UWorld

Question 1

Erythematous, hot, shiny, swollen area in skin with irregular borders - hx of DM - dx?

Answer 1

Cellulitis - infxn involving deep dermis and superficial fat (vs. erysipelas which involves superficial dermis and lymphatics)

Question 2

Can you use lidocaine in cases of cellulitis? Why?

Answer 2

Areas of infections tend to be slightly acidic and local anesthetics tend to be basic in nature, thus easily neutralized and become ineffective. If the cellulitis progressed to abscess formation, local anesthetic should still be used to anesthetize the epidermis for draining purposes (not pain control)

Question 3

Locally aggressive benign tumor arising from fibroplastic elements in muscle or fascial planes w/ very low potential for metastasis or proliferation = dx? Complications? Trmt?

Answer 3

Desmoid tumor. Deeply seeded painless mostly in the trunk/extremity, intraabdominal bowel and mesentery, and abdominal wall. Complications = intestinal obstruction and bowel ischemia. HIGH RATE OF RECURRENCE!

Work-up includes CT/MRI if large, symptomatic, or worrisome for histologic dx. Trmt = surgery or radiation for non-surgical candidates

Question 4

Firm hyper pigmented nodule MC on lower extremities seen after trauma = dx?

Answer 4

Dermatofibroma

Question 5

Results from normal epidermal keratin becoming lodged in the dermis = dx?

Answer 5

Epidermoid cyst

Question 6

Asymptomatic skin lesion and benign collection of fat cells = dx? Recurrence risk?

Answer 6

Lipoma. Low risk

Question 7

Capillary proliferation after trauma and is usually dome-shaped papule with recurrent bleeding; seen in pregnant women = ?

Answer 7

Pyogenic Granuloma

Question 8

SIRS Criteria? Desired CVP in suspected hypoperfusion from sepsis?

Answer 8

> 38.5 T, HR > 90, RR > 20, WBC > 12,000 (need 2/4 criteria)

CVP 8-12 via fluid resuscitation (central venous line if necessary). Vasopressors may be needed if persistently hypotensive (Norepinephrine; Dobutamine = more inotropic in suspected poor CO)

Question 9

Cushinoid appearance clues you in to chronic use of what? How does this affect management in sick patients?

Answer 9

Chronic use of steroids; could lead to HPA suppression. Low cortisol level (even in non-chronic corticosteroid users) can be dangerous in shock situations. Should begin tapering dose after 8hrs of presentation for those in shock without chronic use of steroids w/ SBP

Question 10

ADHD course from childhood to adulthood? Increased risk of substance use/abuse w/ stimulant therapy?

Answer 10

Hyperactive physical symptoms tends to subside into adolescence while one to two-thirds of children dx’d with ADHD will experience persistent ADHD into adulthood,

No data supporting increased substance use/abuse with stimulants.

Question 11

Cardiac exam signs (3) indicating severe AS?

Answer 11

Soft/single S2, delayed and diminished carotid pulse “parvus and tardus”, loud and late systolic murmur

Question 12

Work-up of Thyroid Nodule: ?

Answer 12

First: Clinical Eval (fam hx, past radiation, cervical lymphadenopathy, compressing sympt, symptomatic) / TSH Level (NL or elevated TSH) / US (hypoechoic, microcalcifications, internal vascularity)

No RF’s and Low TSH - I-123 Scintigraphy > hot (increased uptake) can treat as hyperthyroid, cold (low uptake) = concerning, get FNA.

RF’s - get FNA

No RF’s and NL or Elevated TSH - FNA, treat findings

Question 13

What should your work-up include with someone who has medullary thyroid cancer? What’s included in each of these categories?

Answer 13

Serum calcitonin and carcinoembryonic antigen, neck U/S (regional mets?), genetic testing for germline RET mutations, and eval for coexisting tumors (hyperparathyroidism, PCCs)

MEN 1 - (PPP) pituitary tumor, primary hyperparathyroidism, enteropancreatic tumors
MEN 2A - (MPP) MTC, parathyroid hyperplasia, pheochromocytoma [Familial Medullary Thyroid Cancer = subset of 2A w/ only MTC]
MEN 2B - (MMP) MTC, pheochromocytoma, mucosal/intestinal neuromas, marfinoid habitus

Question 14

In the setting of a new pleural effusion w/ a patient being treated for TB, what should you order?

Answer 14

Thoracentesis to analyze it. Usually exudative with a lymphocytic predominance secondary to an enhanced immunologic response.

Question 15

Acute jaundice, hepatomegaly, and elevated transaminases - DDx and patterns? Consideration for hospitalization?

Answer 15

Acute viral hepatitis (Hep A/B), alcoholic hepatitis (AST>ALT 3:2), toxic liver injury or drug-induced (acetominophen poisoning), autoimmune hepatitis (likely chronic onset), ischemic liver injury (in setting of trauma), herpesvirus etio (EBV, varicella, herpes simplex, CMV)

Hospitalize if unstable, poor f/u, acute risks, older, unable to tolerate PO

Question 16

Young/middle-aged women who develop severe abdominal pain and have ascites on U/S - dx?

Answer 16

Budd-Chiari Syndrome due to hepatic vein obstruction (from thrombosis); thrombolytic therapy is a treatment option

Question 17

Treatment considerations for acute hepatitis include?

Answer 17

Supportive - most can be followed with appropriate f/u and supportive measures if mildly symptomatic or asymptomatic; low risk of sig complications or fulminant hepatic failure w/ or w/o treatment

Antiviral therapy - for patients with immunosuppression, concurrent Hep C, severe hepatitis or fulminant hepatic failure

Lamivudine - for severe acute Hep B with impaired synthetic function (prolonged PT)

Question 18

Treatment for Hep C?

Answer 18

Interferon alfa-2b and ribavirin

Question 19

Risk of chronic hepatitis after acute Hep B infection? Best prognostic factor?

Answer 19

90% if perinatal transmission; 25-50% if within the first year of life

PT is the best prognostic factor for risk of developing chronic hepatitis. Elevated ALT > 6months also a sign.

Question 20

Acute vs. Chronic Hep B labs?

Answer 20

Acute = HBsAg, HBeAg, IgM Anti-HBc, > ALT
Chronic = HBsAg with Anti-HBe, IgG anti-HBc

Question 21

Child 6months - 5yrs old with sudden refusal to move arm after a pulling force - dx? Workup? Trmt?

Answer 21

Nursemaid’s elbow (radial head subluxation). No radiographs needed. Hyperpronation and Supination/Flexion = 2 primary reduction methods

Question 22

Adequate INR level for someone on Warfarin?

Answer 22

INR 2-3

Question 23

Important complication seen commonly in patients with hip fractures? How to prevent this?

Answer 23

DVT leading to fatal PE. LMWH or low-dose unfractionated heparin with continuation for 10-35 days depending on patient’s risk for thrombosis. It can be stopped 12hrs prior to surgery, low risk of bleeding

Question 24

Pruritic rash on flexor surfaces typically starting on hands and spreading to abdomen, groin, skin folds, axilla, between fingers and toes - worse at night - excoriations with small, crusted red papules - dx? Workup? Trmt considerations?

Answer 24

Scabies - spread via contact; delayed type IV hypersensitivity to mites, ova, and feces.

Dx confirmed by skin scrapings.

Trmt Goals = mite eradication, decrease pruritis, and oral abx for any signs of secondary bacterial skin infection. If widespread, 5% topical permethrin over whole body; if localized, 1% terbinafine cream. Oral Ivermectin is also a treatment option for outbreaks in groups of people (nursing home). Oral antihistamines can help decrease dermatitis. Clothing/bedding cleaned and bagged for 3 days at minimum - mites cannot survive >3 days without human host.

Question 25

Pruritic erythematous rash, circular, scaly lesions with central clearing - dx? Workup?

Answer 25

Tinea. Potassium hydroxide staining of skin sample can confirm dx by showing segmented hyphae and arthrospores.

Question 26

Considerations for the workup of testicular trauma?

Answer 26

Minimal pain/swelling & Normal Exam - supportive care with f/u Moderate pain/swelling - U/S with f/u, or furthered by findings Severe pain/swelling and/or Abnormal PE - experienced U/S and expert surgical consultation **Get retrograde urethrography if blood seen at the meatus or if frank blood on urine dip**

Question 27

Screen for what in veterans with new onset insomnia, inadequate pain control, substance use, interpersonal conflicts? Trmt options?

Answer 27

PTSD. Trmt includes CBT and/or anti-depressants. Prazosin for nightmares

Question 28

Elderly patients having difficulty with discriminating speech in noisy environments - dx?

Answer 28

Presbycusis - sensorineural hearing impairment

Question 29

Difference in testing considerations b/w suspected active and latent TB?

Answer 29

Active (travel, cough, fever, night sweats, weight loss) - obtain chest imaging; abnormal or high suspicion continue with 3 sputum specimens for AFB and culture. Latent - PPD or IGRA for patient's with previous BCG vaccine. These both do not allow differentiation between active and latent

Question 30

What can be used to tell if TB patient is infectious?

Answer 30

3 negative sputum smears. Patient could still have active TB though, just not infectious. Culture will dictate active TB but emperic therapy can be initiated if high suspicion.

Question 31

Progressive dysphagia with solid, then liquids, in pt w/ h/o GERD - dx?

Answer 31

Esophageal Stricture - complication from healing process of ulcerative esophagitis in GERD pts. vs. Achalasia = dysphagia of both solids AND liquids

Question 32

Tricuspid vegetations, septic pulmonary emboli, systolic murmur increased with inspiration = dx?

Answer 32

Right sided endocarditis secondary to IV drug users. Peripheral manifestations are uncommon in these patients.

Question 33

Bradykinesia, tremor, rigidity, unilateral onset of symptoms - dx? Trmt considerations?

Answer 33

Parkinsons - dopamine problem. Initial therapy = dopamine agonists (Bromocriptine, Pramipexole) or Levadopa. However, levadopa can sometimes increase destruction of substantial nigra - begin in patients > 65yrs old with severe symptoms. Entacapone is a COMT inhibitor, helps by prolonging effect of levadopa.

Question 34

Tremor in both hands/forearms that worsens with fine motor activity = dx? Trmt?

Answer 34

Essential tremor. Propanolol and primidone

Question 35

Tamoxifen is used for?

Answer 35

Hormone responsive (estrogen +) BC and for the prevention of BC in woman at high risk. Associated w/ endometrial hyperplasia and cancer.

Question 36

Side effects of the following supplements: Kava kava, Thiazide diuretics, Ginseng, Ginko?

Answer 36

Kava kava - hepatotoxicity, liver failure Thiazides - hypokalemia, hyponatremia, hyperuricemia, elevated glucose and cholesterol Ginko - bleeding 2/2 platelet and anticoagulant effects Ginsing - HA, insomnia, GI symptoms, VB and hypoglycemia

Question 37

Intracellular Gram-negative diplococci - treatment considerations?

Answer 37

Gonorrhea trmt = Ceftriaxone 250mg IM with concurrent Chlamydia trmt 2/2 coinfection rate. Oral doxycycline 100mg BID x7d or oral Azithromycin 1g single dose for Chalmydia trmt

Question 38

Additional vaccinations for HIV + patients? Contraindicated vaccines?

Answer 38

Hep A and B unless previously documented immunity. Pneuomona vaccine PCV13 and PPSV23 8 weeks apart and every five years. Contraindicated: lives vaccines (intranasal influenza - EXCEPTIONS are MMR and varicella zoster IF CD4 >200 and no hx of AIDS defining illness

Question 39

Side effects of Isoniazid? MC and monitoring? Continuation of therapy?

Answer 39

Self-limited transaminitis, drug-induced lupus, nerve damage/muscle weakness. MC = hepatotoxicity in 2 months; get baseline and monthly LFT's If asymptomatic but LFTs > 5x ULN OR Symptomatic with LFT's >3x ULN- discontinue. Give B6 to prevent neuropathy.

Question 40

Asymptomatic hyperuricemia associated with what TB drug?

Answer 40

Pyrazinamide - competes with uric acid excretion in kidneys

Question 41

Side effect of ethambutol?

Answer 41

Ocular toxicity.

Question 42

MC'ly responsible for drug-induced lupus (2 agents)?

Answer 42

Procainamide and hydralazine

Question 43

AIDS patient with hemiparesis, speech/vision/gait disturbances with multiple demyelinating, non-enhancing lesions w/o mass effect, gradual onset - dx?

Answer 43

Progressive Multifocal Leukoencephalopathy - seen in immunocompromised patients via the JC virus - primarily involves cortical white matter. Dx with MRI. VS. Toxo, CNS lymphoma, brain abscess with are ring-enhancing lesions w/ mass effect VS. HIV encephalopathy w/ dementia as main sympt; similar MRI findings but bilateral and symmetric

Question 44

MCC of fecal incontinence in elderly? Trmt?

Answer 44

Fecal impaction. Suppositories for complete emptying. Would use rectal tube for acute pseudo obstruction resultng in dilated colon and abdominal distention

Question 45

Trmt for grouped vesicles or bulla in specific unilateral dermatomal pattern with pain after bodily stress? Unresolved pain trmt months later?

Answer 45

Antiviral acyclovir or valacyclovir started within 72 hrs of onset of rash. Results from reactivation of lent infection in dorsal root ganglion. Post-herpetic neuralgia trmt = amitriptyline (TCA), topical caspaicin, Gabapentin, and long acting oxycodone

Question 46

Give varicella zoster vaccine s/p infection? Precautions?

Answer 46

If >60 yo, reduces the risk of zoster and post-herpetic neuralgia. If patient is immunocompetent, contact precautions with covering until lesions are completely crusted over 2/2 transmission from direct contact. If immunocompromised, hospitalized. VS. primary varicella infxn (chickenpox) transmitted by airborne droplets

Question 47

Vague symptoms like anorexia, decreased activity, irritability, abdominal pain, and insomnia in children should suspect was type of intox? Order what labs?

Answer 47

Lead! CBC, serum Fe, ferritin, reticulocyte count to assess for anemia and iron deficiency.

Question 48

Possible drugs that could increase Lithium levels? Side effect of Lithium involving constipation and fatigue?

Answer 48

Thiazide diuretics, NSAIDs, ACE. Lithium-induced hypothyroidism.

Question 49

Two MC procedure for tattoo removal?

Answer 49

Dermabrasion and laser therapy

Question 50

Continue anticoagulation for how long s/p initial DVT therapy?

Answer 50

3-6 months. Or lifelong if this is the second one. D/c RF's: obesity, smoking, OCP's, HRT, Tamoxifen

Question 51

What lab will prompt initiation of antibiotics in setting of Spontaneous Bacterial Peritonitis?

Answer 51

Neutrophil count >250 in the ascitic fluid

Question 52

What formula used to calculate mortality rate in those with liver disease?

Answer 52

MELD Score = 3.8 (serum bilirubin) + 11.2 (INR) + 9.6(serum creatinine) + 6.4. 95% survival - score 40

Question 53

Difference b/w breast milk jaundice and breastfeeding failure jaundice?

Answer 53

Breast Milk Jaundice - starts end of 1 week and peaks by 2 weeks; high B-glucuronidase in breast milk deconjugates intestinal bilirubin and thus increased level of unconjugated bili Breastfeeding Failure Jaundice - bili secondary to decreased bili elimination; ppor latching, occurs first week, baby looks dehydrated

Question 54

Recent asymmetric oligoarthritis that is inflammatory (elevated WBC's) but sterile (culture negative) with a recent hx of infection - dx? Workup?

Answer 54

Reactive Arthritis - inflammatory (>2,000 WBC's) synovial fluid extraarticular symptoms = urethritis, uveitis, circinate balantitis (painless shallow ulcers on glans penis persist for months). Retest for suspected infections even if asymptomatic or no evident signs. Sources: GI (Salmonella, Shigella, Yersinia, Campylobacter, C Dif) and GU (Chlamydia) Trmt - Abx and NSAIDS

Question 55

Describe pathophys for neonatal breast hypertrophy and galactorrhea.

Answer 55

High estrogen crosses placenta in 3rd trimester; s/p delivery, estrogen drop off stimulates fetal prolactin production. Self-limited - 6 months

Question 56

Episodes of well-circumscribed & raised erythematous plaques - associated intense pruritis - associated with angioedema in 40% - they worsen over minutes to hrs and dissipate within 24 hrs - dx? Trmt? Prog?

Answer 56

Chronic urticaria - from idiopathic stressor or stimulus. Acute - H1/H2 blocker Chronic - second generation H1 blocker (Loratadine, Cetirizine) >> increase the dose >> additional H1 blocker (hydroxyzine), leukotriene receptor antagonist (Montelukast), or H2 blocker (Ranitidine) o brief steroids Prog - most have complete resolution 2-5 yrs

Question 57

When to give Oseltamivir in pts with flu?

Answer 57

> 65yrs, pregnant, high risk medical comorbiditis - hospitalized patients or have involvement of lower respiratory tract - if they present within 48hrs of onset

Question 58

Recent abdominal sx (2-3wks), swinging fevers, leukocytosis, right shoulder tip pain, cough - dx? Workup?

