Uworld CK

Question 1

What does the femoral nerve innervate?

Answer 1

The anterior thigh for knee extension and hip flexion

Sensation to the anterior thigh and medial leg – via the saphenous branch.

Question 2

How should hemodynamically stable pts w/suspected splenic injury be managed?

Answer 2

They should first undergo a FAST.

• If normal FAST, but they have high risk features (anemia or guarding)then they should undergo abdominal CT scan w/contrast.
• If equivocal FAST and stable = CT w/contrast
• If equivocal FAST and unstable = DPL
• if DPL positive = laparotomy

Question 3

How should pts w/massive hemoptysis be managed?

Answer 3

Bronchoscopy is the procedure of choice to identify the site of bleeding and attempt intervention.
This is done after establishing a patent airway, maintaining ventilation/gas exchange, and ensuring hemodynamic stability.
Thoracotomy should only be done if bronchoscopy fails.

Question 4

What are hard signs of vascular injury and how are they managed?

Answer 4

Observed pulsatile bleeding
Presence of bruit/thrill over injury
Expanding hematoma
Signs of distal ischemia (absent pulses, cool extremity)
Pts w/any of these signs should undergo urgent surgical repair.

Question 5

What is the management for SBO?

Answer 5

Nasogastric tube, IV fluids, bowel rest, analgesics and surgical exploration (esp. if they aren’t stable or show signs of ischemia and necrosis – metab. acidosis)

Question 6

Most common complications of cardiac catheterization?

Answer 6

Bleeding, hematoma (local or w/retroperitoneal extension), arterial dissection, actue thrombosis, pseudoaneurysm, or AV fistula formation.
Hemorrhage/hematoma normally occur w/in 12 hrs.

Question 7

Causes, sxs, and dx of a retroperitoneal hematoma:

Answer 7

Causes: Recent cardiac cath., anticoagulation.
Sxs: sudden onset HoTN, tachycardia, flat neck veins, and back pain.
This is diagnosed w/a NON-contrast CT of the abdomen/pelvis.

Question 8

Management of pancreatic pseudocyst:

Answer 8

Expectant mgmt. - (NPO,symptomatic therapy) for those without sxs or cxs
Endoscopic drainage - pts w/significant sxs (N/V/abd pain), infected cysts, or evidence of a pseudoaneurysm.

Question 9

Mgmt of a clavicular fracture:

Answer 9

Careful neurovascular exam to r/o injury to the brachial plexus or subclavian artery. Often involves an angiogram – esp. if a bruit is heard.

Question 10

Ankle-brachial index:

Answer 10

Non-invasive test that is sensitive and specific for PAD in symptomatic pts. (intermittent claudication). Usually the first step taken to confirm the diagnosis.
Done by dividing the higher ankle systolic pressure by the higher brachial artery systolic pressure.

Question 11

What happens to the Left ventricle in states of hypovolemic shock?

Answer 11

It will decrease in size d/t low filling volume, and compensate by increasing the ejection fraction (~75%).

Question 12

Most common causes of massive hemothorax:

Answer 12

Traumatic laceration of the lung parenchyma, or damage to an intercostal or internal mammary artery.

Question 13

Likely post-op complication that would lead to cardiogenic shock?

Answer 13

Perioperative MI

Question 14

What are the interventions for lowering ICP? (5)

Answer 14

1- Head elevation: increases venous outflow from brain
2- Sedation: decreases metabolic demand and controls HTN
3- IV Mannitol: Free H2O clearance from brain tissue –> osmotic diuresis
4- Hyperventilation: CO2 washout –> cerebral vasoconstriction
5- CSF drainage: Decreases Vol/P

Question 15

What anticoagulants are contraindicated in ESRD?

Answer 15

LMWH and Xa inhibitors like Rivaroxaban

Question 16

What is the tx for DVT in patients w/ ESRD?

Answer 16

Unfractionated heparin and warfarin. Must start on both and then stop heparin bc warfarin initially causes prothrombotic state.

Question 17

Who is likely to get bacterial parotitis, how does it present, how can you prevent, most common cause?

Answer 17

Post-op patients and the elderly are most likely to get it.
Presents with fever, leukocytosis and parotid inflammation.
Can prevent with adequate fluid intake and oral hygiene.
S. aureus is most common cause

Question 18

Indications of urgent exploratory laparotomy:

Answer 18

Hemodynamic Instability
Peritonitis (rebound tenderness and guarding)
Evisceration (exposed organs)
Blood from NGT or on rectal exam
Also to remove any foreign material such as knives

Question 19

Signs/Sxs suggestive of meniscal injury:

Answer 19

Acute knee pain a/w catching/popping or reduced ROM.

PE may be normal and should be followed by MRI if suspected.

Question 20

Earliest sign of burn wound infection:

Answer 20

Change in appearance – partial thickness injury turns into full-thickness- of the wound, or loss of a skin graft.

Question 21

Difference in bacteria of burn wound infection:

Answer 21

G+ are common directly after injury

G- and fungi are more common >5 days after injury.

Question 22

What should happen immediately after placing a CVC?

Answer 22

Obtain portable CXR to confirm the catheter is in the correct place before catheter use. Catheter should be visualized just proximal to the angle b/w the trachea and R mainstem bronchus.

Question 23

What is torus palatinus?

Answer 23

Fleshy immobile mass on the midline hard palate. It is a congenital growth, and doesn’t require intervention unless it casues sxs or interferes w/speech or eating.

Question 24

Leriche syndrome:

Answer 24

A triad syndrome from aortoiliac occlusion
Bilat. Hip, thigh, and buttock claudication
Absent/diminished femoral pulses – often w/symmetric atrophy of the bilat. LEs from chronic ischemia
Impotence.

Question 25

What is Extraperitoneal bladder injury? When should this be considered?

Answer 25

Contusion/rupture of the neck, ant. wall, or anterolateral wall of the bladder. Often from pelvic fractures. Get localized pain and gross hematuria. Signs of peritonitis shouldn’t be present (seen in IPBI).

Question 26

Signs and symptoms of necrotizing surgical site infection:

Answer 26

Pain, edema, erythema spreading beyond the surgical site Systemic signs: Fever, HoTN, tachy Par/anesthesia at the wound edges Purulent, cloudy-grey “dishwater drainage” SubQ gas or crepitus

Question 27

Treatment of necrotizing surgical site infections:

Answer 27

Urgent surgical exploration and debridement + parenteral abx

Question 28

What causes the hyperpigmentation/discoloration in stasis dermatitis?

Answer 28

RBC extravasation from the capillaries cause hemosiderin deposition in the tissues.

Question 29

What can be seen on AXR in paralytic ileus?

Answer 29

Gas filled loops in the stomach, SI and LI with no transition point.

Question 30

Common causes of paralytic ileus:

Answer 30

Abdominal surgery is #1 | Others: Retroperitoneal/abd hemorrhage or inflammation, intestinal ischemia, and electrolyte abnormalities.

Question 31

What causes flail chest?

Answer 31

3+ rib fractures in 2+ locations

Question 32

What nerve is most commonly injured in shoulder dislocation, what will it cause?

Answer 32

Axillary nerve is most commonly injured It innervates teres minor and deltoid --> weakened shoulder abduction Provides sensation to lateral shoulder

Question 33

What imaging is indicated for suspected penile fracture? Other indications for this imaging?

Answer 33

Retrograde urethrogram. | Indications for urethrogram: Blood at the meatus, hematuria, dysuria, urinary retention.

Question 34

Shin splints v. Stress fracture:

Answer 34

Stress fractures – have localized point tenderness and activity-related pain, swelling. Often in underweight female athletes Shin splints – diffuse area of tenderness (not point), and is more common in overweight casual runners.

Question 35

What kind of effusion would be expected with a low pleural glucose?

Answer 35

An exudative effusion – typically has glucose <60 mg/dL.

Question 36

What is the light criteria to define an exudative pleural effusion?

Answer 36

Must have at least one of the following (pleural/serum): Pleural fluid protein/serum protein ratio >0.5 Pleural fluid LDH/serum LDH >0.6 Pleural fluid LDH >2/3 of the upper limit of normal for serum LDH.

Question 37

What are empyemas?

Answer 37

Exudative effusions w/low glucose concentration d/t high metabolic activity of leukocytes and bacteria w/in the pleural fluid.

