Step 2 CK: Internal Medicine Flashcards
(118 cards)
0
Q
Risk factors for severe pancreatitis (pancreatic enzymes leak into vascular system & incr vascular permeability –> hypotension and large volumes of fluid in retroperitoneum)
A
Age >75
Alcoholism
Obesity
CRP >150 at 48hr
Increased BUN in 1st 48 hrs (new evidence shows easiest/best marker)
CT = Gold standard to look for pancreatic necrosis and extrapancreatic inflammation.
1
Q
Intervention for PAD (peripheral artery dz)
A
A surpervised graded exercise program improves functional capacity & claudication.
- Antiplatelet agents* (ASA, clopidogrel) does NOT consistently reduce claudication sx, but reduces risk of MI & stroke.
- High-intensity statin therapy*
Others: smoking cessation, DM control (A1C <7%), & BP control.
2
Q
Cerebellar tumor sx
A
ipsilateral ataxia, esp if in hemisphere (pt falls toward lesion side)
Titubation (trunk = forward/backward movement)
Nystagmus, intention tremor, isplat muscular hypotonia
Can obstruct CSF –> incr ICP, HA, N/V, papilledema
3
Q
Tabes Dorsalis
A
Destruction of posterior columns, leads to loss of proprioception
Patient walks w/ his legs wide apart. Feet lifted higher than usual, making a slapping sound when they come in contact with the floor.
4
Q
Lab value that makes it more likely ascites is 2/2 portal HTN?
A
SAAG (serum-ascites albumin gradient)
Serum albumin minus ascites albumin (NOT RATIO)
SAAG >1.1 g/dL means etiology likely portal HTN
5
Q
Bacterial Peritonitis (pts w/ ascites) Dx method
A
PMN count >250 & + peritoneal culture confirms dx
6
Q
Essential tremor (usually worse w/ movement) tx
A
B-blocker (esp if concomitant HTN)
or anti-convulsant like topiramate or primidone
7
Q
Homocysteine elevation tx
A
B6 & folate/B12
Homocysteine –(B6 + CBS)–> cystathione
Homocysteine –(B12 & folate)–> methionine
Regardless of etiology, homocysteine levels decrease with B6 & folate (& B12 if deficient). However, evidence unclear if hypercoag reversed w/ decreased levels.
8
Q
Clopidogrel (Plavix) & Ticlopidine (Ticlid) anti-platelet tx for which thrombosis type?
A
Arterial thrombosis (i.e. MI & stroke) vs. venous (DVT)
9
Q
Tick-bourne paralysis vs GBS
A
- Tick-bourne*: Ascending paralysis developing over hours to days. May be localized or more pronounced in 1 arm/leg. CSF, sensory, and autonomics normal. Ticks take 4-7 days to release neurotoxin. Meticulous search for tick should be preformed. Remove and sx improve starting at an hour and complete recovery in several days.
- Guillaine Barre Syndrome*: Ascending paralysis, symmetric, develop over days - wks. CSF high protein w/ few cells in 90% by 1wk. Autonomic sx (tachy, urinary retention, arrhythmia’s) in 70%.
10
Q
Platelet transfusion indicated when levels fall below…
A
50k
11
Q
Colonoscopy recommended q
A
10 yrs for colorectal screening
12
Q
Rx for elderly pts w/ agitation?
A
Low-dose haloperidol Atypical antipsychotics (risperidone, quetiapine) can also be used.
*Typical antipsychotics = do not use in pts w/ Lewy body dementia, b/c can exhibit neuroleptic hypersensitivity (severe parkinsonism & impaired consciousness)
13
Q
Theophylline toxicity
A
Narrow therapeutic index. CYP450 metabolized.
