UWorld All Subjects 3

Question 1

Pt and management of gender dysphoria

Answer 1

Pt: experiences persistent (>/= 6 months) incongruence between assigned + felt gender
- desires to be another gender
- dislikes own anatomy, desires sexual trains of another gender
- believes feelings/reactions are of another gender
- feels significant distress/impairment
Management: assessment of safety, support w/ psychotherapy (individual or family); referral to specialist services (medical + mental health multidisciplinary)

Question 2

Mechanism, Pt, Dx, and management of optic nerve injury

Answer 2

Mechanism: indirect: shearing forces from facial trauma
direct: penetrating eye trauma
Pt: acute vision loss, decreased color vision, afferent pupillary defect
Dx: CT scan of the orbit
Management: urgent ophthalmology referral; +/- surgical decompression

Question 3

Pt, Dx, and complications of prader-willi syndrome

Answer 3

Pt: hypotonia, weak suck/feeding problems in infancy; hyperphagia/obesity, short stature, hypogonadism, intellectual disability, dysmorphic features (narrow forehead, almond-shaped eyes, downturned mouth)
Dx: deletions on paternal 15q11-q13
Complications: sleep apnea, T2DM, gastric distension/rupture, death by choking

Question 4

What is the MOA of flushing as a side effect of niacin? How can this be managed?

Answer 4

flushing and generalized pruritus are side effects of high-dose niacin therapy due to niacin-induced peripheral vasodilation via drug-induced release of histamine and prostaglandins

low-dose aspirin can greatly reduce or prevent sx if taken 30 min before niacin; flushing and pruritus usually improve after 2-4 weeks of therapy

Question 5

Risk factors, Pt, and management of pubic symphysis diastasis

Answer 5

Risk factors: fetal macrosomia, multiparity, precipitous labor, operative vaginal delivery
Pt: difficulty ambulating, radiating suprapubic pain, pubic symphysis tenderness, intact neurologic examination
management: conservative, NSAIDs, physical therapy, pelvic support

Question 6

Risk factors, Pt, and management of ABO hemolytic disease

Answer 6

Risk factors: infants with blood types A or B born to a mother with blood type O
Pt: jaundice within 24 hours of birth, anemia, increased reticulocyte count, hyperbilirubinemia, positive Coombs test
Management: serial bilirubin levels, oral hydration + phototherapy for most neonates; exchange transfusion for severe anemia/hyperbilirubinemia

Question 7

acalculous cholecystitis path, pt, dx, and tx

Answer 7

Path: cholestasis danders gallbladder ischemia leading to secondary infection by enteric organisms and resultant edema and necrosis of the gallbladder
Pt: severely ill patients in the ICU with multi organ failure, severe trauma, surgery, burns, sepsis, or prolonged parenteral nutrition; fever, leukocytosis
Dx: gallbladder wall thickening, distension, and presence of pericholecystic fluid
Tx: Abx followed by percutaneous cholecystectomy with drainage of any associated abscesses

Question 8

Path, Pt, Dx, and management of Ogilvie syndrome

Answer 8

Path: major surgery, traumatic injury, severe infection; electrolyte derangement (decreased K+, decreased Mg, decreased Ca2+), medications (opiates, anticholinergics), neurologic disorders (dementia, stroke)
Pt: abdominal distension, pain, obstipation, vomiting; tympanic to percussion, decreased bowel sounds; if perforation: guarding, rigidity, rebound tenderness
Dx: X-ray: colonic dilation, normal hausfrau, noldilated small bowel
CT scan: colonic dilation without anatomic obstruction
Management: NPO, nasogastric/rectal tube decompression; neostigmine if no improvement within 48 hours

Question 9

Path, Pt, Dx, and Tx of sporotrichosis

Answer 9

Path: sporothrix schenckii (dimorphic fungus), decaying plant matter/soil, gardeners + landscapers
Pt: subacute/chronic; skin papule -> ulceration with non purulent, odorless drainage; proximal lesions along lymphatic chain; LAD, deeper spread + systemic sx are rare
Dx: cultures (aspirate fluid or biopsy)
Tx: 3-6 months of oral itraconazole

Question 10

hypertrophic osteoarthropathy (HOA) vs hypertrophic pulmonary osteoarthropathy (HPOA)

Answer 10

Pt; digital clubbing + sudden-onset arthropathy, commonly affecting the wrist and hand joints

Hypertrophic pulmonary osteoarthropathy is a subset of HOA where the clubbing and arthropathy are attributable to underlying lung disease like lung cancer, TB, bronchiectasis, or emphysema

Question 11

What do you expect the plasma renin and plasma aldosterone to be in secondary hyperaldosteronism? What can cause this?

Answer 11

elevated plasma renin and elevated plasma aldosterone

causes of secondary hyperaldosteronism:

• diuretic use
• cirrhosis or CHF
• renovascular HTN
• renin-secreting tumor
• malignant HTN
• coarctation of the aorta

Question 12

What do you expect the plasma renin and plasma aldosterone to be in primary hyperaldosteronism?

Answer 12

decreased plasma renin, increased plasma aldosterone

Question 13

what causes of HTN and hypokalemia would have decreased plasma renin and plasma aldosterone?

Answer 13

• CAH
• glucocorticoid resistance
• exogenous mineralocorticoid
• Cushing’s syndrome
• altered aldosterone metabolism

Question 14

What is included in post exposure prophylaxis for sexual assault?

Answer 14

chlamydia: azithromycin
gonorrhea: ceftriaxone
Trichomonas vaginalis: metronidazole
HIV: multidrug regimen (tenofovir-emtricitabine with raltegravir)
Hep B: hep B vaccine +/- Hep B immunoglobulin

Question 15

Dx and Tx of social anxiety disorder

Answer 15

Dx:
- marked anxiety about >/= 1 social situations for >/= 6 months
- fear of scrutiny by others, humialtion, embarrassment
- social situations avoided or endured with intense distress
- marked impairment (social, academic, occupational)
- subtype specifier: performance only
Tx: SSRI/SNRI, CBT, beta blocker or benzodiazepine for performance-only subtype

Question 16

Human bite with possible rabies exposure in a low-risk wild animal (squirrel, chipmunk, mouse/rat, rabbit)?

Answer 16

no post exposure prophylaxis

Question 17

Human bite with possible rabies exposure in a high-risk wild animal (bat, raccoon, skunk, fox, coyote)?

Answer 17

If available for testing: euthanize + test; start PEP if rabies test is positive

Not available for testing: start PEP (post-exposure prophylaxis)

Question 18

Human bite with possible rabies exposure in a pet (dog, cat, ferret)?

Answer 18

If available for quarantine: observe for 10 days; no PEP if animal is healthy

Not available for quarantine: start PEP

Question 19

Generalized convulsive status epileptics path, dx, and tx

Answer 19

Path: structural brain abnormality (brain tumor, stroke), metabolic abnormality (hyponatremia, hypoglycemia), infection (meningitis), or drug withdrawal (alcohol, benzos), epilepsy esp with noncompliance
Dx: seizure lasting >/= 5 mins OR >/= 2 seizure events in which the patient does not completely regain consciousness
Tx: ABC, IV benzos (lorazepam, m diazepam) for seizure termination, then a nonbenzo anti epileptic med should be administered to prevent seizure recurrence (fosphenytoin, phenytoin, levetiracetam, or valproic acid)

Question 20

Path, Risk factors, Pt, and Management of primary dysmenorrhea

Answer 20

Path: excessive prostaglandin production
Risk factors: 
1. age <30
2. BMI < 20
3. tobacco use
4. Menarche at age < 12
5. Heavy/long menstrual periods
6. sexual abuse
Pt: pain first 2-3 days of menses, N/V/D, normal pelvic examination
Management: NSAIDs, combo OCPs

Question 21

Pt of prolapsing leiomyoma uteri

Answer 21

a uterus with irregular enlargement on exam suggests uterine liomyomata; speculum and bimanual examination confirms the firm, smooth, round mass at the cervical os consistent with an aborting sub mucous myxoma

Question 22

What is the Cushing triad? tx?

Answer 22

HTN, bradycardia, and irregular expirations (indicates elevated ICP); immediate tx is hypertonic saline to decrease the ICP and reduce the risk of cerebral herniation

Question 23

Precipitating factors, Pt, and Tx of myasthenic crisis?

Answer 23

Precipitating factors: infection or surgery, pregnancy or childbirth, tapering of immunosuppressive drugs, medications (ahminoglycosides, beta blockers)
Pt: increased generalized and oropharyngeal weakness, respiratory insufficiency/dyspnea
Tx: intubation for deteriorating respiratory status; plasmapheresis or IVIG as well as corticosteroids

Question 24

Path, Pt, and Complications of Sjogren syndrome

Answer 24

Path: immune-mediated destruction of the lacrimal and salivary glands; can occur as primary disease or secondary with other autoimmune disorders (SLE, RA)
Pt:
- dry eyes (keratoconjunctivitis sicca)
- dry mouth (xerostomia), salivary hypertrophy
- dry sin (xerosis)
- Raynaud phenomenon
- Cutaneous vasculitis
- Positive anti-Ro (SSA) and/or anti-La (SSB)
Complications: non-hodgkin lymphoma; corneal damage, dental caries

Question 25

Risk factors for avascular necrosis

Answer 25

1. steroid use 2. alcohol abuse 3. SLE 4. Antiphospholipid syndrome 5. Hemoglobinopathies (sickle cell) 6. Infections (osteomyelitis, HIV) 7. Renal transplantation 8. Decompression sickness

Question 26

What steps are known to minimize the risk of long term opioid abuse?

Answer 26

1. check the prescription drug-monitoring program data for undisclosed coprescription 2. perform random urine drug screening 3. schedule frequent follow-up visits (q 3 months min)

Question 27

Wafarin-associated intracerebral hemorrhage Path and management

Answer 27

Path: use of over-the-counter cold meds, which often contain acetaminophen (potentiates anticoagulant effect of warfarin) and decongestants such as phenylephrine (may elevated BP) Management: IV Vit K, prothrombin complex concentrate (PCC) (consider FFP if PCC not available)

Question 28

subclavian steel syndrome Path, Pt, PE, Dx, and Tx

Answer 28

Path: severe atherosclerosis of the left subclavian artery proximal tot he origin of the vertebral artery (left more commonly affected than the right) Pt: ischemia in the affected UE (pain, fatigue, paresthesias), vertebrobasilar ischemia with concurrent atherosclerosis of the circle of Willis (dizziness, ataxia, disequilibrium) PE: lower brachial systolic BP (>15) in the affected arm and a systolic bruit in the suprclavicular fossa on the affected side; S4 may be present due to LVH Dx: dopper u/s or MR angiography Tx: lifestyle management (lipid-lowering meds, smoking cessation) and sometimes stent placement

Question 29

In patients with abnormal uterine bleeding, what does bleeding after progesterone administration indicate?

Answer 29

confirms normal endogenous estrogen production and proliferative endometrium; rules out causes of estrogen deficiency (primary ovarian insufficiency), endometrial abnormalities (intrauterine adhesions), and outlet tract abnormalities (imperforate hymen)

Question 30

Path, Pt, Labs and Tx of serum sickness-like reaction

Answer 30

Path: type III hypersensitivity, immune complex formation, Abx (beta-lactam, sulfa), acute Hep B Pt: symptoms 1-2 weeks after exposure; fever, skin rash, polyarthralgia Labs: nonspecific hypocomplementemia and elevated inflammatory markers (ESR, CRP) Tx: remove/avoid offending agent, supportive care, steroids or plasmapheresis if severe

Question 31

UTI with urinary alkalinization (pH > 8) indicates what causes? What other sx might you see?

Answer 31

urease-producing bacteria such as Proteus mirabilis (MC) or klebsiella pneumoniae; might also see struvite stones (magnesium ammonium phosphate)

Question 32

Congenital contractural arachnodactyly Path and Pt

Answer 32

Path: autosomal dominant with mutations in fibrillin-2 gene Pt: tall stature, arachnodactyly, multiple contractures involving large joints

Question 33

Path, Pt, and Dx of pheochromocytoma

Answer 33

Path: - arises from neuroendocrine cells in adrenal medulla - 25% inherited: VHL gene, RET gene (MEN 2), NF1 - symptoms result from increased catecholamine secretion Pt: HA, tachycardia/palpitations, sweating, HTN Dx: elevated urinary and plasma catecholamines + metanephrines

Question 34

What is the rule of 10s in pheochromocytoma?

Answer 34

- 10% bilateral - 10% extraadrenal - 10% malignant

Question 35

Path, Pt, Dx, and Tx of pediatric septic arthritis

Answer 35

Path: age < 3 months: Staph aureus, group B strep, gram negative bacilli - Age >/= 3 months: staph aureus, group A strep Pt: acute-onset joint pain, swelling, limited motion; refusal to bear weight; fever >/= 101.3 Dx: increased WBC, ESR, CRP; blood culture; joint aspiration (synovial WBC of > 50,000), effusion on u/s or MRI Tx: joint drainage + debridement; IV Abx

Question 36

UTI in infants Risk factors, Pt, Labs, and Tx

Answer 36

Risk factors: female, uncircumcised males, vesicoureteral reflux, constipation Pt: fever, fussiness, poor feeding, decreased urine output Labs: pyuria, bacteriuria Tx: Abx, renal u/s (if febrile), +/- voiding cystourethrogram (third-get cephalosporin, such as cefixime)

Question 37

Path, Pt, Dx, Tx of SIBO; what organisms would you expect?

Answer 37

Path: anatomical abnormalities (strictures, surgery); motility disorders (DM, scleroderma) Pt: abdominal pain, diarrhea, bloating, flatulence; malabsorption, WL, anemia, vitamin deficiency Dx: jejunal aspirate + culture showing >10^5 organisms; carbohydrate breath testing (lactulose, glucose) Tx: Abx (rifaximin, amox-clav), avoid antimotility agents (narcotics), dietary changes (high-fat, low carb), promotability agents (metoclopramide) Organisms: streptococci, bactericides, escherichia, lactobacillus

Question 38

Dumping syndrome Pt

Answer 38

Path: complication of gastric bypass and occurs when high-carb foods are rapidly emptied into the small bowel, leading to osmotically driven fluid shifts from the plasma to the intestine Pt: abdominal pain and diarrhea < 30 min after meals, sympathetic activation due to fluid shifts -> tachycardia, diaphoresis, flushing; hypoglycemia may also occur

Question 39

Path, Risk factors, Pt, Dx, and Tx of adenomyosis

Answer 39

Path: abnormal endometrial tissue within the uterine myometrium Risk factors: age >40, multiparty, prior uterine surgery Pt: dysmenorrhea, heavy menstrual bleeding, chronic pelvic pain, diffuse uterine enlargement (globular uterus), +/- uterine tenderness Dx: clinical presentation, MRI + u/s: thickened myometrium; confirm via pathology Tx: hysterectomy

Question 40

What is the difference between adenomyosis and leiomyomata uteri?

Answer 40

adenomyosis can cause chronic pelvic pain whereas leiomyomata uteri (fibroids) can cause pelvic pressure, but usually not chronic pelvic pain. Fibroids cause a firm, irregularly enlarged uterus whereas adenomyosis causes diffuse uterine enlargement (globular)

Question 41

diplopia, right eye ptosis, ophthalmoplegia, and pupillary dilation - dx?

Answer 41

non-pupil-sparing oculomotor nerve palsy

Question 42

What are the causes of non-pupil-sparing CN III palsies? Next step in management?

Answer 42

mass effect should be considered an intracranial aneurysm until proven otherwise; patients should undergo immediate MR or CT angiography

Question 43

What are the causes of pupil-sparing CN III palsies? What is the next step in management?

Answer 43

typically caused by microvascular ischemia associated with diabetes, hypertension, hyperlipidemia, and advanced age; observation and supportive care may be appropriate

Question 44

What are the potential side effects of lithium therapy?

Answer 44

hyperparathyroidism, nephrogenic diabetes insipidus, CKD, thyroid dysfunction (most often hypothyroidism), teratogenic effects in first trimester (Ebstein anomaly)

Question 45

What are the symptoms of Lyme disease at the early localized stage (days to 1 month)?

Answer 45

1. erythema migrans 2. fatigue, HA 3. myalgias, arthralgias

Question 46

What are the symptoms of Lyme disease at the early disseminated stage (weeks to months)?

Answer 46

1. multiple erythema migrans 2. U/L or B/L CN palsy (CN VII) 3. Meningitis 4. Carditis (AV block) 5. Migratory arthralgias

Question 47

What are the symptoms of Lyme disease at the late stage (months to years)?

Answer 47

1. arthritis 2. encephalitis 3. peripheral neuropathy

Question 48

What is the definition of fetal tachycardia, and what are the common causes?

Answer 48

fetal baseline heart rate > 160/min Common causes include maternal infection, poorly controlled maternal hyperthyroidism, medication use 9terbutaline), and abruptio placentae

Question 49

Path, Pt, Dx, and Tx of esophageal perforation?

Answer 49

Path: instrumentation (endoscopy), trauma; effort rupture (Boerhaave syndrome), esophagitis (infectious/pills/caustic) Pt: chest/back +/or epigastric pain, systemic signs (fever0; crepitus, harman sign (crunching on auscultation); pleural effusion with atypical (green) fluid Dx: CXR or CT scan: widened mediastinum, pneumonmediastinum, pneumothorax, pleural effusion CT scan: esophageal wall thickening, mediastinal fluid collection EGD with water-soluble contrast: leak from perforation Management: NPO, IV Abx + PPI; emergency surgical consultation

Question 50

What murmur is associated with aortic dissection?

Answer 50

aortic regurgitation

Question 51

What will you see on u/s of a tubo-ovarian abscess?