Question 38

What are the different biopsy techniques for central v. peripheral tumors?

Answer 38

Central are done by EBUS (endobronchial US) directed biopsy. | Peripheral are hard to reach via EBUS and are normally done by VATS (Video-Assisted Thoracoscopic Surgery).

Question 39

What lung ca is most likely to cause SVC syndrome?

Answer 39

SCLC

Question 40

Most common locations of lung mets:

Answer 40

Brain, Bone, Adrenals, Liver

Question 41

When is surgical resection indicated for lung ca.?

Answer 41

If the predicted post-op FEV1 is 800mL+

Question 42

What type of skin cancer is more common in males v females?

Answer 42

Basal cell more common in males | Squamous more common in females

Question 43

What are the vaccine recommendations for a patient post-splenectomy? When are they given post-splenectomy?

Answer 43

Give pneumococcal, meningococcal, and H. influenzae vaccines on 14th post-op day

Question 44

Most common surgical txs of Subclavian steal syndrome:

Answer 44

Carotid-subclavian bypass Carotid transposition Percutaneous angioplasty w/ stenting Surgical intervention should only be done in symptomatic patients

Question 45

What is the next best step in mgmt. of a new solitary pulmonary nodule w/out previous images to compare it to?

Answer 45

Obtain chest CT If CT shows intermediate to high chances of malignancy then a PET should be ordered. If PET suggests malignancy then do a biopsy.

Question 46

Common findings a/w Peutz-Jegher:

Answer 46

Polyps in both the small bowel and colon, perioral melanosis, breast malignancy

Question 47

Treatment for anal fissures:

Answer 47

High fiber diet + adequate fluid intake Stool Softeners Sitz baths Topical anesthetics + Vasodilators – Nifedipine, nitroglycerin, etc.

Question 48

Management of spontaneous pneumothorax:

Answer 48

Small (< 2cm) can be managed w/observation and O2 Large + Stable need needle aspiration or chest tube. Unstable – tube thoracostomy

Question 49

Management of tension pneumothorax:

Answer 49

(variant w/ one-way valve causes expansion of pneumothorax during inspiration) Urgent needle decompression or chest tube placement

Question 50

Why is Supplemental O2 used in tx of pneumothorax?

Answer 50

It increases the rate of resorption.

Question 51

Where should a needle be placed to decompress a pneumothorax? What size needle should be used?

Answer 51

A large bore 14-18 gauge needle is inserted in the 2nd or 3rd ICS in midclavicular line, or the 5th ICS in the mid/anterior axillary.

Question 52

Visualization of a dilated common bile duct in the absence of stones is commonly seen in what disorder?

Answer 52

Sphincter of Oddi dysfunction – dyskinesia and stenosis of the sphincter can cause obstruction of flow through the sphincter which mimics a structural lesion. Gold standard for dx: Sphincter of Oddi manometry.

Question 53

Characteristics/Causes of Bile reflux gastritis:

Answer 53

d/t incompetent pyloric sphincter, often following gastric surgery. Allows retrograde flow of bile-rich duodenal fluid into the stomach and esophagus Sxs: Vomiting, frequent heartburn, abdominal pain.

Question 54

Presentation of ruptured ovarian cyst:

Answer 54

Sudden-onset, severe, unilateral lower abdominal pain immediately following strenuous (exercising) or sexual activity. Will see fluid in pelvis on US Hemodynamically unstable pts require immediate surgery.

Question 55

In a patient post-MVA what should an elevated PCWP be suspicious of? What is the next best step? (What does PCWP measure, and what's a normal value?)

Answer 55

Myocardial dysfxn d/t cardiac contusion. These pts need an urgent echo. (PCWP = pulmonary artery occlusion pressure = left atrial pressure. Normal value is 4-12mm)

Question 56

What is the typical course leading to an appendiceal abscess? Sx and Dx tests?

Answer 56

Acute appendicitis with delayed presentation and >5 days of sxs. This often leads to appendiceal rupture with a contained abscess. These pts often have fever and leukocytosis but palpation of the abdomen may be normal. Need to use psoas and other tests to assess for the deep abdominal spaces. CT can be used to confirm Post-op cxs in these pts is extremely high, they should wait 6-8 weeks before removal.

Question 57

Management for duodenal hematomas:

Answer 57

Gastric decompression via NGT and parenteral nutrition. | Surgery or percutaneous drainage only if non-surgical mgmt. fails.

Question 58

Presentation , dx, labs of Emphysematous cholecystitis:

Answer 58

Fever, RUQ pain, N/V, crepitus in abd wall. See air-fluid levels in GB and gas in GB wall. Cultures w/gas-forming Clostridium, or E. coli Labs: UC hyperBRemia (from clostridium-induced hemolysis), slight elevation in aminotransferases

Question 59

Risk factors of emphysematous cholecystitis:

Answer 59

DM, vascular compromise, IMCP

Question 60

Tx of Emphysematous cholecystitis:

Answer 60

Emergent cholecystectomy Broad-spectrum abx w/clostridium coverage (pip-tazo, ertapenem, amp-sulbactam) Bile cultures

Question 61

Immediate (0-2hr) Post-op fever causes:

Answer 61

Prior trauma or infection Blood products Malignant Hyperthermia

Question 62

What is the most likely acid-base disturbance to occur in atelectasis?

Answer 62

Respiratory Alkalosis – pts become hypoxic and hyperventilate to compensate. This decreases the arterial PaCO2, and PaO2. pH will increase.

Question 63

Factors that decrease risk of post-op atelectasis:

Answer 63

Adequate pain control, deep-breathing exercises, directed coughing, early mobilization, and incentive spirometry.

Question 64

How does post-op atelectasis occur? What is the result of these mechanisms?

Answer 64

Post-op changes in lung complicance can lead to shallow inhalations which limit the recruitment of alveoli at the lung bases, and then impaired cough can predispose to small-airway mucus plugging. These both result in hypoxia --> increased RR and low pCO2.

Question 65

Common cause of poor wound healing in alcoholic:

Answer 65

Vit. C deficiency

Question 66

Most common organisms of prosthetic joint infection:

Answer 66

Early <3 months – S. aureus, G- rods, anaerobes (Pseudomonas) Delayed 3-12 months – Coag-neg staph (S. epidermidis), Propionibacterium, Enterococci Late >12 months – S. aureus, G- rods, B-hemolytic strep.

Question 67

What is a cx of eschar formation from a circumferential, full-thickness burn?

Answer 67

It may lead to constriction of venous and lymphatic drainage, fluid accumulation and result in distal acute compartment syndrome.

Question 68

What is abdominal succussion splash, and when is it seen?

Answer 68

It is elicited by placing the stethoscope over the upper abdomen and rocking the pt. back and forth. Seen in gastric outlet obstruction – malignancy, PUD, strictures, etc.

Question 69

What are some cxs of infection w/in the retropharyngeal space?

Answer 69

The retropharyngeal space drains inferiorly to the superior mediastinum. Infection can spread to the carotid sheath --> thrombosis of the IJV and deficits in CNs IX, X, XI, and XII. Extension through alar fascia can cause acute necrotizing mediastinitis.

Question 70

What should be suspected of an extra-axial dural-based brain mass? Tx?

Answer 70

Meningioma. These are treated via surgical resection.

Question 71

What is likely in a pt. w/persistent pneumothorax, and persistent air leak post-chest tube placement? Cause?

Answer 71

Tracheobronchial rupture. This is rare and often follows blunt chest trauma. Other sxs: pneumomediastinum, subcutaneous emphysema.

Question 72

What likely causes esophageal rupture and what will be the findings?

