TOPIC LIST FROM TEST 1

Question 1

UNSTABLE VENTRICULAR TACHY

Answer 1

PATHOPHYSIOLOGY:
3 or more PVC’s
Complication of MI or Dilated Cardiomyopathy
Hypokalemia, Hypomagnesemia

PATIENT PRESENTATION:
Stable:
No symptoms of hemodynamic compromise

UNSTABLE:
Symptoms of hypoxia
Chest Pain, Dyspnea, Hypotension, ALofC

DIAGNOSIS:
EKG

TREATMENT:
STABLE → AMIODARONE → LIDOCAINE → PROCAINAMIDE

PULSE → CARDIOVERT

PULSELESS → DEFIBRILLATE

PEARLS:
Sustained >30 secs
Nonsustained <30 secs
VTach → VFib → Cardiac Arrest

Question 2

A Fib

Answer 2

PATHOPHYSIOLOGY:
Irregular rhythm → blood clots
Elderly, Alcohol

PATIENT PRESENTATION:
Palpitations, Syncope, Dyspnea

DIAGNOSIS:
EKG
NO P WAVES

Paroxysmal <7 days
Persistent >7 days

TREATMENT:
-RATE:
CCB or BB
Diltiazem or Verapamil
Metoprolol
Anticoagulation (After assessment with CHAD2VASC)
DOAC:
Dabigatran, Rivaroxaban, Apixaban, Edoxaban
Warfarin (Mechanical Heart Valves)
INR 2.5

-RHYTHM:
<48 hours:
Cardiovert
>48 hours:
Anticoagulation

UNSTABLE → Synchronized Cardiovert

PEARLS:
“Irregularly Irregular”
Risk of stroke/embolism
HTN - MC RISK FACTOR

Question 3

Pericarditis

Answer 3

PATHOPHYSIOLOGY:
Inflammation of the pericardium
From radiation to the chest, viral infection, uremia, SLE, etc.

PATIENT PRESENTATION:
Pleuritic chest pain, worse laying down

DIAGNOSIS:
EKG → ST elevation in V1-6
CXR → Water Bottle Sign

TREATMENT:
NSAIDS
>48hrs → steroids
Colchicine can be added for ACUTE

PEARLS:
“Friction Rub”
Worse laying down
Better leading forward
ST elevation in V1-V6

DRESSLER’S SYNDROME:
- Post MI pericarditis + fever

Question 4

Aortic Dissection

Answer 4

PATHOPHYSIOLOGY:
Tear in the aorta
HTN, Atherosclerosis, Smoking, Infx

PATIENT PRESENTATION:
Tearing chest pain that radiates to the back
BP/Pulse different between arms and legs
Cardiac Tamponade

AORTIC REGURGITATION:
Decrescendo early diastolic blowing murmur

DIAGNOSIS:
CT
US
MRA = GOLD (Angiogram)
CXR → Widened Mediastinum

TREATMENT:
Ascending Aorta → Surgery
Descending Aorta → Beta Blockers
Metoprolol, Esmolol, Labetalol

PEARLS:
SCREENING FOR AAA:
Men 65-75 yo who has ever smoked need an US

Question 5

Aortic Stenosis

Answer 5

PATHOPHYSIOLOGY:
Narrowing of the aorta

PATIENT PRESENTATION:
Harsh systolic “Crescendo Decrescendo” radiates to neck/axillae (Split S2)
Syncope, Dyspnea, Angina

DIAGNOSIS:
ECHO
Helmet Cells/Schistocytes
BNP >550

TREATMENT:
Valve replacement

PEARLS:
Valsalva decreases
Squatting increases

Question 6

PAD

Answer 6

PATHOPHYSIOLOGY:
Blood vessels narrow → restrict blood flow to the extremities

MCC - Atherosclerosis
Smoking

PATIENT PRESENTATION:
Claudication (muscle pain in extremities due to hypoxia)
Ischemia
Weak femoral pulses
Shiny skin, pallor, rubor (red)
Hair loss
Diminished/Absent pulses
Pain with exercise

DIAGNOSIS:
AB Index < 0.9
GOLD = Arteriography
Hypercholesterolemia >240

TREATMENT:
Stop smoking
Exercise
Platelet Inhibitors:
Aspirin, Clopidogrel, Cilostazol
ACE-I & Statins
Revascularization surgery (PREFERRED)

