Review Notes Flashcards
(309 cards)
1
Q
Pt presents with 2 days of fever, headache, confusion, malaise, and myalgias. He reports a tick bite 2 weeks ago while hiking in Arkansas. PE is normal, including absence of any rash. Labs reveal thrombocytopenia, leukopenia, elevated LFTs and LDH. Dx and Tx?
A
Ehrlichiosis
Tx with empiric doxycycline while awaiting confirmatory testing (intracytoplasmic morulae in monocytes, PCR testing)
[Think Rocky Mountain spotted fever without the rash]
2
Q
Normal creatine kinase, normale aldolase, elevated ESR. Pt presents with proximal muscle stiffness and pain
A
Polymyalgia rheumatica
3
Q
thin, off-white vaginal discharge, pH >4.5, no vulvar/vaginal inflammation
A
bacterial vaginosis
4
Q
In patients presenting with fever and cough productive of foul-smelling sputum after instrumentation of upper airway or esophagus, an anaerobic lung infection should be suspected. What are 3 common antibiotic options for anaerobic coverage?
A
Amoxicillin + Metronidazole
Amoxicillin-clavulanate
Clindamycin
5
Q
Asking about smoking in the social history is an example of _______ prevention
[primary/secondary/tertiary]
A
secondary
[Primary prevents disease from occurring, Secondary typically involves screening and further action if screening is positive, tertiary is providing tx to reduce negative impact of dx]
6
Q
Painless mass in the thyroid gland; psammoma bodies
A
Papillary carcinoma
7
Q
Pts <45 who have endometrial cells seen on Pap smear do not have these included in the report, because this is a common benign finding (especially in proximity to menstrual cycle). However, pts >45 will have them included in the report if found, as this is concerning for abnormality. What is the next step in management if a pt >45 has endometrial cells seen on routine Pap smear?
A
endometrial biopsy
8
Q
Best benzo to use in pts with liver insufficiency
A
Lorazepam
9
Q
Children <2 y/o with a first febrile UTI should receive 1-2 weeks of antibiotics as well as what additional test?
A
renal and bladder US to evaluate for abnormalities that may lead to recurrent UTIs
10
Q
Pt presents with hypercalcemia secondary to excess ingestion of calcium tablets. IV fluids are administered, but hypercalcemia persists. What is the next step in management?
A
Intranasal calcitonin and bisphosphonates
11
Q
Treatment for hair loss in women vs. men
A
Female pattern hair loss (vertex, center of scalp sparing hairline) = minoxidil
Male pattern hair loss (vertex, frontal hairline, temporal areas) = minoxidil, finasteride
12
Q
A pt with a combination of renal failure, hypercalcemia, and anemia should be evaluated for multiple myeloma. Renal insufficiency is a common complication. What is the cause of kidney injury in MM?
A. Glomerular damage B. Renal artery stenosis C. Renal tubular damage D. Urinary outflow tract obstruction E. None of the above
A
C. Renal tubular damage
[Light chain cast nephropathy with resultant renal tubular injury]
13
Q
50 y/o male presents for routine physical. He had a mechanical aortic valve replacement 5 years ago for endocarditis. Vital signs are normal. Auscultation reveals 2/6 diastolic murmur at left sternal border. What is the next best step in management?
A. CBC with smear B. Echocardiogram C. Exercise stress test D. Coagulation panel E. Routine follow up
A
B. Echocardiogram
Diastolic murmur may represent aortic regurgitation, and raises concern for prosthetic valve dysfunction
Note that aortic regurg due to valvular issues (cusp degeneration, annular degeneration, infective endocarditis, etc.) is best heard at left sternal border (in contrast to typical aortic listening post, which reveals AR due to root dilation)
14
Q
Hemangioblastomas
Clear cell renal carcinoma
Pheochromocytoma
A
von Hippel-Lindau syndrome
15
Q
empiric coverage for septic arthritis
A
Ceftriaxone and vanc
16
Q
MEN2A
A
Hyperparathyroidism
Medullary thyroid cancer
Pheochromocytoma
17
Q
First line abx therapy for actinomyces israelii
A
Penicillin
18
Q
Pt with hx of IV drug use presents with bilateral lower extremity paralysis. He has had low back pain and malaise for several days and was unable to get out of bed this morning. He was recently released from prison. Temp is 101, BP 130/85, HR 100. Neuro exam shows loss of sensation and 0/5 strength in b/l lower extremities. Upper extremity assessment is unremarkable. Most likely dx?
A
Spinal epidural abscess
19
Q
which of the following is a risk factor for neonatal RDS?
A. IUGR B. Maternal DM C. Maternal HTN D. Prolonged ROM E. Vaginal delivery
A
B. Maternal DM
20
Q
Pt presents with ocular albinism, neutropenia, and immunodeficiency. Most likely etiology?
A. Abnormal tyrosine kinase B. Defective DNA repair enzyme C. Defective IL-2 receptor D. Microtubular dysfunction E. Reduced NADPH oxidase activity
A
D. Microtubular dysfunction
[Chediak higashi]
21
Q
Young pt with hilar and mediastinal LAD, fever, and weight loss undergoes positron emission tomography scan with 18-fluorodeoxyglucose which confirms suspected dx – what is the dx?
A
Hodgkin lymphoma
[PET scan with FDG is imaging test of choice]
22
Q
Pt with sickle cell trait presents with polyuria, normal serum sodium, and urine with low specific gravity. Most likely dx?
A
hyposthenuria
[inability of kidneys to concentrate urine]
23
Q
acid base disorder seen in atelectasis
A
respiratory alkalosis
24
Q
Gynecomastia, small testicles (hypogonadism), tall stature, long arms/legs, difficulty in school
A
Klinefelter syndrome
25
Ethylene glycol and methanol poisoning share similarities (e.g., they are substitutes for ethanol, induce HAGMA). However, whereas _______ damages the eyes due to effects of its formate metabolite, _________ damages the kidneys (e.g., elevated creatinine) due to glycolate-induced tubule damage and square, envelope-shaped crystals may be seen
methanol; ethylene glycol
26
infant with hepatosplenomegaly, jaundice, and periventricular calcifications. Dx and most common sequela?
Congenital CMV
leads to sensorineural hearing loss
27
Contraindications to IUD placement
Endometrial or cervical cancer
Unexplained/abnormal vaginal bleeding pattern
Gestational trophoblastic disease
Distorted endometrial cavity
Acute pelvic infection
28
65 y/o woman with progressive rash that was initially painful with itchy red spots on her right leg that gradually enlarged and began to crust. PE now shows erythematous plaques with central clearing and eroded borders on the right thigh. There are scattered papule with crusting over lower abdomen and perioral skin. ROS is positive for occasional watery stools and 22 lb weight loss in 6 months. PMH is significant for T2DM. Most likely dx?
Glucagonoma
[rash is called necrolytic migratory erythema]
29
Close contacts of Neisseria meningitidis get prophylaxis. Options include rifampin, ceftriaxone, or ciprofloxacin. What ppx do you give in pregnancy?
Ceftriaxone
30
Which is more important in preventing progression of AAA, smoking cessation or blood pressure control?
Smoking cessation
31
Fanconi syndrome is a rare disorder of proximal kidney tubule function that results in excess amounts of glucose, bicarbonate, phosphate, uric acid, potassium, and certain amino acids being excreted in the urine
What class of abx is associated with the adverse effect of Fanconi syndrome?
Tetracyclines (i.e., doxycycline)
32
TB, varicella, SARS, and measles require what type of isolation precautions?
airborne precautions
33
Methotrexate is contraindicated in management of ectopic pregnancy that is larger than ____ cm, therefore laparoscopic surgery is indicated
4 cm
34
dyspnea and cough in pt that worked in a shipyard
asbestosis
lung biopsy will stain positive with Prussian blue
35
Looking at the reticulocyte count can help in the evaluation of normocytic anemia. What 3 conditions should you consider with a decreased reticulocyte count?
Leukemia
Aplastic anemia
Anemia of chronic disease
36
MEN1
Hyperparathyroidism
Pancreatic tumors
Pituitary tumors
37
What is the single most effective intervention for slowing the progression of diabetic nephropathy?
tight blood pressure control
38
Pt with hx of cardiac dz and T2D requests an additional drug for his diabetes that will help with weight loss. Best option?
```
A. Dipeptidyl peptidase-4 inhibitor
B. Glucagon-like peptide-1 agonist
C. Long acting insulin
D. Sulfonylurea
E. Thiazolidinedione
```
B. Glucagon-like peptide-1 agonist
Recommended options for add-on therapy in its with established cardiovascular disease include GLP-1 agonists (exenatide, liraglutide) which help with weight loss and decrease mortality, as well as SGLT2 inhibitors (canagliflozin, empagliflozin).
39
Preferred treatment for osteoporosis in pts with GFR <30-35
Denosumab
[Bisphosphonates contraindicated in advanced CKD]
40
How long do you anticoagulate in a provoked DVT vs. unprovoked/unknown cause DVT?
provoked DVT: 3-6 months
unprovoked/unknown cause/negative workup: indefinitely
41
Pt presents with altered mental status, anemia with schistocytes, thrombocytopenia, renal insufficiency, and fever. Most likely dx?
Thrombotic thrombocytopenia purpura (TTP)
Classic pentad is thrombocytopenia, microangiopathic hemolytic anemia, renal insufficiency, neurologic changes, and fever
42
Colorectal cancer
Endometrial cancer
Ovarian cancer
Lynch syndrome
43
Polycythemia with high circulating EPO indicates secondary polycythemia. This is usually due to tumors that produce EPO or chronic hypoxia (e.g., cardiopulmonary dz, OSA). Individuals that present with secondary polycythemia in the absence of hypoxia should undergo what next diagnostic step?
Abdominal CT -- to evaluate for renal cell carcinoma (common tumor that produces EPO)
44
Pregnant lady with chronic hepatitis C infection presents for prenatal visit. She has never received hep A and B vaccines. When should she get these?
Now. All pts with chronic hep C infection, including pregnant women, should be immunized against hep A and B if not already immune
45
Both congenital CMV and congenital toxo present with intracranial calcifications, how can you differentiate the 2?
