USMLE Flashcards

Question

carotid artery dissection

Answer 1

unilateral headache ipsilateral horner's syndrome ptosis + pupillary constriction

Answer 2

1. Monocular (blind in one eye) 2. Bitemporal hemianopia - Loss of temporal (lateral) visual fields in both eyes - inferior chiasmal compression = pitutary adenoma) - superior chiasmal compression = craniopharyngioma, more in children) 3. Left homonymous hemianopia (Same side visual field loss in both eyes) 4. Right homonymous hemianopia 5. Left inferior homonymous quadrantanopia - Contralateral parietal lobe pathology 6. Left superior homonymous quadrantanopia - Contralateral temporal lobe pathology 7. Right inferior homonymous quadrantanopia - Contralateral parietal lobe pathology 8. Right superior homonymous quadrantanopia - Contralateral temporal lobe pathology 9. Left homonymous hemianopia 10. Right homonymous hemianopia 11. Tunnel vision (Glucoma / retinitis pigmentosa) 12. Scotoma (optic neuropathy) 13. Prosopagnosia

Answer 3

reaction to medication that starts with flu-like symptoms, followed by a painful rash that spreads and blisters Medications: - Allopurinol - Anticonvulsants (phenytoin, phenobarbital, carbamazepine, lamotrigine)

Answer 4

pain syndrome characterised by severe unilateral electric like pain. The vast majority of cases are idiopathic but compression of the trigeminal roots by tumours or vascular problems Tx- carbamazepine

Answer 5

CN III palsy Medial leminscus (contralateral loss of proprioception and vibration) Artery involved: PCA

Answer 6

CN III (down and out) corticospinal tract (contralateral hemiparesis) corticobulbar tract (pseudobulbar palsy - UMN + exaggerated gag reflex + spastic tongue) Artery involved: PCA

Answer 7

Ipsilateral horner's syndrome (miosis ptosis anhydrosis) Ipsilateral facial sensory loss of pain and temperature contralateral sensory loss of pain and temperature CN 9 + 10 (hoarseness + absent gag reflex etc) Nystagmus vertigo PICA

Answer 8

contralateral motor + sensory weakness in arm + face > legs Left side (parietal) - Aphasia - right homonymous hemianopia Right side (parietal) - Hemineglect

Answer 9

contralateral motor + sensory weakness in legs > arm + face Urinary incontinence

Answer 10

A/W HTN Caused by lipohylainosis - Contralateral pure motor hemiparesis of face + arm + leg EQUALLY - Contralateral pure sensory hemiparesis of face + arm + leg EQUALLY - Contralateral ataxic hemiparesis - Dysarthic-clumsy hand syndrome

Answer 11

post lacunar (thalamus) stroke chronic burning pain on the contralateral side

Answer 12

1. Brain to spinal cord (extensor plantars) Hyperreflexia Spastic Positive or upgoing babinski / extensor plantars Clonus 2. Spinal cord to muscles (absent ankle reflex) Hyporeflexia Flaccid Fasciculations Muscle atrophy Weakness Absent or downgoing babinski / flexor plantars 3. Cranial nerve IX to XII Dysarthria Dysphagia Tongue fasciculations Tongue atrophy Absent gag reflex

Answer 13

1. - PLS - MS - Hereditary Spastic Paraplegia (HSP) - Stroke 2. - GBS - MG - Diabetic neuropathy - SMA - PMA 3. - ALS - PBP - Subacute combined degeneration of the cord (vitamin b12 deficiency) - Frederich's ataxia - Taboparesis (syphilis) - Syringomyelia

Answer 14

if occipital lobe - Contralateral homonymous hemianopia with macular sparing if thalamic lobe - contralateral sensory loss

Answer 15

Assess clinically: - resp failure? -> NIPPV (BIPAP) - cardiogenic shock? -> dobutamine / milrinone Improve sx: - IV diuretics (lasix) Investigation: - ECG - ECHO - Troponin

Answer 16

aortic vlave (AR) stroke (carotid artery) horners syndrome (carotid sympathetic plexus) AR (aortic root annulus) MI (coronary artery ostia) tamponade (pericardium) hemothorax (pleural cavity) Intestinal ischemia Renal infarction Lower extremity paralysis (spinal arteries)

Answer 17

Cardiac - Arrhythmogenic - Cardiovascular (valvular HD, CAD, structural HD, PE, tamponade) Non cardiac - Reflex * vasovagal * situational * carotid sinus syndrome - Orthostatic * orthostatic hypotension (> 20 mmHg drop from standing and sitting) * POTS

Answer 18

thick interventricular septum (due to increased deposition of glycogen and fat) small ventricle Tx- IV fluids + BB Spontaneous regression by age 1

Answer 19

underdeveloped left ventricle Cyanosis ensues Tx- 1. prostagalndin 2. palliative surgery 3. cardiac transplant if mx is refractory to the first two

Answer 20

lipodermatosclerosis (upside down champagne sign) Stasis dermatitis Skin ulcer on medial malleolus Telangiectasia / varicose veins Pitting edema Leg pain Tx- leg elevation, exercises, compression stockings If all fail, doppler to be done ABPI to r/o PVD

Answer 21

PVD (6 p's) Punched out ulcer Dorsum of foot etc Doesnt bleed Worse on elevating foot, better with putting it down ABPI to diagnose

Answer 22

suspected in patients who have IE and have: - Persisntent bacteremia - AV blocks - Aortic regurgitation (early diastolic murmur heard best during expiration v4 LSB) Dx- TOE Tx- surgery

Answer 23

best hear on expiration in V4 left sternal border best hear on expiration in V2 right sternal border