Answer 58

Subphrenic Abscess. Abdominal U/S

Question 59

Types of hypersensitivity?

Answer 59

Type I - IgE mediated, release of vasoactive mediators from mast cells and basophils (anaphylaxis) Type II - IgG mediated, antibody attack with complement (autoimmune hemolytic anemia) Type III - Antibody-complex deposition causing damage (serum sickness, PAN, glomerulonephritis in Hep B) Type IV - Cell mediated; memory cell activation of macrophages - delayed hypersensitivity (contact dermatitis)

Question 60

Likelihood ratio of having and not having the disease given a positive/negative result respectively? Formula?

Answer 60

Likelihood ration: (+) = sensitivity / (1 - specificity) (-) = (1 - sensitivity) / specificity

Question 61

Elevated TSH and normal T4 w/o symptoms, dx? Trmt necessary? Workup?

Answer 61

Subclinical hypothyroidism. Treat if: +antithyroid ab's, abnormal lipid profile, symptomatic, ovulatory/menstrual dysfxn Workup: get anti-thyroid ab's; only get U/S if abnormal PE finding

Question 62

How to calculate RR when only one relation is known?

Answer 62

If you know the RR of A compared to B = x, then the RR of B compared to A = 1/x

Question 63

Saw palmetto = alternative med trmt for? St. John's wort? OA? Garlic?

Answer 63

Saw palmetto - BPH St. John's Wort - anxiety/depression Garlic - hypercholesterolemia Glucosamine and Chondoitin = OA

Question 64

Popular alternative meds with increased bleeding risk?

Answer 64

Ginko biloba, saw palmetto, ginseng, black cohosh, and garlic

Question 65

St John's Wort side effects?

Answer 65

GI distress, dizziness, fatigue, photosensitivity, and dry mouth

Question 66

2 MCC of diaphragmatic paralysis in the newborn = ?

Answer 66

Birth injury and cardiothoracic injury causing damage to phrenic nerve

Question 67

Strongest known risk factor for male BC?

Answer 67

Klinefelter Syndrome = 47 XXY, resultant hypogonadism, low T, and gynecomastia

Question 68

CVS sampling best done at what GA? why?

Answer 68

>11 wks GA 2/2 lowest risk for limb reduction anomaly

Question 69

Neurologic symptoms that vary in time and space with intermittent recovery - common symptom = optic neuritis (monocular vision loss and eye pain w/ movmt) - dx? Best test? If atypical, helpful test?

Answer 69

Multiple Sclerosis. MRI shows ovoid periventricular white matter lesions. If unsure, LP will show elevated oligoclonal bands and elevated IgG index. MS patients can also develop transverse myelitis = UMN signs and sensory deficits below the level of the lesion

Question 70

Trmt considerations for MS?

Answer 70

Acute exacerbation = IV/Oral Corticosteroids If optic neuritis involved, IV route b/c increased risk of recurrence with PO steroids Refractory to glucocorticoids = plasmapharesis Maintenance = disease-modifying = beta-interferon and glatiramer acetate are indicated for chronic maintenance in relapsing-remitting MS Treated similarly in pregnancy - higher rate of assisted deliveries

Question 71

Management of MS comorbidities? Depression, fatigue, muscle spasticity, neuropathic pain, urge incontinence...

Answer 71

Depression - SSRI's Spasticity - Baclofen, massage Fatigue - Amantadine Neuropathic pain - Gabapentin or duloxetine Urge Incontinence - Oxybutynin, timed voiding

Question 72

Diagnostic considerations for Allergic Bronchopulmonary Aspergillosis? Presentation? Trmt and monitoring?

Answer 72

Hx of Asthma, + skin test reactivity to Aspergillus, + serum Ab's, serum IgE concentration > 1000, eosinophilia, bilateral upper lobe infiltrates, central bronchiectasis. Intense IgE and IgG response in asthmatic patients with ABPA causes fever, malaise, cough w/ brown expectorant, wheezing, and signs of bronchial obstruction Treat with oral steroids (NOT inhaled) - follow serum IgE concentration and clinical symptoms for improvement

Question 73

3 considerations to help distinguish cause of hypoglycemia?

Answer 73

Serum insulin, C-peptide, and hypoglycemic drug assay: - insulinoma will have negative drug assay; U/S or CT to investigate (or 72hr fasting challenge) - exogenous insulin will have negative c-peptide and assay - exogenous hypoglycemia agent will have + assay

Question 74

Considerations for giving tetanus rx's w/ injuries?

Answer 74

If the patient's hx is good (has >3 immunizations): - minor/clean cut: only give tetanus toxoid IF last shot was >10 yrs ago - major/dirty cut: only give tetanus toxoid IF last shot was > 5 yrs ago If the pt's hx is bad (

Question 75

Proximal symmetric muscle weakness in upper/lower extremities, Gottron's papules, heliotrope rash, ILD, dysphagia, myocarditis = dx? Work up? Trmt?

Answer 75

Dermatomyositis. Elevated CPK, Anti-RNP, Anti-Jo-1, Anti-Mi2 (EMG and muscle biopsy if uncertain) Trmt = high dose glucocorticoids + glucocorticoid-sparing agent *** Screen for malignancy *** Adenocarcinoma of cervix, ovaries, pancreas, bladder, lung, stomach

Question 76

Mostly seen in women, 30-65 yo, with milady elevated LFT's with elevated Alk Phos, itching - dx? Tests? Trmt? Screen for what complication?

Answer 76

Primary Biliary Cirrhosis - autoimmune problem of small to mid-sized bile ducts - causing progressive fibrosis, ESLD Antimitochondrial Ab's (AMA) = high sensitivity and specificity; diagnostic confirmation requires liver bx Can see xanthelasma from elevated LDL and hypercholesterolemia Trmt = ursodeoxycholic acid / transplant Complication = Osteoporosis via bone densitometry 2/2 malabsorption of fat soluble vitamins A, D, E, K

Question 77

Anti-smooth muscle Ab's association = ?

Answer 77

Type 1 Autoimmune Hepatitis

Question 78

Liver disease, skin hyper pigmentation, DM, arthropathy, cardiac involvement, and hypogonadism - dx? Abnormal lab profile?

Answer 78

Hemochromotosis - abnormal deposition of Fe. Elevated LFT's > Alk Phos

Question 79

Treatment for patients that have white/blue discolored fingers in the cold? Additional workup?

Answer 79

Dihydropyridine Ca-channel blockers (nifedipine/amlodipine) and diltiazem; nitroglycerin in refractory pts Workup with ANA, RF, CBC, blood chem, UA and complement levels in pts with systemic manifestations

Question 80

How can an infant get botulism? Trmt considerations?

Answer 80

Infant vs. Foodborne Botulism via ingestion of Clostridium Botulinum spores from environmental dust vs. performed c. botulinum toxin with canned foods. Human-derived botulism Immune Globulin vs. Equine-derived botulism antitoxin Toxin inhibits presynaptic release of cholinergic transmission. It can predominate in infant GI flora b/c still developing flora. Higher in CA, PA, UT - disturbed soil (farming/construction) Most infants require hospitalization for 1-3 months with complete recovery

Question 81

HIV rxs in pregnancy?

Answer 81

HAART - 2NRTI's (Zidovudine and Lamivudine) + 1 protease inhibitor or NNRTI; Efavirenz is preferred after 8th wk gestation b/c risk of NT, cleft lip, anopthalmia. However, DONT CHANGE AN EFFECTIVE REGIMEN IF THE PATIENT STARTED IT ALREADY - risk of transmission from changing a regimen outweighs risk of teratogenicity. Reduces rate of transmission from 25% to 2%

Question 82

Delivery considerations with HIV+ its?

Answer 82

C/S if VL> 1,000. UD viral load and complaint with HARRT can have vaginal delivery

Question 83

Reasons to not BF?

Answer 83

HIV infection (unless in developing country), active TB (can start after 2 wks s/p trmt initiation), herpetic breast lesions, Varicella infxn

Question 84

Causes of acquired long QT Syndrome?

Answer 84

Bradyarrhythmias = MCC of Torsades Meds: diuretics (electrolyte imbalance), antipsychotics, tricyclic antidepressants, antiarrhythmics (amiodarone, sotalol, flecainide), anti-infective drugs (macrolides, fluoroquinolones Other: hypothermia, hit, MI

Question 85

% correlations for std deviations 1, 2, and 3?

Answer 85

68%, 95%, 99.7%

Question 86

Risk factors for invasive aspergillosis? Presents with?

Answer 86

Allogenic transplantation, older age, acute graft-vs-host disease and corticosteroid therapy. Fever, sinus symptoms, and pulmonary complaints

Question 87

Formula for NNT?

Answer 87

1/ARR = NNT ARR = percentage of relapse/disease in treated group subtracted from placebo group

Question 88

Common side effects of: 1) CCB's 2) ACEi's 3) HCTZ

Answer 88

1) Lower extremity edema 2/2 precapillary vasodilatation (25% with DHP's like Amlodipine/Nifedipine in 6mo's of therapy); headache, flushing, dizziness 2) Angioedema (0.1-0.7%) 3) Hyponatremia, hypokalemia, renal failure, hyperuricemia (acute gout),. and elevated glucose and lipid levels

Question 89

What is Type II Polyglandular Autoimmune Failure?

Answer 89

Addison's disease w/ Type 1 DM

Question 90

Considerations for breast mass work up?

Answer 90

- Spontaneous, unilateral, and bloody = concerning and warrants work up with mammo (MCC of pathologic nipple discharge = papillary tumor) - Bilateral milky white discharge should first be assessed with prolactin levels 2/2 hyperprolactinemeia from prolactinoma, medications (antipsychotics), hypothyroidism, and pregnancy

Question 91

RF for developing reactive arthritis?

Answer 91

HLA-B27 positive with gram-negative rods

Question 92

Athletic women with secondary ammenorrhea have low levels of what three hormones?

Answer 92

GnRH, LH, and estrogen

Question 93

Common causes of recurrent sinusitis?

Answer 93

Smoke exposure (via damage to cilia), inadequately treated acute sinusitis. structural abnormalities of palate or septum, and allergic rhinitis

Question 94

Monitor what value to reassess asthmatics in ED? Considerations?

Answer 94

PEF: - >70% and no distress = good to d/c - 40-69% = admit to hospital ward - 42 and severe signs = admit to ICU

Question 95

Treatment of syphylis by stage?

Answer 95

- Primary, Secondary, Early Latent (12 months), unknown, gummatous/CV sylph = Benzathine PCN 2.4M IM weekly x 3 wks - Neurosyph = Aqueos PCN 3-4M IV q4hrs for 14 days - Congenital Syph = Aqueos PCN 50,000units/kg IV q 8-12hrs for 10 days

Question 96

Rxn developing within 24hrs after initiation of treatment for spirochetal infxn = dx? Prevention?

Answer 96

Jarisch-Herxheimer Rxn - no prevention. constituted by fever + malaise/chills/HA/myalgias

Question 97

RF's for Lithium toxicity? Levels? Presents?

Answer 97

Low GFR (elderly, renal pts), volume depletion, drug interactions (thiazide diuretics, ACEi's, NSAIDs) Sympt = confusion, ataxia, neuromuscular excitability (tremor), N/V/D Trmt = Lithium levels q2hrs, IV hydration, hemodialysis

Question 98

Pathophys for: - Toxic Shock Syndrome - Bacterial Endocarditis - Septic Shock

Answer 98

- TSS = (MCC Staph Aureus) exotoxin (TSS toxin-1) causes widespread activation of T cells, acting like super antigens - leading to massive cytokine production - Endocarditis = bacterial overgrowth and dissemination - Septic Shock = massive bacterial lysis and subsequent circulating endotoxin

Question 99

Treatment of Toxis Shock Syndrome =

Answer 99

Fluid replacement (up to 20L/day), Clindamycin theoretically prevents toxin synthesis, and Antistaph antimicrobial therapy (vancomycin, oxacillin or nafcillin)

Question 100

Frequency of UTI's to start prophylaxis? Meds?

Answer 100

2 in six months or 3 in 1yr Bactrim, fluoroquinolones, and Nitrofurantoin

Question 101

What thionamide rx's to use in pregnancy and at what GA? Why?

Answer 101

Propylthiouracil (PTU) - risk of liver disease - use in 1st trimester Methimazole (MMI) - teratogenicity - use in 2nd/3rd trimester

Question 102

Whipple's triad confirming true hypoglycemia?

Answer 102

1) low BG 2) symptomatic 3) relief of symptoms with glucose

Question 103

Advice for hypoglycemia during exercise for diabetics with insulin reqmt?

Answer 103

Exercise increases insulin uptake by exercising muscles so avoid injections into exercising limbs, can try snack before exercising, and decrease prior dosage. Check BG before and after exercising

Question 104

Different presentation of Giardia based on acuity? Trmt and prevention?

Answer 104

Asymptomatic - shed cysts for 6 months Acute - diarrhea, steatorrhea, flatulence, N, F, weight loss Trmt - not for asymptomatic; if symptomatic, use Metronidazole, nitazoxanide, or tinidazole. Prevent by contact isolation and hand hygiene

Question 105

What's a positive apnea test?

Answer 105

Can confirm brain death: absent respiratory response off the vent for 8-10 minutes with a PaCO2 >60mmHg and a final aerial pH

Question 106

Symptoms of B12 def? Complication with hematologic phenomena?

Answer 106

Dementia, subacute combined degeneration, dorsal spinal column probs (loss of vibratory sense, + Romberg test) and lateral corticospinal tract abnormalities (spastic paresis, hyperreflexia) Secondary to poor DNA synth in RBC's, they mature improperly and are megaloblastic, eventually lysing in the bone marrow and causing indirect hyperbili (can see decreased haptoglobin, elevated LDH)

Question 107

Difference b/w nightmare d/o and night terrors?

Answer 107

Night terrors = non-REM poor/little recollection Nightmare D/O = REM stage d/o and child has vivid dream recall

Question 108

Symptoms of carbon monoxide poisoning and lab?

Answer 108

Multiple people having fatigue, malaise, throbbing HA's, nausea. Get a carboxyhemoglobin

Question 109

Knee pain, decreased ROM, skin changes, and vasomotor changes (skin color changes) after a recent injury = dx? Trmt? Pathogenies?

Answer 109

Complex Regional Pain Syndrome. Patho = nerve injury causing increased sensitivity to sympathetic nerves, abnormal response to and sensation of pain, and increased neuropeptide release causing allodynia

Question 110

Presentation of HSV encephalitis?

Answer 110

Hemorrhagic infarction of the temporal love with elevated RBC on CSF analysis

Question 111

Patients are at risk for what who have history of chronic lymphocytic infiltration of the thyroid? Presentation? What PE test?

Answer 111

Hashimotos is a RF for Thyroid lymphoma. Rapid and acute swelling of thyroid area. Pemberton's test = raising hands over head and + if patient becomes plethoric, indicating thyroid is the cause of obstructive symptoms.

Question 112

A1c goal range for DM2?

Answer 112

6-7%

Question 113

Contraindication to HPV vaccine?

Answer 113

Hypersensitivty to yeast

Question 114

RF's for intussusception? Presentation? Dx and trmt?

Answer 114

Recent viral illness or rotavirus vaccination, polyps, tumors, HSP, celiac disease, meckels. Occurs 6mo - 3yr. Episodic crampy abdominal pain, sausage mass, currant jelly stools. Target sign on U/S = clue. Don't need imaging if clear dx from presentation - use air or water soluble enema.

Question 115

Distinguishing characteristics and labs of CAH types? Trmt?

Answer 115

21-hydroxylase = ambiguous genitalia in girls, hypotension, hypoglycemia 2/2 increased testosterone (shunted products), decreased cortisol and aldosterone causing hypoglycemia, hyperkalemia, hyponatremia. See elevated 17-hydroxyprogesterone. = MC type of CAH. Give glucocorticoids and mineralocorticoids 11B-hydroxylase = HTN 17a-hydroxylase = HTN

Question 116

Findings in gout arthro? vs. pseudogout?

Answer 116

Monosodium urate crystals = negatively birefringent, needle shaped crystals under polarizing light (yellow) Pseudogout = positively birefringent rhomboid shaped crystals (blue) CPPD crystals (calcium pyrophosphate dihydrate); more likely to present in RA or OA - MC'ly seen in knees

Question 117

Trmt considerations in gout?

Answer 117

NSAIDS (Indomethicin) - contra = AKI/CKD, CHF, PUD, Anticoagulation Colchicine - contra = severe or liver disease Intraarticular steroids - contra = >2 joints involved

Question 118

Types of common causes of male urethritis? Trmt considerations?

Answer 118

Gonorrhea - purulent, gram negative rods Chlamydia - PCR, give azithro Trich - metronidazole Mycoplasma Genitalium - covered by azithro Ureaplasma - covered by azithro

Question 119

Differential for moving paralysis?