Answer 72

``` Often iatrogenic (w/endoscopy) or esophagitis-related. Findings: pneumomediastinum and pleural effusions. ```

Question 73

Postpericardiotomy Syndrome presentation + Tx?

Answer 73

Presents w/fever, leukocytosis, tachy, and chest pain. Often AI and occurs few weeks after a procedure w/ a pericardium incision. Tx: NSAIDs or steroids, and pericardial puncture if tamponade occurs.

Question 74

Acute Mediastinitis findings and tx:

Answer 74

Often follows cardiac surgery. Sxs: fever, chest pain, leukocytosis, mediastinal widening on CXR Tx: Drainage, surgical debridement, and prolonged abx.

Question 75

Which rotator cuff tendon is most commonly injured?

Answer 75

Supraspinatus – d/t degeneration of the tendon w/age and repeated ischemia induced by impingement b/w the humerus and acromion during abduction.

Question 76

What abx should be given in GB disease?

Answer 76

Ones that cover G- rods and anaerobes Ciprofloxacin + Metronidazole Ampicillin-Gentamycin + Metroniadazole DO NOT pick pip-tazo on tests

Question 77

When should diastolic and continuous murmurs be evaluated?

Answer 77

ALWAYS these are almost always pathological. Midsystolic murmurs in young healthy people don't need further evaluation.

Question 78

What needs to occur pre-op in pts. on Warfarin?

Answer 78

Rapid reversal of anticoagulation, done by infusion of FFP.

Question 79

What should be done to manage acute cholecystitis?

Answer 79

Cholecystectomy within 72 hours

Question 80

What is normal urine output?

Answer 80

800-2000 mL per 24hrs. | Oliguria is <500 mL per 24 hrs.

Question 81

What can post-op pneumonia lead to and how is it managed?

Answer 81

Septic shock – fever, tachy, HoTN, oliguria. Treat w/IVF (0.9% saline) and abx for the underlying infection. If the patient fails to respond or has signs of V-overload w/out improvement in BP then vasopressors (Dopamine) should be started to improve perfusion.

Question 82

Anterior Cord Syndrome presentation? Cause?

Answer 82

Loss of movement, pain and temp Vibration, touch and proprioception still intact. May be a cx of thoracic AA repair, bc there’s decreased blood flow through the radicular aa.

Question 83

What is one of the most common postgastrectomy cxs, and how is it managed?

Answer 83

Dumping syndrome – N/D/V, palpitations, diaphoresis, HoTN Loss of normal pyloric sphincter axn --> rapid emptying of gastric contents Tx: Dietary modification – frequent, small meals, eat slowly, avoid sugars, increase fiber and protein, drink fluids b/w and not during meals.

Question 84

Causes of initial hematuria:

Answer 84

Reflects Urethral damage | Urethritis, Trauma to urethra (caths)

Question 85

Causes of terminal hematuria:

Answer 85

Reflects bladder or prostate damage | Urothelial ca., Cystitis, Urolithiasis, BPH, Prostate ca.

Question 86

Causes of continuous hematuria (7):

Answer 86

Reflects Kidney or ureter damage | Renal mass, Glomerulonephritis, Urolithiasis, PCKD, Pyelonephritis, Urothelial ca., Trauma to kidney

Question 87

Marjolin Ulcer:

Answer 87

SCC arising within a burn wound. SCC may arise in chronically wounded, scarred or inflamed skin. SCC in chronic wounds tends to be more aggressive.

Question 88

Steps in management of complicated diverticulitis:

Answer 88

Fluid collections <3cm – IV abx and observation >3cm – CT-guided percutaneous drainage If sxs are still uncontrolled by 5th day – surgical drainage and debridement Sigmoid resection for pts w/ fistulas, perforation w/peritonitis, obstruction or recurrent attacks.

Question 89

What is a cx of PP mechanical ventilation in a pt w/hypovolemic shock?

Answer 89

Pts in hypovolemic shock have decreased CVP, and the initiation of mechanical ventilation can cause acute loss of RV preload --> loss of CO and cardiac arrest.

Question 90

What are the criteria for initiating long-term O2 therapy in pts. w/COPD?

Answer 90

1. Resting PaO2 <55mmHg or SaO2 <88% on room air | 2. PaO2 <59mmHg or SaO2<89% in pts. w/cor pulmonale, evidence of RHF or Hct >55%.

Question 91

What causes the constitutional symptoms in cardiac myxomas?

Answer 91

Overproduction of IL-6 --> fever, weight loss, or Raynaud phenomenon.

Question 92

Most common causes of hyperkalemia:

Answer 92

Acute or Chronic kidney disease | Medications or disorders that impair the RAAS.

Question 93

Clinical and ECG findings of hyperkalemia:

Answer 93

Chronic may be asx until K+ > 7mEq/L Acute causes sxs at lower levels --> ascending m. weakness, flaccid paralysis ECG changes = peaked Twaves, short QT interval, QRS widening, sine wave w/vFIb

Question 94

Therapy for hyperkalemia and when it should be instituted:

Answer 94

Acute tx: Calcium gluconate or chloride, insulin w/glucose | Should be given to pts. w/ ECG changes, K+ > 7 w/out ECG changes, or rapid K+ d/t tissue breakdown.

Question 95

What is the most common cause of acute limb ischemia post-MI? Mgmt?

Answer 95

Arterial embolus from LV thrombus. | Mgmt: immediate anticoag., vascular surgery consult, and transthoracic echo to screen for thrombus.

Question 96

Classic murmur in Aortic Regurg:

Answer 96

Decrescendo, blowing, diastolic murmur best heard at the L 4th ICS at the sternal border.

Question 97

Murmur in Aortic stenosis:

Answer 97

Systolic, crescendo-decrescendo radiating to the carotids. Best heard in R 2nd ICS at sternal border.

Question 98

Murmur in Mitral regurg:

Answer 98

HoloSystolic, best heard at apex, radiates to axilla.

Question 99

Murmur in mitral stenosis:

Answer 99

Rumbling diastolic with opening snap (closer snap is to S2 worse the stenosis). Best heard at apex.

Question 100

Diagnosis and management of AAA:

Answer 100

Use US for screening/diagnosis NOT arteriogram Anything >3.5cm is considered AAA TX: >3.5cm -- re-screen every 12 mos >4.5cm -- re-screen every 6 mos >5.5cm or growing >0.5cm/6mos -- surgery

Question 101

How to diagnose aortic dissection

Answer 101

Hemodynamically stable pts: CT Angiogram (but can't do in renal failure/elevated Cr) Unstable pts and renal failure: TEE MRA can be used but is not preferred and should also be avoided in pts w/severe kidney disease

Question 102

How to diagnose PVD: | How to identify the lesion location:

Answer 102

``` ABI: >1.4 = calcified vessel, need to do TBI instead 1.0-1.4 = normal 0.9-1 = equivocal, do exercise ABI 0.8-0.9 = Mild 0.4-0.8 = Moderate <0.4 = Severe Can use Doppler US and CTA to find where lesion is ```

Question 103

How to treat PVD:

Answer 103

Use Angioplasty/Stent if the lesion is above the knee or small Use Bypass if lesion is below the knee or large All should f/u with medical tx (Cilostazol, Pentoxyphylline)

Question 104

How to differentiate b/w neonatal conjunctivitis, and treatment:

Answer 104

Onset: <24 hr -- Chemical/Silver Nitrate, tx w/topical erythromycin 2-7d -- Gonorrhea: PURULENT. Tx: Ceftriaxone 5-14d -- Chlamydia: MUCO-Purulent. Tx: Oral Erythromycin

Question 105

How to differentiate between RAS and Primary Hyperaldosteronism:

Answer 105

Both will have HTN and Hypokalemia. Conns: Aldosterone:Renin >20 RAS: Aldosterone:Renin <10

Question 106

How to diagnose esophageal rupture?

Answer 106

Water-soluble contrast upper GI study.

Question 107

How to calculate amount of fluid needed for resuscitation in burn victims:

Answer 107

Parkland formula: | 4 x Weight in Kg x % Area Burned

Question 108

Treatment of hypocalcemia:

Answer 108

IV calcium gluconate

Question 109

Common presentation of atrial myxoma:

Answer 109

Fever, fatigue, night sweats, weight loss. Low-pitched rumbling diastolic murmur heard at the apex that disappears when pt. rolls onto R side (d/t tm obstructing mitral valve). May also have decreased Hb.

Question 110

Where does brain cancer metastasize?

Answer 110

Trick question bitch!!! | It doesnt. It stays in the brain.

Question 111

Diagnostic test for brain tm?

Answer 111

MRI w/contrast is best, then MRI w/o contrast, then CT w/contrast. Once located bx.

Question 112

Brain ca tx?

Answer 112

Resection, radiation, chemo, steroids, seizure ppx.