Answer 24

regurgitaiton, which causes HF

Answer 25

PASES FAPIL Major: Pan-carditis Arthritis (poly) Sydenham's chorea Erythema marginatum Subcutaneous nodules Minor: Fever Arthralgia PR prolongation Increased inflammatory markers Leukocytosis

Answer 26

Persistent bacteremia Hard to treat pathogens (fungus, MDR) HF Extension of infection (abscess / AV blocks) Large vegetation > 1cm (increasing risk of infective emboli)

Answer 27

congenital cardiovascular anomaly characterized by a narrowing of the aortic lumen, typically located just distal to the origin of the left subclavian artery at the site of the ductus arteriosus (see Image. Coarctation of the Aorta). This condition results in a significant obstruction in blood flow, leading to increased pressure proximal to the constriction and reduced distal perfusion. Coarctation of the aorta presents with a broad spectrum of clinical manifestations, ranging from asymptomatic hypertension to life-threatening heart failure in infancy. Complications including hypertension, left ventricular hypertrophy, aortic dissection, and intracranial hemorrhage In infancy, symptoms of CHF occur a few days after delivery, especially during feeding, due to closure of PDA

Answer 28

Production of catcehcolamines during apneic episodes Obese Systemic HTN Nocturnal awakening Daytime fatigue Loud snoring RHF (due to pulmonary HTN) Tx- CPAP

Answer 29

everything normal grade 1-2 intensity Venous hum- continuous murmur, best heard over infraclavicular area, decreases when supine Still murmur- systolic, best heard over LLSB, increases when supine Pulmonic flow murmur- systolic, best heard in the LUSB, may radiate to axilla

Answer 30

due to: - atherosclerosis (older population) - firomuscular dysplasia (younger population- women) Worsening AKI after initiation of ACEi Recurrent Flash Pulmonary Edema HTN Abdominal bruit

Answer 31

Sudden cardiac death Mutation in RYR2 receptor of myocardium

Answer 32

CPVT HOCM ARVC Brugada syndrome Congenital long QT syndrome

Answer 33

Sudden blunt chest trauma (e.g., baseball hit) Induces ventricular fibrillation without structural damage.

Answer 34

- Easy bruising, poor healing Joint hypermobility- dislocation High arched palate Normal height COLA gene Tall with long extremities Joint hypermobility- dislocation Aortic root abnormalities FBN1 gene Short stature Joint hypermobility- dislocation fibroblast growth factor receptor 3

Answer 35

Epidural = trauma + lucid interval + middle meningeal artery and biconvex on ct Subdural = gradual onset of fluctuating consciousness + alcoholics / elderly / anticoagulated patients who had trauma days back + crescent-shaped on CT + bridging veins Subarachnoid = ruptured aneurysm + worst headache of their life Intracerebral = HTN + charcot bouchard anuerysm + amyloid elderly and AVM (HHT) in children Intraparenchymal = HTN + lenticulostriate arteries Cephalohematoma = neonate + does not cross sutures. Subgaleal = neonate + does cross sutures

Answer 36

high risk for hemorrhagic transformation

Answer 37

1. BP control (140-160 mmHg) 2. Reverse anticoagulation 3. Maintain normal ICP - Mannitol (normal Cr + stable) / hypertonic saline (AKI / CKD + unstable) - Head elevation at 30* - Sedation to reduce metabolic demands - CSF removal (external ventricular drain) - Decompressive craniectomy

Answer 38

When there is an evidence of impeding brain herniation: - large hematoma with midline shift - Raised ICP refractory to medical mx

Answer 39

Causes: - crush injuries - strenuous exercise - seizure - collapse/coma - drugs - co-prescribed statins with macrolides or fibrates Features - AKI due to ATN - CK > 5x ULON - Hypocalcaemia - Hyperphosphatemia - Hyperkalaemia - lactic acidosis (if prolonged unconciousness) - Myoglobinuria: dark or reddish-brown colour Mx- Aggressive IV Fluid Resuscitation

Answer 40

Cardiac: - Congential that causes paradoxical emboli (PFO) - Bacterial endocarditis Vascular: - Non-inflammatory: * arterial dissection - Inflammatory: * Takayasu arteritis / vasculitis * SLE Hematologic: - Sickle cell disease

Answer 41

for patients with ischemic stroke, eligibility for thrombolysis and thrombectomy is evaluated independently, as patients can be eligible for both, one, or neither Refer to word document

Answer 42

Get MRI spine Syringomyelia When a patient has chiari malformation, its a congenital abnormality which causes can part of the cerebellum to herniate through the foramen magnum, resulting in increased pressure in the spinal canal, which can cause the CSF to rupture through the spinal cord, and forms a fluid filled cavity known as syringomyelia

Answer 43

Narrowing of the subclavian artery just before vertebral artery branches (atherosclerosis / vasculitis / rib impingment) Left arm > right arm Sx: - > 15 mmHg difference in BP between both arms - Radio-radial delay - Arm claudication - Arm numbness and parasthesia - Vertebrobasilar artery insufficiency sx (vertigo, disequilibrium, ataxia, other CN palsy sx etc.) Dx: CT/MR angiography Tx: Lifestyle modification HTN, DM, DLP control Stent placement

