UW Pre-Reset

Question 1

FATRN: fever, anemia (microangiopathic hemolytic anemia), thrombocytopenia, renal insufficiency, neuro *HA confusion, dx? mgmt?

Answer 1

TTP! (small vessel thrombi that consume platelets, shear RBCs, and cause end organ damage; emergency tx w/ plasma exchange +/- steroids. TTP is caused by def in plasma protease ADAMTS13 (d/t formation of autoantibody); lots of vWF accumulate on endothelial wall trapping platelets and generate thrombi

Question 2

TTP vs HUS

Answer 2

Very similar in that both cause MAHA and thrombocytopenia; except HUS a/w E. coli and is primarily a disorder of renal system - no neuro findings or fever

Question 3

MAHA - microangiopathic hemolytic anemia on peripheral blood smear?

Answer 3

Schistocytes/RBC fragments

Question 4

Pt w/ recent fever, chills, productive cough, and leukocytosis has 3rd episode of RLL pneumonia in past several months

Answer 4

Recurrent pneumonia occurring in the same anatomic location of lung raises suspicion for localized airway obstruction, which if present can lead to impaired bacterial clearance and predisposition to infection; get CT to r/o cancer

Question 5

PFTs for chronic lung diseases: asthma, COPD, ILD/restrictive chest wall disease

Answer 5

Asthma and COPD: normal to inc TLC, dec FEV1/FVC, DLCO dec in COPD but normal in asthma

ILD/restrictive chest wall (restrictive pattern): dec TLC, normal FEV1/FVC, dec DLCO for ILD and normal for restrctive chest wall disease

Question 6

Splenic abscess p/w fever, leukocytosis, LUQ pain; pts develop left sided pleuritic chest pain and left pleural effusion and splenomegaly, risk factors for splenic abscess?

Answer 6

Hematogenous spread ie infective endocarditis

Question 7

Pure motor hemiparesis, lesion where?

Answer 7

Lacunar stroke (single modality defect) affecting posterior limb of internal capsule (commonly a/w chronic HTN which leads to arteriolar sclerosis)

Question 8

47yo man, recurrent blisters on dorsum of his hand and forearm, fatigue and occasional joint pain, elevated transaminases, dx?

Answer 8

Porphyria cutanea tarda d/t chronic hepatitis C virus (other extra hepatic manifestations = mixed cyroglobuinemia syndrome *paplpable purpura, athralgias, glomerulonephritis, low
complement), lichen planus

Question 9

Lady w/ transient (lasting just hours) of foot drop and sensory changes over dorsal foot and lateral shin; PE shows impaired ankle dorsiflexion and great toe extension w/ preserved plantar flexion and reflexes, dx?

Answer 9

Common fibular neuropathy aka common peroneal d/t peripheral nerve compression; common peroneal travels near fibular head and is susceptible to compressive injuries eg cast/bedrest/leg crossing. This is not MS since resolved in hours (MS episodes take days to weeks)

Question 10

Edema in just the UE, venous congestion in anterior chest, dx?

Answer 10

Superior vena cava syndrome (60% of cases d/t cancer, get cxr)

Question 11

Muffled voice, deviated uvula w/ unilateral lymphadenopathy, dx and mgmt?

Answer 11

Tonsilitis -> progressed to peritonsilar abscess; dx w/ needle peritonsilar aspiration and give IV abx

Question 12

Dvlpt of clubbing and sudden onset joint arthropathy in a chronic smoker, dx?

Answer 12

Hypertrophic osteoarthropathy, this condition is a/w lung cancer, get cxr

Question 13

vWF blood panel findings? DIC findings?

Answer 13

vWF deficiency = prolonged bleeding and aPPT, normal platelets
DIC = consumption of all coagulation cascade components - thrombocytopenia, microangiopathic hemolytic anemia, low clotting factors (fibrinogen, factors V and VIII), and prolonged PT and aPTT

Question 14

Lady w/ fluctuating double vision, found to have antibodies against nicotinic receptors on the motor end plate, next steps?

Answer 14

She has myasthenia; get CT scan chest to look for thymoma that is operable since that can lead to long-term improvement; side note while ACH receptor antibodies are highly specific - other tests for MG include muscle specific tyrosine kinase antibodies -> EMG -> or edrophonium test (less specific though since it is just acetylcholinesterase inhibitor)

Question 15

Complication of dermatomyositis that over 15% of adult pts will develop or have?

Answer 15

Malignancy commonly ovarian, lung, pancreatic, stomach, colorectal, non-Hodgkin

Question 16

Anti-RNP, anti-Jo-1, dx?

Answer 16

Dermatomyositis

Question 17

Persistence of nocturnal and early morning penile erections helps ddx psychogenic from organic causes of male ED

Answer 17

Normal nocturnal erections indicate vascular and nerve function

Question 18

Old lady, focal neuro symptoms - drops spoon, right sided weakness - followed by vomiting, pressures of 180/105, dx?

Answer 18

Intracranial hemorrhage 2/2 HTN occurring commonly in basal ganglia, thalamus, pons, cerebellum. Pts present w/ focal symptoms progressing to signs of elevated ICP (nausea, vomiting, HA)

Question 19

Other bugs involved w/ GBS besides campy

Answer 19

Herpes viruses, mycoplasma, haemophilus influenzae; GBS occurs more frequently in pts w/ lymphoma, sarocoidosis, SLE

Question 20

Hemolysis can occur intra or extra vascularly

Answer 20

Intravascular hemolysis is d/t significant RBC structural damage resulting in RBC destruction within intravascular space (eg paroxysmal nocturnal hemoglobinuria, or DIC) Extravascular hemolysis: RBCs predominantly destroyed by phagocytes in the reticuloendothelial system (eg lymph nodes, spleen). Less HgB release than intravascular hemolysis but still low haptoglobin, elevated LDH and elevated indirect bilirubin. Extravascular is d/t antibody mediated RBC destruction (AIHA), intrinsic RBC enzyme (G6PD def) or membrane defects (hereditary spherocytosis) *AIHA vs hereditary spherocytosis: same spherocytes, but AIHA is coombs positive while hereditary is family hx auto dom/negative Coombs/positive osmotic fragility test

Question 21

Dramatic leukocytosis, absolute basophilia, shift towards very early neutrophil precursor cells (promyelocytes, myelocytes), dx? Use what score to ddx from leukemoid rxn?

Answer 21

Chronic myeloid leukemia. Leukocyte alkaline phosphatase score is low in CML while it is high in leukemoid reaction (which is caused by severe infection where as CML is d/t BCR-ABL fusion). More myelocytes in CML, more metamyelocytes in leukemoid rxn

Question 22

Blood transfusion following liver injurt from MVA, now w/ numbness in fingertips/lips, forceful flexion of wrist w/ abduction of the thumb while nurse measures BP (trousseau signs), dx?

Answer 22

Acute hypocalcemia (chelation - blood citrate from transfusion binds free ionized calcium causing functional hypocalcemia)

Question 23

RA vs Parvovirus B19 infection

Answer 23

RA presents w/ joint stiffness for at least an hr in the morning, joint swelling, and symptoms for > 6 weeks
B19: although similar joints affected as RA (MCP, PIP, wrist) symptoms are acute (10 days) and there was absence of joint swelling or prolonged joint stiffness in the morning; look for erythema infectiosum rash/diarrhea/fatigue/fever; look for anti-B19 IgM antibodies but self-resolving course

Question 24

Bugs that can cause infective endocarditis?

Answer 24

Staph aureus, viridans, staph epidermidis, enterococci (nosocomial UTI question), strep bovis, fungi

Question 25

SOB, productive cough (despite worse w/ exertion), evidence of destruction of lower lung lobes, look for panacinar emphysema causing destruction in lower lobes (vs smoking causing centrilobular emphysema of the upper lobes), dx?

Answer 25

Alpha-1 antitrypsin deficiency; dx confirm w/ serum AAT levels, tx w/ pooled human AAT

Question 26

Complication of subarachnoid hemorrhage post coiling?

Answer 26

Vasospasm that can result in cerebral infarction; prevented w/ nimodipine

Question 27

Substance abuse and incarcerated pt, p/w subacute/chronic fevers, weight loss, fatigue, and pulmonary symptoms, CXR shows diffuse reticulonodular pattern (millet seed), dx?

Answer 27

TB!

Question 28

Jarisch-Herxheimer rxn

Answer 28

Acute, febrile rxn that occurs <12 hrs after initial tx of early syphilis. Symptoms = fever, HA, myalgias, rigor, sweating, hypotension, and worsening syphilitic rash. Manifestations self limited and resolves spontaneously 48hrs

Question 29

Partial acid fast gram positive bacteria, on chest CT showing multiple cavitary nodules, dissemination to brain forming abscess, pt is immunocompromised, dx and tx?

Answer 29

Nocardia, tx w/ bactrim (add carbapenems for brain involvement); tx duration is 6mo-1yr

Question 30

Cushing reflex?

Answer 30

Inc ICP response = HTN, bradycardia, respiratory depression (everything down except pressures)

Question 31

Urate crystals deposited in skin resulting in formation of tumors w/ chalky white appearance

Answer 31

Chronic tophaceous gout

Question 32

What virus causes mononucleosis like illnesss (fever, malaise, fatigue, absolute lymphocytosis w/ atypical lymphocytes), but these pts have mild to absent pharyngitis/lymphadenopathy/splenomegaly? What tests to order? and tx?

Answer 32

CMV mononucleosis (~10% of pts seroconvert); look for negative heterophile antibody test (that is negative monospot) but positive CMV IgM serology. -cyclovir

Question 33

Individuals w/ history of high risk sexual intercourse should be screened for HIV and HepB

Answer 33

Individuals who use IV drugs, have high risk needle stick exposure, or received blood transfusions before 1992 should be screened for HepC

Question 34

Elevated alk phos and elevated TB + DB = obstructive pattern

Answer 34

Post hepatic: conjugated bilirubin will build up and over flow bucket = build up of TB and DB = obstruction. If TB > DB and indirect bili elevated = think pre hepatic or hemolysis picture

Question 35

4th and 5th fingers w/ decreased sensation and weak grip, dx?

Answer 35

Ulnar nerve entrapment; most common site is at elbow where ulnar nerve lies at medial epicondylar groove (leaning on elbow at computer)

Question 36

Tumor lysis syndrome: risk, manifestations, tx, prophylaxis

Answer 36

Risk: initiation of cytotoxic chemotherapy Manifestations: severe electrolyte abnormalities - cellular contents (K and phosphorus and uric acid *from nucleic acids* are released -> phosphorus binds up calcium causing hypocalcemia and precipitating calcium phosphate stones -> so now CaPO4 and uric acid stones can cause AKI -> oh and cardiac arrhythmias w/ electrolytes Tx: telemetry, manage lytes Proph: IV fluids, allopurinol to control uric acid metabolism

Question 37

Chronic large artery vasculitis affecting Asian women <40; involves aorta, symptoms include fever/athralgias/weight loss, arterio-occlusive manifestations (claudication, distal ulcers) particularly in UE. BP discrepancies in either arms (like aortic dissection), pulse deficits and bruits. Cxr shows aortic dilation and widened mediastinum (thickening of large artery walls and lumenal narrowing); tx w/ systemic glucocorticoids

Answer 37

Takyasu arteritis | *Aortic coarctation can cause BP discrepancies more in lower rather than upper extremities

Question 38

Drugs of choice for stabilizing bony metastatic lesions to prevent hypercalcemia of malignancy and pathologic fractures?

Answer 38

Bisphosphonates (zoldrenoic acid, pamidronate), normal Ca = 8.4 - 10.2

Question 39

Acute erosive gastropathy

Answer 39

Dvlpt of hemorrhagic lesions after ischemia or exposure of gastric mucosa to various injurious agents (alcohol, aspirin, cocaine)

Question 40

Old man p/w fatigue, forget fullness, abdl pain/constipation/anorexia, PERIPHERAL neuropathy, lab findings w/ microcytic anemia and basophilic stippling on peripheral smear

Answer 40

Lead poisoning

Question 41

Caustic ingestion w/ sodium or KOH causes immediate esophageal injury w/ liquefaction necrosis and potential perforation

Answer 41

Endoscopy is recommended within the 1st 12-24hrs to assess severity of dmg and guide further therapy. Activated charcoal, corticosteroids, emetics and acid neutralization are not recommended

Question 42

HTN pt w/ acute severe thunderclap HA (maximal intensity reached in <1 minute) and symptoms of meningeal irritation (nausea/vomiting/photophobia), dx and imaging findings?