Question 113

Presentation and Dx of epididymitis:

Answer 113

Spontaneous pain in testicle with relief on elevation. Vertically lying testicle (opposed to horizontal in torsion) Dx w/Doppler US

Question 114

Difference in Epididymitis etiology and tx based on age:

Answer 114

<35 yrs most likely an STD -- tx w/Ceftriaxone + Azithromycin >55 yrs most likely E. coli -- tx w/a fluoroquinolone.

Question 115

Best diagnostic test for kidney stones:

Answer 115

Non-con CT | cant do CT? do US

Question 116

Presentation, Dx, and Tx of Transient synovitis:

Answer 116

Can occur at any age Presents as hip pain following a viral illness. May be so severe that the pt is non-weight bearing. Dx= clinical; Tx= supportive

Question 117

Treatment of a fracture that involves the growth plate in a kid?

Answer 117

Surgery always

Question 118

Ant. v. Post. dislocations of the shoulder:

Answer 118

Both will be adducted. Anterior- from any trauma, even minor, will have external rotation (shows palm of hand) Posterior- from massive trauma, a/w seizures and lightning strikes. Will have internal rotation (shows back of hand).

Question 119

Hard signs of neck injury:

Answer 119

Airway: gurgling, stridor, loss of airway Vasculature: Expanding hematoma, pulsatile bleeding, stroke, shock, flat neck veins

Question 120

Soft signs of neck injury:

Answer 120

Dysphonia Dysphagia SubQ air/emphysema Mild hard signs (hematoma not expanding, bleeding but not pulsatile etc.)

Question 121

Treatment of Spinal Cord syndromes:

Answer 121

Steroids-- dexamethasone | Then diagnose w/MRI

Question 122

Mgmt of pelvic fractures:

Answer 122

Typically external fixation and stabilization w/blood transfusions is enough. Only go to surgery if they are bleeding into the peritoneum. If just bleeding into pelvis don't go.

Question 123

What complication should be investigated for in electrical burns?

Answer 123

Burnt muscle will lead to Rhabdomyolysis so check CK and Creatinine.

Question 124

Rxs that cause hyperkalemia:

Answer 124

TMP-SMX – blocks eNac channel BBs – interfere w/B2 mediated K+ uptake ACEIs, ARBs, Ksparing diuretics – block eNac Digoxin – Inhibits NaK-ATPase Cyclosporine – Blocks aldosterone Heparin – Blocks aldosterone NSAIDs – decrease renal perfusion and K+ delivery to CDs Succinylcholine – extracell leakage of K+ through Ach Rs.

Question 125

Renal effects of TMP-SMX:

Answer 125

Blocks ENac channels --> hyperkalemia. Also competitively inhibits renal tubular creatinine secretion --> artificial increase in serum Cr. GFR does NOT change. Pts should have serial monitoring of K+ to avoid complications.

Question 126

Mgmt of Hypercalcemia:

Answer 126

``` Only severe (>14 mg/dL) or symptomatic pts require treatment. Short term: Normal saline + Calcitonin; Avoid loop diuretics Long term: Bisphosphonate (Zoledronic acid) ```

Question 127

What is the mgmt. and contraindications for chest pain in cocaine use?

Answer 127

Managed with benzos for BP and anxiety Aspirin, Nitroglycerin, and CCBs for pain BBs are contraindicated and Fibrinolytics should be avoided d/t risk of ICH. Cardiac catheterization w/reperfusion done when indicated.

Question 128

What are the different aspiration sites in recumbent v. upright pts?

Answer 128

Recumbent – posterior segment of the upper lobes | Upright – lower lobes or right middle lobe

Question 129

Obesity Hypoventilation Syndrome definition, and other features:

Answer 129

``` Daytime hypercapnia (PaCO2 >45mmHg) in an obese patient (BMI >30), without another explanation for the hypercapnia. Other features: dyspnea, polycythemia, RESP. ACIDOSIS w/renal compensation, pHTN, and cor pulmonale. ```

Question 130

Enoxaparin:

Answer 130

LMWH

Question 131

Factor Xa inhibitors:

Answer 131

Fondaparinux (injection), Rivaroxaban (oral)

Question 132

What defines severe renal insufficiency?

Answer 132

Estimated GFR <30 mL/min/1.73 m2.

Question 133

Expected changes in hyponatremic hypovolemia for: Serum electrolytes Urine electrolytes Enzymes

Answer 133

Decreased serum and urine Na+, Increased renin, aldosterone, and ADH.

Question 134

How do nitrates exert their effect?

Answer 134

Nitrates like nitroglycerin cause venodilation which increases peripheral venous capacitance. They cause systemic vasodilation and decrease cardiac preload --> reduce LV wall stress.

Question 135

What is the first line tx for HTN d/t renal artery stenosis (RAS)?

Answer 135

ACEIs or ARBs. If pts are refractory to therapy then revascularization or stenting may be considered.

Question 136

How will pleural pH change based on the type of effusion?

Answer 136

Normal pleural pH: 7.6 Transudative pH: 7.4-7.55 Exudative pH: 7.3-7.45 pH <7.3 norm. d/t Empyema, pleuritis, tm., pr pleural fibrosis

Question 137

What are the common respiratory findings in Granulomatosis w/Polyangitis?

Answer 137

(aka. Wegener’s) URT: chronic rhinosinusitis, otitis, saddle-nose deformity LRT: tracheal narrowing w/ulceration and CXR w/multiple lung nodules w/cavitation and alveolar opacities.

Question 138

Tx of Uric Acid stones:

Answer 138

Alkalinization of the urine w/oral Potassium Citrate, hydration, and a low-purine diet.

Question 139

How are diuretics related to renal stones?

Answer 139

Furosemide and loop diuretics increase urinary calcium excretion and can cause calcium stones. Thiazides decrease Ca2+ excretion and is used in the tx of calcium stones.

Question 140

What patients have a higher association of angiodysplasia?

Answer 140

Those with advanced renal disease, Von Willebrand, and Aortic stenosis (d/t acquired vWF deficiency).

Question 141

How does Angiodysplasia often present?

Answer 141

Episodic painless GI bleeding – often seen as dark colored stools w/normal bowel movements in between episodes. Will often have signs of anemia as well

Question 142

How is angiodysplasia diagnosed?

Answer 142

Via endoscopy – Upper GI or colonoscopy. | However it is often missed d/t poor bowel prep or location behind a haustral fold.

Question 143

EKG findings in pericarditis:

Answer 143

Diffuse ST elevation with the exception of depression in aVR.

Question 144

First line therapy for Dressler’s syndrome:

Answer 144

NSAIDs

Question 145

Common AEs of inhaled B2-agonists:

Answer 145

Hypokalemia – they drive K+ into cells, causes muscle weakness and can be confirmed w/a BMP. Headache, tremors, and palpitations.

Question 146

Hepatic Hydrothorax – Cause and presentation:

Answer 146

Seen in some pts w cirrhosis and portal HTN. Results from small defects in the diaphragm that allow peritoneal fluid to pass into the pleural space. Occurs more commonly on the right. Causes dyspnea, cough, pleuritic chest pain, and hypoxemia.

Question 147

Hematologic effects of glucocorticoids:

Answer 147

Causes leukocytosis with NP predominance. Mobilizes marginated NPs into the blood, where they are non-fxnl. Decreases LPs and eosinophils.

Question 148

Oliguria:

Answer 148

<250 mL of urine in 12 hrs.

Question 149

Post-op Oligura definition + management?

Answer 149

<0.5 mL/kg/hr – needs immediate assessment w/bladder scan, if urinary retention is present they need a catheter.

Question 150

Scleroderma renal crisis:

Answer 150

Sudden onset of renal failure (w/o previous kidney disease), malignant HTN (HA, blurry vision, N). UA may show mild proteinuria PBS may show microangiopathic hemolytic anemia or DIC w/schistocytes and thrombocytopenia.

Question 151

What is the common finding of a hepatic mass with central scarring on CT scan?

Answer 151

Focal nodular hyperplasia. | Doesn't require tx unless symptomatic -- then resection.

Question 152

What hematologic abnormalities may be seen in Meckel Diverticulum?

Answer 152

Ongoing bleeding from the diverticulum may cause Iron Deficiency anemia

Question 153

CXR shows: pleural effusion w/extensive soft tissue density. Dx? Thoracentesis findings?

Answer 153

Mesothelioma -- extensive soft tissue density = pleural plaques. Thoracentesis will show bloody, exudative effusion.

