TL Flashcards

Question

59 yo M comes to ED with 1 day history of fever, chills and dysuria. PMH hypothyroidism, HTN, obesity. Vitals show 101.2, 146/79, HR 92, RR 18. PE shows exquisitely tender prostate on DRE. The most appropriate empiric treatment is?

Answer 1

Trimethoprim-sulfamethoxazole or a fluoroquinolone (eg, ciprofloxacin, levofloxacin) Patient has acute bacterial prostatitis. E. coli is the MC causative organism

Answer 2

Gross or microscopic hematuria on urinalysis Patient has nephrolithiasis

Answer 3

Abdominal ultrasound or non contrast spiral CT of the abdomen and pelvis Hydration and pain control Strain urine (evaluate composition) -CCB and tamsulosin may help relax the ureter, resulting in less pain and improved passage of the stone 20 mm: percutaneous nephrolithotomy

Answer 4

Urinary catheterization Patient has urinary retention due to recent diphenhydramine use

Answer 5

Amitriptyline atropine Diphenhydramine Epidural anesthesia Opioid analgesics Pelvic surgery (eg, bladder injury)

Answer 6

Ototoxicity (CN VIII damage) Renal agenesis

Answer 7

Renal failure

Answer 8

Neural tube defects Cardiac defects

Answer 9

Cleft palate Renal agenesis

Answer 10

Neural tube defects

Answer 11

Cleft palate Microphthalmia Cardiac defects

Answer 12

Bone defects Congenital heart disease

Answer 13

Ebstein anomaly

Answer 14

Aplasia cutis congenita

Answer 15

Bone/teeth defects

Answer 16

Fetal hemorrhage Bone defects

Answer 17

Testicular cancer -Germ cell: 95% of testicular cancers and classified as seminomatous or non-seminomatous

Answer 18

Fluoroquinolone (eg, ciprofloxacin) MC cause in patients over 35 yo = E. coli MC cause in patients less than 35 yo = suspect gonorrhea or chlamydia and treat with ceftriaxone and doxycycline

Answer 19

Renal biopsy This patient has acute interstitial nephritis which occurs several days after initiating or increasing use of a new mediation (often an abx or NSAID). Symptoms include a maculopapular rash, fever, malaise, nausea, and polyarthralgia. Most definitive test for confirming dx is renal biopsy demonstrating mononuclear and eosinophilic inflammatory infiltration of the renal parenchyma with sparing of the glomeruli and blood vessels PIC

Answer 20

Anterior: Posterior IT band (outer femur) Posterior: Lateral sacral base bilaterally

Answer 21

Eosinophils on microscopy Patient has acute interstitial nephritis

Answer 22

Obstructive uropathy PIC

Answer 23

Chronic outlet obstruction The patient has urinary bladder diverticulum. BPH is a common cause of this

Answer 24

DRE A rectal exam should be avoided in neutropenic patients if the patient is thrombocytopenia because of increased bleeding risk

Answer 25

Red blood cell casts or dysmorphic red blood cells (glomerulonephritis) may be seen Patient has Alport syndrome (X-linked dominant) caused by a defect in type IV collagen, involving the basement membranes of the kidney and also frequently affecting the cochleas and eyes.

Answer 26

Retrograde urethrogram (gold standard for diagnosing urethral injuries) Avoid Foley catheter placement Place a suprapubic catheter if the urethrogram is positive for a urethral injury Anterior urethral injury: urgent repair (<24 hours) Posterior urethral injury: suprapubic catheter; delayed repair

Answer 27

-Treat the diagnosed STI with appropriate antibiotics -Provide counseling on safer sex practices -Screen for HIV -Provide hepatitis B vaccine if unvaccinated -Encourage the patient to contact past sexual partners to be evaluated and, if needed, treated -Notify the public health department of the disease, as required in all states

Answer 28

Proteinuria Patient likely has diabetic nephropathy (Kimmelstiel-Wilson disease). Treatment includes either hand ACE-I or ARB with aggressive lifestyle modification and glycemic control

Answer 29

Transrectal ultrasound guided biopsy Rule out prostate cancer because of his high PSA TRUS is negative, MRI-guided biopsy may be used for diagnosis where there is an ongoing concern for prostate cancer because of a further increase in PSA or abnormalities on examination

Answer 30

Renal abscess

Answer 31

Suspected based on clinical findings of suprapubic pain and gross hematuria and confirmed intraoperatively or with CT cystogram

Answer 32

Diuresis Treatment for mild cases is supportive, including water and salt restriction and gentle diuresis

Answer 33

A tetracycline that inhibits the 30s ribosomal subunit

Answer 34

Superior mesenteric artery

Answer 35

Chordee This is a severe form of hypospadias where urethra opens at the base of the scrotum and the the chordee pulls penis down Ventral opening of urethra = hypospadias Urethral meatus found on the dorsal surface of the penis = epispadias

Answer 36

-Hemodynamic status (hypotension) -Ability to reliably consume oral medications (nausea, vomiting, etc) -Certain comorbidities (eg, renal disease, poorly controlled DM) -Presence or absence of complicated disease (eg, sepsis, organ failure)

Answer 37

Outpatient: oral fluoroquinolone (eg, ciprofloxacin) Inpatient: IV fluoroquinolones or ahminoglycosides +/- ampicillin

Answer 38

-Complicated pyelonephritis (eg, sepsis, renal failure) -Persistent symptoms despite 48-72 hours of treatment -History of nephrolithiasis -Unusual urinary findings (eg, gross hematuria)

Answer 39

Sertoli cell tumor (type of sex cord-stomal tumors)

Answer 40

Actinomyces israelii

Answer 41

CT abdomen and pelvis with contrast

Answer 42

low serum calcium

Answer 43

Increased calcitriol and urinary calcium, decreased PTH PTH is decreased because hypercalcemia in sarcoidosis occurs due to extrarenal calcitriol production in the lungs and lymph nodes and is independent of parathyroid hormone

Answer 44

Hyperuricemia: purine nucleic acids from lysed tumor cells are metabolized by xanthine oxidase to uric acid. Because uric acid is poorly soluble in urine, patients often develop obstructing uric acid stones in the renal tubules, which causes AKI. Hyperphosphatemia: tumor cells frequently contain >3 times more intracellular phosphate than healthy cells. Phosphate (renally excreted) binds calcium in the renal tubules and forms obstructing calcium-phosphate stones; this can also cause AKI and leads to systemic hypocalcemia. Hyperkalemia: intracellular potassium is released into the circulation, which can cause cardiac arrhythmias.

Answer 45

Lymphocytic infiltration of the interstitium Patient likely has allergic interstitial nephritis, most likely from a diuretic

Answer 46

Anti ds-DNA Decreased C3 and C4 Biopsy is gold standard Urine sediment with WBC, RBC, or casts (granular, WBC, RBC)

Answer 47

Cytoscopy Obviously you would get urinalysis before that though and it would show >3 RBC

Answer 48

Cigarette smoking Opium use Occupational carcinogen exposure (including arsenic and trihalomethane compounds from chlorination of drinking water)

Answer 49

Increase fluid intake Increased dietary calcium intake (calcium rich foods) Increased dietary potassium intake Decreased dietary sodium intake Avoidance of high-dose vitamin C supplements Thiazide diuretics Allopurinol

Answer 50

Genetic testing (COL4A3, COL4A4, COL4A5)

Answer 51

Ciprofloxacin, ceftazidime, cefepime

Answer 52

B-hCG Histology reveals abundant necrosis and hemorrhage and mixed cytotrophoblasts and syncytiotrophoblasts

Answer 53

Observation Increase oral fluid intake Bed rest

Answer 54

Observation Incision and drainage is indicated for painful lesions Patient has a bartholin gland cyst

Answer 55

A- Acidosis: severe metabolic acidosis E- Electrolytes: severe hyperkalemia I- Ingestion: toxic alcohol, lithium O- Overload: refractory fluid overload (refractory to medication management) U- Uremia: uremic pericarditis or encephalopathy

Answer 56

Metabolic acidosis, regardless of drug level Elevated levels of methanol or ethylene glycol (more than 50 mg/dL Evidence of end organ damage (eg, visual changes, renal failure)

Answer 57

Ethacrynic acid

Answer 58

Ciprofloxacin

Answer 59

Renal ultrasound CT/MRI would be a better option in a patient that has a FH of ADPKD

Answer 60

MRI of lumbar spine If imaging shows nerve root compression then emergency neurosurgical consult

Answer 61

Urinalysis with microscopic analysis THEN Cystoscopy CT urogram or MRI urogram Urine cytology

Answer 62

Portable chest x-ray to ensure correct position and evaluate for complications Only exception to this rule is if a CVC is placed in a hemodynamically unstable or actively decompensating patient

Answer 63

Leydig cell tumors Reinke crystals are eosinophilic cytoplasmic crystals characteristic of Legged cells and are present in up to 1/3 of Lydia cell tumors

Answer 64

Impaired H+ secretion by alpha intercalated cells in the distal tubule Hypokalemia Urine pH > 5.5

Answer 65

Impaired HCO3- reabsorption in the proximal tubule Hypokalemia Urine pH is variable and often <5.5

Answer 66

Reduced aldosterone activity Hyperkalemia Urine pH <5.5

Answer 67

Bladder disease Initial hematuria is characterized by blood at the beginning of the voiding cycle and often reflects a urethral source. Total hematuria is characterized by blood during the entire voiding cycle and can reflect bleeding from anywhere in the urinary tract (eg, bladder, kidneys). Terminal hematuria is characterized by blood at the end of voiding cycle and often suggests bleeding from the prostate, bladder neck or trigone, or posterior urethra.