Answer 42

Nontraumatic subarachnoid hemorrhage d/t ruptured saccular berry aneurysm; CT w/o contrast (good for blood) will show high density signal around brain stem and basal cisterns (middle of brain); tx = cerebral angiography to confirm and craniotomy w/ aneurysm clipping or endovascular methods (coiling/stenting aneurysm)

Question 43

Acute pyelonephritis: uncomplicated vs complicated

Answer 43

Uncomplicated: otherwise healthy, nonpregnant, primarily E. coli, tx w/ oral fluoroquinolone or bactrim, IV abx if vomiting/septic/elderly Complicated: DIABETES, urinary obstruction/instrumentation, renal failure, immunosuppression, hospital acquired, inc risk of abx resistance and tx failure consider IV fluoroquinolone, aminoglycoside

Question 44

Abnormal copper deposition in liver, basal ganglia, cornea, autosomal recessive in younger individuals, how to dx?

Answer 44

``` Wilson's disease, presence of low serum cerulopasmin in conjunction w/ inc urinary copper excretion or Kayser-Fleischer rings. Clinical findings can include asymptomatic aminotransferase elevations to fulminant hepatic failure while young peeps get neuropsychiatric disease (tremor, rigidity, depression, paranoia, catatonia) ```

Question 45

OA vs RA x-ray findings?

Answer 45

OA: narrowing of joint space and osteophytes RA: periarticular osteopenia and joint margin erosions

Question 46

Pseudogout findings? Gout findings?

Answer 46

Pseudogout: CPPD deposition, rhomboid and positively birefringent crystals Gout: Inflammatory effusion, needle shaped and negatively birefringent crystals; x-rays w/ punched out erosions w/ rim of cortical bone

Question 47

Mechanism of G6PD?

Answer 47

G6PD enzyme deficient erythrocytes cannot bind oxidative metabolites - this causes membrane instability and leads to acute episodic hemolysis in the spleen *bite cells. Lab findings suggestive of hemolysis include low HgB, inc indirect bilirubin, inc LDH, dec haptoglobin. G6PD activity assay may be negative during acute hemolytic episode

Question 48

G6PD all you need to know:

Answer 48

Epi: hemolytic anemia (indirect bili inc, hapto negative, hemoglobin dec, inc LDH), following oxidative stress (infection, sulfa drugs like bactrim, fava beans), Asian/Black x-linked! Manifestations: dark urine (d/t hemolysis), jaundice, abdl back pain (w/ severe hemolysis) Labs: bite cells w/ Heinz bodies, G6PD activity assay level may be low during attack Mgmt: remove or tx agent/condition, supportive care

Question 49

Mild pulmonary illness,cutaneous manifestations include circumscribed verrucous nodules and plaques that progress to microabscesses (warty heaped up skin lesions w/ violaceous hue and sharply demarcated border; some crusted lesion w/ peripheral ulcer), dx?

Answer 49

Blastomycosis (endemic to south/south central states, Mississippi and Ohio River Valleys); other organ involvements include lung, skin (wartlike lesions, violaceous nodules, skin ulcers), osteomyelitis, GU - prostatitis or epididymo-orchitis)

Question 50

Antibodies found in systemic sclerosis

Answer 50

ANA, anti-topoisomerase, anti-centromere (anti-scl-70 and anti-RNA pol III a/w diffuse cutaneous systemic sclerosis)

Question 51

Complications a/w systemic sclerosis

Answer 51

Lung: ILD, pulmonary arterial HTN Kidney: HTN, scleroderma renal crisis (oliguria, thrombocytopenia, MAHA) Heart: myocardial fibrosis, pericarditis, pericardial effusion

Question 52

Antibodies and associated disorders

Answer 52

RF: many autoimmmune but predominantly RA Anti-dsDNA: SLE Anti-CCP: more specific for RA Anti-mitochondrial: primary biliary cholangitis ANCA: GPA (Wegner), microscopic polyangitis, other vasculitidies Anti-scl-70: systemic sclerosis (anti-RNA pol III) Anti-Jo1: dermatomyositis HLA-B27: ankylosing spondylitis Anti-smooth muscle antibodies: autoimmune hepatitis

Question 53

Syringomyelia is a fluid filled cavity located within cervical and thoracic spinal cord that is most commonly a/w Arnold Chiari malformation type 1

Answer 53

Pts p/w areflexic weakness in the UE and dissociated sensory loss following cape distribution (neck, shoulders, upper arms)

Question 54

HIV pt w/ subacute onset low grade fever, HA and signs of inc ICP (papilledema, vomiting), evaluate for what?

Answer 54

Cryptococcal meningitis using cryptococcal antigen or isolation of organism in CSF

Question 55

JC virus causes what in HIV pts?

Answer 55

Multifocal leukoencephalopathy - MRI shows patchy areas of white matter c/w demyelination

Question 56

Any patient w/ acute, severe illness may have abnormal thyroid function tests, syndrome?

Answer 56

Euthyroid sick syndrome "low T3 syndrome" is characterized by a fall in total and free T3 levels w/ normal T4 and TSH levels; self-resolving

Question 57

Hereditary spherocytosis info?

Answer 57

Epidemiology: autosomal dominant, northern european Clinical: hemolytic anemia, jaundice, splenomegaly Lab findings: elevated MCHC, spherocytes (spheres on peripheal smear), negative coombs, can confirm w/ osmotic fragility test or eosin-5-maleimide binding test Tx: folid acid supplementation, blood transfusions, splenectomy Complication: pigment gall stones, aplastic crises from parvovirus B19 infection Spherocytes also found in G6PD and autoimmune hemolytic but these have other lab findings

Question 58

Vitreous hemorrhage vs retinal tear?

Answer 58

Vitreous hemorrhage: sudden vision loss, floaters, fundus is hard to visualize! Retinal detachment: sudden vision loss, floaters, photopsia (flashing lights), fundoscopy will show elevated retina w/ folds and or a tear CRAO: sudden painless vision loss, opthalmoscopic signs show disk swelling venous dilation/tortuosity, retinal hemorrhages and cotton wool spots

Question 59

Young female w/ MS and prolonged immobilization p/w sudden onset CP, dyspnea, tachycardia, small pleural effusion, dx?

Answer 59

PE! Pleural effusion d/t hemorrhage or inflammation (generally exudative, grossly bloody, can be a/w pain d/t irritation); where as aspiration pneumonia presents as lobar infiltrate

Question 60

Large RBCs and hypersegmented neutrophils?

Answer 60

Megaloblastic anemia d/t either folate or cobalamin (B12) def, either def will result in elevated homocysteine

Question 61

Which lab can ddx btw folate and cobalamin def?

Answer 61

Measure MMA concentration (if inc = cobalamin deficiency since cobalamin is also involved in conversion of methymalonyl-CoA to succinyl-Coa *unlike folate)

Question 62

Definition of solitary pulmonary nodule:

Answer 62

Rounded opacity, <3cm, completely surrounded by pulmonary parenchyma, no associated lymph node enlargement. Lesions w/ high malignancy risk require surgical excision. If .8cm but w/ no suspicion for malignancy consider PET for further eval or f/u w/ serial CT

Question 63

Young man, sharp localized pain and tenderness over anteromedial part of tibial plateau just below joint line of knee, recent fall, valgus stress test negative (not MCL involvement), x-rays normal, dx?

Answer 63

Pes anserinus pain syndrome

Question 64

Sjorgen syndrome is an autoimmune disorder characterized by a lymphocytic inflammatory infiltrate in the exocrine glands and can present w/ dry eyes and dry mouth

Answer 64

It may occur independently or a manifestation of another autoimmune disorder (systemic sclerosis). However, onset is typically in middle age, and initial presentation after 65 is unusual. Also pts have ANA positive and those with systemic sclerosis have associated systemic manifestations

Question 65

Traveler's diarrhea that is prolonged, profuse, and watery, dx?

Answer 65

Cryptosporidium parvum (transiently severe but self-limited in healthy individuals; AIDS pts are at risk for chronic infection)

Question 66

What bacteria causes IE in pts w/ colon cancer or IBD

Answer 66

Strep bovis aka strep gallolyticus

Question 67

Most common cause of IE in structurally normal heart valves, IVDU, prosthetic valve or implanated device pts

Answer 67

Staph aureus - look for acute high fever and rapid progressive cardiac dysfunction; whereas strep viridans (or mutans) is typically subacute w/ several weeks of fatigue and low grade fever

Question 68

>40yo indolent pain worse by activity relieved by rest; joint is not tender and systemic symptoms are absent, dx?

Answer 68

Osteoarthritis (affects knees, hips, DIP joints)

Question 69

Delayed sleep wake phase disorder vs shift work disorder

Answer 69

DSWPD: long history of sleep difficulties that occur when work or school schedule requires and early rise time (sleep onset insomnia and excessive morning sleepiness); basically's internal clock for sleeping does not align with her social/professional schedule; consider light or behavioral therapy Shift work disorder: person has normal circadian rhythm who is now required to work night shift

Question 70

Ear pain and ear drainage w/ granulation tissue, dx and bug? Progression of infection can lead to osteomyelitis of skull base and cranial nerve damage (facial drooping)

Answer 70

Malignant otitis externa, pseudomonas, pts w/ diabetes and are old are at risk

Question 71

MOS of bacillus cereus?

Answer 71

Preformed enterotoxin, hence why expect to see quick onset vomiting predominant

Question 72

RANDOM FACTS

Answer 72

Brain death is a clinical dx, characteristic findings are absent cortical and brain stem functions; spinal cord may still be functioning hence DTR can be present still Innocent flow murmur d/t hyper dynamic circulation from fever - HIV pt w/ lobar pneumoniae and midsystolic upper left sternal border murmur Individuals w/ resolved HepB infection are positive for anti-HBs and anti-HBc but negative for HBsAg. Individuals who are immunized w/ HepB vaccine are positive for anti-HBs but negative for HBsAg and anti-HBc. Recovery phase of HepB = presence of anti-HBs, anti-HBc (now IgG) and anti-HBe. Chronic HepB still has HbsAg. The HBe antigen and antibody usually indicates either active infection or very recent infection that is nearing cessation or low infectivity A normal D dimer result is useful in excluding pulmonary venous thromboembolism (VTE) in patients w/ unlikely pretest probability. However, a normal D-dimer (as in negative D- dimer) result is not useful in pts w/ likely pretest probability (f/u w/ V/Q scan or CTA). An elevated D dimer result in any pt is not diagnostic of VTE, and must be followed up AVM malformation common in intracranial hemorrhage in kids. Cardioembolic stroke multiple ischemic infarctions at grey-white matter junction. Ischemic stroke = hypodense (bleeding is hyper dense on CT). Subarachnoid hemorrhage - severe thunderclap HA and hyperattenuation of sulci and basal cisterns on CT Aminoglycoside can cause ototoxicity by damaging cochlear cells and some aminoglycosides like gentamicin can also damage motion sensitive hair cells in inner ear causing vestibulopathy

Question 73

Mgmt of frostbite?

Answer 73

Rapid rewarming in water bath

Question 74

Telogen effluvium vs alopecia areata

Answer 74

Telogen: acute diffuse noninflammatory hair loss triggered by STRESS; hair pull test shows extraction of >10% fibers - scalp and hair shaft appear normal. Reassurance! Alopecia areata: autoimmune disorder w/ circumscribed patches of hair loss; hair shafts show narrowing close to surface and may be broken off

Question 75

Pneumovax 23 vs prevnar 13, who gets what and mechanism for each

Answer 75

Prevnar 13 for all infants and young children; Pneumovax 23 for adults <65 w/ predisposing comorbidities (chronic heart or lung disease, diabetes mellitus, cirrhosis). For adults >65 and immunocompromised = both vaccines Pneumovax - less robust immune response since just polysaccharides (capsular material) Prevnar - more robust since capsular polysaccharides attached to inactivated diptheria toxin protein inducing T cell dependent B cell response

Question 76

Atropine and pralidoxime as antidote?

Answer 76

Treats cholinergic toxicity (bradycardia, miosis, bronchospasm, vomting, diarrhea), caused by organophosphate poisoning. Atropine blocks peripheral effects of acetylcholine at muscarinic receptors whereas pralidoxime aids in reactivation of acetylcholinesterase

Question 77

Symptoms begin w/ bilateral cranial neuropathies (blurred vision, diplopia, facial weakness, dysarthria, dysphagia), then descending muscle weakness (hands then feet) or diaphragmatic weakness w/ respiratory failure, dx and tx?

Answer 77

Foodborne botulism; tx w/ equine serum heptavalent antitoxin (passive immunoglobulins)

Question 78

Painless maroon colored rectal bleeding, hx of CKD or aortic stenosis or vWF deficiency, dx?

Answer 78

Angiodysplasia - dilated submucosal veins and AVM

Question 79

Ankylosing spondylitis: inflammatory back pain, exam findings, complications, lab findings, imaging?

Answer 79

INFLAMMATORY back pain: relieved w/ exercise worse in morning, not relieved by rest Exam findings: AREDU (arthritis, reduced chest expansion/spinal mobility), enthesitis (tenderness at tendon), dactylitis (swelling of finger toes), uveitis Complications: osteo/vertebral fractures, aortic regurg, cauda equina. Most common extraarticular manifestation of AS = anterior uveitis (inflammation of uveal tract - iris, ciliary body, choroid) Lab: HLA B27, ESR CRP Imaging: x-ray of SI joints

Question 80

CT w/ contrast vs CT w/o contrast

Answer 80

W/ contrast = good for indentifying structural abnormality or mass lesions W/o contrast = good for investigating bleeds (intracranial bleeds)

Question 81

Elevated ALP and the use of GGT

Answer 81

ALP is found in liver and bones; however GGT is only in liver -> so if ALP is elevated but GGT is normal than the elevated ALP is d/t bone issue

Question 82

Focal bone pain, elevated ALP but normal GGT, dx and mechanism?

Answer 82

Paget disease of bone - d/t abnormal osteoclast activity leading to inc bone turnover and bad remodeling

Question 83

X-ray findings for Paget's disease and other complications

Answer 83

Cortical thickening and osteolytic or mixed lytic/sclerotic lesions on x-ray and focally inc radiotracer uptake on bone scan. Complications include involvement of cranial bones w/ frontal bossing, inc hat size, hearing loss (enlargement of temporal bone and encroachment on cochlea)

Question 84

Hypocalcemia (seen w/ hyperventilation and blood transfusions) = carpopedal spasms vs hypercalcemia (seen w/ = abdl pain, constipation, polydipsia

Answer 84

Hypercalcemia causes renal vasoconstriction and dec glomerular blood flow -> loss of sodium and free water

Question 85

Milk alkali syndrome?

Answer 85

Excessive intake of Ca and absorbable alkali - pts taking calcium bicarb for osteoporosis; look for symptomatic hypercalcemia (abdl pain, constipation, polydipsia), metabolic alkalosis and AKI

Question 86

What drugs to be cautioned about when given sildenafil?

Answer 86

Alpha blockers, nitrates or any hypotensives

Question 87

Erysipelas vs cellulitis

Answer 87

Erysipelas: typicall streptococci infection, limited to epidermis and superficial dermis = which gives it characteristic RAISED, sharp borders and intense erythema Cellulitis: deep dermal and subcutaneous fat infection typically caused by either beta hemolytic streptococcus (nonpurulent) or staph aureus (purulent); look for warm tender erythematous FLAT indistinct borders

Question 88

Long standing joint pain (RA), severe erosive joint disease and deformity, neutropenia (ANC <1500), splenomegaly, recurrent ulcerative skin lesions, dx?

Answer 88

Felty syndrome d/t long standing RA; dx w/ anti-CCP and RF, markedly elevated ESR

Question 89

Aspergillosis vs PCP cxr and clinical findings

Answer 89

Aspergillosis: pulmonary nodules or segmental infiltrates (like that TB cavitary lesion w/ aspergillosis ball); fever/pleuritic CP/hemoptysis; tx w/ voriconazole and enchinocandin. THIS has ground glass opacities PCP: bilateral diffuse interstitial infiltrates; fever/nonproductive cough (hemoptysis not common)

Question 90

Arsenic vs lead poisoning:

Answer 90

Arsenic: painful sensorimotor polyneuropathy, SKIN LESIONS (hypo and hyper pigmentation, hyperkeratotic), pancytopenia, mild transaminase; dx w/ urine arsenic levels, tx w/ chelation Lead poisoning: can lead to sensorimotor neuropathy in stocking glove distribution w/ microcytic anemia, GI complaints common!