Question 7

Small Bowel Obstruction

Answer 7

PATHOPHYSIOLOGY:
MCC: Adhesions, hernias, cancer, intussusception, post-op ileus
Children: Intussusception

PATIENT PRESENTATION:
Abdominal pain and Distention
Vomiting
High-pitched bowel sounds (at first) then silent bowel

DIAGNOSIS:
X-Ray (KUB)
Intralumen Free Air

TREATMENT:
NG Suction
Surgery
(EXAM ASKED FOR A MEDICATION TX?? CAN’T FIND ONE)

Question 8

Hep B

Answer 8

PATHOPHYSIOLOGY:
Spread by blood to blood: needles, sex, mother-to-child, close contact

PATIENT PRESENTATION:
Jaundice
Flu symptoms

DIAGNOSIS:
Antibody testing → (more below)
anti-HBs (surface antibody) = immunity
HBsAg (surface antigen) = current infection
Core Antibody = there forever
Elevated LFTs

TREATMENT:
Acute: Supportive
Chronic: Alpha-Interferon 2b, Lamivudine, Adefovir

Vaccination: 0, 1, 6 months

PEARLS:
Antigen = virus in body
Antibody = fights the antigen

Question 9

Ascending Cholangitis

Answer 9

PATHOPHYSIOLOGY:
Inflammation of Biliary Tract due to obstruction → biliary stasis + bacterial growth
E.Coli

PATIENT PRESENTATION:
Charcot’s Triad: RUQ Pain, Jaundice, Fever
Reynold Pentad: RUQ, Jaundice, Fever, AMS, SHOCK

DIAGNOSIS:
Ultrasound of Gallbladder
ERCP (Gold Standard)

TREATMENT:
ADMIT → ABX and ERCP to remove stone, insert splint, etc.

ABX: Ceftriaxone+Metronidazole, Amp-Sulbactam, Piperacillin-Tazo
Cholecystectomy

Question 10

Gallstone Pancreatitis

Answer 10

PATHOPHYSIOLOGY:
Pancreatitis due by gallstone

PATIENT PRESENTATION:
Epigastric/RUQ pain radiates to the back
Pain decreases when you lean forward
Diminished Bowel Sounds

Grey Turner: Flank Bruising
Cullen’s Sign: Umbilical Bruising

DIAGNOSIS:
CT Abd/Pelvis (TOC)
X-Ray: Sentinel Loops
Lipase (elevated)

TREATMENT:
IV fluids, pain meds
IV ABX (Cipro-Metro)
ERCP

Question 11

IDIOPATHIC THROMBOCYTOPENIA PURPURA

Answer 11

PATHOPHYSIOLOGY:
Autoimmune reaction to platelets → Splenic platelet destruction
Chronic in adults/Acute in kids
Can present after a viral infection

PATIENT PRESENTATION:
Easy bruising, Petechiae, purpura
Gum bleeding

DIAGNOSIS:
Low Platelets
Primary = <100,000 w/o known cause
Secondary = <100,000 WITH underlying condition

TREATMENT:
>30,000 & NO bleeding = observe
<30,000 = Steroids or IVIG (if C/I)

Persistently <20,000 = Splenectomy
Splenectomy if refractory

PEARLS:
TTP has hemolytic anemia and schistocytes (ITP does not)

Question 12

Multiple Myeloma

Answer 12

PATHOPHYSIOLOGY:
Cancer of plasma cells that build up in the bone marrow

PATIENT PRESENTATION:
Weight loss, Bone pain

DIAGNOSIS:
Serum Protein Electrophoresis
M Protein spike
UA
Bence Jones Protein
Peripheral Blood Smear:
RBC Rouleaux Formation
Hypercalcemia
XRay → Punched out lesions

TREATMENT:
Bone Marrow Transplant (Definitive)
Melphalan (Chemotherapy)
Steroids (reduces effects of chemo)
Thalidomide, Lenalidomide (immunomodulatory agents)
Bortezomib (Proteasome Inhibitors)

PEARLS:
- “CRAB”: Calcium Elevated, Renal Insufficiency, Anemia, Bone Lesions
- Need the strep pneumo vaccine