Answer 51

complex multiloculated adnexal mass with thick wall and internal debris

Question 52

Toxic megacolon treatment

Answer 52

IVF, broad-spectrum Abx, and bowel rest; IV corticosteroids are preferred for treating IBD-induced toxic megacolon; emergency surgery may be required if the colitis does not resolve

Question 53

posterior urethral injury

Answer 53

Pt: blood at the urethral meatus, inability to void (due to urethral discontinuity), perineal bruising, and a high-riding prostate on digital rectal examination Dx: urethrography - extravasation of contrast from the urethra is diagnostic Tx: anterior urethral injuries (penile fracture, straddle injury) are typically repaired urgently (within 24 hours) whereas most PUIs are treated with temporary urinary diversion via suprapubic catheter, followed by delayed repair

Question 54

Risk factors, Pt, Dx, and Tx of Takayasu arteritis

Answer 54

Risk factors: female, asian, age 10-40 Pt: constitutional (fever, WL), arterio-occlusive (claudication, ulcers) in upper extremities, arthralgias/myalgias PE: BP discrepancies, pulse deficits, arterial bruits Dx: elevated inflammatory markers (ESR, CRP); CXR: aortic dilation, widened mediastinum; CT/MRI: wall thickening, narrowing of lumen Tx: systemic glucocorticoids

Question 55

Pt, Dx and Tx of congenital hypothyroidism

Answer 55

``` Pt: initially normal at birth; symptoms develop after maternal T4 wanes: - lethargy - enlarged fontanelle - protruding tongue - umbilical hernia - poor feeding - constipation - dry skin - jaundice Dx: increased TSH + decreased free T4 levels; newborn screening Tx: levothyroxine ```

Question 56

What are migraine preventive options that are acceptable during pregnancy?

Answer 56

beta blockers, such as propranolol or metoprolol; CCBs (verapamil) are also safe and effective in pregnancy

Question 57

Pt and Dx criteria for acute liver failure

Answer 57

Pt: - generalized symptoms (fatigue, lethargy, anorexia, nausea) - RUQ pain - pruritus + jaundice due to hyperbilirubinemia - renal insufficiency - thrombocytopenia - hypoglycemia Dx criteria: - severe acute liver injury (ALT + AST often > 1000) - signs of hepatic encephalopathy (confusion, asterixis) - synthetic liver dysfunction (INR >/= 1.5)

Question 58

melena, RUQ pain, jaundice, anemia, and hyperbilirubinemia after recent livery biopsy - Dx? Tx?

Answer 58

hemobilia (u/s or CT scan can identify heamtomas and intraabdominal free fluid, and endoscopic evaluation may reveal oozing of blood from the papilla) Tx: usually self-limited and managed conservatively

Question 59

What is the treatment for toxoplasmosis encephalitis?

Answer 59

sulfadiazine + pyrimethamine (plus leucovorin)

Question 60

involved site and pt of myasthenia gravis as a paraneoplastic syndrome

Answer 60

``` Involved site: acetylcholine receptor in postsynaptic membrane Pt: fluctuating muscle weakness: - ocular (ptosis, diplopia) - bulbar (dysphagia, dysarthria) - facial, neck + limb muscles ```

Question 61

Involved site and pt of Lambert-eaton syndrome as a paraneoplastic syndrome

Answer 61

involved site: presynaptic membrane voltage-gated calcium channels Pt: proximal muscle weakness, autonomic dysfunction (dry mouth), cranial nerve involvement (ptosis), diminished or absent DTRs (~50% associated with an underlying malignancy, mostly small cell lung cancer)

Question 62

Involved site and pt of dermatomyositis/polymyositis as a paraneoplastic syndrome

Answer 62

Involved site: muscle fiber injury Pt: - symmetrical + more proximal muscle weakness - interstitial lung disease, esophageal dysmotility, Raynaud phenomenon - polyarthritis - esophageal dysmotility - skin findings (Gottron papules, heliotrope rash) in dermatomyositis

Question 63

Bell palsy Path, Pt

Answer 63

Path: peripheral neuropathy involving CN VII due to reactivation of a neurotrophic virus, most commonly HSV; results in nerve compression and degeneration of the myelin sheath Pt: unilateral mouth drooping, disappearance of the nasolabial fold, involvement of the upper face (distinguishes from UMN disorders like stroke), decreased ipsilateral eye lacrimation, hyperacusis, and decreased sensation of taste of the anterior 2/3 of the ipsilateral tongue; weakness typically develops at night; sx progress over 2-3 weeks with gradual improvement over 3-6 months Tx: glucocorticoids

Question 64

migraine with aura involving the brainstem pt

Answer 64

vertigo, dysarthria, diplopia, and possible LOC, typically followed by a severe occipital HA

Question 65

antipsychotic medication effect of the mesolimbic, nigrostriatal, and tuberoinfundibulnar dopamine pathways

Answer 65

mesolimbic: antipsychotic efficacy nigrostriatal: extrapyramidal symptoms: acute dystonia, akathisia, Parkinsonism tuberoinfundibulnar: hyperprolactinemia

Question 66

humoral hypercalcemia of malignancy path/pt

Answer 66

``` Path: due to PTHrP; associated with squamous cell (lung, head, and neck), renal, bladder, breast, or ovarian carcinomas Pt: - very high (>14) calcium levels - polyuria, constipation, nausea - low PTH ```

Question 67

Path and PT of cyclic vomiting syndrome

Answer 67

Path: personal or family hx of migraines; episodes often have identifiable trigger (infection, stress) Pt: stereotypical vomiting episodes with acute onset of N/V/HA and abdominal pain; self-limited, lasting 1-2 days; asymptomatic between episodes; often regular intervals (2-4 weeks)

Question 68

CSF rhinorrhea path, pt, dx, and management

Answer 68

Path: accidental trauma (MC), surgical trauma, non traumatic (elevated ICP) Pt: U/L watery rhinorrhea with salty or metallic taste; possible complication: meningitis Dx: - test for CSF-specific proteins (beta-2 transferrin, beta-trace protein) - imaging (with intrathecal contrast) - endoscopy (+/- intrathecal fourescein dye) Tx: bed rest, head of bed elevation, avoidance of straining; lumbar drain placement; surgical repair

Question 69

description, normal result, and abnormal result of fetal non stress test

Answer 69

description: external fetal HR monitoring for 20-40 mins normal: reactive: >/= 2 accelerations abnormal: nonreactive: < 2 accelerations; recurrent variable or late decelerations

Question 70

description, normal result, and abnormal result of fetal biophysical profile

Answer 70

description: non stress test plus u/s assessment of the following: - amniotic fluid volume - fetal breathing movement - fetal movement - fetal tone (2 points per category if normal + 0 points if abnormal) normal: 8-10 points abnormal: equivocal: 6 points; abnormal: 0, 2, 4 points; oligohydramnios

Question 71

description, normal result, and abnormal result of fetal contraction stress test

Answer 71

description: external fetal HR monitoring during spontaneous or induced (oxytocin, nipple stimulation) uterine contractions normal: no late or recurrent variable decelerations abnormal: late decelerations with >50% of contractions

Question 72

description, normal result, and abnormal result of fetal doppler sonography of the umbilical artery

Answer 72

description: evaluation of umbilical artery flow in fetal intrauterine growth restriction only normal: high-velocity diastolic flow in umbilical artery abnormal: decreased, absent, or reversed end-diastolic flow

Question 73

Pt, Dx, and Tx of vasovagal syncope

Answer 73

Pt: inciting event (stress, prolonged standing), prodrome (pallor, nausea, diaphoresis), consciousness regained rapidly (<1 minute) Dx: mainly clinical; upright tilt table testing in uncertain cases Tx: reassurance, avoidance of triggers, counter pressure techniques for recurrent episodes

Question 74

acute poststreptococcal glomerulonephritis Pt & Labs

Answer 74

Pt: can be asymptomatic; if symptomatic: - gross hematuria (tea- or cola-colored urine) - edema (periorbital, generalized) - HTN Labs: - U/A: + proteins, + blood, +/- RBC casts - serum: low C3 and possible low C4, increased serum Cr, increased anti-DNase B + AHase, increased ASO and anti-NAD (from preceding pharyngitis)

Question 75

acute hemolytic transfusion reaction Path, Pt, Labs, complications

Answer 75

Path: ABO incompatibility, intravascular hemolysis Pt: onset within minutes to 24 hours of transfusion; fever, chills, hypotension; hemoglobinuria, flank pain Labs: positive direct Coombs test; hemolysis (increased LDH, increased indirect bilirubin) Complications: acute renal failure, DIC

Question 76

Pt of acute PCP intoxication

Answer 76

- violent behavior - dissociation - hallucinations - amnesia - nystagmus (horizontal or vertical) - ataxia

Question 77

Pt of acute LSD intoxication

Answer 77

- visual hallucinations - euphoria - dysphoria/panic - tachycardia/HTN

Question 78

Pt of acute cocaine intoxication

Answer 78

- euphoria - agitation/psychosis - chest pain - seizures - tachycardia/HTN - mydriasis

Question 79

Pt of acute methamphetamine intoxication

Answer 79

- violent behavior - psychosis, diahphoresis - tachycardia/HTN - choreiform movements - tooth decay

Question 80

Pt of acute marijuana intoxication

Answer 80

- increased appetite - euphoria - dysphoria/panic - slow reflexes, impaired time perception - dry mouth - conjunctival injection

Question 81

Pt of acute heroin intoxication

Answer 81

- euphoria - depressed mental status - miosis - respiratory depression - constipation

Question 82

Path, Pt, Dx, and Tx of spinal epidural abscess

Answer 82

Path: staph aureus (65%); inoculating sources: - distant infection (cellulitis, joint/bone) - spinal procedure (epidural catheter) - injection drug use Pt: classic triad - fever - focal/severe back pain - neurologic findings (motor/sensory change, bowel/bladder dysfunction, paralysis Dx: elevated ESR, blood and aspirate cultures, MRI of the spine Tx: broad-spectrum Abx (vancomycin plus ceftriaxone), aspiration/surgical decompression

Question 83

What is the treatment of a pelvic fracture in a stable vs unstable patient?

Answer 83

in an unstable patient, they are at risk of life threatening hemorrhage from the venous plexus so rapid external stabilization with a pelvic binder should be performed as soon as possible to promote tamponade of venous bleeding

Question 84

Path, Pt, Dx, and Tx of syringomyelia

Answer 84

Path: destruction of the crossing fibers of the spinothalamic tract int he ventral white commissure Pt: progressive loss of pain and temp sensation (cape-like distribution) Dx: MRI will show intramedullary cavity Tx: usually requires surgical shunt placement

Question 85

What can you infer from a HgA1c of >10% as compared to HgA1c of around 8%?

Answer 85

HgA1c of > 10% suggest significant hyperglycemia throughout the day, whereas lesser abnormalities are often due to elevation sin only postprandial glucose levels

Question 86

uremic coagulopathy path, pt, labs, and tx

Answer 86

Path: abnormal hemostasis in the setting of chronic renal failure due to platelet dysfunction Pt: ecchymoses and epistaxis are MC but GI bleeding, hemoperricardium, subdural hematoma, and bleeding from surgical or invasive sites can still occur Labs: aPTT, PT, and TT normal, bleeding time (reflective of platelet function) is prolonged, normal platelet count Tx: DDAVP, cryoprecipitate, and conjugated estrogens have been used to correct this

Question 87

chronic suppurative otitis media

Answer 87

otorrhea and hearing loss for > 6 weeks and TM perforation one xam

Question 88

otitis media with effusion

Answer 88

may cause hearing loss and poor TM mobility BUT in contrast to acute otitis media, there is a lack of acute inflammation (fever, TM bulging)

Question 89

tinea versicolor

Answer 89

Path: malassezia globes skin flora grows in exposure to hot and humid weather PT: hypo pigmented, hyper pigmented, or middle erythematous lesions, +/- fine scale, +/- pruritus Dx: KOH prep shows hyphae and yeast cells in a "spaghetti + meatballs" pattern Tx: topical ketoconazole, terbinafine, or selenium sulfide

Question 90

bacterial conjunctivitis treatment options

Answer 90

1. erythomycin ointment 2. polymyxin-trimethoprim drops 3. azithromycin drops 4. preferred agent in contact lens wearers: fluroquinolone drops

Question 91

viral conjunctivitis treatment

Answer 91

warm or col compresses +/- antihistamine/decongestant drops

Question 92

allergic conjunctivitis treatment

Answer 92

- OTC antihistamine/decongestant drops for intermittent symptoms - mast cell stabilizer/antihistamine drops for frequent episodes

Question 93

Clinical manifestations of hemochromatosis based on body system

Answer 93

skin - hyperpigmentation (bronze diabetes) MSK - arthralgia, arthropathy + chondrocalcinosis GI - elevated hepatic enzymes with hepatomegaly (early), cirrhosis (late) + increased risk of hepatocellular carcinoma Endocrine - DM, secondary hypogonadism + hypothyroidism Cardiac - restrictive or dilated cardiomyopathy + conduction abnormalities Infections: increased susceptibility to Listeria, Vibrio vulnficus + Yersinia enterocolitica

Question 94

clinical associations of infective endocarditis with staph aureus

Answer 94

- prosthetic valves - intravascular catheters - implanted devices (pacemakers, defibrillator) - IV drug use

Question 95

clinical associations of infective endocarditis with viridans strep and which bugs belong in this group?

Answer 95

- gingival manipulation - respiratory tract incision or biopsy viridans group: - strep sanguinis - s mitis - s oralis - s mutans - s sobrinus - s milleri

Question 96

clinical associations of infective endocarditis with staph epidermidis

Answer 96

- prosthetic valves - intravascular catheters - implanted devices

Question 97

clinical associations of infective endocarditis with enterococci

Answer 97

- nosocomial UTIs

Question 98

clinical associations of infective endocarditis with strep gallolyticus

Answer 98

- colon carcinoma | - IBD

Question 99

clinical associations of infective endocarditis with fungi (candida)

Answer 99

- immunocompromised host - intravascular catheters - prolonged Abx therapy

Question 100

PT, PTT, BT, platelet count, RBC count of von Willebrand disease

Answer 100

``` PT - normal PTT - high BT - high Platelet count - normal RBC count - normal **autosomal dominant (look for family hx) ```

Question 101

PT, PTT, BT, platelet count, RBC count of hemophilia A/B

Answer 101

``` PT - normal PTT - high BT - normal Platelet count - normal RBC count - normal **x-linked recessive; A = low factor 8; B = low factor 9 ```

Question 102

PT, PTT, BT, platelet count, RBC count of DIC

Answer 102

``` PT - high PTT - high BT - high Platelet count - low RBC count - normal/low **appropriate history, low level of factor 8 ```

Question 103

PT, PTT, BT, platelet count, RBC count of liver failure

Answer 103

``` PT - high PTT - high BT - normal Platelet count - normal/low RBC count - normal/low **jaundice, normal factor 8 level; do not give vitamin K (ineffective), use FFP ```

Question 104

PT, PTT, BT, platelet count, RBC count of heparin use

Answer 104

``` PT - normal PTT - high BT - normal Platelet count - normal RBC count - normal **watch for thrombocytopenia and thrombosis ```

Question 105

PT, PTT, BT, platelet count, RBC count of warfarin use

Answer 105

``` PT - high PTT - normal BT - normal Platelet count - normal RBC count - normal **Vitamin K antagonist (factors 2, 7, 9, 10) ```

Question 106

PT, PTT, BT, platelet count, RBC count of ITP (idiopathic thrombocytopenia purpura)

Answer 106

``` PT - normal PTT - normal BT - high Platelet count - low RBC count - normal **watch for preceding URI ```

Question 107

PT, PTT, BT, platelet count, RBC count of TTP (thrombotic thrombocytopenia purpura)

Answer 107

``` PT - normal PTT - normal BT - high Platelet count - low RBC count - low **hemolysis (smear), CNS symptoms (hallucinations, AMS, HA, stroke); tx with plasmapheresis; DO NOT give platelets ```

Question 108

PT, PTT, BT, platelet count, RBC count of scurvy

Answer 108

``` PT - normal PTT - normal BT - normal Platelet count - normal RBC count - normal **fingernail and gum hemorrhages, bone hemorrhages; caused by vitamin C deficiency ```

Question 109

Lab findings of X-linked agammaglobulinemia

Answer 109

decreased or absent. cells | decreased immunoglobulines

Question 110

Lab findings of common variable immunodeficiency

Answer 110

Normal B cells | decreased immunoglobulins

Question 111

Lab findings of IgA deficiency

Answer 111

Normal B cells | decreased IgA

Question 112

Lab findings of Hyper-IgM syndrome

Answer 112

normal B cells decreased IgG + IgA increased IgM

Question 113

What is the next step in management after initial stabilization of acute MI with persistent pain, HTN, or heart failure?

Answer 113

IV nitroglycerin (not if hypotension, RV infarct, or severe aortic stenosis occurs)

Question 114

What is the next step in management after initial stabilization of acute MI with persistent severe pain?

Answer 114

IV morphine

Question 115

What is the next step in management after initial stabilization of acute MI with unstable sinus bradycardia?

Answer 115

Intravenous atropine

Question 116

What is the next step in management after initial stabilization of acute MI with pulmonary edema?