Question 91

Biostatistics:

Answer 91

NNT formula: 1/ARR Statistical method to compare means: two sample T Sensitivity = proportion of positive test results among subjects w/ the disease (will incorporate false negatives) Specificity = proportion of negative test results among subjects without the disease (the total will incorporate false positives) Prevalence affects PPV and NPV only, does not affect sensitivity/specificity (high prevalence = PPV is high, NPV is low) Pts in a study no they are part of control/experimental group, alter their activities because of said info = Hawthorne effect

Question 92

Gradual painless PERIPHERAL vision loss; optic disc enlargement w/ inc cup:disc ratio

Answer 92

Open angle glaucoma (central vision loss in macular degen)

Question 93

Progressive CENTRAL vision loss, pt has vascular risk factors, both eyes affected, funduscopic shows drusen yellow deposits

Answer 93

Macular degeneration (peripheral vision loss in glaucoma)

Question 94

Elderly pt, acute, painless monocular vision loss, cherry red spots and cotton wool spots on funduscopy

Answer 94

CRAO

Question 95

Painful red eye, blurry vision, photphobia

Answer 95

Anterior uveitis

Question 96

Acute onset monocular vision loss w/ central scotoma, afferent pupillary defect, changes in color perception, pain w/ eye movement, dx and association

Answer 96

Optic neuritis and MS

Question 97

Inc homocysteine levels predispose to venous thrombosis as well as atherosclerosis (d/t vascular dmg, clotting mechanism activation, inhibition of antithrombosis), it is usually metabolized to either cysteine or methylated to form methionine, what factors are involved in these pathways?

Answer 97

B6 (pyridoxine) - cysteine pathway; folate and cobalmin (B12) - methionine pathway. Can normalize homocysteine levels w/ either B6 or folate; B12 if B12 def is documented

Question 98

NO B SYMPTOMS, pancytopenia (granulocytopenia causing infections, anemia causing fatigue, thrombocytopenia causing bleeding), splenomegaly (early satiety), peripheral smear w/ B cells showing cytoplasmic projections (many finger like extensions), dx? dx technique? tx?

Answer 98

Hairy cell leukemia, bone marrow bx w/ flow cytometry, tx is chemo (life expectancy great); hair cell leukemia = clonal B cell neoplasm affecting middle age older adults d/t BRAF mutation

Question 99

Chronic B cell neoplasm that infiltrates bone marrow, spleen, and peripheral blood resulting in cytopenia, splenomegaly, peripheral smear w/ evidence of hairy cytoplasmic projections, no B symptoms, dx?

Answer 99

Hair cell leukemia (low cell lines and hair projection, no b symptoms!)

Question 100

Significant leukocytosis, lymphadenopathy, B symptoms, peripheral smear shows smudge cells (blobs)

Answer 100

CLL chronic lymphocytic leukemia

Question 101

Occupations a/w asbestosis, and what type of cancer?

Answer 101

Plumbers, electricians, carpenters, pipefitters, insulation workers; bronchogenic carcinoma (look at card comparing cxr/CT findings for carcinoma vs mesothelioma)

Question 102

Cxr and CT findings for bronchogenic carcinoma 2/2 asbestosis

Answer 102

CXR: atelectasis and bilateral PLEURAL PLAQUES over the diaphragm CT: reticular opacities of lung fields, multiple PLEURAL PLAQUES and round single cavitary mass Compared to pleural mesothelioma (another risk factor of asbestosis) but presents as unilateral pleural abnormality w/ large pleural effusion

Question 103

Diabetes meds and important points to remember: metformin, sulfonylureas, pioglitazone, DPP-IV inhibitors, GLP-1

Answer 103

Metformin initial therapy for T2DM, weight neutral, low risk hypoglycemia, CARE for lactic acidosis Sulfonylureas: added if failed metformin, weight gain and hypoylgycemia are main side effects Pioglitazone: used if can't tolerate metformin/sulfonylureas, side effects include everything (weight gain, edema, CHF, bones, bladder CA), can use in renal insufficiency DPP-IV inhibitors: low hypoglycemia risk, weight neutral, can be used in renal insufficiency GLP-1: GOOD FOR WEIGHT loss, low hypoglycemia risk

Question 104

New anticoagulation, 5-10 days later, >50% drop in platelets, new clot, dx?

Answer 104

Heparin induced thrombocytopenia (Type 2 - immune mediated via antibodies against platelets, days after tx vs Type 1 = immediate non-immune mediated drop in plts that resolves)

Question 105

Periorbital cellulitis vs cavernous sinus involvement:

Answer 105

Opthalmoplegia = sign of orbital muscle and nerve damage; the presence of HA and bilateral face and eye symptoms reflects involvement of the cavernous sinus

Question 106

Cheek insect bite, now severe HA, bilateral periorbital edema, restricted extraocular movements, forehead/mid-face tender to palpation, dx?

Answer 106

Infectious cavernous sinus thrombosis

Question 107

Skin findings in meningococcemia

Answer 107

Petechial rash that progresses to ecchymosis, bullae, vesicles, and gangrenous necrosis; pts have fever, nausea, vomiting, severe myalgias, meningeal signs, and shock

Question 108

Rocky mountain spotted fever rash?

Answer 108

Petechial, starts in extremities and migrates inward, starts a few days after fever onset

Question 109

Toxic shock syndrome associations, skin findings, clinical findings?

Answer 109

A/w menstruation (tampons), nasal packing (epistaxis), post sx infections; pts develop fever, myalgias, marked hypotension, diffuse erythematous macular rash; thrombocytopenia more common than leukocytosis!; immature neutrophils (bands) present as well; mainly staph aureus

Question 110

Bilateral nontender enlargement of submandibular glands, dx and cause?

Answer 110

Sialadenosis - found in pts w/ liver disease (alcoholic and nonalcoholic cirrhosis). Benign noninflammatory swelling of salivary glands; reassurance. DDx includes salivary gland stones (swelling pain w/ meals) and sialadenitis (focal tenderness erythema fever)

Question 111

Mechanism of ARDS

Answer 111

Lung injury and inflammation and edema leading to alveolar collapse and poor oxygenation

Question 112

Complications of positive pressure ventilation?

Answer 112

Alveolar damage, pneumothorax, and hypotension

Question 113

Calcium oxalate crystals, hypocalcemia, flank pain, hematuria, oliguria, AKI, anion gap metabolic acidosis, dx and tx?

Answer 113

Ethylene glycol posioning (ethylene glycol and methanol found in antifreeze, ingested as substitute for ethanol); tx w/ fomepizole (competitive inhibitor of alcohol dehydrogenase prevents further breakdown of ethylene glycol into toxins oxalic acid and glycolic acid); consider hemodialysis for end organ dmg or sodium bicarb to help metabolic acidosis (only if pH < 7)

Question 114

Intracranial HTN or pseudotumor cerebri mgmt?

Answer 114

Tx goals are prevention of BLINDNESS, reduction of ICP, and symptomatic relief of HA; 1st line meds is acetazolamide which inhibits choroid plexus carbonic anhydrase thereby decreasing CSF production, furosemide can be added if symptoms persist. Refractory to med pts w/ vision loss = sx intervention w/ optic nerve sheath decompression or lumboperitoneal shunting

Question 115

Causes of acute liver failure (which = ALT and AST >1000, encephalopathy, and synthetic liver dysfunction INR >1.5)

Answer 115

Viral hepatitis (everything but C, also HSV and CMV), drug toxicity, ischemia (shock liver or Budd-Chiari look for RUQ pain), autoimmune hepatitis, Wilson disease, malignant infiltration

Question 116

Rapid onset of severe eye pain seeing halos around lights, DILATED pupil w/ poor response to light, can have tearing and HA w/ nausea and vomiting, dx?

Answer 116

Acute angle closure glaucoma (dilated eyes, neuro symptoms, severe eye pain); can be precipitated as a response to pupilary dilation from meds (anticholinergics, sympathomimetics)

Question 117

Wells score >4, next steps for dx?

Answer 117

Get that CT angiogram or V/Q scan, skip the D-dimer

Question 118

RA sites of involvement?

Answer 118

Progressive and symmetrical involvement of peripheral joints: MCPS and PIP of fingers, metatarsophalangeal joint of toes; RA most commonly affects cervical spine joints in axial skeleton and can cause spinal subluxation and spinal cord compression - radicular pain, neck pain/stiffness, hyperreflexia or babinski w/ spinal cord

Question 119

Tx of uric acid stones (not seen on x-ray d/t radiolucency but seen on US or CT)

Answer 119

Occurs in low urine pH -> therefore tx by alkalinzation of urine to pH 6.0 w/ oral potassium citrate. Tx hypercalciuric renal stones w/ HCTZ since that dec urinary calcium excretion (this is also tx for osteo)

Question 120

Kidney stones info:

Answer 120

Recurrent calcium stone formation d/t hyperoxaluria - restrict dietary oxalate Potassium citrate tx for pt presenting w/ stone d/t citrate deficiency Complete urinary evaluation for stones include Ca, citrate, uric acid, oxalate, pH and sodium levels *For stones less than 5mm in diameter = can pass spontaneously w/ conservative mgmt (including fluid intake >2L to inc urinary flow rate and lower urinary solute concentration)

Question 121

PaCO2 in asthma exacerbation

Answer 121

Generally expect dec PaCO2 d/t hyperventilation; so if PaCO2 is normal or high or w/ no wheezes = ominous signs -> if unresponsibe to duonebs (SABA/SAMA and systemic corticosteroid) then consider intubation!

Question 122

Dull HA a/w nausea and vomiting (d/t inc ICP), focal neurologic manifestations *unilateral weakness d/t invasion or compression, symptoms worse during the night or w/ positioning *early morning HA d/t laying in bed, dx?

Answer 122

Brain mass, dx w/ MRI

Question 123

Sensory ataxia and lancinating pain, syphilis, dx?

Answer 123

Tabes dorsalis (affects dorsal column - proprioception, discriminative touch, vibration)

Question 124

Low back pain w/ neuro symptoms (sensory loss weakness in legs) worse w/ spinal extension (walking/standing) but improved leaning forward or lying down (shopping cart sign)

Answer 124

Lumbar spinal stenosis

Question 125

Lumbosacral strain - pain in paraspinal area w/o significant tenderness over midline vertebra. Localized point tenderness over midline, normal neuro exam, old lady, recent lifting incident, dx?

Answer 125

Vertebral compression fracture

Question 126

Mechanism of graft versus host disease:

Answer 126

Recognition of host major and minor HLA antigens by DONOR T cells and consequent cell mediated immune response; organs affected include skin (maculopapular rash involving palms, soles, and face), intestine (blood positive diarrhea), and liver (abnormal LFTs and jaundice)

Question 127

CSF findings in GBS

Answer 127

ONLY elevated PROTEIN, totally normal cell count (normal whites, reds, and glucose)

Question 128

CSF findings: bacterial meningitis, TB meningitis, viral meningitis, GBS

Answer 128

Bacterial: elevated whites, low glucose, high protein TB meningitis: elevated whites, much lower glucose, elevated protein Viral: elevated whites, normal glucose, high normal protein GBS: just elevated protein

Question 129

Adenocarcinoma = most common type of primary lung cancer in both smokers and nonsmokers; the predominant type in non smokers. CXR findings of adeno

Answer 129

Peripherally located solitary nodule; squamous is centrally located and often has necrosis/cavitation. Vs TB lesion = hilar adenopathy and/or cavitary patchy lung lesions *variable x-ray findings (though definitely not solitary nodules). Sarcoidosis = bilateral hilar adenopathy sometimes w/ scattered opacities

Question 130

Hallmark of prolonged seizures (status epilepticus = sz >5mins OR cluster of sz w/ pt not recovering mental status in btw)

Answer 130

Cortical laminar necrosis

Question 131

Side effects of trimethroprim sulfamethoxazole?

Answer 131

Hyperkalemia - blocks epithelial sodium channel in collecting tubule (similar to action of K sparing diuretic) Elevated serum Cr - Bactrim competitively inhibits renal tubular Cr secretion causing artificial inc in serum Cr, however GFR is unchanged

Question 132

Painless loss of monocular vision w/ cardiovascular risk factors, dx and tx?

Answer 132

CRAO; look for diffuse ischemic retinal whitening and cherry red spots; tx the opthalmologic emergency w/ ocular massage (dislodge the embolus) and high flow oxygen

Question 133

When and how to screen for lung cancer in at-risk pts?

Answer 133

Low dose CT yearly for pts 55-80yo, w/ >30 pack year smoking hx, and currently smoking or quit within past 15 years

Question 134

Colon cancer screening?

Answer 134

Avg risk starts at 50; if family hx of colon cancer, consider screening at 40 or 10 years before family member's initial dx

Question 135

S/s of ICP (nausea, vomiting, HA that worsens w/ changes in position, coughing or sneezing) = space occupying lesion. CT/MRI showing butterfly appearance w/ central necrosis, dx?

Answer 135

Gliobastoma multiforme = high grade astrocytoma (heterogenous and serpiginous contrast enhancement)

Question 136

Definition of nephrotic syndrome

Answer 136

Heavy proteinuria (> 3.5g/24hs) w/ hypoalbuminemia and edema; other findings = hyperlipidemia and inc lipids in urine

Question 137

Causes of nephrotic syndrome in adults = either primary glomerular (membranous nephropathy, FSGS, and minimal change) OR secondary glomerular (diabetes mellitus, amyloidosis)

Answer 137

Primary renal causes and their associations - (FSGS and membranous most common) FSGS: African American or Hispanic, obesity/HIV/heroin Membranous nephropathy: adenocarcinoma (breast/lung), NSAIDs, HepB, SLE Membranoproliferative glomerulonephritis: HepB and HepC, lipodystrophy Minimal change: NSAIDs, lymphoma IgA nephropathy: upper respiratory tract infxn

Question 138

Sickle cell pt, progressive hip pain, limited internal rotation/abduction, no tenderness, normal x-rays and inflammatory markers, dx?

Answer 138

Osteonecrosis caused by occlusion of end arteries supplying femoral head leading to necrosis/collapse of periarticular bone and cartilage (common complication in SCD = disruption of microcirculation in bone by sickling as well as inc intraosseous pressure d/t bone marrow hyperplasia)

Question 139

Homeless person w/ lacerations over extremities, now fever, muscle stiffness, trismus/lockjaw, painful muscle spasms triggered by stimuli, dx?

Answer 139

Tetanus, MOA = toxin binds to peripheral nerve terminals and w/ retrograde axonal transport arrives at CNS where it blocks release of inhibitory neurotransmitters glycine/GABA. Tx = clean wound, start abx, human tetanus immunoglobulin and tetanus toxoid

Question 140

HIV pt, blurred vision, floaters, photopsia, fundoscopy shows multiple yellow-white fluffy hemorrhagic lesions along vasculature (full thickness retinal inflammation that moves centripetally along vasculature), dx and tx?

Answer 140

HIV and eye issue = CMV retinitis (or HIV retinopathy but HIV is not hemorrhagic); tx w/ valganciclovir (if lesions near fovea or optic nerve then tx w/ intravitreal injections)

Question 141

More eye diseases: herpes simplex keratitis, herpes zoster opthalmicus, HIV retinopathy

Answer 141

Herpes simplex keratitis: corneal lesions resulting in ocular pain, tearing, discharge Herpes zoster opthalmicus: eye pain and vesicular eruption involving cornea/iris HIV retinopathy: cotton wool retinal lesions that are not hemorrhagic, tend to resolve over weeks to months *does not cause floaters or blurred vision as in CMV retinitis

Question 142

Pt w/ past cholecystectomy now w/ recurring pain similar to pre-procedural pain, dx and mgmt?

Answer 142

Postcholecystectomy syndrome: persistent abdl pain/dyspepsia either months of even years after chole. Etiologies = biliary (retained stone in CBD or cystic duct) or extra biliary (pancreatitis, PUD). Abdl US then ERCP to dx and guide tx

Question 143

Woman w/ giant cell arteritis (aka temporal arteritis) recently started on tx, now p/w proximal muscle weakness in LE (manifests as difficulty getting up from chair, climbing stairs, brushing hair), dx?

Answer 143

