticulosis

(hemorrhoid bleeds rarely massive)

diagnose diverticular bleed with colonoscopy

most diverticular bleeds spontaneously resolve, if not, endoscopic or surgical therapy

130

diverticulosis most common in the ___ colon but diverticular bleed most common in the ___ colon

diverticulosis left colon
but diverticular bleeds more common right colon

so may get a little darker, maroon

131

___ causes sudden onset abdominal pain and tenderness followed by rectal bleeding.... due to inadequate perfusion of watershed area of colon (splenic flexure) in setting of nonocclusive ischemia or surgical intervention

ischemic colitis

132

indoor barbecue, headaches nausea vomiting abdominal pain confusion coma pinkish-red skin hue

think
get
treat

CO poisoning
Carboxyhemoglobin level
Hyperbaric oxygen

133

bitter almond breath is characteristic of inhaled ___

bitter almond breath is characteristic of inhaled Cyanide

134

drug or environmental exposure, headache nausea vomiting abdominal pain confsion coma bluish discoloration of skin and mucous membranes

think

methemoglobinemia

135

CO poisoning vs Methemoglobinemia

skin color?

CO Pinkish-red skin

Methemoglobinemia Bluish cyanosis

136

plaque-like reddish-brown velvety lesions at intertriginous areas without cyst formation think

condylomata lata
(secondary syphilis)

137

young guy with agitation, dilated pupils, atrophic nasal mucosa, htn, MI

think
pathophys
treat with 4
avoid 2

cocaine
block norepinephrine reuptake by sympathetics, increased sympathetic alpha and beta adrenergic stim, hr bp cardiac oxygen demand, coronary vasoconstiction, platelet activation

Supplemental O2 and IV BENZODIAZEPINE... reduces sympathetic outflow
ASPIRIN
NITRATES and CCBs

avoid bb's... can unappose alpha and worsen coronary vasoconstriction
avoid thrombolytics unless STE like always

138

all patients with acute cocaine toxicity and myocardial ischemia should be treated initially with supplemental oxygen and ___

IV Benzodiazepines for cocaine toxicity.

...reduces sympathetic outflow and symptoms

139

empiric treatment of CAP

outpatient healthy
outpatient comorbidities
inpatient
ICU

Macrolide or Doxy if healthy outpatient

respiratory fluroquinolone (Levofloxacin or Moxifloxacin) or Beta Lactam and Macrolide (Ceftriazone and Azythromycin) if comorbidities outpatient or inpatient (IV if inpatient)

Beta Lactam and Macrolide (Ceftriaxone Azythromycin) or
Beta Lactam and Fluoroquinolone (Ceftriaxone and Levo or Moxi)
IV if ICU





140

to admit for CAP?

CURB-65
Confusion
Urea (BUN) ^20
Respiratory rate ^30
BP v90/60
^65yo

outpatient if 0
admit if 1-3
prob ICU if 4-5

because mortality

141

define excess alcohol
define binge drinking

excess ^2 drinks per day
binge ^5 drinks at a time

142

what does FeNa v1% tell you about AKI

likely prerenal
(kidneys retaining most sodium and fluid, not excreting in urine)

143

TF
prerenal AKI can lead to ATN

T

144

lactational mastitis

pathophys
bug

how do myalgia chills malaise change management? erythema and tenderness in one quadrant but no fluctuance?

treatment?

sin fluora or infant oral fluora multiplying in stagnant milk ducts
Staph Aureus most common

myalgia chills malaise common, do not change management, neither does tenderness localized to one quadrant without fluctuance

-still Keep Breastfeeding (for infant nutrition and to treat mastitis, better than pumping)
-Analgesia
-anti-MSSA abx Dicloxacillin or Cephalexin... if MRSA Clindamycin TMPSMX or Vancomycin

145

2 keys to differentiating between cholecystitis and cholangitis

total / direct bili? transaminases?

cholangitis will have additional Jaundice and Higher Alk Phos

not bili so much... cholecystitis can cause mild transaminase elevations and bili elevation up to 4 mg/dl