Answer 44

SIGNS OF IIM - Symmetrical proximal muscle weakness - Elevated CK + aldolase + AST + ALT + myoglobin - Classic EMG findings - Classic muscle biopsy findings (GOLD STANDARD) TYPES OF IIM - Dermatomyositis (anti-Mi-2 abs) * signs of IIM + skin rash * heliotrope rash * gottron papules * shawl rash - Polymyositis * signs of IIM without characteristic features of others (diagnosis of exclusion) - Overlap myositis * signs of IIM + other autoimmune disorders - Antisynthetase syndrome (anti-Jo-1 abs) * Triad: ILD + arthritis + signs of IIM * reynaud's phenomenon + mechanics hand - Inclusion body myositis * signs of IIM + symmetric distal muscle weakness (finger flexors) + dysphagia - Immune-mediated necrotizing myopathy (anti-SRP abs) * Severe form of IIM * A/W statin use - Juvenile IIM * signs of IIM in < 18 y/o

Answer 45

type of conversion disorder prolonged LOC recalls events during LOC normal findings

Answer 46

DCM in all chambers and hypokinesia

Answer 47

Upper / lower abdominal, flank, back, groin pain Hemodynamically stable: - CT abdomen -> Medical optimization and repair Hemodynamically unstable - Abdominal US -> emergency repair

Answer 48

scaly dry skin on legs, chest, and abdomen Defect in FLG gene Worse during winter, better in summer Tx- long baths + keratolytics

Answer 49

Autoantibody formation prodrome eczematous / urticarial like rash that then becomes pruritic tense bullae tx- topical steroids (clobetasol) oral steroid / oral doxycycline

Answer 50

GFD Dapsone PO

Answer 51

flat purple papules with overlying white scribbles (wickham stria)

Answer 52

pearly nodule with telangiectasia Diagnosis: Biopsy (shave, punch , excisional) Tx Excision with 4 mm margin

Answer 53

hyperpigmented lichenified plaque

Answer 54

Milia Miliaria rubra (heat rash) Erythema toxicum neonatorum Neonatal pustular melanosis Neonatal cephalic pustilosis (acne)

Answer 55

causes - low SVR (vasodilation) - High cardiac output (increased VR + increased HR) - High PCWP (due to impeding high-output HF, causing back up of fluid in lungs)

Answer 56

rapid onset of sx + 1 of the following: - Skin involvement + hypotension OR resp distress - 2 or more system involvment: * skin * cardio * resp * GI - Hypotension right after being exposed to the allergen

Answer 57

menstruating women who use tampons Anti-staphylococcal abx

Answer 58

- Rocker bottom feet - Clenched overlapping fingers - low set ears + micrognathia + prominent occipit - Heart defects - kidney defects - weak hip abduction

Answer 59

New Moms Hate Labour Nifedipine (2) Methyldopa (4) Hydralazine (3) Labetalol (1)

Answer 60

hypothyroidism-associated DLP needs to be treated with levothyroxine, because statins can cause statin myopathy

Answer 61

Surgery or childbirth or trauma High grade fever Tachycardia Hypertension A fib Lid lag Sweating delerium seizure Diarrhea Tx: - BB (Propanolol, esmolol if CHF, NDHP-CCB if asthma / reynaud's, or any other contraindication) (reduce adrenergic manifestations) - PTU (reduce hormone synthesis) - iodine solution (SSKI) (reduce thyroid hormone release) - Hydrocortisone (reduce conversion of t4 -> t3)

Answer 62

1. Anesthesia / succinylcholine / hyperthermia / hyperkalemia / hypercalcemia / high CK / rigidity / myoglobinuria / dantrolene / 2. antipsychotics (haloperidol / resperidone) or antiemetics (metoclopramide) / hyperthermia / hyperkalemia / hypocalcemia / lead-pipe rigidity / high CK / myoglobinuria / dantrolene + bromocriptine (dopamine agonist) 3. SSRI / SNRI / TCA / opioid / hyperthermia / hyperreflexia / rigidity / altered mental status / clonus / mydriasis / high CK / symptoms resolve within 24 hours of cessation of serotonergic drugs / benzodiazipine for agitation / cyprohepatidine

Answer 63

during first trimester bhcg stimulates tsh receptros to release t4 bhcg suppreses tsh

Answer 64

occurs in severe non-thyroid illness Total + free t3 reduced reversed t3 elevated TSH + T4 normal (can be reduced if prolonged sickness)

Answer 65

causes neonatal thyrotoxicosis due to maternal passage of TSH stimulating abs Storm sx + goiter + low birth weight + microcephaly Methemazole + BB, for a few months, then D/C as it self resolves

Answer 66

high TSH / normal T3 + T4 low TSH / normal T3 + T4

Answer 67

get MRI spine to r/o syringomyelia its a fluid filled cavity in the spinal cord that occurs when a patient has increase in the CSF pressure Chairi malformation does that as it is a congenital defect that causes part of the cerebellum to herniate through the foramen magnum

Answer 68

increase it to meet demands since bhcg reduced tsh reduce dose of levo

Answer 69

in return it increases total T4 OCP HRT Pregnancy

Answer 70

if patietns are on biotin, they need to stop it for 3 - 7 days before blood withdrawel, as it can mimic hyperthyroidism For patients who are hypothyroid, it can make it seem like the dose of levo is OVER correcting them Also omeprazole and calcium salts reduce absorption of levo

Answer 71

Primary - Due to PT adenoma (most common) -> hyperplasia -> carcinoma - PTH is high, calcium is high - Surgery - medical mx- bisphosphonates (if osteoporosis) / calcimimetics Secondary - Due to hypocalcemia, in return causes PTH hyperplasia * CKD * vitamin D deficiency * malabsorption: celiac's + IBD + bariatric surgery * Phenytoin + Rifampin + Denosumab - PTH is high, calcium is normal / low, phosphate is low (unless in CKD, it will be high) - treat underlying cause Tertiary - refractory PTH release in response to untreated sHPT - PTH is high, calcium is V. high - tx is like pHPT