``` Drug induced (glucocorticoid) myopathy - no muscle inflammation or tenderness, CK and ESR are normal. DDx to polymyalgia rheumatica: seen in 50% pts w/ temporal arteritis, morning stiffness/aching w/ pain and dec ROM in shoulders/necks/hip girdle - but NORMAL muscle strength; elevated ESR *improves w/ glucocorticoids ```

Question 144

Hypercalcemia, normocytic anemia, renal insufficiency, protein gap > 4 (seen in infection, connective tissue dz, excessive monoclonal protein), rouleaux formation (stacking of RBCs like coins)

Answer 144

Multiple myeloma; dx w/ SPEP to see if protein gap is monoclonal (M-spike) then bone marrow bx to show >10% clonal PLASMA cells

Question 145

Dyspepsia (indigestion), intermittent epigastric, postprandial discomfort (fullness bloating) and nausea, pt from low income country, dx?

Answer 145

PUD w/ H. pylori

Question 146

Systemic sclerosis subtypes and their s/s: limited cutaneous vs diffuse cutaneous

Answer 146

Limited cutaneous: scleroderma on head and distal UE, prominent vascular manifestations Raynaud/cutaneous telangiectasia/PA HTN, CREST syndrome, anticentromere antibodies, better prognosis Diffuse cutaneous: scleroderma on trunk and UE, internal organ involvement (scleroderma renal crisis, myocardial ischemia/fibrosis, INTERSTITIAL LUNG DISEASE, anti-scl-70 antibodies, anti-RNA pol III ab, worse prognosis

Question 147

Patients w/ SIADH who are asymptomatic or have mild symptoms or Na 120-130 usually respond to fluid restriction

Answer 147

Pts w/ severe symptoms, neuro symptoms, or Na < 120 = need hypertonic saline (care, less than 8 correction in 24hrs or .5-1 over an hr)

Question 148

More skin stuff: pyogenic granuloma, dermatofibromas, BCC, SCC

Answer 148

Dermatofibromas: fibroblast proliferation causing, lesions on LE, nontender, hyperpigmented <1cm, fibrous component causing dimpling in center when area is pinched "dimple or buttonhole sign" Pyogenic granuloma: benign vascular skin tumor that presents as small red papule that grows rapidly over weeks, to pedunculated or sessile shiny mass, common on lip/oral mucosa Basal cell: pearly nodule w/ small telangiectasias in sun exposed (upper lip) Squamous cell carcinoma: firm scaly papules, plaques or nodules (lower lip)

Question 149

Acute epididymitis epidemiolopgy, symptoms, dx, tx

Answer 149

Age <35: usually sexually transmitted (chalmydia/gonorrhea); asymptomatic urethritis Age >35: bladder outlet obstruction coliform bacteria ie E.coli Symptoms: unilateral testicular pain, epididymal edema, dysuria/frequency only w/ coliform infection not stds Dx: UA and culture, NAAT for chalmydia and gonorrhea Tx: ceftriaxone/doxy if STI, levo for coliform bacteria

Question 150

Alz dementia, CT w/ hyperdensity in entire lobe (ie parietal lobe hemorrhage), dx?

Answer 150

Parietal lobe hemorrhage d/t cerebral amyloid angiopathy - amyloid deposition in arteries results in vessel wall weakening and predisposition to rupture. Hemorrhage occurs during routine activity, and commonly involves occipital/parietal lobes

Question 151

What prophylaxis is considered in HIV pts w/ CD4 <200, <100, <50?

Answer 151

Bactrim for <200 (PCP - remember a/w oral candidiasis), bactrim for <100 (toxo), and azithromycin for coverage against mycobacterium avium complex (MAC - c/f disseminated MAC causing systemic symptoms and splenomegaly) for <50. Acyclovir and fluconazole not needed for proph but only for acute infections

Question 152

Acute urinary incontinence in elderly pts, consider reversible etiologies first especially if new onset - think DIAPPERs

Answer 152

``` D: delirium I: infection UTI very common, routine U/A is not bad A: atrophic urethritis/vaginitis P: pharmaceuticals (alpha blockers, diuretics, anticholinergics) Psychological: depression E: excessive urine output: T2DM, CHF R: restricted mobility: post sx S: stool impacton ```

Question 153

Leukocyte esterase vs nitrites in urine signify?

Answer 153

Leukocyte esterase = significant pyuria | Nitrite = presence of enterobacteriaceae which convert nitrates to nitrites

Question 154

Pt w/ CAP takes metformin, lisinopril, atorvastatin at home, presents w/ s/s pre-renal azotemia, next steps?

Answer 154

Discontinue metformin (can cause lactic acidosis in AKI and sepsis - must withhold until renal fxn improves) and start fluids

Question 155

Thyroid nodule pathway -> clinical evaluation (for cancer risk factors = family hx, radiation exposure, cervical lymphadenopathy, compressive symptoms like hoarseness/difficulty swallowing, and current thyroid status hyper or hypo) -> TSH and US

Answer 155

If suspicious for cancer via clinical or US findings go to FNA. If no cancer risk factors of suspicious US findings and low TSH = Iodoine 123 scintigraphy -> if hot then tx hyperthyroidism if cold then FNA c/f cancer

Question 156

Manifestations of SLE: clinical vs lab

Answer 156

Clinical: constitutional, arthritis, butterfly rash and photosensitivity, serositis (pleurisy, pericarditis, peritonitis), thromboembolic events d/t vasculitis and antiphospholipid antibodies, cognitive dysfn and seizures Lab: hemolytic anemia, thrombocytopenia, leukopenia (all three cell lines d/t peripheral destruction!), hypocomplementemia (C3 and 4), antibodies = ANA (sensitive), anti-dsDNA and anti-Sm (specific). If pancytopenia = d/t peripheral immune mediated destruction of all 3 cell lines; however can w/u by doing bone marrow biopsy to r/o drugs/leukemia/myelodysplasia/malignant invasion

Question 157

1st line tx for MS exacerbation

Answer 157

Glucocorticoids (IV methylpred); plasmapharesis if pt is refractory to corticosteroid therapy. No evidence for cyclophosphamide or IVIG during flare

Question 158

Complications of heat stroke (epistaxis mechanism)

Answer 158

Rhabdo, renal failure, ARDs, and DIC - DIC can lead to coagulopathic bleeding which explains persistent epistaxis

Question 159

What disorders are associated w/ vitiligo?

Answer 159

Autoimmune disorder (since vitiligo is an autoimmune destruction of melanocytes) pernicious anemia, definitely autoimmune thyroid disease, T1DM, primary adrenal insufficiency, hypopituitarism, alopecia areata

Question 160

MEN1 associated conditions

Answer 160

Hyperparathyroidisms, Zollinger Ellison syndrome, pituitary tumors

Question 161

When to tx pts w/ metabolic acidosis w/ sodium bicarb

Answer 161

Only if severe acidosis w/ pH < 7.1

Question 162

Median age 60, inc in production of all three blood cell lines and splenomegaly, dx?

Answer 162

Polycythemia vera

Question 163

Diffuse telangiectasias (ruby colored papules on lips that blanch w/ pressure), digital clubbing, recurrent epistaxis, wide spread AV malformations, dx?

Answer 163

Hereditary telangiectasia (Osler-Weber-Rendu syndrome); auto dominant disorder. AVMs in lungs can shunt blood from right to left side of heart causing chronic hypoxemia and reactive polycythemia

Question 164

Pulmonary symptoms, IVDU, cavitary lesions on imaging, dx?

Answer 164

Septic embolism from infective endocarditis of tricuspid valve most commonly w/ staph aureus

Question 165

Causes of high anion gap metabolic acidosis: CAT MUDPILES

Answer 165