Question 154

What will be seen on XR of toxic megacolon?

Answer 154

Loss of haustra and dilated bowel. | Use sigmoidoscopy-guided placement of rectal tube to manage.

Question 155

What lab values will be seen with decreased excretion of BR?

Answer 155

Hyperbilirubinemia with predominately conjugated BR. If it is 50-50 Direct-Indirect or predominately indirect then look for another cause of the hyperbilirubinemia (overproduction of BR after transfusion, etc.)

Question 156

Why might alcoholics develop Hypocalcemia?

Answer 156

They are at increased risk for Hypomagnesemia d/t renal tubular loss. W/o magensium PTH cannot be released and therefore Ca2+ levels fall.

Question 157

When is it safe to give anticoagulants post-op?

Answer 157

They can be given 6-12 hrs post-op

Question 158

Tx of hyperaldosteronism:

Answer 158

Spironolactone or other Aldosterone receptor blockers

Question 159

What are ARBs?

Answer 159

ANGIOTENSIN RECEPTOR BLOCKERS!!!!!

Question 160

Management of anal mass:

Answer 160

When thought to be cancer first biopsy to prove cancer, and then use Nigro chemoradiation protocol. If this is not successful in eliminating it completely (90% success rate) then surgery can be used as a last resort in rare cases to remove residual tumor.

Question 161

Causes of fistulas:

Answer 161

``` Foreign body Epithelization Tumors Irradiation Inflammation/IBD Distal obstruction ```

Question 162

What abx should be given in pancreatitis w/proven infection?

Answer 162

Carbapenem

Question 163

When should a pancreatic pseudocyst be drained?

Answer 163

Needs draining if >6cm or if its been present >6 weeks. This indicates complication and high risk of infection. <6cm or 6 weeks you can observe.

Question 164

Colonoscopy schedule:

Answer 164

q10 if clean or hyperplastic q5 if polyp is seen q3 if polyp is CIS or villous q1 if polyp has dysplasia

Question 165

Treatment of urethral injuries:

Answer 165

Anterior- immediate surgical repair | Posterior- suprapubic cystostomy tube and wait for repair

Question 166

What does the cyanide-nitroprusside test detect?

Answer 166

Elevated levels of cystine. Can help confirm the dx of Cystinuria.

Question 167

What metabolic disorder can develop in carcinoid syndrome?

Answer 167

Pellagra (Niacin deficiency). This is d/t the depletion of tryptophan for the preference of conversion to serotonin and 5-HIAA. Tryptophan is needed for both 5-HT and Niacin synth.

Question 168

What metabolic disorder can Isoniazid therapy lead to?

Answer 168

B6/pyridoxine deficiency --> peripheral neuropathy Pellagra/Niacin deficiency --> Diarrhea, Dementia and Dermatitis. D/t interference of tryptophan metabolism (less common, seen in prolonged tx).

Question 169

ABG findings in CHF:

Answer 169

hypoxic, hypercapnic, respiratory alkalosis.

Question 170

What drug therapy is started in pts w/Coronary heart disease to reduce morbidity and mortality?

Answer 170

Dual-antiplatelet therapy: Aspirin + P2y12R blocker (clopidogrel, prasugrel, ticagrelor) BBs ACEIs or ARBs Statins Aldosterone Antagonists (spironolactone, eplerenone)

Question 171

Complications of PEEP:

Answer 171

Alveolar damage, pneumothorax, and HoTN. | Pts. w/underlying lung disease (ARDS, pneumonia, COPD) are especially susceptible.

Question 172

Clinical features of Pneumothorax:

Answer 172

``` Hyperresonance to percussion Diminished breath sounds Decreased tactile fremitus HoTN from decreased VR (collapsed lung compresses the IVC) Tachycardia from impaired RV filling Increased CVP ```

Question 173

Features of obstructive ureterolithiasis:

Answer 173

Severe L lower AbdP radiating to the groin, vomiting, and unremarkable findings on PE. Dx w/US or noncon CT

Question 174

Renal vein thrombosis:

Answer 174

Complication of any nephrotic syndrome, but most commonly a/w membranous glomerulopathy. D/t the loss of antithrombin III in the urine. Presents acutely w/AbdP, fever, hematuria Or more commonly progressive as a gradual worsening of renal fxn, and proteinuria in an asx pt.

Question 175

Clinical presentation of spontaneous bacterial peritonitis:

Answer 175

T > 37.8/100 Abdominal Pain/tenderness Altered mental status HoTN, Hypothermia, paralytic ileus w/severe infection

Question 176

What is spontaneous bacterial peritonitis?

Answer 176

Ascitic fluid infection w/out an obvious intraabdominal surgical etiology. Seen in pts w/cirrhosis.

Question 177

Metabolic AEs of thiazides:

Answer 177

``` Hyperglycemia Increased LDL and TGs Hyperuricemia Hypokalemia Hyponatremia Hypomagnesemia Hypercalcemia ```

Question 178

Tx to rapidly lower K+:

Answer 178

Insulin w/glucose B2-agonists Sodium bicarb in acidotic patients Ca2+ gluconate will stabilize the cardiac membrane, but will not reduce K+

Question 179

Tx to slowly remove K+ from the body:

Answer 179

Diuretics Cation exchange resins Hemodialysis

Question 180

What cardiac issues are associated with malignancies?

Answer 180

Malignancy causes a hypercoagulable state which can lead to massive PE --> RV dysfxn: hemodynamic collapse, syncope, decreased VR, decreased CO. Elevated CVP/JVP

Question 181

What arrhythmia is most specific for Digoxin toxicity?

Answer 181

Atrial tachycardia w/AV block

Question 182

What test is advised for all pts w/suspected gallstone pancreatitis?

Answer 182

RUQ US Then managed w/ERCP to remove the stone Biliary causes of pancreatitis typically present w/ALT > 150

Question 183

How to differentiate b/w osmotic and secretory diarrhea:

Answer 183

Osmotic will have an elevated stool osmotic gap (>125mOsm/kg) Secretory will have a reduced SOG (<50mOsm/kg)

Question 184

Difference between stress and urgency incontinence treatments:

Answer 184

Stress- Lifestyle mods, pelvic floor exercises, pessary, pelvic floor surgery Surgery for stress incontinence can cause urge incontinence later. Urge- Lifestyle mods, bladder training, then antimuscarinics (oxybutynin)

Question 185

Overflow incontinence tx:

Answer 185

Cholinergic agonists, intermittent self-catheterization.

Question 186

If urine osmolality is <100mOsm what should be considered?

Answer 186

Primary polydipsia and malnutrition (beer drinker’s potomania)

Question 187

Difference b/w thrombus and emboli:

Answer 187

Emboli is a fragment that travels and blocks. Thrombus is a blockage that develops in the site it blocks.

Question 188

What ECG findings are consistent with LVH?

Answer 188

High-voltage QRS complexes, lateral ST depression and lateral T wave inversion.

Question 189

Persistent HTN, headaches and nosebleeds in a young pt is concerning of what?

Answer 189

Coarctation of the Aorta—should asses w/ bilateral arm and leg BP readings and pulse checks for brachial-femoral delay.

Question 190

Diagnostic test of choice for PE:

Answer 190

CT angio

Question 191

Most common source of liver mets?

Answer 191

Colorectal cancer—blood from the colon travels through the portal circulation directly to the liver. Lung and breast also commonly met to the liver.

Question 192

What is likely in a young woman with a subauricular systolic bruit?

Answer 192

Fibromuscular dysplasia – causes internal carotid a. stenosis and presents w/recurrent HA, pulsatile tinnitus, TIA and stroke. May also have an abdominal bruit from the RAS --> secondary HTN (leads to hyperaldosteronism) and flank pain.

Question 193

Most common CoD in dialysis pts:

Answer 193

CVD. Also the most common CoD in renal transplant pts.

Question 194

Varying amplitude of QRS complexes suggests what?

Answer 194

Electrical alternans which is highly specific for pericardial effusion. Tx would be emergency pericardiocentesis.

Question 195

Treatment of variant/vasospastic angina:

Answer 195

Prevention w/diltiazem (CCB = potent coronary dilator, but weak systemic dilator) and sublingual nitroglycerin for abortion of an episode. BBs and aspirin are contraindicated in variant angina.

Question 196

What drugs are likely used to tx MDR pyelonephritis?

Answer 196

Aminoglycosides (like Amikacin) bc they treat serious G- organisms which commonly cause pyelonephritis. These may cause ARF in the setting of CKD though. Renal function should be monitored closely.

Question 197

What complication is often secondary to viral pericarditis?

Answer 197

Pericardial effusions – causes electrical alternans on EKG, enlarged cardiac silhouette, distended neck veins and distant heart sounds. PE can vary, but almost all patients have an impalpable PMI

Question 198

What should be done first in mgmt. of suspected cardiac tamponade?

Answer 198

Urgent echo to confirm diagnosis. | Most likely will present with signs of cardiogenic shock

Question 199

What will be seen on pulmonary artery catheterization in the setting of cardiac tamponade?

Answer 199

Elevation and equalization of intracardiac diastolic pressures RA, RV, and PCWP will all resemble LA pressure.

Question 200

What is a positive Kussmaul’s sign and what does it suggest?

Answer 200

Increase in JVD with inspiration | Often positive in RV failure.

Question 201

What are signs of RV MI?

Answer 201

Often in patients w/acute inferior wall MI d/t occlusion of the RCA proximal to the RV brs. Signs/Sxs: chest pain, HoTN, autonomic signs (diaphoresis, V), and EKG findings of ST elevation in leads II, III, and aVF. May also have JVD, +Kussmaul’s sign, and clear lung fields suggestive of RVF Possible bradycardia or AV block bc enhanced AV tone.

Question 202

What special mgmt. is implemented in RVF in addition to standard MI therapy?

Answer 202

Boluses of IVF to improve RV preload and increase LV filling. These pts are preload dependent and anything that reduces preload (nitrates, diuretics) should be avoided.

Question 203

What coronary a. is involved in papillary muscle rupture?

Answer 203

RCA

Question 204

What complications are associated with the LAD coronary?

Answer 204

Free wall rupture LV aneurysm Interventricular septum rupture

Question 205

What coronary vessels can be involved in a IV septum rupture?

Answer 205

LAD (apical septal) | RCA (basal septal)

Question 206

Most common signs/sxs of PE:

Answer 206

Dyspnea, pleuritic chest pain, tachypnea, tachycardia | Often CXR is abnormal, but many cases may have normal CXR

Question 207

Mgmt of BB overdose:

Answer 207

Initially secure airway, IVF, IV atropine. Pts w/refractory or profound HoTN may then require IV glucagon as the next step. This may also treat CCB overdose. Other therapies include: IV Ca2+, vasopressors (E/NE), high dose insulin and glucose, and IV lipid emulsion.

Question 208

Most common cause of constrictive pericarditis in developing countries:

Answer 208

TB

Question 209

Beck’s triad:

Answer 209

HoTN, Distended neck veins, muffled heart sounds – a/w cardiac tamponade Pulsus paradoxus and +hepatojugular reflux are other common signs of tamponade

Question 210

What is responsible for the sxs of cardiac tamponade?

Answer 210