Answer 68

This patient with lower urinary tract symptoms (eg, urinary frequency, nocturia, impaired flow) consistent with benign prostatic hyperplasia (BPH) has a slowly rising creatinine level; urinalysis does not show evidence of albuminuria, hematuria, or pyuria, making intrinsic kidney disease less likely. This presentation raises suspicion for BPH-induced obstructive uropathy (eg, enlarged prostate, palpable bladder), which may result in permanent kidney damage due to blockage of free flow of urine. With obstructive uropathy, a renal ultrasound examination (which should be performed in all patients being evaluated for creatinine elevation or chronic kidney disease) typically reveals hydronephrosis; it can also help assess the extent of kidney injury. If irreversible kidney damage (eg, cortical atrophy on sonogram due to increased pressure) has not yet occurred, management of BPH may improve creatinine levels.

Answer 69

Epididymitis Normal prehn is relief of pain with testicular elevation Localized tenderness to the posterior aspect of the testicle Urinalysis may show pyuria Dx based on H&P Get a urinalysis & also get urine culture and testing for gonorrhea and chlamydia Tx: >35 & low risk for STI = fluoroquinolone <35 & high risk for STI = one time dose of ceftriaxone and a day 10 course of doxycycline to cover G&C. Don't wait for cultures and results of STI to initiate treatment

Answer 70

Thinning and splitting of the glomerular basement membrane ("basket weave appearance")

Answer 71

Transvaginal doppler ultrasound

Answer 72

Liddle syndrome

Answer 73

Isotonic fluid like 0.9% normal saline until patient is euvolemic In asymptomatic patients give hypotonic solution Once patients are euvolemic, hypotonic fluids (eg, 0.45% saline, 5% dextrose) can be given for ongoing hypernatremia

Answer 74

CT abdomen and pelvis without contrast For pregnant patients get US of the kidneys

Answer 75

Low pH and greater than compensated PCO2

Answer 76

Metabolic alkalosis, producing a contraction alkalosis

Answer 77

Manual detorsion then surgical intervention and orchipexy to prevent retorsion

Answer 78

Penicillin G Bacteria is Actinomyces israelii

Answer 79

24 hour urinary fractionated metanephrine and catecholamine testing Obtain a serum calcium level to assess for hypercalcemia MEN2A: pheochromocytoma,primary hyperparathyroidism, medullary thyroid cancer

Answer 80

Mesangial proliferation Patient has IgA nephropathy

Answer 81

Obtain thorough H&P Obtain a sexual assault forensic exam (even if the patient already showered) Management: -Assess and treat and physical injuries -Psychologic assessment and support -Pregnancy prevention -Treatment and prevention of STIs (NAA for G&C, trichomonas) -Forensic evaluation

Answer 82

End-stage kidney disease

Answer 83

-Intravenous dye that colors the urine such as sodium fluorescein, indigo carmine, methylene blue -Intravesical contrast (methylene blue) -Intravesical fluid distension (mannitol) -Preoperative oral phenazopyridine -Cytoscopy -Retrograde pyelography

Answer 84

Alkalinizing the urine with potassium citrate. Uric acid becomes soluble at an alkaline pH

Answer 85

Gaucher Deficiency of the enzyme glucocerebrosidase

Answer 86

Bartter syndrome Defective Na and Cl reabsorption in the thick ascending limb of the LoH

Answer 87

Persistent symptoms despite 48-72 hours of treatment. The imaging (CT abdomen pelvis) will evaluate for potential complications such as renal abscess, perinephric abscess, and emphysematous pyelonephritis

Answer 88

Loop or thiazide diuretics

Answer 89

Administering desmopressin with initial treatment If overcorrection is found, coadministration of desmopressin can help lower the serum sodium to reach the target threshold

Answer 90

Endotracheal intubation and mechanical ventilation to protect the airway and provide ventilatory assistance

Answer 91

24 hour urine protein measurement

Answer 92

Renal artery doppler ultrasound Renal artery angiogram is the gold standard however it is performed only if the initial imaging is inconclusive due to its invasive nature and potential risks, which include contrast-induced nephropathy, bleeding, infection and atheroembolic phenomena

Answer 93

Single dose of oral azithromycin Alternative treatment regimens: -Ceftriaxone single IM dose -Erythromycin 3 times a day for 7 days -Ciprofloxacin twice a day for 3 days

Answer 94

Sodium bicarbonate

Answer 95

Parathyroidectomy In asymptomatic patients any one of the following are indications for parathyroidectomy: 1) renal function- impaired GFR < 60 mL/mi 2) osteoporosis- bone density consistent with osteoporosis (T-score < -2.5) or vertebral compression fracture 3) age- primary hyperparathyroidism in those age < 50 yo 4) calcium level- serum concentration of calcium > 1 mg/dL above the upper limit of normal

Answer 96

TSH: normal or high Ultrasound: hypo echoic thyroid mass, microcalcifications, extracapsular extension Fine needle aspiration

Answer 97

Graves: orbitopathy, hyperthyroidism, diffuse thyroid enlargement Toxic multi nodular goiter: discrete thyroid nodules, hyperthyroidism Subacute thyroiditis: painful thyroid, hyperthyroidism (signs and sx of hyperthyroidism and a very tender thyroid gland, typically occurs after a viral infection, radioactive iodine scan will show reduced uptake) Subclinical hyperthyroidism: asymptomatic Thyrotoxicosis: hyperthyroidism, usually normal thyroid examination

Answer 98

Severe hypothyroidism leading to decreased mental status and hypothermia. It also produces other abnormalities like macroglossia, hypothermia, hypotension, bradycardia, hypoventilation, hyponatremia and hypoglycemia. Will have high TSH, low free T3 and T4 Initial treatment consists of thyroid hormone (levothyroxine and liothyronine) replacement. Glucocorticoids are often administered as well because of the possibility of concomitant adrenal insufficiency

Answer 99

Wet beriberi characterized by dilated high-output cardiomyopathy

Answer 100

Glargine insulin Onset of 1-4 hours Duration of approx 24 hours

Answer 101

-HbA1c > 6.5%* -Fasting plasma glucose > 126 mg/dL* -Two-hour plasma glucose >200 mg/dl following a 75-gram oral glucose tolerance test* -Random plasma glucose > 200 mg/dL in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis * = need two tests with values in the diabetic range to dx diabetes -Use insulin as first-line in patients with A1c > 10%

Answer 102

Common finding in individuals with long-standing and poorly controlled diabetes, resulting in impaired sympathetic nervous system reflexes and orthostatic hypotension resulting in syncope

Answer 103

Sufonylureas (eg, glyburide) which increase insulin release from pancreatic beta cells by closing potassium channels in the plasma membrane of these cells Meglitinides (eg, repaglinide) which block ATP-dependent potassium channels promoting insulin release from pancreatic beta cells

Answer 104

Proinsulin and c-peptide levels are low Plasma insulin will be high C-peptide levels will be elevated with sulfonylureas

Answer 105

exogenous insulin or secretagogues (most commonly sulfonylureas)

Answer 106

Increased plasma insulin, plasma c-peptide and plasma proinsulin

Answer 107

Increased plasma insulin Decreased plasma c-peptide and plasma proinsulin

Answer 108

Increased plasma insulin, plasma c-peptide, plasma pro-insulin and insulin secretagogue

Answer 109

Cigarette smoking Patient most likely has pancreatic cancer

Answer 110

3 times daily Glucose should be monitored before each insulin dose, usually at least 4 times daily (once before each of 3 meals and once before the administration of long-acting insulin0

Answer 111

Condition in which the serum total thyroxine is abnormal without evidence of thyroid disease (normal TSH) Will have increased TBG and free T4. Normal TSH and total T3

Answer 112

If potassium level is: > 5.2 --> IV insulin + isotonic fluids > 3.3 and < 5.2 --> IV insulin + IV fluids with added K+ < 3.3 --> IV fluids + K+, hold insulin until K+ > 3.3 to prevent fatal cardiac arrhythmia from total body hypokalemia

Answer 113

MEN 1 mutation Pituitary adenoma Parathyroid hyperplasia Pancreatic islet cell tumors (gastrinoma) Prolactinoma

Answer 114

RET oncogene Parathyroid hyperplasia Pheochromocytoma Medullary thyroid carcinoma

Answer 115

RET oncogene Pheochromocytoma Medullary thyroid carcinoma Marfanoid body habitus Mucosal neuromas

Answer 116

The malignancy is characterized by extracellular amyloid composed of calcitonin from thyroid parafollicular cells

Answer 117

Insulin-like growth factor one (IGF-1) to screen for acromegaly The patient likely has acromegaly with a mass effect from a pituitary tumor

Answer 118

ACTH to differentiate ACTH-dependent vs independent causes of Cushing syndrome

Answer 119

Adrenal crisis Suspect adrenal crisis due to steroid withdrawal in post-op patients who suddenly develop hypotension, shock and hyperkalemia. Immediate treatment with corticosteroids should be instituted if adrenal crisis is suspected, even if it has not been confirmed

Answer 120

Propylthiouracil in the first trimester due to potential teratogenicity of methimazole (aplasia cutis) Methimazole in the second and third trimesters and in non-pregnant patients due to risk of hepatotoxicity with PTU

Answer 121

Start spironolactone Patient has 17-alpha-hydroxylase deficiency which can present with hypertension and delayed puberty (primary amenorrhea, minimal body hair, absence of secondary sexual characteristics) in females Labs: low cortisol and androgens, elevated ACTH and 11-deoxycortisone Management involves spironolactone to block the effects of excessive aldosterone production and a glucocorticoid to treat inadequate cortisol production

Answer 122

Basal insulin is adjusted for preprandial glucose levels Bolus insulin is adjusted for postprandial levels

Answer 123

Control blood glucose levels

Answer 124

appropriate hospital protocols

Answer 125

Prostate-specific antigen (PSA): prostate Carcinoembryonic antigen (CEA): colon Cancer antigen (CA19-9): pancreatic Cancer antigen (CA125): ovarian Alpha-fetoprotein (AFP): hepatocellular or germ cell Calcitonin: medullary thyroid