CMV = Periventricular calcifications
Toxo = Diffuse calcifications and ventriculomegaly
46
18 y/o woman presents after fracturing her radius when she fell off a chair. Pt had ambiguous genitalia at birth, and a laparotomy performed at 17 months of age revealed a normal uterus and Fallopian tubes. Ovarian bx performed at that time revealed normal-appearing primordial follicles. She has never had a period. Vitals are normal. Pt has nodulocystic acne over the chest and back. No breast development, normal pubic and axillary hair, and marked clitoromegaly are present. Labs show normal female karyotype and normal glucose and electrolytes. Estradiol and estrone are undetectable in the serum. Serum FSH, LH, testosterone, and androstenedione are high. Pelvic imaging reveals multiple ovarian cysts. Most likely dx?
```
A. Aromatase deficiency
B. Congenital adrenal hyperplasia
C. Kallmann syndrome
D. McCune Albright syndrome
E. Ovarian hyperthecosis
```
A. Aromatase deficiency
Female pts have normal internal genitalia and ambiguous external genitalia at birth. In adolescence, pts have delayed puberty, osteoporosis, undetectable estrogen, and high concentrations of gonadotropins that result in polycystic ovaries
47
When giving tPa for ischemic stroke, it is important to temporarily allow permissive HTN. However, you still need to maintain BP of less than _____, because higher than that is a contraindication to tPA
185/110
48
What must the viral load be in order for HIV positive mom to have a vaginal delivery?
Viral load < 1,000 -- mom gets ART and vaginal delivery
[if viral load is >1,000, mom gets ART + zidovudine + cesarean delivery]
49
Acute salicylate intoxication should be suspected in pts with triad of tinnitus, fever, and tachypnea. It usually causes a mixed primary respiratory _____ and primary metabolic _______ with arterial pH often within normal range
alkalosis; acidosis
50
first-time baby mama is dx with ectopic pregnancy and undergoes salpingectomy. Her blood type is A negative and her Coombs test is negative. Does she need Rhogam?
Yes
Those who are Rh-negative and have a negative Coombs test (negative antibody screen) need Rhogam because the fetal blood type is typically unknown and potentially Rh(D) positive
51
Which of the following ophthalmologic findings is most SPECIFIC to diabetic retinopathy?
```
A. AV nicking
B. cotton wool spots
C. microaneurysm
D. neovascularization
E. retinal hemorrhage
```
D. neovascularization
[AV nicking is more common to HTN. others are seen in both HTN and DM]
52
First-line medication choice in bipolar pts with renal dysfunction
Valproate
53
Federal insurance program that provides health insurance to specific categories of low-income people including children, pregnant women, people with disabilities, and nursing home patients
```
A. Fee-for-service plan
B. Health maintenance organization (HMO)
C. Medicaid
D. Medicare
E. Preferred provider organization (PPO)
```
C. Medicaid
54
normal PT
prolonged aPTT
deficient factor VIII
X-linked recessive
Mixing study corrects the aPTT
Hemophilia A
55
Malignancy and PE cause what type of pulmonary effusion?
Exudative
56
Immunocompromised pt presents with systemic sxs, lung nodules, and brain abscesses resulting in seizures. Cultures grow gram-positive, partially acid-fast, filamentous branching rods. Dx and tx?
Nocardia
Tx with TMP SMX
57
leg length discrepancies of less than ___ cm can be managed with an in-sole shoe lift
2 cm
58
Current guidelines for prevention of infective endocarditis recommend abx prophylaxis for specific invasive procedures in pts with cardiac conditions that are associated with the highest risk of adverse outcomes from IE. What are these conditions?
Prosthetic heart valve
Previous hx of infective endocarditis
Structurally abnormal valve in a transplanted heart
Certain congenital heart disease (unprepared cyanotic CHD, repaired CHD with prosthetic material within 6 months of repair, repaired CHD with residual defect)
59
Looking at the reticulocyte count can help in the evaluation of normocytic anemia. What 3 conditions should you consider with an increased reticulocyte count?
Hemorrhage
Hemolysis due to:
- Spherocytosis
- G6PD def
- Autoimmune
- Microangiopathic
60
Wisconsin farmer presents with fever, night sweats, productive cough, and unintentional 17 lb weight loss over 3 months. Several days ago he noticed skin lesions which appear as multiple well circumscribed verrucous crusted lesions. CXR shows left upper lobe consolidation and 2 lytic lesions in the anterior ribs. Dx?
Blastomycosis
[s/s resemble TB and histoplasmosis, but blastomycosis causes characteristic ulcerated skin lesions and lytic bone lesions; tx with Itraconazole or amphotericin B]
61
Pt presents after a high speed MVA with contusions to the left forehead, left arm, chest, abdomen, and pelvis, but no external hemorrhage. Trachea is midline, heart and breath sounds are normal, abdomen is soft/nontender/nondistended, has normal muscle tone, and FAST scan shows no pericardial or intraperitoneal free fluid. Vitals suggest hemorrhagic shock. Where is this pt likely bleeding from and what is next test?
pelvic fracture leading to tearing of presacral and/or lumbar venous plexus -- blood loss often hidden within retroperitoneum so PELVIC X-RAY is typically performed as an adjunct to trauma primary survey
62
Newborn with microcephaly, micrognathia, overlapping fingers, absent palmar creases, and rocker bottom feet
Trisomy 18 (Edwards syndrome)
Congenital heart disease occurs in more than half of affected pts with VSD being the most common abnormality
63
Uric acid kidney stones are highly soluble in alkaline urine; alkalization of the urine to a pH of 6-6.5 with oral __________ is the tx of choice
potassium citrate
64
Which of the following would relieve pruritus due to cholestasis in the setting of pancreatic cancer?
```
A. Daily antihistamines
B. Daily benzodiazepines
C. Endoscopic stent placement
D. Surgical bypass procedure
E. Ursodeoxycholic acid
```
C. Endoscopic stent placement
[bc pancreatic cancer is causing CBD obstruction, only way to tx is to do stenting. If cholestasis were due to intrahepatic cause, ursodeoxycholic acid would be effective]
65
5 y/o F pt presents with joint pain and rash. Joint pain initially started in her knees, then resolved, but now her ankles and wrists are tender. She also has a nonpruritic pink rash on her back. Pt had a sore throat a few weeks ago that resolved on its own. Temp is 101. Cardiac exam is normal and lungs are clear. Wrists and ankles are stiff and tender to manipulation. Multiple large, well demarcated erythematous nonpruritic patches with slightly raised borders are present on trunk and proximal limbs. CRP and ESR are elevated. Most likely dx?
Acute rheumatic fever
[Look for major and minor Jones criteria - migratory polyarthritis, carditis, subcutaneous nodules, erythema marginatum, Sydenham chorea, fever, arthralgias, elevated ESR/CRP, and prolonged PR interval]
66
Wallenberg's test is a PE maneuver used to test for ____
vertebral artery insufficiency
67
An ECG finding of electrical alternans is pathognomonic for _________
pericardial effusion
68
Pt presents with new onset tachycardia and fever following routine cholecystectomy. She reports recent weight loss of 12 kg, temp is 103.2, BP is 80/52, HR is 148, and RR is 28. PE remarkable for reactive pupils, hyperkinesis with negative babinski, and warm wet skin without edema. What is the most likely adverse event if you leave this condition untreated?
```
A. acute renal failure
B. atrial fibrillation
C. hematochezia
D. intracerebral hemorrhage
E. medullary carcinoma
```
B. atrial fibrillation
[this is hyperthyroidism; a fib is a common arrhythmia in thyroid disease and incidence increases with age]
69
Acute unilateral motor weakness without sensory deficits or higher cortical dysfunction (pure motor hemiparesis) suggests a stroke at what location?
Lacunar stroke affecting posterior limb of internal capsule
70
Pt presents with megaloblastic anemia. Labs reveal equivocal folate and vitamin B12 levels (low end of normal). Follow-up testing reveals elevated homocysteine level and normal methylmalonic acid level. Dx?
Folic acid deficiency
[If both are elevated, it's B12]
71
Pt presents after his roommate is dx with meningococcal meningitis. He had his meningococcal booster 4 months ago. Do you give prophylaxis or not?
YES - prophylaxis for close contacts regardless of immunization status
Can use Rifampin, Ceftriaxone, or Ciprofloxacin
72
Most common type of ovarian cancer in postmenopausal women. Symptoms are often vague and include pelvic and abdominal discomfort as well as urinary symptoms. Pleural effusion and rectovaginal modularity are signs of metastatic spread
Epithelial ovarian carcinoma
73
first line therapy for nonclassical CAH (mild 21-hydroxylase deficiency resulting in hyperandrogegism and oligomenorrhea)
OCPs
[Start spironolactone 6 months later if inadequate response to OCPs. Can also use steroids but not first line]
74
Imaging of choice for developmental dysplasia of the hips in pts >6 months
AP radiograph with hips in neutral position
[prior to 6 months, imaging of choice is US of the hips]
75
A reactive fetal NST means that during a 20 minute interval, there are ____ fetal heart rate accelerations that peak at ___ beats per minute above baseline, and last at least ____ seconds
2+ FHR accelerations
15+ bpm above baseline
15+ seconds
76
What type of RTA?
Hyponatremia and hyperkalemia with urinary pH <5.5 secondary to increased excretion of H+
Caused by a defect in sodium reabsorption, H+ excretion, and K+ excretion
RTA type IV
Etiologies include primary aldosterone deficiency or hyporeninemic hypoaldosteronism, which is seen in diabetes, interstitial nephritis, ACE-inhibitor use, NSAID use, and heparin use
77
66 y/o pt with uncontrolled diabetes presents with 6 months of bloating, abdominal pain, and loose stools unrelated to eating. Carbohydrate breath testing using glucose is abnormal. Most likely dx?
Small intestinal bacterial overgrowth (SIBO)
Gold standard for dx is jejunal aspiration, but the more common test is the carbohydrate test. Treatment is with antibiotics (rifaximin, neomycin)
78
Treatment of ankylosing spondylitis includes NSAIDs and COX-2 inhibitors. If these fail or disease continues to progress, what is next in line?