Answer 72

Autosomal dominant Inherited from the mother (GNAS gene imprinting) short stature intellectual disability Persistent hypocalcemia despite ↑ PTH levels

Answer 73

prolactinoma dopamine antagonst (bromocriptine)

Answer 74

prolactin (released from pituatary)

Answer 75

causes: - Pituitary adenoma (had headache and bitemporal hemianopsia) - Hypothalamic-pituitary stalk damage (less dopamine to inhibit prolactin) - Primary hypothyroidism (causes increased TRH which stimulates prolactin release) - Dopamine antagonists (antipsychotics) sx: inhibits GnRH -> less LH and FSH -> reduced estrogen, leading to: osteoporosis vaginal atrophy and dryness Galactorrhea low libido infertility due to anovulation amenorrhea dx: ↑ Serum prolactin > 20 ng/mL in men > 25 ng/mL in women tx: dopamine agonists (Cabergoline / bromocriptine)

Answer 76

Acromegaly: Excess GH + IGF-1 in adults Large hands, feet, coarse facial features, macroglossia, enlarged organs Dx: IGF-1 levels OGTT and check GH levels 2 hrs after, if not suppressed, it goes with acromegaly Tx Transsphenoidal adenomectomy Somatostatin analogs (octreotide) Gigantism: Excess GH + IGF-1 in kids (before epiphyseal plate closure) - IGF-1 level: typically ↓; may be normal - Confirmatory testing: GH stimulation test - Procedure *Record baseline serum GH level. Administer stimulating agent (e.g., macimorelin). * Interpretation: ↓ GH level supports a GH deficiency

Answer 77

SIADH (high urine osmolality) Hypovelmia (includes diuretic use) Adrenal insufficiency Hypothyroidism Polydipsia Hyperglycemia

Answer 78

- Increased pituitary ADH secretion * stroke * trauma * infection - Paraneoplastic ectopic ADH production * small cell lung carcinoma - Nephrogenic SIADH * enhanced ADH receptor activation in the kidneys as a result of mutation of vasopressin-2 receptor gene sx: Euvolemic Hypoosmolarity Hyponatremia High urine sodium High urine osmolality tx: hypertonic saline

Answer 79

AVP-D: Causes - Hereditary - Brain tumor - Neurosurgery - Hypopituitarism AVP-R: - Demeclocycline - Lithium - Hypokalemia - Hypercalcemia - ADPKD NOCTURIA (daytime sleepiness) Polyuria Polydipsia Dx: 24 hour urine collection (has to be > 3L) Urine osmolality <300? -> plasma sodium < 145? -> water deprivation test to distinguish between AVP and PP (if Na > 145 and plasma osmolality > 295, then no need to do WDT as AVP is confirmed) water deprivation test interpretation: - Urine osmolality increases to > 800 mOsm/kg: Primary polydipsia is confirmed. - Urine osmolality remains ≤ 800 mOsm/kg: AVP disorders are likely - to distinguish between AVP-D & AVP-R, administer desmopressin. Interpretation: - Initial urine osmolality 300–800 mOsm/kg and: * Significant increase (≥ 10%) after desmopressin: partial AVP-D * No or minimal increase (< 10%) after desmopressin: primary polydipsia - Initial urine osmolality < 300 mOsm/kg and: * Significant increase (> 50%) after desmopressin: complete AVP-D * No or moderate increase (< 50%) after desmopressin: AVP-R Alternative: Plasma copeptin (reflects circulating AVP) Measure random plasma copeptin levels. ≥ 21.4 pmol/L: AVP-R is confirmed. < 21.4 pmol/L: hypertonic saline infusion test. * > 4.9 pmol/L: primary polydipsia * ≤ 4.9 pmol/L: AVP-D Tx: AVP-D: desmopressin AVP-R: Thiazide diuertics + NSAIDs + Amiloride (IF AVP-R caused by lithium and patient HAS TO continue on it)

Answer 80

Causes: - nonsecretory pituitary macroadenoma (> 10 mm) - pituitary apoplexy - Sheehan syndrome - Post irradiation GH -> delayed growth Prolactin -> failure of lactation LH & FSH -> hypogonadotrophic hypogonadism TSH -> secondary hypothyroisidm ACTH -> secondary adrenal insufficiency ADH (panhypopituitarism) -> AVP-D

Answer 81

complication of hypothyroidism IV levothyroxine IV liothyronine IV hydrocortisone

Answer 82

O-SHIT-ME Oxygen Salbutamol Hydrocortisone Ipratropium Theophylline Magnesium sulphate Escalate to ICU

Answer 83

21 hydroxylase deficiency (more androgens, less mineralo + glucocorticoid) - Hyponatremia + hypotension + hyperkalemia + hypoglycemia + metabolic acidosis - elevated 17-hydrxyprogesterone - Classical * salt-wasting type Early onset (neonatal period) signs of shock hypoglycemia females present with ambigous genitalia * simple virilizing type early onset No signs of shock Males have precoscious puberty Females present with ambigous genitalia - Non-classical late onset (late childhood - adulthood) No signs of shock precocious puberty females have irreguler menses Hirsuitism Acne tx: * mineralocorticoid (Fludicoritisone) * glucocorticoid (hydrocortisone / prednisone / dexamethasone) 17 hydroxylase deficiency (more mineralo + glucocorticoid, less androgens) hypernatremia + hypertension + hypokalemia + metabolic alkalosis + hyperglycemia males have female external genitalia females have delayed puberty tx: spironolactone + estrogen RT for females 11 hydroxylase deficiency (more mineralo + glucocorticoid, more androgens) - hypernatremia + hypertension + hypokalemia + metabolic alkalosis + hyperglycemia - males have normal genitalia, but precocious puberty - Females have external male genitalia