Answer 126

Primary adrenal insuffiiciency is MC caused by autoimmune adrenalitis and can present with symptoms of fatigue, anorexia, and decreased libido that may mimic psychiatric diagnoses such as MDD or adjustment disorder. Other findings that strongly suggest PAI over psychiatric diagnoses is hypotension, hyperpigmentation, hypoglycemia, and/or electrolyte abnormalities

Answer 127

seek a court order to allow for treatment of a child

Answer 128

Thyroid storm An acute event such as surgery can precipitate thyroid storm in patients with untreated or poorly controlled hyperthyroidism. Immediate treatment for patients with thyroid storm includes thionamides (PTU or methimazole), beta-blockers (propranolol) and glucocorticoids (hydrocortisone) Iodine should be given >1 hour after the first dose of thionamide is taken This reduces the risk of iodine producing new thyroid hormone instead of preventing the release of thyroid hormone

Answer 129

take extra care to identify and preserve the parathyroid tissue during thyroid surgery Serum calcium levels, as well as symptoms of hypocalcemia should be closely monitored after thyroidectomy

Answer 130

Amiloride which blocks epithelial sodium channels in principal cells and thereby prevents lithium from entering these cells Lithium can cause nephrogenic DI by entering principal cells of the collecting ducts to interfere with aquaporin-2 water channels

Answer 131

Increase levothyroxine dose This patient has common symptoms of menopause, including insomnia, vasomotor symptoms (eg, hot flashes), and mood swings. In the absence of contraindications (eg, history of breast cancer, tobacco use), first-line treatment for severe menopausal vasomotor symptoms is oral estrogen-based hormone therapy. However, estrogen has notable effects on thyroid metabolism. More than 99% of circulating thyroid hormone is bound to plasma proteins, primarily thyroxine-binding globulin (TBG). Estrogen upregulates the production of TBG in the liver; an increase in estrogen activity (eg, pregnancy, oral contraceptive use, menopausal hormone therapy) raises circulating TBG levels, causing a corresponding reduction in free T4 and T3 levels (Choice C). In patients with a normal hypothalamic-pituitary-thyroid axis, lower free thyroid hormone levels trigger a transient increase in TSH release, leading to increased thyroid hormone production until the additional TBG becomes saturated with thyroid hormone and free hormone levels are restored. However, patients with hypothyroidism are dependent on exogenous thyroid hormone and are unable to increase production to compensate for the increased TBG. Therefore, patients on thyroid replacement therapy who are prescribed oral estrogens require a compensatory adjustment in levothyroxine dose.

Answer 132

High renin, low aldosterone Hyponatremia, hyperkalemia, hypoglycemia, lower DHEA-s, non-gap metabolic acidosis

Answer 133

Prolongation of the QT interval

Answer 134

ACTH, TSH, LH, FSH, prolactin, GH

Answer 135

serum beta hydroxybutyrate

Answer 136

21-hydroxylase deficiency deficiency Tx: correction of electrolyte abnormalities, supplement with glucocorticoids and mineralocorticoids to prevent adrenal crisis

Answer 137

hypothyroid before they recover

Answer 138

pyridoxine (B6)

Answer 139

Gastroparesis Causes: -DM (autonomic neuropathy) -Medications (eg, opioids, anticholinergic drugs) -Traumatic/postsurgical injury (ie, vagus nerve injury) -Neurologic (eg, multiple sclerosis, spinal cord injury) -Idiopathic/postviral Diagnosis: -Exclude obstruction with upper endoscopy +/- CT/MR enterography -Upper endoscopy may reveal food in the stomach despite an overnight fast -Assess motility with nuclear gastric-emptying study Treatment -Frequent small meals (low fat, soluble fiber only) -Promotility drugs (eg, metoclopramide, erythromycin) -Gastric electrical stimulation and/or jejunal feeding tube (refractory symptoms)

Answer 140

Results from early activation of the hypothalamic-pituitary-gonadal (HPG) axis. Pulsatile GnRH secretion stimulates elevated FSH and LH levels Patients with true precocious puberty will have increased estrogen/testosterone levels that accelerate skeletal maturation, resulting in advanced bone age and increased growth velocity Patient will have onset of secondary sexual characteristics in girls age <8 and boys age <9 Require MRI brain to evaluate for a hypothalamic or pituitary tumor activating the HPG axis If negative, the cause is most likely idiopathic precocious puberty and GnRH therapy can be initiated- it desensitizes the pituitary and suppresses FSH and LH secretion to slow pubertal progression and maximize height potential

Answer 141

Caused by gonadal or adrenal release of excess sex hormones Basal levels of FSH and LH are typically low due to negative feedback and remain low following GnRH agonist stimulation

Answer 142

Low cortisol and ACTH Normal aldosterone Mechanism: disruption of HP axis Etiologies: chronic glucocorticoid therapy, infiltrative disease, ischemia of the anterior pituitary Will present with less severe symptoms, euvolemia, minimal electrolyte disturbance, no hyperpigmentation. Potassium is normal

Answer 143

Low cortisol and aldosterone High ACTH Mechanism: destruction of bilateral adrenal cortex Etiologies: autoimmune adrenalitis, infection, malignancy Etiologies: more severe symptoms, hypovolemia, hyperkalemia, hyponatremia, hyperpigmentation Treat with glucocorticoids (eg, hydrocortisone, prednisone) and mineralocorticoids (eg, fludrocortisone) Adrenal crisis give hydrocortisone or dexamethasone and rapid IV volume repletion

Answer 144

delayed clearance of insulin by the kidneys

Answer 145

Low calcium and phosphate High PTH Because of vitamin D deficiency and secondary hyperparathyroidism

Answer 146

Pituitary tumors, hyperprolactinemia, medications like opioids, glucocorticoids, exogenous androgens (withdrawal phase), infiltrative disease (eg, hemochromatosis), chronic/severe illness, eating disorders, severe weight loss Clinical feature care fatigue, decreased libido, testicular atrophy, will have low testosterone and low/normal LH Primary will have gynecomastia

Answer 147

Weight loss, necrolytic migratory erythema (erythematous papule that coalesce to form large, indurated plaques with central clearing), DM/hyperglycemia, GI symptoms like diarrhea, anorexia, abdominal pain Diagnosis: markedly elevated glucagon level, abdominal imaging (MRI or CT scan)

Answer 148

Sinus tachycardia, premature atrial and ventricular complexes, atrial fibrillation/flutter, systolic hypertension and increased pulse pressure, increased contractility and cardiac output, decreased systemic vascular resistance, increased myocardial oxygen demand, high output heart failure, exacerbation of preexisting low-output failure, coronary vasospasm, preexisting coronary atherosclerosis

Answer 149

Labs: Low 25-hydroxyvitamin D, urine calcium, phosphorus Elevated alkaline phosphatase, PTH Low/normal calcium Clinical manifestations Decreased muscle tone & delayed development Delayed fontanelle closure, frontal bossing Widening of epiphyses Hypertrophy of costochondral joints Short stature, femoral & tibial bowing

Answer 150

Occurs in patients with undiagnosed or inadequately treated hyperthyroidism Caused by rapid increase in serum thyroid hormone levels or increased sensitivity to thyroid hormone -Thyroid or nonthyroidal surgery -Acute illness (eg, trauma, infection), childbirth -Acute iodine load (eg, iodine contrast) -Fever as high as 40-41.1 C (104-106 F) -Tachycardia, hypertension, congestive heart failure, cardiac arrhythmias (eg, atrial fibrillation) -Agitation, delirium, seizure, coma -Goiter, lid lag, tremor, warm & moist skin -Nausea, vomiting, diarrhea, jaundice -β blocker (eg, propranolol) to ↓ adrenergic manifestations -PTU followed by iodine solution (SSKI) to ↓ hormone synthesis & release (give iodine at least 1 hour after PTU to prevent excess iodine incorporation into thyroid hormone) -Glucocorticoids (eg, hydrocortisone) to ↓ peripheral T4 to T3 conversion & improve vasomotor stability -Identify trigger & treat, supportive care

Answer 151

Severe neutropenia

Answer 152

Watery diarrhea Hypo- or achlorhydria due to decreased gastric acid secretion Associated flushing, lethargy, nausea, vomiting, muscle weakness/cramps Labs: hypokalemia, hypercalcemia, hyperglycemia, stool studies show secretory diarrhea with increased sodium and osmolal gap <50 CT or MRI scan of the abdomen to localize the tumor in pancreas (usually in pancreatic tail)

Answer 153

-Serum electrolytes -Serum creatinine -Urinalysis -Urine albumin/creatinine ratio (optional) -Fasting glucose or hemoglobin A1c -Lipid profile -TSH -ECG -Echo (optional) -CBC -Uric acid (optional)

Answer 154

to prevent bone loss Prolactin suppresses GnRH in the hypothalamus leading to decreased FSH and LH so decreased estrogen.. you need estrogen to build bone

Answer 155

monofilament testing

Answer 156

Early/mild T3- decreased T4- normal TSH- normal Prolonged/severe T3- decreased T4- decreased TSH- decreased

Answer 157

serum anion gap

Answer 158

Concentric left ventricular hypertrophy, cardiomyopathy, heart failure

Answer 159

Increased alkaline phosphatase, PTh Decreased serum calcium and phosphorus, urinary calcium, 25(OH)D levels

Answer 160

Estrogens (eg, pregnancy, OCs, HRT) & estrogenic medications (eg, tamoxifen), acute hepatitis

Answer 161

Parkinson disease

Answer 162

OCPs Letrozole for ovulation induction

Answer 163

Microvascular complications (eg, nephropathy, retinopathy)- improves Macrovascular complications (eg, acute MI, stroke)- no change (short-term) Mortality- no change or increased

Answer 164

Hypofunctioning ("cold") nodules

Answer 165

Defect in Btk (Bruton agammaglobulinemia tyrosine kinase) which results in impaired B lymphocyte maturation and decreased levels of immunoglobulins of all classes. Patients present after age 6 months with recurrent sinopulmonary and gastrointestinal infections