Answer 116

IV furosemide (not if Patience's tis hypotensive or hypovolemic)

Question 117

Risk factors, Pt, and Tx of calcaneal apophysitis (Sever disease)

Answer 117

Risk factors: running/jumping sports, growth spurts, athletic cleat use or footwear without heel padding Pt: heal pain (50% b/l), pain with calcaneal palpation or compression, decreased gastrocnemius/soleus flexibility Tx: NSAIDs, ice, activity limitation

Question 118

Path, Pt, Dx, and Tx of infant botulism

Answer 118

Path: ingestion of Clostridium botulinum spores (environmental dust/soil, honey), spores colonize GI tract + produce toxin; toxin inhibits presynaptic ACh release Pt: age < 12 months; constipation, poor feeding, hypotonia; oculobulbar palsies (absent gag reflex, ptosis), symmetric descending paralysis, autonomic dysfunction (decreased salivation, fluctuating HR/BP) Dx: clinical, confirmation by stool C botulinum spores or toxins Tx: botulism immune globulin

Question 119

Path, Pt, Dx, and Tx of neonatal thyrotoxicosis

Answer 119

Path: transplacental passage of maternal anti-TSH receptor Abs; Abs bind to infant's TSH receptors + cause excessive thyroid hormone release Pt: warm, moist skin; tachycardia; poor feeding, irritability, poor weight gain; low birth weight or preterm birth Dx: maternal anti-TSH receptor Abs (>500% normal) Tx: self-resolves within 3 months; methimazole PLUS beta blocker

Question 120

What drugs are indicated in the treatment of preeclampsia to lower BP acutely to decrease stroke risk?

Answer 120

hydralazine IV (vasodilator), labetalol IV (beta blocker with alpha-blocking activity), or nifedipine PO (CCB)

Question 121

Modified Wells criteria for pretest probability of pulmonary embolism

Answer 121

``` +3 points = - clinical signs of DVT - alternate diagnosis less likely than PE +1.5 points = - previous PE or DVT - HR > 100 - recent surgery or immbolization + 1 point = - hemoptysis - cancer Total score = 4 = PE unlikely > 4 = PE likely ```

Question 122

Pt of ED due to vascular causes?

Answer 122

- cardiovascular risk factors (HTN, smoking, diabetes) | - abnormal vascular examination (bruits, decreased pulses)

Question 123

Pt of ED due to neurologic causes?

Answer 123

- neurologic comorbidity (diabetic neuropathy, MS, spinal injury/surgery) - gradual onset, loss of bulbocavernous reflex

Question 124

Pt of ED due to psychogenic causes?

Answer 124

- suddent onset - situational (ED with partner, normal erection during masturbation) - normal nonsexual nocturnal erections

Question 125

Pt of ED due to endocrine causes?

Answer 125

- additional symptoms due to underlying disorder | - abnormal hormone levels (TSH, prolactin)

Question 126

Pt of ED due to medication causes?

Answer 126

- onset related to starting medication | - antihypertensives, SSRIs, anti-androgenic medications

Question 127

Pt of ED due to hypogonadism causes?

Answer 127

- gradual onset - decreased libido, gynecomastia, testicular atrophy - low serum testosterone

Question 128

DSM-5 criteria for schizoaffective disorder

Answer 128

1. major depressive or manic episode concurrent with symptoms of schizophrenia 2. Lifetime history of delusions or hallucinations for >/= 2 weeks in the absence of major depressive or manic episode 3. mood episodes are prominent + recur throughout illness 4. not due to substances or another medical condition

Question 129

How do you differentiate major depressive or bipolar disorder with psychotic features from schizoaffective disorder?

Answer 129

major depressive or bipolar disorder with psychotic features: psychotic symptoms occur exclusively during mood episodes

Question 130

How do you differentiate schizophrenia from schizoaffective disorder?

Answer 130

schizophrenia: mood symptoms may be present for relatively brief periods

Question 131

Path, manifestations, and management of von hippel-lindau disease

Answer 131

Path: mutation in the VHL tumor suppressor gene on chromosome 3 Manifestations: cerebellar + retinal hemangioblastomas; pheochromocytoma; renal cell carcinoma (clear cell) Management: surveillance for associated malignancies: - eye/retinal examination - plasma or urine metanephrines - MRI of the brain + spine - MRI of the abdomen tumor resection

Question 132

Path and Pt of tabes dorsalis

Answer 132

Path: increased incidence of syphilis in men who have sex with men + HIV-infected patients; HIV positive patients develop neurosyphilis more rapidly Treponema pallidum spirochetes directly damage the dorsal sensory roots; secondary degeneration of the dorsal columns Pt: sensory ataxia, lancinating pains, neurogenic urinary incontinence, associated with argyll Robertson pupils

Question 133

What are risk factors for homicide?

Answer 133

``` young male unemployed impoverished access to firearms substance abuse antisocial personality disorder history of violence or criminality history of childhood abuse impulsivity ```

Question 134

Name the drugs, indication, C/I, and side effects of bisphosphonates

Answer 134

Drugs: alendronate, risedronate Indication: first-line tx for osteoporosis C/I: not recommended for patients with renal impairment SE: atypical fractures possible with prolonged use *Take with water on an empty stomach an hour before food + other meds

Question 135

Indication and SE of denosumab

Answer 135

Indication: osteoporosis SE: risk of infection + skin reactions; close monitoring for hypocalcemia needed

Question 136

Indication and SE of teriparatide

Answer 136

Indication: severe osteoporosis SE: monitor serum calcium, uric acid, and renal function

Question 137

Name and SE for selective estrogen receptor modulators as tx for osteoporosis

Answer 137

Name: raloxifene SE: may lower risk of breast cancer, increased risk of DVT **Less effective than bisphosphonates

Question 138

Path, Pt, Dx, and Tx of fat embolism syndrome

Answer 138

Path: fracture of marrow-containing bone, orthopedic surgery, pancreatitis Pt: 24-72 hours following inciting event; clinical triad: respiratory distress, neurologic dysfunction (confusion), petechial rash Dx: based on clinical experience Tx: early immobilization of fracture; supportive care (mechanical ventilation)

Question 139

CD4 count + Pt of cryptosporidium diarrhea in AIDS

Answer 139

CD4: < 180 Pt: severe watery diarrhea, low-grade fever, WL

Question 140

CD4 count + Pt of micros-iridium/Isosporidium diarrhea in AIDS

Answer 140

CD4: < 100 Pt: watery diarrhea, crampy abdominal pain, WL, fever is rare

Question 141

CD4 count + Pt of mycobacterium avium diarrhea in AIDS

Answer 141

CD4: <50 Pt: watery diarrhea, high fever (>102.2), WL

Question 142

CD4 count + Pt of CMV diarrhea in AIDS

Answer 142

CD4: <50 Pt: frequent, small-volume diarrhea, hematochezia, abdominal pain, low-grade fever, WL

Question 143

Path, Pt, and Tx of severe combined immunodeficiency

Answer 143

Path: gene defect leading to failure of T cell development; B cell dysfunction due to absent T cells; X-linked recessive and autosomal recessive Pt: recurrent, severe viral, fungal, or opportunistic (pneumocystis) infections, failure to thrive, chronic diarrhea Tx: stem cell transplant

Question 144

Path, Pt, and causes of fetal hydrops

Answer 144

``` Path: increased cardiac output demand causing heart failure, increased fluid movement into interstitial spaces (third spacing) Pt: pericardial effusion, pleural effusion, ascites, skin edema, placental edema, polyhydramnios Causes: immune: - Rh(D) alloimmunization Nonimmune: - parvo B19 - fetal aneuploidy - CV abnormalities - thalassemia (hemoglobin Barts) ```

Question 145

Pt, Labs, and Tx of intrahepatic cholestasis of pregnancy

Answer 145

Pt: develops in 3rd trimester, generalized pruritus, pruritus worse on hands + feet, no associated rash, RUQ pain Labs: increased total bile acids (>10), increased transaminases, +/- increased total + direct bilirubin Tx: delivery at 37 weeks gestation, ursodeoxycholic acid, antihistamines

Question 146

What are the obstetric risks of intrahepatic cholestasis of pregnancy?

Answer 146

intrauterine fetal demise preterm delivery meconium-stained amniotic fluid neonatal respiratory distress syndrome

Question 147

What are the risk factors for gout?

Answer 147

1. medications (diuretics, low-dose aspirin) 2. surgery, trauma, recent hospitalizations 3. volume depletion 4. diet: high protein foods (meat, seafood), high fat foods, fructose or sweetened beverages 5. heavy alcohol consumption 6. underlying medical conditions (HTN, obesity, CKD, organ transplant)

Question 148

What factors decrease the risk of gout?

Answer 148

1. dairy product intake 2. vitamin C (>/= 1500 mg/day) 3. coffee intake (>/= 6 cups/day)

Question 149

Path, Risk factors, Pt, Dx, and Tx of onychomycosis

Answer 149

Path: trichophyton rubrum Risk factors: advanced age, tinea pedis, diabetes, peripheral vascular disease Pt: thick, brittle, discolored nails Dx: KOH, periodic acid-Schiff stain, culture Tx: first line: terbinafine, itraconazole; second line: griseofulvin, fluconazole, ciclopirox

Question 150

What are the primary indications and features of cognitive behavioral therapy?

Answer 150

Primary indications: depression, GAD, PTSD, panic disorder, OCD, eating disorders, negative thought patterns Features: - combines cognitive and behavioral therapy - challenges maladaptive cognitions - targets avoidance with behavioral techniques (relaxation, exposure, behavior modification)

Question 151

What are the primary indications and features of interpersonal psychotherapy?

Answer 151

Primary indications: depression | Features: links symptoms to current relationship conflicts and interpersonal skill deficits

Question 152

What are the primary indications and features of supportive psychotherapy?

Answer 152

Primary indications: lower functioning; psychotic disorders, patients in crisis Features: - maintains hope; provides encouragement - reinforces coping skills, adaptive defenses

Question 153

What are the primary indications and features of psychodynamic psychotherapy?

Answer 153

Primary indications: higher functioning, personality disorders Features: - builds insight into unconscious conflicts + past relationships - uses transference - breaks down maladaptive defenses

Question 154

What are the primary indications and features of motivational interviewing?

Answer 154

Primary indication: substance use disorders Features: - nonjudgmental; acknowledges ambivalence + resistance - enhances intrinsic motivation to change

Question 155

What are the primary indications and features of dialectical behavioral therapy?

Answer 155

Primary indications: borderline personality disorder Features: - improves emotion regulation, distress tolerance, mindfulness - decreases self harm; builds skills

Question 156

What are the primary indications and features of biofeedback?

Answer 156

Primary indications: prominent physical symptoms; pain disorders Features: - improves control over physiological reactions to emotional stressors

Question 157

What are the absolute contraindications to combined hormonal contraceptives?

Answer 157

``` migraine with aura >/= 15 cigarettes/day PLUS age >/= 35 HTN >/= 160/100 heart disease diabetes mellitus with end-organ damage history of thromboembolic disease antiphospholipid-Ab syndromne - Hx of stroke - breast cancer - cirrhosis + liver cancer - major surgery with prolonged immobilization - use < 3 weeks postpartum ```

Question 158

Path, Pt, Dx, and Tx of cutaneous larva migrans

Answer 158

Path: hookworm larvae; dog (ancylostoma canine) or cat (A braziliense); humans are incidental hostos - barefoot contact with contaminated sand or soil Pt: primarily lower extremity; cutaneous (deeper infection rare); erythematous, pruritic papule at site of entry; intensely pruritic, migrating, serpiginous, reddish-brown tracks Dx: history and clinical findings; eosinophils usually normal Tx: antihelmintic (ivermectin)

Question 159

What effect do beta 1 blockers have on the RAAs system?

Answer 159

inhibit beta 1 sympathetic stimulation of the juxtaglomerular apparatus of the kidney (which would normally stimulate renin release)

Question 160

What conditions predispose to aspiration pneumonia?

Answer 160

- altered consciousness impairing cough reflex/glottic closure (dementia, drug intoxication) - dysphagia due to neurologic deficits (stroke, neurodegenerative disease) - Upper GI tract disorders (GERD) - Mechanical compromise of aspiration defenses (nasogastric + endotracheal tubes) - protracted vomiting - large volume tube feedings in recumbent position

Question 161

Pt, Labs, U/sm and Tx of epithelial ovarian carcinoma

Answer 161

Pt: - acute: SOB, obstipation/constipation with vomiting, abdominal distension - subacute: pelvic/abdominal pain, bloating, early satiety - asymptotic adnexal mass Labs: increased CA-125 U/s: solid mass, thick separations, ascites Tx: exploratory laparotomy

Question 162

Pt and Dx of chronic granulomatous disease

Answer 162

Pt: majority of cases X-linked recessive; recurrent pulmonary and cutaneous infections with catalase-positive pathogens (Staph aureus, Serratia, Burkholderia, Aspergillus Dx: neutrophil function testing (dihydrorhodamine 123 test, nitro blue tetrazolium test)

Question 163

Path, Pt, and CXR of transient tachypnea of the newborn

Answer 163

Path: inadequate alveolar fluid clearance at birth results in mild pulmonary edema Pt: tachypnea begins shortly after birth + resolves by day 2 of life CXR: bilateral perihilar linear streaking

Question 164

Path, Pt, and CXR of respiratory distress of the newborn

Answer 164

Path: surfactant deficiency result Sina alveolar collapse + diffuse atelectasis Pt: severe respiratory distress + cyanosis after premature birth CXR: diffuse, reticulogranular (ground-glass) appearance, air bronchograms, low lung volumes

Question 165

Path, Pt, and CXR of persistent pulmonary HTN as a cause of neonatal respiratory distress

Answer 165

Path: high pulmonary vascular resistance results in right-to-left shunting and hypoxia Pt: tachypnea + severe cyanosis CXR: clear lungs with decreased pulmonary vascularity

Question 166

Path, Pt, Labs, Tx of classic congenital adrenal hyperplasia

Answer 166

Path: autosomal recessive, 21-hydroxylase deficiency Pt: ambiguous genitalia in girls, salt-wasting syndrome: affects most girls + boys; hypotension, dehydration + vomiting Labs: decreased sodium, increased potassium, decreased glucose; increased 17-hydroxyprogesterone Tx: glucocorticoids + mineralocorticoids; high-salt diet; genital reconstructive surgery for girls; psychosocial support

Question 167

When should you expect to begin to see salt wasting in classic congenital adrenal hyperplasia?

Answer 167

1-2 weeks of age

Question 168

Path, Management, complications of infantile hemangioma

Answer 168

Path: may present as patch of telangiectasia at birth - proliferation: age 0-1; bright red, raised nodule - involution: age 1-9; deeper red/violent, regression in size Management: observation; topical beta blocker (propranolol) for ulcerated or cosmetically sensitive ares (face) Complications: ulceration/scarring, vision impairment if near eye, life-threatening if near airway

Question 169

Risk factors, Pt, Dx and Management of postpartum uriary retention

Answer 169

Risk factors: primiparity, regional neuraxial anesthesia, operative vaginal delivery, perineal injury, cesarean delivery Pt: inability to void >/= 6 hours after vaginal delivery, incomplete bladder emptying, dribbling of urine Dx: urethral catheterization; post-void residual volume of >/= 150 mL Tx: self-limited; intermittent catheterization

Question 170

Causes, Pt, Dx, and management of sciatica (acute lumbosacral radiculopathy)

Answer 170

Causes: herniated intervertebral disk (MC), degenerative spondylosis, malignancy, epidural abscess Pt: - pain in low back radiating down posterior leg to food - positive straight-leg raising test - possible dermatomal sensory loss and weakness of hip dorsiflexion Dx: primarily clinical; MRI recommended for: - significant/progressive or B/L neurologic deficits - suspected malignancy or epidural abscess Management: activity modification, NSAIDs, surgery for disabling symptoms

Question 171

In what circumstances can minors provide thier own consent?

Answer 171

Medical emancipation: - emergency care - sexually transmitted diseases - mental health + substance abuse tx - pregnancy care - contraception Legal emancipation: - financially independent - parent - married - active military service - high school graduate

Question 172

Path, U/S, Pt, Dx, and Tx of congenital toxoplasmosis

Answer 172

Path: undercooked meat, unwashed produce, unprotected handling of cat feces U/S: bilateral ventriculomegaly, diffuse intracranial calcifications Pt: chorioretinitis, hydrocephalus, seizures, intellectual disability, sensorineural hearing loss Dx: maternal: serology fetal: amniotic fluid PCR Tx: spiramycin

Question 173

Path, pleural fluid analysis, pleural fluid gram stain + culture, Tx of uncomplicated parapneumonic effusions

Answer 173

Path: steroid exudate in pleural space pleural fluid analysis: pH >/= 7.2, glucose >/= 60, WBC = 50,000 pleural fluid gram stain + culture: negative Tx: Abx

Question 174

Path, pleural fluid analysis, pleural fluid gram stain + culture, Tx of complicated parapneumonic effusions

Answer 174

Path: bacterial invasion of pleural space Pleural fluid analysis: pH <7.2, glucose < 60, WBC > 50,000 pleural fluid gram stain + culture: negative Tx: Abx and drainage

Question 175

What are complications of excessive weight gain in pregnancy?

Answer 175

- gestational diabetes mellitus - fetal macrosomia - cesarean delivery

Question 176

What are complications of inadequate weight gain during pregnancy?

Answer 176

- fetal growth restriction | - preterm delivery

Question 177

Pt, Dx, Management, and Complications of acute diverticulitis

Answer 177

Pt: abdominal pain (usually lower left quadrant), fever, nausea, vomiting, ileus (peritoneal irritation) Dx: abdominal CT (oral + IV contrast) Management: bowel rest, Abx (ciprofloxacin, metronidazole) Complications: abscess, obstruction, fistula, perforation

Question 178

What are the indications for surgical repair of primary mitral regurgitation?

Answer 178

- surgery if LVEF 30-60% (regardless of sx) - consider surgery if successful valve repair is highly likely: - symptoms + LVEF < 30% - asymptomatic + LVEF >60%

Question 179

Path, Pt, Dx, and Tx of eosinophilic esophagitis

Answer 179

Path: chronic, immune-mediated esophageal inflammation Pt: dysphagia, chest/epigastric pain, reflux/vomiting, food impaction, associated atopy Dx: endoscopy + esophageal biopsy (>/=15 eosinophils per high-power filed) Tx: dietary modification, +/- topical glucocorticoids

Question 180

What protein level is considered high-protein ascites? What are the common causes of this? What about low-protein ascites?