Answer 84

Systolic blood pressure > 140 mm Hg or diastolic > 90 mm Hg AND resistant to three-drug therapy Hypernatremia Hypokalemia metabolic alkalosis dx- screening test: > ARR > PAC < PRA confirmatory test - Oral sodium loading test Adrenal venous sampling - shows if its uni or bilateral Unilateral- laparoscopic unilateral adrenalectomy BL- spironolactone

Answer 85

Exogenous Endogenous - primary (ACTH-independent) * Adrenal adenoma - secondary (ACTH dependent) * Cushing's disease (ACTH secreting pituatary adenoma) * Ectopic ACTH production Sx: hirsuitism thin skin proximal muscle weakness purple abdominal striae central obesity buffulo hump moon facies hyperglycemia and insulin resistence depression decreased libido irregular menses dx (2 out of the 3): - 24-hr urine free cortisol collection - low dose dexamethasone suppression test - late night salivary cortisol Once all positive, check serum ACTH levels to differentiate between primary and secondary cushings syndrome If ACTH is high, it means its secondary CS. Do CRH stimulation test OR desmopressin test to differentiate between cushing's disease (ACTH high after CRH or desmopressin) and ectopic ACTH production (ACTH normal/low after CRH or desmopressin) tx: Surgical: - Primary hypercortisolism: unilateral or bilateral laparoscopic or open adrenalectomy for adrenocortical tumors - Cushing disease: transsphenoidal hypophysectomy - Ectopic ACTH production: tumor resection Medical: - Primary hypercortisolism: * Mifepristone * Ketoconazole - secondary hypercortisolism: * cabergoline * pasireotide

Answer 86

Primary: - Autoimmune adrenalitis - Infectious adrenalitis (TB | CMV in AIDS | histoplasmosis) - Adrenal hemorrhage (DIC, neisseria meningiditis -> sepsis -> waterhouse fridrechson syndrome) - Adrenalectomy - Vitamin B5 deficiency - 21β-hydroxylase deficiency - drug-induced adrenal insufficiency (KPFR- ketoconazole | phenytoin | fluconazole | rifampin) - infilteration (malignancy | amyloidosis | haemochromatosis) Secondary: (conditions that decrease ACTH production) - Sudden discontinuation of prolonged glucocorticoid use - Hypopituitarism * nonsecretory pituitary macroadenoma (> 10 mm) * pituitary apoplexy * Sheehan syndrome Tertiary: (conditions that decrease CRH production) - Sudden discontinuation of prolonged glucocorticoid use Sx: Primary: features of hypoaldosteronism + hypocortisolism + hypoandrogenism + hyperpigmentation on non-sunlight exposed areas secondary + tertiary: features of hypocortisolism + hypoandrogenism Dx: - Make sure patient is not on any steroids before test * 24 hrs after the last dose of hydrocortisone * 48-72 hrs after the last dose of prednisolone * 1 week after the last dose of dexamethasone - Morning cortisol * low in all (pAI + sAI + tAI) - Morning ACTH * high in pAI * low in sAI + tAI) - ACTH stimulation test (cosyntropin test) * in pAI, no increase in cortisol * in sAI, increase in cortisol * in tAI, little to no increase in cortisol - < PAC / > PRA - < DHEA-S Tx: pAI- * mineralocorticoid (Fludicoritisone) * glucocorticoid (hydrocortisone / prednisone / dexamethasone) * androgens (over-the-counter DHEA- as needed)

Answer 87

hyperkalemia metabolic acidosis hyponatremia hypotension hypoglycemia TX: Glucocorticoid mineralocorticoid IV fluids D50% IV

Answer 88

osmotic diuresis to urea or glucosuria

Answer 89

dilute urine

Answer 90

endocrinopathies low GH + FSH + LH + TSH + ADH + ACTH bitemporal hemianopsia Rathe cleft cyst though has no calcifications

Answer 91

radio iodine ablation

Answer 92

adrenal medullary metanephrine secreting tumour A/W: MEN 2A / 2B + VHL + NF-1 Sx: - Polycythemia (if secretes EPO) - Episodic HTN (triggered by palpation fn the tumor area + foods rich in tyramine like wine and cheese + surgery + anesthetic agents) - Diaphoresis - Throbbing headache - Palpitations - Weight loss - Hyperglycemia - MEN 2A: Medullary thyroid cancer and parathyroid hyperplasia - MEN 2B: Medullary thyroid cancer, oral/intestinal neuromas, and marfanoid habitus - NF1: Cutaneous neurofibromas, cafe-au-lait spots, and Lisch nodules - VHL: Renal cell carcinoma, hemangioblastoma Dx: - Increased serum metanephrine (supine) - 24-hr urinary metanephrine level - CT abdomen and pelvis with contrast Tx: - Adrenalectomy (no-touch technique) - Preoperative management (7-14 days before surgery) * BP target 90>x>130/80 mmHg Start with alpha blockers: - Phenoxybenzamine - doxazosin * Heart rate target 60–80/min while seated Add a beta blocker after effective alpha blockade - Metoprolol - propranolol * Consider the following for additional blood pressure control: - CCB - Metyrosine * Ensure high sodium and fluid intake to prevent postoperative hypotension - Post-operative Look out for primary adrenal insufficiency and treat accordingly