``` Fluid accumulation in the pericardial cavity increases intrapericardial P above the diastolic ventricular P. The sxs (Beck’s triad) are d/t an exaggerated shift of the IV septum toward the LV cavity, this reduces LV preload, SV, and CO. ```

Question 211

Most common cause of sudden cardiac arrest immediately post-MI:

Answer 211

Reentrant ventricular arrhythmias (vFib)

Question 212

How does a ventricular aneurysm present on EKG?

Answer 212

With persistent ST-elevation after a recent MI (5d-3m), and deep Q waves in the same leads.

Question 213

What is a systolic-diastolic abdominal bruit most suggestive of?

Answer 213

Renal artery stenosis.

Question 214

What should be suspected in pts w/diffuse atherosclerosis and resistant HTN?

Answer 214

Renovascular HTN (RAS)

Question 215

Why are IMCPd more likely to develop nocardia infections?

Answer 215

Bc the branching, filamentous growth prevents phagocytosis making host defense dependent on cell-mediated immunity which is often lacking in IMCPd.

Question 216

Tx for nocardiosis:

Answer 216

TMP-SMX txs pulmonary Nocardiosis, may require additional abx like amikacin in severe disease. Carbapenems are added when the brain is involved

Question 217

Who should receive the HAV vaccine?

Answer 217

Pts w/chronic liver disease (HBV, HCV etc) MSM IVDU Travelers to endemic countries

Question 218

Presentation of vitreous hemorrhage:

Answer 218

Sudden loss of vision and onset of floaters. Reduced visual acuity to light perception, loss of fundus details, floating debris and a dark red glow. Diabetic retinopathy is #1 cause

Question 219

What is the best way to monitor a pts response to treatment in DKA and HHS?

Answer 219

Monitor the serum anion gap, or direct assay of beta-hydroxybutyrate

Question 220

What condition classically causes bilateral internuclear ophthalmoplegia?

Answer 220

MS – bilateral lesions in the MLF, bilateral adduction difficulties and nystagmus in the abducted eye.

Question 221

Why do some pts w/celiac disease have negative results on IgA testing?

Answer 221

Many patients have an associated selective IgA deficiency as well. This causes the anti-tissue transglutaminase and anti-endomysial tests to be negative.

Question 222

What MRI changes are associated with alzheimers disease?

Answer 222

Temporal lobe atrophy, mostly in the medial temporal lobes and hippocampi. Parietal may be seen but is much less likely - more likely to be seen in Primary Progressive aphasia Dementia syndrome

Question 223

What will an EKG show in moderate hypokalemia?

Answer 223

Broad, flattened T-waves, U-waves, ST-depression and PVCs | May have some or all

Question 224

When does workup need to be done for a murmur?

Answer 224

Grade III and above systolic murmurs, and all diastolic murmurs. Start w/ echo

Question 225

Why are pts w/Multiple Myeloma at increased risk of infection?

Answer 225

Bc the neoplastic cells infiltrate the bone marrow and impair normal lymphocyte proliferation – ineffective Ab production and hypogammaglobulinemia.

Question 226

What will CSF analysis of Guillain-Barre look like?

Answer 226

Normal except for increased protein.

Question 227

Most commonly isolated organisms to cause brain abscess:

Answer 227

S. aureus and S. viridans

Question 228

What should be used to reduce thromboembolic events in pts w/aFib?

Answer 228

Warfarin or non-VitK antagonist anticoagulants. | These are much more effective than the antiplatelet agents (aspirin, clopidogrel)

Question 229

What is a factorial design?

Answer 229

A study that involves the randomization to different interventions w/additional study of 2+ variables.

Question 230

What is likely to cause chondrocalcinosis?

Answer 230

Pseudogout, which is typically caused by: - hyperPTHism - HypOthyroidism - Hemochromatosis Chrondrocalcinosis = irregular opaque structures in articular cartilage (looks like white stuff IN BETWEEN joint lines)

Question 231

What is Adhesive capsulitis?

Answer 231

When the glenohumeral joint loses its normal distensibility d/t chronic inflammation, fibrosis, and contracture of the joint capsule. Have shoulder stiffnes >> pain, and ROM is markedly reduced both actively and passively.

Question 232

How to distinguish Grave’s from painless (silent) thyroiditis:

Answer 232

Radioiodine uptake. Painless/silent will have decreased uptake Graves will have increased uptake

Question 233

What metabolic/lab abnormalities can hypothyroidism cause?

Answer 233

Hyperlipidemia (decreased LDL-Rs or decreased LDL-R activity) Hyponatremia (d/t decreased free H2O clearance) Asx elevation in creatinine kinase Elevated serum transaminases Macrocytic anemia

Question 234

What can and cannot be calculated in a case-control study?

Answer 234

Odds ratio can- it measures the association between exposed individuals and the controls. Relative risk cannot- it can be calculated in cohort studies that follow individuals over time. The OR generally approximates the RR in case-controls if the disease is rare (low disease prevelance), or the disease incidence (# of new cases) is low --> “rare disease assumption”

Question 235

When do Relative Risk and Odds Ratio approximately equal each other?

Answer 235

In rare disease states.

Question 236

What type of skin cancer is most common in IMCPd?

Answer 236

SCC is common especially in post-transplant patients or those on immunosuppressants. It is also more aggressive in these pts. with increased risk of local recurrence and mets.