Answer 180

>/= 2.5 (high-protein ascites): - CHF, constrictive pericarditis, peritoneal carcinomatosis, TB, Budd-Chiari syndrome, fungal <2.5 (low-protein ascites): cirrhosis, nephrotic syndrome

Question 181

What SAAG ratio indicates portal HTN? What are the common causes? What about in the absence of portal HTN?

Answer 181

>/= 1.1 (indicates portal HTN): cardiac ascites, cirrhosis, Budd-Chiari <1.1 (absence of portal HTN): TB, peritoneal carcinomatosis, pancreatic ascites, nephrotic syndrome

Question 182

Characteristics and time frame of rotavirus + norovirus diarrhea

Answer 182

short-term brief illness vomiting common

Question 183

Characteristics and time frame of enterotoxigenic E. coli and Enteropathogenic E coli diarrhea

Answer 183

short-term | contaminated food + drinking water

Question 184

Characteristics and time frame of campylobacter diarrhea

Answer 184

short-term prominent abodminla pain pseudoappendicitis bloody diarrhea

Question 185

Characteristics and time frame of salmonella diarrhea

Answer 185

short-term | frequent fever

Question 186

Characteristics and time frame of shigella diarrhea

Answer 186

short-term fever bloody diarrhea abdominal pain

Question 187

Characteristics and time frame of entamoeba histolytica

Answer 187

long-term (>2 weeks) | prolonged bloody diarrhea

Question 188

Characteristics and time frame of giardia diarrhea

Answer 188

long-term (>2 weeks) prolonged watery diarrhea fat malabsoprtion, bloating common asymptomatic patients may continue to shed organism for months

Question 189

Characteristics and time frame of cryptosporidium, cystoisospora (formerly isospora), microscporidia species diarrhea

Answer 189

long-term (>2 weeks) | chronic watery diarrhea in immunosuppressed patients

Question 190

Characteristics and time frame of cyclosporine diarrhea

Answer 190

long-term (>2 weeks) | may cause prolonged, relapsing infection

Question 191

characteristics of focal nodular hyperplasia as a cause of a solid liver mass

Answer 191

- associated with anomalous arteries | - arterial flow + central scar on imaging

Question 192

characteristics of hepatic adenoma as a cause of a solid liver mass

Answer 192

- women on long-term OCPs | - possible hemorrhage or malignant transformation

Question 193

characteristics of regenerative nodules as a cause of a solid liver mass

Answer 193

acute or chronic livery injury (cirrhosis)

Question 194

characteristics of hepatocellular carcinoma as a cause of a solid liver mass

Answer 194

- systemic symptoms - chronic hepatitis or cirrhosis - elevated alpha-fetoprotein

Question 195

characteristics of liver metastasis as a cause of a solid liver mass

Answer 195

- single/multiple lesions | - known extra hepatic malignancy

Question 196

What is ascertainment (sampling) bias?

Answer 196

type of selection bias: study population differs from target population due to nonrandom selection methods

Question 197

What is nonresponse bias?

Answer 197

type of selection bias: high nonresponse rate to surveys/questionnaires can cause errors if non responders differ in some way from responders

Question 198

What is Berkson bias?

Answer 198

type of selection bias: disease studied using only hospital-based patients may lead to results not applicable to target population

Question 199

What is prevalence (Neyman) bias?

Answer 199

Type of selection bias: exposures that happen long before disease assessment can cause study to miss disease patients that die early or recover

Question 200

What is attrition bias?

Answer 200

type of selection bias: significant loss of study participants may cause bias if those long to follow-up differ significantly from remaining subjects

Question 201

What is recall bias?

Answer 201

type of observational bias: common in retrospective studies, subjects with negative outcomes are more likely to report certain exposures than control subjects

Question 202

What is observer bias?

Answer 202

type of observational bias: observers misclassify data due to individual differences in interpretation or preconceived expectations regarding study

Question 203

What is reporting bias?

Answer 203

type of observational bias: subjects over- or under-report exposure history due to perceived social stigmatization

Question 204

What is surveillance (detection) bias?

Answer 204

type of observational bias: risk factor itself causes increased monitoring in exposed group relative to unexposed group, which increases probability of identifying a disease

Question 205

characteristics of genital ulcers caused by HSV

Answer 205

painful small vesicles or ulcers one erythematous base mild LAD

Question 206

characteristics of genital ulcers caused by haemophilus ducreyi (chancroid)

Answer 206

painful larger, Depp ulcers with gray/yellow exudate well-demarcated borders + soft, friable base - severe LAD that may suppurate

Question 207

characteristics of genital ulcers caused by treponema palladium (syphilis)

Answer 207

painless single ulcer (chance) regular borders + hard base

Question 208

characteristics of genital ulcers caused by chlamydia trachoma's serovars L1-L3 (lymphogranuloma venereum)

Answer 208

painless small, shallow ulcers (often missed) can progress to painful, fluctuant adenines (buboes)

Question 209

What are risk factors for septic arthritis?

Answer 209

abnormal joint: OA, RA, prosthetic joint, gout age > 80 diabetes IVDA, alcoholism intra-articular glucocorticoids injections

Question 210

Pt, Dx, and Tx of septic arthritis

Answer 210

Pt: acute monoarthritis: hot, swollen, decreased ROM, fever, elevated ESR + CRP Dx: blood cultures, synovial fluid analysis: leukocytosis (>50,0000), gram stain, culture Tx: gram positive cocci: vancomycin gram negative rod: third gen cephalosporin negative microscopy: vancomycin (+ 3rd gen cephalosporin if immunocompromised)

Question 211

fetal hydantoin syndrome path and pt

Answer 211

Path: due to in utero exposure to an anti epileptic (phenytoin, carbamazepine, valproate) Pt: cleft lip and palate, wide anterior fontanelle, distal phalange hypoplasia, and cardiac anomalies (pulmonary stenosis, aortic stenosis), neural tube defects, microcephaly

Question 212

Where are pressure ulcers most common?

Answer 212

bony prominences, such as the sacrum, ischial tuber-sixties, malleoli, heels, and 1st and 5th metatarsal head

Question 213

What is used to correct hyponatremia? What is the goal for raising the Na?

Answer 213

patients with serum Na <130 with any symptoms of elevated intracranial pressure should be treated with hypertonic 3% saline boluses; the goal is to raise serum Na levels by 4-6 over a period of hours (maximum rate of correction is 8 in 24 hours to prevent ODS)

Question 214

What is a serious risk of untreated infection of the retropharyngeal space?

Answer 214

retropharyngelal space drains inferiorly to the superior mediastinum; spread to the carotid sheath can cause thrombosis of the internal jugular vein and deficits in cranial nerves IX, X, XI, and XII; extension through the alar fascia into the "danger space" can lead to acute necrotizing mediastinitis (fever, chest pain, dyspnea, odynophagia, and requires urgent surgical intervention)

Question 215

what is the difference between small fiber and large fiber nerve injury?

Answer 215

small fiber injury is characterized by the predominance of positive symptoms (pain, paresthesia, allodynia) large fiber involvement is characterized by the predominance of negative symptoms (numbness, loss of proprioception and vibration sense, diminished ankle reflexes)

Question 216

What can systemic blastomycosis cause? Where is it found?

Answer 216

found in Great Lakes, Mississippi River, and Ohio river basins (Wisconsin); systemic blastomycosis may cause characterizes ulcerated skin lesions and lytic bone lesions

Question 217

what do you expect to see on peripheral smear of someone with CMV?

Answer 217

atypical lymphocytes

Question 218

acute transverse myelitis path, pt, dx, and tx

Answer 218

path: infiltration of inflammatory cells into a segment of the spinal cord, leading to neuron and oligodendrocyte cell death and demyelination; most cases follow a recent infection but it's also associated with MS and systemic disease (sarcoidosis); MC in teens and those age 30-40 Pt: inflammation localizes to >/= 1 contiguous spinal cord segments, leading to rapidly progressive myelopathy characterized by: 1. motor weakness that progresses from flaccid to spastic paraparesis with UMNS 2. autonomic dysfunction including bowel/bladder incontinence or retention and sexual dysfunction 3. sensory dysfunction including pain, paresthesia, or numbness with a distinct sensory level Dx: MRI shows enhancement of the affected cord segments without evidence of compression Lumbar puncture: CSF pleocytosis and elevated IgG Tx: high dose IV glucocorticoids

Question 219

What symptoms are typical of cauda equina?

Answer 219

associated with severe back pain and sensory loss that involves the thighs and buttocks

Question 220

How is diverticulitis complicated by abscess treated?

Answer 220

- fluid collection < 3 cm can be treated with IV Abx and observation with surgery reserved for patients with worsening sx - fluid collection >/= 3 cm should receive Abx and have Ct-guided percutaneous drainage; if the sx are not controlled within a few days, surgical drainage and debridement are recommended

Question 221

pituitary apoplexy path and pt

Answer 221

path: sudden hemorrhage into an enlarged pituitary adenoma (prolactinoma) Pt: sudden onset, severe HA as well as visual disturbances (diplopia, bitemporal hemianopsia) and eye dysfunction (ptosis); loss of all pituitary function; in the acute setting the loss of ACTH is most important and can lead to adrenal crisis

Question 222

What bruises are suspicious of abuse?

Answer 222

patterned (belt buckle, hand) or located on the neck, ear, torso, and buttocks

Question 223

retinal detachment path, pt, dx, tx

Answer 223

path: separation of the layers of the retina; age 40-70; inciting event usually occurs months before retinal detachment pt: photo-Dia (flashes of light) and floaters (spots in the visual filed), sometimes a "curtain coming down over my eyes" Dx: ophthalmoscopic exam revels a grey, elevated retina Tx: laser therapy and cryotherapy

Question 224

How does central retinal artery occlusion differ from retinal detachment in regards to the ophthalmoscopic exam?

Answer 224

central retinal artery occlusion = pallor of the optic disc, cherry red fovea, and boxcar segmentation of blood int the retinal veins retinal detachment - grey, elevated retina

Question 225

What CSF finding would you expect in a patient with suicidal behavior?

Answer 225

low levels of 5-HIAA (primary metabolite of serotonin)

Question 226

diffuse 3-Hz spike and wave pattern on EEG - Dx?

Answer 226

characteristic of childhood absence seizures

Question 227

generalized slowing with periodic sharp wave complexes on EEG and increased CSF 14-3-3 protein. - Dx?

Answer 227

Creutzfeldt-Jakob disease (progressive dementia, myoclonus, pyramidal/extrapyramidal dysfunction, mutism)

Question 228

low concentration of hypocretin (orexin) int he CSF is found in what disorder?

Answer 228

narcolepsy

Question 229

analgesic nephropathy path + pt

Answer 229

path: most common form of drug-induced chronic renal failure; most commonly seen in females (age 50-55 yo) who habitually use combined analgesics (aspirin + naproxen); generally seen after cumulative ingestion of 4.4-6.6lbs of the drug; papillary necrosis and chronic tuluointerstitial nephritis are the most common paths seen Pt: polyuria, sterile pyuria with WBC casts; HTN, mild proteinuria, and impaired urinary concentration can occur as disease advances

Question 230

right ventricular mI

Answer 230

Pt: RV failure leads to decreased preload and resultant hypotension, ST-segment elevation in inferior leads II, III, ave, JVD, Kussmaul's sign (increase in JVD with inspiration), clear lung fields Dx: confirmed with >/= 1mm ST-segmenet elevation in right-sided precordial leads V4R-V6R tx: treated with IVF boluses to improve RV preload and facilitate LV filling

Question 231

What anti-hypertensive commonly causes peripheral edema?

Answer 231

CCB - likely related to preferential dilation of precapillary vessels, which leads to increased capillary hydrostatic pressure and fluid extravasation into the interstitium (other side effects include HA, flushing, and dizziness)