Answer 166

Croup (parainfluenza MC, RSV, influenza, adenovirus) Inspiratory stridor, barking cough Children 6 months-3 years Low grade fever Steeple sign Mild cases treat with cool mist therapy and rest and moderate to severe cases are treated with immediate nebulizer racemic epinephrine to open the airway and oral/intramuscular/intravenous dexamethasone to reduce swelling Hospitalization may be required for serial racemic epinephrine treatments and supplemental oxygen *moderate to severe is defined as presence of stridor at rest

Answer 167

Toxic looking, drooling High fever Thumbprint sign

Answer 168

Soft tissue swelling posterior to the pharynx Toxic, drooling Hot potato voice High fever

Answer 169

Expiratory stridor Prolonged prodromal phase, followed by acute decompensation over a period of hours 3 months-2 years Subglottic narrowing

Answer 170

4 months of RIPE (rifampin, isoniazid, pyrazinamide, ethambutol) 2 months of isoniazid and rifampin

Answer 171

4 months of rifampin

Answer 172

RIPE ONGO Rifampin- orange urine Isoniazid- Pyrazinamide

Answer 173

TB Measles Chickenpox COVID-19 Disseminated herpes zoster

Answer 174

Tracheobronchial injury (eg, bronchial rupture) suspect when a patient has a persistent pneumothorax and/or pneumomediastinum despite tube thoracostomy (chest tube) Diagnose with bronchoscopy Manage with surgical repair

Answer 175

Palpitations + tachycardia = arrhythmia Chest pain + hypotension = myocardial infarction Productive cough + fever = pneumonia Chest pain + tachycardia = pulmonary embolism

Answer 176

Usually occurs in the setting of sepsis or another serious acute medical condition. Characterized by diffuse activation of the coagulation system leading to consumptive coagulopathy and subsequent spontaneous bleeding Labs are low platelet and fibrinogen level, elevated PT, aPTT and D-dimer and evidence of microangiopathic hemolytic anemia (low hemoglobin/hematocrit, schistocytes, helmet cells on blood smears) PIC

Answer 177

aka neurocardiogenic syncope MC cause of syncope among adults, especially in those without apparent cardiovascular or neurologic disease. Pathophysiology is thought to be related to a temporary and self-limited symptomatic hypotension mediated by decreased sympathetic tone resulting in bradycardia or peripheral vasodilation. Occurs while sitting or standing since supine position maintains cerebral perfusion. Younger patients are more likely to have the classic triggers such as emotional or orthostatic stress, painful stimulus, prolonged standing or physical exertion

Answer 178

Arrhythmia: v tach, long QT syndrome, Brugada syndrome, sinus arrhythmias Ischemia: acute coronary syndrome, myocardial infarction Structural abnormalities: valvular disease, cardiomyopathy, atrial myxoma, tamponade, dissection Hemorrhage: trauma, GI bleeding or other source of bleeding Pulmonary embolism Subarachnoid hemorrhage

Answer 179

Isotonic IV fluids (to increase preload and cardiac output) Aspirin therapy Emergent cardiac catheterization (to decrease mortality and allow for revascularization) No preload reducers like furosemide or nitrates because they can further reduce CO Hypotension and JVD that worsen with inhalation (Kussmaul sign) are signs of RV infarction

Answer 180

ABCD Adenosine Beta blockers (B1) Calcium channel blocks (non-DHP- verapamil and diltiazem) Digoxin

Answer 181

Chronic lymphocytic leukemia MC in older men, often found incidentally. Immunophenotypic analysis with flow cytometryis the key diagnostic component. Will see smudge cells on peripheral smear

Answer 182

Cardioembolic disease (eg, stroke, acute mesenteric ischemia) and acute decompensated heart failure

Answer 183

Multisystem disease that often presents with cardiac, GI, hematologic and renal manifestations. It is a form of restrictive cardiomyopathy that primarily presents with signs of right heart failure. Echo will reveal concentric LVH, left atrial enlargement and preserved ejection fraction

Answer 184

Syncope, exertion angina, exertional dyspnea Pulsus parvus et tardus - low volume and slow rising pulse

Answer 185

Cocaine use, sumatriptan, and smoking Presents as intermittent chest pain with ST segment elevation when symptomatic and normal ECG when asymptomatic First line tx is with diltiazem or amlodipine

Answer 186

Decreased cardiac index and central venous pressure Increased systemic vascular resistance Normal to low pulmonary artery and pulmonary capillary wedge pressures Examination may reveal hypotension, tachycardia, narrow pulse pressure and extremities that are cool and pale

Answer 187

IV fluids when hemodynamic compromise is present PIC

Answer 188

Metabolic side effects including weight gain, dyslipidemia and impaired glucose tolerance (leading to type 2 diabetes mellitus)

Answer 189

double therapy with a P2Y12 inhibitor (eg, clopidogrel) to prevent stent thrombosis and a direct oral anticoagulant (eg, rivaroxaban) for embolic stroke prophylaxis

Answer 190

Microcytic anemia, elevated serum iron, ferritin and transferrin saturation and a low TIBC Isoniazid can interfere with pyridoxine (vitamin B6) metabolism, leading to a functional pyridoxine deficiency. This can result in impaired heme synthesis, presenting as sideroblastic, microcytic anemia

Answer 191

Ambulatory blood pressure monitoring

Answer 192

Venlafaxine Fluoxetine TCAss Caffeine Decongestants like pseudoephedrine and phenylephrine Herbal supplements like licorice and St. John's wort Hormonal birth control OCPs NSAIDs Stimulants

Answer 193

DHP-CCB like amlodipine

Answer 194

RAS is most commonly caused by atherosclerosis Once BP is controlled in RAS, preventative measures 9eg, an HMG-CoA reductase inhibitor, smoking cessation, low-dose aspirin) should be initiated to prevent further cardiovascular disease

Answer 195

Urgent cardioversion For patients with SVT that is not associated with sevre symptoms or hemodynamic collapse: 1. Vagal maneuvers 2. IV adenosine 3. IV non-DHP CCB or IV BB 4. Cardioversion in selected persistent cases or if the patient is unstable

Answer 196

Patients should be transferred to a nearby hospital for definitive management, as long as their initial evaluation-to-balloon time is within 90 minutes

Answer 197

Splenic rupture secondary to splenomegaly caused by leukocyte infiltration Patients should avoid contact sports for at least 4 weeks and avoid vigorous exercise for 21 days from the onset of symptoms

Answer 198

ACE-I (regardless of ethnicity)

Answer 199

1. make a comparison with prior radiographs (if available) 2. If prior radiographs are not available or if the nodule is new, a CT of the chest should be obtained

Answer 200

TTE is typically initial test of choice TEE provides better diagnostic accuracy and can be performed initially in certain clinical situations and in patients with prosthetic heart valves

Answer 201

BCR-ABL philadelphia chromosome abnormal chromosome 22 t(9;22) Tx with tyrosine kinase inhibitors like imatinib

Answer 202

One unit of packed RBC increases the hemoglobin level by 1 g/dl and the hematocrit by 3%. The recommended transfusion hemoglobin threshold is <7 g/dL So if a patients hgb is 4 then give them 3 units of packed RBC

Answer 203

glucagon or atropine

Answer 204

Nonselective beta-blockers like propranolol because they can worsen vasoconstriction through unopposed alpha-1 activity. Vasospastic angina should be treated with CCB and nitrates

Answer 205

vitamin B12 deficiency

Answer 206

Short PR interval Delta wave Prolonged QRS Patients who have uncertain diagnosis based on ECG and other noninvasive testing need to undergo electrophysiology study

Answer 207

Paralytic AE include hyperkalemia, hypercalcemia and malignant hyperthermia

Answer 208

Venous thrombosis (not arterial)

Answer 209

Percutaneous transluminal angioplasty

Answer 210

internal mammary arteries and these arteries arise from the anterior surface of the subclavian arteries

Answer 211

Continuous cardiac monitoring and echo Patients with ECG abnormalities and/or elevated troponin --> admit for continuous cardiac monitoring

Answer 212

Cardioversion used if pulse is palpable Defibrillation is used if a pulse is not palpable

Answer 213

First step after securing the airway is end-vascular treatment with or without stent placement Presents ass SOB, cough, facial plethora, headache, respiratory distress with stridor, Pembertons sign (face becoming erythematous when bringing arms up to face) Non small cell carcinoma followed by small cell carcinoma along with non-hodgkin's lymphoma is the most common malignancies causing SVC compression

Answer 214

Incision and drainage along with antibiotics Patient has a cutaneous abscess- presents as a painful, fluctuant nodule with surrounding erythema

Answer 215

Abdominal distension and tenderness, rectal bleeding and/or diarrhea, vomiting and lethargy. It produces the pathognomonic sign of bowel wall gas (pneumatosis intestinalis) on abdominal x-ray

Answer 216

Infraspinatus- suprascapular nerve Teres minor- axillary nerve These muscles are commonly torn in pitchers

Answer 217

Gonococcal conjunctivitis Diagnosis is with positive culture on Thayer-Martin agar (gold standard) Treatment is with a single intramuscular dose of a 3rd generation cephalosporin such as cefotaxime This condition can be prevented with appropriate maternal screening (and treatment of any maternal infection) plus topical erythromycin prophylaxis for all infants

Answer 218

Tinnitus, metallic taste, perioral numbness, tachycardia and hypertension. Many patients can develop seizures and/or life threatening cardiovascular collapse Management consists of immediate drug cessation, lipid emulsion rescue therapy, supportive care and treatment with benzodiazepines for seizure control

Answer 219

TMP-SMX, ACE-I, NSAID

Answer 220

Bacterial infections Viral and fungal infections

Answer 221

CT abdomen without contrast (won't be able to see the stone with contrast) Renal ultrasound in pregnant patients

Answer 222

Fredreich ataxia Progressive degenerative disease affecting the dorsal columns and sspinocerebellar tract Repeats of GAA lead to disruption of the frataxin gene on chromosome 9; frataxin regulates iron chaperoning and detoxicfation Hypertrophic cardiomyopathy is a common complication and the most common cause of death in these patients