TNF-a inhibitors (etanercept, infliximab)
Anti-IL-17 antibodies (secukinumab)
79
newborn with hx of shoulder dystocia has claw hand and ipsilateral Horner syndrome. Dx?
Klumpke palsy -- injury to C8 and T1
80
Best option for intrauterine fetal demise in breech position at 24+ weeks gestation
Induction of labor and vaginal delivery (should be done within 2-3 weeks to avoid developing coagulopathy)
REGARDLESS OF FETAL PRESENTATION!
Dilation and evacuation is indicated for IUFD diagnosed at <24 weeks
81
Infant with persistent jaundice, hemolytic anemia, elevated MCHC, and reticulocytosis
hereditary spherocytosis
82
Pt presents with PNA 5 months after liver transplant. CXR shows bilateral diffuse interstitial infiltrate and labs reveal elevated LDH. Etiology?
Pneumocystis pneumonia
83
Most effective emergency contraceptive
Copper IUD
84
What type of RTA?
Presents with signs of renal failure, hypokalemia, and a urinary pH >5.3
Caused by a defect in H+ secretion
RTA type I
Etiologies include hereditary ion channel defects, cirrhosis, autoimmune disorders like Sjogrens or SLE, hypercalciuria, sickle cell, lithium, or nephrolithiasis
85
Pt presents with s/s gonococcal urethritis. NAAT testing is positive for N.gonorrhoeae and negative for Chlamydia trachomatis. What abx?
Ceftriaxone and azithromycin
[Dual tx recommended for gonococcal urethritis due to evolving resistance]
86
what class(es) of hypertensives must be avoided in pts with bilateral renal artery stenosis?
ACE inhibitors
| ARBs
87
Treatment for mycobacterium avium complex
Macrolide + ethambutol
88
Pt presents with left sided weakness. ROS is positive for progressive exertion dyspnea, nocturnal cough, irregular palpitations, and occasional hemoptysis. Most likely dx?
```
A. aortic insufficiency
B. HOCM
C. Mitral stenosis
D. PAH
E. Wolff Parkinson White
```
C. Mitral stenosis
89
How do the following change in CHF due to left ventricular systolic dysfunction:
Cardiac output/index
Systemic vascular resistance
LV end diastolic volume
CO/CI decreases
SVR increases
LVEDV increases
90
Most common complication of sickle cell trait
Hematuria (due to sickling in renal medulla)
[other complications include hyposthenuria, and UTIs - particularly in pregnancy]
91
26 y/o pt presents with blurry vision in left eye that initially began as a "smudge" that gradually enlarged to involve almost entire left visual field. She also states that colors appear "washed out" and there is mild discomfort with eye movement. On PE, when light is moved from right eye to left, the left pupil dilates. Exam is otherwise normal. Dx?
```
A. Acute anterior uveitis
B. Cortical blindness
C. Macular degeneration
D. Open angle glaucoma
E. Optic neuritis
F. Retinal detachment
```
E. Optic neuritis
92
Pts with 30+ year smoking history and are currently smoking or quit within the last 15 years are recommended to get yearly low-dose chest CT to screen for lung cancer starting at age ___
55 (continue until 80)
93
Pt with osteomyelitis after stepping on a nail and Staph Aureus is not an option - what bug?
Pseudomonas aeruginosa
94
Pt recently returned from Nepal and complains of RUQ pain, fever, and hepatomegaly. Abdominal US reveals solitary hypo echoic lesion in right liver lobe. LFTs are mildly elevated. Dx?
Entamoeba histolytica
[protozoan infection, dx with stool ova and parasites, stool Ag test, or serology; TX with metronidazole or intraluminal abx (paromomycin)]
95
Pt with episodic facial flushing, diaphoresis, diarrhea, HTN, tachycardia, and an elevated 5-hydroxyindoleacetic acid level. Where is the primary tumor?
small intestine
[this is carcinoid that has mets to the liver]
96
At birth, classic physical findings include macrosomia, macroglossia, hemihyperplasia, and medial abdominal wall defects (umbilical hernia, omphalocele). Newborns must be monitored carefully because fetal hyperinsulinemia can result in profoundly low glucose at birth
Beckwith-Wiedemann syndrome
97
Autoinflammatory disorder of childhood characterized by arthritis for >6 weeks and fever for >2 weeks. Hepatosplenomegaly and lymphadenopathy are common, and quotidian fevers (spiking once daily) are often accompanied by evanescent pink rash
Systemic juvenile idiopathic arthritis
98
Pt presenting with signs/symptoms of bipolar disorder - what lab should you look at before deciding tx plan?
creatinine -- lithium must be avoided in pts with renal dysfunction
99
Occupations at increased risk for asbestosis include plumbers, electricians, carpenters, construction workers, shipbuilders, and insulation workers. What is the most common malignancy diagnosed in pts exposed to asbestos?
Bronchogenic carcinoma
100
GCS includes best eye response, verbal response, and motor response. What are the scores for motor response?
Obeys commands = 6
Localizes to pain = 5
Withdrawal to pain = 4
Abnormal flexion (decorticate) = 3
Abnormal extension (decerebrate) = 2
None = 1
101
Tx for ventilator-associated PNA due to pseudomonas
amikacin and piperacillin
102
Protracted labor is defined as cervical change slower than expected (>1 cm/hr during active phase of labor) +/- inadequate contractions and can be managed with oxytocin. Arrest of labor is defined as NO cervical change for ___ hours with adequate contractions, or NO cervical change for ____ hours with inadequate contractions, and is managed with cesarean delivery
4+; 6+
103
9 month old presents with a UTI. Most appropriate empiric pharmacotherapy?
third-generation cephalosporin (such as cefixime)
104
Newborn presents with irritability, high-pitched cry, poor sleeping, tremors, seizures, sweating, sneezing, tachypnea, poor feeding, vomiting, and diarrhea. Dx?
neonatal abstinence syndrome - usually d/t opiates
105
Pt with carpal tunnel syndrome tries wrist splints with no relief. What is the next best step in tx?
local corticosteroid injection
[uworld says NSAIDs are ineffective, so next step if steroid injection fails would be surgery]
106
Operates accreditation programs to subscriber hospitals and other healthcare organizations. A hospital that meets this accreditation is deemed to meet the Medicare Conditions of Participation (which is a requirement for Medicare)
A. Centers for medicare and medicaid services
B. Healthcare integrity and protection data bank
C. Joint commission
D. National committee for quality assurance
E. National practitioner data bank
C. Joint commission
107
most common urinalysis finding in acute interstitial nephritis
WBC casts
108
12 y/o boy presents with dark urine for the last 2 days but denies any abdominal pain, dysuria, frequency, urgency, etc. 3 weeks ago he had a fever and sore throat which resolved after 1 week. Family history is significant for a paternal uncle with sensorineural hearing loss and a cousin who recently had a renal transplant. Temp is 99, BP is 150/90, and HR is 84. PE reveals periorbital edema and 1+ pitting edema in lower extremities. UA reveals many RBCs/hpf but is otherwise normal. Dx?
Acute post streptococcal glomerulonephritis
109
first line migraine preventative therapy in pregnancy
beta blockers (propranolol and metoprolol have the best fetal safety profile)
[other options include CCBs]
110
Tx for RTA type IV
furosemide, mineralocorticoids +/- glucocorticoids, low K+ diet
111
first line tx for epiglottitis
Ceftriaxone + vancomycin
[third gen cephalosporins are replacing ampicillin d/t increasing resistance]
112
If you determine that a pt has a primary metabolic acidosis, 3 further steps are necessary to make a diagnosis of the acid-base disturbance.
First, calculate anion gap: Na - (Cl + HCO3)
Then, look for respiratory compensation: (1.5 x HCO3) + 8 +/- 2
The third step is to look for concurrent metabolic acidosis or alkalosis using the formula for delta anion gap. What is the formula?
HCO3 + (anion gap - 12)
If <22 there is concurrent metabolic acidosis
If >26 there is a concurrent metabolic alkalosis
113
Pt with infective endocarditis develops focal neurologic deficits, evidence of increased intracranial pressure, and fever. Most likely dx?
brain abscess
[caused by hematogenous seeding of bacteria or systemic embolization of vegetations]
114
enlargement of lateral cerebral ventricles is the most common finding associated with what psychiatric condition?
schizophrenia
115
First line tocolytic at <32 weeks gestation
indomethacin
116
Common causes of transudative effusions
Hypoalbuminemia (cirrhosis, nephrotic syndrome)
CHF
117
Which of the following is representative of acute poststreptococcal glomerulonephritis?
```
A. Abnormal type IV collagen
B. Basement membrane IgG Abs
C. IgA mesangial deposits
D. Mesangial immune complex deposits
E. Papillary ischemic necrosis
```
D. Mesangial immune complex deposits
118
What type of casts are associated with pre-renal acute kidney injury?
hyaline casts
119
Polycythemia vera is a myeloproliferative disorder characterized by erythrocytosis. It often presents with HTN, transient vision disturbances, aquagenic pruritus, or thrombosis. Facial plethora and splenomegaly are common on PE. Tx is primarily _______. Bone marrow suppressive drugs like ______ may be added if there is a high risk of thrombosis
serial phlebotomy; hydroxyurea
120
How do serum calcium and serum phosphorus change in Paget disease?
Both will remain normal in the absence of other factors (prolonged immobility, concurrent hyperparathyroidism)
121
9 month old presents with his 4th episode of otitis media in the past 3 months. Uncle also had frequent infections and recently died of pneumonia. Evaluation shows low levels of IgG and very few mature CD-19 cells. Most likely etiology?
```
A. Abnormal tyrosine kinase
B. Defective DNA repair enzyme
C. Defective IL-2 receptor
D. Microtubular dysfunction
E. Reduced NADPH oxidase activity
```
A. Abnormal tyrosine kinase
[X-linked agammaglobulinemia, typically repeated infections with encapsulated bacteria like Strep pneumo, H. influenzae type b, and N.meningitidis. Without activity of Bruton's tyrosine kinase, B cells do not mature properly, leading to low production of IgG and low numbers of mature B cells]
122
Pt with advanced CKD on dialysis presents with persistent bleeding after a blood draw. Which of the following is the mechanism causing his bleeding?
