STEP 2 Flashcards

Question

Revised Cardiac Risk Index (RCRI) (cardiovascular risk of noncardiac surgery)

Answer 1

6 risk predictors High-risk surgery (eg, vascular, intrathoracic) Ischemic heart disease History of congestive heart failure History of cerebrovascular disease (stroke or TIA) Diabetes mellitus treated with insulin Preoperative creatinine >2 mg/dL Risk of cardiac death, nonfatal cardiac arrest, or nonfatal MI 0-1 factor: low risk* ≥2 factors: elevated risk

Answer 2

This patient has a life-long history of sleep difficulties that occur when she is required to wake up early. She also has a natural, pronounced "night owl" tendency to fall asleep and wake up late. This is most consistent with delayed sleep phase disorder, a type of circadian rhythm disorder most commonly seen in adolescents and young adults. When patients with delayed sleep phase disorder fall asleep and wake up according to their internal circadian rhythm, they have normal sleep quality and duration and no bothersome symptoms (as in this patient who did well with shift work that allowed her late sleep and wake times). However, the disorder is typically unmasked when patients attempt to conform to a different schedule requiring early wake times, leading to bothersome symptoms such as daytime drowsiness, malaise, and gastrointestinal issues. Diagnosis can be established with a sleep log with or without actigraphy (recording sleep patterns using a wearable device). Management includes bright light therapy in the morning and slowly advancing sleep and wake times. (Choice A) Advanced sleep-wake phase disorder is also a circadian rhythm abnormality; however, it manifests with markedly early (rather than delayed) sleep and wake times (eg, drowsiness starting in early evening, waking several hours before dawn).

Answer 3

Methotrexate Folate antimetabolite Hepatotoxicity Stomatitis Cytopenias Leflunomide Pyrimidine synthesis inhibitor Hepatotoxicity Cytopenias Hydroxychloroquine TNF & IL-1 suppressor Retinopathy Sulfasalazine TNF & IL-1 suppressor Hepatotoxicity Stomatitis Hemolytic anemia TNF inhibitors (eg, adalimumab, certolizumab, etanercept, golimumab, infliximab) Infection Demyelination Congestive heart failure Malignancy

Answer 4

DASH diet -Diet high in fruits & vegetables & low in saturated & total fats -11 Weight loss Reduction of BMI to <25 kg/m2 6 per 10-kg loss Aerobic exercise 30 minutes/day for 5+ days/week 7 Dietary sodium <1.5-2.3 g/day (response varies) 5-8 Alcohol limitation ≤2 drinks/day in men, ≤1 drink/day in women 5

Answer 5

Abortives Triptans (eg, sumatriptan) NSAIDs (eg, naproxen) Acetaminophen Antiemetics (eg, metoclopramide, prochlorperazine) Ergotamines (eg, dihydroergotamine) Preventives Topiramate Divalproex sodium Tricyclic antidepressants Beta blockers (eg, propranolol)

Answer 6

Causes Mechanical (eg, disc herniation, spinal stenosis) Malignancy (eg, lung, breast, prostate cancers) Infection (eg, epidural abscess) Symptoms Gradually worsening, severe back pain Pain worse in recumbent position/at night Physical examination Early signs Symmetric extremity weakness ↓ Deep tendon reflexes Late signs ↓ Rectal tone ↑ Deep tendon reflexes, bilateral Babinski reflex Paralysis Management Emergency MRI of the spine Emergency surgical ± radiation oncology consultation Intravenous glucocorticoids (eg, malignancy) or antibiotics (eg, infection)

Answer 7

Bloody diarrhea is most often caused by infectious gastroenteritis due to bacterial pathogens, specifically Shiga toxin–producing Escherichia coli (STEC), Shigella, or Campylobacter; other organisms that often cause watery stools (eg, Salmonella) can occasionally cause bloody stools. Of the given answer choices, STEC is the most likely diagnosis. STEC transmission typically occurs via consumption of contaminated beef products, although outbreaks can occur in association with other foods such as fruits, leafy vegetables, and milk products. Isolated cases without a clear source are also common. The presentation classically involves inflammatory diarrhea with abdominal pain and stools that are initially watery but later contain blood. This patient's lack of fever is typical of infection with STEC; although a minority of patients with STEC gastroenteritis may have low-grade fever, the presence of a temperature >38.5 C (101.3 F) suggests an alternate diagnosis. The diagnosis can be confirmed with multiplex nucleic acid amplification testing or assay for Shiga toxin in stool; stool culture should always be obtained for strain identification and outbreak tracing. Treatment is generally supportive (eg, aggressive fluid administration), and antibiotics should be avoided due to the increased risk for hemolytic uremic syndrome.

Answer 8

Assessing the clinical significance of hypocalcemia detected in a common serum metabolic panel requires correction for the serum albumin concentration. The serum calcium concentration decreases by 0.8 mg/dL for every 1 g/dL decrease in serum albumin; the corrected calcium level can be calculated using the following formula: Corrected calcium = (measured total calcium) + 0.8 × (4.0 g/dL − serum albumin in g/dL) This patient with nephrotic syndrome (heavy proteinuria, hypoalbuminemia, edema) has a corrected calcium of 8.94 mg/dL ([7.5 mg/dL] + 0.8 × [4 g/dL − 2.2 g/dL]). The hypocalcemia is most likely due to hypoalbuminemia (from nephrotic-range proteinuria) and is not clinically significant. Direct measurement of ionized calcium is performed in many clinical laboratories, but it requires special handling and may not be readily available.