Question 237

What complication is a/w neurologic deterioration w/in 2 days after an ischemic stroke?

Answer 237

Hemorrhagic transformation – often when the stroke affects large areas, is d/t an embolic cause or the pt. has been treated with thrombolytics. Often need urgent surgical decompression to treat.

Question 238

When will you see the Jarisch-Herxheimer reaction?

Answer 238

W/in 6-48 hrs of treating a spirochetal disease – mostly syphilis but could be lyme etc.

Question 239

What complications can be prevented by lowering HbA1c/achieving glycemic control in DM?

Answer 239

The microvascular complications – nephropathy and retinopathy – will be reduced. It will have no change on the macrovascular complications – MI, stroke.

Question 240

How to differentiate bed bug rash from scabies:

Answer 240

Scabies are often on the palms, flexor wrist, lateral surface of the fingers and finger webs. It is v pruritic and worse at night. Bed bugs often cause small, punctate lesions in a linear track of clusters. Not commonly on the palms or soles bc of the thickness of the skin.

Question 241

Tx of scabies:

Answer 241

Topical permethrin or oral ivermectin.

Question 242

When is abx prophylaxis indicated for patients w/rheumatic fever valvular defects?

Answer 242

ONLY if they have a history of IE. | If no hx of IE then the risk of developing it following a dental procedure is v low and abx aren’t indicated.

Question 243

How does PCV affect EPO levels?

Answer 243

It causes them to be low bc the constitutively active JAK2 is what causes the overproduction of RBCs and high Hb, not hypoxia.

Question 244

What is Riluzole?

Answer 244

A glutamate inhibitor for ALS. Doesn’t stop progression, but may prolong time to tracheostomy.

Question 245

Most common location of ectopic foci to cause aFib?

Answer 245

Pulmonary veins

Question 246

Best treatment for acute for cluster headaches? And prophylaxis?

Answer 246

Tx: 100% O2 by facemask – most rapid-acting and effective w/out any major AEs. - SubQ sumatriptan can be used if there are no contraindications. Pphx: Verapamil or lithium and should be started asap after the onset of an acute attack.

Question 247

What causes of Hyperthyroidism cause ophthalmopathy?

Answer 247

ONLY graves. If a patient has elevated thyroid hormones and ophthalmopathy then it has to be graves.

Question 248

How to differentiate between Subacute granulomatous (De Quervian) vs. Subacute lymphocytic thyroiditis:

Answer 248

BOTH: - Progress from hyper to hypothyroidism w/ a diffusely enlarged thyroid. - Screen: T3/T4, thyroglobulin (increased), and TSH - Confirm: Increased ESR, decreased iodine uptake - Tx: BB + NSAIDS (MTZ is contraindicated!) for thyrotoxic, levothyroxine for hypothyroid phase Subacute granulomatous = due to infection + painful thyroid +/- jaw pain. Subacute lymphocytic = due to drugs/autoimmune/post-pregnancy + not painful

Question 249

What auto-Abs may be seen in PBC?

Answer 249

Anti-mitochondrial are the most commonly associated. Anti-smooth muscle may also be present but these are more commonly seen in Autoimmune hepatitis.

Question 250

What is goat’s milk deficient in?

Answer 250

Folate

Question 251

What test should be done in a patient with a low Wells score meaning PE is unlikely?

Answer 251

D-dimer – it has high negative predictive value and can exclude the diagnosis of PE. Patients with a high wells score should undergo a CTA, or a V/Q scan if they have contraindications to a CTA.

Question 252

What chromosome is linked to CF?

Answer 252

Chromosome 7 at position F508 is most common.

Question 253

What drug is often a/w an increased risk of PML?

Answer 253

Natalizumab an alpha-4-integrin inhibitor. Often used to treat MS and Crohn’s. It interferes w/LCs, MCs and vascular adhesion of inflammatory cells. Rituximab a CD20 antagonist. Used to treat B-cell NH lymphoma, CLL, RA, and ITP.

Question 254

Most common cranial nerve palsy a/w idiopathic intracranial HTN?

Answer 254

CN VI

Question 255

Medications that can cause idiopathic intracranial HTN:

Answer 255

Growth Hormone Tetracyclines (minocycline, doxy) xs Vit. A and its derivatives: Isotretinoin, ATRA.

Question 256

What FiO2 levels can cause O2 toxicity?

Answer 256

Anything >60%. | When pts are first put on ventilators these levels are often exceeded but should be reduced asap to prevent toxicity.

Question 257

What bone complication can be caused by Celiac and what would the lab findings be?

Answer 257

Osteomalacia – impaired osteoid matrix mineralization. | Have increased AlkPhos and PTH, decreased serum and urinary Ca2+, and 25 OH-D levels.

Question 258

Characteristic radiologic finding of osteomalacia:

Answer 258

Decreased bone density w/thinning of the cortex Bilateral and symmetric pseudofractures (looser zones) Eventually will cause "codfish" vertebral bodies w/a concave shape.

Question 259

Management of tachyarrhythmia causing hemodynamic instability:

Answer 259

Immediate synchronized direct current cardioversion.

Question 260

Initial management for patients with hypertriglyceridemia:

Answer 260

Statin therapy Weight loss Decreased EtOH intake Increased exercise ** Although fibrates decrease TGs these are rarely needed in addition to statins.

Question 261

Treatment of Shingles:

Answer 261

Acyclovir, Famciclovir, Valacyclovir

Question 262

What is Hepatorenal syndrome?

Answer 262

Complication of end-stage liver disease. Characterized by decrease in glomerular filtration w/out another clear cause of renal dysfxn., minimal hematuria (<50 RBCs) and lack of improvement w/volume resuscitation. Pts. develop splanchnic arterial dilation and decrease in vascular resistance, get renal HoPerfusion.

Question 263

Treatment of Painless/Silent thyroiditis:

Answer 263

It is normally self-limiting and doesn’t require therapy, but a BB (propranolol) may be prescribed to control the hyperthyroid sxs.

Question 264

Complications of Metoclopramide and Prochlorperazine:

Answer 264

Both are dopamine antagonists and used as antiemetics. They can cause EPS like acute dystonias, akathisia, and parkinsonism.

Question 265

What is telogen effluvium?

Answer 265

One of the most common causes of hair loss in adults. Follicles undergo widespread shedding and cease growing. Often follows a stressful event – weight loss, pregnancy, major illness/surgery, or psychiatric trauma. In the hair pull test, extraction of >10-15% of fibers suggests TE. Self-limiting but may take up to a year to resolve.

Question 266

Characteristics and treatment of Ehrlichiosis:

Answer 266

Transmitted by tick, causes flu-like illness w/ fever, HA, myalgias, chills, neuro sxs Leukopenia and thrombocytopenia w/elevated liver enzymes and LDH Tx: doxycycline.

Question 267

Rxs that contribute to increased LDL-C levels:

Answer 267

Thiazides Cyclosporine Glucocorticoids Amiodarone

Question 268

Treatment of central retinal a. occlusion:

Answer 268

Emergently treated w/ocular massage and high-flow O2. | Can give thrombolytics if w/in 4-6hrs but must be admin’d intra-ARTERIALLY cannot be given systemically via IV.

Question 269

Presentation of Multiple Myeloma:

Answer 269

Often presents w/anemia and hypercalcemia in a patient with bone pain (chest or back). Classically progresses to renal insufficiency w/bland urinalysis and evidence of granular casts.

Question 270

Treatment of Bacillary angiomatosis:

Answer 270

Oral erythromycin

Question 271

Cause of bilateral trigeminal neuralgia:

Answer 271

MS is one of the only conditions that causes b/l trigeminal neuralgia – d/t demyelination of the nucleus of the CN V nerve or nerve root.

Question 272

Management of Infectious Mononucleosis:

Answer 272

Supportive, and avoidance of sports for >3 weeks (4 if its contact sports) d/t risk of splenic rupture.

Question 273

What test can identify patients w/ Primary adrenal insufficiency (Addison’s)?

Answer 273

ACTH stimulation (cosyntropin test). Should also include 8AM serum cortisol measurement.

Question 274

What has the strongest association with both ischemic and hemorrhagic strokes?

Answer 274

HTN – d/t the shearing force on the intracerebral vascular endothelium, it accelerates AS and promotes thrombi formation.

Question 275

What test is commonly used to compare two means?