Answer 119

Tick paralysis - normal CSF, occurs hours to days (remove tick) GBS - days to weeks, elevated CSF protein w/ normal WBC (IV immunoglobulin or plasmapharesis) Myasthenia gravis - not ascending paralysis, end of day onset (acetyl cholinesterase inhibitors) Botulism - descending paralysis

Question 120

Side effects of amiodarone?

Answer 120

Thyroid dysfunction, corneal deposits, skin discolorations, pulmonary fibrosis, and liver toxicity

Question 121

When do you give prophylactic acyclovir to pregnant patients?

Answer 121

At 36wks GA if they have hx of HSV; c/s if active at term. If no hx but exposed, type specific antibody testing for HSV1/2 is appropriate to determine infections; if negative nothing is needed, but if + can begin prophylactic trmt at 36 wks

Question 122

MCC of malignant otitis media? Trmt options?

Answer 122

Pseudomonas Fluoroquinolones = cipro PCN's - Piperacillin, Ticarcillin 3rd Gen Cephalosporins = Ceftazidime Should start trmt IV then switch to PO

Question 123

What is Ramsay Hunt Syndrome?

Answer 123

Reactivated zoster virus causing ear pain, vesicles in external auditory canal and ipsilateral facial paralysis

Question 124

Characteristics of: NF1, NF2, Tuberous Sclerosis, Sturge Weber Syndrome, Osler Rendu Weber?

Answer 124

NF1 - unilateral acoustic neuromas, cutaneous neurofibromas, axillary freckling, hyperpigmented cafe-au-lait spots NF2 - hypo pigmented spots, hx of bilateral deafness from bilateral acoustic neuromas SW - facial port wine and leptomeningeal angiomatosis TS - congenital hypopigmented maculae (ash leaf), glial proliferation, and several organ hamartomas/cysts ORW - multiple telangiectasias and vascular lesions of CNS

Question 125

Common type of PTHrP releasing malignancy?

Answer 125

Squamous Cell Carcinoma

Question 126

Describe Hand-Foot-Mouth Disease. Cause?

Answer 126

Exanthem can be on palms, soles, genitalia, and/or buttocks with herpangina (vesicles on posterior oropharynx). Caused by Group A Coxsackievirus

Question 127

Intoxication causing: confusion, lethargy, bradycardia, skin flushing, miosis, wheezing, garlic like odor?

Answer 127

Organophosphate poisoning. Test with RBC cholinesterase

Question 128

Treatment of ACS?

Answer 128

MONA HABS Clopidogrel - Morphine, Oxygen, Nitrates, Aspirin, Heparin, B-blockers, Statin, Clopidogrel - 2 antiplatelet therapies = aspirin and clopidogrel

Question 129

Risk factors for elder abuse?

Answer 129

Female gender, mental/physical illness, and old age.

Question 130

Factors protected by confidentiality in minors:

Answer 130

pregnancy, contraception, substance use, STD's, psych illness - UNLESS they become a danger to themselves

Question 131

Molluscum contagiousum is caused by what virus? spread? Suspect any additional infections?

Answer 131

Poxvirus - skin to skin contact. Test for HIV if these are widespread and/or involve the face

Question 132

How to treat chlamydia in pregnancy?

Answer 132

Erythromycin base 500mg PO QD x7days Amoxicillin 500mg PO TID x7days Nonpregnant: azithromycin 1g PO, doxycycline 100mg BID x7days

Question 133

Non-SSRI antidepressant options for people with sexual dysfunction on SSRI's?

Answer 133

Bupropion or Mirtazapine; can consider adding sildenafil (phosphodiesterase-5 inhibitor)

Question 134

Dx for decreased sensation over the anterolateral thigh without any muscle weakness or DTR abnormalities - hx of chronic flexion at waist? Nerve involved?

Answer 134

Meralgia paresthetica - entrapment of lateral femoral cutaneous nerve (purely sensory, direct branch from lumbar plexus runs under inguinal ligament)

Question 135

T-scores for assessing bone mineral density? via DEXA. When to add rx's?

Answer 135

above - 1 = normal -1 to -2.5 = osteopenia below -2.5 = osteoporosis Pharm therapy with T less than -2.5 or those with fragility fractures (hip/vertebral fractures from low-trauma) = bisphosphonates generally 1st line (Alendronate decreases bone resorption) + 1200mg/day elemental calcium and 800IU/day Vitamin D

Question 136

Episodic HA, young age htn, refractory htn, adrenal mass, sweating, tachycardia = screen for? Via? If elevated next steps?

Answer 136

Pheochromocytoma with plasma free metanephrine levels or 24-hr urine collection for catecholamine and metanephrine If elevated: CT/MRI of abdomen and surgical veal, genetic testing, alpha (maybe beta) blockade w/ phenoxybenzamine prior to surgery, MIBG (functional scintigraphy w/ norepi-like substance) scan if >5cm. Surgery only after 10-14 days of BP control, IV fluids. If elevated and negative imaging, get MIBG to assess for undetected tumors

Question 137

Complications with pheochromocytoma surgery and how to handle them?

Answer 137

1) HTN Crisis - IV nitroprusside, phentolamine, or nicardipine 2) Hypotension - normal saline bolus, pressers if unresponsive 3) Hypoglycemia - IV dextrose 4) Cardiac tachyarrhythmias - IV lidocaine or esmolol

Question 138

Cardiac resynchronization w/ biventricular pacing device is recommended in pts w/: ???

Answer 138

Sinus rhythm and: severe LVSD w/ EF 150msec)

Question 139

Next step in pulseless electrical activity? What rhythms are shockable? Cardiovert?

Answer 139

CPR. Defibrillate someone with Vfib or pulseless Vtach. Can cardiovert with unstable tachycardia (has pulse still)

Question 140

Indications for IVC filter? Acute/longterm risks?

Answer 140

Indicated in those who have contraindications to anticoagulation (recent surgery, hemorrhagic stroke, bleeding prob, active bleeding). Acute probs = insertion site thrombosis, hematoma, AV fistula. Chronic probs = recurrent DVTs (stops them from traveling but not their recurrence)

Question 141

Hyperglycemia, metabolic acidosis, + ketones = dx? Important formula? Therapy algorithm.

Answer 141

DKA - Anion Gap = (Na - [Cl + HCO3-]), normal = 7-13. Initially, IV fluid support with continuous IV insulin (be wary of hypokalemia); add to K to fluids if K 135. Insulin: switch to SQ when patient can eat, glucose 15. Overlap SQ and IV by 1-2hrs Bicarb: if pH

Question 142

What to start in asthmatic exacerbation?

Answer 142

Immediate O2 > inhaled B2 agonist > systemic IV steroids Life threatening exacerbations, IV Magnesium

Question 143

MC type of bias in case-control studies?

Answer 143

Recall bias - those with disease more likely to report exposure.

Question 144

Unilateral HA's occuring 1-3x daily, lasts 30min - 3hrs, severe retroorbital pain, lacrimation, conjunctival injection, rhinorrhea, sweating, and pallor occurring for 4-8 wks at a time = dx? Prevention? Abortifactant?

Answer 144

Cluster HA. Verapamil can be used for prevention with duration of HA's longer than two months (Lithium if refractory). Can use prednisone if expected use is

Question 145

When to use injection sclerotherapy for varicose veins?

Answer 145

Failed 3-6 months of conservative treatment. Try conservative measures first: leg elevation, wt loss, compression stockings (don't use if they have underlying arterial insufficiency)

Question 146

Hemodynamic measurements of heart?