Answer 223

-COVID-19 -Measles -Tuberculosis -Varicella

Answer 224

-Colonization with multidrug-resistant organisms (eg, methicillin-resistant Staphylococcus aureus) -Enteric infections (eg, E. coli O157:H7, C. diff) -Parasitic infections -Viral respiratory infections (eg, respiratory syncytial virus, COVID-19, influenza)

Answer 225

-Adenovirus -Bacterial meningitis -Influenza -Mycoplasma pneumoniae

Answer 226

Immunosuppressed patients

Answer 227

-Cirrhosis -Alcoholic hepatitis -Heart failure -Budd-Chiari syndrome -Portal vein thrombosis -Tamponade

Answer 228

-Pancreatitis -Serositis -Nephrotic syndrome -Peritoneal tuberculosis -Peritoneal carcinomatosis

Answer 229

-Temperature > 37.8 or 100F -Abdominal pain and/or tenderness -Altered mental status -Polymorphonuclear leukocytes (PMNs) count > 250 cells/mm3 Treat with 3rd gen cephalosporin like cefotaxime

Answer 230

Patients with ascites, fever, abdominal pain, altered mental status and/or polymorphonuclear leukocytes >250 cells/mm3 Treat with 3rd gen cephalosporin

Answer 231

Contralateral homonymous hemianopia (inability to see half of the visual field on the opposite side of the lesion) Cortical blindness (occipital lobe) and/or memory deficits and behavior changes (temp PCA supplies the occipital and medial temporal lobe

Answer 232

Pure motor symptoms but also be purely sensory or cause ataxic hemiparesis

Answer 233

Face and arms Contralateral hemiparesis, paresthesia and hemianopia (blindness in half of the visual field) and preference of gaze toward the side of the lesion Agnosia (inability to name objects) may also be seen

Answer 234

Occlusion of PICA Hoarseness, dysphagia, vertigo, ipsilateral ataxia, dysmetria, horner syndrome, loss of pain and temperature sensation on the ipsilateral face and contralateral body MC cause of PICA infarct is a vertebral artery dissection

Answer 235

calcium from the sarcoplasmic reticulum of skeletal muscle cells this leads to excessive accumulation of calcium ions within the intracellular space of these cells, resulting in sustained muscle contraction and hyper metabolism Tx with dantrolene

Answer 236

Confirmed with ultrasound or MRI but MRI allows for optimal detailed visualization of soft tissue structures and can determine partial vs. complete tears as well as the degree of retraction, which is useful information for surgical repair

Answer 237

NPO IV fluid administration IV PPIs PIC

Answer 238

Progestin therapy or hysterectomy with atypia or endometrial cancer then hysterectomy

Answer 239

Rest, ice and strengthening and stretching exercises If symptoms persist, professional orthotics or OtC arch support soles can be recommended Glucocorticoid injections may be used for refractory pain and surgery may be considered be pts who do not respond to conservative therapy

Answer 240

Increased left ventricular wall thickness and asymmetric septal hypertrophy TTE

Answer 241

Brief psychotic disorder: >1 day and < 1 month (no negative symptoms part of diagnostic criteria) Schizophreniform disorder: > 1 month and < 6 months Schizophrenia: > 6 months

Answer 242

Schizoaffective = major mood episode (depressive episode or manic) + criterion A symptoms of schizophrenia Mood disorder with psychotic features =

Answer 243

reduces central respiratory drive causing hypoventilation and acute respiratory acid

Answer 244

SSRIs like citalopram Mirtazpine

Answer 245

Lorazepam Antipsychotics lower the seizure threshold and should not be used to treat psychosis that occurs secondary to benzodiazepine withdrawal

Answer 246

Paranoid: holding grudges, suspicions of others true motives, resistance in confiding in others, and fidelity or loyalty. Quick to interpret benign remarks as demeaning Schizoid: detached from relationships, restricted range of emotional expression Schizotypal: magical thinking, odd or eccentric appearance, social and interpersonal deficits

Answer 247

Antisocial: belief of inadequacy that interferes with interpersonal relationships and prevents engaging in a new relationship, social situation or activity, disregard and violation of the rights of others, lack of remorse and empathy Borderline: mood changes are abrupt (within hours), usually triggered by a stressor. Fear of abandonment and nonsuicidal self-harming injuries Histrionic: excessive emotionality, attention seeking behavior Narcissistic: sense of grandiosity, need for admiration, jealousy of others

Answer 248

Avoidant: feelings of inadequacy, social inhibition, believing they are inferior to others, this belief prevents them from engaging in social activities or new relationships Dependent: excessive need to be taken care of by others, leads to submissive behavior, difficulty expressing disagreement, feeling lost when alone and the inability to make simple everyday decisions independently or assume responsibilities Obsessive-compulsive personality: preoccupation with organization, perfectionism that interferes with task completion, excessive time spent on work, difficulty delegating tasks to others, inability to discard objects with no monetary value and being strict with money and morals

Answer 249

Wide complex tachycardia, hyperthermia, hypotension, flushed skin and hypoventilation Cardiotoxicity related to TCAs is treated with sodium bicarbonate

Answer 250

Fomepizole (competitive inhibitor of alcohol dehydrogenase)

Answer 251

Pick bodies consisting of hyperphosphorylated tau proteins

Answer 252

Lactulose MOA is reducing intraluminal pH which promotes the conversion of ammonia to ammonium ion. Ammonium ions cannot be absorbed in the gut and are thus excreted in the stool, resulting in reduced serum ammonia levels

Answer 253

6-12 hours = tremor, tachycardia, hypertension 12-48 hours = seziures 2-7 days = delirium tremens

Answer 254

hyponatremia

Answer 255

Neonates <1month: ampicillin + cefotaxime (same for empiric) Children to adults < 50 years of age: ceftriaxone + vancomycin + dexamethasone Adults >50: ceftriaxone + vancomycin + ampicillin + dexamethasone (same for empiric) Immunocompromised: vancomycin + ampicillin + cefepime or meropenem + dexamethasone Empiric: vanc + 3rd gen cephalosporin like ceftriaxone or cefotaxime + post exposure prophylaxis for close contacts with rifampin

Answer 256

Used for treatment of severe depression, treatment-refractory depression or both. It is safe for use in pregnancy

Answer 257

> 3 episodes of depression Strong family history of depression >1 severe episode (an episode with several symptoms in excess of the required 5) Comorbid, nonaffective psychiatric diagnosis or chronic medical disorder

Answer 258

Acetylcholinesterase inhibitors such as donepezil, galantamine and rivastigmine Memantine is used in moderate to severe cases, it blocks over excited N-methyl-D-aspartate glutamate receptors

Answer 259

Haloperidol

Answer 260

Sudden onset eye pain, blurry vision, redness with an elevated IOCP, unilateral headache, non-reactive pupil, can be triggered by anti-cholinergic medications Shallow anterior chamber, inadequate drainage of aqueous humor Gonioscopy is gold standard Ocular emergency and must be treated promptly to prevent blindness (oral acetazolamide, topical timolol, apraclonidine, pilocarpine) Primary = patients are automatically predisposed with no identifiable cause Secondary = primary process (eg, fibrovascular membrane, mass, hemorrhage) is responsible for narrowing or closure of the anterior chamber angle

Answer 261

Elevated IOCP, asymptomatic, found incidentally

Answer 262

Can be caused by either direct, penetrating trauma or indirectly following head/orbit trauma Present with acute, ipsilateral vision loss and a relative afferent pupillary defect on PE (Marcus gunn pupil which is when light shined in affected eye, both pupils dilate and when light shined in unaffected eye both pupils constrict) Diagnosis is confirmed via CT imaging of the orbit Optho consult +/- surgical decompression

Answer 263

Medical emergency triggered by inhalational anesthetics (sevoflurane) or succinylcholine Presents with autonomic instability (hyperthermia, hypertension, tachypnea), hypercarbia (difficult ventilation, increased end tidal carbon dioxide), generalized muscle rigidity, cardiac arrhythmias, rhabdomyolysis and delirium Treatment is immediate removal of the offending agent followed by administration of IV dantrolene

Answer 264

Periorbital cellulitis is an infection of the soft tissues of the orbit that is differentiated from orbital cellulitis by a lack of vision changes and pain with eye movement Periorbital = eyelid swelling +/- erythema, +/- eye pain/tenderness, +/- fever or leukocytosis Orbital = eyelid swelling +/- erythema, eye pain/tenderness, painful eye movement, proptosis likely present, vision impairment likely present, chemosis (edema of conjunctiva) may be present, fever or leukocytosis So PAIN with eye movement = orbital

Answer 265

Antipsychotics as they can precipitate Parkinsonism or acutely worsen pre-existing Parkinsonism

Answer 266

Alcohol use disorder, nystagmus, confusion Caused by thiamine deficiency which is also linked with wet and dry beriberi Wet beriberi is characterized by dilated high-output cardiomyopathy and heart failure Dry beriberi is characterized by distal peripheral polyneuropathy

Answer 267

X-linked mutation in the MECP2 gene Stereotypic hand-wringing movements, intellectual and verbal disability like loss of spoken language, decelerated head growth, epilepsy, growth failure, gait and motor abnormalities, breathing abnormalities

Answer 268

Enhance the activity of GABA-A receptors

Answer 269

bacterial toxin blocks the release of presynaptic neurotransmitters, leading to weakness, hypotonia and possibly respiratory failure

Answer 270

Slit lamp test Fluorescein can be a useful adjunct to simple slit lamp examination when the diagnosis is unclear

Answer 271

Cyanopsia (blue-tinted vision0 via inhibition of PDE-6 in the retina

Answer 272

First line tx for juvenile mycoclonic epilepsy AE: acute pancreatitis, hepatotoxicity, tremor and eight gain Can also cause neural tube defects and should not be used during pregnancy

Answer 273

Azathioprine Corticosteroids Didanosine Diuretics (loop and thiazide) Valproic acid

