Step 2 Internal Med Flashcards
(473 cards)
1
Q
What kind of acid/base d/o does vomiting cause? What is the generation phase and maintenance phase? How do you correct it?
A
Hypochloremic Hypokalemic Metabolic Acidosis
Generation Phase - lose of gastric fluids (HCl, NaCl, and water) causes loss of acids (HCl) w/o compensatory loss of a base (HCO3-); thus a metabolic imbalance
Maintenance: B/c there’s a concomitant loss ECV, the RAAS system is turned on, via unperfused kidneys, and Aldosterone attempts to maintain intravascular volume w/ Adlosterone at the expense of K+ and H+.
Give IVF and potassium!!!
2
Q
Dx a woman who presents with weight gain, fatigue, constipation, hoarseness, and vision memory changes…
MCC?
Trmt?
A
Hypothyroidism 2/2 Hashimoto’s; give Levothyroxine
3
Q
A woman would most likely present with this d/o when pregnant w/ the S/S of: orthopnea, Afib, pulm edema, with previous infections and from Eastern Europe. What is this the leading cause of worldwide? S/S?
A
Dx: Rheumatic Heart Disease - declares itself in preg 2/2 increase in blood volume
Mitral Stenosis - hear diastolic rumble at apex, opening snap
4
Q
Best screening lab to order in NON-African American pt for hemoglobinopathy? VS if pt is AA?
A
CBC if non-AA; then if abnormal, get hemoglobin electrophoresis.
Whereas if pt is AA, start with hemoglobin electrophoresis
5
Q
Suspect this cardiac dz with a pt having HA’s, recurrent epistaxis, and signs of LV hypertrophy….
Xray Signs…
Defect commonly found at…
Congenital or Acquired or both?
A
Coarctation of the Aorta: “brachial femoral delay” can be felt on PE with notching of ribs 3-8 2/2 to erosion by intercostal arteries.
Xray would show “3” sign just distal to left subclavian artery by ligamentum arteriosum
Congenital or acquired via Takayasu vasculitis.
6
Q
What would a patients neuro exam look like with suspected MS? Esp. the ocular exam…
A
Changing neuro defects that couldn’t be explained by a single lesion. Symptx exacerbated by hot weather or exercise is a good clue!!!
Medial Longituidnal Fasiculus involvement is characteristic in MS with complete inter nucleate opthalmoplegia (when pt looks right, R eye abducts with horizontal nystagmus with stationary L eye; when pt looks left, L eye abducts with horizontal nystagmus and R eye is stationary)
7
Q
Explain categorization of Glomerulonephritis.
Types of each respective GN.
Explain how complement helps make a dx
A
When you see elevated Cr, proteinuria, and hematuria, suspect GN.
Nephrotic GN: proteinuria >3.5g, bland sedimentation, mild hematuria.
Nephrotic GN Types: FSGS, MCD, Membranous Nephropathy, DM, primary amyloidosis, and IgA
Nephritis GN: RBCs/WBCs, casts, mild proteinuria.
Nephritic GN Types: IgA, Lupus Nephritis, Postinfectious GN, MPGN, RPGN, and vasculitis (cryoglobulinemia with Hep C)
Low complement is associated with PostInfectious, Lupus, or Vasculitic…look for recent illness (10-21 days), positive ANA, or elevated liver enzymes/+RF respectively
8
Q
How might cryoglobulinemia associated with Hep C present? What is the pathophys? Trmt?
A
Skin findings: palpable purpura/Raynauds
Kidney: MPGN
Nervous: motor sensory axonopathy
MSK: arthralgias
IgM against IgG Anti-Hep C Ab’s, hep C virus RNA, and complement cause deposition of the antibody complexes in endothelium, small blood vessels, etc causing inflammation and damage
Tmt: of underlying Hep C, plasmapharesis for cryoglobulins and immunosuppressants (glucocorticoids and cyclophosphamide)
9
Q
How does Crohns Disease or other fat malabsorption d/o’s cause symptomatic hyperoxaluria?
A
Oxalate is normally bound to calcium in the gut and is therefore not absorbed. With fat malabsorption, the calcium binds with fat leaving oxalate to be absorbed.
10
Q
What should be ordered in all pts with suspected CAP? Why could is be a false negative in a pt?
A
CXray
Might not show anything with neutropenia, dehydration, or atypical infxn (PJP)
11
Q
A psoas abscess might result from hematogenous infection of skin, bone, or nearby bowel. What sign differentiates it from appendicitis?
A
Deep palpation and the ABSENCE of rigid abdomen, rebound tenderness or periumbilical pain.
12
Q
Pt who presents with nausea, vomiting, headache, stiff neck, and myalgias is concerning for what type of meningitis?
What additional signs would you expect to see in a patient with meningococcal meningitis with meningococcemia?
A
Bacterial Meningitis.
Signs of hypotension, tachycardia, myalgia, and petechial/purpuric skin lesions point more towards this specific type.
13
Q
Pt who presents with rhinitis, anosmia post nasal drip, and has a hx of allergy to NSAIDs most likely has what on PE?
A
Bilateral nasal polyps. This is highly associated with aspirin exacerbated respiratory disease.
14
Q
What do you want to do with a newly diagnosed pt with Lupus?
A
Get a renal biopsy to determine the extent (Class I - IV); then immunosuppressive meds can be initiated
15
Q
What is the post-exposure prophylaxis for the exposed healthcare workers to active Hep B?
A
Hep B vaccine series + Hep B Immunoglobulin
16
Q
What do you do first after a pt presents with splinter hemorrhages, AR, and hematuria s/p dentist work?
A
Get 3 blood cultures from different sites over time for suspected Infective Endocarditis
17
Q
What is the Modified Dukes Criteria for Infective Endocarditis?
A
Major:
1) Blood Culture + (Step Viridens, Stap Aur, or Enterococcus)
2) Echocardiographic evidence of valvular vegetation
Minor:
1) Fever
2) Predisposing Cardiac Lesion
3) IVDU
4) Emoblisms
5) Immunologic phenomena
6) Other + blood cultures
Definite Diagnosis:
2 major / 1 major + 3 minor
Possible Diagnosis:
1 major + 1 minor / 3 minor
18
Q
Differentiate the different types of optho probs:
1) Diabetic Retinopathy
2) Central Retinal Vein Occlusion
3) Macular Degeneration
4) Open Angle Glaucoma
5) Retinal Detachment
A
1) Hard exudates, micraneurysms, retinal edema w/ progressive loss of vision - use argon photocoagulation
2) Sudden unilateral loss of vision upon waking; bulging disc, venous dilation and tortuosity, retinal hemorrhages
3) Distorted central vision with scotomas; atrophic vs. exudative - can see drussen deposits; reading and driving likely to go first; age = RF but smoking increases risk too!
4) Progressive unilateral blurriness; hanging retina in vitreous
5) Gradual loss of peripheral vision; pathologic cupping of disc causing tunnel vision
19
Q
A pt with metabolic syndrome and elevated liver enzymes w/ mild to no EtOH hx make you think of?? This d/o is likely 2/2 to (patho)?
What is the histo findings?
A
Non-alcoholic fatty liver disease. Pts will have diabetes, be obese, hyperlipidemia, hypertension.
Patho: insulin resistance causing increased peripheral lipolysis, increased triglyceride synthesis, and hepatic uptake of FA’s leading to intrahepatic fatty acid oxidation > pro inflammatory cytokines»_space; fibrosis and cirrhosis
Histo: macro vesicular fat deposition and peripheral displacement of the nucleus (looks like AFLD)
20
Q
A UTI with a pt having a urine pH > 7 makes you think of what pathogens? What hint would the question provide most likely?
A
Pt most likely having an indwelling catheter. A urease producing organism will cause an alkylotic pH; urease producing organisms = Proteus (struvite stones), Klebsiella, Morganella Morganii, Pseudo, Providencia, Staph, and Ureaplasma
21
Q
A false + Prot S Def could be caused by what anticoagulant?
A
Warfarin b/c it inhibits Vit-K dependent factors 2, 7, 9, 10 and C/S
22
Q
Which joints are affected early in RA? Which part of the axial spine is affected with RA with what possible side effects? What labs correlate with activity?
A
MTP, MCP, PIP and wrists are affected early with difficulty griping being a sensitive sign of early severe disease.
The cervical spine is the most likely affected area of the axial skeleton with the subsequent risk of subluxation and spinal cord compression.
CRP and ESR
23
Q
What type of medications are preferred for weight gaining in terminal cancer pts?
A
Progesterone Analogs: megestrol acetate and medroxyprogesterone acetate
24
Q
What pathogen causes a halo or crescent sign on pulmonary nodules in a immunocompromised pt?
A
Aspergillosis - it’s ubiquitous! Beware of this in patients with chronic high dosed corticosteroids, cytotoxic drug therapy, or neutropenia.
25
Geographic infections cause ____ and found _____ for:
1) Histoplasmosis
2) Blastomycosis
3) Coccidiomycosis
1) Causes hilar adenopathy (disseminated form found in HIV pts) and found in SE and mid atlantic and central U.S.
2) Causes asymptomatic or flu-like illness but involves the skin, lungs, bones, joints, and prostate. Found in central/south and central/north U.S. Does NOT normally infect immunocompromised pts.
3) Causes cutaneous findings: erythema nodosum or erythema multiform with arthralgias. Found in SW U.S. and parts of Central and South America.
26
What factors delineate the three common causes of esophagitis in an HIV patient?
1) Candida - white oral plaques that can be scraped off
2) HSV - visible vesicles, or large oval ulcers
3) CMV - long linear ulcerations in the distal esophagus
27
What are you suspecting in a pt with rapidly progressive dementia, myoclonus, and spiked triphasic synchronous discharges on EEG?
Creutzfeldt-Jakobs disease, caused by prions, a spongiform encephalopathy VS. Pick's which has a predominance of personality changes VS. Huntington's which occurs earlier (35-50) and has a progressive choreiform movements in all limbs
28
Gran negative rods causing nosocomial infections…which grows in mucoid colonies and predominates in the upper lung fields?
Pseudo, Proteus, E. Coli, Enterobacter, Klebsiella, Serratia Marc.
Klebsiella!!! Watch for in alcoholics
29
What is a pt at risk for who is currently experiencing PAD?
Myocardial infarctions and stroke!
30
What would you suspect on PE/imaging with a suspected esophageal rupture? What's the diagnostic test of choice? What can cause this? What else would you do for them?
Hammans Sign - crunching of the mediastinum or air/effusion seen on CXray. Gastrograffin-contrast esophagography. Can occur from iatrogenic causes (surgery), pill esophagitis (watch out for K Chloride meds), or other conditions that cause damage to the esophagus. Give them parenteral nutrition, surgical repair, and immediate antibiotics.
31
What would laboratory studies of Calcium, Phosphorus, and Alk Phos show in a pt with Paget's Disease? What is the pathophys? What are the symptoms and PE signs?
Normal labs except for elevated Alk Phos! An idiopathic increase in bone resorption via osteoclasts thereby leading to an increase in osteoblastic activity to rebuild broken bone. It occurs to quickly so the "woven bone" yields to fractures and isolated bone pain. Pts are normally asymptomatic but could complain of 'bone pain', increased hat sizes, headaches, or hearing difficulties (2/2 to cochlear nerve impingement). Also, frontal bossing could be seen.
32
How can late onset CAH be distinguished from PCOS?
Elevated 17-hydroxyprogesterone. It can be confirmed with a dramatic increase of 17-hydroxyprogesterone in response to an ACTH stimulus test. This is a disease with varying levels of severity so electrolytes could be normal in later in life, less severe presentations.
33
How would you distinguish the three most common mechanical complications occurring in the Day 3- 7 post-MI range?
1) Ventricular Wall Defect - high mortality, likely to cause pericardial tamponade, hypotension, pulses paradoxes, pericardial rub, JVD
2) Ventricular Septal Rupture - holosystolic murmur heard best at the LSB, associated thrill
3) Papillary Muscle Rupture - leading to pansystolic murmur heard best at the apex, radiates to axilla, soft S1, pulmonary edema with SOB
34
What about a pt's history with Frontotemporal Dementia differentiates them from other disease processes?
Early behavioral/personality changes, early onset (35-50), strong family predominance, and compulsions (hyperorality), primitive reflexes, and only LATE memory probs
35
In light of nephrotic GN, acute onset of fever, hematuria, and flank pain make you think of what? Which type of GN is this associated with most commonly?
Renal vein thrombosis!!! MC to occur in membranous GN although it can occur in any nephrotic type of GN. Occurs 2/2 to loss of ATIII.
36
What differentiates osteomyelitis in regards to S/S? Predisposing RF's? MCO? Most significant diagnostic study?
Osteomyelitis pain is elicited from light palpation of the vertebral body, does not improve with rest (vs. herniation/inciting event), not improved through the day or associated with progressive limitation of the back (vs. ankylosing spondylitis), no night pain (vs. pain from prostate cancer), and not associated w/ sig. changes in lumbar flexion/extension (vs. spinal stenosis - better/worse). WBC/fever = variable. Elevated platelets and ESR = inflammatory signs.
IVDU, SS, immunosuppression, or distal infections (ex: UTI)
Staph Aureas.
MRI
37
What is the management of a pt presenting with Hepatic Hydrothorax?
This is a pt presenting with, MC, a right-sided pleural effusion in the ABSENCE of any cardiopulmonary etiologies for an effusion. Therapeutic thoracentesis with salt-restricted diet and diuretics = primary trmt. If refractory, can proceed to TIPS procedure. The BEST option for trmt is liver transplant.
38
What are the three types of treatment options for someone with anogenital pappiliform, verucous skin-colored/pink lesions? What is this?
Condyloma Accuminata 2/2 HPV.
1) Chemical Trmt = podophylin, epinephrine gel, 5-FU or trichloroacetic acid
2) Immune Therapy = imiquimod / interferon a
3) Surgery
39
What is suspected in a pt with thrombocytopenia, new onset easy bruising, purpura/petechiae, hx of bacterial infections, and skin findings of eczema? MCO's w/ infections?
Triad of Thrombocytopenia, Recurrent Bacterial Infxns (Step Pna, H. Flu, Neisseria Men) and Eczema = X-linked Wiskott-Aldrich Syndrome.
"TREX WAS here"
40
What do you worry about with a woman on OCP's complaining of RUQ pain with palpable mass, or hepatomegaly, or jaundice with elevated GGT/Alk Phos and normal liver enzymes? Causes? Histo? Management?