Answer 146

``` R Atrial P = 4 PCWP (L atrial surrogate) = 9 Cardiac Index (pump fxn) = 2.8-4.2 SVR = 1150 ``` Septic shock has low SVR and increased CO = differentiates this from cardiogenic and hypovolemic causes. While increased R atrial and PCWP are increased in cardiogenic secondary to back up.

Question 147

3 criteria for Lewy Body Disease? Trmt?

Answer 147

Cognitive FLUCTUATIONS, visual hallucinations, and parkinsonism. Mix of Alzheimers and Parkinsons. Trmt = cholinesterase inhibitors (AD) and levadopa and dopamine agonists (PD)

Question 148

Dx: disinhibition, personality changes, extremem agitation, and urinary incontinence?

Answer 148

Frontotemporal dementia - occurs in 50's.

Question 149

Urge to move legs and is exacerbated with inactivity, relieved with movement = dx? Other causes? Trmt?

Answer 149

Restless leg syndrome. Secondary causes = iron deficiency anemia, uremia, DM, MS, pregnancy, antidepressants. Trmt - start with iron if ferritin low

Question 150

Diagnostic criteria for acute pancreatitis? Workup for etiology? Complication if the patient deteriorates days later with supportive care?

Answer 150

Classical symptoms of abdominal pain radiating to the back with elevated amylase and lipase (more specific). CT not absolutely necessary. Alcohol is leading cause; can order U/S if suspecting gallstones, LFT's, Calcium, or lipid panel for hypertriglyceridemia Pancreatic necrosis can cause SIRS.

Question 151

Treat this first in AF?

Answer 151

Rate control with beta blockers.

Question 152

What is the Standardized Incidence Ratio?

Answer 152

Used to see if the incidence is higher in a particular group in relation to larger population = Observed Cases / Expected Cases

Question 153

Treatment for Hidradenitis Suppurativa?

Answer 153

RFs = hx of HS, obesity, smoking, skin stress Topical Clindamycin or oral antibiotics for flare up in those with initial; solitary lesion Abscess formation and purulent sinus tracts oral tetracyclines are preferred (Doxy) Diffuse tracts and severe disease = infliximab (tnf alpha inhibitors), surgical excision

Question 154

HIV testing timeline after exposure? How often to check CD4 and VL in confirmed cases?

Answer 154

Using ELISA (HIV RNA PCR) or test for p24 antigen at 6, 12, and 24wks. Check every 3-4months

Question 155

Considerations for who to take to the cath lab?

Answer 155

Take STEMI patients immediately. Take NSTEMI in 24-48 hrs (differentiated from unstable angina with elevated troponins). Cardiac enzymes might not rise for 6 hrs!!!! Need to monitor! Stress test those after r/o acute MI

Question 156

Periarticular erosions, elevated RF levels, symmetric swelling and mild hyperemia of the proximal small hand joints, wrists and knees = dx? Treatment considerations?

Answer 156

RA. Start with methotrexate; if refractory to this + steroids for 6 months, can use infliximab or etanercept (get TB testing first!!!!); if refractory can try hydroxychloroquine, methotrexate, and sulfasalzine OR switching to cyclosporine

Question 157

MCC of hemoptysis? Trmt?

Answer 157

Acute bronchitis; antibiotics

Question 158

Window of time for tPA? Considerations prior to therapy?

Answer 158

Given less than 3-4.5hrs after the onset of symptoms. Assess for: active internal bleeding, platelets 185/110

Question 159

Recurrent lapses into sleep, napping multiple times in day at least 3x/wk for 3 months with cataplexy by trigger, REM sleep latency

Answer 159

Narcolepsy. Get a polysomnography. Modafenil. Can also use SNRI (Venlafaxine) or SSRI, or TCA if refractory treatment with cataplexy specifically.

Question 160

Protective factors in SI?

Answer 160

Social support/family connectedness, Pregnancy, Parenthood, Religion

Question 161

How to decide when to treat strep?

Answer 161

CENTOR Criteria: tonsillar exudates, anterior cervical lymphadenopathy, fever, absence of cough. If 1 or less = treat symptoms If 2 = get rapid strep test If 3 or more = 50% PPV for strep

Question 162

Elevated glucose levels without ketones in a DM2 patient = dx? Start by giving?

Answer 162

Hyperosmolar hyperglycemic state - FLUIDS (8-10L behind)

Question 163

Pathophys for pernicious anemia? What to monitor after starting B12 in patients?

Answer 163

Atrophic gastritis secondary to autoimmune destruction of parietal cells, leading to achlorhydria, and decreased production of intrinsic factor. This causes less binding of B12 which then cannot be taken to terminal ileum for absorption. Monitor K because sudden uptake of K for newly formed RBC's can be life threatening.

Question 164

Acromegaly long term risks?

Answer 164

Cardiac disease!!! DM, respiratory probs, increased colon cancer risk.

Question 165

Screen for what in patients with short stature, hypogonadism, short 4th metacarpal bones, multiple nuchal folds, large carrying angles, 45 XO ? Dx?

Answer 165

Turner Syndrome - screen for cardiac probs with echo (coarctation, bicuspid aortic valve, MVP, hypo plastic heart), renal U/S (horseshoe kidney) , TSH 9hypothyroidism), and hearing test.

Question 166

Work through diagnostics of delayed gastric emptying?

Answer 166

Could be from obstruction (internal/external) or impaired motility. R/o obstruction first with upper GI endoscopy, then consider CT ONLY if suspicious of external compression after non diagnostic endoscopy. Then consider scintigraphic gastric emptying study.

Question 167

GI Motility agents?

Answer 167

Erythromycin and Metoclopromide.

Question 168

Adolescents are at increased risk of what in pregnancy compared to those 20-24yrs?

Answer 168

perinatal mortality, preterm delivery, premature, and LBW infants

Question 169

Indications for lung cancer screening?

Answer 169

Age 55-80 with 30 pack yr hx of smoking and still smoking OR recently suit within 15 yrs.

Question 170

Increased incidence in spring/summer of skin infection with multiple, coalescing, small circular maculae that vary in color (white, pink, or brown); asymptomatic, seen on upper trunk, arm, neck, and abdomen = dx? Trmt?

Answer 170

Tinea Versicolor - organism prevents pigment tranfer to keratinocytes and makes affected skin paler than unaffected tanned skin. Trmt = topical ketoconazole/terbinafine/clotrimazole/selenium sulfide

Question 171

Seborrheic Dermatitis = looks like?

Answer 171

Inflammatory d/o with erythematous patches with oily scales, where there are many sebaceous glands

Question 172

Glascow score

Answer 172

Intubate

Question 173

Kids with fever, chills, flank/suprapubic pain = dx? Trmt considerations? Imaging?

Answer 173

Pyelonephritis. Oral cephalosporins are first line UNLESS patient is vomitting, failed oral abx before, or are hemodynamically unstable, or had positive blood culture. If failing all antibiotics, renal U/S to assess for renal or perinephric abscess. Can also work up in kids

Question 174

RF's for constipation in children? Look for? Complications? Trmt?

Answer 174

RF's = starting solid foods, cow's milk, toilet training, school entry Straining with BM, pellet stool, 2days s/p delivery Complications = anal fissures, hemorrhoids, encopresis, UTI's, vomiting, laxative, suppositories Trmt - increased fiber, limit cows milk,.

Question 175

Preexcitation syndrome w/ an accessory pathway resulting in a shortened PR interval (delta wave), widened QRS (> 0.12) = dx? Likely caused by? Trmt?

Answer 175

Wolff-Parkinson-White Syndrome - tachyarrhythmia. If symptomatic, catheter ablation recommended; controversial for those asymptomatic. Atrial fib is especially dangerous because it can precipitate vfib in these patients.

Question 176

MCC of SAH? Workup considerations?

Answer 176

Ruptured saccular aneurysm. Noncontrast Head CT = first choice. Lumbar puncture is required to exclude SAH. +CSF = elevated openning pressure, xanthochromia, elevated RBCs in 4 tubes of CSF (if the RBC's decrease in 4 subsequent tubes, it's a traumatic tap)

Question 177

Side effects of Nicotinic Acid?

Answer 177

Can lower triglyceride level but has Seffx: flushing, pruritus, and hepatotoxicity.

Question 178

Rx's for Triglycerides > 500 or

Answer 178

Fibrate (gemfibrozil) for >500; statin or Nicotnic Acid for

Question 179

Who's at risk for developing toxic megacolon early in their disease? Signs/symptoms? Mgmt considerations?

Answer 179

Those with IBD. 6cm dilated traverse colon, multiple air-fluid levels, loss of austral markings, pneumoperitoneum if perforated. Peritonitis signs may be absent!!! Patient look toxic (fever, tachycardia, "dry"). Try medical mgmt first: fluids, abx, bowel rest, NG tube. Start steroids IF the underlying reason isn't for infectious etiologies. AVOID ANTICHOLINERGICS AND OPIATES

Question 180

Emotional/orthostatic stress (venipuncture, prolonged standing, heat exposure, exertion)

Answer 180

Vasovagal syncope. Clinical dx, only do tilt table if unclear dx.

Question 181

Long term risks with PPI's?

Answer 181

Osteoporosis/hip fracture (2/2 decreased Ca absorption, inhibits ocsteoclastic activity, reduces bone mineral density); higher risk of infections (C Diff), hypomagnesemia, interstitial nephritis, and decreased absorption of Vitamin B12 and Fe.

Question 182

60% of head and neck cancers are locally advanced at time of diagnosis; what treatment modalities should be considered?

Answer 182

Combined chemo and radiotherapy.

Question 183

List manifestations of Sarcoidosis. Pathophys of hypercalcemia?

Answer 183

Formation of non-caseating granulomas in lymph nodes and organs causes: bilateral hilar adenoapthy, interstitial;infiltrates, anterior uveitis, posterior uveitis, peripheral lymphadenopathy, hepatomegaly, splenomegaly, acute polyarthritis, central DI, hypercalcemia, maculopapular rash, nodular lesions, erythema nodosum erythema nodosum, hilar adenoapthy, migratory polyarthralgias, fever = Lofgren's Syndrome Macrophages in sarcoid granulomas make 1-alpha-hydroxylase coverting 25-hydroxyvitamin D to 1, 25-dihydroxyvitamin D leading to increased absorption of Ca (see elevated Ca in urine with decreased serum PTH) Give steroids to bring down Ca levels

Question 184

Tremor presenting in upper distal extremities, more pronounced with outstretched arms, increases at end of activity = dx? rx? inheritance?

Answer 184

Familial tremor or benign essential tremor. Autosomal dominant inheritance. Can give beta-blockers

Question 185

Acute PAINLESS monocular vision loss ddx?

Answer 185

Central Retinal Artery Occlusion - MCC = carotid atherosclerosis - lower intraocular pressure FAST with massage, anterior chamber paracentesis, IV acetazolamide, or mannitol. Cherry red spot and surrounding pallor Central Retinal Vein Occlusion - likely non-embolic cause. Tortuous dilated veins, diffuse hemorrhages, disk swelling, and cotton wool spots. "flame storm"

Question 186

Acute loss of vision with severe eye pain, injected conjunctiva, poorly reactive but dilated pupil, HA, N/V = dx?

Answer 186

acute angle-closure glaucoma

Question 187

What are patients at risk for with TURP therapy?

Answer 187

Dry ejaculate 2/2 bladder neck failing to close after the procedure which enables sperm to flow backward to the bladder. (70% incidence)

Question 188

Amiodarone's effect on thyroid functions include:...

Answer 188

Can decrease peripheral conversion of T4 to T3 with minimal change in TSH = f/u If it induces frank hypothyroidism, treat with levothyroxine If it causes thyrotoxicosis, give steroids

Question 189

RR and tidal volume correlate with = ? This is changed to regulate what ? Fi02 and PEEP are used to regulate what?

Answer 189

Ventilation - affects CO2 P02 - increasing PEEP can worsen hypotension by reducing preload and can recruit non-functioning alveoli with resultant barotrauma.

Question 190

How do glucocorticoids cause bone loss and low Ca?

Answer 190

They decrease Ca gut absorption, cause renal Ca wasting, and have direct anti-anabolic effect on the bone. They suppress GnRH which can lead to hypogonadism and aggravate bone loss

Question 191

Appearance of sporotrichosis? Trmt?

Answer 191

Ulcerates with non-purulent d/c and similar lesions forming along lymphatic tract. Trmt = itraconazole for 3-6months

Question 192

Actinomysis RF's?

Answer 192

Gingivitis, dental caries, extraction, and oromaxillofacial trauma. Chronic slow growing mass evolving into multiple abscesses, fistulae, and draining sinus tracts with thick yellow or serrous d/c

Question 193

Tests to see if appropriate Rhogham given?

Answer 193

Rosette test = qualitative test to determine presence of feto-maternal hemorrhage. If negative, standard dose given. If positive, evaluate with Kleihaur-Betke stain or fetal red cell stain using flow cytometry

Question 194

What's the MCC of postoperative hypoxemia in post-op patient with recent thoracoabdominal sx occurring around 2-5 days?

Answer 194

Atelectasis - secondary to splinting, retained secretions, and diminished lung compliance. Obesity and OSA = RF's

Question 195

Differentiate nonallergic rhinitis and allergic rhinitis. Trmt?

Answer 195

NAR = nasal congestion, rhinorrhea, post nasal drip, no obvious trigger, develops later in life, erythematous nasal mucosa - intranasal glucocorticoids (fluticasone) or antihistamine (azelastine) AR = watery rhinorrhea, sneezing, eye symptoms predominate, earlier age of onset, identifiable allergen, pal/bluish nasal mucosa, associated with other allergic d/o - intranasal glucocorticoids and antihistamines

Question 196

Presentation for cardiac tamponade?

Answer 196

JVD, hypotension, diminished heart sounds, pulses paradoxus (drop in SBP > 10mmHg with inspiration), electrical alternans, right atrial and ventricular collapse during diastole

Question 197

New onset DM, arthropathy in 2nd 3rd metacarpophalangeal joints, morning stiffness, decreased libido, hepatomegaly, subchondral cysts, sclerosis, osteopenia and hook like osteophytes on xray = dx? labs?

Answer 197

Hemachromatosis. Presents b/w 50-60 normally. Common for there to be CPPD crystals in joint. Get transferrin saturation, serum iron, and ferritin levels

Question 198

Problem adducting the leg and sensory loss of small area in medial thigh?

Answer 198

Obturator neuropath - pelvic trauma or surgery

Question 199

Inability to extend knee, loss of knee jerk reflexes, and sensory loss over anterior and medial aspects of the thigh, medial aspect of shin, and arch of foot = ?

Answer 199

Femoral nerve injury.

Question 200

Problem with foot drop and weakness in foot dorsiflexion and eversion, paresthesias over dorsum of the foot and lateral shin = ?

Answer 200

Common personal nerve injury

Question 201

Common complication of CABG, develops after pericardial effusion, develop peripheral edema, ascites, hepatic congestion with hepatomegaly, elevated JP, hepatojugular reflux, Kussmauls sign (lack of decrease in JVP with inspiration) and pericardial knock = dx? trmt?

Answer 201

constrictive pericarditis - antiinflammatory agents and pericardiectomy.

Question 202

Modifiable RF's for ischemic stroke?

Answer 202

HTN (most important), DM, smoking, and dyslipidemia

Question 203

Common causative bugs in acute otitis media?

Answer 203

Strep Pna, H. Influe, and Moraxella Catarrhalis

Question 204

Match it's associated autoimmune d/o: 1) Ant-dsDNA 2) Anti-Centromere 3) Anti-Smith 4) Anti-Ro/SSA

Answer 204

1) SLE - anti dsDNA also helpful in following course of disease 2) CREST 3) SLE (less than dsDNA) 4) Sjogrens

Question 205

Lupus treatment considerations:

Answer 205

Prednisone-cyclophosphamide = serious lupus manifestations (lupus nephritis, CNS or vasculitic manifestations) Methotrexate-prednison = significant organ involvement with had incomplete response to prednisone alone Hydroxychloroquine-prednisone = arthralgias, serositis, and cutaneous symptoms

Question 206

Dermatitis herpetiformis = what presentation? association?

Answer 206

Associated with Celiac disease, and has pruritic vesicles and papules on elbows, knees, lower back, and buttocks

Question 207

Human bites tend to have = infection type? Trmt?

Answer 207

Polymicrobial infections. Associated with alpha-hemolytic streptococci, step aureus, and anaerobic bacteria, Eikenella corrodes. Primary closure should be avoided. Start antibiotics and consider tetanus booster Trmt = Oral amoxacillin/Clavulanate

Question 208

Abnormal deposition of collagen in multiple organ systems associated with GERD, and Raynauds= dx? Dangerous effect on kidneys? Trmt for this complication?

Answer 208

Systemic Scleroderma - malignant htn can result!!! ACEi and IV nitroprusside

Question 209

Meds for Strep Pharyngitis? Helps prevent ______ but not ______.

Answer 209

Oral PCN x 10 days; single IM PCN if cannot tolerate PO. 5 day course of Azithromycin is acceptable for PCN allergic patients Prevents Rheumatic Fever but not post-strep glomerulonephritis (1-3wks s/p infxn)

Question 210

Mesenteric ischemia MCC = ? from ?

Answer 210

Thrombus/emoblism from superior mesenteric artery

Question 211

Papillary/follicular thyroid cancer surgery decision based on?

Answer 211

Neck U/S and LN biopsy - lobectomy for 1cm and/or tumor extension, multi-node involvement, mets

Question 212

When to give joint injections for gout?

Answer 212

Contraindiciations to NSAIDS (bleeding, renal failure)

Question 213

MCC's of demyelinating ascending polyneuropathy = ? Monitor what?

Answer 213

Campylobacter jejuni, CMV, EBV, HSV. Monitor vital capacity!

Question 214

ADPKD BP range and when to screen for berry aneurysms? MCC extra renal manifestation? How to screen asymptomatic family members?

Answer 214

BP

Question 215

When to test for H Pylori?

Answer 215

Dyspepsia (abd fullness or pain w/o heartburn) - test if 55yo use endoscopy to r/o malignancy

Question 216

Septate uterus has problem with _____ but not _____?

Answer 216

miscarriages, not implantation; abnormal blood flow to septate causes recurrent miscarriages. Treat with hysteroscopic metroplasty

Question 217

Red, painful, sharply demarcated, edematous, elevated - MC on lower extremities but if seen on the face is butterfly distribution - has systemic symptoms like fever, chills, malaise - dx? Etiology?

Answer 217

Erysipelas secondary to Group-A Streptococcus

Question 218

When to draw labs for lead poisoning? Treatment algorithm?

Answer 218

Test if: home built before 1978, peeling paint, pica, sibling with poisoning, low SES, immigrant. If level 70 = Dimercaprol + Ca disodium edentate (EDTA)

Question 219

Which chromosomal abnormalities increase or don't with AMA?

Answer 219

No increased risk = Turners; increased risk = Downs and Klinefelters

Question 220

All children

Answer 220

> 7days. Renal and bladder U/S to evaluate for anatomical abnormalities. Voiding cystourethrogram is indicated in children with abnormal findings OR w/ recurrent UTI's

Question 221

Subacute/chronic knee pain, increased with squatting, prolonged sitting, using stairs = dx? What's a test for this? Trmt?

Answer 221

Patellofemoral Syndrome - compress the patella and extend the knee. Exercise and strengthen thigh muscles = trmt

Question 222

Episodic pain and tenderness at inferior patella seen in jumpers = dx?

Answer 222

Patellar tendonitis

Question 223

Increased knee pain with sports, relieved with rest, tenderness and swelling at tibial tubercle = dx?

Answer 223

Osgood-Schlatter Disease

Question 224

Common cause medial knee pain with localized pain/tenderness distal to joint line - acute/episodic - dx?

Answer 224

Anserine bursitis

Question 225

Seen in people who work on their knees a lot, acute, highlight localized with visible swelling anterior of the patella- dx? Complication?

Answer 225

Prepatellar bursitis = housemaid's knee. Complicated by secondary infection due to Stap Aureus

Question 226

Patient with neurologic symptoms who is having orthopnea, decreased ability to breathe while laying supine, paradoxical abdominal wall movement during inspiration, atelectasis on pulm exam = dx?

Answer 226

Diaphragmatic Paralysis

Question 227

Cerebral aneurysms causing suddent onset HA, nausea, nuchal rigidity, ptosis, anisocoria = SAH where?

Answer 227

Posterior communicating artery aneurysm w/ presentation due to location of CN III

Question 228

Childhood (

Answer 228

Respiratory Syncitial Virus = MCC of bronchiolitis

Question 229

URI causing hoarseness in children, barky cough, and inspiratory stridor from upper airway inflammation = dx? MCC?

Answer 229

Croup via Parainfluenza virus.

Question 230

Walking PNA bug?

Answer 230

Mycoplasma PNA

Question 231

Fatigue, exertional dyspnea, systolic murmur increased with valsalva, asymmetric septal hypertrophy = dx? Dominance? When to considered Implantable Cardioverter-Defibrillator?

Answer 231

Hypertrophic Cardiomyopathy = autosomal dominant. Trmt = for those w/ symptoms, use negative inotropic agents (B-blockers, Verapamil, Disopyramide) - alcohol septal ablation is a last agent resort ICD - those with hx of cardiac arrest or sustained ventricular tachycardia or at risk for malignant arrhythmias (family hx of sudden cardiac death, recurrent or exertional syncope, non sustained VT, hypotension w/ exercise, extreme LVH)

Question 232

Common drugs affecting Lithium levels = ?

Answer 232

Diuretics, NSAIDS (except aspirin), SSRI's, ACEi's, ARBS, antiepileptics (carbamazepine, phenytoin). Use Beta-Blockers and Dihydropyridine CCB's (Amlodipine) for BP control in patients with Lithium

Question 233

Warfarin can cause what to the fetus?

Answer 233

Nasal/limb hypoplasia and fetal bleeding. Can substitute with LMWH for most hypercoaguable patients (no crossing the placenta). However, if patient is extremely high risk, can use warfarin in 2nd/3rd trimester with substation of unfractionated heparin in last few weeks because it can be quickly reversed with protamine. NO anticoagulation at onset of labor or before epidural

Question 234

What to give pts with alcoholic ketoacidosis?

Answer 234

IV saline with dextrose and thiamine (prevent Wernicke's)

Question 235

Antibiotics most likely to cause seizure in those w/ hx, older age, renal insufficiency = ?

Answer 235

Beta lactams = PCNs, cephalosporins, monobactams, carbapenems, and fluoroquinolones

Question 236

Doxycycline side effect?

Answer 236

Bone discoloration and photosensitivity

Question 237

Gentamicin side effect?

Answer 237

Vertigo, ataxia, and ototoxicity

Question 238

Back pain associated with morning stiffness that gets better with exercise, insidious onset, lasts > 3 months, reduced range of forward flexion and reduced chest expansion = dx? How to diagnose? Monitor with? Most common and worrisome extraarticular manifestations?

Answer 238

Ankylosing Spondylitis - get an X-ray for DX. Monitor with AP/LA X-rays of lumbar spine and ESR Associated with: acute anterior uveitis, aortic regurg, apical pulmonary fibrosis, IgA nephropathy, and restrictive lung disease, HLA-B27 Counsel against smoking!!!! No overall increased mortality - most have no functional or employment disabilities - encourage exercise!

Question 239

Eye redness and mucopurulent discharge = dx? Complications? Trmt? Common pathogens?

Answer 239

Bacterial conjunctivitis. Complication risk of keratitis (inflammation of cornea - foreign body sensation, photophobia, and corneal opacity/ulceration) Trmt = Erythromycin ointment, sulfa drops, polymixin/trimethoprim drops for coverage of Staph aureus, strep pna, moraxella catarrhalis, and h flu. Can return to social contact after 24 hrs s/p abx; ideally once no more d/c

Question 240

Fever, pharyngitis, and URI with injected conjunctiva = dx? Trmt?

Answer 240

Viral conjuncitivitis 2/2 adenovirus. Give Ciprofloxacin drops; also give these to contact wearers b/c risk of Pseudo!

Question 241

Primary amennorhea, breast development, no hair development, suspicious inguinal masses = dx?

Answer 241

Androgen Insensitivity - testosterone converted to estrogen so breasts develop but no mullein structures present! 46 XY 2/2 mutation of androgen receptor

Question 242

Difference b/w aspiration PNA and aspiration pneumonitis?

Answer 242

Aspiration PNA - infxn 2/2 gram + cocci, gram neg rods, and anaerobes in pts w/ RF's occuring 1-5 days after event, w/ evidence of infection in dependent lung fields, treated with Clindamycin or Beta-lactam w/ beta-lactamase inhibitor Aspiration Pneumonitis - inflammation of lung parenchyma due to aspiration of foreign contents (GI acid) occurring 2-5 hrs after pt with depressed LOC has event - can have cough, tachypnea, hypoxemia, respiratory distress, can see evidence of dependent lobe involvement - NO ABX

Question 243

Occurs 2/2 to renal ischemia, sepsis, nephrotoxins (aminoglycosides, radiocontrast media), FeNa >2%, muddy brown casts = dx? Urine Osmolality?

Answer 243

Acute Tubular Necrosis - approx. 300mOsm/kg vs. PreRenal Azotemia with BUN/Cr >20, FeNa 500 (trying to hold onto fluid so it's concentrated)

Question 244

Fever, fatigue, young, pharyngitis, and posterior cervical lymphadenopathy = dx? Caused by? Caution against? Tests?

Answer 244