Question 13

GUILLAIN-BARRE SYNDROME

Answer 13

PATHOPHYSIOLOGY:
Autoimmune demyelinating polyneuropathy
After vaccinations
Post Infection → Campylobacter Jejuni (will have diarrhea)

PATIENT PRESENTATION:
Ascending, SYMMETRICAL paralysis starting at the feet

DIAGNOSIS:
LP → Elevated Protein in CSF (normal WBC and Glucose)

TREATMENT:
Plasma Exchange (remove circulating antibodies)
IVIG (not as effective)

Question 14

HYDATIDIFORM MOLE / “Molar Pregnancy”

Answer 14

PATHOPHYSIOLOGY:
Complication of pregnancy
Unusual growth of trophoblast cells

(These cells become the placenta)

PATIENT PRESENTATION:
N/V, Dark brown/red blood from vagina
Pelvic Pressure

DIAGNOSIS:
Transvaginal Ultrasound
Uterus growing too fast and too large

TREATMENT:
D&C

Question 15

Dysfunctional Uterine Bleeding

Answer 15

Pathophysiology:
- Uternal bleeding with no known cause
Patient Presentation:
- <16 pregnancy, anovulation, breakthrough bleeding, VWB
- 16-40 pregnancy, anovulation, BTB, STI?PID, Endometremosis/Adenomyosis, Endometrial Cancer
- >40 ENDOMETRIAL CANCER UNTIL PROVED OTHERWISE, Pregnancy, Anovulation, OCP
Diagnosis:
- HCG Pregnancy test
- Transvaginal Ultrasound
- Labs FSH, LH, Prolactin, Estadiol, Testosterone, TSH, T3, T4, DHEAS, coach
- Uterine Dilation and Curettage (GOLD)
Treatment:
- Depends on cause
- Progesterone Therapy, OCP
o Provera 14 days
- NSAIDS (Naproxen, Ibprofen)

PEARLS:
- Polymenorrhea: Multiple menses within 21 days
- Hemorrhagia: More blood loss than normal
- Menorrhagia: Prolonged heavy bleeding in regular intervals
- Metrorrhagia: bleeding frequently and irregularly

Question 16

Biceps Tendonitis

Answer 16

Pathophysiology:
- Inflammation of the biceps tendon
Patient Presentation:
- Painful ROM of the shoulder
- Pain in bicep groove and on the anterior portion of the shoulder
- Similar to rotator cuff with resisted supination of the elbow
- Worse with sleeping, repetitive activity, pulling, lifting anf follow through motion of throwing rotation
Diagnosis:
- XR (rule out fracture)
- US, MR
- SPEED TEST: forward elevation with elobow extension/supinated
- YERGASON’S: elbow flexed at 90, wrist sup against resistance
Treatment:
- NSAIDS, PT
PEARLS:
- Popeyes Deformity if it ruptures Surgery

Question 17

Acute Gout

Answer 17

Pathophysiology:
- Uric acid build up in the joint
- Secondary to purine-rich foods alcohol, liver, yeasts
o Medications Diuretics, ACEI, Aspirin, Pyrazinamide
Patient Presentation:
- Red, warm, swollen joint
- MC in big toe (podagra)
- Unilateral
Diagnosis:
- Joint Aspiration
o Negatie Birefringent
- XR: Punched-out erosions
- Increased serum uric acid >8
Treatment:
- Acute: Indomethacin, Naprosyn
o Colchicine (2nd Line)
- Chronic: Allopurinol (inhibits xanthine oxidase decreased uric acid production)
o Probenecid (renal uric acid secretion decreases)
o Prophylax add NSAIDS/Colchicine for 3-6 months
PEARLS:
- Pseudogout Calcium Pyrophosphate Knees MC NSAIDS/Colchicine

Question 18

Costocondritis

Answer 18

Pathophysiology:
- Inflammation of rib cartilage and rib to breastbone
Patient Presentation:
- Pain/tenderness on breastbone worse with deep breath/cough
- >40, high impact sports, labor, RA, AS, Reactive Arthritis
Diagnosis:
- Reproducable with palpation
- Can Xray
Treatment:
- NSAIDS
- Heat/Compression
- Steroid Injections