```
A. DIC
B. Platelet dysfunction
C. Factor VIII deficiency
D. Consumptive coagulopathy
E. Thrombocytopenia
```
B. Platelet dysfunction
Platelet dysfunction is the most common cause of abnormal hemostasis in pts with CKD. PT, PTT, and platelet count are normal. Bleeding time is prolonged. DDAVP is tx of choice
123
Characterized by pancytopenia, intravascular hemolysis, and acute thrombosis. Flow cytometry demonstrates absence of CD55 and CD59
Paroxysmal nocturnal hemoglobinuria
124
54 y/o pt presents with chronic blistering on his neck, chest, and hands over the past 2 years. Exam reveals hemorrhagic blisters, hyperpigmentation, and hypertrichosis of dorsal hands and forearms. There are also areas of dyspigmentation with small superficial cysts. In addition, some nail plates have separated from the nail bed. Dx?
Porphyria cutanea tarda
125
The 2 most common causes of microcytic anemia are iron deficiency and ________, and they have similar lab findings. Differentiation requires iron studies, but empiric iron supplementation is sometimes prescribed without further investigation. If pt is started on iron supplementation and microcytic anemia does not improve, the pt likely has [blank]
thalassemia minor
[hemoglobin defect caused by alterations to 1+ of the hemoglobin subunits]
126
3-drug Tx for neurocysticercosis presenting with seizures
Prednisone
Phenytoin
Albendazole
127
Which of the following classes of medication are useful in treating overflow incontinence due to neurogenic bladder?
```
A. Beta-adrenergic agonist
B. Cholinergic agonist
C. Muscarinic antagonist
D. Tricyclic antidepressant
E. None of the above
```
B. Cholinergic agonist
[aids bladder contraction and urethral relaxation. Beta agonists and muscarinic antagonists may be used in URGE incontinence]
128
late complication (several months) following STEMI, suggested by ECG demonstrating persistent ST elevation with deep Q waves. Pts most commonly have progressive left ventricular enlargement and dyskinetic wall motion leading to heart failure
Ventricular aneurysm
129
Chronic maternal HTN is a risk factor for which of the following fetal complications?
```
A. Fetal heart defect
B. Fetal macrosomia
C. Polyhydramnios
D. Preterm labor
E. Preterm premature rupture of membranes
```
D. Preterm labor
[Fetal risks include fetal growth restriction, perinatal mortality, preterm delivery, and oligohydramnios]
130
weakness with external rotation of upper extremity with 90 degree flexion at the elbow; empty can test is negative, no pain with flexion of biceps against resistance. What muscle affected?
```
A. biceps tendon
B. serratus anterior
C. supraspinatus
D. teres major
E. teres minor
```
D. teres minor
[teres minor/infraspinatus responsible for external rotation]
131
A chest tube placed to treat a tension pneumothorax improves clinical status by increasing which of the following?
```
A. End-expiratory pressure
B. Intravascular volume
C. Left ventricular contractility
D. Systemic vascular resistance
E. Venous return
```
E. Venous return
spontaneous pneumothoraces can lead to rapid development of hypotension as the high intrathoracic pressure impedes venous return to the right atrium by compressing the vena cava
132
Severe hypertension + classic triad of paroxysmal headaches, tachycardia, and sweating
pheochromocytoma
133
Pt with hx of Roux en Y gastric bypass presents with signs of overt hyperthyroidism, vaginal bleeding, and US findings of enlarged uterus with heterogenous mass composed of small cystic structures
Hydatidiform mole
[Pts with Roux en Y at increased risk due to vitamin A deficiency; beta hcg shares similar structure to TSH, so elevated hCG can mimic hyperthyroidism]
134
Lichen planus and lichen sclerosis can both present with vulvar pruritus and white vulvar plaques with associated erosions. They can be differentiated based on the presence of vaginal involvement. Which one is more likely to present with vaginal involvement?
Lichen planus
135
Pts who have undergone splenectomy should be prescribed what abx as prophylaxis while awaiting appropriate vaccinations?
Amoxicillin-clavulanate
136
Newborn presents with hearing loss and chorioretinitis. US of the brain reveals intracranial calcifications. Further history reveals mom's diet throughout pregnancy consisted of fried food and occasional consumption of undercooked pork or a hamburger with the meat cooked rare. She denies sick contacts or animal exposures. What congenital infection?
toxoplasmosis
[you can get toxo from cats, insect-contaminated food, cysts in undercooked meat, or contact with infected materials or insects in soil; NOTE that CMV presents similarly, but transmission is by sexual contact or direct contact with infected blood, urine, or saliva.]
137
Isolated posterior ST-elevation MI is a rare and often missed diagnosis. It shows up on ECG as deep ST depressions in leads V1-3, with ST elevations when leads V7-9 are placed beneath the left scapula. This is most commonly due to occlusion of:
```
A. left circumflex a.
B. left anterior descending a.
C. left main coronary a.
D. obtuse marginal a.
E. proximal right coronary a.
```
A. left circumflex a.
138
Klinefelter syndrome pts will have _____ LH and FSH, ______ estradiol, and _____ testosterone
elevated; elevated; low
[Hypergonadotropic hypogonadism]
139
A newborn presents with lab findings suggestive of alpha thalassemia. These include a _____ MCV, _____ erythrocyte count, and _____ cells on peripheral smear
low; increased; target
140
Pt presents with red, swollen knee and joint aspiration reveals few rhomboid-shaped crystals, leading you to the dx of pseudogout. Which of the following is most likely associated with this pt's condition?
```
A. Conjunctivitis
B. Heberden nodes
C. Meniscal calcification
D. Rheumatoid factor
E. Tophi
```
C. Meniscal calcification
Pseudogout is associated with chondrocalcinosis on imaging
141
right-handed pt presents with right-sided homonymous hemianopia, inability to name objects on a page, and impaired memory. He can tell you his name and answer questions, but cannot recall 3 objects after 5 minutes. Which artery is occluded?
```
A. Lenticulostriate
B. Right posterior cerebral
C. Left posterior cerebral
D. Right middle cerebral
E. Left middle cerebral
```
C. Left posterior cerebral
[PCA supplies occipital lobe and medial temporal lobe]
142
Primigravid woman presents in first trimester with vaginal bleeding and subsequent fetal loss. Her blood type is AB negative and Anti-Rh antibody titer is negative. Does she need anti-D immune globulin?
Yes
Anti-D immune globulin (RhoGam) is indicated in unsensitized, Rh-negative women at 28 weeks gestation or within 72 hours of any procedure or incident in which there is any possibility of veto-maternal blood mixing
143
Aminoglycosides may cause sensorineural hearing loss in addition to what potentially life threatening complication?
acute tubular necrosis (can subsequently result in acute renal failure)
144
Differentiate Chiari I vs. Chiari II malformation
Chiari I -- inferior displacement of cerebellar tonsils, frequently asymptomatic or may present in childhood with occipital headache and/or neck pain, sometimes increased ICP, cranial neuropathies (eg dysarthria) and cerebellar dysfunction (eg ataxia); may be associated with SYRINGOMYELIA
Chiari II -- herniation of the cerebellar tonsils and vermis, as well as inferior displacement of the medulla; associated with MYELOMENINGOCELE
145
T/F: A pt using oxycodone will have a negative standard urine drug screen
True - standard urine drug screens do not detect semisynthetic (hydrocodone, hydromorphone, oxycodone) or synthetic (fentanyl, meperidine, methadone, tramadol) opioids
146
nerve roots affected in erb Duchenne palsy
C5-7
Upper extremity adducted and internally rotated, elbow extended, forearm pronated, wrist and fingers flexed ("waiters tip" position)
147
GCS includes best eye response, verbal response, and motor response. What are the scores for verbal response?
Oriented/normal conversation = 5
Confused speech = 4
Inappropriate speech = 3
Incomprehensible sounds = 2
None = 1
148
Most common cause of macrocytic anemia in a heavy alcohol user
Folate deficiency
149
Cause of intrauterine fetal demise associated with growth restriction, multiple limb fractures, and hypoplastic thoracic cavity
Type II osteogenesis imperfecta (AD)
150
What happens to renal blood flow, GFR, and renal basement membrane permeability in pregnancy?
all increase
151
Pt with untreated HIV presents with 2 weeks of progressive fever, exertional dyspnea, and nonproductive cough. Temp is 102, BP is 120/80, HR 100, and respirations 28. Pulse ox is 80% on room air. ABGs show pH 7.45, PaO2 54, PaCO2 44. CD4 is 170 and LDH is 480. CXR shows bilateral interstitial infiltrates. Most likely dx?
PCP pneumonia
This pt needs TMP SMX + corticosteroids due to PaO2 <70 (other indications to add corticosteroids include A-a gradient >35, or pulse ox <92% on RA)
152
Federal insurance program primarily for people age 65+ (as well as some young people with specific disabilities, and people with end-stage renal disease)
```
A. Fee-for-service plan
B. Health maintenance organization (HMO)
C. Medicaid
D. Medicare
E. Preferred provider organization (PPO)
```
D. Medicare
153
in a sacral torsion, the axis will be on the _____ side of the seated flexion test
opposite
154
32 y/o female with depressed mood, memory impairment, loss of libido, anorexia, salt cravings, weight loss, and decrease in axillary and pubic hair. Dx?
Primary adrenal insufficiency
Usually d/t autoimmune destruction of adrenal cortex
Dx with cosyntropin (ACTH) stimulation test --> low production of cortisol confirms dx
155
Strict EXCLUSION criteria for stroke thrombolytic therapy include blood pressure greater than _____, platelets less than _____, or glucose less than _____, and anticoagulant use with INR >1.7, PT >15 sec, or increased aPTT
BP >185/110
Platelets <100,000
glucose < 50
156
34 y/o man with untreated HIV presents with 3 weeks of fever, night sweats, fatigue, cough, SOB, and 10 lb weight loss. CD4 count is 80. Temp is 101, BP 110/66, HR 108. There are small ulcers on hard palate and multiple LNs in cervical and inguinal chains. Pulmonary exam reveals scattered crackles. Abdomen is soft and nontender but there is prominent HSM. Labs show pancytopenia and elevated LFTs. CXR shows bilateral reticulonodular opacities with hilar lymphadenopathy. Dx?