Question 232

Pt, PE, Dx, and Tx of fibromuscular dysplasia

Answer 232

``` Pt: 90% women Internal carotid artery stenosis: - recurrent HA -pulsatile tinnitus -TIA -stroke Renal artery stenosis - secondary HTN - flank pain PE: sub auricular systolic bruit, abdominal bruit Dx: imaging preferred (duplex u/s, CTA, MRA), catheter-based arteriography Tx: antihypertensives (ACE inhibitors or ARBs 1st line), PTA (percutaneous transluminal angioplasty), surgery (if PTA unsuccessful) ```

Question 233

tachycardia, HTN, sweating, anxiety, neuropathy (weakness, numbness) and severe abdominal pain - Dx?

Answer 233

acute intermittent porphyria

Question 234

dermatitis herpetiformis Pt, skin biopsy, immunofluorescence, associated disease, and Tx

Answer 234

Pt: intensely pruritic erythematous papules, vesicles, and bullae symmetrically grouped on extensor surfaces of elbows, knees, back and buttocks Skin biopsy: sub epidermal micro abscesses at the tips of the dermal papillae Immunofluroescence: deposits of anti-epidermal transgluatminase IgA in the dermis associated with celiac disease Tx: dapsone + gluten free diet

Question 235

urethras diverticula

Answer 235

Path: recurrent periurethral gland infections that develop into an abscess that breaches the urethral mucosa -> tender anterior vaginal wall mass that can cause dyspareunia; can also have purulent discharge, dysuria, and postpaid dribbling Dx: MRI Tx: surgical excision

Question 236

Pt, pediatric etiologies, adult etiologies of nephrotic syndrome

Answer 236

Pt: edema, fatigue, proteinuria, absence of hematuria, hypoalbuminemia Peds: minimal change disease Adults: FSGS, membranous nephropathy, membranoproliferative glomerulonephritis

Question 237

Pt, pediatric etiologies, adult etiologies of nephritic syndrome

Answer 237

Pt: HTN, oliguria, hematuria, proteinuria, casts Peds: poststreptococcal glomerulonephritis, HUS adults: IgA nephropathy, membranoproliferazive glomerulonephritis, crescentic glomerulonephritis`

Question 238

What is a significant risk factor for the development of membranous nephropathy? What labs would you expect?

Answer 238

hepB (can occur in children also); 24-hour urine sample with protein excretion >3g/day, and low serum C3

Question 239

lower back radiucalr pain plus: - motor deficits in the affected dermatome; reflex responses in the knee or ankle often absent - patchy sensory loss in the affected dermatomes; saddle anesthesia - rectal spinster, bladder, and/or sexual dysfunction Dx?

Answer 239

cauda equina syndrome either due to lumbar disc herniation (L4-S1) or epidural tumors (metastatic squamous cell lung cancer), epidural abscess, or inflammatory diseases in the region (sarcoidosis)

Question 240

Pt of pyromania

Answer 240

deliberate fire setting > 1 occasion fascination with fire tension/arousal prior to act; pleasure/relief when setting/witnessing fires no external motivation (financial gain, political statement, recognition)

Question 241

Complications, maternal management, and prevention of vertical transmission of hep C in pregnancy?

Answer 241

Complications: gestational diabetes, cholestasis of pregnancy, preterm delivery Maternal management: - ribavirin is teratogenic and should be avoided - no indication for barrier protection in serodiscordant, monogamous couples - hep A and B vaccination Prevention of vertical transmission: - vertical transmission strongly associated with maternal viral load - C-section not protective - breastfeeding should be encouraged unless maternal blood present (nipple injury)

Question 242

Pt and biopsy of seborrheic dermatoses

Answer 242

Pt: velvety or greasy surface and well-demarcated border, stuck on appearance; benign although sudden onset of multiple SKs may indicate an occult internal malignancy (Leser-Trelat sign) Biopsy: (not necessary) will show small cells resembling basal cells with variable pigmentation, hyperkeratosis, and keratin-containing cysts

Question 243

What are the indications for endometrial biopsy based on age?

Answer 243

age >/=45 = abnormal uterine bleeding, postmenopausal bleeding age <45 = abnormal uterine bleeding PLUS: - unopposed estrogen (obesity, an ovulation) - failed medical management - Lynch syndrome (hereditary nonpolyposis colorectal cancer) Age >/=35 = Atypical glandular cells on Pap test

Question 244

Risk factors, Pt, Imaging, and management of sigmoid volvulus

Answer 244

Risk factors: sigmoid colon redundancy (dilation/elongation from chronic constipation), colonic dysmotility (underlying neurologic disorder) Pt: slowly progressive abdominal discomfort/distension +/- obstructive symptoms (nausea, emesis, obstipation), abdomen distended + tympanic to percussion Imaging: X-ray: dilated, inverted, U-shaped loop of colon (coffee bean sign) CT scan: dilated sigmoid colon, mesenteric twisting (whirl sign) Management: endoscopic detorsion (flexible sigmoidoscopy) + elective sigmoid colectomy; emergency sigmoid colectomy if perforation/peritonitis present

Question 245

What is the first step in management of a neonate with bilious emesis?

Answer 245

stop feeds NG tube decompression IV fluids X-ray

Question 246

If the abdominal X-ray of a neonate with bilious emesis shows free are, hematemesis, or unstable vital signs, what is the next step?

Answer 246

surgery

Question 247

If the abdominal X-ray of a neonate with bilious emesis shows dilated loops of bowel, what is the next step? What are the possible outcomes of the next step?

Answer 247

contrast enema microcolon -> meconium ileus rectosigmoid transition zone -> Hirschsprung disease

Question 248

If the abdominal X-ray of a neonate with bilious emesis shows the NG tube misplaced int he duodenum, what is the next step? What is the possible outcome of this next step?

Answer 248

Upper GI series -> ligament of Treitz on the right side of the abdomen -> malrotation

Question 249

If the abdominal X-ray of a neonate with bilious emesis shows double bubble sign, what is the dx?

Answer 249

duodenal atresia

Question 250

What is the effect on PPV and NPV as prevalence of a particular disease increases in a population?

Answer 250

PPV increases, NPV decreases

Question 251

What is the effect on PPV and NPV as prevalence of a particular disease increases in a population?

Answer 251

PPV decreases | NPV increases

Question 252

Path, Pt, Dx, and Tx of lung abscess

Answer 252

Path: aspiration of oropharyngeal/gingival anaerobes - risk factors: dysphagia, substance abuse, seizures - Pneumonitis -> pneumonia -> abscess/empyema Pt: subacute fever, night sweats, weight loss; cough with putrid sputum Dx: cavitary infiltrates with air-fluid levels, cultures rarely useful Tx: amicillin-sulbactam, imipenem, meropenem Alternate: clindamycin

Question 253

What are the likely causative organisms of deep infections following puncture wounds? What is the treatment?

Answer 253

Stap aureus and Pseudomonas (pseudomonas especially after puncture wounds through the sole of a shoe); Tx = IV Abx (ciprofloxacin, pipperacilin-tazobactam) and surgical debridement

Question 254

What does diffuse uptake of radioactive iodine indicate?

Answer 254

Graves disease

Question 255

What does a nodular pattern of radioactive iodine indicate?

Answer 255

toxic adenoma, multinodular goiter

Question 256

What is the next step in workup with low radioactive iodine uptake? What are the possible outcomes?

Answer 256

measure serum thyroglobulin; high -> thyroiditis or iodine exposure low -> exogenous hormone

Question 257

What factors make a pancreatic cyst concerning for malignancy?

Answer 257

large size (>/=3cm) solid components or calcifications main pancreatic duct involvement (ductal dilation) thickened or irregular cyst wall

Question 258

How does cryptococcus neoformans cause increased ICP? What symptoms are associated?

Answer 258

replicates in the CNS and clogs the arachnoid villi with yeast components, leading to CSF outflow obstruction and increased ICP -> progressive HA, N/V, confusion, 6th cranial nerve invovlement with lateral gaze palsy and diplopia (patients also frequently have fever, malaise, and umbilicate skin lesions that resemble molluscum contagiosum)

Question 259

What are the AIDS-defining malignancies and their cause?

Answer 259

Kaposi sarcoma (HHV8) Invasive cervical carcinoma (HPV) Non-Hodgkin lymphoma (EBV) Primary CNS lymphoma (EBV)

Question 260

Elevated PT and/or PTT, 1:1 inhibitor mixing study results in normal PT and/or PTT -> etiologies??

Answer 260

factor deficiency, evaluate for individual factor assays

Question 261

Elevated PT and/or PTT, 1:1 inhibitor mixing study does not correct PT and/or PTT -> etiologies??

Answer 261

inhibitor likely present; test for coagulation factor inhibitors

Question 262

Pt and management of keratoacanthoma

Answer 262

Pt: rapidly growing nodule with ulceration + keratin plug; often shows spontaneous regression/resolution Management: excisional biopsy with complete removal of lesion **may resemble or progress to squamous cell carcinoma

Question 263

Risk factors, path, and Pt of struvite stones

Answer 263

Risk factors: recurrent upper URI; urease-producting organisms (Klebsiella, Proteus); stones made of magnesium ammonium phosphate) Path: hydrolysis of urea to yield ammonia, increased urine pH, precipitation of magnesium ammonium phosphate salts Pt: large staghorn calculi; fever, mild flank pain due to infection; obstruction of collecting system and atrophy of renal parenchyma

Question 264

Mechanism and causes of normal anion gap metabolic acidosis

Answer 264

Mechanism: loss of bicarb Causes: severe diarrhea, renal tubular acidosis, excess saline infusion, intestinal or pancreatic fistula, carbonic anhydrase inhibitor + mineralocorticoid receptor antagonist diuretic

Question 265

Renal tubular acidosis type 1

Answer 265

(distal) Path: impaired H+ excretion by alpha-intercalated cells in the distal tubule Pt: hypokalemia due to reduced K+ reabsorption, urine pH >5.5

Question 266

Renal tubular acidosis type 2

Answer 266

(proximal) Path: impaired HCO3- reabsorption in the proximal tubule Pt: hypokalemia, variable urine pH usually <5.5

Question 267

Renal tubular acidosis type 4

Answer 267

Path: reduced aldosterone activity leading to impaired H+ and K+ excretion in the collecting duct Pt: hyperkalemia, urine PH <5.5

Question 268

What two tests are required for dx of ectopic pregnancy?

Answer 268

pregnancy test and transvaginal u/s

Question 269

What medications should be avoided with G6PD deficiency?

Answer 269

dapsone, isobutylene nitrite, nitrofurantoin, primaquine, rasburicase

Question 270

Drug names, MOA, indications, and adverse effects of selective estrogen receptors modulators (SERMs)

Answer 270

Drug names: tamoxifen, raloxifene MOA: competitive inhibitor of estrogen binding; mixed agonist/antagonist action Indications: 1. prevention of breast cancer in high-risk patients 2. Tamoxifen: adjuvant treatment of breast cancer 3. Raloxifene: postmenopausal osteoporosis Adverse effects: hot flashes, venous thromboembolism, endometrial hyperplasia + carcinoma (tamoxifen only)

Question 271

What are the symptoms and cause of refeeding syndrome?

Answer 271

Pt: arrhythmia, CHF (pulmonary edema, peripheral edema), seizures, Wernicke encephalopathy Cause: increased insulin

Question 272

What nerve can be injured in a Colles fracture, and what effect does that have?

Answer 272

colles fracture (dorsal displacement of the radius) can result in compression of the median nerve, which provides sensation to the lateral 3 1/2 digits and motor innervation tot he thenar muscles

Question 273

What is the first step in management of a fetus with recurrent variable decelerations? What is the next step?

Answer 273

intrauterine resuscitation with maternal repositioning (left lateral, all fours), which may reduce cord compression and improve fetal-placental blood flow; if this does not improve the variable decelerations, an amnioinfusion can be administered

Question 274

What is the normal findings of the amniotic fluid volume component of the biophysical profile?

Answer 274

single fluid pocket >/= 2 x 1 cm or amniotic fluid index > 5

Question 275

What is the normal findings of the fetal movements component of the biophysical profile?

Answer 275

>= 3 general body movements

Question 276

What is the normal findings of the fetal tone component of the biophysical profile?

Answer 276

>/= 1 episodes of flexion/extension of fetal limbs or spine

Question 277

What is the normal findings of the fetal breathing movements component of the biophysical profile?

Answer 277

>/= 1 breathing episode for >/= 30 seconds

Question 278

Path, Pt, Labs, and Prevention of infantile vitamin K-deficient bleeding

Answer 278

Path: low vitamin K stores (poor placental transfer, sterile gut, low content in breast milk), inefficient vitamin K use by immature liver Pt: classically presents on day 2-7 of life with easy bruising, umbilical, mucosal + GI bleeding, intracranial hemorrhage Labs: increased PT, increased PTT (if severe), normal platelet count Prevention: intramuscular vitamin K at birth

Question 279

Path, pt, and tx of lymphangitis

Answer 279

Path: cutaneous injury -> pathogen invasion of lymphatics in deep dermis; strep progenies + MSSA Pt: tender, erythematous streaks proximal to wound; regional tender LAD; systemic symptoms (fever, tachycardia) Tx: cephalexin

Question 280

Risk factors, Pt, and management of biosphosphonate-related osteonecrosis of the jaw

Answer 280

Risk factors: high-dose, parenteral bisphosphonates; dental procedures (extractions, implants), concurrent glucocorticoid use, concurrent or previous malignancy Pt: chronic, indolent symptoms; mild pain, swelling; exposed bone, loosening of teeth, pathologic fractures Management: oral hygiene, antibacterial rinses, Abx and debridement as needed

Question 281

Path, Pt, and management of primary varicocele

Answer 281

Path: compression of left renal vein between SMA and aorta; incompetent venous valves Pt: "bag of worms" mass, pubertal onset, left-sided, decompresses when supine Management: reassurance and observation

Question 282

Path, Pt, and management of secondary varicocele

Answer 282

Path: extrinsic compression (renal or retroperitoneal mass) of IVC; venous thrombus Pt: "bag of worms" mass, prepubertal onset, right-sided, persists when supine Management: abdominal u/s

Question 283

What are structural causes of recurrent pregnancy loss?

Answer 283

uterine: fibroids, adhesions, polyps | cervical insufficiency

Question 284

What are the chromosomal causes of recurrent pregnancy loss?

Answer 284

aneuploidy, translocations/rearrangements, mosaicism

Question 285

What are the immunologic/hematologic causes of recurrent pregnancy loss?

Answer 285

hypercoagulable disorders (antiphospholipid syndrome), alloimmune intolerance

Question 286

What are the endocrine causes of recurrent pregnancy loss?

Answer 286

thyroid disease, PCOS, DM, hyperprolactinemia

Question 287

What is the pt of renal parenchymal disease as a cause of HTN

Answer 287

``` elevated serum Cr abnormal urinalysis (proteinuria, RBC casts) ```

Question 288

What is the pt of renovascular disease as a cause of HTN

Answer 288

severe HTN with onset after age 55 recurrent flash pulmonary edema rise in serum Cr abdominal bruit

Question 289

What is the pt of primary aldosteronism as a cause of HTN

Answer 289

spontaneous or easily provoked hypokalemia

Question 290

What is the pt of pheochromocytoma as a cause of HTN

Answer 290

paroxysmal HTN with tachycardia | pounding HA, palpitations, diaphoresis

Question 291

What is the pt of Cushing syndrome as a cause of HTN

Answer 291

cushingoid body habitus proximal muscle weakness hyperglycemia

Question 292

What is the pt of primary hyperparathyroidism as a cause of HTN

Answer 292

hypercalcemia, kidney stones, neuropsych sx

Question 293

What is the pt of coarctation of the aorta as a case of HTN

Answer 293

lateralizing HTN, brachial-femoral pulse delay

Question 294

Path, Pt, Labs, Imaging, and Tx of Paget disease of the bone

Answer 294

Path: osteoclast dysfunction, increased bone turnover Pt: most asymptomatic; bone pain and deformity: skull: HA, hearing loss spine: spinal stenosis, radiculoapthy long bones: bowing, fracture, arthritis of adjacent joints giant cell tumor, osteosarcoma Labs: elevated alkaline phosphatase, elevated bone turnover markers (PINP, urine hydroxyproline), calcium + phosphorus are usually normal Imaging: X-ray: osteolytic or mixed lytic/sclerotic lesions bone scan: focal increase in uptake Tx: bisphosphonates

Question 295

Whipple disease path, pt, and biopsy

Answer 295

Path: tropheryma whippelii; MC in men in the fourth-to-sixth decades of life Pt: WL, abdominal pain, diarrhea, and malabsorption with distension, flatulence, and steatorrhea; migratory polyarthropathy, chronic cough, myocardial or valvular involvement leading to CHF or valvular regurgitation Later stages characterized by dementia, supranuclear ophthalmoplegia, and myoclonus; intermittent low grade fever, pigmentation, and LAD Biopsy: PAS-positive material in the lamina propria of the small intestine

Question 296

What neurologic findings would you expect in a patient with major depressive disorder?

Answer 296

increased cortisol, decreased hippocampal and frontal lobe volumes, decreased REM sleep latency and decreased slow-wave sleep

Question 297

Triggers, Pt, Dx, and management of complex regional pain syndrome

Answer 297

Triggers: trauma: fracture, sprain; surgery Pt: pain: severe, regional (not dermatomal), burning/stinging edema, abnormal sweating vasomotor changes, altered skin temp trophic skin, hair + nail changes Dx: primarily based on clinical features; X-ray: patchy demineralization; bone scintigraphy: increased uptake in affected limb Management: physical + occupational therapy, exercise Meds: NSAIDs, antineuropathic medications (pregabalin, TCAs)

Question 298

What do you expect to find on PE of aortic regurgitation?

Answer 298

1. early diastolic mumur 2. bounding pulse/"water hammer" pulse (because AR is associated with an increased stroke volume, which produces an abrupt rise in the SBP and rapid distension of the peripheral arteries)

Question 299

What is pulsus paradoxus and what condition do you expect to see it in?

Answer 299

refers to a fall in the systemic arterial pressure by more than 10 mmHg during inspiration, and is often associated with cardiac tamponade

Question 300

What are the causes of pleuritic chest pain?

Answer 300

costochondritis, pericarditis, malignancy, infection (pneumonia), PE

Question 301

dyspnea, tachycardia, tachypnea, U/L LE edema, pleural effusion, low-grade fever, and troponin elevations - Dx?

Answer 301

PE

Question 302

Pt and Tx of nonallergic rhinitis

Answer 302

Pt: - nasal congestion, rhinorrhea, sneezing, postnasal drainage - later onset common (age >20) - no obvious allergic trigger - perennial symptoms (may worsen with season changes) - erythematous nasal mucosa Tx: mild: intranasal antihistamine or glucocorticoids moderate or severe: combination therapy

Question 303

Pt and Tx of allergic rhinitis

Answer 303

Pt: - watery rhinorrhea, sneezing, eye symptoms - earlier age of onset - identifiable allergen or seasonal pattern - pale/bluish nasal mucosa - associated with other allergic disorders (eczema, asthma, eustachian dysfunction) Tx: intranasal glucocorticoids, antihistamines

Question 304

Definition, Pt, and Tx of nonalcoholic fatty liver disease

Answer 304

Definitino: hepatic steatosis on imaging or biopsy, exclusion of significant alcohol use, exclusion of other causes of fatty liver Pt: mostly asymptomatic, metabolic syndrome, +/- steatohepatitis (AST/ALT ratio <1), hyper echoic texture on u/s Tx: diet + exercise, consider bariatric surgery if BMI >/= 35

Question 305

cholesterol emboli presentation

Answer 305

skin: livedo reticular (reticulated, mottled, discolored skin), blue toe syndrome kidney: acute kidney injjry GI: pancreatitis, mesenteric ischemia

Question 306

Pt, Tx, and complications of nasal foreign body

Answer 306

Pt: inorganic substance: asymptomatic, mild pain/discomfort organic substance: unilateral, foul-smelling, purulent discharge button battery: epistaxis, purulent discharge Tx: positive pressure (patient exhalation with unaffected nares occluded), mechanical extraction Complications: infection (sinusitis), local irritation, aspiration into airway, nasal septal perforation (with button battery or multiple magnet insertion)

Question 307

Pt and Tx of preseptal cellulitis

Answer 307

Pt: eyelid erythema + swelling, chemoses Tx: oral Abx

Question 308

Pt and Tx of orbital cellulitis

Answer 308

Pt: symptoms of preseptal cellulitis PLUS pain with EOM, proptosis +/or ophthalmoplegia with diplopia Tx: IV Abx +/- surgery

Question 309

week of headaches, dizziness, blurry vision with a large gamma gap and "sausage-link" retinal changes - Dx?

Answer 309

Waldenstrom macroglobulinemia; gamma gap = difference between total protein and albumin

Question 310

Pt and X-ray findings of SBO

Answer 310

Pt: N/V, obstipation, acute abdomen, hyperactive or absent bowel sounds X-ray: air fluid levels, dilated proximal bowel, collapsed distal bowel, little/no air in colon/rectum

Question 311

Pt and X-ray findings of ileus

Answer 311

Pt: N +/- vomiting, no flatus, abdominal distension, decreased or absent bowel sounds X-ray: no transition point, dilated loops of bowel, air in colon/rectum

Question 312

What is the effect of vagal maneuvers on the heart?

Answer 312

Vagal maneuvers (carotid sinus massage, cold-water immersion or diving reflex, Valsalva maneuver, eyeball pressure) increase parasympathetic tone in the heart and result in temporary slowing of the AV node and an increase in the AV node refractory period, leading to termination of AVNRT

Question 313

autonomic dysreflexia path, pt

Answer 313

path: potentially life-threatening complication of spinal cord injury Pt; severe HTN, HA, diaphoresis, flushing, and bradycardia in the setting of urinary retention

Question 314

In which scenarios is a trial of labor contraindicated?

Answer 314

hx of classical cesarean delivery (vertical incision) and hx of abdominal myomectomy with uterine cavity entry

Question 315

Path, Pt, Labs, and Tx of folate deficiency anemia

Answer 315

Path: chronic hemolysis (sickle cell dz), poor dietary intake, malabsorption (gastric bypass), medications (methotrexate, phenytoin) Pt: dyspnea, fatigue, pallor, weakness Labs: microcytic anemia, poor reticulocyte response (low to normal), hyperhsegmented neutrophils, low serum folate Tx: folic acid supplementation

Question 316

Screening for, serologic tests, Tx, pregnancy effects, and fetal effects of syphilis infection in pregnancy

Answer 316

Screening: universal at first prenatal visit; third trimester + delivery if high risk Serologic tests: nontreponemal (RPR, VDRL), treponemal (FTA-ABS) Tx: intramuscular penicillin G benzathine Pregnancy effects: intrauterine fetal Demis, preterm labor Fetal effects: hepatic (hepatomegaly, jaundice), hematologic (hemolytic anemia, decreased platelets), MSK (long bone abnormalities), failure to thrive

Question 317

hyponatremia with serum osmolality >290 is caused by what?

Answer 317

makred hyperglycemia or advanced renal failure

Question 318

hyponatremia with serum osmolality <290 and urine osmolality < 100 is caused by what?

Answer 318

primary polydipsia or malnutrition (beer drinker's potomania)

Question 319

hyponatremia with serum osmolality >290, urine osmolality >100, and urine sodium >25 is caused by what?

Answer 319

SIADH, adrenal insufficiency, hypothyroidism

Question 320

hyponatremia with serum osmolality >290, urine osmolality >100, and urine sodium <25 is caused by what?