Hepatic Adenoma's present the risk of severe intra-adenoma hemorrhaging (which is why they are NEVER biopsied) and malignant transformation. Causes = OCP's, anabolic androgen use, DM, pregnancy, and glycogen storage disease. Histo = sheets of enlarged adenomas w/ glycogen and lipid and loss of hepatic cell architecture. Follow if asymptomatic. Symptomatic = resection. Always f/u with AFP levels to assess for possible malignant transformation.
41
MCC of hydatid cysts? RF's? Histopath?
Ecchinococcus Granulosus (cystic echinococcus). SW U.S. and people exposed to sheep and dogs. Looks like encapsulated and calcified cyst with fluid and budding cells.
42
What is seen in S/S of Cushing Syn? What electrolyte abnormality is seen? Why does this happen? MCC?
Fatigue, weight gain, central adiposity, proximal muscle weakness, supraclavicular fullness, easy bruising, hyperglycemia, osteoporosis and osteopenia, hypertension, acne, cataracts, and predisposition to infxns.
Hypokalemia, hypernatremia, and hypervolemia 2/2 to elevated corticosteroids having some effect on aldosterone receptor.
MCC = iatrogenic cortisol injections
43
```
Clinical associations with common GN's:
FSCS
Membranous
MPGN
MCD
IgA Neph
Crescentic
```
1) FSGS - blacks, hispanics, obesity, HIV, and heroin
2) Membranous GN - adenocarcinoma, NSAIDs, hep B, SLE
3) MPGN - Hep B/C and lipodystrophy, chronic bacterial infxns
4) MCD - NSAIDS and Lymphoma
5) IgA Neph - concurrent URI
6) Crescentic GN - hematuria, hypertension, autoimmune d/o
44
Wt loss and post-prandial pain that causes abdominal angina is MC 2/2? Diagnostic imaging?
Atherosclerosis of mesenteric arteries. Use angiography or Doppler U/S. Pt may have abdominal bruit.
45
Removal of K FROM THE BODY can be accomplished with what three methods?
Dialysis, Cation exchange resins, or diuretics. Kayexalate (sodium polystyrene sulfonate) is a cation-exchange resin which acts on GI to promote exchange of Na and K.
46
Side Effx's of Cyclosporine? MoA?
GI disturbances in the form of N/V/D, increased risk of SCC and lymphoproliferative d/o, infection, glucose intolerance, gingival hypertrophy, hirsutism, hypertension 2/2 renal vasoconstriction (use CCB for trmt), and nephrotox (hyperuricemia, hyperkalemia, hypophosphatemia, and hypomagnesemia), and tremor. Hemorrhagic cystitis, bladder carcinoma, sterility and myelosuppression
MoA = inhibits transcription of IL-2 and other T-helper lymphocytes
47
SEffx of Tacrolimus? MoA?
Similar to cyclosporine but more commonly has neurotoxicity with diarrhea and glucose intolerance.
MoA = same as cyclosporine
48
Seffx of Azathioprine? MoA?
Dose related diarrhea, leukopenia, and hepatotoxicity.
MoA = purine analog that's converted to 6-MP
49
Seffx of Mycophenolate? MoA?
Reversible inhibitor of inosine monophosphate dehydrogenase (IMPDH) - enzymes in purine synthesis and major suppression of bone marrow!!!!
50
Pale patches of skin with hyper pigmented borders around body orifices and in acral locations is most likely?
Vitiligo - 2/2 destruction of melanocytes
51
What are some common causes of metabolic acidosis with an increased Anion Gap? When would you calculate osmolar gap?
```
MUDPILES:
M- methanol (formic acid accumulates)
U- (ESRD) can't excrete H+ and NH4+
D- Diabetic Ketoacidosis
P- Phenformin (Metformin)
I- Iron, Isoniazid
L- lactic acidosis
E- ethylene glycol (glycolic and oxalic acid accumulation), ethanol
S- salicylates (w/ resp. alk)
```
Calculate osmolar gap for suspected ethylene glycol, ethanol, or methanol
52
Gastric cancer staging is very important since most are diagnosed at such a late stage - what's the next best step in mgmt?
Order a CT to stage the cancer once there's a histologic dx.
53
New or worsening respiratory sympt. during/within 1 week of known clinical insult with bilateral lung opacities is consistent with what dx? How is it categorized?
ARDS: get objective assessment to r/o primary cardiopulmonary d/o. Severity is based on PF Ratio:
PaO2/FiO2 < 300mmHg with PEEP > 5cm H2O
ARDS can happen 2/2 pancreatitis from transfer of elevated pancreatic enzymes causing alveolar damage
54
What else is associated with PPH besides Sheehan Syn?
Primary Adrenal Insufficiency 2/2 adrenal hemorrhage - the pt would have hypotension
55
What electrolyte abnormality do you need to be wary of w/ a pt on Furosemide? What cardiac problem is associated with this + Digoxin?
Hypokalemia and Hypomagnesemia can lead to ventricular tachycardia. Digoxin + this electrolyte abnormality can exacerbated Vent. Tachy.
56
What classifies the different types of MEN?
MEN I = Pituitary, Parathyroid, and Pancreatic tumors ("PPP")
Men IIA = Medularry Thyroid Cancer, Pheochromocytoma, Parathyroid hyperplasia ("MPP")
Men IIB = Marfinoid Habitus/Mucosal Tumors, Medullary Thyroid Cancer, Pheochromocytoma
57
Thickened gastric folds, heartburn, and pain, diarrhea, multiple petic ulcers, and ulcers distal to duodenum and jejunum make you think of?
Gastrinoma - look for MEN syndromes!!!
58
How does Histo present differently in immunocompetent vs. immunocompromised people? What's the fastest and most sense. test? Trmt?
Mild cold or asymptomatic presentation in immunocompetent people. In immunocompromised people it presents as fever, fatigue, weight loss and involves cytopenias, lymphadenopathy, and hepatosplenomegaly with reticulonodular pulm infiltrates or cavitary lung lesions.
Urine antigen immunoassay!
Itraconazole or Amphotericin B for severe disease.
59
Anti-phospholipid antibody syndrome should be suspected in people with SLE and clotting hx. It causes what type of lab abnormality? How would you confirm it's presence?
An artificially prolonged PTT 2/2 to the IgG/IgM binding to the lipids in the assay - doesn't actually increase bleeding. It does NOT correct when mixed with 1:1 plasma. The Russell viper venom test will be prolonged if this is presently happening.
60
How do nitrates work primarily as an anti-ischemic and anti-anginal medication?
They cause systemic ventilation (decreasing the preload), arteriole dilation and coronary dilation. It's the significant and systemic vasodilation that causes a decrease in the LVEDV and therefore decreased myocardial stress on the heart.
61
What is the main risk factor of using Raloxifene for osteoporosis prevention? What else could it cause? Protective factors? How does it work?
Venous Thromboembolism!!!
Can cause hot flashes and leg cramps.
It decreases risk of Breast Cancer!!
It's a selective estrogen receptor modulator (SERM) that increases bone mineral density and is used to prevent osteoporosis. It's an antagonist in the vaginal and breast tissue but an agonist in bone.
62
Describe how the following present and any respective path findings:
1) Giant Cell Tumor of Bone
2) Baker's Cyst
3) Osgood-Schlatter
4) Osteitis Fibrosa Cystica (von Recklinghausen disease of bone)
5) Osteoarthritis
6) Osteoid Osteoma
1) Benign and locally aggressive bone tumor in young adults. Appears at epiphyseal region of long bones, MC distal femur and proximal tibia. Sheets of large osteoclast cells that are round or elongated mononuclear cells. See cystic and hemorrhagic cysts on MRI. "Soap Bubble" Surgery = trmt
2) Bakers Cyst appear on medial side of popliteal fossa 2/2 gastrocnemius-semimembranosus bursa 2/2 degenerative joint disease and/or injury.
3) Overuse injury accompanied with rapid growth spurt. Xray shows avulsion of the apophysis of the tibial tubercle.
4) 2/2 Hyperparathyroidism from parathyroid cancer. Bone resorption replaced with fibrous tissue (brown tumors). Imaging shows subperiosteal bone resorption on radial aspects of middle phalanges, distal clavicular tapering, salt and pepper appearance of skull, bone cysts and brown tumors on long bones
5) Joint space narrowing, subchondral sclerosis, osteophyte formation, and subchondral cysts.
6) Causes pain that's worse at night and unaffected by movement, readily decreased pain with NSAID use. Corticol lesion with central nidus of lucency.
63
A young pt presenting with progressive lower back pain and stiffness with decreased lumbar spinal mobility and tenderness over the sacroiliac joints = ??? What is the first initial best test for dx? What category of autoimmune d/o's does it fall under?
Ankylosing spondylitis! Get an Xray to assess for fusion of sacroiliac joints and/or bamboo spine.
It's a seronegative spondyloarthropathy so DO NOT ORDER ANA. Don't get an HLA-B27 either because if +, only 5% have AS vs. 90% of people with already dx'd AS have + HLA-B27
64
What drugs increase/decrease the action of Warfarin?
Increase: Acetominophen, NSAIDS, Omeprazole, Ginko Biloba, Vit E, Thyroid hormone, SSRI, Amiodarone, Antibiotics, Cranberry Juice and Antifungals
Decrease: Rifampin, Carbamazepine, OCP, Ginseng, St. John's Wort, Green veggies
65
Flushing in the cheeks, nose, forehead and chin with associated telangiectasias and papules/pustules in the setting of hot drinks, emotional states, heat or other rapid body changes is???? Initial Trmt?
Rosacea! Metronidazole
66
Describe the histo of:
1) Herpetic Lesions
2) Apthous Ulcers
3) BCC
4) SCC
1) Giant cells on Tzanck prep
2) Shallow fibrin coated ulcerations with underlying mononuclear infiltrates
3) Invasive clusters of spindle cells surrounded by palisaded basal cells
4) Invasive cords of squamous cells with keratin pearls; look for sun exposure, vermillion border locale = epi clue
67
What markers would be elevated in a nonseminomatous germ cell tumor? What else would you look for? Almost all mediastinal tumors are primary or metastatic?
AFP and B-hCG!
Do a testicular U/S to exclude primary tumor.
Primary mostly.
*Seminomas present with isolated elevation of B-hCG
**Thymoma are associated with myasthenia gravis and pemphigus
68
What value does MRI have over Xray in suspected Osteomyelitis? When would you order a radionuclide scan?
Xray can be negative for 2-3 weeks and MRI can also detect complications like epidural abscess and cord compression. Bone scan for those that cannot undergo an MRI
69
What is associated with the condition with painful subcutaneous pretibiall nodules?
(Erythema Nodosum) associated MC w/ recent strep infxn. Other causes = Histo, TB, Sarcoid, HIV, IBD
70
What are these heart meds generally used for?
1) Atropine
2) Amiodarone
3) Adenosine
4) Epinephrine
1) Decrease vagal tone and increase HR in setting of sinus bradycardia
2) Antiarrhythmic used for supra ventricular and ventricular tacchyarrhythmias to slow SA and AV nodes.
3) Adenosine causes temporary AV block to help identify/terminate supra ventricular tachycardias
4) Use in hemodynamically unstable pts
71
Do superficial thromboses need anticoagulation? Do DVT's? What do you use?
No. Yes, begin Heparin as they begin to transfer to Warfarin for > 3 months in a pt with an identifiable/reversible cause. Can begin as soon as 2-3 days s/p surgery w/o increase risk of bleeding.
72
Young (15-50) female with transient vision loss in one eye, headaches, carotid bruit, hypertension and family hx of stroke makes you think of??? This d/o causes??? Order???
Fibromuscular displasia causes vessel stenosis, aneurysm, or dissection MC w/ carotids, renal, and vertebral arteries. Get a CT angio or Duplex U/S.
*Aldosterone/Renin ratio < 20 signifies that adrenal patho is unlikely
73
With a high suspicion of testicular tumor, what's the next step in mgmt?
Kill first, investigate later…high inguinal orchiectomy. Then examine to determine if further surgery, radiation or chemo is appropriate.
*Testicular cancer has one of the highest cure rates of all types of cancers.
74
Lidocaine is used widely to control complex forms of ventricular tachycardia in patients with ACS, but it should not be used prophylactically to prevent VFib b/c of an increased risk of….
asystole
75
____ is the MCC of lower gI bleeding in an elderly pt. RF's?
Diverticulosis. False diverticula that have chronic constipation from a low-fiber diet as the MCC RF! Diverticula can erode a penetrating piece of the bowel vasculature and cause profuse self-limited bleeding per rectum.
76
Differentiate the presentations of ascending paralysis w/ tick paralysis, GBS, and spinal cord tumors.
Tick-borne paralysis occurs rapidly (hours) and can be asymmetrical, no hx of fever or sensory abnormalities and NORMAL CSF. GBS presents over days to weeks (not hours) and involves autonomic instability, mild sensory loss, with CSF of high protein with few cells (Trmt = immunoglobulins or plasmapharesis). Tumors take a days to weeks to present and sensation is either moderately to grossly abnormal; get an MRI to confirm and IV steroids!
*Botulism presents with descending paralysis
77
Craniopharyngiomas present w/...? Age distribution?
These suprasellar tumors present with signs of hypopituitarism, HA's and bitemporal blindness. Children and 55 - 65 yrs = bimodal distribution. Kids present with retarded growth MC'ly and adults with sexual dysfxn.
78
Name that hemorrhage!
1) MC site of hypertensive hemorrhage is ______. The Internal capsule is adjacent thereby leading to hemiparesis, hemi-sensory loss, homonymous hemianopsia, stupor and coma. Eyes deviate away from lesion.
2) Present with ataxia, vomiting, occipital HA, gaze palsy, and facial weakness. NO hemiparesis.
3) P/w deep coma and paraplegia, pinpoint pupils reactive to light - rigid.
4) Hemiparesis, upgaze palsy, nonreactive pupils, eyes deviate towards the lesion
1) Putamen Hemorrhage
2) Cerebellar Hemorrhage
3) Pontine Hemorrhage
4) Thalamus
* Htn is MC and important RF for an intraparenchymal brain hemorrhage!!!
79
What's the CSF like for Herpes Encephalitis?
Elevated RBC and WBC with normal protein and glucose levels.
80
Hepatorenal Syndrome is a deadly complication of ESLD. What would the pt's clinical picture look like? MCC of death? Best trmt?