Infectious Mononucleosis by Epstein Barr Virus. Maculopapular Rash can develop if given Amoxicillin or Ampicillin = immune mediated by circulating antibodies to PCN derivatives + heterophile antibody test (monospot - can be negative in first week of illness); atypical lymphocytes, transient hepatitis Avoid contact sports >3weeks

Question 245

Different manifestations of Lyme disease based on: acute (days - 1month), weeks to months, months to years after tic bite?

Answer 245

Days - 1 Month: Erythema Migrans, fatigue, malaise, HA, neck stiffness, myalgias, arthralgias Weeks to Months: Carditis (AV block, cardiomyopathy), unilateral/bilateral CN involvements (CN VII), migratory arthralgias, conjunctivitis, multiple erythema migrans Months - Years: Arthritis, encephalomyelitis, peripheral neuropathy

Question 246

Work up of Lyme if bite happened months ago?

Answer 246

Enzyme-linked immunosorbent assay followed by western blot. All IgG serologies will be + for Borrelia Burgdorferi

Question 247

What tests to order for chronic, symmetric polyarthritis with morning stiffness = ?

Answer 247

Rheumatoid factor and anti-citrullinated peptide antibodies

Question 248

Treatment of Lyme disease considerations?

Answer 248

28day course of oral doxycycline; or amoxicillin for children

Question 249

Treatment of acute seizure?

Answer 249

Benzodiazepines (lorazepam) > barbidurates (phenobarbital) or phenytoin/fosphenytoin

Question 250

Mental status changes, diaphoresis, tachycardia, HTN, hyperthermia, diarrhea, hydriasis, hyperreflexia, tremor, rigidity, myoclonus, ocular clonus = dx? Trmt? Cause?

Answer 250

Serotonin Syndrome. D/c rx's, supportive measures, and sedation with BZD's (severe cases need serotonin antagonist = cyproheptadine). Not waiting >5wks before transitioning between SSRI's (fluoxetine, paroxetine, sertraline, citalopram), MAOIs (phenelzine, tranylcypromine); or interaction with ondansetron, sumatriptans, St Johns Wort

Question 251

NMS differs from Serotonin syndrome by?

Answer 251

Has lead pipe muscular rigidity from dopamine antagonist.

Question 252

Sensory ataxia, lshooting pains, neurogenic incontinence, accommodating but non-reactive pupils = suspicious for?

Answer 252

Tabes Dorsalis 2/2 late neurosyphilis - differentiated from Vitamin B12 deficiency by spastic paresis and hyperreflexia.

Question 253

What can inhibit absorption of levothyroxine?

Answer 253

Calcium and Fe - take on empty stomach apart from other meds

Question 254

Management of calcified gallbladder?

Answer 254

Porcelain gallbladder is from chronic calcium salt deposits 2/2 chronic inflammation - high risk of GB carcinoma = surgery

Question 255

Seborrheic dermatitis causative agent? Trmt?

Answer 255

Malassezia furfur Trmt = shampoos with ketoconazole, tar, zinc, pyrithione, or selenium sulfide

Question 256

Features of Histrionic personality d/o?

Answer 256

Excessive emoitionality, attention seeking behavior, provocative/seductive traits, considers relationships more intimate than they are.

Question 257

Antisocial d/o = ?

Answer 257

Disregard rules of others

Question 258

Borderline personality d/o = ?

Answer 258

Attention seeking, manipulative, exhibit self-injurious behavior, intense anger, chronic feelings of emptiness, splitting behavior

Question 259

Differentiate factors b/w alpha and beta thalassemia minor: ?

Answer 259

Both: low MCV, normal RDW (all small), target cells, normal or increased Fe and ferritin (2/2 more turnover), no improvement with response to Fe supplementation Alpha: Normal electrophoresis Beta: elevated Hemoglobin A2

Question 260

Medical vs. Surgical management for rectal prolapse?

Answer 260

Medical for non-full thickness prolapse - adequate fiber/fluid intake, pelvic floor exercises, biofeedback Surgery for full thickness prolapse with concentric rings seems or for those with prolapse for fecal incontinence and/or constipation

Question 261

Treatment of HIV-thrombocytpenia?

Answer 261

Can occur at any time of the disease regardless of CD4 count or VL; distinguished by no confounding reason for thrombocytopenia. Giving the patient Antiretroviral Therapy generally improves it - only need to give corticosteroids or IV immunoglobulin if the patient is bleeding actively (this is transient fix)

Question 262

Expected VL drop with patients starting HAART for the first time?

Question 263

Infant 3-6 wks with post-prandial projectile vomiting, palpable olive shaped mass in abdomen = dx? Workup? RF's?

Answer 263

Hypertrophic Pyloric Stenosis causing hypochloremic, hypokalemic, metabolic alkalosis. Get abdominal U/S (hint: get Abd Xray for Duodenal Atresia or malrotation) RF's = Postexposure prophylaxis for pertusis with erythromycin OR macrocodes in BF'ing women

Question 264

Causes of these on ECG: 1) Poor R wave progression 2) Prolonged QT

Answer 264

1) LVH, RVH, COPD, anterior infarct, conduction defects, and cardiomyopathy 2) Prolonged if measuring > R-R internal 2/2 anti arrhythmic drugs, antidepressants, hypokalemia, stroke, seizures

Question 265

Characteristics and trmt of Psoriatic Arthritis?

Answer 265

Pain and early a.m. stiffness relieved by physical activity in DIP and axial skeleton. Those pts with psoriasis and joint pain or systemic manifestations warrant methotrexate. IF pt does NOT have arthritis and only mild psoriasis (

Question 266

Who should you not treat asymptomatic bacteruria?

Answer 266

Nonpregnant, non menopausal women, elderly, diabetics, patients with spinal cord injury, patients with chronic indwelling catheters. Treat pregnant women, those getting urologic interventions, and hip arthroplasty.

Question 267

Pt with elevated AFP should get what next before considering amniocentesis?

Answer 267

OB U/S

Question 268

Lesion of the skin that rapidly progresses into nodular patch with hemorrhage, ulceration, and necrosis = dx? Associated causative agent? Trmt?

Answer 268

Ecthyma Gangrenosum - Pseudomonas Trmt = Aminoglycoside (tobramycin/amikacin) and extended-spectrum antipseudomonal PCN (piperacillin) or antipseudomonal cephalosporin (ceftazidime or cefepime)

Question 269

Prevent development of ventricular dysfunction from asymptomatic to symptomatic HF with?

Answer 269

ACE inhibitor. Consider digoxin to treat symptomatic HF

Question 270

Clues for patient with adrenal failure?

Answer 270

Patient's w/ preexisting autoimmune d/o's and weight loss, eosinophilia, low Na, high K, pre renal azotemia, and low blood glucose levels.

Question 271

What to advise patients taking valproate who are thinking of becoming pregnant?

Answer 271

High dose folic acid before conception. The use of anti epileptics is generally advised to continue their use EXCEPT valproate BUT you should only switch if she has not become pregnant yet!! If already conceived, do not switch. NOT A CONTRAINDICATION FOR BF'ing

Question 272

Management of pts with bicuspid aortic valve? When to do surgery?

Answer 272

TTE for diagnosis. Screen first degree relatives (autosomal dominant with incomplete penetrance). Get an echo every 1-2 yrs to monitor for signs of: regurg, stenosis, ascending dissection, aortic root dilatation , endocarditis Do surgery (balloon valvuloplasty) in symptomatic pts with AS, gradient > 50mmHg, and NO sig. AV calcification or regurg. Can also do in those planning to become pregnant

Question 273

PAtient not responding to antiresorptive bone meds, have very rapid progression of bone loss, multiple fractures, or have other constitutional symptoms (weight loss, pallor) = keep this on your DDX?

Answer 273

Multiple Myeloma - get an SPEP and UPEP

Question 274

Best non-invasive test for osteomyelitis? Gold std? MCC?

Answer 274

MRI. Bone Biopsy. MCC = Staph aureus, GBS, Proteus, Pseudo, E Coli, Candida, Bacteroides, Peptococcus, and Clostridium. Get culture from deep curettage.

Question 275

What vision change can accompany viagra use?

Answer 275

Blue-green vision; thus pilots shouldn't fly until after 6 hrs after taking it

Question 276

What can you give people with lactose intolerance to help with symptoms?

Answer 276

Yogurt with live culture

Question 277

In patients with suspected disseminated gonococcal infection, get what tests? Unique signs of this type of joint infection?

Answer 277

Culture the joint fluid, mucosal surfaces, urethra, cervix, rectal and oral mucosa Unique = tenosynovitis at wrist, fingers, ankle, and toes. Pustular or vesicle-pustular skin rash that is transient and goes away in a few days

Question 278

Causes of hyponatremia?

Answer 278

Primary polydipsia, adrenal insufficiency, hypothyroidism, excessive ADH v. SIADH

Question 279

Causes of SIADH?

Answer 279

Small Cell Lung cancer, carbamazepine, cyclophosphamide, SSRI's, pulmonary disease, HIV, post-operative patients (esp. when receiving large fluid boluses)

Question 280

Nausea, malaise, HA, lethargy, obtundation, seizures, coma, and respiratory arrest = course of hyponatremia - pathophy? trmt?

Answer 280

It's from cerebral edema!! Treat if Na falls

Question 281

How to differentiate etiologies of ascites?

Answer 281

SAAG =serum-ascites albumin gradient (their difference) > 1.1 = portal htn: CHF, cirrhosis, alcoholic hepatitis

Question 282

Low TSH and low T4 should make you suspicious of? Look out for? Order?

Answer 282

Central hyothyroidism - look out for low sodium/glucose/hypotension. Can get serum ACTH and short ACTH stimulation test (cosyntropin, synthetic ACTH) to assess: - low response, low ACTH level = central adrenal insuff - low response, high ACTH = primary adrenal insuff Should get MRI of the pituitary too.

Question 283

What to give patient who p/w: delirium, seizures, respiratory depression, sinus tach, hypotension, dry mouth, blurred vision, dilated pupils, flushing, hyperthermia w/ psych hx?

Answer 283

Sodium Bicarb = neutralizies TCA to non-iodized form making them less likely to bind to Na fast channels in the heart ,preventing QRS widening; if refractory give magnesium or lidocaine

Question 284

Causes of decreased medication use secondary to cytochrome P450 induction = ?

Answer 284

phenytoin, carbamazepine, ethosuximide, phenobarbital, topiramate NOT valproate or gabapentin

Question 285

Atypical PNA's = ?

Answer 285

PCP, Mycoplasma, Chlamydia

Question 286

Legionella PNA causes what symptoms?

Answer 286

Diarrhea, nausea, vomiting, HA, confusion - sputum shows many neutrophils, no to little organisms

Question 287

Area of hair loss w/o local scaling or inflammation = dx? trmt? prog? Ddx?

Answer 287

alopecia areata - discrete, smooth and circular area of hair loss over scalp - occurs over few weeks w/ recurring pattern; most have regrowth over time. Thought to be autoimmune (t-cell infiltrate near hair follicles - seen with other autoimmune d/o's). Intralesional or topical steroids = trmt. Chronic recurring d/o. Ddx: secondary syph (moth-eaten, scarring), tinea capitis (scaling, inflammation), discoid lupus (hypopigmentation, other lesions)

Question 288

ARDS assessed by? Pathophys?

Answer 288

PaO2/FiO2

Question 289

Mechanical vent settings in ARDS = ? Be careful of?

Answer 289

Low tidal volumes (8mL/kg then to 7 over next 1-3 hrs), plataeu pressure 95 can increase risk of toxicity (reactive O2 species) - decrease FiO2 once reaching goals

Question 290

Trmt for primary dysmenorrhea?

Answer 290

1st line = NSAIDS 2nd = OCPs 3rd = eval for secondary causes Primary dysm 2/2 prostaglandin excess

Question 291

What surgery and when is it recommended in pts with carpal tunnel syndrome?

Answer 291

Volar carpal ligament release. If they have motor weakness or atrophy of thenar eminence. Typical Trmt = splint > steroids > surgery

Question 292

Initial trmt for cancer of the glottis?

Answer 292

Radiation therapy, laser excision, or partial vocal cordectomy

Question 293

CPK levels in rhabdo? RF's? Mgmt? Complications

Answer 293

CK > 10,000. RF's= cocaine, severe trauma, exertion, NMS, hypothermia, hypothyroidism. Mgmt = IV fluids and then alkalinize the urine Complications = renal failure, hyperphosphatemia, hyperkalemia, hypocalcemia

Question 294

Criteria for MM? What should you get after fractures? Complications?

Answer 294

1) monoclonal protein in serum or urine 2) > 10% clonal plasma cells in bone marrow or soft tissue/bone 3) CRAB Get skeletal survey to assess extent of fractures (punched out lytic lesions) Complications = hypercalcemia (hydrate, steroids bisphosphonates), renal insufficiency 2/2 light chain cast nephropathy (plasmapharesis), Infection (vaccinate), hyperviscosity (bleeding, blurry vision, neuro changes - plasmapharesis), thrombosis

Question 295

Elevated IgM condition with associated risk of hyper viscosity?

Answer 295

Waldenstrom's macroglobulinemia

Question 296

Treatment considerations for actinic keratosis? Risk?

Answer 296

Early lesions: 5-FU, imiquimod, cry destruction with liquid nitrogen Biopsy if: unclear dx, lesion >1cm, ulceration present, tenderness, growing rapidly, refractory Risk of SCC (1-20%) Biopsy + SCC - get Mohs sx or excision with 4mm margins

Question 297

Absence of peristaltic waves in lower 2/3 of esophagus and decrease in LES tone w/ complaints of GERD and dysphagia ("sticking") = dx?

Answer 297

Scleroderma

Question 298

Two mortality reducing settings for vent settings in ARDS setting?

Answer 298

Limited plateau pressure

Question 299

Orthopnea, paroxysmal nocturnal dyspnea, tachycardia, diffuse crackles, S3, JVD, peripheral edema = dx? Trmt considerations?

Answer 299

Decompensated Heart Failure. Acutely give O2, IV loop diuretic (furosemide), consider IV nitroglycerin. If becomes hypotensive, give NE. Goal = reduce cardiac preload

Question 300

MC pathogen from cultures in corneal foreign bodies = ?

Answer 300

Coagulase negative Staphylococcus (other common = strep, Haemophilus, and Pseudo)

Question 301

CXray findings indicative of active TB = ?

Answer 301

Upper lobe infiltrates, cavities, hilar adenopathy, or pleural effusions

Question 302

when to treat children with dysentery with antibiotics?

Answer 302

Causing sepsis, if immunocompromised,

Question 303

Fever, crampy abdominal pain, low-volume bloody diarrhea in children = dx?

Answer 303

Bacterial Enteritis (dysentery) - Salmonella = MCC in US. Others = Shigella, E. Coli (O157:H7), Yersebia, Campylobacter - produce bloody diarrhea by directly invading enterocytes or injecting toxin into cells *DONT GIVE ABX TO E COLI O157:H7 - PUTS AT RISK FOR HUS!

Question 304

Prog for patient with 1x episode of depression and treated successfully?

Answer 304

Stay on for 6months - 1 yr and then can be tried off meds. Once they've have 2 episodes, they should stay on!

Question 305

Confusion, ataxia, nystagmus = dx? Trmt? Complication?

Answer 305

Wernicke's Encephalopathy. Give IV Thiamine Korsakoff's psychosis can endure with profound confabulation and anterograde/retrograde amnesia - see maxillary bodies and thalamus primarily affected in diencephalon

Question 306

Acute delirium/dementia in elderly patient with elevated MCV, reticulocytes, pancytopenia, increased indirect bili?

Answer 306

B12 Deficiency - don't have to have motor signs!!!

Question 307

characteristics of MArfans?

Answer 307

Ectopia lentis, increased arm/height ratio, decreased upper/lower body ratio, arachnodactyly, breastbone dipping inward or outward, scoliosis/kyphosis, joint hyper mobility = auto dominant by mutations in ECM protein fibrillin-1. Main M/M = aortic root disease (dilatation, AR, dissection) - all should get CT or echo. COUNSEL against intense sports

Question 308

Concurrent otitis media + purulent conjuncitivits = causative agent?

Answer 308

Nontypeable H flu

Question 309

AOM + nonpurulent conjunctivitis, URI, and gastroenteritis = causative agent?

Answer 309

H Influenzae

Question 310

Acute otitis externa = MCC?

Answer 310

Pseudomonas

Question 311

Trmt considerations for AOM?

Answer 311

Uncomplicated AOM = 10d high-dose amox. Repeat infxn within a month = Augmentin

Question 312

RF's for contrast induced nephropathy? Prevent with?

Answer 312

Age > 75, reduced GFR, reduced renal perfusion (hypoten), increased contrast load Prevent with IV saline or IV sodium bicarbonate - hold diuretics and NSAIDS

Question 313

Dysuria, dull/aching pain in perineal region and testicles, blood-tinged ejaculate = dx?

Answer 313

Prostatitis. Negative UA + >20 leuks/HPF on prostatic secretions = Chronic nonbacterial prostatitis (symptomatic treatment)

Question 314

Thick, brittle, discolored nails = dx? RF's? Trmt?

Answer 314

Onychomycosis. RF's = increased age, tine pedis, diabetes, PVD. Dx w/ KOH, periodic acid-Schiff stain, culture Trmt = terbinafine, itraconazole; second line = griseofulvin, fluconazole, ciclopirox (12wk therapy for toes, 6 wks for fingernails) . Trmt risks = hepatotoxicity, treatment failure, recurrence.

Question 315

Why CCB's contraindicated in ACS?

Answer 315

Hypotension and subsequent increased risk of increased sympathetic reflex activity.

Question 316

Extraintestinal findings of Celiac's Disease? How to screen?

Answer 316

Fatigue, wt loss, dermatitis herpetiformis, vitiligo, osteopoenia - malacia, anemia, peripheral neuropathy, HA, autoimmune thyroiditis, Type I DM, depression, psychosis Screen with anti-endomysial Ab and anti-tissue transglutaminase Ab. Gold std = bx of Small Intestine

Question 317

Mets of prostate cancer locale? Best imaging? Trmt for mets?

Answer 317

Bones, especially axial skeleton. Radionuclide bone scan. Want androgen depletion: LHRH like leuprolide bind and cause LH/FSH release with transient rise in testosterone; dissipates after a week - this causes flare of symptoms, thus anti androgen (flutamide) is used 1 wk prior to block effects of elevated T

Question 318

Trmt of CIN 2 vs. 3 in young patient

Answer 318

Can wait and observe with pap/colpo with CIN 2 in prepregnant patient because of cervical stenosis and cervical insufficiency resultant from therapy. But if CIN 3, need LEEP, cryosurg

Question 319

Indications for carotid endarterectomy: ?

Answer 319

Men: - asymptomatic 60-99% stenosis - symptomatic 50-69% (IIA) / 70-99% (IA) Women: - symptomatic/asymptomatic 70-99% stenosis

Question 320

Back pain that gets better with sitting down, leaning forward/flexion, and gets worse with standing and extension = dx? trmt?

Answer 320

Lumbar stenosis - try conservative management, lumbar epidural block, or surgical decompression via laminectomy

Question 321

MRI findings w/ lumbar stenosis = ?

Answer 321

Encroaching osteophytes at the facet joints, hypertrophy of the ligamentum flavum, and protrusion of intervertebral disk in narrowing of spinal canal.

Question 322

When to give antibiotics in acute pancreatitis?

Answer 322

Contrast-enhanced CT showing 30% or more of the pancreas is necrotic , prophylactic abxs are of use (imipenem and meropenem)

Question 323

Marked increase in serum Cr s/p ACEi in renal transplant pts is suggestive of?

Answer 323

Renal artery stenosis

Question 324

Asymptomatic hyperkalemia with mild metabolic acidosis?

Answer 324

Hypoaldosteronism

Question 325

MCC of chronic adrenal insufficiency = ?

Answer 325

Autoimmune destruction. Other = hemorrhagic infarction, metastatic disease, and infection (TB)

Question 326

Features of chronic adrenal insufficiency?

Answer 326

Hyponatremia, hyperkalemia, and hyperchloremia metabolic acidosis. = lab findings Fatigue, weight loss, myalgia, increased pigmentation, and decreased axillary and pubic hair.

Question 327

A cause of sudden cardiac death that has no abnormal ECG or echo findings?

Answer 327

Anomalous origin of the coronary artery - left main artery from the right sinus of valsalva and the origin of RCA from left coronary sinus.

Question 328

Brugada syndrome = ?

Answer 328

RBBB and ST-segment elevations in leads V1-V3

Question 329

When to screen for chlamydia in women?

Answer 329

age 24 and less or those with high risk sexual practices

Question 330

Adolescents with upper-extremity myoclonic jerks and subsequent generalized tonic-clonic seizures = dx? Trmt? See on EEG?

Answer 330

Juvenile Myoclonic Epilepsy - Valproic acid. Bilateral polyspike and slow discharge in interictal periods

Question 331

When to get endoscopy with suspected C diff patient? Abx culprits?

Answer 331

If enzyme immunoassay is negative but high suspicion (neg lab tests), they aren't getting better on abx, or need urgent dx (look for pseudomembranous colitis. PCR = more sensitive than enzyme assay Commonly associated abx = Fluoroquinolones, enhanced-spectrum PCNs, cephalosporins, and Clindamycin

Question 332

How to rapidly in tube someone?

Answer 332

Rapid sedative = etomidate, propofol, midazolam and paralytic = succinyl choline, rocuronium

Question 333

Evidence of PE on Echo?

Answer 333

RV strain = increased RV size, tricuspid regurg, decreased RV function, and RV thrombus

Question 334

Magnesium hydroxide is safe for longterm use?

Answer 334

Yes- it's Milk of Mag

Question 335

Surgical treatment for RCC?

Answer 335

Confined in the renal capsule = Stage I (partial nephrectomy) Extends through renal capsule but not through Gerota's fascia (stage II) and radical nephrectomy is the choice (can do with stage III too)

Question 336

Cushing's Triad indicating increased intracranial pressure?

Answer 336

Bradycardia, HTN, and respiratory depression

Question 337

Hyperthryoid symptoms, fever, painful, diffusely enlarged thyroid = dx? Trmt?

Answer 337

Subacute thyroiditis - inflammatory response causing release of stored hormones; has mixed inflammatory thyroid infiltrate of lymphocytes, neutrophils, histiocytes, and multinucleate giant cells; low radio iodide uptake b/c huge release of hormones already Trmt = Bblocker and NSAID

Question 338

What abx penetrate prostate?

Answer 338

Fluoroquinolone (cipro or levi for 6-12 wks) or Bactrim

Question 339

Post partum endometritis abx? Biggest RF?

Answer 339

Clindamycin and gentamicin Route of delivery - C/S!!!!

Question 340

Dog and cat bites get what?

Answer 340

Tetanus consideration! Amoxicilin/Clavulanate

Question 341

Low grade fever, lymphadenopathy w/ posterior cervical and occipital LN's, and maculopapular rash beginning on face and spreading caudally, patchy erythema on soft palate= ? Complications = ?

Answer 341

Rubella Acute arthritis, thrombocytopenia, and encephalitis. Soft palate spots = forscheimer spots

Question 342

High fever that rapidly resolves, rosy nonpruritic rash originating on trunk spreading to extremities = dx?

Answer 342

Roseola

Question 343

Cough, Conjunctivits, and Coryza, fever, photophobia, blue-white Koplik spots, maculopapular rash ("brick red") starting on face and spreads caudally to trunk/extremities = ?

Answer 343

Rubeola

Question 344

Screening for thyroid probs in preg with? What is the change of reference for total T4/T3?

Answer 344

TSH - then get total T4/total T3 if abnormal. Total T4/T3 reference range can be adjusted 1.5x

Question 345

Pain control for metastatic prostate cancer in axial skeleton that's refractory to hormone therapy = ?

Answer 345

Focal external beam radiation therapy

Question 346

MC cancers to metastasize to the brain = ?

Answer 346

Lung, breast, melanoma, and colon cancer

Question 347

Signs on MRI of mets vs. primary brain tumors?

Answer 347

Multiple, well-circumscribed lesions, and large amount of vasogenic edema as compared to the size of the lesions

Question 348

What kind of test do you want to have a higher PPV? NPV?

Answer 348

Higher sensitivity = higher NPV (b/c lower FN) Higher specificity = higher PPV (b/c lower FP)

Question 349

arrest of labor in first stage = criteria?

Answer 349

=/> 6cm, ROM: - no cervical change >4 hrs w/ adequate ctx - no cervical change >6hrs w/ inadequate ctx

Question 350

Good screening tools for sarcoidosis? Confirmation of dx?

Answer 350

Screening w/ ACE levels or CXray Bx of palpable LN, subcutaneous nodule (NOT ERYTHEMA NODOSUM), enlarged parotid, lacrimal gland

Question 351

Acute ischemic colitis RF? Areas at risk?

Answer 351

Atherosclerosis = RF. Present w/ abdominal pain followed by bloody diarrhea. Vulnerable areas = watershed areas (splenic flexure and rectosigmoid junction)

Question 352

Criteria for cervical insufficiency = ? RF's? Trmt = ?

Answer 352

H/o painless dilation w/ second trimester loss, painless dilation in current pregnancy in 2nd trimester, h/o preterm birth and current CL

Question 353

Presence of multiple dilated bowel loops and absence of rectal air, no meconium passage, bilious emesis, visible transition zone b/w normal/narrow rectosigmoid and dilated descending colon = dx?

Answer 353

Hirschsprung Disease - absence of ganglion cells on rectal mucosal suction bx Associated with congenital anomaly (renal) and chromosomal defect (Downs)

Question 354

What medication is associated with fluid retention in patient with heart failure?

Answer 354

Thiazolidinedione medications (Pioglitazone)

Question 355

Trmt choice for ALS?

Answer 355

Riluzole = glutamate inhibitor

Question 356

Abx trmt for acute rhinosinusitis?

Answer 356

First line = augmentin | 2nd line = doxy or fluoroquinolones

Question 357

Complication of appendicitis in pregnancy depending on trimester?

Answer 357