``` C: carbon monoxide, cyanide A: aminoglycosides T: theophylline, toulene (glue sniffing) M: methanol U: uremia D: DKA, alcoholic ketoacidosis, starvation ketoacidosis P: paraldehyde, phenformin, paracetamol/acetaminophen I: iron, isoniazid, inborn erros metabolism L: lactic acidosis E: ethylene glycol, ethanol S: salicylates ```

Question 166

Victims of house fire, concern for what toxicities?

Answer 166

Cyanide and carbon monoxide; tx cyanide w/ hydroxocobalamin or sodium thiosulfate OR w/ nitrates to induce methemoglobinemia

Question 167

Intermittent diarrhea and lower abdl pain now w/ low back pain/stiffness for two months; pain helps w/ NSAIDs but makes diarrhea worse. Labs show anemia and thrombocytosis and SI joint inflammation, dx?

Answer 167

``` IBD complicated by spondylarthritis - extraintestinal manifestations of IBD (including both) = arthritis, eye, skin (pyoderma gangrenosum), hepatobiliary dz (primary sclerosing cholangitis). Arthritis common in IBD and can involve axial or peripheral joints; tx the IBD to treat arthritis (DMARDs) ```

Question 168

Pt w/ T2DM on metformin and glargine (long acting basal) but still elevated A1c but good fasting blood glu, likely cause

Answer 168

Postprandial hyperglycemia -consider combined long acting basal (to control baseline and fasting glucose) and add rapid acting meal time insulin to control postprandial glu

Question 169

When to do barium enema or sigmoidoscopy or colonoscopy?

Answer 169

Left sided pathology

Question 170

What type of infection and tx for pt w/ fever and cough productive of foul smelling sputum after instrumentation of upper airway (other risk factors = poor dentition, impaired consciousness)

Answer 170

Aspiration pneumoniae d/t anaerobes - tx w/ clindamycin for anaerobic coverage

Question 171

What diagnostic tool/score to determine placement and guide tx for community acquired pneumonia

Answer 171

``` CURB65 C - confusion U - BUN >30 R - respirations > 30 B - pressures < 90 sys or < 60 dia 65yo Score 0-1 outpatient, 2-3 likely inpatient, >3 inpatient +/- ICU ```

Question 172

Tx for CAP and types of bugs?

Answer 172

Covering strep pneumo, haemophilus influenzae, legionella, mycoplasma pneumoniae SO need beta-lactam coverage and atypicals = 1) for inpatient coverage: fluoroquinolone (eg moxi) or beta-lactam plus macrolide (ie ceftriaxone plus azithro), 2) outpatient consider just macrolide or doxy

Question 173

Toxin drug not shown on usual drug screen (cocaine, PCP, THC, alcohol, and meth show up), long duration of effect (agitation, combativeness, delirium, psychosis), effects of intoxication take up to a week to subside, drug?

Answer 173

Bath salts

Question 174

Painless genital ulcer (chancre) in setting of high risk sexual behavior, dx and types of tests?

Answer 174

Primary syphilis, nontreponemal vs treponemal; non treponemal (VDRL serum) lower sensitivity w/ false negative early on in dz, treponemal like florescent treponemal antibody absorption has higher sensitivity

Question 175

Single most important prognostic consideration in tx of pts w/ breast cancer?

Answer 175

TNM staging; other stuff like ER/PR status, HER-2/neu oncogene, and histological grading are important but less so

Question 176

OSA pathophys, s/s, sequelae

Answer 176

Relaxation of pharyngeal muscle causes airway closure w/ loud snoring w/ periods of apnea, daytime somnolence/morning HA/affective cognitive symptoms, look for systemic HTN and pulmonary HTN and right heart failure, also hypoxemia causes kidneys to respond by increasing EPO -> erythrocytosis elevated hematocrit/HgB (polycythemia)

Question 177

Men 40-60, weight loss, steatorrhea, fever, abdl pain, athralgia, chronic cough, valvular regurgitation, pigmentation, PAS positive material in lamina propria of small intestine, foamy macrophages dx?

Answer 177

Whipple's disease = rare multi systemic illness caused by bacillus Tropheryma whippelii

Question 178

Winter's Formula for determining respiratory compensation during metabolic acidosis

Answer 178

PaCO2 = 1.5(HCO3) + 8 (+/- 2)

Question 179

D-xylose for proximal small intestinal malabsorption

Answer 179

Normally D-xylose absorbed w/o need for degradation by pancreatic or brush border enzymes; subsequently excreted in urine if absorption unimpaired. Low urinary D-xylose indicates poor absorption d/t mechanical likely atrophy of intestinal villi as in Celiac disease. If D-xylose excretion is normal indicates good absorption and likely enzymatic issue like chronic pancreatitis

Question 180

Evaluate ascites as portal htn vs non portal htn with what?

Answer 180

SAAG serum albumin to ascites gradient >1.1 = portal HTN (cardiac ascites or cirrhosis). SAAG <1.1 = non portal HTN (malignancy, pancreatitis, nephrotic, TB). Calculating SAAG = serum albumin - ascites albumin

Question 181

Erythema nodosum (painful subcutaneous nodules common on anterior lower legs), athralgias, cough/dyspnea/CP, anterior posterior uveitis, black woman, path showing noncaseating granulomas (negative for acid-fast or fungi), dx and what on cxr?

Answer 181

Sarcoidosis, cxr shows bilateral hilar lympphadenopathy w/ reticular opacities. Non-caseating = non-necrotic not infectious

Question 182

MS, new plaque at thoracic spinal cord, expected deficits

Answer 182

Leg weakness (lateral corticospinal tract), dec pinprick sensation (lateral spinothalamic tract), dec proprioception (dorsal columns), urinary continence (descending motor and parasympathetic autonomic fibers)

Question 183

Lesion at cerebellar hemisphere expected symptoms

Answer 183

Dysdiadochokinesia, dysmetria, limb ataxia, intention tremor

Question 184

Brain stem lesion expecting s/s

Answer 184

Ipsilateral cranial nerve dysfunction, contralateral motor and sensory deficits

Question 185

1st line tx for trigeminal neuralgia, side effects of said drug?

Answer 185

CBZ - care for nausea, vomiting, aplastic anemia (well technically leukopenia)

Question 186

OA vs RA

Answer 186

OA: idiopathic aging or chronic wear and tear causing chronic pain, stiffness, bony enlargement of large weight bearing joints on LE or small peripheral joints in hands/cervical/lumbar spine; look for Bouchard noges (PIP) and Herbeden nodes (DIP) RA: most frequently involves metacarpophalangeal joints/PIP/wrist, and improvement throughout day

Question 187

African American, cough, hilar adenopathy, erythema nodosum, non caseating granulomas, dx?

Answer 187

Sarcoidosis! This pt was tx w/ high dose glucocorticoids but rapidly decompensated, hx of farmer in Mississippi, found to eventually have histoplasmosis (appropriate epidemiologic setting Mississippi Ohio River, mediastinal or hilar lymph nodes, athralgias, and erythema nodosum)

Question 188

Chronic hypoventilation d/t COPD, obesity hypovent, neuromuscular causes have chronic hypercapnia w/ respiratory acidosis, compensation how?

Answer 188

Kidneys inc bicarb retention creating secondary metabolic alkalosis

Question 189

Cancers a/w paraneoplastic syndrome (tumor producing hormones and or cytokines)

Answer 189

Lung, breast, ovaries, lymphomas

Question 190

Pt w/ lung cancer and muscle weakness/purple violaceous papules involving dorsum of fingers, dx?

Answer 190

Paraneopalstic syndrome w/ dermatomyositis (other syndromes affecting peripheral nerve and or muscle = myasthenia or lambert); symmetrical proximal muscle weakness and erythematous rash on finger (Gottron's sign) and or upper eyelids (heliotrope eruption), dx w/ muscle bx

Question 191

Myasthenia vs Lambert

Answer 191

Myasthenia: antibodies against ACH receptor in postsynaptic membrane; fluctuating weakness worsens w/ use Lambert: presynaptic membrane voltage gated Ca channels; gets better w/ use

Question 192

PE -> hyperventilation -> respiratory alkalosis -> crampy pain/paresthesias/carpopedal spasm -> what happened to Ca?

Answer 192

Calcium exists as 3 forms = ionized (45%), albumin bound (40%), calcium bound to inorganic/organic ions (just 15%); the alkalosis shifted pH to basic = H+ ions dissociate from albumin freeing up albumin to bind w/ calcium inc total albumin bound calcium and lowering ionized ca (this is what matters) = causing dec in free calcium while total calcium unchanged. Alkalosis -> H+ dissociate from ablumin -> albumin binds Ca -> hypocalcemia = carpopedal spasms etc

Question 193

``` Episodic flushing (pounding sensation), chronic diarrhea, weight loss, valvular heart dz w/ tricuspid regurg, miscellaneous includes niacin deficiency w/ dermatitis/diarrhea/dementia (pellagra), dx and mgmt? ```

Answer 193

Carcinoid syndrome, dx w/ elevated 24hr urinary excretion of 5-HIAA, CT/MRI of abdomen/pelvis to localize tumor, tx w/ octreotide for symptomatic patients and prior to sx/anesthesia, sx for liver mets

Question 194

What is carcinoid syndrome?

Answer 194

Neuroendocrine tumor common in distal small intestine, proximal colon and lung, strong mets to liver = secrets histamine, serotonin, and VIP that are metabolized in liver; in pts w/ liver mets these hormones are released directly into systemic circ leading to carcinoid syndrome

Question 195

Cherry angiomas = senile hemangiomas (common benign vascular tumors in adults) vs the kid version?

Answer 195

Strawberry hemangiomas = infantile, rapidly grow but regress by age 5-8

Question 196

A single brain abscess results from direct extension of adjacent infection (otitis, sinusitis, dental); most common bugs = viridans strep, staph aureus; look for HA/fever/focal deficits/seizure w/ brain imaging showing SINGLE ring enhancing lesion w/ central necrosis, other ddx?

Answer 196

Cerebral toxo = HIV w/ CD4 <100, look for multiple ring enhancing lesions Rhizopus causing mucormycosis = necrotic and highly destruction multiple lesions, most infxn in pts w/ bad T2DM or immunocompromised Primary brain neoplasm = lymphoma or gliobastoma or mets could cause sz and single ring enhancing lesion too HOWEVER this pt w/ fever and weeks of sinusitis = brain abscess more likely

Question 197

Young man, two months cough w/ pulmonary nodules and retroperitoneal lymphadenopathy - think metastatic - so what common malignancies are in young men and what is this dx?

Answer 197

Common malignancies (obviously rare) = testicular, lymphoma, leukemia. Testicular - unilateral painless testicular nodules, dull abdominal ache, metastatic symptoms (dyspnea, low back pain d/t retroperitoneal lymph node compression); dx w/ tumor markers AFP and beta-hCG, scrotal US, staging imaging w/ CT/CXR, tx w/ radical orchiectomy/chemo

Question 198

``` Mammogram guidelines? Colon cancer guidelines? HIV guidelines? Hyperlipidemia guidelines Osteoporosis screen guideliens ```

Answer 198

Every two years starting at 50; routine mammo not necessary after 75 Age 50-75; every ten years or yearly fecal occult blood (40 or 10 year before family member's dx) 15-65yo HIV antibody screen once Men 35+ every 5 years, women starting 45 every 5, uncertain when to quit Women 65+ DEXA, interval unknown

Question 199

Old lady, recent sx for femoral fracture 4 months ago following a fall, now w/ progressive confusion/weakness/unsteadiness for days, dx and MOA?