146

treat PBC

if elevatged Alk Phos and anti-mitochondrial antibody but asymptomatic?

if PBC advanced?

early, even asymptomatic PBC - URSODEOXYCHOLIC ACID... limits bile injury to bile duct and antiinflammatory and immunomodulatory

if advanced PBC with cirrhosis - LIVER TRANSPLANT

147

TF treat PBC with steroids

F
treat PBC with Ursodeoxycholic acid
(treat AI Hepatitis with Steroids)

148

___ should be initiated as soon as diagnosis of PBC is made

Ursodeoxycholic acid

should be initiated as soon as PBC diagnosed, even if asymptomatic... limits bile duct injury and has antiinflammatory and immunomodulatory effects

149

best test to diagnose acute Hep B infection

HBsAg and anti-HBc IgM

HBsAg is the Ag that occurs early with other Ags in infection but lasts the longest

anti-HBc IgM because covers window period in which HBsAg vanishes but anti-HBs is yet to arise

-HBcAg is not detectible in serum
-HBeAg demonstrates INFECTIVITY but levels fall early so HBsAg a better marker of infection

HBV DNA used in chronic HepB to indicate antiviral treatment and monitor response

150

TF
esophageal rupture possible with vomiting

T
it's called Boerhaave syndrome

151

in smoker with chronic cough and small sputum production exacerbated by URTIs, also with dyspnea, decreased vital capacity on PFT, which of the following is true?

alveolar-capillary membrane thickening

decreased FRC

air trapping with expiration

decreased lung distensibility

This patient has cOpd - bronchitis (chronic cough smoker some sputum urti viral exacerbations) and emphysema (dyspnea)
OBSTRUCTIVE

so Air Trapping

not alveolar thickening - destruction
not decreased frc - increased frc.. cannot get air out
not decreased distensibility - increased lung distensibility

152

hypercalcemia associated with which lung cancer

SCC
sCa++mous cell carcinoma
PTHrp

153

TF
suspect TB in USA non-immigrant with unilateral hilar mass and hypercalcemia

F
not so much, TB rare in USA unless immunosuppressed

think more SCC squamous cell carcinoma of the lung

154

TF
small cell lung cancer causes hypercalcemia via PTHrp

F
SCLC - SIADH and ACTH

Squamous cell carcinoma SCC - PTHrp
sCa++mous cell carcinoma

155

TF
suspect sarcoidosis in unilateral hilar mass and hypercalcemia

F
think more SCC squamous cell carcinoma of the lung PTHrp

think sarcoid if Bilateral hilar masses and erythema nodosum

156

treat / prevent uric acid ureteral stone

hydration
Alkalinize Urine to pH 6-6.5 with Potassium Citrate
Allopurinol if recurrent despite above

157

thiazide diruetic, loop diuretic, or potassium citrate to treat uric acid kidney stone?

Potassium Citrate to treat Uric Acid stone -- K Alkalinizes urine to pH 6-6.5, Citrate inhibits stone formation

thiazides decrease Calcium stone formation

loops increase calcium stone formation... bad...

158

most common cause of aortic regurge

developing countries

developed countries

developing country AR - rheumatic heart disease

developed country AR - bicuspid aortic valve, aortic root dilation

159

most common electrolyte abnormality in alcoholism and how does it cause refractory hypokalemia

hypomagnesemia most common in alcoholic

normally inhibits K+ secretion by kidney, so low magnesium makes hard to replete K+ because kidney just excretes it

160

low albumin causes __ total calcium, because...

low albumin LOW total calcium... because lots of calcium is protein bound

161

adult patient with nephrotic proteinuria and anasarca gets acute flank pain and hematuria

caused by
why
renal biopsy most likely shows

caused by Renal Vein Thrombosis

nephrotic proteinuria loses Antithrombin III

possible with any nephrotic syndrome but most common with MG Membranous Glomerulonephropathy

RVT MG