HRS has decreased GFR in the absence of shock, proteinuria, or other causes of renal dysfxn…it fails to respond to 1.5L of NS. 2/2 decreased total renal blood flow and vasodilatory substance synthesis. Infxn and hemorrhage = MCC of death in these patients. It is BEST treated with liver transplant!
81
Any patient with recent hx of travel to developing country or camping trip who returns with foul smelling stools, fatty stools, bloating, flatulance, N, malaise and abdominal cramps…dx? Patho? Trmt?
Giardia lamblia has adhesive disks that cause malabsorption. Empiric trmt w/ Metronidazole!
82
What 4 things make up the rotator cuff? MC'ly damaged? PE finding?
Tendons of the Supraspinatous, Infraspinatus, trees minor, and subscapularis. MC'ly damaged = Supraspinatus. Arm Drop test is + = can't abduct arm or hold arm at the 90 degree angle.
83
What causes a pt to have a "winged scapula"? What muscles does this involve? When is it commonly seen?
Seen MC'ly by iatrogenic injury during axillary lymphadenopathy to the long thoracic nerve affecting the serratus anterior.
84
Polyuria, polydipsia, N/V, and constipation make you think of what electrolyte abnormality?
Hypercalcemia - PTH is suppressed in most its when this is 2/2 to malignancy and the Ca levels are usually very high > 13 vs. those with primary hyperparathyroidism.
*Sarcoidosis causes increase conversion of 1,25-hydroxyvitamin D in granulomatous tissue
VS.
*low levels of " " in CKD
85
Sickle Cell patients can have:
1) Acute Hg Drop + No Reticulocyte Response
2) Acute Hg Drop + Reticulocyte Response
3) Acute Hg Drop + Hypotension
1) Aplastic Crisis (Parvo B19)
2) Hyperhemolytic Crisis
3) Splenic Sequestration (get a splenectomy)
*Aplastic crisis in SS pt is different than aplastic anemia = pancytopenia
86
Screening tests for microalbuminuria?
Timed and Spot Urine Test to assess micro albumin to creatinine ratio. 24 hr collection works too but is inconvenient
87
Three D's of Endometriosis? Trmt?
Dyschezia, Dysmenorrhea, Dyspareunia…unless urgent or contraindicated, try NSAIDS and OCPs first
88
Parkinsonism + autonomic dysfunction (postural hypotension, abnl sweating, bowel/bladder control, etc) + widespread neuro signs = ???
Shy-Drager Syndrome - treat with IVF and fludricortisone, salt supplementation, alpha-adrenergic agonists, and constrictive garments for lower body.
89
Riley-Day syndrome or familial dysautonomia = AR disease seen in Jews and p/w...
autonomic dysfxn and severe orthostatic hypotension
90
What would you prescribe with your pt taking niacin for elevated levels of triglycerides? Preventing???
Low-dose aspirin to reduce possible affect of histamine and prostaglandins induced from the medication. Results in flushing and extreme itching.
91
Constrictive Pericarditis is caused by scarring and thickening that results in signs of decreased CO and venous overload. MCC in developing vs. developed countries?
Developed = viral/idiopathic, heart surgery, chest radiation.
Developing = TB
92
What causes Chagas Disease? It's endemic to _____ and can cause?
Trypanosoma Cruzi
Megacolon, Megaesophagus, and cardiac disease
93
What to give a patient to help decrease risk of potential rhabdo?
1) IVF
2) Mannitol
3) Alkalinize the Urine
94
Name that lung tumor!
1) centrally located, necrotic w/ cavitation p/w hypercalcemia
2) peripherally located p/w clubbing and hypertrophic osteoarthropathy
3) peripherally located, p/w gynecomastia and galactorrhea
4) centrally located p/w Cushing syndrome, SIADH, and Lambert Eaton Syn
1) Squamous Cell Carcinoma
2) Adenocarcinoma
3) Large Cell Carcinoma
4) Small Cell Carcinoma
* Adenocarcinoma = MCC of lung cancer in both smokers/non-smokers; stage and respectability determine prognosis and survival respectively
95
MCC of Vitreous Hemorrhage is? Clue on fundoscopy?
Diabetic Retinopathy - hard to visualize the optic disk, obscure details
96
Central Retinal Artery Occlusion differs from Retinal Emboli by….
Pallor of the optic disc, cherry red fovea, and boxcar segmentation of blood in arteries and veins.
The latter has white edematous retina tracing the arterioles
97
Treat of dx with young pt having headaches, elevated BP, and renal bruit, female is….
Angioplasty w/ stent placement for renal artery stenosis 2/2 Fibromuscular Dysplasia
98
Elderly patients presenting with sympt of depression and complaining of memory loss likely suffer from...
Pseudodementia
99
Absent/weak peripheral pulses, BP difference > 20mmHg in R and L arm, diastolic decrescendo murmur heard better on the right sternal border suggests...
Aortic dissection….tearing chest pain radiating to back with Aortic Regurg
100
Chondrocalcinosis (2/2 calcium pyrophosphate dihydrate crystals) is associated with what three things?
Hypomagnesemia, Hyperparathyroidism, and Hemochromatosis.
*Hemochromatosis pt = more at risk for Listeria, Vibrio, Yersinia
101
Hallmark ECG findings of acute pericarditis?
Diffuse ST elevation with down-sloping PR segments
102
Differentiate compression fracture, herniated disk, and lumbago (lumbosacral strain)...
Compression fractures are acute in nature with its predisposed to osteoporosis w/ no hx of trauma. (watch out for steroid users!!!)
Herniated disk would have positive straight leg test and sciatica like pain
Lumbar muscle strain normally has paravertebral tenderness rather than spinal tenderness; less dramatic onset and related to physical strain
103
Premature Ventricular Complexes are described as……seen commonly after…..and you treat symptomatic vs. asymptomatic pts via...
Wide QRS, bizarre morphology, and compensatory pause. Seen after MI's and despite their presence indicating a poor prognosis and cardiac pathology, preventative trmt has been shown to WORSEN survival. Just observe asymptomatic patients with B-Blockers being first line for symptomatic pts.
104
Children presenting with bifrontal or unilateral head pain that is recurrent, accompanied with photophobia, phono phobia, N/V and visual, auditory or linguistic aura = dx?
Migraines - treat with conservative mgmt and acetaminophen. Triptans can be tried for refractory cases.
105
Treatment of a limb with pulselessness, pallor, parenthesis, poikilothermia, and pain =?
Surgical embollectomy, intra arterial fibrinolysis/mechanical embolectomy via interventional radiology
106
Light's criteria for exudative effusion? Causes?
LDH ratio >0.6
Protein ratio >0.5
LDH > 2/3 of normal
Malignancy, PNA, TB, PE, connective tissue disease, and iatrogenic causes.
107
ADPKD is characterized by what three findings? What common complication is considered dangerous but not warranting screening? What 4 extra-renal complications occur?
Hypertension, bilateral palpable abdominal masses, and microhematuria. Get an U/S!!!
Berry Anneurysm
Hepatic Cysts (MC), AR or MVP, Colonic Diverticula, and Abdominal Wall or Inguinal Hernia
108
Traveling to an endemic area for this dx, + RUQ pain, diarrhea (possible dysentery), leukocytosis, elevated alk phos level, hepatic solitary lesion with anchovy paste = ??? Trmt??? What NOT to do???
Amebic Abscess (Entamoeba Histolytica) is treated with metronidazole (or tinidazole) b/c aspirating could cause complications or problems if it's an undiagnosed echinococcus (seen with close contact with dogs!). Also give luminal treatment (paromomycin, iodoquinol, diloxanide furoate)
109
Always suspect ???? in a young patient with chronic diarrhea, abdominal pain, weight loss, elevated platelets and white count, and anemia...
Crohns
110
Dyspnea on exertion + exertional syncope + exertional angina w/ peripheral edema, clear lungs, elevated JVP, RVH, R-sided heave, pulsatile liver, tricuspid regurg w/ a hx of COPD = ???
Cor Pulmonale!
COPD = MCC, others = ILD, thromboembolic event, OSA
EKG would show RBBB, RVH, enlarged R atrium
Enlarged Pulm Art w/ decreased retrosternal space (2/2 RVH)
R Heart Cath = gold standard, showing elevated RVEDP, CVP, and mean pulm artery pressure (>25 mmHg)
111
Intracranial pressure is determined by volume and compliance and depends on brain parenchyma, CSF and _____. What 3 things increase the cerebral blood flow? Ways to decrease ICP?
Blood
Hypercapnia, increased metabolic demand, and hypoxia cause vasodilation.
Hyperventilation, elevated head of bed, sedation to decrease metabolic deman, IV mannitol for diuresis
112
COPD is diagnosed with FEV1/FVC of < ???? This is caused by what>
< 0.7 and is caused by air trapping on exhalation 2/2 damaged alveoli
113
Arterial occlusions can occur in the lower extremity from these three main causes? How to differentiate b/w this and arterial thrombosis or DVT? Where do they most commonly originate from?
Trauma, Emboli, or Thrombosis
Thrombosis causes bilateral narrowing, so this is a gradual process. DVT has more dull and achey characteristics to the pain vs. sudden and acute in arterial emboli; also appears warm to the touch since a DVT causes retrograde congestion vs. pale from arterial occlusion.
MC'ly originate from heart via the ventricles following a MI or from atria in the setting of A-fib
114
What women get screened for Gonorrhea/Chlamydia and Hep C in preg? What about Syph, HIV, and Hep B?
Women at risk get screened for Hep C, GN, and CL.
ALL women get screened for HIV, Syph, and Hep B
115
What do you do in a laboring patient with active HSV vesicles found on PE?
C-section
116
Osmotic diarrhea has an osmotic gap > ??? and is calculated by this formula...
> 50
290 - [2 x (Stool Na + Stool K) ]
117
Lactose Intolerance occurs commonly in this group of patients…? It causes a high osmotic gap, no steatorrhea, with what stool pH (acidic/alkalotic)?
Test?
Asian Americans. Acidic pH 2/2 fermentation products.
Lactose Hydrogen breath test will be + because lactase (brush border enzyme that hydrolyzes lactose) is decreased and is fermented in GI tract.
118
Allergic Contact Dermatitis is what kind of hypersensitivity reaction? Example?
Differentiate this with type I/II/III hypersensitivity =) You're getting smarter
Type IV - cell mediated, therefore the pt had to have prior contact - Ex = poison ivy (wheepy and itchy)
Type I - IgE mediated; allergen crosslinks two IgE molecules that are attached to Mast cell (Ex = atopy, urticaria and anaphylaxis) = Immediate
Type II - Antibody Mediated; IgG and IgM attachment to antigens cause cytotoxic events w/ complement activation resulting in cellular damage (ex = immune hemolytic anemia, Rh hemolytic disease)
Type III - Immune complex-mediated; Ab-antigen complex activates complement and additional inflammatory processes (ex = serum sickness and Arthus reaction)
119
When would a pt with suspected RF present? What could happen to the left main stem bronchus?
Anything that causes tachycardia (exercise, pregnancy, anemia)
L-atrial enlargement can occur 2/2 MS and impinge on recurrent laryngeal nerve or displace the left main stem bronchus.
*Afib = common complication
120
Superficial skin lesion seen in hot, humid climates with pruritic, erythematous, scaly lesions with a red ring and central clearing = dx? Trmt?
Tinea Corporis = Ring Worm
Treat with Terbinafine
*Nafcillin is used to treat cellulitis, a painful, erythematous, and indurated skin lesion
121
Increased water intake, serum Na < 137, antipsychotic use, polyuria and low urine osmolality (urine osmolality < 1/2 the serum osmolality) = ???
Primary Polydipsia - serum osmolality is maintained by diuresing fluid.
122
Central DI = clinical path? Causes? Features?
Insufficient ADH release from pituitary 2/2 trauma, pituitary surgery, ischemic encephalopathy, or idiopathic cause. Serum Na > 150 b/c body doesn't reabsorb water, thus leaving concentrated serum. Low urine osmolality. Dysfunctional thirst mech
123
Nephrogenic DI = clinical path? Causes? Features?
Varying kidney response to ADH 2/2 chronic lithium use, hypercalcemia, or hereditary AVPR2 mutation. Serum Na is about normal 2/2 intact thirst mechanism.
124
What would you use for suspected ectopic preg with a B-hCG of 2,000?
Trans-vaginal U/S b/c b/w 1,500 - 6,000 you can see gestational sac with trans-vag but not trans abd (> 6,000)
125
A resp quotient (CO2/O2) production can tell us what with a person we're trying to wean off a respirator?
Quotient of 0.8 = normal b/c 1.0 is for PURe glucose metabolism and since we don't just use glucose, it's a little less than 1.0 in normal physiology. But with a tube-fed pt, an elevated quotient above one tells us that the pt is being overfed and producing too much CO2 and subsequently make it harder to wean off the respirator
126
How would you manage an empyema?
If it's NOT complex and w/o a rim of fibrinous material, attempt antibiotics or a drain. If it's complex, antibiotics alone will not work. If there's a fibrinous ring, only surgery is the answer.
* Pt has low grade fever and it's best diagnosed with CT
* *Hemothorax = excellent medium for bacterial growth
127
A man complaining of sexual dysfunction, unintentional weight loss, fatigue, bilateral gynecomastia, small firm tests should make you think of? Labs?
Chronic liver disease. Normal TSH and low total T3 and T4 b/c liver is responsible for making serum binding proteins, therefore the concentration of free hormone isn't changed but total (free + bound) accounts for loss.
*Alcohol and Hemochromotosis = common causes
128
Differentiate clinical features of Babesiosis, Lyme, and Ehrlichiosis… =) Smarter every day!!!
Babesiosis = Babesia from Ixodes tick causes RBC to hemolyze. Labs will show hemolytic anemia, thrombocytopenia, leukopenia, atypical lymphocytosis, elevated ESR, abnormal LFT's, and decreased complement levels, hemoglobinuria, renal failure and pt may have jaundice. Dx with Giemsa-stained thick and thin blood smear. Trmt = Quinine-clindamycine and atovaquone-azithromycin.
Lyme = look for erythema chronic migrans
Ehrlichiosis = "spotless RMSF" fever malaise, HA, N/V. Labs show leukopenia and thrombocytopenia NO HEMOLYSIS OR JAUNDICE!