Histoplasma
Dx with urine histoplasma Ag, tx with amphotericin B
157
Pt presents with glomerulonephritis 4 days after a URI. Serum complement levels are normal. Most likely dx?
IgA nephropathy
[MCC of glomerulonephritis in adults, similar to post strep glomerulonephritis, but presents sooner after URI and has normal serum complement]
158
Benign ovarian tumor that may present with Meigs syndrome (ascites and/or pleural effusion)
Ovarian fibroma
159
ST segment elevation in V1-4 with reciprocal ST depression in II, III, and aVF
acute anterior wall MI
160
Newborn presents with bilious emesis on day 4 of life. He has not had a stool since discharge. Abdominal Xray shows dilated loops of bowel but no signs of perforation. What is your next step?
Contrast enema
determines level of obstruction and differentiates Hirschsprung from other etiologies (eg meconium ileus)
161
How do afterload, preload, and cardiac output change following placement of AV fistula?
Afterload decreases
Preload increases
Cardiac output increases
162
Pt with right ear otalgia and hearing loss, pyoderma gangrenosum, and glomerulonephritis. Most likely dx?
Granulomatosis with polyangiitis (Wegeners)
[Nectrotizing vasculitis affecting small to medium sized blood vessels]
163
thin, yellow-green discharge, pH >4.5, vaginal inflammation present
trichomoniasis
164
newborn with ambiguous genitalia, HR 155, and BP 60/40. Genital exam reveals blind ending vaginal pouch and clitoris measuring 1.5 cm. Masses are palpable in inguinal canals bilaterally. Serum lab studies do not reveal any overt abnormalities. US shows absence of uterus or Fallopian tubes. Most likely karyotype and hormonal abnormality?
A. 46, XX with decreased 17-hydroxyprogesterone
B. 46, XX with elevated 17-hydroxyprogesterone
C. 46, XX with elevated ratio of testosterone to DHT
D. 46, XY with elevated 17-hydroxyprogesterone
E. 46, XY with elevated ratio of testosterone to DHT
E. 46, XY with elevated ratio of testosterone to DHT
[5-alpha reductase deficiency; exam findings suggest child is male so Y must be present, but conversion of testosterone to stronger DHT is inadequate, preventing the development of normal external male genitalia.]
165
34 y/o with abdominal pain and bloody diarrhea after recent return from Africa. Abdominal pain began 8 days ago, bloody diarrhea began 2 days ago, now having 3 bloody BMs daily. Prior to that she had intermittent fevers, occasional chills and headaches. Over the last day she noted rash on trunk and abdomen. She denies eating any new foods including seafood or poultry. VS reveal temp 102, BP 117/72, HR 70, RR 14. PE reveals RUQ tenderness, splenomegaly, and faint red macule on abdomen. Labs reveal normal BMP and CBC showing leukopenia with left shift, but normal Hb and platelet count. Peripheral smear is normal. Etiology?
```
A. Campylobacter jejuni
B. E coli O157:H7
C. Salmonella typhi
D. Shigella dysenteriae
E. Vibrio parahemolyticus
```
C. Salmonella typhi
166
36 y/o man with skin lesions on right forearm and back of neck consisting of painless nodules and large warlike lesions. He also c/o dry cough with mild malaise for 2 months. He works as agricultural irrigation mechanic in southern WI. Exam shows 4-5 cm warty heaped up lesions with a violaceous hue and sharply demarcated border. The lesion on the neck has a crusted appearance and small peripheral ulcer. Wet prep of the skin scrapings shows yeast. Dx?
```
A. Actinomycosis
B. Aspergillosis
C. Blastomycosis
D. Coccidiomycosis
E. Histoplasmosis
```
C. Blastomycosis
167
most common cause of large bowel obstruction
malignancy (>50% of cases)
168
dopamine agonist that is first line in tx of prolactinoma
Carbergoline
| bromocriptine second line
169
Spot urine sodium < 20 mEq/L
FeNa < 1%
Urine osmolality > 500 mOsm/kg
What type of AKI?
pre-renal
170
When the active phase of labor takes longer than expected, it is called protracted labor. Protracted dilation in a nulliparous woman is determined when there is less than ____ cm dilation in 1 hour. In multiparous women, it is defined as a dilation of less than ____ in 1 hour (remember this is AFTER a dilation of 6 cm is achieved)
1. 2 cm
| 1. 5 cm
171
GCS includes best eye response, verbal response, and motor response. What are the scores for eye response?
spontaneous = 4
to verbal command = 3
to pain = 2
none = 1
172
Pt presents with infective endocarditis and is initially treated with IV vancomycin. Culture and sensitivity reveals Strep mutans that is susceptible to penicillin. What should you switch his abx to?
IV penicillin G
-OR-
IV ceftriaxone
[x4 weeks]
Oral agents are generally not recommended for infective endocarditis
173
Pt presents following blunt head trauma with Cushings reflex, worrisome for impending transtentorial (uncal) herniation. This will lead to neurologic signs/symptoms including ipsilateral hemiparesis, contralateral homonymous hemianopsia, altered level of consciousness/coma, and compression of what cranial nerve?
oculomotor (CN III)
Leads to ipsilateral mydriasis, ptosis, and down-and-out gaze
174
Exudative effusion characterized by very high protein levels (always >4 g/dL), lymphocytic leukocytosis, and low glucose. Other classic features include markedly elevated LDH (often >500 U/L) and low pH. Dx?
Tuberculosis
175
Abx for Fitz Hugh curtis syndrome
IV cefoxitin and doxycycline
176
Pts with chronic immune thrombocytopenia have platelets <100,000 for >1 year. ______ is the next treatment step in those with persistent bleeding and thrombocytopenia despite repeated pharmacologic interventions (eg, glucocorticoids, anti-D, IVIG)
splenectomy
177
Bacterial infections with N.meningitidis, H.influenzae B, or M.pneumoniae, as well as viral infections with influenza or adenovirus require what type of isolation precautions?
droplet precautions
178
While magnesium sulfate has been shown to be superior in seizure prophylaxis of pre-eclamptic patients, ____ is used in management of recurrent eclamptic seizures that are not responsive to magnesium sulfate
diazepam
179
Which of the following is the most likely complication in a pt with hereditary hemochromatosis?
```
A. Acute leukemia
B. Atrophic gastritis
C. Gallstones
D. Osteoporotic fractures
E. Renal insufficiency
F. Venous thromboembolism
```
C. Gallstones
180
Pharmacologic treatment options for neuroleptic malignant syndrome
bromocriptine
amantadine
dantrolene
[dopaminergic agents first line]
181
Pretreatment prophylaxis for tumor lysis syndrome
IV fluids
Allopurinol, rasburicase, or febuxostat
182
Which of the following is a metabolic disturbance likely to be found in pt taking chlorthalidone?
```
A. Decreased LDL
B. Decreased triglycerides
C. Hyperglycemia
D. Hyperkalemia
E. Hypocalcemia
```
C. Hyperglycemia
[occurs more with chlorthalidone than other thiazides. Thiazides also can cause hyponatremia, hypokalemia, hypomagnesemia, and hypercalcemia]
183
Combats fraud and abuse in health insurance and healthcare delivery
A. Centers for medicare and medicaid services
B. Healthcare integrity and protection data bank
C. Joint commission
D. National committee for quality assurance
E. National practitioner data bank
B. Healthcare integrity and protection data bank
184
Newborn with microcephaly, micrognathia, overlapping fingers, absent palmar creases, and rocker bottom feet
Trisomy 18 (Edwards syndrome)
Congenital heart disease occurs in more than half of affected pts with VSD being the most common abnormality
185
Pt presents with polycythemia, progressive abdominal discomfort, ascites, and hepatosplenomegaly. Labs reveal mild/moderate elevations in liver transaminases, bilirubin, and alkaline phosphatase. This is highly suspicious for _____________, and dx should be established with _______
Budd-Chiari syndrome; abdominal US
186
normal PT
prolonged aPTT
deficient factor IX
X-linked recessive
Mixing study corrects the aPTT
Hemophilia B
187
Pt presents at 39 weeks gestation with signs of chorioamnionitis. Cervix is 2 cm dilated, vertex is at -1 station, and fetal heart rate monitoring is category 1. Tocometry shows contractions every 10 minutes. Which of the following is next step in management?
```
A. Administer corticosteroids
B. Administer tocolytics
C. Cesarean delivery
D. Expectant management
E. Labor augmentation
```
E. Labor augmentation
[C-section only if non-reassuring fetal signs. Expectant management might take too long -- augment to eliminate source of infection more quickly.]
188
Abx used in tx of TSS
Vancomycin + Clindamycin
189
Assessment of serum-to-ascites albumin gradient (SAAG) in ascitic fluid analysis can help to diagnose etiology. This is done by subtracting the peritoneal fluid albumin concentration from the serum albumin concentration. A value of greater than or equal to 1.1 g/dL is indicative of what etiology?
Portal HTN (cardiac ascites, cirrhosis, Budd chiari syndrome)
ascites occurs as a result of increased capillary hydrostatic pressure
A value of <1.1 occurs in the absence of portal HTN -- etiologies include TB, peritoneal carcinomatosis, pancreatic ascites, or nephrotic syndrome
190
Tx for RTA types I and II
potassium citrate
191
Spot urine sodium > 40 mEq/L
FeNa > 2%
Urine osmolality 300-400 mOsm/kg
What type of AKI?
intra-renal
192
Autosomal recessive disorder caused by a DNA repair defect usually presenting in childhood with signs of thrombocytopenia, macrocytic anemia, short stature, hyper- or hypo pigmentation, and absent or hypoplastic thumbs
Fanconi anemia
[most common congenital cause of aplastic anemia; tx with hematopoietic stem cell transplant]
193
_____ dislocation of the hip presents with shortened and internally rotated leg. Complications include sciatic nerve injury (impaired dorsiflexion) and arterial injury with avascular necrosis of femoral head
posterior
[anterior hip dislocations present when leg appears shortened and EXTERNALLY rotated]
194
Pre-eclampsia is defined as new-onset HTN at >20 weeks gestation PLUS proteinuria and/or end-organ damage.