``` 1st = 1/3 can have SAB 2nd = PTD 3rd = pylephlebitis (infectious thrombosis of portal veins) ```

Question 358

Associated defects found with Down Syndrome children? Increased risk of?

Answer 358

Endocardial cushion defects (get echo), duodenal atresia, Hirschsprung's, atlanto-axial instability, and hypothyroidism Increased risks = Acute leukemia! Alzheimer dementia, autism, ADHD, depressive d/o, and seizure d/o

Question 359

Steps for workup of polycythemia?

Answer 359

Recheck Hgb. Get EPO level - majority cases caused by elevated EPO 2/2 chronic hypoxia from lung/cardiac disease. Elevated EPO could also indicated RCC. Low EPO = PCV primary, CML JAK2 for additional testing for PCV

Question 360

Trmt regimens for latent tuberculosis (+ testing but negative CXR) = ?

Answer 360

Isoniazid + Rifapentine wkly for 3mo Isoniazid mono therapy for 6-9 mo Rifampin for 4mo Isoniazid & rifampin for 4 mo

Question 361

Non-positional vertigo, dizziness, dysarthria, diplopia, and numbness = dx? RF's? Causes?

Answer 361

Vertebrobasilar insufficiency 2/2 emboli, thrombi, or arterial dissection.

Question 362

Aortic valve area less than ____ = severe AS? Trmt of choice?

Answer 362

1.0 cm^2; onset of symptoms markedly affects prognosis in patients w/ AS AV replacement associated wit harked reduction in symptoms and mortality in patients with symptomatic AS

Question 363

MAssive colonic bleeding in elderly: top 2 causes? Associated findings?

Answer 363

1) Diverticulosis | 2) Angiodysplasia - associated w/ AS and ESRD

Question 364

Palivizumab for infants to prevent RSV = ? Associated prognosis?

Answer 364

Preterm birth

Question 365

Trmt for CAP?

Answer 365

Ceftriaxone and Azithromycin

Question 366

Abdominal pain, myalgia, sweating, drooling, watery eyes, confused, serious diarrhea, constricted pupils, salivating, wheezing = dx? Trmt?

Answer 366

Organophosphate poisoning. Give Atropine to reverse muscarinic effects and pralidoxime which activated cholinesterase's.

Question 367

Acetominophen overdose = trmt? Opiod intox? BZD overdose?

Answer 367

N-acetylcysteine / Nalozone / Flumazenil

Question 368

When to do ORIF with clavicular fractures?

Answer 368

Open fractures, neurovascular compromise, skin tenting, widely displaced fractures, significant shortening. If only minimally displaced or non displaced = conservative trmt

Question 369

Erection > 3hrs long = emergency; management algorithm = ?

Answer 369

Ice packs, alpha-adrenergic agonsit ( phenylephrine, epinephrine q5min) , oral terbutaline

Question 370

Signs of thyroiditis vs. other causes of hyperthyroidism?

Answer 370

Low radioactive iodine uptake (vs. general uptake in Graves vs. focal in nodular), elevated thyroglobulin (destruction of cells), no tenderness can help differentiate postpartum causes from subacute thyroiditis

Question 371

Chronic alcoholics are frequently depleted of this electrolyte even in the face of a normal serum level = ? Refeeding them can cause?

Answer 371

Phosphate. Refeeding can cause intracellular shift and lead to rhabdo.

Question 372

BF'ing concern with metronidazole?

Answer 372

If given for trick, give 2 g by mouth for 1 dose and BF'ing should be d/c'd for next 12-24hrs.

Question 373

What causes bleeding from diverticulosis?

Answer 373

Erosion of the artery 2/2 fecalith in diverticular sac

Question 374

RF's for adenocarcinoma and SCC in the esophagus?

Answer 374

AC = chronic GERD / Barrett's esophagus SCC = EtOH and Tobacco

Question 375

Causes of Pseudotumor Cerebri = ?

Answer 375

Idiopathic, endocrine d/o's (hypothyroidism, adrenal insufficiency, Cushing disease, hypoparathyroidism), Meds (Isotretinoin, tetracycline, steroids, danazol, tamoxifen, levothyroxin, lithium, nitrofurantoin)

Question 376

Chronic pancreatitis test = ? Advise?

Answer 376

CT - can show calcifications, enlargement, ductal dilatation, and pseudocysts Of note, serum amylase and lipase may be slightly elevated or normal because they become decreased in pancreas as it's fibrosed over time Advise against EtOH and low fat diet, small frequent meals

Question 377

ECG patterns of MI's = ?