Cimetidine, cipro, erythromycin,verapamil added = can cause toxicity
Symptoms: CNS stimulation (HA, insomnia, szr), GI (N/V), & cardiac toxicity (arrhythmia)
14
Q
DM CN III neuropathy
A
Ischemic - somatic nerve ischemia
CNIII has somatic and PS blood supply separate
Sx: ptosis with eye “down and out,” normal accommodation and light reflex
(CNIII PS innervation = iris and ciliary muscle)
15
Q
Graves dz tx and outcomes
A
Radioactive iodine ablative therapy
MC see results 6-8wks after tx
Many pts euthyroid w/ 1 dose
Hypothyroid (cx) rates: 10-30% in 1st 2yrs, 5%/yr after
Contraindications: preggo or very severe opthalmopathy
16
Q
Mixed cryoglobulinemia
A
Suspect w/ palpable purpura, proteinuria, and hematuria
Most pts + for HCV
Arthralgias, hepatosplenomegaly, low complement also common
DDX: HSP + many more; look for HCV +
17
Q
Classic triad for disseminated gonococcal infection?
A
- polyarthralgia
- tenosynovitis
- painless vesiculopustular lesions (2-10, may be dismissed as pimples or furnuncles)
Pt often has h/o unprotected sex w/ new partner
+/- fever & chills
18
Q
Retinal detachment
A
Sx: photopsia (flashes of light) & floaters (spots in vision)
Classic: “curtain coming down over my eyes”
Trauma often occurs months before sx
Eye exam: grey, elevated retina
Tx: Laser therapy & cryotherapy to create adhesions b/t retinal layers
19
Q
HbA1C 1% increase = X increase in average plasma glucose?
A
35mg/dL increase in mean plasma glucose per 1% increase in HbA1C
20
Q
MCC of aortic regurg? Sx?
A
In developing countries: rheumatic fever
In developed countries: aortic root dilation (e.g. marfan or syphilis) or congenital bicuspid aortic valve
Sx: widened pulse pressure, pounding heart sensation, exertional dyspnea
21
Q
Central retinal artery occlusion tx?
A
Ocular massage & high flow O2
Sx: painless loss of monocular vision
22
Q
Acute angle glaucoma sx? tx?
A
Sx: acute, painful vision loss with red eye
Tx: topical pilocarpine and b-blocker
23
Q
Recommendation for patients with chronic Hep C?
A
Obtain Hep A & B vaccination if not already immune
*NB, if preggo, cannot get ribivarin/IFN tx
24
Foreign body feeling in eye (after drilling & pt felt something go into eye, for example) that has a (-) gross examination...next step?
*Fluorescein* examination (woods or slit lamp)
| Will reveal corneal abrasion or foreign body not seen before.
25
Imaging of choice in patients w/ h/o chronic pancreatitis & jaundice vs no jaundice?
U/S if jaundiced
| CT w/ contrast if no jaundice
26
Secretin test is used for what?
Dx chronic pancreatitis
| Measures the ability of ductal cells to produce bicarb
27
Dermatomyositis: association
Increased with of malignancy, ovarian MC
Breast and other urogenital CA also seen
*>10%* of DM pts have underlying malignancy
28
Urge incontinence tx
Anticholinergics:
*Oxybutynin*
*Tolterodine*
Urge incontinence: overactive bladder - sense of urgency but can't get to bathroom in time.
Adrenergic rx have not proven efficacious
29
Tx for urinary sx assoc w/ BPH
a-adrenergic blockers, e.g.
| *Doxazosin* or *Tamsulosin*
30
Ddx for new onset urinary incontinence?
DIAPERS
*D*rugs, *I*nfection, *A*trophic vaginitis, *P*sych (depression, delirium, dementia), *E*ndocrine (hyperglycemia, hypercalcemia), *R*estricted mobility, *S*tool impaction
31
4 MC Rx to cause gingival hyperplasia?
Phenytoin (Dilantin)
Cyclosporin (transplant prophylaxis, RA, psoriasis)
Nifedipine (DHP CCB)
Verapamil (non-DHP CCB)
32
4 MCC of cough?
Cough variant asthma
Post-nasal drip
GERD
Drugs (ACEi)
33
ST elevation in young, black, athletic males (<40 yo) is a normal variant due to what?
Early repolarization
34
What type of drug should never be given in a pt using cocaine who p/w MI?