Answer 93

Due to: Alcoholics Major depressive disorder Anorexia Obesity Pregnancy Poorly managed DM How to differentiate between that and true Cushing's syndrome? - Dexa-CRH test + desmopressin stimulation test Dexa-CRH test in psuedo-cushings and normal people would be little to no increase in ACTH + cortisol, since the pituatary closed off because of dexa, so no more CRH can stimulate it. where as in cushing's disease, there is no negative feedback, so ACTH is always producing meaning dexa couldnt stop it, and so CRH can stimulate it and further drive ACTH + cortisol UP

Answer 94

Cause: - excessive intake of calcium carbonate supplement for osteoporosis - excessive intake of antacids - High dose thiazide diuretics / ACEi / ARBs / NSAIDS Sx: - Boans, stones, groans, psychiatric understones - Polydipsia + polyuria Dx: - Hypercalcemia - Hypophosphatemia - Hypomagnesemia - Metabolic alkalosis - AKI - Low PTH Tx: - Stop agent - Rehydration - Loop diuretics

Answer 95

1-2 cm nodule with no lymph node invasion -> partial thyroidectomy > 2 cm nodule and / or lymph node involvement -> total thyroidectomy Post surgery, to reduce recurrence: - Radioiodine ablation - Adequate doses of thyroid replacement to suppress TSH (stimulates growth of metastatic cells)

Answer 96

autosomal recessive gene mutation (phenylalanine hydroxylase) that converts phenylalanine to tyrosine Sx: - Microcephaly - Developmental delay - Intellectual disability - Seizures - Hypopigmentation - Bad body odor - Eczema Dx: - High phenylalanine levels (serum amino acid analysis) Tx: - Phenylalanine restricted diet (protein rich) - Tyrosine supplements

Answer 97

IIM Hypothyroidism (+ myalgia + absent delayed reflexes) Cushings syndrome Corticosteroid Statin- (especially in combination with omeprazole or macrolide or fibrates)

Answer 98

malignancy (PTHrP or increased 1,25-dihydroxyvitamin D) Immobilization Vitamin D toxicity Vitamin A toxicity Milk-alkali syndrome

Answer 99

> 2 from the following criteria: - Fever > 38 *C or < 36*C - HR > 90 - RR > 20 or PaCO2 < 32 - WBC > 12,000 or < 4,000 > 2 SIRS criteria + suspected or confirmed underlying infection Sepsis + at least 1 organ damage

Answer 100

Bisphosphonates (alderonate) - Avoid in renal impairment Denosumab - Can cause hypocalcemia, skin reactions, and infections Raloxifene - Recommended for patients with increased risk of breast cancer - Increases risk of DVT

Answer 101

Hypercalecmia due to release of PTHrP by malignant cells Prevalant in: Squamous cell carcinoma (lung) Renal and bladder Ovarian and breast

Answer 102

- PTHrP (HHM) - Bone metastasis / osteolytic malignancies (breast + MM) - Increased 1,25-dihydroxyvitamin D (hodgkin's lymphoma)

Answer 103

Hypoparathyroidism (low PTH) * Post-operative neck surgery * Autoimmune * Non-autoimmune destruction but infilterative (haemochromatosis | wilson) * DiGeorge syndrome * TSS Secondary hyperparathyoidism TLS Rhabdo Blood transfusion EDTA (used in lead poisoning) Hyperreflexia Seizures Pararsthesias Chvostek's sign (facial twitch with tapping) Trousseau's sign (carpal spasm with BP cuff) Bones, stones, groans, psychaitric undertones polyuria pancreaitits PUD

Answer 104

Occurs after initiating cytotoxic treatment in patients with hematologic malignancies Hypocalcemia Hyperkalemia Hyperphosphatemia Hyperuricemia AKI (PUKE Calcium) Phosphortus | uric acid |potasssium elevated Tx: Aggressive fluid IV mx Fix electrolyte imbalances Treat hyperuricemia: - Low risk prophylaxis- allopurinol - intermediate - high risk prophylaxis / tx of established TLS: Rasburicase

Answer 105

early secondary sexual characteristics development before the age of 8 years in girls and 9 years in boys: - Bone age radiograph A) advanced bone age (≥2 years ahead of the patient’s chronological age) - high LH -> central precocious puberty / gonadotropin-dependent precocious puberty (early activation of HPG axis: idiopathic | CNS tumor (MRI brain to be done)) - Low LH -> GnRH stimulation test -> * Low LH -> peripheral precocious puberty / gonadotropin-independent precocious puberty (gonadal or adrenal release of excess sex hormones: non-classical CAH | adrenal / gonadal tumors | Primary hypothyroidism) * High LH -> CPP B) normal bone age (early activation of adrenal androgens) - isolated breast development -> premature thelarche - isolated uterine bleeding -> premature menarche - isolated pubic hair development -> premature pubarche - pubic hair, acne, and/or adult-type body odor -> premature adrenarche (hepatoblastoma ONLY in males) CPP tx: GnRH agonist (e.g., leuprolide, goserelin) PPP tx: Tx of underlying cause

Answer 106

women > 40 y/o pelvic mass, ascites, or abdominal pain thyrotoxicosis No thyroid enlargment

Answer 107

1. serum creatinine (SC) 2. Urine output (UO) Stage 1 - SCr: * 1.5 - 1.9 x baseline with 7 days * Increase of 0.3 mg/dL | 26.5 μmol/L within 48 hrs - UO: * < 0.5 ml/kg/hr over 6 - 12 hours Stage 2 - SCr: * 2 - 2.9 x baseline - UO: * < 0.5 ml/kg/hr over ≥ 12 hours Stage 3 - SCr: * ≥ 3 x baseline * Increase to ≥ 4 mg/dL | ≥ 354 μmol/L - UO: * < 0.3 ml/kg/hr over ≥ 24 hours * ≥ 12 hours anuric - Need for RRT (dialysis) - In patients < 18 years of age: decrease in eGFR to < 35 mL/min/1.73 m2