Answer 377

``` Anterior = V1-V6 Lateral = I, aVR, aVL, V5-V6 Inferior = II, III, aVF ```

Question 378

PCOS trmt = ?

Answer 378

Weight loss > clomiphene if wanting to become pregnant OCPs if not wanting to become pregnant

Question 379

Adjunct therapy for bipolar breakthrough?

Answer 379

- FIRST, make sure Lithium level is therapeutic (0.6 - 1.2); closer to 1 is target - can add lamotrigine for depression - can add antipsychotic (risperidone) for severe mania/psychosis

Question 380

LLQ pain in older individual, +FOBT = dx? Outpt trmt?

Answer 380

Acute Diverticulosis If stable on CT and clinical findings, can give Cipro and Metro for mild disease. May need CT to assess for abscess, perforation, and fistulas

Question 381

Handing solitary pulmonary nodule = ?

Answer 381

Up to 3cm, compare with previous X-rays - if none, get CT. Benign features = serial CT scans Indeterminate = Biopsy or PET Suspicious = sx excision

Question 382

Trmt options for condyloma accuminata?

Answer 382

Internal = Trichloroacetic acid External = TCA, Podophylin,

Question 383

Immune Thrombocytpenia = presentation? Labs? Trmt?

Answer 383

Can have previous viral infection, asymptomatic petechiae/ecchymosis, mucocutaneous bleeding. Likely due to anti platelet Ab Isolated Thrombocytopenia 30,000 w/o bleeding = observe. Plt

Question 384

Features of DIC = ?

Answer 384

Leads to bleeding and clotting. Associated with sepsis, trauma, obstetric complications, malignant. Elevated D-dimer, prolonged PT, prolonged aPTT, low fibrinogen. = consumptive coagulopathy

Question 385

TTP characteristics = ?

Answer 385

thrombocytopenia, MAHA, elevated lactate dehydrogenase, renal failure, fever, and neuro symptoms

Question 386

Active bleeding variceal management = ?

Answer 386

Stabilize > early endoscopic intervention > repeat if necessary; if fails twice, consider TIPS or surgical shunting. Once stabilized, can put on non-selective beta blockers (propanolol or nadolol)

Question 387

Level that warrants phototherapy in hyperbilirubinemia in neonates?

Answer 387

Serum bili > 18. If more than 25, that's severe and are at risk for neuro complications.

Question 388

Unilateral thunderclap HA associated with Horner's syndrome should consider = dx? Workup? Complications?

Answer 388

Carotid dissection. CT angio > MR angio or catheter angiography (gold std). Manage with antithrombotic therapy 2/2 stroke as a major complication

Question 389

Trmt of prolactinoma = ?

Answer 389

Cabergoline, bromocriptine = dopamine agonists

Question 390

Distortion of head, eyes, and involuntary tongue movements s/p medication initiation = dx? Trmt?

Answer 390

Acute Dystonic Reaction 2/2 antipsychotics, metoclopramide Give IV Diphenhydramine. If refractory, give IV Benztropine

Question 391

Trmt for Salmonellosis = ?

Answer 391

None if immunocompetent and > 1yr old

Question 392

Trmt for post exposure HepB exposure in persons w/ and w/o adequate prophylaxis?

Answer 392

Hep B immune globulin and initiate vaccination within 12 hrs. Those previously immunized w/ adequate response = no trmt

Question 393

MC location of abdominal aneurysm? Screening? Mgmt? Repair?

Answer 393

Infrarenal (>3cm). Screen in men age 65-75 who have smoked. SMOKING CESSATION!!! Aspirin and statin therapy. Repair: if large (>5.5), rapidly enlarging (>0.5cm in 6months), AAA w/ peripheral artery disease. Can f/u

Question 394

Absolute contraindications for combined OCP's?

Answer 394

Migraine w/ aura, >15cigarettes/day & > 35yrs old, BP > 160/100, H/o stroke/ischemic heart disease/VTE, cirrhosis,

Question 395

Granular casts, elevated WBC's/HPF, 4+ proteinuria, and elevated Cr w/ h/o of NSAID used = dx??

Answer 395

Acute Interstitial Nephritis

Question 396

Small effusion, locking sensation with knee extension, can't fully extend leg, joint line tenderness = dx?

Answer 396

Menicus injury; + McMurray test

Question 397

Common complication associated with compartment syndrome? Measure what for mgmt?

Answer 397

Acute Renal Failure - heme pigment released from damaged muscle is directly toxic to proximal tubular cells, combines with Tamm-Horsfall protein to form tubular casts, and induces vasoconstriction which reduces medullary blood flow Measure tissue pressure (>30mm Hg OR DBP - compartment pressure

Question 398

Alternative med supplement that can cause HTN?

Answer 398

Licorice

Question 399

SLE, hematuria, proteinuria, renal insufficiency, HTN, marked hypocomplementemia = next work up step? Mgmt based on? Monitor what labs?

Answer 399

Renal Bx. Depends on type of glomerular involvement: I/II - no trmt III/IV - require immunsuprresion Monitor Anti-dsDNA and complement levels

Question 400

Workup of testicular mass?

Answer 400

Transillumination test > U/S; if suspicious for malignancy, follow w/ CT and measure tumor markers (B-hcg, alpha fetoprotein); if high suspicion, gold std = radical inguinal orchiectomy

Question 401

First step in evaluating ASYMPTOMATIC person w/ exposure to TB?

Answer 401

PPD

Question 402

Endometriosis mgmt?

Answer 402

Can try emperic therapy w/ NSAIDS, GnRH analogs, Danazol - synthetic androgen, OCP's BUT, if the patient is expediency severe symptoms, infertile, and unresponsive to conservative pain meds, get laparoscopy first to confirm diagnosis. May need surgical therapy

Question 403

If you have elevated TSH, T3/T4 = ddx? Differentiate?

Answer 403

TSH-secreting pituitary adenoma or thyroid resistance syndrome; the former has elevated alpha-subunit levels; the latter normally has hypothyroid clinical picture

Question 404

What is familial dysalbuminemic hyperthyroxinemia?

Answer 404

Abnormal albumin has high affinity for T4 but not T3. Normal TSH

Question 405

Densley pigmented lesion with irregular borders seen on optho exam = dx? Mgmt?

Answer 405

Ocular melanoma = primary malignant tumor from melanocytes. U/S = most sensitive to diagnose the lesion while MRI used to document any extrascleral extensions for staging/trmt purposes If asymptomatic and small (

Question 406

Squamous cell skin cancer trmt option?

Answer 406

Surgical excision!! Also can use cry therapy, electrosurgery, and radiation therapy.

Question 407

Trmt options for Grave's hyperthyroidism = ?

Answer 407

Antithyroid drugs = mild cases, older, pregnant Radioactive Iodine = mod/severe disease w/ or w/o opthalmopathy Thyroidectomy = very large goiter, suspicion for cancer, coexisting parathyroidism, pregnant patients unable to tolerate antithyroid drugs, severe opthalmopathy, obstructive symptoms

Question 408

What to measure s/p radioactive iodine in Grave's patients for eval?

Answer 408

Get Total T3 and free T4 to monitor response. thyroid antibodies can help predict relapse in patient with treatment but doesn't gauge functional status

Question 409

When to use amiodarone in ACLS?

Answer 409

Wide complex, regular tachycardia - pulseless VT/VF refractory to initial defib

Question 410

All patients with known atherosclerotic CVD regardless of baseline LDL levels should have this onboard to improve cardiovascular outcomes and mortality?

Answer 410

Statins!

Question 411

Light's criteria?

Answer 411

Transudate = pleural/serum protein 50%, LDH > 60% or > 2/3 ULN

Question 412

UTI rx's safe in preg?

Answer 412

Amoxicillin, cephalexin, or Nitrofurantoin

Question 413

PE/symptoms that should prompt you to think of Sjogren's? Increased risk of what malignancy?

Answer 413

Keratoconjunctivitis sicca (gritty, burning sensation), Xerostomia (dry mouth, many dental caries) - get Anti-Ro/SSA and Anti-La/SSB. Schirmer test confirms eye problem. B-cell non-Hodgkin's lymphoma 2/2 polyclonal B cell activation and infiltration of the salivary glands

Question 414

Erythemaouts, itchy, scaly painful rash which starts cleaning from the center and can migrate + diarrhea + DM + angular cheilosis +facial flushing = dx?

Answer 414

Glucagonoma. Necrolytic migratory erythema. Most are malignant and mainly mets in liver. Also have VIP, calitonin, and GLP1 release

Question 415

Dementia, diarrhea, dermatitis, stomatitis, and cheilosis = dx?

Answer 415

Pellagra from niacin deficiency

Question 416

Type I vs. II error

Answer 416

Type II = fail to reject a null hypothesis when it's false (false negative); w/ higher sample size, lower Beta, less chance of type II error Type I = rejects a null hypothesis that is true (false positive) Power = 1 - B (type II error)

Question 417

Correlation coefficient info

Answer 417

-1 to +1, 0 being no correlation (if negative, one goes up while the other goes down)

Question 418

Factitious d/o = ?.

Answer 418

When a pt inflicts harm on themselves to act the sick role. Differs from malingering b/c no external incentive

Question 419

Likelihood ratio = ?

Answer 419

Does not vary with prevalence of disease = probability of a given test result in a pt with d/o compared to probability of same result in patient w/o d/o Positive = sens / (1-spec) Neg = (1-sens) / spec

Question 420

Top reasons for Fever of Unknown Origin?

Answer 420

Connective tissue disease, infection, malignancy Dx of exclusion with fever on multiple occasions over a time space exceeding three weeks and s/p negative workup

Question 421

Risks to infants of Diabetic mothers?

Answer 421

Macrosomia, hypocalcemia, hypoglycemia, hyperviscosity 2/2 polycythemia, respiratory difficulties, cardiomyopathy (hypertrophic interventricular septum), CHF

Question 422

Indications for parathyroidectomy in primary PTH?

Answer 422

All symptomatic patients. Asymptomatic patients with serum Ca > 1 above ULN, young age (

Question 423

Dull crampy abdominal pain worse after meals in a vasculopath w/ negative work up = ? Workup?

Answer 423

Chronic mesenteric ischemia. CT/MR angio, duplex U/S = non-invasive methods for evaluating and locating obstruction Angiography = gold std

Question 424

Child with sore throat, trouble swallowing, muffled voice, tongue hanging out sometimes, drooling, difficulty breathing = causative agent?

Answer 424

Haemophilus influenzae b causing epiglottitis (can see "thumb print" sign)

Question 425

N/V/D, increased bowel sounds, increased HR/BP, can't sleep, myalgia, arthralgia, lacrimation, rhinorrhea, piloerection, mydriasis = dx? Trmt?

Answer 425

Opiod withdrawal. Agonists = Methadone or buprenorphine Nonopiods = clonidine, BZD's, antiemetics, antidiarrheals Depends on treatment center - if the patient can be monitored closely, can give agonist (2/2 worsening from partial agonistic effect)

Question 426

How to transport severed digit?

Answer 426

Wrap in sterile gauze, dampen with saline, put in sterile bag. Put in cooler w/ 50% water 50% ice

Question 427

Trmt prophylaxis for those in close contact with meningococal infection?

Answer 427

Rifampin (600mg BID x 2days) Ceftriaxone (250mg once) Ciprofloxacin (500mg once)

Question 428

Mgmt algorithm of epistaxis?

Answer 428

Nostril pinching > topical vasoconstrictor (Oxymetazoline) > Silver nitrate w/ topical lidocaine > anterior nasal packing with bacitracin

Question 429

Matrix glycosaminoglycan accumulation (myxedema, macroglossia, coarse dry skin), depression, myalgia, hypercholesterolemia, delayed DTR's, cognitive slowing = screen for?

Answer 429

Hypothyroidism - can have macrocytosis, hyponatremia, and dementia

Question 430

> 50, pain or decreased ROM in neck/shoulder/hips, constitutional symptoms, elevated ESR, bilateral pain and morning stifness = dx? Associated with?

Answer 430

Polymyalgia rheumatica (differs from RA b/c no synovitis) - patient points to soft tissue as painful, not joints. Associated with Giant Cell Arteritis!!! Glucocorticoids = treatment of choice.

Question 431

When do you not have to taper glucocorticoid therapy?

Question 432

What is Immune Reconstitution Inflammatory Syndrome?

Answer 432

Paradoxical worsening of preexisting infections in HIV + individuals that occurs days-weeks after initiation of trmt with HAART. Best managed w/ HAART and continued abx for underlying pathogen

Question 433

In addition to surgery, what should you give to someone with perforated PUD?

Answer 433

IV fluids, IV PPI, abx

Question 434

Right colon and cecum dilatation w/ no evidence of mechanical cause = ?

Answer 434

Ogilvie's Syndrome

Question 435

Primary CNS lymphoma = associated with? Related to what causative bug? Trmt?

Answer 435

HIV 2/2 EBV. Give HAART, radiation therapy, corticosteroids

Question 436

What are the pertinent lab values for pseudohypothyroidism?

Answer 436

Hypocalcemia, hyperphosphatemia - it's secondary to resistance of PTH on its target tissue VS. Vit D Deficiency = low Ca and Phosph

Question 437

What type of cells are seen in diffuse alveolar hemorrhage syndromes?

Answer 437

Hemosiderin laden macrophages; in Wegener's, Goodpasture's and other systemic vasculitis

Question 438

Best diagnostic vs. best next step in mgmt for someone with suspected endobronchial obstruction?

Answer 438

Best initial mgmt = CT Most diagnostic = flexible bronchoscopy

Question 439

Management of hypocaliuric hypercalcemia = ?

Answer 439

Nothin - Familial Hypocalicuric Hypercalcemia (problem with Ca-sensing receptor)= PTH elevated but WNL, elevated Calcium, urine calcium

Question 440

Plasma osmolality = ?

Answer 440

2xNa + Glucose/18 + BUN/2.8 NL = 280-290

Question 441

Correcting hyponatremia = ?

Answer 441

If mild/moderate (115-124) can be managed with H2O restriction. If there's an identifiable cause, treat underlying cause Severe

Question 442

Signs of ethylene glycol (antifreeze) intoxication? Trmt?

Answer 442

Metabolized by alcohol dehydrogenase into oxalic acid. See severe anion gap acidosis, Kussmaul's respiration (rapid/deep) Antidote = Fomepizole (competitive inhibitor of ADH)

Question 443

Remove IUD in asymptomatic female w/ IUD and + actinomyces?

Answer 443

No - this gram-positive anaerobic bacillus = common in normal vaginal flora w/ low risk of complication.

Question 444

Congenital rubella features = ?

Answer 444

Sensorineural hearing loss cardiac anomalies, cataracts, glaucoma

Question 445

How to differentiate volume depletion vs. hepatorenal syndrome?

Answer 445

Patients with cirrhosis have decreased vascular resistance 2/2 to splanchnic vasodilatation which would not respond with a fluid bolus (since both have BUN/Cr > 20:1) - if diagnosed should give octrotide, midodrine and albumin ( or NE by itself)

Question 446

Nystagmus in awake or agitated patients is characteristic of = ? trmt?

Answer 446

PCP intoxication (difference with other intoxications is that pts are sedated) - put in low-stimulation environment

Question 447

Lyme trmt if there is carditis or neuro symptoms other than cranial nerve palsy?

Answer 447

IV ceftriaxone Normal Trmt = doxy, amoxicillin, or cefuroxime

Question 448

Tomatoe-red plaques and satellite papules in diaper area in setting of abx use = dx? Trmt?

Answer 448

Candidal diaper rash. Differs from diaper dermatitis because it does NOT spare crural folds like diaper rash does. Trmt = antimycotic cream (clotrimazole)

Question 449

In patient w/ extensive smoking hx, recurrent PNA in same place or not resolving = suspicious for?

Answer 449

Obstructing endobronchial malignancy

Question 450

Rabies vaccination criteria = ?

Answer 450

Pre-exposure prophylaxis = rabies vaccine Post-Exposure Prophylaxis (not vaccinated before) = rabies immunoglobulin and rabies vaccine Post exposure w/ previous vaccination = rabies vaccine

Question 451

Only conditions you'd get a pap smear before 21?

Answer 451

Immunocompromised (HIV, SLE, organ transplants) at the time of sexual intercourse

Question 452

Trmt of PNA in patient's w/ Cystic Fibrosis? MCC = Staph when young, Pseudo when older

Answer 452

Cefepime and amikacin - want pseudomonal coverage! S. Aureus if another offender! Add vancomycin if had MRSA before

Question 453

Diagnosis of rheumatic fever?

Answer 453

JONES Criteria = Joint pain (migratory), carditis, subcutaneous nodules, erythema marginatum, sydenham chorea. Late findings = Mitral regurg/stenosis Prevent with PCN for Group A Strep (Strep. Pyogenes)

Question 454

Lower extremity claudication, absent or dimished femoral pulses, erectile dysfunction = dx? Evaluate what?

Answer 454

Leriche Syndrome Evaluate ABI -

Question 455

Treating Lead intox guidelines = ?

Answer 455

Mild (5-44) = no rx's Mod (45-69) = Meso-2,3-dimercaptosuccinic acid (DMSA, Succimer) > 70 = Dimercaprol + Calcium Disodium Edetate (EDTA)

Question 456

Stages of euthyroid sick syndrome =

Answer 456

When they're ill = low T3, T4, and TSH. Then low T3, normal T4 and TSH levels = MC findings Recovery phase = slightly elevated TSH, normal T4 No trmt necessary!!!

Question 457

Fever + vesicles and ulcers on anterior oral mucosa and around mouth = dx?

Answer 457

Herpes gingivostomatits 2/2 HSV1

Question 458

Intention to treat analysis helps support what study quality?

Answer 458

Randomization

Question 459

Screening protocol for those with increased CRC risk w/ first degree relative

Answer 459

Colonoscopy at 40 or 10 yrs before fam dx (WHICHEVER IS SOONER) and repeat every 3-5 yrs *Not needed if fam member dx'd > 60 yrs

Question 460

Common agents able to cause acute pancreatitis?

Answer 460

Diuretics, IBD rx's (5-ASA), Immunosupressive agents, Seizures/Bipolar use of Valproic acid, AIDS (Didanosine, Pentamidine), Abx (metronidazole, tetracycline)

Question 461

CHA2DS-VAS2C Score = ?

Answer 461

CHF, Hypertension, Age >75 (2pts) or Age 65-75 (1pt), DM, Stroke/TIA, Vasculopathy (prior MI), Sex (female) Anticoagulate with AF and score 2 or more

Question 462

Target-specific oral anticoagulants are approved for what patients with AF?

Answer 462

Those w/ non-valvular AF (dabigatran, rivaroxaban, apixaban, edoxaban) DON'T use w/: MS, prosthetic heart valves, ESRD, severe decompensated valvular disease

Question 463

SLE pts at risk for development of what that subsequently leads to leading cause of mortality in pts w/ SLE?

Answer 463

Premature Coronary atherosclerosis and accelerated atherosclerosis

Question 464

Neonatal chlamydial infections can cause what two things?

Answer 464