What features qualify it as pre-eclampsia with severe features?
```
SBP >160 or DBP >110
Thrombocytopenia
Elevated transaminases
Elevated creatinine
Pulmonary edema
Visual or cerebral symptoms
```
195
Negotiates for lower fees with a network of health care service providers and gives policy holders a financial incentive to stay within the network. Does not require a referral to see in-network specialists, but for out-of-network providers they will have to pay the entire bill and submit for reimbursement, and may have to pay a deductible or the difference between the in-network and out-of-network charge
```
A. Fee-for-service plan
B. Health maintenance organization (HMO)
C. Medicaid
D. Medicare
E. Preferred provider organization (PPO)
```
E. Preferred provider organization (PPO)
196
Pt presents with lower extremity weakness. He was seen by his PCP last week and was put on TMP SMX for a skin infection he acquired recently on a hunting trip. He now complains of weakness and palpitations. Home meds include enalapril, metformin, and naproxen. Vitals reveal temp 98, BP 88/53, HR 104, and RR 26. PE reveals oriented male with cap refill 5 seconds and 4/5 b/l LE strength with 1+ reflexes b/l. Most likely etiology?
```
A. Botulism
B. GBS
C. hyperkalemia
D. hypocalcemia
E. tick borne illness
```
C. hyperkalemia
Next step is to get an ECG!
[Hyperkalemia can mimic GBS in that there is ascending muscle weakness and areflexia that can lead to flaccid paralysis, however respiratory failure is unlikely. TMP SMX is a common culprit of causing hyperkalemia, especially in older pts on an ACE-I. NSAIDs and ARBs are also high risk for hyperkalemia, especially when combined.]
197
Chronic asthmatic on SABA and ICS presents with b/l wheezing, patchy right upper lobe infiltrate with increased bronchial markings, and CT showing proximal bronchiectasis with mucus plugging. Most likely dx?
Allergic bronchopulmonary aspergillosis
198
Pt presents at 35 weeks gestation d/t leakage of clear fluid that became bloody a few minutes later. Exam shows minimal vaginal bleeding and you are unable to detect fetal heart tones, although mom says she felt baby move earlier today. Dx?
Vasa previa
199
Pulmonary capillary wedge pressure (PWCP) is reflective of the pressure in which heart chamber?
Left atrium
200
35 y/o male presents with cyclical fevers and lymphadenopathy that becomes tender after consumption of alcohol. Dx?
Hodgkin lymphoma
201
3 Blood pressure management options for pre-eclampsia
Hydralazine IV
Labetolol IV
Nifedipine PO
202
Patient with severe mitral regurgitation would most likely have what additional finding?
a. finger clubbing
b. opening snap
c. S3
d. S4
e. uvular pulsation
c. S3
203
what type of transfusion reaction?
fever, FLANK PAIN, and hemoglobinuria within 1 hr of transfusion initiation; can progress to acute renal failure, DIC, and shock
ABO incompatibility
204
Management of acute angle closure glaucoma
Combo tx with topical agents like timolol, pilocarpine, and/or apraclonidine
Add IV acetazolamide
Laser iridotomy if necessary
205
Kallman syndrome is a disorder of migration of fetal GnRH and olfactory neurons that results in delayed puberty (i.e. primary amenorrhea) and anosmia. Due to a lack of GnRH secretion, pts have hypogonadotropic hypogonadism (low FSH). What is the genotype in these pts?
consistent with phenotype! Males will be 46, XY and females will be 46, XX
206
Mammary Paget disease is suspected anytime there is a persistent, eczematous, and/or ulcerating rash is localized to the nipple and spreads to the areola. What is the most common underlying malignancy?
Adenocarcinoma
207
SMACK mnemonic for salter Harris fractures
S = Slipped (type I)
M = Metaphyseal (type II)
A = Articular-epiphyseal (type III)
C = Complete metaphyseal and epiphyseal (type IV)
K = Krush (type V)
208
How do serum BUN, serum creatinine, and renal protein excretion change in pregnancy?
Serum BUN decreases
Serum creatinine decreases
Renal protein excretion increases
209
3 most common causes of necrotizing fasciitis
Clostridium perfringens
Staph aureus
Strep pyogenes (group A strep)
210
Watery diarrhea that occurs even during fasting or sleep, findings include a low stool osmotic gap (<50). What type of diarrhea?
Secretory
211
Older pt just started on SSRIs presents with altered mental status and labs reveal hyponatremia. Most likely dx?
SIADH
SSRIs are commonly associated with SIADH and elderly pts are at increased risk.
212
16 year old presents due to not having a period yet. On exam, breasts are Tanner stage 4 and there is minimal axillary and pubic hair. External genitalia appear normal and vagina is 3 cm in length. Cervix is not visible. There is no uterus, cervix, or ovaries palpable on bimanual exam. Labs reveal testosterone of 400 ng/dL (nl 15-75 in females). Most likely dx?
```
A. 5 alpha reductase deficiency
B. Androgen insensitivity syndrome
C. Mullerian agenesis
D. Sertoli Leydig tumor
E. Turner syndrome
```
B. Androgen insensitivity syndrome
Pt with primary amenorrhea and male-range testosterone most likely has AIS
213
Splenic sequestration crisis is a life-threatening complication of sickle cell disease in which RBCs become entrapped within the spleen. Pts present with anemia, splenomegaly, and hypovolemic shock. Tx focuses on the restoration of circulatory volume with IV fluids as well as what other tx measure?
```
A. Norepinephrine infusion
B. PRBC transfusion
C. Splenectomy
D. Tranexamic acid
E. Whole blood transfusion
```
B. PRBC transfusion
214
Electrolyte abnormalities seen in tumor lysis syndrome
Hyperuricemia
Hyperkalemia
Hyperphosphatemia
Hypocalcemia
[think about intracellular contents getting released; hypocalcemia d/t calcium phosphate binding]
215
T/F: All pregnant pts with pyelonephritis require inpatient admission and empiric IV abx (eg ceftriaxone)
True
this is bc of the high risk of severe maternal and fetal complications associated with pyelonephritis -- sepsis, preterm delivery, ARDs, etc
216
Sudden onset contralateral sensory loss involving all sensory modalities (pure sensory stroke); What are of the brain affected?
Thalamus
[Lacunar stroke of posterolateral thalamus]
217
medication that causes green halos in visual field
amiodarone
218
Pregnant moms with asymptomatic bacteriuria are at increased risk for what?
Acute pyelonephritis and preterm labor/delivery
219
Preferred anti-hypertensive for resistant HTN, defined as not being at BP goal despite 3 anti-hypertensive medications including a diuretic
K+ sparing diuretic
[Amiloride, triamterene, spironolactone, eplerenone]
220
Elevated serum creatine kinase, aldolase, and positive ant-Jo-1 antibodies
Normal ESR
Pt presents with proximal muscle weakness
Polymyositis
221
Diagnostic modality of choice for primary sclerosing cholangitis
MRCP
[Can also do ERCP or liver biopsy but MRCP is first choice]
222
Dx and Tx of TTP
Peripheral blood smear - shows signs of intravascular hemolysis (schistocytes, helmet cells, triangle cells)
Tx emergently with plasma exchange; glucocorticoids often added (UW also lists rituximab)
223
Lymphadenopathy and mediastinal mass in a pt 15-35 y/o should prompt concern for Hodgkin lymphoma, which is associated with _____ infection
EBV
224
skin lesion associated with P aeruginosa bacteremia that typically progresses rapidly from a small erythematous macule to a larger, nontender nodule with necrosis (black center)
ecthyma gangrenosum
225
Lemierre syndrome is caused by an oropharyngeal infection, usually pharyngitis or tonsillitis, that leads to local invasion of the lateral pharyngeal wall and infection of the neuromuscular bundle, especially the internal jugular vein. Thrombosis of this vein allows dissemination of septic emboli to distal sites. What is the most frequent bacterial cause?
```
A. Clostridium perfringens
B. Fusobacterium necrophorum
C. Haemophilus influenzae b
D. Klebsiella pneumoniae
E. Streptococcus pyogenes
```
B. Fusobacterium necrophorum
226
Periumbilical pain, headaches, fevers, weight loss, weakness, malaise
abdominal angiogram shows multiple aneurysms in mesenteric and renal arteries
Dx?
polyarteritis nodosa
confirmatory test = tissue bx from medium sized arteries
227
Sickle cell pts are at high risk for sepsis from strep pneumo, H flu, and N meningitidis. Even with proper vaccinations, _____ remains by far the most common cause of sepsis in pts with SCD
Strep pneumo
228
Tx for toxoplasma encephalitis
Sulfadiazine + Pyrimethamine (plus leucovorin)
229
Autosomal dominant disease that manifests with cerebellar and retinal hemangioblastomas, pheochromocytoma, and/or renal cell carcinoma (clear cell)
von Hippel-Lindau disease
230
Major manifestation of chronic lung transplant rejection common to recipients >5 yrs post transplant. Dx is usually made based on consistent clinical presentation of gradually progressive dyspnea and nonproductive cough, and PFTs show obstructive pattern
Bronchiolitis obliterans
231
Pt age >50, muscle stiffness > pain in shoulders, hip girdle, neck, NO muscle weakness; elevated ESR and CRP, normal CK/aldolase/AST
Polymyalgia rheumatica
232
Testicular tumor that causes feminization (eg gynecomastia) due to production of estrogen by tumor cells
Leydig cell tumor
[causes secondary inhibition of FSH and LH]
233
68 y/o man presents with progressive fatigue and decreased exercise tolerance. PE shows pallor but is otherwise normal. Labs reveal megaloblastic anemia, thrombocytopenia, and leukopenia. Peripheral smear shows ovalomacrocytosis and neutrophils with reduced segmentation. Serum electrolytes, renal function, and B12 are normal. Most likely dx?