129
A pt who develops skin necrosis is different than a pt who has bruising and hemorrhage…what does this distinguish b/w in terms of bleeding/clotting problems?
The first characterizes a prothrombotic state vs. the latter being a bleeding diathesis
*Warfarin can cause a sudden drop in Prot C (half life of Prot C = 9 hrs) so it can cause paradoxical pro-coagulant state!
130
Common HIV therapy reactions to know:
1) Didanosine
2) Abacavir
3) Lactic Acidosis
4) Stevens-Johnson Syndrome
5) Nevirapine
6) Protease Inhibitor
1) Induced Pancreatitis
2) Hypersensitivity Syn
3) NRTI's
4) NNRTI's
5) Liver Failure
6) Crystal-induced nephropathy
* -navi (protease)
* * -virines (NNRTI)
131
What inherited thrombosis-promoting problem is MC?
Factor V Ledien - can't be broken by protein C/S
132
Three common causes of + hepatojugular reflex? What does this show?
Constrictive pericarditis, RV infarction, and restrictive cardiomyopathy = shows the R-hearts inability to compensate for increase venous return
*helps differentiate cardiac vs. portal hypertension
133
Formula for serum osmolarity = ?? Normal range
2xNa + BUN/2.8 + Glucose/18
Normal = 280 - 295
134
When you have hyponatremia, what do you want to calculate and know?
Calculate serum osmolarity, ECV, and any urine findings.
135
Work through hyponatremia w/u….
Hyponatremia = Na < 130
Is the patient's serum osmolarity:
1) Normal
2) High (>295)
3) Low ( 20 = renal salt loss (diuretics, ACEi, mineralocorticoid def)
If low osmolarity AND Euvolemic, what does the urine tell us? (1) Urine Na >20 AND Urine Osm > 300 = SIADH (**HINT urine osm > serum osm)
(2) Urine Na > 20 and Urine Osm < 300 = psychogenic polydipsia, beer potomania
if low osmolarity and Hypervolemic = CHF, hepatic failure, or nephrotic syndrome.
YOU DID IT!!! =)
136
Cut off for a D-Dimer?
< 500 = excludes PE, more than 500, get a CT pulmonary angiography
137
With cramping leg pain while walking, relief with rest and elevated Brachail index…what's your management plan?
RF stratification: stop smoking, lipid-lowering therapy, evaluate for hypertension and DM.
Start low dose aspiring, statin and exercise for 30 min 3x weekly for 3 months!
138
What abx commonly put people at risk for C. Diff?
Fluoroquinolones, penicillins, cephalosporins, and clindamycin.
* unexplained leukocytosis in hospitalized patients should raise concern for c. diff even if not diarrhea
* * switch from oral metro to oral vanco if severely elevated WBC's >15k
139
Tumors will high cell turnovers are frequently associated with Tumor Lysis Syndrome, these 2 tumors are? Electrolyte changes seen?
Lymphomas (like Burkitt's) and Leukemias (ALL and AML)
Elevated: uric acid, potassium, and phosphate.
Decreased: calcium 2/2 to phosphate binding
140
What to give a child presenting with Lyme disease, specifically someone < 8?
Amoxacillin b/c Doxy can cause slow bone growth in pregnant women and enamel hypoplasia with permanent teeth stains during tooth development in young children
141
Suprachondylar fracture of the humerus is common in young children and adolescents who have fallen on an outstretched arm. A complication of fractures like this is compartment syndrome characterized by these 5 P's and the final feared sequela with respect to the muscle is...
5 P's = pallor, pulselessness, pain, paresthesia, poikilothermia
Volkmann's ischemic contracture is the final sequel of compartment syndrome in which dead muscle has been replaced w/ fibrous tissue
142
Three MCC of AS? Presents w/?
Congenital Bicuspid Aortic Valve (MC in patients under 70), calcified senile aortic stenosis, and RHD.
Systolic murmur heard best at upper L-sternal border radiating to carotids. Associated S4
143
Caustic ingestion w/ Sodium or K OH causes immediate injury to the esophagus and should get _______ in addition to supportive care and X-ray.
upper endoscopy to assess severity of damage and guide further therapy
144
Why does serum screening for down syndrome not help in the setting of an identified marker for down syndrome on U/S?
These serum tests do not provide any further diagnostic value than the already identified U/S marker for down syndrome…thus a more diagnostic approach should be taken, get a CVS (b/w 10-12 weeks) for fetal karyotyping.
145
What is the most significant risk factor for distal limb reduction defects associated with CVS?
The gestational age of the fetus; before 10 wks = associated great risk
146
How do you correct Ca levels for low albumin pt?
Ca= measured Ca + [0.8( 4 - measured albumin)]
147
Sustained prolonged PR interval > 0.2 sec (5 boxes) = ??? Mgmt differences b/w a normal and abnormal QRS?
First degree AV-block. QRS that is widened (>120 msec) is associated with conduction delay below the AV node and can have spontaneous progression to advanced 2nd degree or complete heart block thus get a electrophys test for this pt vs. someone with normal QRS, just observe =)
148
What are the meds suggested for angina pectoris?
B-blockers = first line b/c they improve exercise tolerance and decrease O2 demand via decreased HR. CCB's and long-acting nitrates are second line therapy options if pt is bradycardic or cannot tolerate B-blockers or if not responding adequately.
149
IgA and Postinfectious GN timeline differences and finding differences?
IgA occurs within 5 days vs. > 10 for post-infect. Normal serum complement levels with mesangial IgA in kidney with IgA GN VS. low C3, ASO titers, anti-DNAse B titers, kidney bx w. humps of C3 complement
150
When can you not give Fondaparinux (injection Xa inhibitor) and Rivaroxaban (oral Xa inhibitor)?
When a pt has GFR < 30
151
First line trmt for PE?
Unfractionated heparin with subsequent warfarin initiation s/p therapeutic INR (1.5-2)
152
What should you order for a pt before starting her on Trastuzumab (Herceptin) for HER2 + breast cancer?
Echo b/c trastuzumab + chemo can cause cardiotoxicity
153
A pt that develops acute joint, often knee pain s/p surgery or illness is likely to have what findings on synovial analysis?
Rhomboid shaped, positively birefringent needles = Pseudogout = CPPD crystals and is associated with Chondrocalcinosis
154
Femoral bowing of the town, recent hearing loss, old age, elevated alk phos, mosaic lamellar bone, and bone pain =???
Paget's disease = hyper functioning osteoclasts …MC'ly affect the skull, long bones, spine and pelvis
155
Which anatomic site is most likely the cause of a fib?
Pulmonary veins
156
What should everyone get with central precocious puberty?
Brain CT or MRI (central = elevated FSH and LH 2/2 increased GnRH) vs. peripheral = adrenal or gonadal excess of sex hormones, low LH FSH
157
Parathyridectomy is recommended for asymptommatic hypercalcemia patients who have one of these four things:
1) serum Ca >1 above normal
2) young age
3) bone mineral density < T -2.5
4) reduced renal fxn
Get a neck scan w/ sestamibi scintigraphy and U/S to locate pathology before sx
158
How to distinguish b/w primary hyperparathyroidism and familial hypocalciuric hypercalcemia?
Both can have elevated PTH, high serum calcium, but the latter will have 24hr urinary Ca <100
159
Pt with a hx of viral infection with subsequent weight loss, polydipsia, and rapid deep breathing….
DKA
160
How to statistically compare:
1) means
2) > 3 means
3) proportions
1) double sided z-test/t-test
2) ANOVA
3) Chi-Square
161
Screening for breast mammography...
Starting at 50 every two years and can stop at age 75
162
Which class of meds is most likely to benefit an asymptomatic woman with multiple first degree relatives with breast cancer?
Raloxifene or Tamoxifen - SERMS
*Aromatase inhibitors (anastrozole, letrazole) are good for preventing mets of current dx of breast cancer
163
Recd's for pap smears….age range…combination screening
21 - 65 every three years
Between ages 30 - 65 a combined Pap + HPV screening stretches interval to 5 years
HPV vaccine from women 11- 26
164
Chlamydia screening?
Age 15 - 25
165
Regarding PSA, if the pt requests the test you should _____; if it inquires about mortality, then ______
Do the PSA if they request
Does not lower mortality
166
Cholesterol and Lipid screening should begin at what ages in men and women? Or it should start if a pt has?
Men 35 Women 45
| If they have metabolic problems: aortic disease, PVD, CAD
167
BP screening begins at age ____ and is "screened" every ____ yrs
Begin at age 18 and is used for screening every 2 years
168
What dx's trigger DM screening? How do you screen?
If they have hypertension or hyperlipidemia. Test fasting glucose for >125 or HgA1C > 6.5
169
Do not give live vaccines for which pts?
Pts > 50 yrs old or if they have chronic heart/lung/kidney disease (asthma), HIV/AIDS, Steroid users, immunocompromised, cancer pts, functional or anatomical asplenia, DM
170
Who gets influenza vaccine and who gets pneumococcal vaccine?
Flu - everyone, healthcare workers, pregnant pts
Pneumococcal - over the age of 65, cochlear implant, CSF leaks, Alcoholics. Everyone gets one vaccination over the age of 65 or a single revaccination IF they are immunocompromised or they had their first shot right before age 65
171
High dose varicella vaccine for pts over the age of? Preventing?
Over 60. It prevents post-herpetic neuralgia.
172
What are the general Hep A/B indications in adults and what are their respective differences?
All adults with: chronic liver disease, MSM or multiple sex partners, household contact with hepatitis A/B, IVDU
Hep A: traveling to endemic areas
Hep B: End-stage renal disease, DM, Healthcare worker
173
Tetanus vaccination schedule:
Toxoid (Td) booster every ten years. One Tdap for one of the boosters. If never vaccinated, give Tetanus Immunoglobulin.
If you get a dirty wound, revaccinate in 5 years. Clean wound = 10 years
174
Meningococcal is routine for kids at age ____ and for adults with the following indications:
Age 11
College student, military, pilgrimage, terminal complement deficiency, asplenia
175
Every woman should be screened at the age of 65 for osteoporosis with ….
DEXA scan
176
All men above 65 yrs w/ a hx of smoking should receive what screening?
Abdominal U/S for AAA. If > 5cm, get surgical repair.
*Also screen age 65-75 for those with a fam hx of AAA
177
Common characteristics of OA: findings, lab tests, most accurate test, imaging findings, trmt
Occurs in DIP, have crepitations, (PIP nodules = Bouchard, DIP = Heberden) stiffness is <15 min, does not improve through the day, lab tests are NL. Xray = most accurate test.
Joint space narrowing, subchondral sclerosis/cysts, osteophytes
Trmt: weight loss - Acetominophen - NSAIDS - Capsaicin cream - Intra-articular steroids - Hyaluronan Injection - Joint Replacement
178
Two etiologies of gout...
Overpoduction: Cell turnover (hemolysis, cancer, psoriasis, chemo), Idiopathic, Enzyme Def (Lysch Nyhan, glycogen storage disease)
Underexcreter: renal insufficiency, thiazides and aspirin, ketoacidosis/lactic acidosis
179
Deposits of uric acid crystals in parts of the body cause?
Tophi…uric acid crystal could also be seen
180
Most accurate test for Gout? How to treat acutely and chronically?
Synovial fluid tap - showing needle shaped negatively birefringent needles, pred neturophils w/ WBC 200 - 50,000. Labs will shows leukocytosis and elevated ESR.
Acute Attack: NSAIDS, corticosteroids if refractory/contraindication (renal), then Colchicine
Chronic Mgmt: diet mod, stop thiazides/aspirin/niacin (can use Losartan for Htn), Colchinine can help prevent 2nd attack, Allopurinol decreases uric acid prod, Pegloticase dissolves uric acid, Probenecid and Sulfinpyrazone are uricosurics
181
Gout drugs contraindicated in renal insufficiency:
NSAIDS, Probenecid, Uricosurics (the ones that affect the kidney excretion). Allopurinol = safe
182
Can you start a pt on Allopurinol or Uricosuric agent during acute attack?
No, but can continue allopurinol if they were on it previously
183
Adverse effects of Uricosurics, Allopurinol, and Colchicine
```
Uricosurics/Allopurinol = hypersen. (AIN, rash, hemolysis)
Allopurinol = TEN, SJS
Colchicine = diarrhea and bone marrow suppression
```
184
The most common RF's for pseudo gout: ? Findings? Tap? Trmt?
Hemochromatosis, Hyperparathyroidism. Less commonly = hypothyroidism, DM, Wilsons.
MC'ly in wrist and knee. Positively birefringent rhomboid shaped crystals, elevated wbc 200 - 50,000
Trmt: NSAIDS first, then steroids if refractory. Colchicine can help prevent recurrence.
185
Differentiate Cord Compression, Epidural Abscess, and Disk Herniation...
Cord Compr - hx of cancer, onset of neurological defects, sensory level loss below lesion, hyperreflexia, point tenderness. Xray = initial, MRI = most accurate. Steroids, chemo, surg.
Epidural Abscess - same as cord comp presentation but the ESR and fever make this more likely. MCC = staph aureas. Xray = initial, MRI = most accurate BUT steroids given first to decrease pressure
Disk Herniation - positive straight leg test, loss of lower extremity reflexes, pain radiating to below buttock and knee. Unless severe, no imagine. NSAIDS w/ continuation of normal activity, NOT bed rest
186
Trmt of epidural abscess...
Steroids first. Then vanco or linezolid for empiric trmt. If staph sensitivity is found, switch to beta lactam Oxacillin, Nafcillin, Cefazolin. Add gentamicin for synergy (like endocarditis)
187
Lumbar spinal stenosis presents like…what are the hallmark points in the hx? Trmt? Imaging?
Presents like PAD. Pt NL'y over age of 60 with pain that is worse with walking, worsened by going downhill, relieved by leaning forward. ABI and pulses being NL help!
Trmt = NSAIDS
Imaging = MRI
188
Chronic MSK pain and tenderness with trigger points in the trapezius, medial fat pad of the knee, and lateral epicondyle. This young woman also has HA, sleep d/o, and fatigue. All labs are NL
Dx: Fibromyalgia
Trmt: Amitriptyline or Milnacipran (SNRI) and Pregablin
NO STEROIDS
189
Associated diseases w/ Carpal Tunnel Syndrome?
"Pradah"
| Pregnancy, RA, Acromegaly, DM, Amyloidosis, Hypothyroidism
190
Carpal Tunnel findings:? Most ACCURATE test? Trmt?