Conjunctivitis - occurs 5-14 days, thickened injected conjunctivae, water/muco/blood-stained discharge, eyelid swelling, pseudomembrane on eyes PNA - 4-12wks, staccato cough, nasal congestion, hyperinflation TRMT = oral erythromycin for 14 days

Question 465

Dx choice and mgmt for acute mesenteric ischemia?

Answer 465

CT angio of abdomen. Fluid resuscitation, abx, correct metabolic acidosis, NG tube for decompression, sx consult

Question 466

Doxazosin = what type of blocker? Consideration with Sildenafil?

Answer 466

Alpha blocker - give 6 hrs apart from Sildenafil to reduce risk of hypotension

Question 467

Hydrophobia, aerophobia, pharyngeal spasms, agitation, ascending paralysis, hx of spelunking w/ no bat scracth/bitch recalled = dx? Prognosis?

Answer 467

Rabies - can be from unrecognized contact or aerosolized particles in caves Post-exposure prohylaxis = effective IF given PRIOR to manifestation of symptoms. Mst symptomatic pts develop coma and death within weeks

Question 468

2 contraindications for Tdap?

Answer 468

anaphylaxis within 7 days of administration of previous Tdap encephalopathy within 7 days of Tdap

Question 469

Lumbosacral myelomeningocele is associated with what MC extra neural finding?

Answer 469

Bladder dysfunction > GI probs > lower extrem fractures

Question 470

Red flags for back pain = ?

Answer 470

Age >50, nighttime pain, constitutional symptoms, hx of malignancy, trauma, IVDU, infectious risk, >1month w/o improvement

Question 471

Differentiate Statin-induced myopathy with PMR?

Answer 471

statin-induced has elevated CPK and normal ESR vs. elevated ESR and normal CPK in PMR

Question 472

Features of Tuberous Sclerosis = ? Screen for? Leading cause of death?

Answer 472

AD or de novo mutation. Derm - hypopigmented macules Neuro - Epilepsy, cognitive disabilities, autism (progressive seizures= MCC of death) CV - rhabdomyomas Renal - Angiomyolipomas Screen for: skin exam, fundoscopy, brain MRI, EEG, abdominal U/S

Question 473

Nelson's dx = what two features?

Answer 473

Microadenoma with suprasellar extension on MRI and extremely high plasma ACTH levels

Question 474

Symptomatic pregnant patients w/ BV = trmt options(2)?

Answer 474

Oral metronidazole (crosses placenta, no known teratogenicity) or oral Clindamycin

Question 475

C. Diff Trmt algorithm ?

Answer 475

Mild-Mod (WBC 15k, Cr > 1.5x, Serum albumin 20k, toxic megacolon present; then subtotal colectomy, diverting loop ileostomy

Question 476

Trmt for reccurent C dif??

Answer 476

First recurrence = same as initial therapy Second = pulsed oral vancomycin for 6-7 wks More = fecal transplant

Question 477

Non-occupational HIV post exposure prophylaxis = ?

Answer 477

High risk exposure via high risk contact - begin triple therapy within 72 hrs for 4wks! Don't initiate if >72hrs

Question 478

Arthralgias, palpable purpura, lymphadenopathy, HSM, peripheral neuropathy, asymptomatic hematuria/proteinuria/mild Cr elevation = dx? Historical clue or RF for patient = ? What Complement will be low? Trmt?

Answer 478

Mixed Cryoglobulinemia. Hep C!!! Low C3/C4/CH50 Get cryoglobulin level! Trmt = alpha-interferon and ribavirin (if no renal dysfxn); only alpha-interferon if sig renal impairment

Question 479

Granulomatosis w/ polyangitis = test?

Answer 479

Upper airway and kidney involvement! C-ANCA; has normal complement levels

Question 480

ASO used for what screening? Affected Complement?

Answer 480

Post-streptococcal glomerulonephritis C3/CH50 = low, normal C4

Question 481

Attributable risk percent = excess risk that estimates the proportion of disease among exposed individuals = calc?

Answer 481

ARP = (RR - 1)/RR OR ARP = (risk of exposed - risk unexposed)/risk of exposed

Question 482

Population attributable risk percent = excess risk in total population, not only exposed subjects = calc?

Answer 482

PARP = (Risk in total Pop - Risk in Unexposed)/Risk in Total Pop Can use weighted average to calculate Risk in total Pop= (risk in smokers)(proportion of smokers) + (risk in unexposed)(proportion of nonsmokers) OR PARP = (Prevalence)(RR-1) / [(Prevalence)(RR - 1) +1]

Question 483

Who to give PPSV23 and PCV13 pneumococcal immunization to?

Answer 483

Give 23 for common comorbidities in those 19-64 Sequential 13 and 23 for those at high risk (immunocompromised) in same age group Sequential in those >65

Question 484

Mitral Stenosis = sound?

Answer 484

Low-pitched rumble at the cardiac apex

Question 485

Be wary of this side effect of blood transfusions in those with kidney/liver/hypothermia/shock or those in surgery needing transfusions =?

Answer 485

Hypocalcemia secondary to these patient's poor metabolism of citrate, which binds to calcium but might not show on measured serum Ca

Question 486

Signs of hypocalcemia = ?

Answer 486

Hyperactive DTR, muscle spasms in the face upper extremities, diaphoretic, bilateral hand contracture, tonic clonic seizures

Question 487

Anatomical predisposing factor for MAllory-Weiss Syndrome?

Answer 487

Hiatal Hernia

Question 488

When to start PCP prophylaxis with HIV?

Answer 488

CD4

Question 489

When to start prophylaxis against MAC?

Answer 489

CD4

Question 490

How to evaluate patients on cardiotoxic chemo?

Answer 490

Radionuclide ventriculography - decrease in EF >10% may warrant discontinuation

Question 491

Mgmt of hepatic adenomas on OCP's?

Answer 491

D/C OCP's. If >5cm, evaluate for surgical ressection OR if symptomatic. 2 risks = rupture or malignant transformation

Question 492

Carbamazepine risks involving blood lines and fluid levels?

Answer 492

Can cause marrow suppression = fever, mouth ulcers, easy bruising SIADH

Question 493

Profile description for traumatic tap?

Answer 493

RBC > 6k, elevated WBC (1per 750-1000 RBCS), elevated protein and elevated glucose

Question 494

Side effects of Haloperidol?

Answer 494

Sedation, orthostatic hypotension, Anticholinergic side effects, tar dive dyskinesia, extrapyramidal symptoms (can add on BZD as adjunct to reduce extrapyramidal side effects)

Question 495

Children with Failure to Thrive have associated ___ at home.

Answer 495

Defined as weight less than 5% in those

Question 496

Complications of lead poisoning in children?

Answer 496

Cognitive impairment, behavior problems, encephalopathy, constipation, abdominal pain, decreased Vit D absorption, Interstitial nephritis, Hemolytic anemia

Question 497

General acne mgmt principles?

Answer 497

Start with topical retinoids and benzyl peroxide > topical abx (erythromycin, clindamycin) > oral abx (tetracyclines)

Question 498

Beside IV diuretics in those with acute decompensated HF, what else can you give patients to help?

Answer 498

IV vasodilators (nitroglycerin, nitroprusside)

Question 499

Methods for decreasing BP in patients with aortic dissection?

Answer 499

Want to control BP with IV Beta-blockers like labetalol, propanolol, or esmolol to SBP

Question 500

How to differentiate two main causes of precocious puberty?

Answer 500

Precocious puberty = premature activation of HPOG axis; tend to see sequential and gradual development of testicular enlargement, penis enlargement, pubic hair growth, and growth spurt VS. Precocious Pseudo Puberty = gonadotropin-independent process (excess sex steroids) - p/w severe androgen excess (severe acne, significant growth acceleration)

Question 501

Differences b/w Ehlers Danlos and MArfans?

Answer 501

ED - transparent skin, hyper extensible skin, easy bruising, velvety (doughy) fragile skin w/ atrophy, pectus excavatum, arched palate, scoliosis, MVP, develop hernias, COL5A1/COL5A2 gene mutations, AD Marfans - pectus carinatum, spontaneous PNTX, FBN1 gene mutation, AD

Question 502

MC in Mexico, Central/S. America, biventricular heart failure w/ cardiomegaly, ventricular apical aneurysm, mural thrombosis w/ embolic complications, fibrosis leading to conduction abnormalities, progressive dilation of esophagus and colon = dx?

Answer 502

Chagas Disease

Question 503

Mgmt of inguinal hernias in pediatric group?

Answer 503

Should be surgically repaired early as possible 2/2 complications like incarceration esp. if it remains open during first months of life

Question 504

_____ is a major cause of respiratory muscle weakness and can lead to the failure of being able to wean patients off vent; 2/2 continuous glucose infusions (esp. alcoholics)

Answer 504

Hypophosphatemia

Question 505

Causes of Zinc deficiency?

Answer 505

Diarrhea, diuresis, malnutrition, CRF, burns and prolonged illness. More susceptible to infections and skin rash.

Question 506

Nonimmune direct effect of heparin on platelet activation and presents in first 2 days of heparin exposure = dx?

Answer 506

Type 1 HIT - continure Heparin as platelets will normalize Can see necrotic skin lesions

Question 507

Immune-mediated d/o 2/2 Ab's to platelet factor 4 complexed with heparin; leads to platelet aggregation, thrombocytopenia, and thrombosis (arterial and venous); presents 5-10d after heparin initiation = dx?

Answer 507

Type 2 HIT

Question 508

Mgmt s/p suspecting HIT?

Answer 508

STOP ALL HEPARIN!!! Confirm w/ serotonin release assay, heparin-induced plt aggregation assay, heparin-PF4 antibody ELISA If + and needs anticoagulation, use direct thrombin inhibitor

Question 509

Drugs for smoking cessation?

Answer 509

Nicotine patches - no significant side effects; helps with cravings and withdrawal symptoms Bupropion - decreased post-cessation wt gain, good choice in depressed pts - DONT USE IN SEIZURE OF EATING d/o Varenicline = more effective than bupropion or NRT- HIGHER RISK OF CARD EVENTS, INCREASED RISK OF SUICIDE AND DEPRESSION

Question 510

Weight loss, splenomegaly, marked WBC count, + Philadelphia chromosome (translocated 9/22) creates bcr/abl fusion protein causing unregulated tyrosine kinase activity = dx? Trmt>?

Answer 510

Chronic Myeloid Leukemia Tyrosine Kinase Inhibitors (Imatinib)

Question 511

Dx if pt p/w old age/critically ill, fever leukocytosis, and steady RUQ pain radiating to back and R shoulder but no gallstones on abd U/S = dx? If unsure get?

Answer 511

Acalculous acute cholycystitis = higher M&M Get HIDA if unsure

Question 512

Etio of cat-scratch fever? Complications?

Answer 512

Bartonella Henselae Complications = lymphatic suppuration, neuroretinitis, encephalopathy, HSM

Question 513

Abx for pyelo in pregnancy?

Answer 513

Ceftriaxone or Amp/Gent until afebrile for 24hrs - entire PO abx for 10-14 days

Question 514

Trmt for metastatic brain disease = ?

Answer 514

Whole brain radiation therapy can improve survival 3-6months

Question 515

Filaggrin problem (skin barrier), associated with intense pruritic skin lesions that have lichenification, flexural eczema, high serum IgE, Eosinophilia, increased leukocyte phosphodiesterase = dx? Trmt?

Answer 515

Atopic dermatitis Avoid hot/dry climates, harsh soaps and detergents. Regular use of emollients to help skin hydration + oral antihistamines are helpful!! If refractory: topical glucocorticoid cremes (hydrocortisone)> high potency = triamcinolone, betamethasone (BUT DONT USE ON FACE…use calcineurin inhibitors = Tacrolimus)> UV light

Question 516

Mgmt of cocaine-induced CP?

Answer 516

DONT GIVE B-BLOCKER! Give lorazepam to decrease anxiety and agitation. If refractory BP, use phentolamine (alpha antagonist), nitroglycerine, or nitroprusside

Question 517

ADPKD extra-renal manifestations = ?

Answer 517

Hepatic/pancreatic/splenic. and pulm cysts; cerebral aneursyms, aortic aneurysm, colonic diverticula, MVP, inguinal/abdominal hernia

Question 518

3 or more p-waves of different morphologies, narrow QRS complexes, variable P-R and R-R intervals = dx? Causes?

Answer 518

Multiform atrial tachycardia Causes = hypoxia, COPD, hypokalemia, hypomagnesemia, CAD

Question 519

Splenic vein thrombosis can occur as a complication of what in alcoholics?

Answer 519

Chronic recurrent pancreatitis causing anemia, thombocytopenia, and leukopenia - can have gastric varices without esophageal varicose;

Question 520

Trastuzumab-related cardiotoxicity pr/w w/ asymptomatic decline in LV EF and sometimes overt HF - is it reversible?

Answer 520

Yes; decline is unrelated to cumulative effects

Question 521

Patients p/w hypogonadism and low gonadotropin levels and elevated alpha-subunit, vision changes, mild elevation of prolactin = ?

Answer 521

Nonfunctioning pituitary adenoma - treated with trans-sphenoidal sx

Question 522

Transurethral resection of the prostate (TURP) associated w/ what electrolye complication?

Answer 522

Hyponatremia 2/2 20-30 L of isosmotic flushing flushing solns

Question 523

Cherry red flushing, later occurring cyanosis, AMS, seizures, coma, arrhythmias, pulmonary edema, abd pain, nausea, vomiting, metabolic acidosis w/ nitroprusside = dx? Trmt?

Answer 523

Cyanide toxicity - treat with sodium thiosulfate

Question 524

After suspected HIT and heparin stopped, when do you restart Warfarin?

Answer 524

When PLT recover to > 150,000 - it's usually restarted with a non-heparin anticoagulant

Question 525

Painless blisters on dorsum of hand , increased fragility of the skin, facial hypertrichosis, and hyper pigmentation = dx?

Answer 525

Porphyria cutanea tarda - deficiency of uroporphyrinogen decarboxylase Phlebotomy or hydroxychlorowuine may provide relief with interferon alpha in those affected by Hep C.

Question 526

Patient's with rhinitis can take what before scuba diving?

Answer 526

Non-sedating decongestants (pseudoephedrine) - can reduce incidence of ear and sinus barotrauma by 75%

Question 527

Major problem that leads to difficulties in finding cross-matched blood in pts with a hx of multiple transfusions = ?>

Answer 527

Alloantibodies

Question 528

Different b/w first degree and second degree block? Difference b/w second degree block? What makes them worse/better?

Answer 528

First degree = prolonged PR interval with no dropped beats. Second degree (type I Mobitz) = progressive PR interval with subsequent dropped beat (exercise/atropine makes better; carotid massage makes worse) VS. Type II Mobitz = maintained PR interval but intermittent dropped beats (exercise/atropine makes worse and carotid massage improves)

Question 529

What heart block patients get permanent pacemakers?

Answer 529

Symptomatic Second Degree Type I Mobitz and Type II Mopbitz being asymptomatic/symptomatic; can use temporary pacer

Question 530

Patients w/ refractory hypoglycemia 2/2 possible sulfonourea trmt?

Answer 530

Octreotide because somatostatin analogue

Question 531

Treatment for hyperkalemia causing EKG changes?

Answer 531

Calcium Gluconate - see peaked t-waves, loss of p wave, widened QRS w/ sine wave

Question 532

Jaundice, fever, RUQ pain = dx? Mgmt?

Answer 532

Acute Cholangitis - blood cultures and abx (gent+amp or levofloxacin or imipenem), fluids! Then ERCP afterwards

Question 533

Loss of pupillary reaction, vertical gaze paralysis, loss of optokinetic nystagmus, and ataxia = dx?

Answer 533

Parinaud's syndrome 2/2 Pineal tumor. Can have HA from obstructive hydrocephalus. Can sometimes secrete B-hcg causing precocious puberty

Question 534

Abx to prevent endocarditis is necessary when?

Answer 534

Dental procedures, pulm procedures w/ bx, GI/GU procedure w/ concomittant infection, procedures on infected skin or MSK

Question 535

With someone experience urinary incontinence, ataxia, and loss of cognitive function, what's the first test to determine mgmt?

Answer 535

LP puncture - if they get better, can proceed with Ventriculoperitoneal shunt 2/2 normal pressure hydrocephalus

Question 536

Physiologic jaundice occurs how long after birth?

Answer 536

24 hrs

Question 537

MC deficiency causing hemolysis w/ unconjugated hyperbili in newborn from africa/med/asia?

Answer 537

G6PD - usually asymptomatic when young Thalassemias and SCD usually manifest later because baby is dependent on HgbF

Question 538

Criteria for delayed puberty in male? Tests?

Answer 538

No teste enlargement by 14yrs - MCC = constitutional delay Need bone age via L wrist X-ray

Question 539

PEA/asystole trmt=?

Answer 539

CPR and vasopressor therapy; search for reversible causes: Hypoxia/Hypothermia/Hydrogen Ions/Hypovolemia/Hypo-Hyperkalemia TPTHX/Tamponade/Thrombosis/Trauma/Toxins

Question 540

Lung Associations = 1) Small Cell- 2) Asbestosis 3) Mesothelioma - 4) Large Cell 5) Squamous Cell Cancer

Answer 540

1) SIADH 2) Fibrosis- shipyard workers, chest tightness, wheezing 3) Linked to asbestos; nodular thickening of pleura 4) Large cell - large peripheral mass 5) Cavitary lesion on bronchus - hypercalcemia 2/2 PTHrP

Question 541

Thickening of outer bone cortex, bowing, sclerosis, increased uptake on Technetium bone scan = dx and trmt?>

Answer 541

Pagets - treat if bone pain, weight-bearing bones affected, neuro compromise, hypercalcemia, hypercalciuria, and CHF w/ bisphosphonates

Question 542

Malignancy risk in celiac patients?

Answer 542

Intestinal T cell lymphoma - affects Jejunum commonly, nodular/ulcerative; surgery and chemo - high relapse rate

Question 543

Fever, facial swelling, maxillary pain, tenderness, nasal discharge thats foul smelling, opthalmoplegia, and HA w/ black discoloration in DM pt = dx? trmt?

Answer 543

Mucormycosis 2/2 to fungal infection from Zygomycetes - biopsy to confirm - debride and give amphotericin B

Question 544

OCD trmt?

Answer 544

CBT special for desensitization and serotonergic antidepressants (SSRI's and Clomipramine, a TCA)

Question 545

When to give IV IG to ITP patient?

Answer 545

Plt

Question 546

Trmt of acute dystonic reactions?

Answer 546

Diphenhydramine or Anticholinergic rx's (benztropine or trihexyphenidyl)

Question 547

BP mgmt in gouty pts?

Answer 547

ARB's

Question 548

Abx for suspected ped sepsis based on age?

Answer 548

28 = Ceftriaxone or Cefotaxime +/- Vanc (if meningeal involvement suspected) - Step PNA/Neisseria

Question 549

Initial test for suspected exogenous hyperthyroidism = ?

Answer 549

24-hr radioactive iodine uptake test

Question 550

Best PE test for achilles tendon rupture?

Answer 550

Thompson test = squeeze gastroch

Question 551

Myaesthenia gravis associationg w/ what thyroid problem?

Answer 551

Thymoma