Answer 274

Glutamate antagonist (eg, riluzole) to aid with increased life expectancy secondary to reducing glutamate receptor excitotoxicity

Answer 275

tremor is often bilateral vs parkinson disease starts unilateral

Answer 276

CAG = huntingtons CGG = fragile x CTG = myotonic dystrophy GAA = Friedrich ataxia GCC = FRAAXE mental retardation

Answer 277

Reassurance, supportive care, including antipyretics Abortive therapy (eg, diazepam) if seizure lasts > 5 minutes

Answer 278

hyperparathyroidism --> hypercalcemia Thyroid dysfunction (hypothyroidism) Nephrogenic diabetes insipidus Chronic kidney disease Teratogenic (Ebstein anomaly)

Answer 279

Bilateral sacral flexion Negative standing and seated flexion tests Deep sacral sulci Shallow ILAs Anterior sacral rotation about a middle transverse axis

Answer 280

inferior transverse axis

Answer 281

Semitendinosus Semimembranosus Biceps femoris They all do knee flexion and hip extension Semitendinosus & semimembranosus = hip internal rotation Biceps femoris = hip external rotation

Answer 282

Motion Superior transverse: craniosacral Middle transverse: anatomic Inferior transverse: innominate Oblique: torsion

Answer 283

Acetaminophen Then aspirin and NSAIDs

Answer 284

Consider sepsis in any neonate presenting with temperature instability and lethargy. The most common cause of sepsis in those under 7 days of age is group B strep which is a gram positive cocci

Answer 285

Mild (can tolerate upright position and care for their baby) --> increased hydration, bed rest as needed, oral pain meds, antiemetics If the headache continues to be debilitating then can give --> epidural blood patch (performed 24 hours following placement of epidural catheter). Second line includes transnasal sphenopalatine block using topical intranasal anesthetic to provide temporary relief or greater occipital nerve block to interrupt pain transmission

Answer 286

RA + splenomegaly + neutropenia

Answer 287

RA + pneumoconiosis

Answer 288

Plasmapheresis GBS is an immune mediated polyneuropathy

Answer 289

Carbamazepine Phenytoin Chloramphenicol Sulfonamides Methimazole Propylthiouracil Indomethacin

Answer 290

Immediate surgical decompression

Answer 291

Visual hallucinations, parkinsonism, fluctuating mental status Classic eosinophilic cytoplasmic inclusion bodies within the substantia nigra and locus coeruleus Tx with cholinesterase inhibitors

Answer 292

brain MRI should be repeated at a later time if initial imaging is normal

Answer 293

Staph epidermis which is a gram positive coagulase negative bacteria

Answer 294

Autoimmune condition that is caused by T cell sensitization to self-antigens Type IV hypersensitivity Can affect injured and uninjured eye Prevent via enucleation of the injured eye Manage via glucocorticoids and biologic agents

Answer 295

Normal WBC, RBC, negative gram stain or culture Elevated protein

Answer 296

Permanent pacemaker because they have an increased risk of sudden cardiac death

Answer 297

Blood pressure first has to be reduced to the target range typically SBP < 185 mmHg and diastolic pressure < 110 mmHg IV labetalol and nicardipine are common anti HTN agents used for BP reduction prior to tPA

Answer 298

CT head without Once hemorrhage is identified by CT then cerebral angiography or CT angiography is preferred If the angiography is negative then an MRI of the head is indicated

Answer 299

Oxygen saturation Finger stick glucose level check Noncon brain CT If there is no evidence of hemorrhage on CT and the patient is within the therapeutic window, tPA should be administered Window ranges from < 3 hours up to 4.5 hours

Answer 300

IV methylprednisolone

Answer 301

Arterial blood gas A mixed respiratory alkalosis and metabolic acidosis would support the diagnosis

Answer 302

Fatigue, post-exertional malaise, unrefreshing sleep, cognitive impairment, orthostatic related symptoms persisting for > 6 months. May begin suddenly after an infection or may develop gradually

Answer 303

Urgent head MRI done before lumbar puncture to rule out other potential causes of increased ICP

Answer 304

This patient's pulsating, unilateral headache with nausea and vomiting is very typical of acute migraine headache, which can sometimes vary in intensity and response to treatment. Many migraines are adequately treated with simple analgesics (eg, nonsteroidal anti-inflammatory drugs, acetaminophen). For refractory cases, triptans (eg, sumatriptan) can be used as first-line abortive therapy. However, triptans (as well as ergots) are 5-hydroxytryptamine (5-HT1B/D) agonists that can cause vasoconstriction; therefore, they should be avoided in patients with cardiovascular or atherosclerotic disease due to the potential risk for triggering a serious vasoocclusive complication (eg, myocardial infarction, stroke) (Choice E). In patients with significant cardiovascular history, metoclopramide is often used. It blocks dopamine (D2) receptors and does not have significant vasoconstrictive adverse effects. It is particularly effective in the treatment of migraines with significant associated nausea/vomiting, so it is also sometimes used for patients without a cardiovascular history if nausea and vomiting are prominent symptoms of the acute migraine. Diphenhydramine is usually coadministered to prevent the occurrence of extrapyramidal effects (eg, akathisia, dystonia).

Answer 305

Vertigo, tinnitus, sensorineural hearing loss (eg, weber lateralizes to the left) Low frequency hearing loss Caused from reduced resorption of endolymph

Answer 306

IV methylprednisolone (+ PPI (as with any patient receiving glucocorticoids to prevent gastritis)) Patients who do not respond to methylprednisolone should be treated with plasmapheresis

Answer 307

Patient has bilateral acoustic neuromas which is consistent with NF2 NF2 can also cause meningiomas, schwannomas of other cranial nerves and ependymomas Other NF2 findings are bilateral cataracts, seizures, skin nodules, cafe au lait spots Acoustic neuromas are caused by compression of vestibulocochlear nerveas a result of the tumor extending into the internal acoustic meatus

Answer 308

CT scan the chest to check for a thymoma PYRIDOstigmine (cholinesterase inhibitor) is the treatment

Answer 309

Contralateral lenticulostriate artery A pure motor stroke is caused by infarction in the posterior limb of the internal capsule which contains the corticospinal and corticobulbar fibers that innervate the motor nuclei on the contralateral side

Answer 310

Middle meningeal artery Initial LOC followed by a lucid interval

Answer 311

focal neurologic deficits (hemiparesis), altered mental staatus, vomiting

Answer 312

Central: brainstem stroke, cerebellar stroke/tumor, nystagmus is immediate and in any direction (vertical, horizontal, rotary), no auditory findings, often has neurological findings, head position doesn't change Peripheral: semicircular canal debris, BPPV, meniere disease, nystagmus is horizontal and unidirectional, occasionally will have auditory findings, no neurological findings, and head position is worsened by changing With central look for rotary or vertical nystagmus

Answer 313

Involves UMN and LMN signs in at least 3 body segments (muscle wasting and weakness, atrophy, spasticity, abnormally active reflexes, pathological reflexes) UMN: spasticity (including spastic dysarthria), hyperreflexia and/or sustained clonus, hoffman sign, extensor planar response, pseudobulbar effect LMN: flaccid muscle tone, muscle atrophy and wasting, muscle cramping, bulbar signs (dysphagia, dysarthria, respiratory weakness), fasciculations Diagnosis: EMG to confirm diagnosis and to exclude mimics- will show fibrillations and loss of innervation in multiple muscle groups Treatment is Riluzole

Answer 314

schemia in the territory of the central retinal artery Presenting sign of carotid stenosis

Answer 315

Penicillamine

Answer 316

MOA: bacterial DNA dependent RNA polymerase and therefore inhibits bacterial protein production SE: discoloration of body fluids, hepatotoxicity

Answer 317

Can compress the oculomotor nerve causing oculomotor nerve palsy

Answer 318

Can compress the optic chiasm causing bitemporal heteronymous hemianopsia

Answer 319

Wallenberg syndrome Decreased pain and/or temperature of the ipsilateral face and contralateral body Patients may also have dysphagia, slurred speech, vertigo, and nystagmus

Answer 320

Surgical resection Whole-brain radiation is recommended for patients with multiple brain metastases, poor performance status and/or extracranial metastasis

Answer 321

Lower = apoE2 Higher = apoE4, amyloid precursor protein gene mutations, presinilin 1 and 2, trisomy 21

Answer 322

Immunocompromised such as those with HIV infection and a CD4+ count < 100 cells/mcl Latest agglutination test of CSF will be positive The combination of amphotericin B and flucytosine is used for induction therapy for the first 2 weeks, followed by fluxonazole for at least 8 weeks and then low dose fluconazole for at least 1 year

Answer 323

Result of primary neuronal dysfunction with the main pathophysiologic mechanism being activation of the trigeminovascular system. This activation leads to the release of vasoactive neuropeptides (substance P, calcitonin gene related peptide, neurokinin A) that trigger neuroinflammation and pain

Answer 324

Depolarizing neuromuscular blocker that acts as an acetylcholine receptor agonist It has a rapid onset and short duration of action Due to the cellular potassium efflux, transient fasciculations may be seen

Answer 325

Otosclerosis Loss of stapedial reflex is a common finding

Answer 326

Retinal and cerebellar hemangioblastoma Renal cell carcinoma Pheochromocytoma Surveillance with MRI of brain and spine, MRI of abdomen regular eye examinations, measurement of serum and/or metanephrines

Answer 327

Hearing loss High dose corticosteroids administered prior to antibiotics have been shown to reduce this risk

Answer 328

Lower GI bleed Upper GI bleed

Answer 329

Presents as anal pruritus, prolapse and occasionally painless rectal bleeding Seen proximal to the dentate line and arise from the superior hemorrhoid veins Painless ENDOderm Treatment is fiber, fluids and possibly laxatives to improve bowel habits Note that when the prolapse is out of the anal canal with defecation or straining WITHOUT reduce spontaneously then manual reduction is required