Atrophy of thenar muscles, worse at night, + Tinel "tap" and + Phalen "flex". Sensory symptoms happens before motor sympt.
Most accurate = electromyography and nerve conduction study
Trmt = splint
191
Dupuytren Contracture is…? Trmt? Associationa?
Hyperplasia of the palmar fascia with nodule formation causing contracture of 4th/5th digits. Give it some "TLC" = Triamcinolone/Lidocaine/Collagenase Inj (last one helps early on in the disease process)
192
Anterior knee pain secondary to trauma, uneven quadricept strength, or meniscal tear. Pain is worse walking up AND down stairs - particularly bad after getting up having been seated for a long period of time. Gets better walking. NL X-rays. Treated with PT
Patellofemoral Syndrome
193
Very severe pain at the bottom of the foot, especially near the calcaneous. Worse in the morning but improves with walking. Point tenderness at the calcaneous. NL Xray. Trt with stretching, arch support, and NSAIDS
Plantar Fasciitis - differentiated from Tarsal Tunnel Syndrome with the hx of worsened symptoms with walking in TTS
194
RA features? Dx test? Radio findings?
Morning stiffness in mutiple, bilateral small joints of hands and feet, notably the PIP, MCP. Morning stiffness lasting > 30 min. Rheumatoid nodules. Other: Episcleritis, pleural effusion and lung nodules, cervical joint subluxation around C1/C2, Baker cyst rupture, pericarditis and pleural disease. Chronic synovitis leads to pannus formation.
Dx w/ Anti-CCP = anti-cyclic citrulinated peptide
Radiographs: joint erosion, panus, osteopenia,
195
Sicca syndrome = constellation of these findings...
Dry eyes, dry mouth
196
MCC of death in RA?
CAD
197
1) RA + Splenomegaly + Neutropenia
| 2) Lung Nodule + Pneumoconiosis + RA
1) Felty Syndrome
| 2) Caplan syndrome
198
Trmt consideration in RA: best initial drug for symptomatic pain relief? best drug to inhibit disease progression? no response to methotrexate? no response to TNFa-inhibs? Mild disease, want to avoid methotrexate? Another combo with methotrex?
Pain = NSAID
Disease Modifier = Methrotrexate
Refractory to Methotrexate = TNFa-inhibitors (etanercept, infliximab, adalimumab)
Refractory still = Rituximab (takes out CD20)
Mild disease = Hydroxychloroquine
Last one, I promise = Sulfasalazine
* Note - TNFa, Ritux, and Sulfa are added to methotrexate despite the poor response, only Hydroxychloroquine can be mono therapy
199
RA drug toxicities/considerations:
1) Methrotrexate
2) TNFa Inhibitors
3) Hydroxychloroquine
4) Sulfasalazine
5) Gold Salts
1) Methrotrexate - pulmonary tox, bone marrow suppression, and liver tox
2) TNFa Inhibitors - reactivation of TB, screen with PPD before initiating; infection
3) Hydroxychloroquine - retinal toxicity (like ethambutol)
4) Sulfasalazine - bone marrow tox, G6PD hemolysis, and rash
5) Nephrotoxicity
200
High spiking fever in a young person with fever-consistent salmon rash on chest and abdomen, with splenomegaly, pericardial effusion, and joint symptoms…Lab to check?
Juvenile Rheumatoid Arthritis/Adult Still Disease
Ferritin is markedly high!
Trt w/ aspirin, NSAIDS, steroids, TNFa-inhib
201
No joint deformation or erosion is characteristic of…MC GN association? Other false +'s seen?
SLE. Membranous. Positive RPR and Leukocyte Esterase cell prep
202
Treat an asymptomatic positive ANA?
NO!
203
What two labs would you expect to see change in an acute flare of lupus?
Decreased complement and increased Anti-DS DNA. Treat with high dose bolus of steroids
204
How do you determine trmt of Lupus Nephritis?
Biopsy! If glomeruloscerosis has occurred, trmt will have no effect.
205
MCC death in young vs. old pts w/ SLE?
```
Young = infection
Old = advanced atherosclerosis
```
206
Antiphospholipid Syndrome has two main types: ? What would you expect to see in each? Best initial vs. specific test?
Either IgG or IgM to negatively charged phosphlipids causing clotting in both arteries, veins, and recurrent abortions. False + RPR or VDRL
1) Lupus Anticoagulant - elevated aPTT, NL INR and PT
2) Anticardiolipin Antibodies - spont abortions
Best initial = mixing study which would show refractory elevation of aPTT
Most accurate = Russel Viper Venom Test which would be prolonged
207
Treat asymptomatic APL?
No
208
What will help prevent recurrent spont. abortions in pt with APL?
Heparin and aspirin
209
A bucket handle tear of the medial meniscus leads to locking of the knee during terminal extension. What does the pt complain of with this tear?
Occurs during forceful torsion of the knee when foot is planted, loud pain, extreme pain w/ little to no swelling. + McMurray sign
*vs. immediate effusion seen with ACL tear
210
Muscle compartment pressure more than ____ mm Hg indicates need for fasciotomy
30
211
Toxic causes of peripheral neuropathy...
Chronic alcoholism, Vincristine, Phenytoin, Isoniazid, heavy metals
212
Raynauds can be caused by what two meds?
Ergotamine and B-Blockers
213
Cochlear dysfunction is a side effect of what two meds?
Aminoglycosides and cisplatin/carboplatin
214
Bulimia Nervosa's timeline...
Twice/week for at least 3 months
215
RF's for acute ottitis media in children? MCO's? Trmt? Complications?
Being formula fed, second hand smoke, allergic rhinitis, viral URI, chronic middle ear effusion. Strep. Pna, H. Flu, Moraxella Catarrhalis. Comp = chronic infection, mastoiditis, labrynthitis, choleastoma, tympnaosclerosis, eardrum perforation, and conductive hearing loss. Trmt = 10 days of Amox. If recurrent give Augmentin (amox + clavulinic acid). Only do tympanostomy tube placement and myringotomy with > three episodes in 6 months or > 4 in a year
216
Differences between CMV mono and EBV mono?
CMV is likely to NOT have pharyngitis and cervical lymphadenopathy, and negative heterophile antibody test, + atypical lymphocytes (large basophilic cells with vacuolated appearance)
217
What cell line will clue you into glucocorticoid def in conjunction with weakness, fatigue, loss of appetite?
Eosinophilia.
*Secondary adrenal insuff does
NOT have salt wasting, hyperkalemia, or hyper pigmentation
218
Sharply demarcated, acute, arythematous, edematous, tender skin lesion with raised borders = ??? MC found? MCO?
Erysipelas. Legs = MC site but face is common too. Group A Betal-hemolytic strep (strep pyogenes)
219
This viral exanthem is caused by human herpes virus 6, the fever peaks with rash onset, and the rash appears as the fever resolves.
Roseola
220
How does the viral exanthem Measles spread?
Fever, cough, coryza, non-purulent conjunctivities, and Koplik spots…spreads cephalocaudally and centrifugally (center to distal extrem)
221
Steroids tend to do what to lymphocytes, neutrophils, and eosinophils?
Increase neutrophils, and decrease lymphocytes and eosinophils
222
Main causes of orthostatic hypotension in elderly?
Progressive decrease in baroreceptor sens. and defect in myocardial response to this reflex
223
Fluphenazine, a high potency typical antipsychotic med is occasionally responsible for?
Hypothermia
224
Post-MI acute pericarditis typically occurs when? What is it called if it occurs weeks later? Trmt?
First couple of days. Dressler Syndrome. Give NSAIDS
225
Sickle Cell disease/trait can cause patient to have nocturia 2/2 ???
Red blood cell sickling in the vasa rectae of the inner medulla, which impairs countercurrent exchange and free water reabsorption = hyposthenuria
226
30-50 yr old presenting with mood disturbances (depression), dementia mildly, and facial grimacing, ataxia, dystonia, tongue protrusion or writhing movements of the extremities…dx?
Huntington's disease
227
MCC of superior vena cava syndrome? What's the best initial test?
Cancer (lung cancer, or non-Hodgkin lymphoma). Cxray. See this with dyspnea, venous congestion, and swelling of the head/neck/arms
228
Fever and lethargy presenting on top of a picture of cirrhosis, dx? Next step in dx? Trmt? MCO?
Spontaneous Bacterial Peritonitis and hepatic encephalopathy. Fever and mental changes are the most common signs. Get a diagnostic paracentesis to culture and assess for a PMN level > 250…if so start Ceftriaxone. Enteric organisms like E. Coli and Klebsiella = MCO.
229
T/F: Alcohol causes a dose-dependent increase in the risk of osteoporotic fractures (>2 drinks/day)?
True
230
Inflammation of the abductor pollicis longs and the extensor pollicis brevis tendons = ? PE test?
De Quervain Tenosynovitis. Finkelstein Test. Classic association with new moms and how they hold their kid. This contrasts flexor carpi radials tenosynovitis b/c pain occurs with radial flexion of the wrist and point tenderness over the trapezium.
231
Common causes of priapism?
1) Sickle cell disease and leukemia
2) Perineal or genital laceration - cuts the cavernous artery
3) Neurogenic lesions - spinal cord injury, cauda equina compression
4) Meds - trazodone and prazosin
232
What meds put you at risk for cholesterol gallstones?
Clofibrate, Octreotide, and Ceftriaxone = "coc block the gallbladder"
233
Types of tremors:
1) bilateral action tremor of the hands or isolated head tremor, relieved with EtOH
2) resting tremor and decreases w/ movement and increases when distracted by mental activity
3) tremor associated with ataxia, dysmetria, or gait disorder - tremor gets worse at hand approaches target
4) low amplitude, not visible normally, acute onset with sympathetic activity (caffeine, stress, etc) and worse with movement - can involve face and extrem
1) Essential
2) Parkinson's
3) Cerebellar
4) Physiologic
234
When you have fat malabsorption, this can lead to insufficient absorption of what? This can lead to deficient levels of what? Can be exacerbated by???
Vit K. Factors II, VII, IX, and X, Protein C/S. Antibiotic usage
235
Bicuspid Aortic valve causes ____ which is a high pitched, blowing, decrescendo diastolic murmur heard best at left sternal border.
Aortic Regurg
236
Low IgG, IgM, IgA with recurrent sinopulmonary infxns around the age 15 - 35, B and T cell numbers are normal, dx?
Common Variable Immunodeficiency
237
If the immunoglobulin levels normalize by age 6 mo - 11 mo, dx?
Transient hypogammaglobulinemia of infancy
238
Formula to see how well lungs adapt to alkalemia? Acidosis?
PaCO2 = (0.9 x HCO3) + 16 +/- 2
Winter's = PaCO2 = (1.5 x HCO3) + 8 +/- 2
239
Rash extending from trunk out and involves palms/soles, generalized lymphadenoptahy and constitutional symptoms...
Secondary Syphilis - treat with IM benzathine penicillin
240
Possible rxn to trmt for Syph?
Jarisch-Herxheimer rxn = acute febrile reaction with headaches, myalgias all occurring within 24 hrs of therapy.
*Doxy or azithromycin can be used for PCN allergic pts
241
A rash that begins on the wrists and ankles, is maculopapular and spreads to trunk, extremities and palms/soles?
RMSF or Ehrlichiosis
242
DDx for pulmonary cavitation in HIV pt?
Tuberculosis, atypical mycobacteria, nocardia, coccidiomycosis, and gram neg rods, and anaerobes
243
HIV pt or Organ transplant w/ gram positive, weakly acid-fast FILAMENTOUS branching rod found in soil and water…=?
Nocardia - treat with Bactrim…
If there was acid fast bacilli = TB, check for PPD > 5mm
244
Use BAL for what types of lung pathology?
Malignancy and opportunistic infections
245
Chronic Granulomatous disease is a problem with phagocytic cells 2/2 dysfunctional NADPH oxidase enzyme complex….this leads to infections of _____ and MC infections are located where? Test?
Catalase positive organismsm.
MC infections = lymphadenitis, abscesses of the skin and viscera.
Dx = blue tetrazolium
246
Severe combined immune def =
recurrent bacterial, viral, fungal infections w/ ABSENT lymph nodes, tonsils, and lymphopenia, absent thymic shadow, abnormal T/B/NK cells
247
What agents shift K intracellular?
Insulin and glucose, sodium bicarb, and beta 2 agonists (albuterol)
248
Irregular vaginal bleeding post-partum for > 8 weeks is abnormal. What are the two forms of gestational trophoblastic disease you're worried about?
1) Choriocarcinoma - likes to met to the lung
| 2) Invasive gestational trophoblastic neoplasia - likes to remain local
249
Get ____ w/ a pt who has sudden onset of photophobia, eye pain, headache, and nausea with a mid-dilated pupil. This suggests...
Tonometry. Glaucoma
Get CT if there were other neuro findings
Redness around the eye can be seen
250
Common causes of gastric outlet obstruction?
Malignancy, PUD, Crohns, strictures (w/ pyloric stenosis) 2/2 caustic ingestion, and gastric bezoars
251
RF's for osteonecrosis?
Chronic corticosteroid use, alcohol use, trauma, and antiphospholipid syndrome
252
Low back pain, hip, buttock and thigh claudication w/ impotence and atrophy of the lower extreme = ? Femoral pulses might also be weak and a bruit heard over the iliac and femoral arteries.
Leriche Syndrome
253
What BP are you worried about for hypertension encephalopathy? 1st line anti-hypertensives?
>180/120 - nitroprusside and labetalol
254
Common first treatments for pt's w/ disoriented presentation = Dextrose, Oxygen, Naloxone, and Thiamine . What would you give someone with confusion + ataxia + ophthalmoplegia?
Thiamine then glucose for suspected Wernicke's encephalopathy
255
What two things predispose someone's angiodysplasia to bleed?
AS (disruption of vWf) and End Stage Renal Disease (platelet dysfunction 2/2 uremia)
256
Reasons for prophylactic anti-D immune globulin with an UNSENSITIZED mom?
Give at 28-32 weeks b/c 6 week half life…and again at 72 hrs before labor
-ectopic preg, molar preg, CVS, amniocentesis, abd trauma, 2nd/3rd trim bleeding, and external cephalic version
257
Digoxin toxicity looks like? WHAT CAN PRECIPITATE IT?
N/V and decreased appetite, confusion, and weakness, blurry vision, changes in color, blindness, arrhythmia.