Answer 199

Subdural hematoma - tearing of bridging veins leads to slow bleeding in subdural space common in pts w/ cerebral atrophy (old/alcoholics) since bridging veins must traverse longer distance. Noncon CT shows crescent shaped hyperdensity that crosses suture lines; if small hematomas manage conservatively where as larger ones w/ neuro deficits = sx evacuation

Question 200

Stroke lesions and their s/s: *first off important note - anterior vasculature is compromised of the ICA and its branches (paired anterior and middle cerebral arteries) while the posterior circ is comprised of the paired vertebrals which combine to form basilar which then divides into paired posterior cerebral

Answer 200

Anterior cerebral artery: contralateral motor and or sensory more pronounced in lower limb; also urinary incontinence d/t damage to micturition center of mesial frontal lobe Lacunar infarcts: small vessel infarcts affecting deep subcortical structures, look for pure motor hemiparesis, pure sensory stroke MCA: contralateral, somatosensory deficits *more pronounced in face/upper limb than lower limb AND homonoymous hemianopia/quadrantanopia (if dom left = aphasia; if nondom right = hemineglect) ICA occlusion: affects both MCA and ACA - dense symptoms Posterior cerebral artery: eye stuff!

Question 201

RA mgmt?

Answer 201

Start DMARDs soon as possible -> methotrexate first -> if s/s >6 months consider step up w/ TNF inhibitor or parallel therapy w/ a nonbiologic eg sulfasalazine/hydroxychloroquine. Save NSAIDs or glucocorticoids for initial temporary symptomatic relief while awaiting response to DMARD

Question 202

Middle aged women 30-50, fatigue/pruritus, progressive jaundice/hepatomegaly/cirrhosis, cutaneous xanthomas (fat under eyelids) and xanthelasmas, dx and complications and mgmt?

Answer 202

Primary biliary cholangitis (bitches are coy so no UC/IBD), look for AMA antibody, cholestatic pattern of livery injury (elevated alk phos and aminotransferases), complications include malabsorption/osteo/hepatocellular carcinoma, tx w/ ursodeoxycholic acid and liver transplant

Question 203

Which vitamin deficiency a/w each condition: chronic alcohol use, vegetarians/vegans

Answer 203

Chronic alcohol = folate d/t limited dietary intake Vegetarians/vegans = Vit B12 def Both folate and B12 cause megaloblastic anemia; however B12 has neuro deficits (proprioception and vibration deficit, memory, irritability and dementia)

Question 204

MOA of senile purpura (old people bruising)

Answer 204

Loss of elastic fibers in perivascular connective tissues: minor abrasions that merely stretch skin of younger pt can rupture superficial blood vessel in elderly

Question 205

Asymptomatic hypercalcemia and normal renal function with high-normal PTH and low urinary calcium excretion, dx? Compared to what other dx?

Answer 205

Familial hypocalciuric hypercalcemia; benign autosomal dominant w/ mutation in calcium sensing receptor - normally high Ca suppresses PTH secretion but in FHH higher calcium concentrations are required to suppress PTH. Compared to primary hyperparathyroidism: pts w/ primary hyperPTH have inc urinary calcium excretion while FHH pts have low urinary calcium. Urine calcium/Cr ratio UCCR is .02 in primary hyperPTH

Question 206

Fire in building, HA w/ altered mentation and dizziness and bright cherry lips, dx and mgmt?

Answer 206

CO poisoning (CO higher binding affinity than O2 -> CO forms carboxyhemoglobin which impairs oxygen delivery to tissue since carboxy heme shifts dissociation curve to left), tx w/ 100% oxygen via nonrebreather to compete w/ CO binding and dec half life of CO; hyperbaric if severe

Question 207

Progression of Alz disease?

Answer 207

Early memory loss!, then language difficulties, apraxia, followed late in course by impaired judgment and personality changes

Question 208

DDx of dementia subtypes: alz, vascular, ftd, dementia w/ lewy, NPH, prion

Answer 208

Alz: early memory loss, language difficulties, and apraxia followed late by impaired judgement and personality changes FTD: early personality changes, compulsive behaviors, and impaired memory Lewy: visual hallucinations, spontaneous parkinsonism (w/ inc sensitivity to antipsychotics), fluctuating cognition NPH: ataxia early, urinary incontinence, dilated ventricles Prion: behavioral change, RAPID progression, MYOCLONUS

Question 209

Types of HA: migraine, cluster, tension

Answer 209

Migraine: female, family hx, variable onset, unilateral, pulsatile throbbing, a/w auras/photophobia/phonophobia/nausea Cluster: male, no family hx, onset during sleep, behind one eye, excruciating/sharp/steady, a/w sweating/facial flushing/nasal congestion/lacrimation/pupillary changes Tension: female, no family hx, onset w/ stress, band-like pattern around head bilateral, dull tight persistent, a/w muscle tenderness in head/neck/or shoulders

Question 210

Three types of acne vulgaris presentation and tx option progression?

Answer 210

Comedonal acne -> inflammatory acne -> nodular cystic acne. Start with topical retinoids +/- organic acid preps like salicylic -> add topical benzoyl peroxide -> add topical antibiotics (erythromycin/clindamycin) -> add oral antibiotics -> finally take oral isotretinoin

Question 211

Pt w/ previous TB tx, now w/ >3 months of weight loss, cough, hemoptysis, and fatigue; imaging shows >1 apical cavitary lesions w/ collecting "ball inside", dx?

Answer 211

Chronic pulmonary aspergillosis; dx w/ aspergillus IgG serology

Question 212

4 types of blood transfusion reaction a/w hypotension:

Answer 212

Anaphylactic: seconds to minutes, rapid shock/angioedema/urticaria/wheeze/respiratory distress, d/t anti IgA antibodies Primary hypotension rxn: minutes, transient hypotension in pts taking ACEi, d/t bradykinin in blood products (normally degraded by ACE) Bacterial sepsis: minutes to hrs, fever/chills/septic shock and DIC Transfusion related acute lung injury: within 6 hrs, resp distress and signs of noncardiogenic pulmonary edema, d/t donor anti-leukocyte antibodies Side note on ABO mismatching: within an hour, clerical errors mostly, will cause acute hemolytic transfusion reaction w/ fever, chills, flank pain, hemoglobinuria, can progress to renal failure and DIC

Question 213

19yoM, recent influenza viral infection, gets better than worsens, now has high fever, productive cough often hemoptysis, and multilobar cavitary infiltrates, dx?

Answer 213

Secondary bacterial pneumonia (common influenza complication - improves than gets worse) d/t MRSA in young <65 following recent influenza

Question 214

Dry skin with rough horny plates resembling fish or repitle scales, dx and mgmt?

Answer 214

Ichthyosis vulgaris - mutation in filaggrin gene - ikthys is Greek for fish; tx w/ emollients but if worse consider keratolytics (coal tar, salicylic acid) and topical retinoids. Psoriasis = silvery scales over extensor surfaces of elbows, knees, scalp, and trunk

Question 215

Acromegaly, initial work up?

Answer 215

Get Insulin-like GF1 first since that mediates most effects of GH and GH not as sensitive d/t wide fluctuations. If IGF-1 elevated -> get oral glucose suppression test since that should suppress GH. If no sppression = MRI brain for pituitary mass vs extrapituitary cause of acromegaly ie ectopic GH tumor

Question 216

Mechanisms of hypokalemia *4 possibilities

Answer 216

Insulin, beta-adrenergic agents (given during COPD exacerbation question), GI losses, and renal wasting (hyperaldo or diuretics)

Question 217

Mgmt and cutoff ranges in carotid artery stenosis?

Answer 217

Initial interventions should include intensive medical mgmt (ASA, statin, BP control, lifestyle); symptomatic patients (ie TIA or stroke in distribution of the affected vessel) w/ high grade stenosis (>70%) = CONSIDER CAROTID ENDARTERECTOMY

Question 218

Chronic HepC infection, mgmt?

Answer 218

Tx of underlying cause and strategies to prevent further liver dmg (alcohol avoidance, HepA and HepB vaccination); sofosbuvir-velpatasvir have improved ability to achieve virologic cure! (side not: lamivudine - reverse transcriptase inhibitor used for HIV and chronic HBV co-infection)

Question 219

Diabetic patients w/ alteration in sensation including loss of propiroception, however w/ motor findings including weakness, positive Babinski and hyperreflexia, dx and mgmt?

Answer 219

Upper motor neuron process (Babinski and hyperreflexia; diabetic neuropathy is purely lower motor neuron); get spine MRI to r/o mass or epidural abscess

Question 220

Pt w/ stroke found down on floor for hours, hx of CKD, EKG abnormalities, dx and mechanism and tx?

Answer 220

Acute on chronic renal failure (d/t on floor for hours = dehydration/rhabdo) w/ hyperK; tx w/ IV calcium gluconate first followed by definitive measures to reduce total K

Question 221

Intravascular and extravascular hemolysis and hemoglobinuria, cytopenias, venous thrombosis, dx/MOA/tx?

Answer 221

Paroxysmal nocturnal hemoglobinuria (PNH); genetic defect causing lack of CD55 and CD59 (needed to prevent membrane attack complexes from forming on RBCs); LOOK for intravascular hemolysis (elevated bili/LDH/low hapto) and thrombosis; flow cytometry for dx; tx w/ iron and folate supplementation and eculizumab to inhibit complement

Question 222

Secondary causes of restless leg syndrome and tx options?

Answer 222

Iron deficiency anemia, uremia, T2DM, MS/Parkinson, pregnancy, drugs Tx: supplement w/ iron when serum ferritin low, supportive measures/avoid aggravating factors if symptoms mild/intermittent. For persistent/moderate 1st line meds = dopamine agonists (pramipexole) or alpha 2 delta calcium channel ligands (gabapentin)

Question 223

Spontaneous red eye in 34yoM, no itching/pain/or discharge, vitals stable, dx and mgmt?

Answer 223

Spontaneous subconjunctival hemorrhage, no tx required

Question 224

Pure sensory stroke, location of lesion

Answer 224

Lacunar stroke of the posterolateral thalamus p/w sudden onset contralateral sensory loss involving all sensory modalities; weeks to months later pts develop thalamic pain syndrome = severe paroxysmal burning pain exacerbated by light touch

Question 225

Pt w/ PE and CKD (estimated GFR <30) mgmt?

Answer 225

Anticoagulation w/ unfractionated heparin d/t severe renal insufficiency; can consider enoxaparin (LMWH), fondaparinux (factor Xa inhibitor), or rivaroxaban (factor Xa inhibitor) if pts not renally impaired

Question 226

Monitor Heparin w/ what? Warfarin?

Answer 226

aPTT for Heparin. PT or INR for Warfarin

Question 227

Criteria for metabolic syndrome:

Answer 227

At least 3/5 criteria: 1) Large waist circumference (>40 men or >35 women) 2) Fasting glu >100-110 3) BP >130/80 4) Triglycerides >155 5) HDL <40 men, <50 women

Question 228

Old man dysphagia, halitosis, aspiration, regurgitation, large neck mass, dx? Dx tests? Mgmt?

Answer 228

Zenker diverticulum; dx w/ barium esophagram or esophageal manometry; open/endoscopic sx or cricopharyngeal myotomy

Question 229

LIver maintains glucose via glycogenolysis and gluconeogenesis. How does gluconeogenesis work?

Answer 229

Main 3 substrates are gluconeogenic amino acids (breakdown of muscle protein), lactate (anaerobic glycolysis), and G3P (triacylglycerol in adipose). Amino acids that can be used in gluconeogenesis = alanine and glutamine. Alanine converted to pyruvate during this process

Question 230

Fluctuating and fatigable proximal muscle wekaness worse later in day, dx? And s/s for different organs, dx, and tx?