Answer 330

Located distal to the dentate line and arise from the inferior hemorrhoid veins Painful Arises from ECTOderm Treatment for symptomatic thrombosed (dark blue purple color) external hemorrhoids is surgical excision Conservative management like sitz baths, topical treatment and antidiarrheal agents are reserved for less symptomatic cases or for patients who present > 72 hours after onset of symptoms

Answer 331

Functional gastrin-secreting tumor that occurs most commonly in the pancreas and/or duodenum Severe GERD, frequent recurrent gastric and duodenal ulcers, recurrent bleeding ulcers, chronic abdominal pain, diarrhea, weight loss Multiple ulcers, ulcers distal to the duodenal bulb, negative testing for H pylori Dx with casting serum gastrin level or positive secretin stimulation test Secretin decreases gastrin secretion from normal G cells but increases gastrin secretion from gastrinoma cells First line drug treatment its PPIs (a somatostatin analog like octreotide can be used if the patient doesnt respond to PPI therapy) Definitive treatment is surgery

Answer 332

Gastrograffin swallow which is esophagography with a water soluble contrast agent Barium swallow is avoided when possible as leakage of barium through a perforation can cause severe inflammation of the mediastinum or pleural cavities Patient likely has a ruptured esophagus (Boerhaave syndrome), crepitus is indicative of subcutaneous emphysema which is a common finding of a transmural tear (ie, rupture) of the esophagus

Answer 333

Etiology: infection of an occluded anal crypt gland Risk factors: anoreceptive intercourse, constipation Pain with defecation, anal pruritis, progression can lead to contrast pain and systemic signs of infection such a s low grade fever PE: indurated, erythematous, painful mass near the anal orifice Treatment: incision and drainage should be performed in order to prevent fistula formation

Answer 334

Pathogenesis: Disruption of normal colonic flora, allowing for proliferation of toxin producing strains of C diff MC occurs with a hx of antibiotic use but can occur in patients with IBD without history of antibiotic use Enzyme immunoassay for glutamate dehydrogenase (GDH) antigen is sensitive but not specific. EIA for GDH should be followed by a more specific test such as EIA for c diff toxins A and B (stool sample). If one of thosr is positive and the other is negative then do a NAAT testing Treatment: oral vancomycin or oral fidaxomycin (RNA polymerase inhibitor that is bactericidal)

Answer 335

Suspected when a child aged younger than 6 months presents with blood-streaked stools and no evidence of anal fissure on exam For breastfed infants --> elimination of dairy from mothers diet Formula-fed infants -->< switched to a hydrolyzed formula Eosinophilic inflammation of the rectosigmoid colon, non-IgE mediated, triggers include cows milk and soy proteins, risk factors include eczema and FH of food allergies

Answer 336

Ammonia is directly related to encephalopathy and is MC treated with lactulose Lactulose may cause a non-anion gap metabolic acidosis as side effect in the setting of diarrhea from large volume losses of bicarbonate Other SE include dehydration, hypernatremia, hypokalemia, abdominal cramps, distension, excessive diarrhea, flatulence, nausea/vomiting

Answer 337

Ultrasound then HIDA (hepatobiliary iminodiacetic acid scan)

Answer 338

Result of intestinal epithelial cell damage following viral gastroenteritis Symptoms due to carbohydrate malabsorption Abdominal pain, bloating and flatulence, watery diarrhea Tx with temporary dietary modification with restriction of dairy products, typically resolve within weeks to months

Answer 339

Congenital malformations of the aortic arch system. Symptoms are caused by tracheal and/or esophageal compression Tracheal compression by a vascular ring will present with biphasic stridor that worsens when crying and feeding and improves with neck extension. Esophageal compression can cause vomiting and dysphagia Diagnosis: CT scan, evaluate for other abnormalities (eg, echo, laryngoscopy) Treatment: surgical division of the ring

Answer 340

Adolescent or middle-aged females with elevated liver enzymes and antinuclear antibodies, esp those with another autoimmune disorder Anti-smooth muscle antibiodies aare he most specific blood tesst and diagnosis caan be confirmed with aa liver biopsy

Answer 341

Caused by the bacterial organism Vibrio cholera and symptoms are the result of a bacterial exotoxin (enterotoxin) that causes impaired intestinal electrolyte absorption Stool microscopy shows no leukocytes or erythrocytes Treatment: aggressive fluid resuscitation and electrolyte replacement +/- antimicrobial therapy

Answer 342

Pathophysiology: impaired relaxation of cricopharyngeal muscle --> increase intraluminal pressure --> herniation of mucosa and submucosa --> pseudodiverticulum (false diverticulum) Located between the 2 parts of the inferior pharyngeal constrictor muscle: thyropharyngeus and cricopharyngeus muscles (Killian triangle) Presentation: progressive dysphagia, halitosis, regurgitation of undigested food, neck mass, aspiration (pneumonia, lung abscess) Initial diagnostic test is barium esophagram Treatment is surgery (diverticulectomy +/- cricopharyngeal myotomy)

Answer 343

Two options: PPI + clarithromycin + amoxicillin (metronidazole in patients allergic to penicillins) PPI + bismuth subsalicyclate + tetracycline + metronidazole 9used in patients with increased likelihood of clarithromycin-resistant disease such as those previously treated with macrolides or living in a region with high clarithromycin resistance rate (>15%))

Answer 344

Congenital absence of both the myenteric and submucosal plexuses in the colon Rectal biopsy (distal to the dilated segment of bowel) is the definitive diagnostic test

Answer 345

stratified squamous cells to simple columnar cells

Answer 346

Gastric ulcer- abdominal pain occurs shortly after eating as food stimulates the release of gastric acid Duodenal ulcers- pain improves with eating because of bicarbonate release into the duodenum and the buffering effects of food

Answer 347

Small intestine (appendix and terminal ileum) Carcinoid syndrome arises from neuroendocrine tumors that have metastasized to the liver. After spreading to the liver carcinoid tumors can metastasize to the lung, bones, skin and other organs. Can also cause valvular abnormalities including tricuspid regurgitation and right sided heart failure

Answer 348

Acute pseudo-obstruction and dilation of the colon in the absence of mechanical obstruction in severely ill patients

Answer 349

Obstruction of hepatic venous outflow MC associated with hypercoagulable states as can occur with OCP use, pregnancy, malignancies and thrombophilias Diagnosis is usually confirmed by Doppler ultrasound of the RUQ

Answer 350

Positive HBsAb and HBcAb

Answer 351

Arching the back while feeding, spitting up, normal height and weight, may also present with emesis following meals, irritability and occasionally a cough Diagnosis is through H&P Although rarely needed to confirm the diagnosis, the gold standard for diagnosing infantile GERD if esophageal pH monitoring Esophageal manometry if motility disorder is suspected EGD used for biopsy if the diagnosis is still unclear Treatment: smaller and more frequent meals, thickening the feeding formula with rice cereal, keep infant upright after feeding, H2 receptor antagonists

Answer 352

Acute cholecystitis- RUQ pain, tenderness on RUQ palpation, radiates to right shoulder, worse after meals, Murphy sign (tenderness to the RUQ that worsens on inspiration)and gallstones in cystic duct. No jaundice (or mild) Ascending cholangitis- bacterial infection of the biliary tree usually occurs from obstruction of common bile duct, ill-appearing, Charcot triad of RUQ pain, jaundice and fever. Reynold pentad is Charcot triad + septic shock and altered mental status) Choledocholithiasis- gallstones in common bile duct. Elevated alk phos and total bilirubin Gallstone ileus- small bowel obstruction resulting from the passage of aa large gallstone into the bowel through a cholecystoduodenal fistula, usually occurs at the ileocecal valve, signs and symptoms of SBO and have pneumobilia or on abdominal radiographs

Answer 353

Oral fluconazole (can do IV if patient cannot tolerate swallowing)

Answer 354

Meslamine (5-aminosalicylate) is first line for induction of remission as well as maintenance of remission If remission is not acheived with meslamine alone, prednisone is typically added

Answer 355

Dietary sodium restriction Diuretic therapy with furosemide + spironolactone is also required in many patients Transjugular intrahepatic portosystemic shunt (TIPS) is an option for some patients with refractory ascites due to hepatic cirrhosis Portal hypertension is the first step in the development of ascites secondary to hepatic cirrhosis. Patients with cirrhosis and a normal portal venous pressure do not develop ascites. Portal HTN leads to splanchnic vasodilation resulting in decreased splanchnic blood flow and systemic vasodilation resulting in low arterial blood pressure To maintain perfusion pressures, the RAAS system is activated, ADH secretion increases and sympathetic NS activity increases. The result is avid sodium and water retention by the kidneys, causing hypervolemic hyponatremia, accumulation of ascites fluid and peripheral edema

Answer 356

CT abdomen and pelvis since crohn flare and acute appendicitis presents similarly

Answer 357

Electromyogram and nerve conduction studies Treatment for mild disease = PT, glucocorticoid injections, cock-up wrist splint Severe = surgical decompression

Answer 358

1. damage to long thoracic nerve (C5-C7) during mastectomy causes medial winging of the scapula via serratus anterior 2. damage to the spinal accessory nerve (CN 11) during radical neck dissection of lymph node metastasis, causing lateral winging of the scapula via trapezius

Answer 359

Chemotherapy and limb-salvage therapy

Answer 360

CT scan is the best study to verify osseous union

Answer 361

Flexing and ADDucting the hip on the affected side to the restrictive barrier with the patient attempting to extend the hip against the physician's equal and opposite counterforce. Performed 3 to 5 times with each contraction lasting 3 to 5 seconds. The hip is flexed to the new barrier after relaxation of each isometric contraction

Answer 362

Chelation with dimercaptosuccinic acid or EDTA

Answer 363

Direct Patient contracts toward position of ease

Answer 364

Medial deviation of the metatarsals with the metatarsals pointing toward the midline relative to the hind foot