Illness and diuretic use can cause pre renal azotemia and concentrate this drug with a narrow therapeutic index.
258
Suspect renovascular hypertension in all its with….
Resistent hypertension and diffuse atherosclerosis, asymmetric kidney size, recurrent flash pulmonary edema and elevation of serum creatinine > 30% from baseline after starting ACEi or ARB!!!
259
Melanosis coli is a dark discoloration of the colon with lymph follicles shining through as pale patches…what drugs can cause this? What to watch out for?
Anthraquinone-contraining laxatives and other laxatives. Beware of factitious diarrhea…very watery, 10-20 x / day
260
Newborn/premie with feeding intolerance, abdominal distention, and bloody stools…look out for? Trmt?
NEC. Poor vascular supply to the GI with feeding substance that acts as good bacteria substrate can cause NEC.
Start broad spectrum antibiotics
261
Hypokalemia, hypophosphatemia, and hypomagnesemia with a pt receiving TPN quickly is caused by what syndrome?
Refeeding Syndrome
262
Distinguish ethylene glycol vs. methanol ingestion via...
Hematuria and flank pain coincide with ethylene glycol poisoning as a result of renal tubular damage and the formation of calcium oxalate crystals. Elevated osmolar gap helps too b/c both have increased anion gap.
Methanol typically causes visual disturbances.
263
An erythematous lesion that quickly develops into bulla surrounded by erythema that subsequently ruptures leaving a painless ulcer with black necrotic center is??? Associated with what bug? Trmt?
Ecthyma Gangrenosum - associated with P. Aeruginosa - treat with anti-pseudomonal PCN
264
What distinguishes orthostatic and vasovagal symptoms?
Vasovagal has pallor, sweating, and nausea with an activity vs. blurry vision and dizziness after getting up
265
The MCC of infectious myocarditis and pericarditis is? What complication could cause pulses paradoxus?
Coxsackievirus - cardiac tamponade. This could lead to CHF in a young pt with no other RF's
266
A pt presenting with Herpes Encephalitis would present with what S/S? What would you expect to find on CSF analysis?
Fever, HA, seizures, with abnormalities in the frontotemporal region of the brain. Other temporal lobe path is suggested by anosmia, gustatory hallucination and bizarre or psychotic behavior.
CSF findings = increased WBCs, RBCs, protein with a NORMAL glucose.
267
Pulmonary fibrosis causes decreases compliance of the lungs and spirometry shows what for TLC, FVC, FEV1, and FVC/FEV1?
Decreased TLC, FVC, FEV1
And normal/elevated FVC/FEV1
268
Why does the hx of increased back pain while walking down hill in an elderly pt still point to osteoarthritis vs. seronegative spondyloarthopathy?
The seronegative spondyloarthropathy is more common in pts in their 20's-30's
Pseudoclaudication refers to lower extremity pain with both walking and prolonged standing that is particularly evident when walking downhill
269
Hormones derived from amino acids?
Dopamine, Serotonin, Epinephrine
270
ACTH is a _____ hormone.
polypeptide
271
Exudative effusions can be 2/2???
Empyema - frank pus with very low glucose and predominance of PMN's
Malignancy
RA
Esophageal Rupture
Pancreatitis - high amylase in the effusion
Pulmonary Infarction - bloody pleural effusion
TB - high total protein concentrations > 4 g/dL, lymphocytic leukocytosis, no purulence, glucose that is just mildly low
272
What should a pt who is just diagnosed with HIV get? When do you begin giving prophylactic antibiotics? At what level And for what?
Pneumococcal vaccine. (conjugate first, then polysaccharide)
CD4 < 200
Give Bactrim for CD4 < 200 for PJP prevention
Azithromycin for CD4 < 50 for MAC proph
273
The primary treatment for SVC syndrome?
Radiation therapy
274
What type of PNA is associated with posterior segment of the basal segment involvement? RF's?
Aspiration PNA 2/2 impaired consciousness, tracheal or NG tubes, and impaired gag reflex.
275
Suspect _____ in a patient with cirrhosis with confusion, fever, leukocytosis, and a non-acute abdomen.
SBP
276
Bullous pemphigoid most commonly affects older people >60 yrs and can have oral lesions; bullae present in flexural areas (groin, axilla) - bx shows the blister being where? Vs. Pemphigous?
Subepidermal for Bullous with Ig deposition in a liner pattern along the basement membrane. Intraepidermal for pemphigous. Intact blisters for pemphigous is rare.
277
The leading causes of brain mets = ?
Lung cancer, breast cancer, melanoma and RCC.
278
Where are the characteristic ovoid plaques in MS?
periventricular region, corpus collosum, and deep white matter
279
Difference b/w polymyalgia rheumatica and polymyositis?
Polymyositis = symmetric weakness of pros muscles with + CPK, LDH, and LFT's vs. pros muscle weakness in rheumatic and not the above lab abnormalities
280
Pt staring blankly for several minutes and having lip smacking/chewing with subsequent leg dragging = ?
Complex partial seizure of the temporal lobe (common) - Todd's paralysis follows
281
How does joint pain related to SLE differ?
Usually polyarticular, migratory, and symmetric with the knees and hands most commonly involved
282
Trmt for wide-complex tacky with monomorphic ventricular tacky is treated with?
Amiodarone!
283
Left-sided pleural effusion, N/V, retching with anterior chest pain and SOB and hematemesis 2/2 esophageal dilation?
Mediastinitis - also have pneumomediastinum
284
Two MCC of acute pancreatitis?
Alcohol and gallstone disease
285
PVD should be suspected in a pt at risk for atherosclerosis w/ an extremity that is shiny, thin, hairless skin and particularly if a non healing ulcer is present. What would help dx this?
```
ABI = 1.0 - 1.3
Abnormal = 0.4 - 0.9 with severe being less than 0.4
```
286
The presence of hypertension with hypokalemia (muscle weakness) =?
Conn's Syndrome = primary hyperaldosteronism
1st - get PAC/PRA (>20)
2nd - salt loading test (suppression?)
3rd - imaging
4th - if no discrete mass, venous sampling to differ b/w bil hyperplasia (med mgmt) or adenoma (sx)
Treat with mineralocorticoid receptor antagonist like spironolactone
287
Two MCC of hypercalcemia =
hyperparathyroidism and malignancy - most pts develop severe symptoms 2/2 the latter
288
Pts who receive gastric bypass are offered what prophylactically for 6 months post op?
Ursodeoxycholic acid
289
Passing blood clots in urine is more suggestive of glomerular or extraglomerular disease?
Extraglomerular
290
How to distinguish b/w primary hyperparathyroidism vs. renal osteodystrophy?
Primary hyperparathyroidism (2/2 single parathyroid adenoma) has low phosphorus and elevated calcium VS. Renal Osteodystrophy (2/2 CKD and parathyroid gland hyperplasia) with elevated levels of phosphorus (2/2 decreased GFR), bone pain, and poor renal function w/ abnormal processing of Vit D creating hypocalcemia; therefore, elevated phosphorus and low calcium stimulate parathyroid. The renal dysfunction also distinguishes this from parathyroid atrophy,
291
Associated with:
1) Anti-Centromere Ab's
2) Anti-neutrophilic cytoplasmic Ab's
3) Anti-smooth muscle Ab's
4) Anti-mitochondrial Ab's
1) Limited Scleroderma, CREST
2) Granulomatosis with Polyangiitis (Wegeners)
3) Autoimmune Hepatitis
4) Primary Biliary Cirrhosis
292
Visceral pain = ? Somatic pain = ?
Visceral pain is harder to localize 2/2 decreased number of nerve fibers.
Somatic is very easily localized from innervation of the peritoneum.
293
Pt with overflow incontinence is treated with:
Augmented voiding (double voiding, suprapubic pressure, timed voids, and catheters) and pharm agents like cholinergic agents (Bethanechol)
294
SBP can be caused by either ___ or ____ ?
Gram negative rods or gram positive cocci
295
Serum-to-ascites gradient > ?? increases risk of ascites?
> 1.1
296
How does spironolactone help cirrhotic patients with ascites?
It's an aldosterone receptor antagonist so it prevents holding onto fluid and is also a potassium-sparing diuretic
297
Two types of conjugated hyperbilirubinemia vs unconjugated hyperbilirubinemia?
Increased Conjugated Hyperbilirubinemia = Rotor and Dubin-Johnson; Rotor is a problem with storage so it leaks into the plasma and there is elevated unconjugated and conjugated forms (no pigment granules) vs. Dubin-Johnson MC seen in Jews with pigmented hepatocytes 2/2 epinephrine granules. Can test for it by seeing elevated Coproporphyrin I in the urine vs normal people having Coproporphyrin III; normal LFT's - benign, no trmt
Increased Unconjugated Hyperbilirubinemia = Crigler-Najjar Syndrome and Gilberts. Gilberts is thought to be provoked by illness, stress or fasting. The former is an autosomal recessive disease w/ phototherapy and plasmapheresis being the mainstay for treatment.
Liver steatosis 2/2 OCP's would have abnormal LFTs
298
Metformin + Signs of Renal Failure = ?
Lactic Acidosis
299
3 MCC of chronic cough are upper-airway cough syndrome (post-nasal drip), asthma, and GERD. What type of medications would cause relief 2/2 to the first cause?
H1 blockers - Anti-histamines. The hx of being awoken at night from her cough is also characteristic of post-nasal drip.
300
What two signs are specific for pericardial effusion?
Electrical alternans (varying amplitude of QRS axis) w/ sinus tachy
301
PBC histology?
Portal tracts are infiltrated by lymphocytes, macrophages, plasma cells, and eosinophills. Noncaseating granulomatous inflammation and progressive destruction are seen in the terminal and conducting bile ducts.
302
Causes of hypoparathyroidism:
1) Post-surgical (MCC)
2) Autoimmune (MC non-surgical cause, low calcium and elevated phosphorus)
3) Congenital absence (DiGeorge)
4) Defective Ca-sensing receptor on PT glands
5) Non-autoimmune destruction of the parathyroid tissue 2/2 infiltrative diseases like hemachromotosis, Wilson, neck radiation
303
Serum phosphorus is ____ in Vit D Deficiency? Insufficient Ca intake results in _____ phosphorus levels?
Low. Low 2/2 activation of PTH system
304
Isolated Systolic Hypertension is an important cause of hypertension in the elderly - most likely 2/2 ?
Decreased elasticity of arterial wall - should always be treated b/c its associated with an increased risk of CV disease. Start with mono therapy of low dose thiazide, an ACE inhibitor, or long acting CCB
305
What are the levels are varying medications used with asthma:
Intermittent: < 2 per week, < 2 per month, < 2 night time probs, no PFT changes = albuterol
Mild Persistent: > 2 per week but NOT daily, < 4 night time wakings/month, normal PFT = albuterol, inhaled corticosteroid
Moderate Persistent: daily, weekly night time wakings, PFT 60-80% = albuterol, inhaled corticosteroid, long-acting beta-agonist (salmeterol)
Severe Persistent: throughout the day exacerbations, frequent nighttime awakenings, FEV< 60% = albuterol, long acting beta agonist and either high dose inhaled corticosteroid OR oral corticosteroid
306
Increased spleen, liver and lymph nodes with fatigue, night sweats, HA dizziness, various visual problems, and pain and numbness in peripheral extreme WITH IgM spike on electrophoresis and signs of hyper viscosity = ?
Waldenstrom's Macroglobulinemia vs. IgG or IgA in multiple myeloma
307
Drug induced esophagitis causes:
Potassium, Aspirin, Iron, NSAIDS, Alendronate, Quinidine, Tetracyclines - sudden onset of odynophagia, retrosternal chest pain
308
Bloody diarrhea with no travel history = 3 MCC?
E Coli (don't try and treat, HUS risk), Shigella, and Campylobacter
309
Damage to CN V1 would affect what?
The trigeminal nerve has three branches, V1 carries sensory fibers to the scalp, forehead, upper eyelid, conjunctiva, cornea, nose and frontal sinuses
310
MC seen in young adult males, this disease has nephritic range proteinuria, urinary sediment with dysmorphic RBC's and RBC casts + pulmonary findings of SOB, hemoptysis, cough. What's the dx? What would be seen on renal bx?
Goodpasture's Disease . IgG lining the basement membrane in immunofluroescence = against type IV collagen
* Systemic symptoms of fever, chills, dyspnea, sweats and weakness are rare
311
Restrict what in a pts diest having kidney stones?
Protein and oxalate; NOT Ca!
312
What to give a pt undergoing splenectomy weeks before the surgery and then after?
Weeks before give Meningococcal, Pneumococcal, Haemophilus Influenza
After surgery, daily PCN for up to 3 yrs
313
What complication should you watch out for in a pt presenting with IBD who seems really sick?
Toxic Megacolon: dx requires
1) radiographic evidence of colonic distention
+ 3/4: fever , tachycardia, anemia, neutrophilic leukocytosis
+ 1/4: volume depletion, altered sensorium, electrolyte disturbances, and hypotension
314
Fluctuating cognition with variations in attention + recurrent visual hallucinations that are well formed and detailed + spontaneous Parkinsonism that doesn't respond well to dopaminergic agents = ?
Dementia with Lewy Bodies
315
Worrisome signs that would make you think a cyst is malignant?
irregular border, multilocular, multiple septations, heterogeneous content and contrast enhancement on MRI - benign cysts can be left alone unless causing the pt a significant amount of pain
316
If someone is stuck with known Hep B needle and their vaccination hx is unknown, what do they receive?
HepB Immunoglobulin and the Vaccine series…this is the same for someone never vaccinated. If immunity is confirmed, reassurance.
317
What test help differentiates Leukemoid reaction vs. leukemia?
Alkaline Phosphatase elevation
318
```
Leukemia markers:
AML
ALL
CLL
CML
```
AML - auer rods (eosinophilic needle-like inclusions), immature leukocytes
ALL - lymphphocytic marker = Tdt; kid predominant
CLL -
CML - leukocytosis > 500,000, Philadelphia chromosome, 9q 22q balanced translocation for bcr/abl fusion gene with tyrosine kinase activity
319
Cerebellar ataxia, telangiectasias and immunodef = ?
Ataxia Telangiectasia
320
Normal iron studies with basophilic stippling?
Lead poisoning
321
Chloramphenicol side effect?