Tx same as normal STEMI, with PCTA or thrombolytics. Nitrates & ASA OK, but *B-blockers* should be avoided.
Leads to unopposed a-agonist activity.
CCBs and a-blockers (i.e. phentolamine) can also help reduce vasospasms in these pts
35
Classic angina characteristics
Typical quality (pressure or crushing) & duration (>20 mins)
Provoked by exercise/emotional upheaval
Revealed with nitro or rest
*Note: "sharp/stabbing" pain - atypical
36
Another name for Streptococcus gallolyticus; clinical significance?
Strep Bovis Type I
| Significant increased risk of colorectal cancer and endocarditis
37
Drug that induces hepatic cell injury, similar to a viral hepatitis picture, but characteristically lacks extrahepatic hypersensitivity sx?
Isoniazid
38
Drug-induced liver disease categories
1. Cholestasis: chlorpromazine, nitrofurantoin, eythromycin, & anabolic steroids.
2. Fatty liver: tetracycline, valproate, & anti-retovirals
3. *Hepatitis:* Halothane, phenytoin, isoniazid, & a-methyldopa
4. Fulminant liver failure: CCl4 & acetaminophen
5. Granulomatous: allopurinol & phenylbutazone
39
Bisphosphonates (-dronate) S/E
Corrosive esophagitis: take w/ water & remain upright for 30 minutes
Osteonecrosis of the jaw
40
Rx causing HYPERkalemia
Digitalis
*Heparin*
non-selective B-blockers (B2 mediated intracellular K+ uptake)
*ACEi/ARB*/K+ sparing diuretics
cyclosporin
*succinylcholine*
*TMP-SMX* (sim to MOA of amiloride; also causes artificial increase in creatinine levels)
41
2 exceptions to having a prophylactic chole in a pt w/ gallstones but no symptoms?
1. Morbidly obese person undergoing gastric bypass (increased risk of gallstone complications)
2. Porcelin gallbladder (increased risk of gallbladder CA)
* *Studies indicate only 20% of asx gallstones will develop sx within 15 yrs.
42
Medical management used to tx pts w/ symptomatic gallstones but who are poor surgical candidates?
Ursodeoxycholic acid
*Note Rx is expensive & if patient stops taking it, gallstones tend to recur unless condition that gave rise to their formation changes.
43
SCREENING test for HIV? (vs confirmatory test)
ELISA for *screening* (sensitivity = 99.9%)
Western blot for *confirmatory* test (specificity = 99.9% when combined with ELISA)
((Remember, ANA & ELISA = very sensitive! screening)
44
EKG finding sometimes assoc w/ PE? Clinical findings that would accompany this dx?
New-onset RBBB in a pt who clinically has tachypnea & tachycardia
45
Cerebellar hemorrhage sx?
16% of all ICH
HA (occipital & radiating to neck/shoulders)
Facial weakness
Gaze palsy/nystagmus
Neck stiffness (2/2 blood in 4th ventricle)
Gait ataxia
Usually *no hemiparesis* or sensory loss
46
SAH sx
Thunderclap headache
| Usually NO *focal* deficits, although global depression (like AMS) can occur
47
Physiologic reason for symptoms in cardiac tamponade?
*Decreased LV preload* --> dec CO
Fluid in pericardial cavity increases the intrapericardial P above the diastolic ventricular P.
D/t increased sympathetic response, cardiac contractility is actually increased (anti-intuitive)
48
All pts w/ new onset Afib should have testing for what?
TSH & free T4 to look for occult hyperthyroidism as an underlying cause
49
Rates of cutaneous & joint involvement in pts w/ SLE
>80% have cutaneous involvement at some point in dz (MC in sun exposed areas)
>90% have joint involvement (arthralgias or true arthritis; often migratory)
50
When to give activated protein C (droteocogin alfa activated) in severe sepsis pts at high risk for death?
Pts w/ *APACHE score >25*. Platelet counts b/t 30-50k decrease relative risk of mortality by 30%.
C/I if plt count <30k, concurrent anticoag rx, or active bleeding
Do not use if APACHE <25 or only 1 failing organ sys
51
Vasopressor of choice in pts with septic shock?