Question 19

Osteoarthritis

Answer 19

Pathophysiology:
- Overuse/wear and tear of the joint causing joint space degeneration
Patient Presentation:
- Swollen joints MC in knees
- Pain, stiffness, crepitus
- Worse after activity
Diagnosis:
- X-Ray narrowed joint space, osteophytes
Treatment:
- Acetaminophen (1st Line)
- NSAIDS (2nd Line)
- Wt reduction, moderate activity

Question 20

Osteoporosis

Answer 20

Pathophysiology:
- Decreased bone density
Patient Presentation:
- Around/After menopause
- Brittle. Low BMI
Diagnosis:
- DEXA Scan
- T-Score <-2.5
Treatment:
- Bisphosphonates
o Postmen women/men >50 hx hip fx, T-Score </= 2.5
o Teriparatide if very high risk
- Diet
- Supplement Calcium (1,200mg/day)
- Supplement Vitamin D (800-1000) Cholecalciferol
- Exercise w/ weight bearing
- Stop smoking
- Reduce alc
PEARLS:
- DEXA recommendation all women >/= 65 yo
o Menopause – 65 if risk factors: fam hx, low bmi, tob/drug use

Question 21

Osteomyelitis

Answer 21

Pathophysiology:
- Inflection of the bone and bone marrow
- After puncture wound
- MCC: STAPH AUREUS
o Pasteurella multocide (cat/dog bite)
o Salmonella (sickle cell)
Patient Presentation:
- Fever, puncture wounds, swollen, tender, warm and red
- Decreased ROM and refusal to bear weight
Diagnosis:
- XR: demineralization, peisoteal rxn, bone destruction
- MRI
- Definitive DX Blood Cultures o Needle Aspiration/Bone Biopsy
Treatment:
- Depends on Organism IV
- Surgery

Question 22

Atypical Pneumonia “Walking Pneumonia”

Answer 22

Pathophysiology:
- Mycoplasma Pneumo
- Chlamydophila Pneumo
Patient Presentation:
- Sore throat, sneezing, cough, HA, low-grade fever
Diagnosis:
- CXR
Treatment:
- Azithromycin/Clarithromycin
- Criprofloxacin/Levoflaxacin
- Doxy/Tetracycline

Question 23

Pneumocystis Pneumonia

Answer 23

Pathophysiology:
- PMH of HIV
- CD4 <200
Patient Presentation:
- SOB, nonproductive cough, fever
Diagnosis:
- CXR: diffuse interstitial or nilateral perihilar infiltrates
- Brochoalveolar Lavage
- Methenamine Silver Stain
- Very low O2 saturation
Treatment:
- Bactrim and steroids
o If allergeric Pentamidine
- Prophylaxis for high risk Daily Bactrim

Question 24

Bacterial Pneumonia

Answer 24

o Community Acquired Strep Pneumo, H.Influ, Staph Aureus, GAS, Moraxella Catarrhalis
Pathophysiology:
- Alveolia sacs fill with fluid/bacteria
- MCC S.Pneumo (rust-colored sputum)
o S.Aureus (Salmon-Colored Sputum)
o Pseudo (Ventilators, CF)
o Legionella (Air conditioner, Aerosolized water)
o Mycoplasma (Young people living in dorms, walking pneumo)
o Klebsiella (alcohol, current jelly sputum)
o Etc…
Patient Presentation:
- Cough, Fever, +/- Sputum
- Tachycardia, Tachypnea
- + egophony, tactile fremitus, dullness to percussion
Diagnosis:
- CXR: pathy, segmental, lobar consolidations
o Blood cultures x2
Treatment:
- Amoxicillin, Azithromycin, or Doxy
- IF COMORBIDITIES: Augmentin, Cefuroximr+Azithromycin or DOXY
o Levofloxacin
o Moxifloxacin
- Inpatient:
o Ceftriaxone + Doxy or Azithromycin
o Levofloxacin, Moxifloxacin, Cefepime, Pip/Tazo, Vanco, Meropenem

Question 25

Solitary Pulmonary Lesion

Answer 25

Pathophysiology:
- Cancerous nodule in the lungs
Patient Presentation:
- >3cm Nodule
- >3cm Mass
- Smooth, well-defined edges Benign
- Ill-defined, lobular, spiculated Cancer
- Pulm Nodules Coin Lesions
Diagnosis/ Treatment:
- Incidental finding on CXR compared to older CXR
- CT Sus = Biopsy
- <8cm CT every 6-12 months
- >8cm Surgical Resection