Aplastic anemia
322
Pna pathogen descriptors:
Gram negative rods =
Gram positive rods =
Gram negative diplococci =
Gram positive diplococci in chains =
Gram negative rods = Klebsiella, Enterobacter, Serratia, Proteus (debilitated pts)
Gram positive rods = Corynebacterium Diptheriae
Gram negative diplococci = Strep. Pna (MCC CAP)
Gram positive diplococci in chains = Moraxella Catarrhalis
(chronic bronchitis, COPD)
323
Differentiate silent lymphocytic thyroiditis and subacute thyroiditis in hx and PE
silent lymphocytic thyroiditis = seen in postpartum pts
subacute thyroiditis = tender and painful
324
Gingivostomatitis and pharyngitis with adjacent vesicles is the MC presentation of?
HSV 1
325
Precipitating factors for Porphyria Cutanea Tarda:
Smoking/Sun-Hep C-Alcohol-Iron-Estrogen use
326
Speckling seen in a joint via arthroscope = indicates what pathology? Vs. what would be seen in bleeding, like hemophilia?
Calcium from pseudo gout = 2/2 costochondritis associated w/ hyperparathyroidism, hypothyroidism, acromegaly, Wilsons disease, hypomagnesemia, hemachromatosis
327
Budd-Chiari normally manifests in association with?
Coagulopathic diseases because it's obstruction of hepatic venous outflow = cancer, sickle cell, PNH, polycythemia vera
328
Angiographic procedures in a pt with atherosclerosis predisposes them to?
Mesenteric Ischemia = sudden severe abdominal pain out of proportion to PE
329
Greenish, foul smelling diarrhea with endoscopic yellow-green plaques adherent to GI mucosa = ?
Pseudomembranous Collitis 2/2 Clostridium Difficile
330
RA is one of the MCC of ______. It can deposit where? Common PE findings? Dx step?
Amyloidosis. Can deposit in the kidneys, skin, tongue, GI, or peripheral nerves. Carpal tunnel, skin plaques around axilla, nephrotic syndrome, HSM, and macroglossia. Biopsy rectal mucoa, abdominal fat, or gingiva to confirm dx.
331
Acute Intermittent Porphyria presents like? Defect?
Sudden abdominal pain manifested by anxiety, insomnia, depression, hallucinations, and paranoia. Hydroxymethylbilane Synthase = defect.
332
Post-gastrectomy pts vs post-ileal resection pts and B12?
Post gastrectomy = intrinsic factor def causes anemia
Post-Ileal resection = Vitamen def 2/2 malabsorption of B12-Intrinsic Factor complex
333
Metatarsal Stress Fracture hx?
Runner who has pain on bottom of foot that has decreased time to onset with each subsequent run and eases with relaxation
334
DIC can be precipitated by?
Trauma, Obstetric complications, Malignancy, Sepsis = low platelets, elevated PT/PTT, shistocytes
335
Pauci Immune D/Os = ?
PAN, Churg-Straus, Wegeners (Granulomatosis with polyangiitis = IgG + complement + granulomatous vasculitis) - first two have p-ANCA vs. latter having c-ANCA. Asthma and blood eosinophelia demarcate Churg-Straus with palpable purpura indicating PAN
336
Dull epigastric pain + glucose intolerance + hypercoagulable =
Pancreatic Cancer
337
Virchow's node (supraclavicular) and Sister Mary Joseph's Node = look for?
Gastric cancer
338
Young male smokers with pain at rest in distal extremities (toes/fingers) with acute neuromuscular bundle inflammation?
Buerger's = Thromboangiitis Obliterans
339
Benign liver fibroma or ovarian tumors + ascites and large effusion -- p/w right pleural effusion possibly with no liver abnormality or stigmata = dx ? Imaging? Trmt?
Meig's Syndrome - get a CT. Remove tumor to remove fluid.
340
T/F - classic OA symptoms can dx the d/o w/o imaging?
True
341
Name the associated d/o with each marking:
CEA -
Alpha-fetaprotein -
5HIAA -
CEA - metastatic colon cancer
Alpha-fetaprotein - Hepatocellular carcinoma
5HIAA - Carcinoid syndrome (diarrhea, facial flushing, bronchoconstriction - requires liver involvement…damage to RHV might be seen)
342
What infection predisposes woman to PTL and still birth (or miscarriage)?
Listeria Monocytogenes - unpasteurized milk, cheese, deli meat and raw veggies
343
Pruritic papule that transforms into vesicle then black eschar with edema, erythema, and a few surrounding vesicles - dx? smear shows? Trmt? Who's at risk epi wise?
Anthrax - Gram positive Encapsulated Rods - Pencillin G
Look out for farmers, vets, and workers in the wool mill!
344
Osteomalacia = def of what? Lab values?
Vit D deficiency 2/2 malabsoprtion, intestinal bypass surgery, celiac spruce, or chronic liver/kidney disease. Very low phosphorus, elevated PTH, low/normal Ca.
*Can see thinning of bone cortex and eventual codfish vertebral bodies and pseudo fractures (Looser zones)
345
A post-bone marrow transplant pt presenting 2wks-4month post-op with lung and GI probs = ?
CMV!!! Upper and lower GI ulcers, pneumonitis, arthralgias, myalgias, esophagitis
346
Symmetrical proximal muscle weakness, smoking hx, and erythematous rash on the dorsum of the fingers or on upper eyes ?dx?
Dermatomyositis - get a muscle bx
347
Prolactinoma treatment?
Dopamine-agonists like Bromocriptine or Cabergoline
348
Antibiotic prophylaxis (IM Benzthine Pen G Q 4wks) for Rheumatic Fever:
1) RF w/o carditis
2) RF w/ carditis but no residual heart/valvular disease
3) RF w/ carditis and persistent or valvular heart disease
1) 5 yrs of until 21 yrs old (whichever is longer)
2) 10 years or until 21 (" ")
3) 10 yrs or until 40 (" ")
*RF = 2/2 Group A beta hemolytic streptococcus
349
5 common Seffx of amiodarone:
1) Pulm tox
2) Thyroid dysfxn = hypothyroidism - get TSH checked before starting bc so common
3) Hepatotoxicity - stop if LFTs increase MORE than 2x
4) Corneal deposits
5) Blue-gray skin discoloration
350
MMSE < 24 = ?? Findings on CT for Alzheimers (besides the MC, which is NL) ?
Diffuse cortical and subcortical atrophy which is disproportionately greater in the parietal and temporal area (around hippocampus)
351
Idiopathic Intracranial Hypertension = symptoms? Trmt?
Usually seen in overweight woman of child bearing age with headaches, no focal neurological defects except 6th CN palsy, papilledema, negative CT but increased opening pressure on lumbar puncture. Can be associated with tetracycline or isotretinoin use!
Acetazolamide = 1st line, decreases CSF production from choroidal plexus -- furosemide if refractory -- shunting/repeated lumbar taps if still not responding
352
FiO2 should be kept below _____ in ARDS to avoid _____
< 40% to avoid Oxygen toxicity
353
In pt's with Hypertrophic Obstructive Cardiomyopathy, what's the deformation with the mitral valve?
Abnormal mitral leaflet motion = "systolic anterior motion"…basically the valve can be sucked into and further obstruct the outflow track
354
Lewy bodies are described as what and seen in what?
They are eosinophilic intracytoplasmic inclusions that represent alpha-synuclein protein and can be seen in the substantial nigra, locus ceruleus, dorsal rap he, and substantial innominata.
Lewy Body Dementia = early dementia + signs of parkinsonism
Neurofibrilary tangles = Alzheimers
355
Signs of anticholinergic toxicity?
Dry skin, dry mouth, constipation, urinary retention, flushing, vision changes (mydriases), and confusion. Trihexphenidyl can cause headache and retro-orbital pain too!
356
Best test for suspected Chlamydia vs. Gonorrhea infxn?
Nucleic Acid Amplification Test.
357
Atypical PNA is different from CAP how? Common Types? What does Erythema Mutiforme point you towards?
More indolent PNA and causes extra pulmonary findings.
Mycoplasma, Coxiela, Chlamydia, Influenza, Legionelle
Mycoplasma = MC and c/w EM
358
Causes of proximal muscle weakness?
Connective tissue (polymyositis), endocrine (hypo/hyper thyroid, Cushing), and neuromuscular (LE or MG), or steroids.
359
Parotid inflammation w/ what MCO? Prevent this how?
Commonly seen in dehydrated post-op pts. MCO = staph. Adequate fluids and good oral hygiene = preventative measures
360
What drug administration distinguishes Crigler-Nijjar Syndrome 1 and 2?
One is more severe with signs of kernicterus and admin of phenobarbital does NOT lower levels; phototherapy and plasmapharesis are needed.
Type 2 is more mild and phenobarbital lowers serum bili.
361
Don't discontinue isoniazid in its with asymptomatic rise in their LFT's unless...
it's > 2x
362
Nipple rash with ulcerating eczematous appearance consider…? Bx with large cells surrounded by halos = ?
Paget's Disease. 85% of pt have underlying breast cancer. This biopsy shows adenocarcinoma and the halos are 2/2 keratin retraction from cancer cells
363
Trmt options for people with hx of liver problems, ascites and elevated BUN/Cr?
Most likely hepatorenalsyndrome - can use midodrine and octreotide
364
Drugs associated with pancreatitis?
1) Diuretics (furosemide and thiazides)
2) Immune drugs (sulfasalazine, 5-ASA, azathioprine)
3) HIV meds (didanosine)
4) Antibiotics (metronidazole, tetracycline)
365
MCC of endocarditis in native valves following dental procedures?
Strep Viridins (S. mitis, S. Sanguis, S. Mutans, S. Salivarius)
366
Find S. Bovis…get what next test?
Colonoscopy
367
S. epidermidis is an important cause of what kind of endocarditis?
Prosthetic valve endocarditis
368
What is required for the dx of AS?
Echo - symptomatic AS warrants valv replacement. DONT GET A STRESS TEST, COULD CAUSE ARRHYTHMIA
369
Medical therapy is recommended for carotid artery stenosis with what % blockade?
< 50%
370
Pulmonary dyspnea with bone and prostate spreading + skin findings like heaped up verrucous or nodular lesions with violacious hue that may evolve into micoabscess = ?
Blastomycosis - oral itraconazole or amphotericin B depending on severity
371
Infectious causes of adrenal insufficiency?
Tuberculosis ( calcified), fungal infections and CMV
372
Pig farmers associated with? vs. Sheep?
Neurocysticercosis vs. Echinococcosis
373
With Cushingoid presentations, what else is no longer suppressed in this pt that might lead to hyponatremia>?
ADH is normally inhibited by cortisol so if the levels are low, then ADH would cause hyponatremia in a Cushing pt.
374
What things to assess to consider hospitalizing a PNA pt?
CURB-65 = Confusion/Urea > 20/RR >30/BP 65
375
Trmt for CAP?
New generation fluoroquinolones like Levofloxacin or Moxifloxacin for inpatient vs. Azithromycin or Doxy for outpt
*Clindamycin for suspected aspiration pna
376
Tenosynovitis + migratory polyarthralgias + purpuric/pustular skin lesions = ?
Dissimenated Gonococcal Infxn
377
ECG findings with PE?
S1Q3T3
378
RCC findings? Lab findings? Test?
Flank pain, palpable abdominal renal mass, hematuria, scrotal varicoceles, and paraneoplastic syndromes (anemia, thrombocytosis, fever, hypercalcemia, and cachexia)
Elevated EPO
Get an abdominal CT!
*varicocele does not go down in recumbent position b/c of blockade
379
Pna with GI manifestation, elevated LFTs, and hyponatremia?
Legionella! Get urine antigen test! Treat with quinolone or macrolide.
380
Oxybutinin is for what? Vs Bethanechol and alpha blockers?
Oxybutynin = urge incontinence
Bethanechol and Alpha Blockers = overflow incontinence
381
GERD predisposes to what two lower esophageal abnormalities?
Benign peptic esophageal strictures (which would be circumferential narrowings leading to decreased GERD symptoms) and Barrett's esophagus (needing biopsy to r/o adenocarcinoma)
Radiation, scleroderma, and caustic ingestions can also causes peptic strictures
382
Causes of high output cardiac failure?
Thyroxtoxicosis, Paget Disease, Anemia, And Thiamine Def, and AVMs. Present's with flushed features, LVH, tachycardia, systolic murmur 2/2 more blood flow.
383
Swelling + angioedema after given what med would make you suspect C1 inhibitor def?
ACEi
384
Hyperkalemia causing drugs>?
ACEi, ARB, Digitalis, Cyclosporine, Heparin, NSAIDS, Succinylcholine, and BACTRIM
385
Old person with isolated elevated alk phos?
PAGETS!
386
Hep C can present with intermittent risings in LFTs and pt can be basically asymptomatic…waxing and waning labs! What extra hepatic association can be seen?
Porpheria Cutanea Tara, Mixed cryoglobulinemia, and membranoproliferative GN, lichen planus.
*low compliment levels 2/2 circulating immune complexes; palpable purpura and arthralgias.
387
How to treat active vs. prophylaxis w/ + PPD?
Active = RIPE + pyridoxine (2 months) then RI (4 months)
+ PPD = Isoniazid and Pyridoxine for 9 months prophylactically
388
Postherpetic neuralgia can be prevented and or treated with what two meds?
TCA and Antiviral therapy
389
Episcleritis is associated with? Vs. Anterior Uveitis?
Episcleritis = RA and IBD
Anterior Uveitis = HAL-B27 stuff
390
What helps distinguish Homocystinuria from Marfans?
Intelectual delay, thromboembolis events, FAIR HAIR AND EYES. See elevated homocysteine and methane levels 2/2 cystathionine synthase def. Give Vit B6, folate, B12 to lower levels. Give anti platelets and anticoagulation too!
391
Glomus tumor MC found where?
Under the tongue = severe intermittent pain, tenderness and sensitivity to touch and is a common vascular benign tumor - can also be seen on palms and wrists
392
Elevated lab value in PCP infxn? What are the indications for steroid use in conjunction with Bactrim again>?
LDH.
PaO2 < 70 mmHg or A-a gradient > 35
393
What things are associated with secondary causes of Restless Leg Syndrome?
Trmt?
Fe def anemia, pregnancy, Parkinsons, MS, antidepressants/metoclopromide, DM, uremia.
Fe supplementation, conservative massaging, dopamine agonists (pramipexole) or alpha-2-delta CC ligands (Gabapentin)
394
What is the causative agent of large, pedunculated, exophytic papule with scales? Dx?