*Norepinephrine* (Levophed)
| Dopamine associated with tachycardia and arrhythmias
52
Osteoarthritis presentation
Ex: hip
Hip pain worse w/ walking & relieved by rest, but morning stiffness or stiffness after prolonged resting = consistent feature; different from RA b/c *morning stiffness lasts <30-60 minutes*
Active & passive internal & external rotation is limited/painful.
*Tenderness to palpation* & systemic symptoms are characteristically *absent* in OA.
53
Initial treatment for HCV in patients w/o C/I
*Peginterferon + ribavirin*
| If HCV genotype 1: add an additional protease inhibitor (telaprevir or boceprevir).
54
Contraindications for HCV antiviral treatment?
Ongoing alcohol or drug abuse
| Major uncontrolled depression
55
Aspirin OD sx triad?
Tinnitis, fever, & tachypnea
56
Drug of choice for pregnant pt with Lyme disease (or if lactating, or <8yo)?
Amoxicillin
57
In pt w/ Lyme dz, doxycycline is also covering for what disease?
Granulocytic anaplasmosis
| also transmitted by ixodes scapularis
58
Winter's formula
PaCO2 = 1.5 (HCO3) + 8
| Looking to see if respiratory compensation occurred w/ metabolic acidosis
59
Cx of SAH?
1st 24 hrs: rebleed
*3-10 days: vasospasm* (dx via CTA)
General: hyponatremia (2/2 SIADH)
60
How to prevent vasospasm after SAH?
Nimodipine
61
Botulism vs MG; which spares pupil?
MG
62
MCC of acute viral arthritis?
Parvo B19
Rubella
HIV
Hep B & C
63
Arthritis in Parvo B19, description.
Polyauricular, *symmetric* arthritis (60%) w/o swelling
Hand involvement similiar to RA (MCP, PIP)
Dx: anti B19 *IgM* antibodies
(Parvob19, SLE, and RA all have same joint/hand involvement)
64
Asymptomatic bacturia associations in pregnant women?
Assoc w/ IUGR, prematurity, etc.
Routinely screened for in pregnant women
If discovered, treated & urine screened for eradication
*Not screened for or treated in other pts (except for before TURP)
65
Mixed cryoglobinemia: sx
Looks like HSP + arthralgia in HCV +ve pt
66
Activated protein C: criteria for use in severe septic pts
Severe septic pts w/ high risk of death, indicated by:
APACHE score >25 OR
Multi-sys organ failure OR
Septic shock requiring pressors OR
Sepsis-induced ARDS
*Plt count b/t 30-50k ideal (dec risk of mortality by 30%)
C/I if plt count <30k
67
Acute prostatitis pt tx w/ flouroquinolones (good penetration of prostate) that fails to respond to tx p 36-72hrs; next step?
Preform TRUS or CT of abd/pelvis to r/o prostatic abscess
If outlet obstruction occurs, transurethral catheter not indicated d/t increased risk of sepsis/abscess formation
Suprapubic catheter preferred
68
Erythrasma
Superficial skin infection, MC in skin folds
2/2 *corynebacterium*, part of skin flora
Dx: Clinical +/- *coral under Wood's lamp*
Tx: *Macrolides*
MC in diabetics, obese, and warm climates
69
Tx for Toxoplasmosis encephalitis?
Sulfadiazine
Pyrimethamine and foilinic acid
Repeat MRI critical to assess tx response. If no therapeutic response after 14 days, brain biopsy needed to r/o other causes (esp a 1* CNS lymphoma)
70
Mc form of meningitis in AIDS pts?
Cryptococcus neoformans
71
Infective endocarditis murmur
1. Mitral *regurgitation*
2. Aortic stenosis
(Pts w/ MVP & assoc regurg = 5-8x incr risk of IE)
Mitral stenosis uncommon in IE, but common in RF
72
Variant (Prinzmetal) angina MC risk factor? Classical timing of angina? Assoc dz?