Answer 320

volume depleition, CHF, cirrhosis

Question 321

Pt, Dx, and Tx of crohn's disease

Answer 321

Pt: GI: abdominal pain, non bloody diarrhea, oral ulcers, malabsorption, weight loss, fistula/abscess formation Extraintestinal: MSK (arthritis), eye (uveitis, scleritis, episcleritis), skin (erythema nodosum, pyoderma gangrenosum) Dx: increased WBC, IDA, increased inflammatory markers Endoscopy: focal ulcerations adjacent to normal mucosa (cobblestoning), skip areas of disease Radiography: strictures, bowel wall thickening Tx: 5-ASA drugs, corticosteroids, Abx; azathioprine; anti-TNF therapies

Question 322

fever, RUQ pain, leukocytosis, elevated liver enzymes with a rounded, hypoattenuating lesion in the liver - Dx? Tx?

Answer 322

pyogenic liver abscess; percuatneous aspiration and drainage = Dx and Tx

Question 323

episodic pounding sensation, chronic diarrhea, WL, valvular heart disease with tricuspid regurgitation - Dx?

Answer 323

carcinoid syndrome

Question 324

gross motor, fine motor, language, and social/cognitive developmental milestones at 2 months old

Answer 324

gross motor: lifts head/chest in prone position fine motor: hands unlisted 50% of the time; tracks past midline Language: alerts to voice/sound, coos Social/cognitive: social smile, recognizes parents

Question 325

gross motor, fine motor, language, and social/cognitive developmental milestones at 4 months old

Answer 325

Gross motor: sits with trunk support, begins rolling Fine motor: hands mostly open, reaches midline Language: laughs, turns to voice Social/cognitive: enjoys looking around

Question 326

gross motor, fine motor, language, and social/cognitive developmental milestones at 6 months old

Answer 326

Gross motor: sits momentarily propped on hands (unsupported by 7 months) Fine motor: transfers objects hand to hand, raking grasp Language: responds to name, babbles Social/cognitive: stranger anxiety

Question 327

gross motor, fine motor, language, and social/cognitive developmental milestones at 9 months old

Answer 327

Gross motor: pulls to stand, cruises Fine motor: 3-finger pincer grasp; holds bottle or cup Language: says "dada" "mama" Social/cognitive: waves "bye," plays "pat-a-cake"

Question 328

gross motor, fine motor, language, and social/cognitive developmental milestones at 12 months old

Answer 328

Gross motor: stands well, walks first steps independently, throws ball Fine motor: 2-finger pincer grasp Language: says first word other than "dada" and "mama" Social/cognitive: separation anxiety, comes when called

Question 329

Timing, path, and Pt of breastfeeding jaundice

Answer 329

Timing: first week of life Path: insufficient intake of breast milk resulting in: decreased bilirubin elimination, increased enterohepatic circulation Pt: suboptimal breastfeeding, signs of dehydration

Question 330

Timing, path, and pt of breast milk jaundice

Answer 330

Timing: starts at age 3-5 days; peaks at 2 weeks Path: high levels of beta-glucuronidase in breast milk deconjugate intestinal bilirubin + increase enterohepatic circulation Pt: adequate breastfeeding, normal examination

Question 331

What do you expect to see on x-ray of a retropharyngeal abscess?

Answer 331

widening of the prevertebral soft-tissue space

Question 332

MOA, indication, and adverse effect of succinylcholine

Answer 332

MOA - binds postsynaptic ACh receptors to trigger influx of sodium ions and efflux of potassium ions through ligand-gated channels -> temporary paralysis Indications: used during rapid-sequence intubation Adverse effects: life-threatening arrhythmia due to severe hyperkalemia

Question 333

What is the diagnostic criteria for antiphopholipid Ab syndrome?

Answer 333

(1 clinical and 1 laboratory criteria must be met) Clinical: 1. vascular thrombosis (arterial or venous) 2. pregnancy morbidity - >/=3 consecutive, unexplained fetal losses before 10th week - >/= 1 unexplained fetal loss after 10th week - >/= 1 premature birth of normal neonate befrore 34th week due to preeclampsia, eclampsia, placental insufficiency Laboratory: 1. lupus anticoagulant 2. anticardiolipid Ab 3. Anti-beta-2 glycoprotein Ab

Question 334

Path, pt, and management of acute limb ischemia

Answer 334

Path: cardiac/arterial embolus (AF, LV thrombus, IE), arterial thrombosis (PAD), iatrogenic/blunt trauma Pt: 6 P's of acute limb ischemia: pain, pallor, paresthesia, pulselessness, poikilothermic (cool extremity), paralysis (late) Management: anticoagulation (heparin), thrombolysis vs surgery

Question 335

Path, pt, dx, and management of guillan-barre syndrome

Answer 335

Path: immune-mediated demyelinating polyneuropathy; preceding GI (Campylobacter) or respiratory infection pt: paresthesia, neuropathic pain; symmetric, ascending weakness, decreased/absent DTR, autonomic dysfunction (arrhythmia, ileus), respiratory compromise Dx: clinical, supportive findings: CSF fluid: increased protein, normal leukocytes; abnormal electromyography + nerve conduction Management: monitoring of autonomic + respiratory function; IV immunoglobulin or plasmapheresis

Question 336

What are the risk factors of acute urinary retention? How is the dx confirmed?

Answer 336

1. male sex 2. advanced age 3. history of BPH 4. history of neurologic disease 5. surgery Dx confirmed by bladder u/s that shows >/= 300 mL of urine

Question 337

sudden-onset, severe, unilateral lower abdominal pain immediately following strenuous or sexual activity with pelvic free fluid - Dx?

Answer 337

ruptured ovarian cyst

Question 338

vesicovaginal fistula pt, dx, and tx

Answer 338

Pt: continuous vaginal discharge with abnormally elevated pH (>4.5) due to urine; pelvic exam shows vaginal pooling of urine, a visible defect, or an area of raised, red granulation tissue on the anterior vaginal wall Dx: bladder dye testing Tx: surgical repair

Question 339

What is the mechanism of anemia in chronic lymphocytic leukemia?

Answer 339

IgG autoantibodies against the erythrocyte membrane (warm agglutinins) -> immune-mediated hemolysis (autoimmune hemolytic anemia)

Question 340

What is the lung cancer screening recommendation?

Answer 340

annual low-dose chest CT in patients age 55-80 with a >/=30 pack year smoking history (who are currently smoking or quit within the last 15 years)

Question 341

Pt, Dx, and prognosis of IgA nephropathy

Answer 341

Pt: usually within 5 days of URI, more common in men age 20-30, recurrent gross hematuria Dx: normal serum complements, mesangial IgA deposits seen in kidney biopsy Prognosis: usually benign, possible radially progressive glomerulonephritis or nephrotic syndrome with worse prognosis

Question 342

Pt, Dx, and prognosis of postinfectious glomerulonephritis

Answer 342

Pt: usually 10-21 days after URI, more common in children age 6-10 but can occur in adults, gross hematuria, adults can be asymptomatic or develop acute nephritic syndrome Dx: low C3 complement, elevated antistreprtolysin O and/or anti-DNase B, kidney biopsy with sub epithelial humps consisting of C3 complement Prognosis: good prognosis in children, possible chronic kidney disease in adults

Question 343

Risk factors, Pt, Dx, and Tx of entamoeba histolytica

Answer 343

Risk factors; developing nations (travel/residence), contaminated food/water, fecal-oral, STI Pt: 90% asymptomatic, colitis (diarrhea, bloody stool with mucus, abdominal pain), liver abscess (RUQ pain, fever) (complications: rupture to pleura/peritoneum) Dx: stool ova + parasites, stool Ag testing (colitis); e histolytica serology (liver abscess) Tx: metronidazole + intraluminoal Abx (paromomycin)

Question 344

What does CXR of histoplasmosis capsulatum usually show?

Answer 344

lobar pulmonary infiltrate and hilar/mediastinal LAD; cavitation rarely occurs

Question 345

Tx of comedonal acne

Answer 345

topical retinoids, salicylic, azelaic, or glycolic acid

Question 346

Tx of inflammatory acne

Answer 346

mild: topical retinoids + benzoyl peroxide moderate: add topical Abx (erythromycin, clindamycin) severe: add oral Abx

Question 347

Tx of nodular (cystic) acne

Answer 347

moderate: topical retinoid + benzoyl peroxide + topical Abx Severe: add oral Abx Unresponsive severe: oral isotretinoin

Question 348

graft-versus-host disease pt

Answer 348

pt: maculopapular rash involving palms, soles, and face, blood-positive diarrhea, abnormal liver function tests and jaundice

Question 349

ear pain, facial weakness, vesicular rash in the external auditory canal - dx?

Answer 349

herpes zoster optics (Ramsay Hunt syndrome)

Question 350

What drugs decrease levothyroxine absorption?

Answer 350

1. bile acid binding agents (cholestyramine) 2. iron, calcium, aluminum hydroxide 3. proton pump inhibitors, sucralfate

Question 351

What drugs increase TBG concentration?

Answer 351

1. estrogen (oral), tamoxifen, raloxifene | 2. heroin, methadone

Question 352

What drugs decreased TBG concentration?

Answer 352

1. androgens, glucocrtoicoids 2. anabolic steroids 3. slow-release nicotinic acid

Question 353

What drugs increase thyroid hormone metabolism?

Answer 353

1. rifampin 2. phenytoin 3. carbamazepine

Question 354

path and pt of granuloma inguinale (donovanosis)

Answer 354

Path: klebsiella granulomatis Pt: extensive and progressive ulcerative lesions without LAD; base may have granulation-like tissue; deeply staining gram-negative intracytoplasmic cysts (Donovan bodies) not painful initial lesions

Question 355

path and pt of lymphogranuloma venereum

Answer 355

path: chlamydia trachomatis pt: small + shallow ulcers; large, painful, coalesced inguinal lymph nodes intracytoplasmic chlamydial inclusion bodies in epithelial cells + leukocytes not painful initial lesions

Question 356

Pt, Labs, and management of acute fatty liver of pregnancy

Answer 356

Pt: N/V, RUQ/epigastric pain, fulminant liver failure Labs: profound hypoglycemia, increased aminotransferases (2-3x normal), increased bilirubin, thrombocytopenia, DIC management: immediate delivery

Question 357

postoperative endophthalmitis path, pt, tx

Answer 357

Path: usually occurs within 6 weeks of surgery; bacterial or fungal infection within the eye Pt: pain and decreased visual acuity, swollen eyelids and conjunctiva, hypopyon, corneal edema and infection tx: based on severity, intravitreal Abx injection or vitrectomy is done

Question 358

Corneal ulceration pt

Answer 358

foreign body sensation, blurred vision, photophobia, and pain, erythematous eye, ciliary injection; purulent exudates are seen in the conjunctival sac and on the ulcer surface

Question 359

What are the etiologies of exudative effusions?

Answer 359

1. empyema (purulent fluid, neutrophil-predominant, + gram stain/culture) 2. chylothorax (milky white fluid, increased triglycerides) 3. malignancy 4. TB (+ acid fast bacterium stain/culture)

Question 360

neonatal lupus path, pt, ECG, and complications

Answer 360

path: passive placental transfer of maternal anti-SSA (Ro) and anti-SSB (La) Abs Pt: cardiac and cutaneous (scalp or periorbital rash); most serious complication is fetal AV block (18-24 weeks gestation due to irreversible injury to the AV node) Fetal heart tracing: persistent fetal bradycardia (<110/min) Complications: with prolonged complete heart block, cardiomyopathy and hydrops fetalis may develop

Question 361

Path, Pt, and Dx of acute epididymitis

Answer 361

Path: age <35: sexually transmitted (chlamydia, gonorrhea) Age >35: bladder outlet obstruction (coliform bacteria; E. coli) Pt: unilateral, posterior testicular pain, epididymal edema, pain improved with testiclular elevation, dysuria, frequency (with coliform infection) Dx NAAT for chlamydia + gonorrhea; UA/culture

Question 362

What complication are patients with Turner's syndrome at risk of during pregnancy (if they can get pregnancy via IVF)?

Answer 362

aortic dissection

Question 363

Tick removal, prophylaxis criteria, and prophylaxis for Lyme disease prevention

Answer 363

Tick removal: grasp with small forceps as close to skin as possible; pull firmly upwards without twists Prophylaxis criteria: must meet all 5 1. Ixodes scapularis (deer tick) identified 2. Tick attached for >/=36 hours or engorged 3. prophylaxis started within 72 hours of tick removal 4. local Borrelia burgdorferi infection rate >/=20% (New England) 5. No contraindications to doxycycline (pregnancy) Antimicrobial prophylaxis: single-dose doxycycline

Question 364

polyarteritis nodosa

Answer 364

lesions resemnling erythema nodosum, but it is usually associated with systemic (fever, arthralgias, weight loss) and extradermal (renal insufficiency, abdominal pain, mono neuritis multiplex) manifestations

Question 365

Pt and Tx of acute decompensated heart failure

Answer 365

Pt: 1. acute dyspnea, orthopnea, paroxysmal nocturnal dyspnea 2. HTN common; hypotension suggests severe disease 3. Accessory muscle use, tachycardia, tachypnea 4. diffuse crackles with possible wheezes (cardiac asthma) 5. possible S3, JVD, peripheral edema Treatment: Normal or elevated BP with adequate end-organ perfusion: supplemental O2, IV loop diuretic, consider IV vasodilator (nitroglycerin) Hypotension or signs of shock: supplemental O2, IV loop diuretic as appropriate, IV vasopressor (norepinephrine)

Question 366

Risk factor, micro, Pt, and Tx of necrotizing (malignant) otitis externa

Answer 366

Risk factors: age >60, DM, aural irrigation (cerumen removal) Micro: Pseudomonas aeruginosa Pt: 1. severe, unremitting ear pain (worse at night + with chewing) 2. deficits of lower cranial nerves (facial, vagus, accessory) 3. granulation tissue in the external auditory canal 4. elevated ESR Tx: IV antipseudomonal Abx (cipro) +/- surgical debridement

Question 367

how do you calculate attributable risk percent and what is it?

Answer 367

ARP represents the excess risk in a population that can be explained by exposure to a particular risk factor ARP = (risk in exposed - risk in unexposed)/risk in exposed OR ARP = (RR-1)/RR

Question 368

When should immediate endoscopic removal be performed with foreign body inhalation?

Answer 368

1. sharp object (needle, safety pin) in the esophagus, stomach, or proximal duodenum 2. Symptoms of esophageal obstruction (drooling, inability to swallow secretions) 3. Symptoms of respiratory compromise 4. button battery in the esophagus (due to the risk of electrical and chemical injury) 5. Magnets in the esophagus or stomach (due to the potential for bowel entrapments as a result of magnetic attraction across intestinal segments

Question 369

primary defect, urine pH, serum K+, and causes of distal type 1 RTA?

Answer 369

Primary defect: poor hydrogen secretion into urine Urine pH >/= 5.5 serum potassium = low-normal Causes: genetic disorders, medication toxicity, autoimmune disorders (Sjogren syndrome, RA)

Question 370

primary defect, urine pH, serum K+, and causes of proximal type 2 RTA?

Answer 370

Primary defect: poor bicarb resorption Urine pH <5.5 Serum potassium: low-normal Causes: fanconi syndrome (glucosuria, phophaturia, aminoaciduria)

Question 371

primary defect, urine pH, serum K+, and causes of type 4 RTA?

Answer 371

primary defect: aldosterone resistance urine pH: <5.5 serum potassium: high causes: obstructive uropathy, congenital adrenal hyperplasia

Question 372

Path, Pt, Labs, and Tx of polycythemia vera

Answer 372

Path: clonal myeloproliferative disorder due to JAK2 mutation that makes RBC production independent of EPO Pt: increased blood viscosity: HTN, erythromelalgia (burning cyanosis in hands/feet), transient visual disturbances increased RBC turnover (court arthritis), aquagenic pruritus, bleeding facial plethora (ruddy cyanosis), splenomegaly Labs: elevated Hgb, leukocytosis + thrombocytosis, low erythropoietin level, JAK 2 mutation positive Complications: thrombosis, myelofibrosis + acute leukemia Tx: phlebotomy; hydroxyurea (if increased risk of thrombus)

Question 373

duodenal ulcer pt and tx

Answer 373

path: either H. pylori infection or NSAIDs pt: epigastric pain and intermittent melena; pain worse on empty stomach and improves with food Dx: endoscopic biopsy or urea breath test (for H. pylori) Tx: (for H. pylori): antisecretory therapy (PPI) and Abx eradication (amoxicillin plus clarithromycin)

Question 374

SCC arising within a burn wound - Dx?

Answer 374

Marjolin ulcer

Question 375

Renal + urinary changes in normal pregnancy (physiologic and lab findings)

Answer 375

Physiologic changes: increased renal blood flow, increased GFR, increased renal basement membrane permeability Labs: decreased BUN, decreased serum Cr, increased renal protein excretion

Question 376

spontaneous speech, comprehension, repetition, and associated features of Broca aphasia

Answer 376

spontaneous speech: sparse + nonfluent comprehension: relatively preserved repetition: impaired associated features: right hemiparesis (face + upper limb)

Question 377

spontaneous speech, comprehension, repetition, and associated features of Wernicke aphasia

Answer 377

spontaneous speech: fluent + voluminous but lacks meaning comprehension: greatly diminished repetition: impaired associated features: right superior visual field defect

Question 378

spontaneous speech, comprehension, repetition, and associated features of conduction aphasia

Answer 378

spontaneous speech: fluent with phonemic errors comprehension: relatively preserved repetition: very poor associated features: none

Question 379

ecthyma gangrenosum path/pt

Answer 379

path: pseudomonas pt: g=prgress very rapidly from a small erythematous macule to larger, nontender nodules with necrosis

Question 380

subacute bacterial endocarditis

Answer 380

path: occurs in patients with a preexisting valvular defect pt: fevers, new or worsening heart murmur, splinter hemorrhages, Osler nodes, Janeway lesions

Question 381

HSV encephalitis

Answer 381

pt: fever, HA, seizures, confusion and stupor, anosmia, gustatory hallucinations, and bizarre/psychotic behavior Imaging: CT, MR imaging, and EEG demonstrate abnormalities in the frontotemporal region of the brain CSF: nonspecific; classic findings are lymphocytic pleocytosis, elevated protein, elevated RBC count, and normal glucose

Question 382

What type of anticoagulation should those with atrial fibrillation be on?