Bartonella Henselae/quintana causes Bacillary Angiomatosis (on skin and viscera)
Dx with biopsy and look for angiomatous histology
RISK OF HEMORRHAGE!!!
395
Cellulitis associated with Tinea Pedis with signs of toxicity, trmt =?
IV Nafcillin or Cefazolin (vanco in MRSA areas)…treat the tinea later, the cellulitis is the main prob
396
A person with unremitting nose bleeds, blanching red papules on oral mucosa, and digital clubbing, and elevated hamtocrit = ?
Osler-Weber-Rendu syndrome (auto dom) = diffuse telangiectasias, recurrent epistaxis, and widespread AV malformations (skin, GI, liver, brain, lung). They can even cause fatal hemoptysis. Can even develop R-L shunting,
397
Elevated Cr in the setting of suspected BPH, what imaging would you get? What med mgmt can help with symptoms of obstructive uropathy?
Renal U/S to look for bilateral hydronephrosis (evidenced by elevated Cr and BPH).
Tamsulosin (alpha blocker) and Finasteride (5-alpha reductase inhibitors) can improve BPH symptoms
398
3 P's of McCune Albright Syndrome = ?
precocious puberty, polyostotic fibrous dysplasia, and pigmentations (cafe au lait)
399
When to treat sarcoid? S/S?
When they are symptomatic! Hilar adenopathy, w/ or w/o reticulonodular infiltrates, biopsy of non-caseating granulomas, serum levels of ACE may be elevated. Give systemic glucocorticoids
400
Three types of partial seizures?
Simple Partial - no LOC, aura, deja vu
Complex Partial - LOC with automatisms, aura
Partial with Secondary Generalization - have tonic clonic manifestations, muscle aches, elevated CPK,
401
Drugs causing crystal-induced acute kidney injury?
Protease inhibitors, Ethylene Glycol, Methotrexate, Sulfonamides, Acyclovir
402
Acanthosis Nigricans can be a sign of what in older people?
GI Malignancy
403
What can be given to slow the progression of MS?
Interferon Beta
404
Polymyalgia rheumatica is different than fibromyalgia how?
Highly elevated ESR, NO muscle pain, just stiffness in the shoulders and pelvic girdle. Associated with Temporal Arteritis!
405
Immediate acting drug for migraines other than triptans?
Chlorpromazine, prochlorperazine, metoclopramide = IV antiemetics as mono therapy of as adjuvent therapy + NSAIDS or triptans
406
What minors don't need parental consent?
Homeless, Lives Alone, Financially Independent, Married, Military OR for med emergency, contraception, STI's, prenatal care, and substance abuse
407
SCC in situ of the skin with thin erythematous plaque with well defined irregular borders with overlying scale or crust?
Bowen's Disease
408
Systemic and topical corticosteroids can induce this eruption characterized by monomorphous erythematous follicular papules distributed in the face trunk and extremities - NO COMEDONES
"Steroid Acne"
409
What meds should be considered for post-transplant pts for prophylaxis?
Bactrim for PCP, Toxo, Nocardiosis, and other infxns. Can also give Ganciclovir or Valganciclovir to prevent CMV infxns.
Vaccinate against Influenza, Pneumococcus, and Hep B
410
Worsening signs of prognosis for CLL?
Splenomegaly ---Anemia ---- Thrombocytopenia
411
Preseptal cellulitis is differentiated from orbital cellulitis how?
orbital cellulitis has opthalmoplegia, pain with EOM movement, proptosis, vision impairment
Staph and Strep = common pathogens
412
Trmt pf prostatitis?
Bactrim/Fluoroquinolones = acute (4-6 wks)
Fluoroquinolones = chronic
413
Don't use these for the treatment of Essential Tremor if the pt has COPD or bradycardia….What else could you use? Seffx?
B-Blockers. Could use Primidone which is an anticonvulsant that converts into phenobarbital and can cause acute intermittent porphyria = abdominal pain, neurologic and psychiatric abnormalities.
414
Mild hypovolemia hypernatremia can be treated with 5% dextrose in .45% saline. What if it's severe?
0.9% saline
415
Medicines causing ototoxicity?
Aminoglycosides, Chemo, Aspirin (high high doses) and loop diuretics like Furosemide!
416
Pts with generalized resistance to thyroid hormones have...
High serum T4 and T3 levels with normal TSH. They typically have features of HYPOthyroidism despite having "HYPERthroid"-like labs
417
Pellgra presents...
Dementia/Dermatitis/Diarrhea and MC'ly 2/2 corn-based diet. Niacin deficiency and the rash gets worse in the sun!
418
Pt with Chronic Renal Failur with bleeding, normal PT, PTT and elevated BT = ? Trmt?
Platete Dysfunction 2/2 uremia - give Desmopressin to releave vWF and Factor VIII
419
Trachoma is characterized by?
Chlamydia Trachomatis Serotype A-C and is a major cause of blindness worldwide. IT has follicular conjunctivitis, pannus (neovascularization).
Start topical erythromycin or oral azithromycin immediately
420
Low leukocyte alkaline phosphatase WITH leukpocytosis = ?
CML
421
3 Causes of spherocytes>?
G6PD def, Hereditary spherocytosis and Autoimmune Hemolytic Anemias
422
Three therapies proven to prolong survival in COPD pts?
Smoking cessation, 02, and Lung reduction therapy in some
Other symptomatic relief can include SABA + anti-muscarinic agents
423
Vasovagal is what kind of diagnosis?
Clinical - but can get a tilt table if unsure
424
PNH = def in what? Test/.
GP1 RBC membrane anchor protein - since this is abnormal it CANT prohibit CH55 and CD59 from binding to it and being subsequently attacked by complement.
Patients with PNH have a tendency towards venous thrombosis, especially in the hepatic veins!!!!!
425
Trmt of Torsades?
Mag Sulfate!
426
Interstital Cystits = ?
Painful bladder syndrome with pelvic pain worsened by bladder filling, intercourse, exercise, spicy foods with urinary frequency, urgency, and nocturne
Cystoscopy shows submucosal petechiae and ulcerations
427
Trmt of acute RF? for the pericarditis/arthritis? for the chorea?
Penicillin G until adulthood. Corticosteroids for the chorea. and NSAIDS for the arthralgia and pericarditis
428
Common causes of viral meningitis>
Echovirus, coxsackievirus
429
Recurrent damage to lungs via infections or chronic thromboembolic disease can cause (esp with COPD) chronic hypoxia leading to?
Constriction of the pulmonary artery system leading to pulmonary hypertension with RVH, and subsequent RVH -- elevated JVP, congestive hepatosplenomegaly, hepatojugular reflux and lower extreme edema
430
Cystinuria cause what kind of stones? Test?
Hexagonal, radioopaque crystals with + urinary cyanide nitroprusside
431
Laying flat and turning to left side can make a patient become more aware of what murmur in particular?
AR - aortic root dilation and bicuspid AV are the MCC in US. RF = MC in other countries with poor access to ABx.
See water hammer pulse and increased pulse pressure
432
Pressure definition of the pulmonary artery for Pulm Htn?
> 25 mmHg at rest or > 30 mmHg
433
Best way to monitor respiratory function in pt with Guillain-Barre Syndrome?
Vital Capacity
434
Differentiate AS from HOCM
They can both have a crescendo-decrescendo murmur BUT the location will differ….AS on the RSB and HOCM on the LSB…AS also tends to have radiating sounds to carotids
435
What nerve is compromised:
1) Anterior shoulder dislocation, forceful abduction and external rotation ?
2) Fracture of the humeral midshaft, fitted crutches, wrist drop, sensory loss of posterior arm and lateral dorsal hand
3) Fracture of the medial epicondyle of the humerus with claw hand
4) Scapular winging, surgery around the axilla
1) Axillary n.
2) Radial n.
3) Ulnar n.
4) Long Thoracic n.
436
Alkalotic pH causes what to happen with Calcium?
Increase in the affinity os serum albumin to calcium, thus decreasing levels of the only active form of calcium, ionized calcium
437
What CD4 count can you give live vaccines?
> 200 = MMR, Varicella, Zoster (age >60)
* this also assumes no hx of AIDS defining illness
438
```
Name the toxicity:
CNS stimulation (HA, insomnia, seizures) and GI distrubances (nausea, vomitting) and cardiac probs (arrhythmias).
```
Theophylline Tox
439
Hepatic encephalopathy is 2/2 decreased ability to rid the body of? What can precipitate this? Trmt?
Excess ammonia 2/2 liver unable to convert it to urea.
Caused by medications, hypovolemia, infection, or excessive nitrogen load (GI bleed, high calorie diet).
Give lactulose/lacitol - it's a non-absorbable disaccharide; it's converted by colonic bacteria into short chain FA's like lactic acid whereby it can convert ammonia to ammonium (a non-absorbable form that will be excreted). Rifaximin can also decrease the number of ammonia-producing bacteria in the colon. Laxatives can help too
440
4 Centor criteria for adults with pharyngitis for trmt?
Fever, Adenopathy (anterior), Tonsilar exudates, and ABSENT cough
441
Give cryoprecipitate for?
loss of fibrinogen, vWF, and Factor VIII def
442
Type II DM = prone to develop what osmolar problem?
Non-ketotic Hyperglycemia = Nonketotic hyperosmolar syndrome …elevated glucose causes increase in cortisol and catecholamine and inhibit insulin (glucose > 600 normally) Causes AMS - can also cause acute change in vision
443
Syphillis trmt in adults who have PCN allergy?
Doxycycline
444
Brushfield spots (white spots on iris), sandal gap toes have what neurocognitive risks, hematolic risks, endocrine, MSK risk?
Down Syndrome
Duodenal atresia, Hirshsprung, Intelectual disability, Alzheimer, Acute Leukemia, Hypothyroidism, T1 DMAtlantoaxial instability, complete AV canal/VSD/ASD
445
Amlodipine can cause?
Peripheral edema (Dihydropyridine Ca-inhibitors)
446
Tinea Versicolor>
Pale, velvety pink or whitish hypo pigmented macules that do not tan and do not APPEAR scaly, but scale when scraped.
Trmt = Selenium Sulfide and ketoconazole shampoo
**VS. Tinea Corporis that has a VISIBLE scaly border
447
Dilated cardiomyopathy caused by acute viral myocarditis = ?
Systolic dysfunction caused by Coxsackie B (MC), Parvovirus B19, human herpesvirus 6, adenovirus, and enterovirus
448
Trmt for diabetic neuropathy?
TCA and Gabapentin
449
Mixed Essential Cryoglobulinemia?
Palpable purpura, proteinuria, hematuria….arthralgias, HSM, low complement - look for underlying Hep C
450
Transudative fluide has a pH of? Exudative?
7. 4 - 7.55
| 7. 3 - 7.45
451
CMV retinitis looks like?>
CD4 less than 50, yellow-white patches of retinal opacification and hemorrhages
452
Gritty sensation, eye discharge, with rhinorrhea, and mild sore throat ?
Viral conjunctivitis! Adenovirus commonly, cool/warm compress
453
Thiazide diuretics metabolic side effects:
Hyperglycemia, elevated LDL, elevated triglycerides, hyponatremia, hypokalemia, and hypercalcemia
454
People whom pneumococcal vaccine is recommended for < 65yrs?
Asthma, COPD, emphysema, chronic heart disease, DM, chronic liver disease, cigarette smoker, alcoholism, cochlear implants, CSF leaks, immunocompromised, function or asplenics, sickle cell, or hemoglobinopathy
* subsequent booster 5 years later
455
Cerebral septic emboli are treated with ?
Antibiotics
456
Sausage fingers, nail pitting, red plaques with silver scaling ?
Psoriatic Arthritis - systemic corticosteroids are relatively contraindicated - use NSAIDS, anti-TNF and methotrexate
457
Meds conferring decrease mortality = >
Acei, arb, bblockers, and spironolactone/eplerenone
Digoxin and furosemie = symptomatic relief
458
Addisons acid status?
Non-anion gap metabolic acidosis
459
Alopecia, abnormal taste, impaired wound healing, bullous pustules surrounding mouth or body orifices ?
Zinc deficiency
*selenium = cardio tox
460
Microcytic hypochromic anemia simulating iron deficiency with two groups of RBCS (normochromic and hypo chromic)…but lab studies show ELEVATED iron and decreased TIBC?
Sideroblastic anemia - B6 deficiency? "Ringed sideroblasts"
461
Acute COPD exacerbation trmt?
O2 (88-92), inhaled bronchodilators and anticholinergics (albuterol and ipratropium) and antibiotics and glucocorticoids
462
What on urine would distinguish diuretic abuse/barter/gitelman syndrome from vomitting/chronic diarrhea?
The first group has increased urinary chloride.
463
Confirm lead levels with?
venous sample
464
Ascite trmt:
Sodium and water restriction - Spironolactone - loo diuretic (furosemide) - recent abdominal paracentesis
465
TTP trmt =>
Plasmapharesis
466
Hypoxemia PaO2/FiO2 < 300, bilateral alveolar infiltrates, decreased lung compliance 2/2 collapsed alveoli, and increased pulm arterial pressure =?
ARDS
467
Bilateral cellulitis of the submandibular and sublingual space = ? MCC?
Ludwig Angina - Strep and Anaerobs infect teeth - MCC of death = asphyxiation
468
Painless blisters, increased skin fragility on dorsum of hands, facial hypertrichosis and hyper pigmentation =?
Porphyria Cutanea Tarda - can be triggered by ethanol or estrogens. Phlebotomy or Hydroxychloroquine and interferon alpha can provide relief
Associated with Hep C
469
Diagnosis of achalasia?
Barium swallow and ENDOSCOPY - malignancy can mimic the findings.
470
HIT management>
STOP HEPARIN - give thrombin inhibitor like Argatroban.
Serotonin release assay = confirmatory test
471
Tumor presenting with shoulder pain, weakness and atrophy of hand muscles, pain or paresthesia too, enlarged supraclavicular lymph nodes = ?
Pancoast tumor (superior sulcus tumor) causing Horner's syndrome
Also see contralateral sympathetic response with flushing and sweating
472
Clear lung fields, hypotension and JVD in the setting of an MI in leads II, II, aVF =>
RV infarct - fluid resuscitation and avoidance of nitrates
473
HOCM would benefit from what meds>
BBlocks or CCB's if they can't have those because these allow heart have more time to fill with blood