Smoking = greatest risk factor (Classically young F)
MC at night 12a-8a; wakes from sleep
Transient ST elevations seen on ECG
Assoc w/ other vasospasmotic dzs, like Raynauds & migraines
*Be careful, migraines often seen in these people and Sumatriptan is tx for cluster HA, which is C/I in prinzmetal angina d/t risk of coronary vasospasm
73
Treatment recommendation for pts w/ Hereditary Spherocytosis undergoing splenectomy?
Pneumococcal, H influenza, and meningococcal vaccine 3 weeks before splenectomy
*PLUS daily oral penicillin* prophylaxis for *3-5 yrs *p splenectomy (or until adulthood if peds pt)
74
Cauda Equina Syndrome
Large midline disk herniation --> nerve root injury
| Sx: Bladder atony, overflow incontinence, bilateral sciatica, saddle anesthesia & loss of anal sphincter tone
75
Urge incontinence
Detrusor instability, MC p/w incontinence preceded by sudden urinary urgency. D/t unregulated spontaneous contractions that are unresponsive to cortical inhibition.
76
Acute migraine tx
IV antiemetics (*chlorpromazine, prochlorperazine or metoclopramide*) can be used as mono therapy or adjuvant therapy in combo w/ NSAIDs or triptans for tx of acute migraine.
77
FiO2 goal in ventilated pts? Assoc toxicity if too high? Next step in management in hypoxic pt w/ adequate FiO2?
1. Goal to keep *FiO2 <40%* at all times.
2. Risk of pulmonary oxygen toxicity if higher.
3. Add PEEP if FiO2 adequate and pt still hypoxic. Prevents alveolar collapse; esp helpful in ARDS
78
Diastolic CHF
Typical features of CHF w/ preserved EF
MCC = systemic HTN --> *LAE --> afib*
Tx: diuretics + BP control
79
Statin therapy indicated in pts w/ LDL 70-189 if ASCVD risk is...
>/= 7.5% via risk calculator
80
Fluorouracil cream used in what type of skin cancer precursor?
Actinic/Solar keratosis
81
CMV gastritis seen in HIV pt w/CD4 count ~50
Intermittent bloody diarrhea with abdominal cramping; colonoscopy shows specimen:
*Eosinophilic intranuclear and basophilic intracytoplasmic inclusions* = classic Q description of "owl eye inclusions"
82
Inflammatory vs non-inflammatory chronic prostatitis
Inflammatory: WBC >10/hpf
Non-inflammatory: normal WBC
*Both: afebrile, irritative urinary sx, normal urine cx, no hx of uti/voiding abnormality
83
Must consider what etiology in a pt having syncopal episodes w/ either advanced systolic CHF or underlying IHD (i.e. prev MI)
*Ventricular tachycardia (VT)* (or any cardiac arrhythmia, incl trifascicular block)
Tends to recur and can cause sudden cardiac death
Seen in pts w/ cardiac hx and no presyncopal prodrome
84
Vasovagal syncope
Prodromal symptoms of nausea, lightheadedness, diaphoresis lasting >10 secs = highly sensitive for dx of vasovagal syncope.
Brief, myoclonic jerking p losing consciousness not unusual.
85
Pathophysiology of vasovagal (neurocardiogenic) syncope
1. Triggers lead to increased PS tone --> dec HR/BP (cardioinhibitory response)
2. Dec sympathetic tone --> vasodilation & hypotension (vasodepressor response)
* One or both can cause
86
Goal of anti-depressive tx? Tx progression?
Goal should be remission of depressive sx, not simply improvement of sx.
If no response to full-dose tx p 6 wks, should start new med or refer to psych
One study showed *25%* of pts with major depression who did not response to an initial antidepressant achieved remission w/ a different med; Rx change can be to a drug in the SAME class
87
Characteristics that make a pt a candidate for pharmacologic therapy after death of a loved one?
If pt has sx of major depression for at least 2 consecutive weeks, 8 or more weeks after loved one's death.
Major depression in the setting of bereavement cannot be dx unless sx persist for >2 months or pt has a qualifier.