Answer 365

CAVE Cavus: exaggerated arch of the midfoot Adductus: forefoot in adduction Varus: hindfoot rotated inward Equinus: ankle/foot fixed in plantar flexion

Answer 366

non-Hodgkin lymphoma

Answer 367

Presents as a clunk sound upon elevation and abduction as well as depression and adduction of the newborn hip joint Risk factors include the 5 F's: femaale, footling (breach), firstborn, flexible (hyperlaxity), family history Diagnosis is confirmed by ultrasound performed from approximately 6 weeks to 4 months of age (<6 weeks then defer imaging until >6 weeks of age) Plain radiographs are used for diagnosis after 4 months of age when the femoral heads and acetabula ossify

Answer 368

Surgical release of the abductor pollicis longus tendon

Answer 369

Woman at age 65 or at an earlier age in postmenopausal women with risk factors for osteoporosis

Answer 370

History of chronic malabsorptive diarrhea (steatorrhea, flatulence, abdominal distension), protein-losing enteropathy, weight loss, migratory non-deforming arthritis, lymphadenopathy and a low-grade fever PAAS + macrophages in the lamina propria containing non-acid-fast gram-positive bacilli (T. whipped)

Answer 371

Weight loss, regular moderate activity, topical or oral NSAIDs Exercises to strengthen the quadriceps muscles can reduce abnormal loading on the joint and protect the articular cartilage from further stress

Answer 372

HLA-DR4 Others are smoking and female gender Anti-cyclic citrullinated peptide antibodies = most specific diagnostic markers for RA Rheumatoid factor = most sensitive marker

Answer 373

Low-dose prednisone

Answer 374

Binds to the RYR1 receptor to inhibit calcium release from the sarcoplasmic reticulum of skeletal muscle

Answer 375

Pagets: increased alk phos, normal calcium, vitamin D, parathyroid, phosphate Osteoporosis Osteomalacia Osteitis fibrosa cystica

Answer 376

Elderly patients that fall laterally onto hip Unable to ambulate, shortened and externally rotated lower extremity on the affected side

Answer 377

Anterior is much less common, affected limb is usually externally rotated and appears longer than the unaffected limb Posterior hip dislocations are usually caused by major traumas such as MVAs, the affected limb is shortened and internally rotated. Sciatic nerve is the only major nerve located posterior to he hip joint- injury in a posterior hip dislocation would result in weakness of knee flexion, ankle plantarflexion, ankle dorsiflexion, toe flexion and toe extension

Answer 378

Proximal femoral epiphysis at the growth plate, resulting in displacement of the femoral hed posteriorly and medially regarding the femoral neck PE: patient will hold affected hip in passive external rotaton thaat is exaggerated with hip flex. Internal rotation at the hip is limited and often painful

Answer 379

AKA avascular necrosis of the femoral head Characterized by atraumatic limp in young children with impaired internal rotation and abduction of the affected hip Typically occurs in younger children with peak incidence at approx 5-6yo Plain radiographs are the best diagnostic tool and will show evidence of femoral head necrosis

Answer 380

Caused by repetitive microtrauma to the carpal bones presents with dorsal wrist pain, decreased grip strength and reduced range of motion

Answer 381

-Physician (if fluent in the patient's preferred language) -Qualified (ie, trained formal interpreters): in-person, teleconferencing, video -Unqualified ad hoc (eg, bilingual family and staff members) -Written

Answer 382

Methotrexate Monitor CBC, can cause myelosuppression

Answer 383

Older ages, chronic joint pain, morning stiffness of < 30 minutes duration, swelling at t he end of the day Radiographic findings include joint space narrowing, subchondral sclerosis and osteophytes Firist like pharmacological traetment is NSAIDs (unless CI like in HTN, peptic ulcer disease, chronic kidney disease) or do not help alleviate pain, ORal duloxetine or intra-articular corticosteroid injection should be considered

Answer 384

Rhomboid shaped crystals with positive birefringence Color when parallel to light = blue Color when perpendicular to light = yellow Predispositions to develop CPPD: hemochromatosis, hyperparathyroidism, hypomagnesemia, hypophosphatasia, familial chondrocalcinosis, familial hypocalciuric hypercalcemia

Answer 385

Decreases osteoclast activity Take on an empty stomach and don't lie down for 30 to 60 minutes after taking to prevent esophageal irritation

Answer 386

Anteromedial knee pain that occurs during lateral movements which are commonly observed in agility sports like soccer, basketball and field hockey

Answer 387

Oral glucocorticoids

Answer 388

Injury causes foot drop and an inverted and plantarflexed foot at rest with lack of eversion and dorsiflexion PED = peroneal everts and dorsiflexes

Answer 389

Dermatomyositis: Anti-Mi-2 Polymyositis: Anti-Jo-1 Multiple sclerosis: Anti-myelin Rheumatoid arthritis: Anti-CCP Type 1 diabetes: Anti-glutamic acid decarboxylase CREST syndrome: Anti-centromere Crohn disease: Anti-Saccharomyces cerevisiae

Answer 390

Talus = internally rotated Foot = inverted, plantarflexed and adducted (supinated)

Answer 391

Electrodiagnostic testing (electromyography and nerve conduction studies)

Answer 392

Cloudy, negatively birefringent, needle-shaped crystals with a WBC between 2,000 to 20,000 cells/mm3

Answer 393

Insert the needle inferior to the lateral edge of the acromion and direct the needle medially and parallel to the acromion

Answer 394

Penicillin If allergic then aztreonam

Answer 395

Bone marrow biopsy +myeloperoxidase +TdT

Answer 396

For children with ITP and no or only mild bleeding, such as this patient with self-limited epistaxis and scattered petechiae, the American Society of Hematology 2019 guidelines recommend observation, irrespective of platelet count. Spontaneous resolution occurs in the majority of pediatric patients with ITP, often within six months, and severe bleeding is rare, even in patients with severe thrombocytopenia (i.e., < 30,000/mm3), because the function of circulating platelets is not impaired in patients with ITP. ITP is a diagnosis of exclusion that is made in patients with isolated thrombocytopenia (i.e., no concurrent anemia or leukocytosis) after other potential causes have been ruled out. It is most commonly diagnosed in children and women of childbearing age. Unlike in children, in whom the indication for pharmacological intervention is based exclusively on clinical presentation, treatment initiation is generally recommended in adults with ITP with a platelet count < 30,000/mm3.

Answer 397

ABO incompatibility usually due to clerical error Intravascular hemolysis Onset within minutes-24 hr of transfusion Fever, chills, hypotension + direct coombs test Hemolysis (increased LDH and indirect bilirubin)

Answer 398

Strep pneumo, H flu, Neisseria meningitides polysaccharide exterior that conceals antigenic epitopes and resists innate phagocytosis. Therefore, these pathogens are largely eliminated via the humoral immune response with antibody-mediatedphagocytosis(opsonization) and antibody-mediated complement activation. Much of this is dependent on splenic macrophages and the generation of splenic opsonizing antibodies. As such, patients with asplenia are at high risk for fulminant infection with encapsulated organisms. These patients should be immunized with pneumococcal, meningococcal, and H influenzae type B vaccines and take oral antibiotics early in the course of any febrile illness.

Answer 399

Do not require specific treatment

Answer 400

This patient, who is exposed to automobile exhaust in an enclosed space, has intermittent headaches, dizziness, nausea, and polycythemia (elevated hematocrit), most likely due to chronic carbon monoxide (CO) poisoning. CO is a byproduct of combusting organic matter (eg, oil, gas, wood). Exposure to toxic levels is more likely in enclosed or poorly ventilated areas. CO tightly binds hemoglobin - forming carboxyhemoglobin - with an affinity much greater than that of oxygen. Nonsmokers have low levels (<3%) of carboxyhemoglobin (due to normal enzymatic reactions). Cigarette smokers may have carboxyhemoglobin levels as high as 10%. Even though patients at this level are generally asymptomatic, small additional amounts of CO exposure may cause toxicity manifesting as headache, malaise, and nausea. Carboxyhemoglobin shifts the oxygen dissociation curve to the left, impairing the ability of heme to unload oxygen at the tissue level. This results in tissue hypoxia. The kidney responds to tissue hypoxia by producing more erythropoietin (EPO). EPO stimulates the bone marrow to differentiate more red blood cells. Chronic CO toxicity is a cause of secondary polycythemia. Pulse oximetry does not differentiate between carboxyhemoglobin and oxyhemoglobin; it cannot be used in the diagnosis of CO poisoning. Diagnosis is made by arterial blood gas with cooximetry. Treat with high-flow 100% oxygen and in severe cases intubation/hyperbaric oxyge

Answer 401

CLL Diagnosed by flow cytometry (showing a clonality of mature B cells)

Answer 402

Chest x-ray If abnormal then chest CT and histology to determine tumor type and guide therapy MC cause of obstruction is malignancy like lung cancer or non-hodgkin lymphoma SVC syndrome is obstruction of the SVC impedes venous return from the head, neck and arms to the heart Signs and symptoms include dyspnea, venous congestion aand swelling of the head, neck and arms

Answer 403

Malignancy is extremely likely in a patient with a persistent (>2 weeks), palpable (>1.5 cm), firm neck mass; a smoking history; and no preceding infection. By far the most common malignancy in an upper cervical node is mucosal head and neck squamous cell carcinoma (SCC). Indeed, the first (and only) apparent manifestation may be a palpable cervical lymph node, representing regional nodal metastasis. Referred otalgia is another common presenting symptom, facilitated by either the glossopharyngeal nerve (CN IX) (innervates both the base of tongue and the external auditory canal [EAC]) or the vagus nerve (CN X; innervates parts of the larynx/hypopharynx and the EAC). Identification of the primary source of head and neck SCC is essential to direct treatment. Thorough examination includes endoscopic visualization using laryngopharyngoscopy as well as neck imaging (CT with contrast) to evaluate the primary site and characterize the cervical nodal disease. Fine-needle aspiration of the lymph node is advised over open biopsy to avoid tumor seeding.