Question 26

Asthma

Answer 26

Pathophysiology:
- Reversible inflammation of the airways
Patient Presentation:
- Breathlessness and Wheezing Attacks
- Lack of wheezing = Emergency
Diagnosis/Treatment:
- Peak flow Monitor Exacerbations
o Spirometry with pre-post therapy
- FEV1 Albuterol inhaled will improve
o FEV1-FVC <80%
- Intermittent:
o <2d/w, <2t/m, FEV1 >80%
o Normal FEV1/FVC
§ SABA prn
- Mild Persistent:
o >2d/w NOT DAILY
o Minor limitations
o 3-4x/mnth
o >80%
§ Low ICS daily with prn SABA
- Mod Persistent:
o Daily
o >1 night/wk but not nightly
o >60%
o REV1/FVC reduced 5%
§ Low dose ICS daily and 1-12 prn inhalation as needed
- Sev Persistent:
o Continual Symptoms
o Limited extremely
o 7x/week
o 60%
o FEV1/FVC reduced >5%
§ Combo medium dose ICS-formoterol daily + 1-12 inhalants as needed
§ Or High dose ICS
o Prednisone for acute exacerbation

Question 27

ACUTE KIDNEY INJURY

Answer 27

PATHOPHYSIOLOGY:
Acute decrease in kidney function which causes accumulation of nitrogenous products in the blood

PATIENT PRESENTATION:
Fatigue, confusion
Decreased UO
Swelling of the legs and feet

DIAGNOSIS:
Criteria: (any of the 3)
Increase in serum creatinine >0.3 mg/dL in 48 hours
Increase in serum creatinine of >/= 1.5x baseline within 7 days
Urine Volume <0.5 for 6 hours
Serum Creatine: Creatinine rises 1-1.5 per day or more
BUN: elevated
UA
Post Void Residual Bladder Volume

TREATMENT:
Depending on cause
Treat pulmonary edema and hyperkalemia
Restriction of water

PEARLS:
Uremia: Symptomatic azotemia → nausea, vomiting, lethargy

Prerenal: perfusion issue (hypovolemia, heart failure, sepsis, peripheral vascular resistance loss)
Weak, Decreased UOP, dizzy, orthostatic BP
FENa <1 (normal)
BUN/CR >20:1

Renal: Glomerular, Tubular, Interstitial
Tubular (ATN) → Prerenal failure MCC, Drugs, Ischemia
Muddle Brown Casts
Interstitial (AIN) → Immune mediated (drugs, strep, etc)
WBC cast, eosinophils & hematuria
Renal Biopsy
Glomerular (AGN) → IGA Nephrology (Berger ds), post infx
Hematuria, RBC CAST
WBC casts = pyelonephritis
Hyaline casts = normal
Waxy casts = chronic renal disease
↑ Osmolality FENa > 2% = Acute tubular necrosis

Postrenal: Obstructive (stone, prostate)
LOW/NO Urine OP
Suprapubic pain
FOLEY cath →
Large UOP = Bladder, Urethra, BPH
Little UOP = ureter
US → Tumors or Hydronephrosis

Question 28

ACUTE URINARY RETENTION

Answer 28

PATHOPHYSIOLOGY:
Inability to void with a full bladder
Risk: Males, Prostate, Epidural, etc.

PATIENT PRESENTATION:
Suprapubic discomfort with urgency and inability to urinate
PAINFUL
Palpable bladder
Hypotension, bradycardia, cardiac dysfunction

DIAGNOSIS:
Bladder US → 500mL
Postvoid residual → >500mL

TREATMENT:
Immediate catheterization
24hr, void trial → treat underlying cause

Question 29

Inhalant Toxicity

Answer 29

PATHOPHYSIOLOGY:
- Inhalation of gases (paint, petroleum, toluene, glue, nail polish)

PATIENT PRESENTATION:
Mild: euphoria, slurred speech, confused, hallucination
Watery eyes, impaired vision, liver issues, rhinorrhea, rash, headache, nausea
High: Cardiopulm failure, liver probs, kidney probs, bone marrow suppression

TREATMENT:
Haloperidol (if aggression)