Answer 108

Intensive glycemic control - Target HbA1C <7 - SGLT2i Intensive BP control - Target BP < 130/80 - ACEi Lipid loweing Smoking cessation

Answer 109

Drugs: quinolones, quinine, beta blockers Sepsis/critical illness Severe hepatic failure Anorexia nervosa (depleted glycogen stores) Alcohol (usually with prolonged starvation) Adrenal insufficiency Insulinoma Non-insulinoma pancreatogenous hypoglycemia syndrome Surreptitious insulin or sulfonylurea use

Answer 110

- MEN 1: Pituatary adenoma (prolactinoma) Parathyroid hyperplasia Pancreatic tumors (gastrinoma) - MEN 2A: Parathyroid hyperplasia Medullary thyroid cancer Phaechromocytoma - MEN 2B: Oral / intestinal neuromas Marfanoid habitus Medullary thyroid cancer Phaechromocytoma

Answer 111

Pro-thrombotic state Happens mostly with other AI diseases (SLE, RA) Miscarriages DVT PVD Thrombosis in organs Livedo reticularis Dx: Symptomatic + the presence of ≥ 1 type of aPL antibody supports the diagnosis: - Lupus anticoagulant - Anticardiolipin (IgG and IgM) - Anti-β2-glycoprotein antibodies (IgG and IgM) Asymptomatic + +ve aPL abs -> no diagnosis HOWEVER Further supportive factors to support the diagnosis: Positive antibodies against: Annexin Protein C Protein S ANA abs Anti-dsDNA antibodies *Patients with APS can test false positive for syphilis (positive VDRL or RPR) because the antigen used in syphilis tests is cardiolipin.* Tx: Non-pregnant patients: - High risk undiagnosed APS (asymptomatic + +ve aPL) -> Aspirin - Diagnosed APS -> warfarin Pregnant patients: - High risk undiagnosed APS (asymptomatic + +ve aPL) -> Aspirin - Diagnosed APS -> Aspirin + LMWH / UFH (theraputic in thrombosis, prophylactic if no thrombosis)

Answer 112

Cervical insufficiency APS Celiac PCOS Hypothyroidism DM Hyperprolactinemia

Answer 113

can transform to overt hypothyroidism if not treated with regards to specific indications 1. TSH >10 mIU/L - Treat with levothyroxine (regardless of symptoms or age) 2. TSH 4.5–10 mIU/L Treat if: Age <65 and symptomatic (fatigue, depression, weight gain) +ve anti-TPO abs Pregnant or trying to conceive Presence of goiter Lipid abnormalities Cardiovascular risk factors

Answer 114

> 1 cm nodule with high risk sonographic features (internal vascularity + microcalcifications + irregular margins) > 2 cm nodule with no sonographic features

Answer 115

vitamin D deficiency (rickets) Causes: Radial/ulnar bowing Skull bones that depress with pressure Delayed fontanel closure Widened wrists Lower extremity bowing (genu varum)

Answer 116

1. Autoimmune Painless Hyperthyroid -> hypothyroid -> euthyroid Anti-TPO +ve Low radioactive iodine uptake There is a thyrotoxic phase Recovers in a year's time Propanolol if thyrotoxic sx / Levothyroxine if hypothyroid sx 2. Autoimmune (< 12 months postpartum) Painless Hyperthyroid -> hypothyroid -> euthyroid Anti-TPO +ve Low radioactive iodine uptake There is a thyrotoxic phase Recovers in a year's time Propanolol if thyrotoxic sx / Levothyroxine if hypothyroid sx 3. Post-viral inflammatory Painful Hyperthyroid -> hypothyroid -> euthyroid No antibodies Low radioactive iodine uptake There is a thyrotoxic phase Recovers in weeks to months Propanolol if thyrotoxic sx / Levothyroxine if hypothyroid sx

Answer 117

- BB (Propanolol, esmolol if CHF, NDHP-CCB if asthma / reynaud's, or any other contraindication) - BB (Propanolol, esmolol if CHF, NDHP-CCB if asthma / reynaud's, or any other contraindication) (reduce adrenergic manifestations) - PTU / methimazole (reduce hormone synthesis) - iodine solution (SSKI) (reduce thyroid hormone release) - Hydrocortisone (reduce conversion of t4 -> t3) - Radioiodine ablation

Answer 118

Celiac causes ADEK vitamins deficiency Vitamin D deficiency causes PTH to be released which causes increased calcium release from bone + increased renal reabsorption, and suppresses renal phosphate reabsorption -> normal - low calcium | low phosphate | high PTH

Answer 119

Thiamine deficiency High-output cardiac failure (due to systemic vasodilation) Dilated cardiomyopathy

Answer 120

central cyanosis absent tricuspid valve PS enlarged RA (p pulmonale) hypoplastic RV ASD VSD (holosystolic murmur) ECG: LAD CXR: decreased pulmonary vascular markings

Answer 121

Pulmonary vein delivers oxygenated blood to RA instead of LA -> cyanosis RA + RV enlargement ECG: RAD CXR: Increased pulmonary vascular markings + cardiomegaly

Answer 122

single arterial trunk arises from the heart and supplies the systemic + pulmonary circulations, instead of having separate aorta and pulmonary arteries -> cyanosis Systolic ejection murmur CXR: Increased pulmonary vascular markings + cardiomegaly