88
Alcohol withdrawal tx?
Benzo's (*lorazepam*) 1st line for withdrawal (dec incidence of DTs & szrs)
WARNING: B-blockers assoc w/ greater incidence of delirium & neuroleptics (i.e. haloperidol) are assoc w/ incr risk of szr during withdrawal.
89
Cocaine abuse pt w/ agitation tx?
IV/IM *Lorazepam*
| *Do NOT use B-blockers* --> unopposed a-blocking effects
90
Rx used in short-term tx of alcohol dependence? MOA?
Naltrexone
| Opoid R antagonist
91
IV Fomepizole tx for what?
Ethylene glycol & methyl alcohol poisoning
| p/w AG metabolic acidosis w/ osmolar gap
92
Tx for cyanide poisoning?
Inhalation of amyl nitrite (followed by)
| IV sodium nitrite or sodium thiosulfate
93
Triad of sx suggestive of spinal cord compression?
Back pain
Muscle weakness
Loss of bowel or bladder control
94
Cough-variant asthma dx confirmed?
with resolution of cough p asthma therapy (trial of inhaled albuterol)
*If does not resolve after albuterol, consider eosinophilic bronchitis. Bronchoscopy w/ biopsy would dx this.
95
MCC of hemoptysis in ambulatory pts?
Infection (bronchitis or pneumonia)
Malignancy
All pts w/ hemoptysis should get CXR
CT + fiberoptic bronchoscopy, even is CXR normal if:
Male, >40, >40 pack years, sx >1 wk
96
Bariatric surgery commonly established referral guidelines.
BMI >/= 40 OR
| BMI >/= 35 + co-morbidity (DM, OSA, severe arthritis, obesity-related cardiomyopathy)
97
Persistent N/V within 1st few months after gastric bypass surgery; Dx?
*Stomal stenosis* or marginal ulcerations/erosions
A stricture at the anastomosis b/t the gastric pouch & jejunum
Dx w/ endoscopy or barium swallow. Stricture can be dilated during endoscopy
98
MC site for hypertensive hemorrhages? Sx?
*Putamen*, which almost always involves the adjacent *internal capsule*, which leads to *contralateral dense hemiparesis* (CST)
99
*P*ontine hemorrhage sx?
Complete *p*araplegia followed by deep coma within a few minutes.
*P*inpoint pupils, but reactive to light
Decerebrate rigidity
100
Intraparenchymal brain hemorrhage sx?
Sudden, focal neurological defects that *worsen gradually within minutes to hours*
HTN = MC risk factor
101
PEEP definiton?
Positive pressure added to the end of the expiratory phase to prevent the alveoli from collapsing
102
Lumbar spinal stenosis sx?
Pain worse with walking, improved with rest
103
Spinal cord compression triad?
Weakness
Bladder incontinence
Pain
104
HIV pt w/ CD count of 34 at risk for...
M. Avium
105
CREST syndrome (know SX); antibodies against what?
anti-centromere antibodies
106
2nd line tx for T2DM After diet/exercise regimen?
Metformin
107
Pt reports room spinning when he reaches over to turn off his alarm in the morning. Dx?
BPV
108
MCC of meningitis in a man in his late 50s? N. meningitis or S. pneumo?
S. pnuemo!
109
COPD pt w/ green sputum. Organism?
Psuedomonas
110
Patients with sickle cell trait can have what sx after heavy exercise?
Gross hematuria
111
Patient describes "curtain falling down over eye" is what?
Amaurosis Fugax
112
BMI >40, after failure with diet & exercise, offer...
bariatric surgery
113
Benzo OD tx MOA?
mu-opiod R antag
114
Shooting pain when old lady brushes her teeth? Tx?
Carbamazapine (tx for trigem neuralgia)
115
Ear abnormality in pt w/ T1DM?
Otitis Externa
116
IVDU with crunching below skin. Dx?
Necrotising Fascitis
117
GI dz w/ presenting sx
1. Older male, smoker, dark stool: CRC
| 2. Woman w/ bloody, mucus stool: U. Colitis