Myelodysplastic syndrome
confirm with bone marrow biopsy
234
afebrile child presents pulling at his ears 2 weeks after successfully treated episode of acute otitis media. Exam reveals air fluid levels behind both TMs with poor mobility. No erythema or bulging seen. You diagnose otitis media with effusion. What is the management?
Observation and follow up - should resolve within weeks
if it becomes chronic (>3 mos), can cause speech delay and long term hearing loss - so pt would need tympanostomy tubes
235
First line tx for open angle glaucoma
Topical prostaglandin (latanoprost, bimatoprost)
Increases drainage of aqueous humor in the anterior chamber
236
medication that causes blue halos in visual field
sildenafil
237
Pt with Graves disease including opthalmopathy. Why is it important to give glucocorticoids with radioactive iodine tx in these pts?
Prevents worsening of ophthalmopathy
238
Second gen antipsychotic well-known to have high frequency of prolactin elevation leading to galactorrhea, gynecomastia, menstrual dysfunction, low libido, etc.
Risperidone
239
Young patients with juvenile idiopathic arthritis must be screened regularly for what serious complication?
Uveitis (can lead to vision loss)
240
15 y/o girl with sickle cell disease presents with signs of stroke. Next step in management?
Exchange transfusion
241
Pt presents with worsening weakness and exertion dyspnea over the past 2 days. You diagnose him with pericardial effusion and cardiac tamponade. Which of the following is the most likely cause pf the pt's complaints?
A. Decreased cardiac contractility
B. Decreased left ventricular preload
C. Increased right ventricular compliance
D. Left ventricular outflow tract obstruction
E. Pulmonary HTN
B. Decreased left ventricular preload
242
56 y/o obese male smoker with progressive dyspnea and nonproductive cough. Auscultation reveals fine bibasilar crackles. Spirometry reveals FEV1 65% of predicted, FVC 58% of predicted, and FEV1/FVC 85% of predicted. Most likely dx?
```
A. Obesity hypoventilation syndrome
B. COPD
C. Asthma
D. CHF
E. Interstitial lung disease
```
E. Interstitial lung disease
[characterized by pulmonary fibrosis and restrictive pattern on spirometry -- decreased FEV1, decreased FVC, and decreased TLC. FEV1/FVC ratio remains normal or may be increased]
243
What other condition is often associated with giant cell arteritis?
polymyalgia rheumatica
244
46 y/o male presents with severe posterior headache associated with nausea, vomiting, and neck stiffness that woke him from sleep 3 hours ago. CT is unremarkable. LP is performed and shows 1255 RBCs/mm, and is otherwise normal. Most likely dx?
Subarachnoid hemorrhage
[classic sign on LP is xanthochromia]
245
In general, what is the first step in the diagnostic workup when a pt presents with primary amenorrhea?
Pelvic exam or ultrasound to determine if uterus is present or absent
If uterus is present, check serum FSH
If uterus is absent, check karyotype and serum testosterone
246
T/F: DES exposure in utero is a risk factor for vaginal SCC
False, DES exposure is linked to vaginal clear cell adenocarcinoma
Biggest risk factor for vaginal SCC is HPV infection, which can be amplified by tobacco use
247
Pts with HIV are at significantly increased risk of malignancy d/t immune dysregulation and reactivation of oncogenic viruses. One of the most common malignancies is non-Hodgkin lymphoma, which is due to reactivation of _______. Pts generally present with diffuse lymphadenopathy and B symptoms
EBV
248
What class of antibiotics should be avoided in pregnancy if possible due to increased risk of renal damage and CN VIII damage?
Aminoglycosides
| gentamicin, neomycin, streptomycin, tobramycin, amikacin
249
10 y/o pt with headache, vomiting, and visual disturbances for the past 2 weeks. Neuro exam reveals bilateral retraction of upper eyelids and limitation of upward gaze with a preference for downward gaze. Pupils react sluggishly to light but respond appropriately to accommodation. Remainder of exam is normal. Most likely dx?
```
A. craniopharyngioma
B. medulloblastoma
C. neuroblastoma
D. pinealoma
E. retinoblastoma
```
D. pinealoma
Visual disturbances are a part of parinaud syndrome, present in most its with pinealoma
250
First line tocolytic at 32-34 weeks gestation
Nifedipine
[Maternal AEs are tachycardia/palpitations, nausea, flushing, HA]
251
Which of the following would characterize the urine findings in a pt with rhabdomyolysis?
A. 1+ blood, 10-20 RBC/hpf, 10-50 WBC/hpf, muddy brown casts
B. 2+ blood, 0-5 RBC/hpf, 1-2 WBC/hpf, pigmented casts
C. 2+ blood, 10-20 RBC/hpf, 1-2 WBC/hpf, red blood cell casts
D. No blood, 0-5 RBC/hpf, 1-2 WBC/hpf, no casts
E. No blood, 0-5 RBC/hpf, 10-20 WBC/hpf, white blood cell casts
B. 2+ blood, 0-5 RBC/hpf, 1-2 WBC/hpf, pigmented casts
252
iron deficiency anemia presents with low serum ferritin, normal to low serum iron, high TIBC, and _____ transferrin
high
[transferrin transports iron from intestines to RBCs, it becomes elevated as the liver produces more in an effort to bring more iron to iron-hungry cells]
253
Cause of exudative pleural effusion characterized by low glucose, very high LDH, and (often) low pH, and is associated with interstitial lung disease
Rheumatoid arthritis
254
Painless GI bleed in the setting of Meckels diverticulum is associated with:
```
A. Ectopic gastric mucosa
B. Hemorrhagic colonic polyp
C. Inflamed lymphoid tissue
D. Intestinal hemangioma
E. Telescoping colonic segments
```
A. Ectopic gastric mucosa
[Meckel diverticulum can contain ectopic gastric mucosa which secretes acid that can lead to ulceration of adjacent bowel resulting in painless GI bleed]
255
Differentiate symptoms of carcinoid vs pheochromocytoma
carcinoid = intermittent diarrhea and skin flushing, sometimes pulmonary and/or tricuspid valve disease
pheochromocytoma = episodic headache, HTN, tachycardia/palpitations, diaphoresis
256
multiple myeloma may lead to a type __ RTA
type II RTA (proximal tubule) aka fanconi syndrome
leads to hypokalemia due to failure of proximal tubule to reabsorb organic substances, triggering secretion of K+ from distal tubule
257
Primary amenorrhea is the absence of menarche in girls <13 with no secondary sexual characteristics. In pts with a uterus, the best next step is ______
FSH level
distinguishes between central (low/normal FSH) and peripheral (high FSH) causes of amenorrhea
258
First line treatment for uterine atony is bimanual uterine massage and high dose oxytocin. In pts with persistent bleeding, the next best step is administration of _________
tranexamic acid
antifibrinolytic that prevents breakdown of clots to achieve hemostasis
259
Young pt with marfanoid body habitus, intellectual disability, downward lens dislocation, joint hyperlaxity, skin hyperelasticity, and hypercoagulability. Dx?
Homocystinuria
260
How would the following lab values change in biliary atresia:
Direct bilirubin
GGT
Alkaline phosphatase
Reticulocyte count
Direct bilirubin increased
GGT increased
Alk phos increased
Reticulocyte count normal (no hemolysis)
261
Osmotic demyelination syndrome can be prevented by slowly correcting a pt's hyponatremia with normal saline at a rate not greater than _____ mmol/L in 24 hours, or ____ mEq/L/hr
10 mmol/L/24h
| 0.5 mEq/L/hr
262
common bacterial skin infection that develops ABRUPTLY, involves the upper dermis, and is classically described as a raised, sharply demarcated area of erythema with advancing margins. It often involves the lymphatics, which causes "streaking"
Erysipelas
MCC is group A beta-hemolytic streptococcus -- Strep pyogenes
263
Pt has positive PPD skin test and a negative chest x-ray, indicating latent TB. What is the classic tx regimen?
Isoniazid for 9 months
[other options include INH + rifapentine for 3 months OR rifampin for 4 months]
264
What effect would increasing the cutoff value for a test have on sensitivity and specificity?
Sensitivity decreases
Specificity increases
265
4 month old presents with progressive lethargy, poor feeding, fatigue, and increasing pallor. PE reveals webbed neck, cleft palate, mild hypertelorism, flat nasal bridge, and pale mucous membranes. Thumbs are triphalangeal. Cardiac exam reveals tachycardia with systolic ejection flow murmur. Labs reveal microcytic anemia. Dx?
Diamond-Blackfan anemia
266
Karyotype XXY
Klinefelter syndrome
267
Hypertension, hyperreflexia, and positive pregnancy test are concerning for preeclampsia with severe features. In addition to new-onset HTN, pre-eclamptic pts often have signs of end organ damage such as RUQ pain and headache. Although preeclampsia typically presents in late third trimester, preeclampsia at <20 weeks gestation can be a complication of __________
hydatidiform mole
268
Policy holder pays a certain deductible, and after that, the insurance company pays the majority of the bill. AKA traditional indemnity coverage
```
A. Fee-for-service plan
B. Health maintenance organization (HMO)
C. Medicaid
D. Medicare
E. Preferred provider organization (PPO)
```
A. Fee-for-service plan
269
What effect would decreasing the cutoff value have on sensitivity and specificity?
Sensitivity increases
Specificity decreases
270
adverse effect of hydroxychloroquine
retinopathy
271
Tx for acute bacterial prostatitis
6 weeks TMP-SMX or fluoroquinolone
272
Proximal muscle weakness (e.g., increasing difficulty climbing up stairs) +/- pain, elevated CK, aldolase, AST, autoantibodies present
Polymyositis
273
Pt on OCPs presents with fatigue, anxiety, and difficulty sleeping for several months. Exam reveals normal thyroid. Serum TSH is 1.5 (nl) and total T4 is 15 (mildly elevated). Explain her labs
Estrogen-induced increase in level of T4-binding globulin (happens in pregnancy and with OCPs or HRT)
Total thyroid hormone levels are elevated, but pts maintain euthyroid state and normal TSH level
274
The best test for diagnosing hypertrophic obstructive cardiomyopathy is _________, which allows for visualization and measurement of the interventricular septum
Transthoracic echocardiogram
275
Diabetic pt presents with decreased proprioception and vibration sense in the feet. Ankle jerk reflexes are absent. Pt sways and tends to fall when eyes are closed. Which of the following processes is predominantly responsible?