Answer 123

Methimazole / PTU Trimethoprim-sulfamethoxazole Clozapine Sulfasalazine Following sx occur within 3 months of initiating the drug: Fever Sore throat Oral ulcerations Tx: D/C culprit drug Abx if WBC < 1000

Answer 124

SCAD Vasospasm CO poisoning Takotsubo cardiomyopathy Coronary microvascular dysfunction (Impaired vasodilation and/or increased vasoconstriction of small coronary vessels)

Answer 125

one time abdominal US for ages 65-75 who have: 1. smoking history 2. Family hx of ruptured AAA 3. male sex 4. HTN

Answer 126

CVP - PCWP - CO - SVR - SvO2 Cardiogenic (cold peripheries): ↑ ↑ ↓ ↑ ↓ Hypovolemic (cold peripheries): ↓ ↓ ↓ ↑ ↓ Obstructive (cold peripheries): PE / TP: ↑ ↓/↔ ↓ ↑ ↓ CT: ↑ ↑ ↓ ↑ ↓ Distributive (warm peripheries): Sepsis / anaphylaxis: ↓ ↓ ↑/↓ ↓ ↓/↑ Neurogenic: ↓ ↓ ↓ ↓ ↓

Answer 127

it is a classic clinical sign of increased intracranial pressure (ICP) and impending brain herniation Presents with: - Hypertension - Bradycardia - Irregular respirations

Answer 128

Hyponatremia

Answer 129

can worsen cognitive function, paradoxical agitation, increase falls

Answer 130

grade 1-2 intensity early or midsystolic decreases during standing / valsalva maneuvar asymptomatic patient

Answer 131

Normal aging Pseudo-dementia Alzeheimers Vascular Lewy body Frontotemporal NPH Parkinsons Wernickie-korsakoff syndrome Wilson's disease Creutzfeldt-Jakob disease Huntington's disease Neurosyphilis Progressive multifocal leukoencephalopathy (e.g., in AIDS)

Answer 132

Clinical features: Cognitive impairement: - short term memory loss - temporal and spatial disorientation - language impairment - Impairment of executive functions and judgment Non-cognitive - apathy - agitation - depression Dx: DSM-5 for dementia criteria MRI brain: cerebral atrophy CSF: ↑ Phosphorylated-tau protein ↓ Aβ proteins Tx: AChEi (causes bradycardia, syncope, heart block): revastagmine | donepizil | galantamine NMDA receptor antagonist: memantine

Answer 133

Depressed mood + dementia Patients are able to recall onset of symptoms Patient gives short answers, e.g., “I don't know"

Answer 134

causes: stroke with prolonged brain ischemia (LVO and / or lacunar infarcts) Comorbidities (DM DLP HTN AF) features of dementia + stroke sx depending on site Tx: treat underlying risk factors

Answer 135

Early changes in personality and behavior → inability to observe social etiquette Dx: DSM-5 for dementia criteria MRI brain: frontotemporal brain atrophy Pick bodies Tx: Supportive therapy

Answer 136

Parkinsonionsm (TRAP) Visual hallucinations Dementia Dx: MRI brain: atrophy of substantia innominata and mesopontine grey matter Lewy bodies: alpha-synuclein-positive Tx: Parkinsonian symptoms: Pharmacological treatment of parkinons Dementia symptoms: revastagmine | donepizil | galantamine | memantine Psychotic symptoms: In severe cases (e.g., functionally impairing psychosis), low-potency second-generation antipsychotic (e.g. quetiapine) can be administered. Can cause: Akinetic crisis- Characterized by inability to move, incomprehensible speech, and possibly hyperthermia Can also be caused by Abrupt withdrawal or reduction of dopaminergic meds in Parkinson’s patients

Answer 137

Urinary incontinence Gait abnormalities (frequent falls, broad-based gait with short shuffling steps: gait apraxia) Dementia No signs of ICP MRI brain: Ventriculomegaly without sulcal enlargement Tx: VP shunt

Answer 138

Depletion of dopaminergic neurons in the substantia nigra Preclinical stage: - Mood disorders - Anosmia - Sleep disturbances (Excessive daytime sleepiness) - Constipation TRAP (unilateral onset): - Tremor (resting pill-rolling) - Rigidity (cogwheel) - Akinesia / bradykinesia - Postural instability (short shuffling steps) Tx: - Levodopa + carbidopa (Honeymoon period (end of dose akinesia)+ dyskinesia + avoid in glucoma as they increase IOP) - Anticholinergics: benztropine (urinary retention + avoid in glucoma as they increase IOP) - Nonergot dopamine receptor agonists: Ropinirole + Pramipexole (in younger patients who have levodopa induced dyskinesia) - NMDA antagonist: amantadine / memantine (akinetic crisis + Levodopa-induced dyskinesia) - COMT inhibitor: entacapone (used in combination with levodopa/carbidopa to improve end of dose akinesia) - MAO-B inhibitors: Selegiline (improve end of dose akinesia)

Answer 139

Thiamine deficiency Chronic alcoholics - malabsorption - anorexia nervosa MRI brain: periventricular hemorrhage and/or atrophy of mammillary bodies Wernickie: AOC Ataxia (gait) - Occulomotor dysfunction (Gaze-induced horizontal/vertical nystagmus + Diplopia) - Confusion Tx: IV thiamine (FOLLOWED BY) glucose (NEVER THE OTHER WAY AROUND AS IT WORSENS ENCEPHALOPATHY) + alcohol abstinence Korsakoff: CARP Confobulation - Anterograde & Retrograde amnesia - Personality changes Tx: oral thiamine + alcohol abstinence

USMLE Flashcards

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