Answer 9

Dietary interventions All calcium stones: ↑ Fluid (produce >2 L/day urine) - ↑ Urine flow, ↓ solute concentration ↓ Sodium (<2,300 mg/day) - ↑ Renal calcium reabsorption ↑ Citrate (fruits & vegetables) - Binds urinary calcium to inhibit stone formation ↑ Potassium - ↑ Urinary citrate excretion ↓ Animal protein - ↓ Urinary calcium excretion Calcium oxalate stones: Adequate calcium intake (1,200 mg/day) - ↓ Oxalate absorption in GI tract ↓ Oxalate (spinach) - ↓ Urinary oxalate excretion Pharmacologic interventions Thiazide diuretics - ↑ Renal calcium reabsorption Potassium citrate - ↑ Urinary citrate concentration

Answer 10

This patient is showing signs of postconcussive syndrome following a mild traumatic brain injury (TBI). TBI of any severity can lead to (a few hours or days later) postconcussive syndrome, which is clinically described by the following constellation of symptoms: headache, confusion, amnesia, difficulty concentrating or with multitasking, vertigo, mood alteration, sleep disturbance, and anxiety. Typically, these symptoms resolve with symptomatic treatment within a few weeks to months following TBI; however, some patients may have persistent symptoms lasting >6 months. (Choice A) Acute stress disorder develops following exposure to threatened death, serious injury, or sexual violation and is characterized by intrusive memories, nightmares, flashbacks, avoidance, and arousal symptoms (eg, hypervigilance, insomnia, irritability, poor concentration). Symptoms last 3 days to 1 month. Although acute stress disorder symptoms overlap with those of TBI, the type of trauma, prominent physical symptoms, and lack of nightmares or flashbacks in this patient make TBI more likely.

Answer 11

Patients with cirrhosis and portal hypertension frequently have abdominal ascites and peripheral edema due to low albumin levels and abnormal extracellular fluid volume regulation. A small number of these patients may also develop hepatic hydrothorax, a pleural effusion not due to underlying cardiac or pulmonary abnormalities. Hepatic hydrothorax generally results in transudative pleural effusions and is thought to occur due to small defects in the diaphragm. These defects permit peritoneal fluid to pass into the pleural space, which occurs much more commonly on the right side due to the less muscular hemidiaphragm. Patients have dyspnea, cough, pleuritic chest pain, and hypoxemia. Diagnosis involves documentation of the effusion (eg, chest x-ray) and testing to exclude other causes (eg, thoracentesis, echocardiogram). Treatment involves salt restriction and diuretic administration. Therapeutic thoracentesis could be attempted in patients with prominent symptoms. Chest tube placement should be avoided as it can result in large-volume protein, fluid, and electrolyte losses as well as other severe complications (eg, renal failure). The definitive option for treatment is liver transplantation, although this may not be appropriate for all patients depending on other factors.

Answer 12

Didanosine, glucocorticoids, alcohol, valproate, azathioprine, diuretics (eg, furosemide, HCTZ)

Answer 13

Hypertension 4× Smoking 2.5× Diabetes mellitus 2× Hypercholesterolemia ≤2× Alcohol intake Variable/inconsistent effect Sedentary lifestyle, obesity Small effect

Answer 14

Clinical criteria Known cause (eg, TBI, stroke) Evidence (eg, clinical, neuroimaging) of devastating CNS event Exclusion of confounding conditions (eg, electrolyte abnormality, intoxication, paralytics) Core temperature >36 C (96.8 F), SBP >100 mm Hg Clinical examination Coma Absent brainstem reflexes: Pupillary Corneal Oculocephalic, oculovestibular Jaw jerk Cough Gag Absent brain-originating* motor responses (including decerebrate & decorticate posturing) Apnea test: no respiratory response to PaCO2 >60 mm Hg

Answer 15

Nonpharmacologic measures Exercise (postural exercises, ROM/stretching exercises) Physical therapy Initial treatment NSAIDs (eg, ibuprofen, naproxen) COX-2 inhibitors (eg, celecoxib) Treatment failure/disease progression TNF-α inhibitors (eg, etanercept, infliximab) Anti–IL-17 antibodies (eg, secukinumab)

Answer 16

First-time seizure in adults Etiology Metabolic (eg, hypoglycemia, electrolyte disorders) Toxic (eg, substance use/withdrawal, medications) Acute brain injury (eg, hemorrhage, meningoencephalitis, stroke) Structural (eg, temporal sclerosis, dysplasia, tumor) Idiopathic/unknown (eg, juvenile myoclonic epilepsy) Evaluation Laboratory: glucose, complete blood count, electrolytes, renal function, liver function, ± urine drug screen Neuroimaging: CT scan (for acute injury; faster) or MRI (for smaller lesions; more time-consuming) ± Lumbar puncture (for fever or nuchal rigidity) EEG Indication to start antiepileptic medications Abnormal EEG or neuroimaging Nocturnal seizure Focal neurologic examination

STEP 2 Flashcards

(40 cards)