A. Axonopathy of large nerve fibers
B. Axonopathy of small nerve fibers
C. Degeneration of cerebellar hemispheres
D. Degeneration of lateral spinothalamic tract
E. Diffuse demyelination of nerve fibers of lower extremities
A. Axonopathy of large nerve fibers
In diabetic neuropathy, numbness, loss of proprioception and vibration, and diminished reflexes indicate large fiber damage. Pain, paresthesia, and allodynia are indicative of small fiber injury.
276
______ should be suspected in pts with sudden-onset abdominal pain, neuropsychiatric symptoms (eg, neuropathies, anxiety, mood changes, psychosis), and a family history of similar episodes. Episodes may be triggered by a period of fasting, certain medications (carbamazepine, phenytoin, rifampin), tobacco, and alcohol
Acute intermittent porphyria
Confirm dx with elevated urinary porphobilinogen levels during an attack
277
5 Components of biophysical profile
1. Non-stress test
2. Fetal breathing movements -- 1+ episode lasting 30+ seconds in 30 minutes
3. Fetal movement -- 3 discrete body or limb movements in 30 minutes
4. Fetal tone -- 1+ extension of limb with return to flexion, or opening/closing of hand
5. Amniotic fluid volume >2 cm
[Each is worth 2 points, all or nothing]
278
6 y/o female with precocious puberty. Bone age is determined to be advanced. Basal LH is high. Next step?
Brain MRI
Eval of precocious puberty starts with bone age. If advanced, check an LH level. If basal LH is high, its central precocious puberty and you have to check for brain masses. If basal LH is low, do GnRH stimulation test, if it is low, it is peripheral, if it is high, it is central.
If bone age is normal, the dx is just isolated premature thelarche and/or adrenarche
279
Pt presents after recently having psychiatric medications adjusted. He complains of nausea, RUQ pain, and hair loss. On exam you note a fine bilateral tremor in the hands. Labs reveal thrombocytopenia. Which of the following medications is most likely responsible?
```
A. Clozapine
B. Haloperidol
C. Lamotrigine
D. Lithium
E. Valproate
```
E. Valproate
280
10 day old infant with green discharge from her eyes for the past 2 days. Initially started as watery discharge, but is now thick and green. Mom was recently started on 5 day course for vaginal infection dx at time of delivery. PE reveals pseudomembrane of exudates overlying both eyes. Eye exam reveals erythematous and thickened conjunctivae with mucopurulent discharge. Etiology?
Chlamydia trachomatis
281
Most significant and strongest risk factor for stroke
Hypertension
[even more than smoking!!!]
282
Alzheimer pt neuroimaging generally demonstrates _____ lobe atrophy
temporal
[most prominent in the hippocampus and surrounding medial temporal lobes]
283
In hemodynamically stable pts presenting in afib with RVR, rate control should be attempted initially with _____ or _______
beta blockers; CCBs
284
32 y/o pt presents with palpable breast mass. Next best step?
Mammography (+/- US)
[Pts age 30+ get mammo first. Pts <30 get US first]
285
systolic murmur at left lower sternal border that increases with inspiration
tricuspid regurgitation
286
Severe aortic stenosis criteria include aortic jet velocity >4 m/s OR mean trans valvular pressure gradient >40 mm Hg; valve area usually less than 1 cm but this is not required.
Indications for valve replacement include severe AS + at least one of the following: onset of symptoms, left ventricular EF less than ____, or undergoing other cardiac surgery
50%
287
Requires a referral from the primary care provider before patients can see a specialist. In general, out-of-network services will not be reimbursed
```
A. Fee-for-service plan
B. Health maintenance organization (HMO)
C. Medicaid
D. Medicare
E. Preferred provider organization (PPO)
```
B. Health maintenance organization (HMO)
288
Pt with hx of cardiovascular disease and aortic aneurysm presents with CAP. Which abx must be avoided in this pt?
```
A. Amoxicillin
B. Azithromycin
C. Ceftriaxone
D. Doxycycline
E. Levofloxacin
```
E. Levofloxacin
Avoid fluoroquinolones due to risk of collagen degradation leading to aneurysm rupture
289
Pt with hx of metastatic breast carcinoma presents with fatigue. Labs reveal anemia, thrombocytopenia, decreased fibrinogen, and increased INR, which are indicative of _____. The patient's anemia is most likely due to _____, which is commonly seen in association with [first blank] and supported by additional lab findings of elevated LDH, reticulocyte count, and bilirubin levels as well as schistocytes on peripheral smear
DIC; microangiopathic hemolytic anemia (MAHA)
290
______ and ______ are the first line antibiotic classes used in tx of uncomplicated community acquired pneumonia in the outpatient setting
tetracyclines; macrolides
291
Mycobacterium avian complex prophylaxis with ______ begins in HIV pts with CD4 count
azithromycin; 50
292
What condition should you suspect when trigeminal neuralgia presents BILATERALLY?
Multiple sclerosis
293
Young male with mediastinal mass positive for beta hCG and AFP. Dx?
Non-seminomatous germ cell tumor
[Seminomas produce beta hCG but not AFP]
294
15 y/o female presents d/t concerns of not having period yet. There is no acne or excessive hair growth. Breast development is Tanner stage 5. There is scant axillary and pubic hair. Pelvic exam reveals normal appearing external genitalia but a blind vaginal pouch. The uterus, cervix, and ovaries are absent on bimanual exam. Most likely karyotype?
```
A. 45, X
B. 46, XX
C. 46, XY
D. 47, XXY
E. 47, XYY
```
C. 46, XY
This is androgen insensitivity syndrome. Pts are genotypical male and phenotypically female.
Contrast with Mullerian genesis (Mayer rokitansky kuster hauser) which is similar in that there is absence of uterus, cervix, and upper one third of vagina, but pts have ovaries as well as normal axillary and pubic hair development
295
Relative EXCLUSION criteria for stroke thrombolytic therapy includes minor or rapidly improving neurodeficits, major surgery/trauma in the past ___ days, myocardial infarction in the past ____ months, GU or GI bleeding in the past ____ days, seizure at stroke onset, and pregnancy
Major surgery/trauma in the past 14 days
MI in the past 3 months
GU or GI bleed in the past 21 days
296
cafe-au-lait macules, axillary and inguinal freckling, Lisch nodules, and neurofibromas
Neurofibromatosis type 1
297
Pt with hypothyroidism on levothyroxine presents after finding out she is pregnant. What do you need to do regarding thyroid treatment?
Increase levothyroxine dose, with subsequent dose adjustments based on TSH and total T4
298
Pt presents at 36 weeks gestation with HELLP syndrome. Next step in management?
Start IV antihypertensive
Give betamethasone
Start magnesium sulfate
Induce labor
[Induce labor in pts >34 weeks. Consider betamethasone in pts <37 weeks]
299
Adolescent pt presents with nephrotic syndrome and an active hepatitis B infection. Most likely dx?
```
A. FSGS
B. Membranous nephropathy
C. Minimal change disease
D. SLE
E. Acute interstitial nephritis
```
B. Membranous nephropathy
[FSGS goes with HIV, Membranous goes with HBV, Minimal change occurs in preadolescent children]
300
common brain tumor in children that can present with headaches, hypothyroidism, and/or adrenal insufficiency
Craniopharyngioma
301
What type of RTA?
Presents with hypokalemia and urine pH initially >5.5 and progresses to urinary pH of <5.5 as disease worsens
Caused by defect in bicarbonate reabsorption
RTA type II (proximal tubule acidosis)
Etiologies include hereditary ion channel defects, fanconi's syndrome, carbonic anhydrase inhibitors, myeloma, amyloidosis, heavy metal poisoning, and vitamin D deficiency
302
Patient on warfarin requires urgent surgery with high risk of bleeding. What do you give them prior to surgery?
Prothrombin complex concentrate (PCC) + Vitamin K
[If not available, can give FFP]
303
Tx for CLL
Rituximab -- monoclonal Ab against CD20 cell surface antigen
304
Presents at age 2-6 months with areflexia, hepatosplenomegaly, cherry red macula, and developmental milestone regression
Niemann Pick disease type A (sphingomyelinase deficiency)
[Tay Sachs presents similarly, but hepatosplenomegaly and areflexia are not seen (B-hexosaminidase A deficiency)]
305
Pt presents with progressive hoarseness. Exam of oral cavity reveals poor dentition and oral thrush. Laryngoscopy shows fungating, irregular mass on left vocal cord that appears white in some areas and red in others with some blood crusting. What is the most likely finding on bx of vocal cord lesion?
SCC
306
Pt presents with fatigue, weight loss, normocytic anemia, renal insufficiency, and hypercalcemia. What is high on your list for differential dx?
Multiple myeloma
307
Stepwise decline with early executive dysfunction. What type of dementia?
vascular dementia
308
How to differentiate cryptosporidium, cytomegalovirus, and mycobacterium avium complex in a noncompliant HIV pt presenting with diarrhea and a CD4 count <50
Cryptosporidium = severe WATERY diarrhea, low-grade fever
CMV = frequent small volume BLOODY diarrhea, low-grade fever
MAC = WATERY diarrhea, HIGH FEVER (>102.2)
309
A study is conducted to assess effectiveness of a new drug. 1000 pts are enrolled and randomly assigned. Alpha and beta values for calculating probability are 0.05 and 0.2 respectively. Results show the new drug is significantly better than standard tx. If this study had been performed in population of only 500 pts, which of the following would be most likely to increase?
A. Chance of type I error
B. Chance of type II error
C. Neither
D. Both
B. Chance of type II error
type I error = false positive (rejecting the null when you should not have)
type II error = false negative (not rejecting the null when you should have)