Answer 230

Myasthenia gravis (typically middle age women, old men); ocular (diplopia, ptosis), bulbar (dysphagia, dysarthria), respiratory muscles (myasthenic crisis). Dx via Edrophonium (Tensilon) test, ice pack test, ACH receptor antibodies! If already confirmed myasthenia -> CT chest to eval thymoma (since that can tx). Tx w/ acetylcholinesterase inhibitors (eg pyridostigmine), immunotherapy w/ corticosteroids/azathioprine, thymectomy

Question 231

Causes of exacerbations to myasthenia gravis:

Answer 231

Meds: fluoroquinolones, aminoglycosides, anesthetic blocking agents, BB Pregnancy/childbirth Sx especially thymectomy

Question 232

Ddx for neuromuscular weakness: upper motor neurons, anterior horn cells, peripheral nerves, NMJ, muscle fibers

Answer 232

Upper motor neurons: leukodystrophies, vasculitis, brain mass, Vit B12 def Anterior horn cells: spinal muscular atrophy, ALS, paraneoplastic syndromes, poliomyelitis Peripheral nerves: hereditary primary motor sensory neuropathy, GBS, diabetic neuropathy, amyloid neuropathy (myeloma), lead poisoning NMJ: myasthenia gravis, Lambert-Eaton syndrome, organophosphate poisoning, Botulism Muscle fibers: muscular dystrophies, polymyositis and dermatomyositis, hypothyroidism, corticosteroids, HIV myopathy

Question 233

UMN and LMN signs (spastic paralysis and muscle atrophy/fasciculations), dx?

Answer 233

ALS

Question 234

Complication of AR where pt develop sudden onset of worsening CP, hypotension, PE, and early decrescendo diastolic murmur

Answer 234

Dissection can propagate proximally from site of intimal tear to involve aortic valve and cause acute AR. The dissection can propagate into pericardial space and lead to hemopericardium/tamponade; these pts have pulsus paradoxus, elevated JVD, and cardiogenic shock but w/ CLEAR lung fields

Question 235

Recurrent episodes of prolonged CP over several months not a/w activity or other accompanying symptoms; EKG, exercise stress test, PE are unremarkable, dx?

Answer 235

Esophageal disorder

Question 236

DDX for chest pain?

Answer 236

CAD: substernal, radiation to arm, shoulder, jaw, exertion, relieved by rest/nitro Pulmonary/pleuritic: sharp stabbing, worse w/ inspiration, pericarditis (worse when flat better leaning forward), PE, pneumothorax (respiratory distress, hypoxia) Aortic: sudden severe tearing pain, radiates to back, elderly men, HTN and risk factors for atherosclerosis GI/esophageal: non-exertional, relieved by antacids, upper abdl and substernal, a/w regurgitation/nausea/dysphagia, nocturnal pain Chest wall/MSK: persistent, prolonged, worse w/ mvmt or change in position, repetitive activity

Question 237

24yo syncope while shoveling snow, SOB, CP recently related to exercise; crescendo decrescendo systolic murmur along left sternal border WITHOUT carotid radiation, dx?

Answer 237

HoCM

Question 238

Tx of hypertriglyceridemia pathway:

Answer 238

Elevate for secondary causes -> 150-500 = lifestyle modifications (weight loss, moderate alcohol, inc exercise) + statin if known cardiovascular disease If >1000: initial goal is pancreatitis prevention w/ fibrates, fish oil, or abstinence from alcohol

Question 239

Wide pulse pressure! (sys >> dia), water hammer pulse, pounding heart sensation, dx?

Answer 239

Chronic aortic regurgitation: LV output leaks back into the left ventricle causing inc in LV end diastolic volume, myocardial hypertrophy, and chamber enlargement -> this brings LV apex close to chest wall causing pounding sensation esp in left lateral decubitus. Most common cause of chronic AR in developing countries = rheumatic; in developed = aortic root dilation/bicuspid

Question 240

More on ventricular aneurysm as a late complication following transmural MI, EKG, and US findings?

Answer 240

Persistent ST elevation and deep Q waves in the same leads as initial MI; look for progressive left ventricular enlargement and dyskinetic wall motion leading to HF

Question 241

What is the most effective lifestyle intervention in controlling BP?

Answer 241

Weight control! (other effective methods but in descending order = DASH diet, exercise, dietary sodium, alcohol intake)

Question 242

Progressive dyspnea, decreased exercised tolerance, A-fib w/ RVR and left

Answer 242

Tachycardia-mediated cardiomyopathy, tx w/ aggressive rate control/restore normal sinus rhythm as this can reverse the tachycardia mediated cardiomyopathy and normalization of LV systolic fxn

Question 243

Two weeks post MI, currently ECG unchanged w/ persistent ST segment elevation along w/ deep Q waves p/w exertional dyspnea and fatigue, faint systolic murmur over apex, dx?

Answer 243

Left ventricular aneurysm; look at question 2731 for good post MI pic

Question 244

Two types of HTN complications

Answer 244

Urgency: 180/120 no s/s or end organ dmg Emergency: malignancy - retinal hemorrgage, exudates, papilledema. Encephalopathy - cerebral edema, non focal s/s

Question 245

MOA of stress testing w/ adenosine?

Answer 245

Pharmacologic vasodilator stress testing that causes inc in blood flow in coronaries; expect to see much larger inc in blood flow in normal coronaries vs occluded vessels

Question 246

Types of stress testing, mechanism, best for, not for

Answer 246

Exercise EKG: inc HR and BP, best for patients able to reach tHR, not for LBBB/pacemaker/pts unable to reach tHR Pharmacologic w/ adenosine or dipyridamole: nonselective adenosine agonist that dilates coronary arteries w/o affecting HR or BP, best for LBBB/pacemaker/pts unable to reach tHR, NOT for reactive airway disease or pts on dipyridamole/theophylline Dobutamine stress: B-1 agonist, inc HR and BP much like exercise, best for reactive airway dz and pts unable to reach tHR, not for tachyarrhythmias

Question 247

Most common cause of MR in developed countries?

Answer 247

MVP *rheumatic heart can cause MS, MR, and AR too but is less common than MVP. MVP: look for mid-systolic click and mid to late systolic murmur -> this can progress to holosystolic murmur if the leaflet dysfunction and prolapse is severe enough. Also look for left atrial dilation w/ severe MR leading to a-fib

Question 248

Acute renal failure, malignant HTN (HA, blurry, nausea), UA w/ mild proteinuria, peripheral blood smear w/ schistocytes, dx?

Answer 248

Scleroderma renal crisis; microangiopathic hemolytic anemia (look for hemolysis w/ elevated bili, dec platelets, schistocytes)

Question 249

RCA occlusion can cause infarctions where, EKG findings?

Answer 249

Inferior and posterior wall MI. Inferior wall MI = ST elevations in inferior leads II, III, aVF; posterior wall MI = ST depression in V1 and V2. Look for hypotension, bradycardia, and AV block (RCA supplies AV node) during inferior MI

Question 250

Risk factors and clinical features a/w aortic dissection:

Answer 250

HTN (most common - think >50 yo), Marfan syndrome (think<40), cocaine use. S/s severe sharp tearing chest or back pain, >20mmHg variation in systolic BP btw arms

Question 251

Complications involved in aortic dissection

Answer 251

Stroke (carotid arteries), acute aortic regurgitation, Horner syndrome, acute MI, pericardial effusion/tamponade, hemothorax

Question 252

Biggest concern in giant cell arteritis (aka temporal arteritis)

Answer 252

Involvement of large vessels - aorta and proximal branches - look for aortic aneurysm and inc risk of dissection (also common symptoms of GCA = fever, weight loss, HA, claudication, visual symptoms)

Question 253

Medication for secondary prevention of coronary heart disease?

Answer 253

DAPT (w/ aspirin and P2y12 receptor blockers like clopidogrel); DAPT for at least a year if drug eluding stent BB ACEi/ARB HMG-CoA Aldosterone antagonist *if left ventricular EF <40% w/ HF symptoms or T2DM

Question 254

Note on use dependence and antiarrhythmic agents

Answer 254

Use dependence = enhanced effects of a durg during faster heart rates (seen in class IC *flecainide and class IV CCBs); class IC agents cause progressive decrease in impulse conduction w/ faster heart rates leading to inc in QRS duration (man w/ a-fib, started on antiarrhythmic, exercise test cause widened QRS)

Question 255

Symmetric duskiness and coolness of ALL symmetric fingertips, currently required pressors for hypovolemic shock, dx?

Answer 255

Norepinephrine induced vasospasm (pt has dec blood flow, vasoconstriction from pressure resulted in ischemia/necrosis). This is not cholesterol emboli w/ blue toe syndrome - since that has no symmetrical involvement

Question 256

Beck's triad?

Answer 256

Cardiac tamponade - fluid in pericardial space (that increases the intrapericardial pressure above the diastolic ventricular pressure) causing hypotension, distended neck veins, muffled heart sounds. This is d/t shift of interventricular septum toward left ventricular cavity causing reduced preload, stroke volume, and cardiac output

Question 257

Ejection click followed by crescendo-decrescendo systolic murmur over left 2nd intercostal space w/ widened splitting of S2 worse during inspiration, defect?

Answer 257

Pulmonic stenosis; ddx to aortic stenosis since murmur diminishes during inspiration (blood flow through lung instead of aorta)

Question 258

Comorbid conditions (hypercholesterolemia, HTN, T2DM), recent cardiac catherization, s/s of erythematous/purple discoloration of skin that blanches (livedo reticularis) and blue toe syndrome, renal injury, ocular involvement (Hollenhorst plaques), GI involvement (intestinal ischemia - nausea/abdl pain), lab findings (elevated Cr, eosinophilia, hypocoplementemia, UA w/ little to none casts/cells), dx??

Answer 258

Systemic atheroembolism from disruption of atherosclerotic aortic plaques (cholesterol crystal embolism). Confirm w/ skin or renal bx: biconvex needle shaped clefts within vessels, perivascular inflammation w/ eosinophils

Question 259

Multisystem involvent w/ renal failure, skin manifestations (livedo reticularis, blue toe), cerebral or intestinal ischemia (abdl pain, nausea), and Hollenhorst plaques after recent arteriography.

Answer 259

Cholesterol embolization! If contrast induced nephropathy = muddy brown casts and not multisystem involvement

Question 260

Drugs used in cardiac cases

Answer 260

Adenosine: (A for affecting AV node) identify/termination of paroxysmal supraventricular tachycardia Atropine: symptomatic sinus bradycardia or AV nodal block Amiodarone: atrial and ventricular tachycardia, IV magnesium: first line for stable pts w/ torsades

Question 261

S3 vs S4 features, when normal, and abnormal associated conditions

Answer 261

S3: ventricular gallop sound after S2, heard during rapid filling of ventricles in diastole, turbulent blood flow to ventricles d/t increased volume; normal in children/young adults/pregnancy; a/w age >40, restrictive cardiomyopathy, high output states S4: atrial gallop sound before S1, heard immediately after atrial contraction phase as blood is forced into stiff ventricle; normal in healthy old folks; abnormal in younger adults/children, a/w ventricular hypertrophy, and ACUTE MI d/t ventricular stiffening and dysfunction induced by ischemia

Question 262

Mechanism of action of statins and why statin induced myopathy?

Answer 262

Statins inhibit intracellular HMG-CoA reductase enzyme - thereby prevents conversion of HMG CoA to mevalonic acid, increases number of cell membrane LDL receptors. Statins dec coenzyme Q10 which is involved in muscle cell energy production possibly contributing to myopathy

Question 263

Mgmt of HCM?

Answer 263

Avoidance of volume depletion, BB/CCB, sx if persistent; goal is to reduce LVOT *slow HR to prolong diastole and dec myocardial contractility

Question 264

Mechanical complications of acute MI: right ventricular failure, papillary muscle rupture, interventricular septum rupture, free wall rupture, left ventricular aneurysm (time course, involved coronary, s/s, echo findings)

Answer 264

1) Rt ventricular failure: acute, RCA, hypotension/clear lungs/kussmaul sign, hypokinetic RV 2) Papillary muscle rupture: acute (3-5 days), RCA, severe pulmonary edema/holosystolic murmur, severe mitral regurg w/ fail leaflet 3) Interventricular septum rupture: acute (3-5 days), LAD or RCA, CP/holosystolic murmur/biventricular failure/SHOCK, left to right shunt w/ inc in O2 from RA to RV 4) Free wall rupture: 5 days - 2 weeks, LAD, CP/shock/distant heart sounds, pericardial effusion w/ tamponade 5) Left ventricular aneurysm: months, LAD, subacute HF/stable angina, thin and dsykinetic myocardial wall

Question 265

Hemodynamics in heart failure

Answer 265

Dec contractility -> dec cardiac output -> compensatory neurohormonal activation -> inc systemic vascular resistance -> inc afterload

Question 266

Pulsus paradoxus is commonly associated with what conditions?

Answer 266

Cardiac tamponade, severe asthma or COPD (inspiration decreases BP - think less left ventricular output d/t either mechanical constriction (effusion or lung expansion *COPD/asthma) or blood stays in pulmonary vasculature longer d/t inc intrathoracic pressure w/ COPD/asthma)

Question 267

What drugs confer survival benefit in CHF vs drugs that reduce symptoms/hospitalizations but not overall survival?