Answer 382

warfarin or non vitamin K antagonist oral anticoagulants (NOACs) NOACs = rivaroxaban, dabigatran, apixaban, and edoxaban

Question 383

TB effusion characteristics

Answer 383

exudative effusions with high protein levels (always >4), lymphocytic leukocytosis, and low glucose levels (<60)

Question 384

headaches that are worse hwen leaning forward, JVD, facial and UE swelling - Dx?

Answer 384

SVC syndrome

Question 385

Pt and Dx of fibromyalgia

Answer 385

Pt: young to middle-aged women, chronic widespread pain, fatigue, impaired concentration; tenderness at trigger points (mid trapezius, costochondral junction) Dx: >/= 3 months of symptoms with widespread pain index or symptom severity score; normal lab studies

Question 386

Pt and Dx of polymyositis

Answer 386

Pt: proximal muscle weakness (increasing difficulty climbing up stairs); pain mild/absent Dx: elevated muscle enzymes (creatine kinase, aldolase, AST), autoantibodies (ANA, anti-Jo-1); biopsy: endomysial infiltrate, patchy necrosis

Question 387

Pt and dx of polymyalgia rheumatica

Answer 387

Pt: age >50, systemic signs and symptoms, stiffness > pain in shoulders, hip girdle, neck; associated with giant cell (temporal) arteritis Dx: elevated ESR, CRP; rapid improvement with glucocorticoids

Question 388

tx for stable ventricular tachycardia?

Answer 388

amiodarone

Question 389

What is adneosine used to treat?

Answer 389

supraventricular tachycardia

Question 390

precipitating factors, Pt, and Tx of hepatic encephalopathy

Answer 390

precipitating factors: drugs (sedatives, narcotics), hypovolemia (diarrhea), electrolyte changes (hypokalemia), increased nitrogen load (GI bleeding), infection (pneumonia, UTI, SBP), portosystemic shunting (TIPS) Pt: sleep pattern changes, AMS, ataxia, asterixis Tx: correct precipitating causes (fluids, Abx), decreased blood ammonia concentration (lactulose, rifaximin)

Question 391

Acute iron poisoning Pt, Dx, and Tx

Answer 391

Pt: abdominal pain, hematemesis, diarrhea, shock, liver necrosis Dx: anion gap metabolic acidosis, elevated serum iron, radiopaque pills on abdominal x-ray Tx: deferoxamine, whole bowel irrigation

Question 392

What is the difference between CML and CLL?

Answer 392

CML - presents with a marked leukocytosis of predominantly neutrophil (not lymphocyte) lineage; BCR-ABL gene; imatinib for tx CLL - marked leukocytosis of predominantly lymphocyte lineage; smudge cells on flow cytometry; rituximab (monoclonal Abx against CD20) for tx

Question 393

What are the typical causative organisms for sickle cell patients with pneumonia, osteomyelitis/sepctic arthritis, bacteremia/sepsis, and meningitis?

Answer 393

pneumonia: strep pneumoniae osteomyelitis/septic arthritis: staph aureus, salmonella bacteremia/sepsis: strep pneumonia, Hib meningitis: strep pneumoniae

Question 394

What cardiac conditions require bacterial endocarditis prophylaxis?

Answer 394

1. prosthetic heart valve 2. previous infective endocarditis 3. structural valve abnormality in transplanted heart 4. Unrepaired cyanotic congenital heart disease 5. Repaired congenital heart disease with residual defect

Question 395

What procedures are indicated and what is the appropriate coverage for bacterial endocarditis prophylaxis?

Answer 395

1. gingival manipulation or respiratory tract incision -> Viridans group strep coverage (amoxicillin) 2. GU or GI tract procedure in setting of active infection -> Enterococcus coverage (ampicillin) 3. Surgery on infected skin or muscle -> Staph coverage (vancomycin) 4. Surgical placement of prosthetic cardiac material -> Staph coverage (vancomycin)

Question 396

What 3 findings are characteristic of an ASD?

Answer 396

1. wide and fixed splitting of the second heart sound (S2) - due to delayed closure of the pulmonic valve due to the enlarged right ventricle's prolonged emptying 2. mid systolic or ejection murmur over the left upper sternal border - resulting from increased flow across the pulmonic valve 3. mid-diastolic rumble - resulting from increased flow across the tricuspid valve

Question 397

Path, Pt, Dx, Tx, and complications of hypertrophic cardiomyopathy

Answer 397

Path: mutations in sarcomere protein genes (MC), autosomal dominant, variable expressivity/penetrance Pt: asymptomatic or identified by family screening; fatigue, chest pain, palpitations, syncope; systolic ejection murmur exacerbated by dehydration/impaired LV filling Dx: ECG: LVH, repolarization abnormalities TEE: LVH, increased LV outflow tract gradient, systolic anterior motion of mitral valve; exercise testing, family screening Tx: avoidance of volume depletion, BBs/CCBs, surgery if symptoms persist Complications: sudden cardiac death, heart failure, stroke

Question 398

What are the clinical associations of focal segmental glomerulosclerosis?

Answer 398

african american + hispanic ethnicity; obesity; HIV + heroin use

Question 399

What are the clinical associations of membranous nephropathy?

Answer 399

adenocarcinoma (breast, lung); NSAIDs, hepB, SLE

Question 400

What are the clinical associations of membranoproliferative glomerulonephritis?

Answer 400

Hep B + C, lipdystrophy

Question 401

What are the clinical associations of minimal change disease?

Answer 401

NSAIDS, lymphoma

Question 402

What are the clinical associations of IgA nephropathy?

Answer 402

URI

Question 403

What are methods used to prevent future gout attacks?

Answer 403

1. weight loss to achieve BMI <25 2. low-fat diet 3. decreased seafood + red meat intake 4. protein intake preferably from vegetable + low-fat dairy products 5. avoidance of organ-rash foods (liver) 6. avoidance of beer + distilled spirits 7. avoidance of diuretics when possible

Question 404

What are common manifestations of superior pulmonary sulcus tumor?

Answer 404

1. shoulder pain 2. horror syndrome (invasion of paravertebral sympathetic chain/stellate ganglion) 3. neurologic symptoms in the arm (invasion of C8-T2 nerves) -> weakness/atrophy of intrinsic hand muscles; pain/paresthesia of 4th/5th digits + medial arm/forearm 4. supraclavicular LAD 5. weight loss

Question 405

Pt, Dx, and Tx of granulomatosis with polyangiitis

Answer 405

Pt: upper respiratory: sinusitis/otitis, saddle-nose deformity lower respiratory: lung nodules/cavitation renal: rapidly progressive GN skin: livedo reticularis, nonhealing ulcers Dx: ANCA:PR3 (~70%), MPO (~20%) Biopsy: skin (leukocytoclastic vasculitis), kidney (pauci-immune GN), lung (granulomatous vasculitis) Tx: corticosteroids + immunomodulators (MTX, cyclophosphamide)

Question 406

Path, Pt, Dx, and Tx of myelodysplastic syndrome

Answer 406

Path: hematopoietic stem cell neoplasm, increased risk with older age and previous chemo/radiation; may transform to acute leukemia Pt: cytopenias: - anemia: weakness, fatigue - leukopenia: infections - thrombocytopenia: bruising/bleeding HSM/LAD are rare Dx: dysplastic red + WBCs on peripheral smear; bone marrow biopsy (hypercellular marrow) Tx: transfusion for symptomatic cytopenias, chemo, hematopoietic stem cell transplantation

Question 407

In which portion of the adrenal gland are catecholamines made?

Answer 407

adrenal medulla

Question 408

Micro, Pt, Tx, and complications of nonbullous impetigo?

Answer 408

Micro: staph aureus, group A beta-hemolytic strep (S progenes) Pt: painful, non-itchy pustules + honey-crusted lesions Tx: topical Abx (mupirocin) Complciations: poststreptococcal glomerulonephritis

Question 409

What are the side effects of efavirenz? What drug class is this?

Answer 409

drug class: non-nucleoside reverse transcriptase inhibitor | Side effects: dizziness, insomnia with vivid or bizarre dreams, depression, anxiety, confused thinking, and aggression

Question 410

What drug class are abacavir and lamivudine? What side effects do they have?

Answer 410

drug class: nucleoside reverse transcriptase inhibitors Side effects: insomnia + depression rarely; more commonly, they can result in lactic acidosis and hepatotoxicity; abacavir is also associated with a potentially fatal hypersensitivity reaction

Question 411

What are the abortive and preventative migraine therapies?

Answer 411

Abortives: triptans NSAIDs, acetaminophen, antiemetics (metoclopramide, prochlorperazine), ergotamine (dihydroergotamine) Preventatives: topiramate, divalproex sodium, TCAs, beta blockers (propranolol)

Question 412

recurrent kidney stones since childhood, family history of nephrolithiasis, hexagonal crystals on u/a - Dx? What test helps dx this?

Answer 412

cystinuria path: impaired transport of cystine and the dibasic amino acids ornithine, lysine, and arginine by the brush borders of renal tubular and intestinal epithelial cells dx: cyanide-nitroprusside test, which detects elevated cystine levels and can help confirm the dx

Question 413

Risk factors, Pt, PE of age-related cataracts

Answer 413

Risk factors: age >60, chronic sunlight exposure, DM, glucocorticoid use, smoking, HIV infection Pt: gradual loss of visual acuity, excessive glare, hallows around bright lights, myopic shift PE: opacification of lens, loss of red reflex

Question 414

platelets >600,000, thrombosis, and hemorrhage - Dx?

Answer 414

essential thrombocythemia

Question 415

MOA, indication, and side effects of indomethacin for tocolytics

Answer 415

MOA: cyclooxygenase inhibition Indication: first-line tocolytic: < 32 weeks Side effects: maternal: gastritis, platelet dysfunction fetal: oligohydramnios, closure of ductus arteriosus

Question 416

MOA, indication, and side effects of nifedipine for tocolytics

Answer 416

MOA: calcium channel blocker Indication: first-line tocolytic: 32-34 weeks Side effects: Maternal: tachycardia/palpitations, nausea, flushing, HA

Question 417

MOA, indication, and side effects of terbutaline for tocolytics

Answer 417

MOA: beta agonist Indication: short-term tocolytic: inpatient use Side effects: maternal: tachycardia/arrhythmias , hypotension, hyperglycemia, pulmonary edema

Question 418

Micro, path, Pt, and Tx of roseola infantum

Answer 418

Micro: HHV-6 is MC Path: age < 2 years PT: 3-5 days of high fever followed by blanching maculopapular rash Tx: supportive care

Question 419

When is screening for hemoglobinopathies indicated for pregnant patients? How do you screen?

Answer 419

indicated for patients with anemia (Hgb <11 during preganncy) and an MCV <80; screen with hemoglobin electrophoresis

Question 420

Pt and PE of complete atrioventricular septal defect (CAVSD)

Answer 420

MC congenital heart defect in patients with Down syndrome due to failure of endocardial cushions to merge Pt: diaphoresis and dyspnea with feeds and crackles typically manifest around age 6 weeks as pulmonary vascular resistance falls PE: 1. fixed split S2 due to delayed pulmonary valve closure from flow across the ASD 2. Systolic ejection murmur from increased flow across the pulmonary valve due to L->R shunt across ASD 3. Holosytolic murmur of VSD that may be soft or absent if large 4. Holosystolic apical murmur depending on the degree of AV valve regurgitation

Question 421

Pt and Tx of magnesium toxicity

Answer 421

Pt: mild: nausea, flushing, HA, hyporeflexia moderate: areflexia, hypocalcemia, somnolence severe: respiratory paralysis, cardiac arrest Tx: stop magnesium therapy; give IV calcium gluconate bolus

Question 422

What is the criteria for initiating long term O2 therapy in those with chronic hypoxemia?

Answer 422

1. resting arterial O2 tension (PaO2) = 55 mmHg or pulse ox saturation = 88% room air 2. PaO2 = 59 mmHg or SaO2 = 89% in patient s with cor pulmonale, evidence of right hareat failure, or Hct > 55%

Question 423

What is the pathology of sialadenosis?

Answer 423

path: benign noninflammatory swelling of the salivary glands; can result from overaccumulation of secretory granules in acing cells in patients with chronic alcohol use, bulimia, or malnutrition; can also result from fatty infiltration of the glands in patients with DM or liver disease

Question 424

Risk factors, Pt, PE, Tx, and complications of pelvic inflammatory disease

Answer 424

Risk factors: multiple sex partners, age 15-25, previous PID, inconsistent barrier contraception use, partner with STI Pt: lower abdominal pain, abnormal bleeding PE: fever >100.9, cervical motion tenderness, mucopurulent cervical discharge Tx: outpatient: ceftriaxone + doxycycline Inpatient: cefoxitin + doxycycline Complication: tuboovarian abscess, infertility, ectopic preganncy, perihepatitis

Question 425

When do patients with sickle cell disease usually undergo autoinfarction of the spleen? What would you expect on peripheral smear?

Answer 425

autoinfarction and functional asplenia by age 5; Howell-jolly bodies on PS (appear as small purple dots within the RBC)

Question 426

What conditions cause basophilic stippling on peripheral smear?

Answer 426

thalassemias and lead or heavy metal poisoning

Question 427

What conditions cause helmet cells or schistocytes on peripheral smear?

Answer 427

traumatic microangiopathic hemolytic conditions such as DIC, HUS, and TTP

Question 428

Path, Pt, and management of staphylococcal scalded skin syndrome

Answer 428

Path: staphylococcus aureus exfoliative toxin Pt: fever, irritability; generalized erythema, blisters; epidermal shedding Managment: antistaphylococcal Abx (nafcillin, vancomycin), wound care

Question 429

Pt of toxic shock syndrome

Answer 429

1. fever usually > 102 2. hypotension with SBP = 90 3. diffuse macular erythroderma 4. skin desquamation, includign palsm + soles, 1-2 weeks after illness onset 5. mulitsystem involvement (3 or more systems): - GI (vomiting +/or diarrhea) - muscular (severe myalgias or elevated CK) - mucous membrane hyperemia - renal (BUN or serum Cr >1-2x upper limit of normal) - hematologic (platelets < 100,000) - liver (ALT, AST + total bilirubin >2x upper limit of normal) - CNS (AMS without focal neuro signs)

Question 430

What labs should you expect with toxic shock syndrome?

Answer 430

luekocytosis may not be present immature neutrophils elevated thrombocytopenia common

Question 431

Path, Pt, Complications of vertebral compression fracture

Answer 431

Path: trauma, osteoporosis, osteomalacia, bone mets, metabolic (hyperparathyroidism), Paget disease Pt: acute: low back pain + decreased spinal mobility, pain increasing with standing, walking, lying on back, tenderness at affected level chronic: painless, progressive kyphosis, loss of stature Complications: increased risk for future fractures; hyperkyphosis, possibly leading to protuberant abdomen, early satiety, weight loss, decreased respiratory capacity

Question 432

Pt, Dx, and Tx of pseudogout (acute calcium pyrophosphate crystal arthritis)

Answer 432

Pt: acute mono- or oligoarticular arthritis, peripheral joints (knee most common) Dx: inflammatory effusion (15,000-30,000 cells), CCPD crystals (rhomboid shape, positive birefringence), chondrocalcinosis on imaging Tx: intra-articular glucocorticoids, NSAIDs, colchicine

Question 433

Path, sources, Pt, Dx, and Tx of foodborne botulism

Answer 433

Path: clostridium botulinum toxin inhibits presynaptic ACh release at neuromuscular junction Sources: improperly canned foods (fruits, veggies), aged seafood (cured fish) Pt: acute onset within 36 hours of ingestion: - B/L cranial neuropathies (blurred vision, diplopia) (facial weakness, dysarthria, dysphagia) - symmetric descending muscle weakness - diaphragmatic weakness with respiratory failure Dx: serum analysis for toxin Tx: equine serum heptavalent botulinum antitoxin

Question 434

What are the indications for noninvasive positive-pressure ventilation?

Answer 434

COPD (severe exacerbation, prevent extubation failure), cardiogenic pulmonary edema, acute respiratory failure (post-op hypoxemia respiratory failure, immunosuppressed patients), facilitate early extubation

Question 435

What is expected on Labs of acute tubular necrosis?

Answer 435

1. BUN-to-Cr ratio of 10-15 2. urine osmolality of 300-350 mOsm/L (but never <300) 3. Urine Na of >20 4. FENa >2%

Question 436

Path, onset, findings, tx of anaphylactic transfusion reactions

Answer 436

Path: anti-IgA Abs (IgG or IgE) in IgA-deficient patient against donor blood IgA onset: seconds to minutes Findings: respiratory distress/wheeze, angioedema, hypotension, hives Tx: immediate cessation of transfusion, epinephrine, antihistamines, O2, fluids, and vasopressors

Question 437

Path, onset, findings, tx of urticarial transfusion reactions

Answer 437

Path: preformed recipient IgE Abs against soluble allergen in donated plasma onset: hours findings: hives, itching Tx: immediate cessation of transfusion, antihistamines, resume transfusion if patient is otherwise asymptomatic

Question 438

How can you tell the difference between Parkinson's disease with dementia and dementia with Lewy bodies?