Answer 267

ACEi, ARBs, BB, sprinolactone confer survival benefit; digoxin/furosemide reduce symptoms/hospitalizations

Question 268

Mobitz type I vs type II

Answer 268

``` I = progressive prolongation of PR interval; benign, transient, tx involves observation and hold meds that affect AV node II = constant PR interval but QRS will drop suddenly; this can progress to complete block, tx requires pacemaker ```

Question 269

Meds that affect AV node =

Answer 269

BB, CCB, digoxin

Question 270

Elevated systolic, normal diastolic (<90) = what dx and MOA

Answer 270

Isolated systolic HTN (elderly); d/t inc stiffness of arterial wall, manage w/ lifestyle modifications and meds

Question 271

Dihydropyridine CCBs and MOA

Answer 271

The -dipines; coronary artery vasodilation increases myocardial oxygen supply; also invokes systemic arterial vasodilation which causes a reduction in afterload causing reduction in myocardial oxygen demand (basically inc supply and dec demand through vasodilation)

Question 272

Signs of digoxin toxicity?

Answer 272

GI symptoms (anorexia, nausea, abdl pain), and neurological visual symptoms (color vision, scotomas, blindness); beware amiodarone can inc dig lvls -> it is recommended to halve the dig when starting amiodarone

Question 273

Most common cause of sudden cardiac arrest in the immediate post infarction period in pts with acute MI?

Answer 273

Re-entrant ventricular arrhythmias (v-fib, ventricular premature beats, or v-tach)

Question 274

Infective endocarditis (IV drug user), dvlpt of AV block, suspicious for what dx?

Answer 274

Perivalvular abscess extending into adjacent cardiac conjunction tissues

Question 275

Maneuvers to change murmurs and their physiologic effect: valsalva, standing, nitro, hand grip, squatting, leg raise

Answer 275

``` Valsava: dec preload Abrupt standing: dec preload Nitroglycern: dec preload aka dec diastolic pressure Sustained hand grip: inc afterload Squatting: inc afterload and inc preload Passive leg raise: inc preload ```

Question 276

Primary valve abnormality in pts with HOCM

Answer 276

Asymmetric septal hypertrophy with LVH leads to systolic anterior motion of the mitral valve (valve makes contact with septum - obstructs blood flow out of LV during systole = LVOT)

Question 277

Tachyarrhythmia (narrow or wide) w/ clinical hemodynamic instability, initial tx?

Answer 277

Cardioversion; cardioversion if QRS complex present (minimize chance of energy delivery during repolarization phase *which can precipitate v-fib). Vs defibrillation -> high energy at random point in cycle indicated in v-fib or pulseless v-tach

Question 278

Prior cardiac sx (coronary artery bypass, valve sx, TB, malignancy, uremia), s/s of right hear failure (peripheral edema, ascites, elevated JVP, pericardial knock, pericardial calcifications), dx?

Answer 278

Constrictive pericarditis

Question 279

How does hyponatremia parallel the severity of heart failure in pts w/ CHF (Na lvl is good predictor of adverse outcomes)

Answer 279

CHF -> low cardiac output and dec perfusion pressure at baroreceptors/renal afferent arterioles causes release of renin and norepinephrine and ADH -> ADH promotes water reabsorption dec Na

Question 280

What is S3; and given the classical dx a/w with S3, immediate mgmt?

Answer 280

Low freq diastolic sound after S2 associated with left ventricular failure (ken-tuc-KY; blood from LA strikes blood that is already still in LV causing reverb). Tx w/ IV diuretics for symptomatic relief

Question 281

Ddx for secondary causes of HTN?

Answer 281

Renal parenchymal disease: elevated serum Cr, abnormal UA w/ proteinuria and RBC casts Renovascular disease: severe HTN >180 and resistant to multiple HTN meds, possible recurrent flash pulmonary edema, unexplained rise in Cr after starting ACEi, abdominal bruit (very specific) Primary aldosteronism: hypoK, slight hypernatremia, HTN w/ adrenal incidentaloma (no effects on HR) Pheochromocytoma: paroxysmal elevated BP w/ tachy, HA/palpitations/diaphoresis, inc urinary excretion of vanillylmandelic acid Cushing: central obesity, facial plethora, muscle weakness, abdominal striae, ecchymosis, inc 24hr urinary free cortisol excretion Coarctation of the aorta: difference in UE vs LE pressures

Question 282

Hemodynamic measurements in shock: hypovolemic vs cardiogenic vs septic (RA pressure = preload, PCWP aka left atrial pressure = preload, cardiac index = pump function, SVR = afterload, MvO2)

Answer 282

Hypovolemic shock: decreased everything except elevated afterload Cardiogenic shock = significantly decreased CI (pump dysfunction duh), elevated preloads and afterload to compensate Septic shock = *main issue is major dilation and capillary permeability causing dec SVR, dec preload; CI and MvO2 increased to compensate

Question 283

Hx of left ventricular systolic dysfunction and persistent a-fib (or rhythm problem), p/w s/s of hypo or hyperthyroidism, hepatotoxicity, bradycardia, heart block, pneumonitis, neurologic symptoms, and visual disturbances, what drug toxicity?

Answer 283

Amiodarone

Question 284

Viral prodrome, heart failure symptoms (dyspnea, orthopnea, edema), chest pain, echo shows dilation (bx w/ lymphocyctic infiltration), dx and tx?

Answer 284

Viral myocarditis; tx w/ meds (diuretics, ACE, BB), temporary ventricular assist device, heart transplant if no recovery

Question 285

Well known side effects of high dose niacin used to tx lipid abnormalities? Mechanism? Tx?

Answer 285

Cutaneous flushing and intensive generalized pruritus. D/t release of histamine and postaglandins resulting in niacin induced peripheral vasodilation. We know its prostaglandin so give aspirin beforehand to reduce symptoms

Question 286

Recent stent placement in LAD, now p/w typical CP/diaphoresis/SOB w/ EKG showing 2mm ST elevations in I, aVL, and V1-V4, dx?

Answer 286

STEMI 2/2 stent thrombosis d/t medication non-compliance (question stem said recently unemployed); pts w/ stent should be counseled on 12mo dAPT w/ ASA and clopidogrel (platelet receptor blocker)

Question 287

Patients w/ cardiac arrhythmias usually have underlying cardiac disorders like

Answer 287

Coronary heart dz, cardiomyopathy, valvular heart dz; pts may not have any prodromal symptoms prior to the syncopal episode (unlike vasovagal or neurocardiogenic syncope pts)

Question 288

Digoxin (used for heart failure/A-fib) toxicity, s/s?

Answer 288

Nausea, vomiting, diarrhea, vision changes, and arrhythmias

Question 289

What does ASCVD risk calculator take into account? Statin at what %?

Answer 289

Race, age, sex, total cholesterol, HDL, diabetes status, smoking status, systolic BP; initiate statin if 10 yr risk of ASCBD >7.5% for PRIMARY prevention. If hx of known ASCVD event or LDL >190 then initiate statin regardless

Question 290

Syncope, prolonged PR interval and prolonged QRS (intraventricular conduction delay), cause of syncope?

Answer 290

Bradyarrhythmia or high-grade AV block | Question 4456 for chart of syncopal etiologies and clinical findings

Question 291

Immigrant, acute dyspnea, hx of rheumatic heart dz, irregularly irregular HR, heart sound findings?

Answer 291

Loud S1 w/ mid diastolic rumble d/t mitral steonsis -> can lead to left atrial dilation and subsequent A-fib

Question 292

Prolonged PR interval (>200), dx? Mgmt if normal QRS vs prolonged QRS

Answer 292

1st deg AV block. Most cases of 1st deg blocks w/ normal QRS = delayed AV nodal conduction (no further eval required if asymptomatic). If AV block w/ prolonged QRS = delay likely below AV node = need EP testing to determine site of delay

Question 293

Pleuritic chest pain (improves when sitting up worse laying down, low grade fever, diastolic sound w/ squeaking quality at left sternal border, non-specific EKG, bun > 60, dx?

Answer 293

``` Uremic pericarditis (inflammation of visceral and parietal layers of pericardium): note unlike other etiologies of pericarditis - no diffuse ST elevation or PR depression as the myocardium is not affected. Squeaky sound at left sternal = friction rub. MUST rule our pericardial effusion/cardiac tamponade prior to tx w/ dialysis ```

Question 294

Acute pericarditis ddx and mgmt?

Answer 294

Viral or idiopathic, autoimmune (SLE), uremia (acute or chronic renal failure), post MI (early = peri-infarction pericarditis, late = Dressler syndrome). Tx w/ NSAIDs and colchicine for viral or idiopathic; variable for other etiologies. Look for pleuritic CP worse laying down better sitting up, low grade fever, friction rub, diffuse ST and PR depression, pericardial effusion on echo

Question 295

EKG findings for left anterior descending artery occlusion (anterolateral MI)?

Answer 295

ST elevation in I, aVL, V2-V6 and reciprocral ST depression in II, III, aVF

Question 296

Mgmt of STEMI:

Answer 296

Rabid stabilization and immediate coronary reperfusion: oxygen, full dose aspirin (chewed = faster), platelet receptor blocker (clopidodgrel, ticagrelor), nitroglycerin for pain w/ morphine, beta blocker, and anticoagulation (heparin)

Question 297

Time frame for STEMI and PCI

Answer 297

Within 12 hours of symptom onset AND within 90 minutes from first medical contact (if facility capable); 120 minutes alloted for non PCI capable facility *room for transport time. PCI > fibrinolysis but can opt for fibrinolysis if PCI not available within 120 mins

Question 298

Excessive vs moderate alcohol intake?

Answer 298

Excessive = >2 drinks a day or binge drinking >5 drinks in a row (a/w w/ inc incidence of HTN) Moderate intake = 1 or 2 for men a day, and 1 a day for women (moderate is a/w dec incidence of coronary heart dz and mortality and dec in blood pressure)

Question 299

Sinus bradycardia (<60HR), mgmt?

Answer 299

IV atropine: anticholinergic, intial tx for bradycardia and hypotension

Question 300

Cardiac drug and their effects: adenosine, amiodarone, IV glucagon, norepi/dobutamine

Answer 300

Adenosine: transient block of conduction at AV node - useful in identifying/terminating supraventricular tachycardia Amiodarone: antiarrhythmic: used for supraventricular/ventricular tachyarrhythmias Glucagon: inc cAMP - tx beta blocker or CCB toxicity Norepi: tx of severe hypotension and shock

Question 301

Tingling, burning of hand a/w localized vesicular rash, not bilateral or symmetric (innoculation by a virus)

Answer 301

Herpetic whitlow

Question 302

Small erythematous papules and irregular burrows predominantly at finger webs, flexural surfaces, belt line, buttocks

Answer 302

Scabies

Question 303

Pruritic, hyperkeratotic patches or annular erythematous lesions on palms, dx?

Answer 303

Tinea manuum

Question 304

Two types of contact dermatitis: allergic vs irritant, ddx?

Answer 304

Allergic: type IV hypersensitiity, poison oak/ivy/nickel/rubber/leather dyes/medications, look for ACUTE erythema, papules/vesicles, primarily on exposed skin well demarcated Irritant: physical of chemical irritation (non-immune), soaps/detergents/chemicals/acid, commonly on hands look for erythema fissure (chronic)

Question 305

Types of hypersensitivity reactions - mneumonic?

Answer 305

ACID = I - IV A - allergic: IgE mediated, quick onset after exposure, bee stings/latex/meds C - cytotoxic: cytotoxic/antibody-mediated, hemolytic rxns/Goodpasture/hyperacute graft rejection I - immune: immune complex/IgG/IgM mediated, hypersensitivity pneumonitis/SLE/polyarteritis nodosa/serum sickness D - delayed: delayed or cell mediated, chronic graft rejections, PPD test, allergic dermatitis

Question 306

Chronic lung disease -> pulmonary HTN -> impaired right ventricular functions. Signs of right ventricular failure = ?

Answer 306

Elevated JVD (w/ prominent a waves), S3, tricuspid regurgitation murmur, hepatomegaly w/ pulsatile liver (from congestion), LE edema/ascites/and or pleural effusions, look for elevated pulmonary artery systolic pressure in cor pulmonale

Question 307

What is an estimation of left ventricular end-diastolic pressure, and is elevated in pts w/ left ventricular systolic/diastolic dysfunction?

Answer 307

PCWP - if elevated look for pulmonary edema on auscultation

Question 308

Methemoglobinemia s/s?

Answer 308

Cyanosis/bluish discoloration. CO poisoning = pinkish-red skin hue; confirm w/ carboxyhemoglobin level