Answer 438

cognitive impairment develops before or at the same time as Parkinsonism in Lewy body dementia whereas Parkinson's disease has Parkinson sx before dementia

Question 439

Type I hypersensitivity reaction immunology and examples

Answer 439

(immediate) IgE mediated Ex: anaphylaxis, urticaria

Question 440

Type II hypersensitivity reaction immunology and examples

Answer 440

(cytotoxic) IgG + IgM auto-Ab mediated Ex: autoimmune hemolytic anemia, Goodpasture syndrome

Question 441

Type III hypersensitivity reaction immunology and examples

Answer 441

(immune complex) Antibody-antigen complex deposition Ex: serum sickness, poststreptococcal glomerulonephritis, lupus nephritis

Question 442

Type IV hypersensitivity reaction immunology and examples

Answer 442

(delayed type) T-cell and macrophage-mediated Ex: contact dermatitis, TB skin test

Question 443

Pt, Path, causes, and Dx of bronchiectasis

Answer 443

Pt: cough with daily mucopurulent sputum production; rhino sinusitis, dyspnea, hemoptysis; crackles, wheezing Path: infectious insult with impaired clearance Causes: airway obstruction (cancer), rheumatic disease (RA, Sjogren), toxic inhlation, chronic or prior infection (aspergillosis, mycobacteria), immunodeficiency (hypogammaglobulinemia), congenital (CF, alpha-1-antitrypsin deficiency) Dx: HRCT scan of the chest (needed for initial Dx), immunoglobulin quantification, CF testing, sputum culture (bacteria, fungi + mycobacteria), pulmonary function testing

Question 444

What will high-resolution CT (HRCT) scan of the chest show with bronchiectasis?

Answer 444

characteristic bronchial dilation, lack of airway tapering, and bronchial wall thickening

Question 445

Definition, risk factor, complications, and management of late and post-term pregnancy?

Answer 445

``` definition: late-term: >/= 41 weeks gestation; post-term: >/= 42 weeks gestation Risk factors: prior post-term pregnancy, nulliparity, obesity, age >/= 35, fetal anomalies (anencephaly) Complications: fetal/neonatal: - macrosomia -dysmaturity syndrome - oligohydramnios - demise Maternal: - severe obstetric laceration - C-section - postpartum hemorrhage Management; frequent fetal monitoring )nonstress test), delivery prior to 43 weeks gestation ```

Question 446

Path, pt, dx, and tx of mediastinitis

Answer 446

Path: complication of dehiscence due to contiguous spread of superficial infection or intraoperative deep tissue contamination Pt: fever, tachycardia, chest pain, chest wall edema/crepitus, and purulent wound discharge Dx: CT scan showing mediastinal fluid collections or pneumomediastinum Tx: emergency surgical debridement, tissue cultures, and empiric IV Abx

Question 447

thromboangiitis obliterans

Answer 447

men 40-45 yo; get ANA and other blood tests prior to arteriogram (bc systemic diseases should be ruled out first)

Question 448

Ascaris lumbricoides path, pt, dx, and tx

Answer 448

Path: parasitic roundworm spread via fecal-oral transmission; endemic to Asia, Africa, and South America Pt: pulmonary manifestations (cough, eosinophilic pneumonitis) are rare but can occur within the first few weeks of infection GI Sx much more common and occur 1-2 months later: abdominal pain, N/V, anorexia, diarrhea Complication: adult worms can obstruct the lumen of the small bowel or hepatobiliary tree, resulting in SBO, biliary colic, cholangitis, or acute pancreatitis Dx: peripheral eosinophilia and signs of malnutrition (vitamind eficiency, anemia); dx confirmed with visualized ascaris eggs or worms in the stool or respiratory secretion Tx: conservative and includes nasogastric suction and fluid/electrolyte repletion; albendazole or mebendazole

Question 449

HIV associated nephropathy Pt, complications, Dx

Answer 449

Pt: untreated HIV infection, edema, acute kidney injury, and proteinuria Complications: can progress quickly to heavy proteinuria and rapidly progressive renal failure Dx: renal biopsy that shows collapsing focal segmental glomerulosclerosis with tubuloreticular inclusions on electron microscopy

Question 450

persistent ST-segment elevation after a recent MI, deep Q waves in the same leads as the MI - Dx? Complications?

Answer 450

ventricular aneurysm -> can progress to LV enlargement, causing heart failure, refractory angina, ventricular arrhythmias, mural thrombus with systemic arterial embolization, or mitral annular dilation with MR

Question 451

What does subarachnoid hemorrhage show on lumbar puncture?

Answer 451

elevated opening pressure and xanthochromia

Question 452

Path and Pt of trichinellosis

Answer 452

Path: ingestion of undercooked meat (usually pork); endemic in Mexico, China, Thailand, parts of central Europe + Argentina Pt: Intestinal stage (within 1 week of ingestion): can be asymptomatic or include abdominal pain, nausea, vomiting + diarrhea Muscle stage (up to 4 weeks after ingestion): myositis, fever, subungual splinter hemorrhages, periorbital edema, eosinophilia (usually >20%) with possible elevated CK and leukocytosis

Question 453

pancreatic fistula

Answer 453

Path: Ldisruption of the pancreatic ducts results in leakage of pancreatic digestive enzymes, most commonly due to acute or chronic pancreatitis Dx: amylase-rich exudative pleural fluid on Light criteria Pt: cough, dyspnea, dysphagia, and chest pain, but can be asymptomatic Tx: bowel rest, but ERCP with sphincterotomy and/or stent placement could be required

Question 454

Pt and complications of infectious mononucleosis

Answer 454

Pt: fever, tonsillitis/pharyngitis +/- exudates, posterior or diffuse cervical LAD< significant fatigue, +/- HSM, +/- rash after amoxicillin Complications: acute airway obstruction, autoimmune hemolytic anemia + thrombocytopenia, splenic rupture

Question 455

Risk factors, Pt, and Tx of Genito-pelvic pain/penetration disorder

Answer 455

Risk factors: sexual trauma, lack of sexual knowledge, history of abuse Pt: pain with vaginal penetration, distress/anxiety over Sx, no other medical cause Tx: desensitization therapy, Kegel exercises

Question 456

CD40L deficiency (hyper IgM syndrome) B cell count, IgG, IgA, IgM, and IgE

Answer 456

``` B cell count: normal IgG: decreased IgA: decreased IgM: increased IgE: decreased ```

Question 457

CVID B cell count, IgG, IgA, IgM, and IgE

Answer 457

``` B cell count: normal IgG: decreased IgA: decreased IgM: decreased IgE: decreased ```

Question 458

Job syndrome (hyper-IgE syndrome) B cell count, IgG, IgA, IgM, and IgE

Answer 458

``` B cell count: normal IgG: normal IgA: normal IgM: normal IgE: increased ```

Question 459

Selective IgA deficiency B cell count, IgG, IgA, IgM, and IgE

Answer 459

``` B cell count: normal IgG: normal IgA: decreased IgM: normal IgE: normal ```

Question 460

X-linked agammaglobulinemia B cell count, IgG, IgA, IgM, and IgE

Answer 460

``` B cell count: decreased IgG: decreased IgA: decreased IgM: decreased IgE: decreased ```

Question 461

What is the treatment for torsades de pointes for unstable vs stable patients?

Answer 461

unstable: immediate defibrillation stable: IV magnesium

Question 462

Pt, hormone levels, long-term consequences, and tx of exercise-induced hypothalamic amenorrhea

Answer 462

Pt: strenuous exercise, relative caloric deficiency, stress fractures, amenorrhea, infertility Hormones: decreased GnRH, decreased LH/FSH, decreased estrogen Long term consequences: decreased bone mineral density, increased total cholesterol, increased triglycerides Tx: increased caloric intake, estrogen, calcium + vitamin D

Question 463

idiopathic intracranial HTN (pseudotumor cerebri)

Answer 463

Path: impaired absorption of CSF by the arachnoid villi Pt: young woman with obesity, HA suggestive of a brain tumor but with normal neuroimaging and elevated CSF pressure, papilledema, visual field defects and sometimes sixth nerve palsy; may be a history of exposure to provoking agents such as glucocorticoids or vitamin A Management: weight reduction and acetazolamide (if weight reduction fails); when medical measures fail or visual field defects are progressive, shunting or optic nerve sheath fenestration is done to prevent blindness

Question 464

What will CXR of primary TB show?

Answer 464

hilar LAD, effusion, consolidation, cavitation

Question 465

tracheoesophageal fistula with esophageal atresia path, pt, dx, and management

Answer 465

Path: defective division of foregut into esophagus + trachea; most commonly results in proximal esophageal pouch + fistula between distal trachea + esophagus Pt: coughing, choking, vomiting with feeding, excessive secretions; commonly part of VACTERL association (vertebral, anal, cardiac, tracheoesophageal, renal, limb defects) Dx: inability oto pass enteric tube into stomach; X-ray: enteric tube coiled in proximal esophagus Management: surgical correction; VACTERL screening: echo, renal u/s

Question 466

acute renal allograft rejection path, pt, labs, dx, and tx

Answer 466

Path: T-cell mediated response to antigens within donor kidney. MC occurs within the first 6 months following transplant Pt: usually asymptomatic; fever, decreased urine output, or graft tenderness possible Labs: increased serum Cr, proteinuria Dx: renal Bx required -> shows lymphocytic infiltration of the intima with inflammatory tubular disruption; intimal arteritis is often present as well Tx: IV glucocorticoids + increased immunosuppression

Question 467

BK virus reactivation path, pt, and dx

Answer 467

Path: excessive immunosuppression in renal allograft recipients -> tubulointerstitial nephritis Pt: asymptomatic increase in serum Cr Dx: renal bx shows intranuclear inclusions and a mixed lymphocytic and neutrophilic infiltrate

Question 468

WAGR syndrome path, pt

Answer 468

Path: gene deletion on chromosome 11p13 Pt: Wilms tumor, Aniridia, Genitourinary abnormalities, Intellectual disability (previously mental Retardation)

Question 469

Risk factors, Pt, Dx, and Tx of greater trochanteric pain syndrome (trochanteric bursitis)

Answer 469

Risk factors: age >/= 50, women > men, obesity, low back + LE disorders (scoliosis, osteoarthritis, plantar fasciitis) Pt: chronic lateral hip pain, pain worse with hip flexion or lying on affected side Dx: focal tenderness over trochanter, X-ray to rule out hip joint pathology; u/s: degeneration of tendons, tendinosis Tx: exercise, PT< activity modification; NSAIDs, corticosteroid injection

Question 470

What is the usual cause of a non traumatic spontaneous pneumothorax in a tall, thin young man?

Answer 470

primary spontaneous pneumothorax from rupture of a sub pleural bleb; can cause dyspnea and subcutaneous emphysema with decreased breath sounds on the affected side

Question 471

Path, pt, Dx, and Tx of bacillary angiomatosis

Answer 471

Path: bartonella henselae/quintana; cat exposure or homelessness (lice), severe immunocompromise (advanced HIV with CD4 <100) Pt: vascular cutaneous lesions (papular, nodular, peduncular); systemic symptoms (fever, night sweats, fatigue); organ involvement rarely (liver, bone, CNS) Dx: lesional biopsy with microscopy/histopathology Tx: doxycycline or erythromycin, antiretroviral therapy

Question 472

What would you expect on labs of infective endocarditis?

Answer 472

normocytic anemia, elevated ESR, elevated rheumatoid factor, u/a positive for blood and protein (immune complex-mediated glomerulonephritis with hematuria and red cell casts)

Question 473

Adult Still disease

Answer 473

uncommon inflammatory disorder characterized by recurrent high fevers. arthritis/arthralgias, and a salmon-colored macular or maculopapular rash ESR may be markedly elevated

Question 474

What is the treatment of primary adrenal insufficiency?

Answer 474

glucocorticoids (hydrocortisone, prednisone) + mineralocorticoids (fludrocortisone)

Question 475

Path, Pt, Dx, and Tx of Legionella pneumonia

Answer 475

Path: contaminated water in hospital or travel (cruise, hotel) Pt: fever > 101.8, relative bradycardia, GI (diarrhea, vomiting, cramps), pulmonary symptoms delayed Dx: hyponatremia CXR - patchy unilobar or interstitial infiltrates sputum gram stain - PMNs, few/no organisms urine legionella Ag Tx: respiratory fluoroquinolone or newer macrolide

Question 476

When does a pap smear with benign-appearing endometrial cells require endometrial evaluation?

Answer 476

premenopausal women with: abnormal uterine bleeding OR risk for endometrial hyperplasia postmenopausal women

Question 477

When does a pap smear with atypical glandular cells require endometrial evaluation?

Answer 477

women age >/= 35 OR at risk for endometrial hyperplasia

Question 478

FSH, LH, prolactin, and TSH of ovarian failure

Answer 478

FSH: elevated LH: elevated Prolactin: normal TSH: normal

Question 479

FSH, LH, prolactin, and TSH of functional hypothalamic amenorrhea

Answer 479

FSH: decreased LH: decreased Prolactin: normal TSH: normal

Question 480

FSH, LH, prolactin, and TSH of asherman syndrome?

Answer 480

FSH: normal LH: normal Prolactin: normal TSH: normal

Question 481

FSH, LH, prolactin, and TSH of prolactinoma?

Answer 481

FSH: decreased LH: decreased Prolactin: increased TSH: normal

Question 482

FSH, LH, prolactin, and TSH of hypothyroidism

Answer 482

FSH: decreased LH: decreased Prolactin: increased TSH: increased

Question 483

When is duloxetine considered first line for depression?

Answer 483

when the patient has depression and diabetic neuropathy (it is an SNRI)

Question 484

Pt, Dx, and Tx of enterobius vermicularis (pinworm)

Answer 484

Pt: perianal pruritus, especially at night Dx: eggs on tape test Tx: pyrantel pamoate OR albendazole for pt + all household contacts

Question 485

Path, Pt, Dx, and Tx of common variable immunodeficiency

Answer 485

Path: abnormal differentiation of B cells into plasma cells -> decreased immunoglobulin production Pt: symptom onset classically age 20-40, as early as puberty, recurrent respiratory infections (pneumonia, sinusitis, otitis), recurrent GI infectinos (Salmonella, campylobacter, giardia); chronic disease: autoimmune (RA, thyroid disease), pulmonary (bronchiectasis), GI (chronic diarrhea, IBD-like conditions) Dx: very low IgG, low IgA/IgM; no response to vaccination Tx: immunoglobulin replacement therapy

Question 486

management of preterm labor from 34 0/7 to 36 6/7

Answer 486

+/- betamethasone, penicillin if GBS positive or unknown

Question 487

management of preterm labor 32 0/7 to 33 6/7

Answer 487

betamethasone, tocolytics, penicillin if GBS positive or unknown

Question 488

management of preterm labor <32 weeks

Answer 488

betamethasone, tocolytics, magnesium sulfate, penicillin if GBS positive or unknown

Question 489

What are alarm features concerning constipation?

Answer 489

onset at older age (>/= 50), accompanied by early satiety or pain unrelated to bowel movement, weight loss, hematochezia, family history of malignancy, hx of inflammatory bowel disease Rule out colon cancer and ovarian cancer in females

Question 490

Pt, Dx, and Tx of psoas abscess

Answer 490

Pt: subacute fever + abdominal/flank pain that may radiate to the groin or hip; anorexia, weight loss, abdominal pain with hip extension (psoas sign) Dx: CT scan of the abdomen + pelvis; leukocytosis, elevated inflammatory markers, blood and abscess cultures Tx: drainage, broad-spectrum Abx

Question 491

chronic alcohol abuse, epigastric pain that worsens postprandially, ascites with high amylase and total protein - Dx?

Answer 491

pancreatic ascites rare complication fo chronic pancreatitis that results from damage to the pancreatic duct, leading to leakage of pancreatic juice into the peritoneal space -> abdominal distension, weight gain, dyspnea, and early satiety; PE = shifting dullness and fluid wave

Question 492

physiologic effect, LV blood volume, and murmur intensity of valsalva, abrupt standing, and nitroglycerin administration on hypertrophic cardiomyopathy

Answer 492

Physiologic effect: decreased preload LV blood volume: decreased Murmur intensity: increased

Question 493

physiologic effect, LV blood volume, and murmur intensity of sustained hand grip on hypertrophic cardiomyopathy

Answer 493

Physiologic effect: increased afterload LV blood volume: increased Murmur intensity: decreased

Question 494

physiologic effect, LV blood volume, and murmur intensity of squatting on hypertrophic cardiomyopathy

Answer 494

Physiologic effect: increased afterload + preload LV blood volume: increased Murmur intensity: decreased

Question 495

physiologic effect, LV blood volume, and murmur intensity of passive leg raise on hypertrophic cardiomyopathy

Answer 495

Phsyiologic effect: increased preload LV blood volume: increased Murmur intensity: decreased

Question 496

Path, Pt, and Dx of Behcet disease

Answer 496

Path: young adults; Turkish, Middle EAstern, or Asian descent Pt: recurrent, painful oral aphthous ulcers, genital ulcers, eye lesions (uvieitis), skin lesions (erythema nodosum, acneiform lesions), thrombosis Dx: pathergy - exaggerated skin ulceration with mnior truama (needlestick); Bx - nonspecific vasculitis of different-sized vessels

Question 497

Causes, Pt, and Dx of osteomalacia

Answer 497

Causes: malabsorption, intestinal bypass surgery, celiac sprue, chronic liver disease, chronic kidney disease Pt: may be asymptomatic, bone pain + muscle weakness, muscle cramps, difficulty walking, waddling gait Dx: increased alkaline phosphatase, increased PTH, decreased serum calcium and phosphorus, decreased urinary calcium; decreased 25-OH-D levels, X-rays may show thinning of cortex with reduced bone density; B/L and symmetric pseudofractures are characteristic radiologic findings

Question 498

Path, pt, and Tx of thrombotic thrombocytopenic purpura

Answer 498

Path: decreased ADAMTS13 level -> uncleared vWF multimers -> platelet trapping + activation; acquired (autoantibody) or hereditary Pt: hemolytic anemia (increased LDH, decreased haptoglobin) with schistocytes; thrombocytopenia (increased bleeding time, normal PT/PTT); sometimes with: renal failure, neurologic manifestations, fever Tx: plasma exchange, glucocorticoids, rituximab