Answer 275

The two-sample t test. | In contrast to the chi-squared test which compares categorical data and proportions between two groups.

Question 276

Best initial test to perform on acute stroke patients?

Answer 276

CT w/out contrast – this will rule out hemorrhage the quickest.

Question 277

How to differentiate b/w CML and Leukemoid rxn:

Answer 277

CML: - LAP low - Immature NP precursors = myelocytes > Metamyleocytes - Absolute basophilia Leukmoid: - LAP high - Mature NP precursors = Metamyelocytes > myleocytes - No basophilia

Question 278

EKG leads involved in anterior MI:

Answer 278

LAD blocked | Some or all of V1-V6

Question 279

EKG leads involved in inferior MI:

Answer 279

RCA or LCX blocked ST elevation in leads II, III, and aVF Inferior MIs are a/w HoTN, bradycardia and AV block.

Question 280

EKG leads involved in posterior MI:

Answer 280

LCX or RCA blocked ST depression in V1-V3 ST elevation in I and aVL (LCX) ST depression in I and aVL (RCA)

Question 281

EKG leads involves in lateral MI:

Answer 281

LCX, diagonal vessel blocked ST elevation in I, aVL, V5 and V6 ST depression in II, III, and aVF

Question 282

EKG leads involved in RV MI:

Answer 282

Blocked RCA ST elevation in V4-V6 Occurs in 1/2 of Inferior MIs

Question 283

What is used to confirm the diagnosis of ankylosing spondylitis?

Answer 283

Lumbar XR. | HLA-B27 is not needed – only seen in 5% of patients.

Question 284

Common causes of secondary amyloidosis (AA):

Answer 284

``` Inflammatory arthritis (RA) Chronic infections (bronchiectasis, TB, osteomyelitis) IBD (crohn’s) Malignancy (lymphoma) Vasculitis ```

Question 285

Diagnosis of secondary amyloidosis (AA):

Answer 285

Abdominal fat pad aspiration biopsy

Question 286

Tx of secondary amyloidosis (AA):

Answer 286

Tx underlying condition | Colchicine for prevention and treatment

Question 287

Management of iatrogenic Hyponatremia:

Answer 287

Hypertonic (3%) saline Serial measurement of electrolytes Increase serum sodium

Question 288

What makes a patient automatically not a candidate for lung cancer surgery?

Answer 288

If they have positive LNs from a mediastinal sampling.

Question 289

What is the initial workup for pts. w/HTN?

Answer 289

Basic lab analysis w/urinalysis, chemistry panel, lipid profile, and baseline EKG. In addition a detailed history and physical should be performed

Question 290

Management of torsades de pointes:

Answer 290

In hemodynamically stable pts. first line is Magnesium sulfate. In hemodynamically unstable patients immediate defibrillation needs to be done.

Question 291

DoC for treating Lyme disease:

Answer 291

Doxycycline for most patients – will also treat/prevent coexisting anaplasmosis. In pregnant/lactating women and young children DoC is amoxicillin or cefuroxime

Question 292

Causes of metabolic alkalosis that are responsive to saline:

Answer 292

``` Vomiting Gastric suctioning Diuretics Laxative abuse Volume depletion Urine Chloride <20 mEq/L ```

Question 293

Saline-resistant causes of metabolic alkalosis:

Answer 293

``` Primary hyperaldosteronism Cushing’s Severe hypokalemia (<2mEq/L) Urine chloride >20 mEq/L May see increased Na+ as there is xs mineralocorticoid in these types of metabolic alkalosis and Na+ retention. ```

Question 294

Most effective non-pharmacological intervention to reduce BP:

Answer 294

Weight loss in overweight patients. | DASH diet in others.

Question 295

What should be suspected in a pt w/painless blisters that heal with scarring, and increased skin fragility?

Answer 295

Porphyria cutanea tarda – especially in a patient with HCV. | May also see facial hypertrichosis, and hyperpigmentation.

Question 296

Effect of cirrhosis on thyroid function:

Answer 296

The liver produces thyroid-binding proteins (thyroxine-binding globulin, transthyretin, albumin etc). When the liver fails, total T3 and T4 levels will decrease (because of decreased transport proteins), but free T3 and T4 remain unchanged. So, TSH will be normal looking like the pt. is euthyroid.

Question 297

Common precipitating factors of thyroid storm:

Answer 297

``` Thyroid surgery NON-thyroid surgery!! Acute illness Childbirth Acute iodine load (iodine contrast) ```

Question 298

In diabetic neuropathy what is responsible for the positive v. negative symptoms?

Answer 298

Axonopathy of large nerve fibers causes the negative sxs (numbness, loss of proprioception and vibration sense, diminished ankle reflexes) Axonopathy of small nerve fibers causes the positive sxs (pain, paresthesias, allodynia)

Question 299

NNT equation:

Answer 299

``` NNT = 1/ARR ARR = Risk in control group – Risk in treatment group ```

Question 300

Main complication of prolonged seizures:

Answer 300

Cortical laminar necrosis – can lead to persistent neuro deficits and recurrent seizures.

Question 301

Treatment of Nocardia:

Answer 301

TMP-SMX for pulmonary | Add Carbapenems if brain is involved

Question 302

Rxs that commonly cause folic acid deficiency:

Answer 302

Phenytoin (plus other anti-epileptics), primidone, phenobarbital, TMP, MTX

Question 303

Presentation of pulmonic valve stenosis:

Answer 303

Severe cases present w/RHF in childhood Mild cases have sxs like dyspnea in early adulthood w/ a crescendo-decrescendo murmur that increases on inspiration with a systolic ejection click and widened split S2.

Question 304

What should be given to patients with hypercalcemia d/t bony metastatic lesions?

Answer 304

Bisphosphonate therapy – will stabilize the destructive tumors, reduce risk of pathologic fractures and malignant hypercalcemia.

Question 305

ABG in salicylate toxicity:

Answer 305

Low PaCO2, Low HCO3, and near-normal pH | Bc there is respiratory alkalosis followed by an anion gap metabolic acidosis.

Question 306

Benign paroxysmal positional vertigo:

Answer 306

Episodic dizziness triggered by positional changes d/t crystalline deposits (canaliths) in the semicircular canals that disrupt the flow of vestibular fluid. This is the most common cause of vertigo

Question 307

Dix-hallpike maneuver:

Answer 307

Vertigo and nystagmus triggered by quickly lying back into a supine position with the head rotated 45 degrees. Used to diagnose benign paroxysmal positional vertigo.

Question 308

Tx of Malignant otitis externa:

Answer 308

IV anti-pseudomonal antibiotics, like ciprofloxacin | +/- surgical debridement

Question 309

Gait in Parkinsonism:

Answer 309

Slow, Shuffling, HYPOKINETIC gait. Typically narrow-based.

Question 310

CYP450 Inhibitors:

Answer 310

``` Increase drug effects. Acetaminophen, NSAIDs Abx/Antifungals (metronidazole) Amiodarone Cimetidine Cranberry juice, Ginko, Vitamin E Omeprazole/ PPIs Thyroid Hormone SSRIs (fluoxetine) ```

Question 311

CYP450 Inducers:

Answer 311

``` Decrease drug effects Carbamazepine, phenytoin Ginseng, St. John’s wort Oral contraceptives Phenobarbital Rifampin ```

Question 312

What foods may have an effect on Warfarin?

Answer 312

Brussel sprouts, spinach, or anything else with a good source of Vitamin K. These decrease warfarin’s effect

Question 313

Treatment of Polymyalgia rheumatica:

Answer 313

Glucocorticoids

Question 314

Lab findings in Antiphospholipid antibody syndrome:

Answer 314

paradoxical aPTT prolongation not reversed on plasma mixing studies – d/t the lupus anticoagulation effect. Anticardiolipin Ab Anti-B2-Glycoprotein-I Ab

Question 315

Treatment of Rhino-Orbital-Cerebral mucormycosis:

Answer 315

Surgical debridement + Amphotericin B

Question 316

What complication is seen with Voriconazole use in pts w/Heme malignancies?

Answer 316

Independent risk factor for Mucormycosis

Question 317

Early side effects of levodopa/carbidopa:

Answer 317

``` Hallucinations Confusion Agitation Dizziness Somnolence Nausea ```

Question 318

How would a patient with metastatic testicular cancer likely present?

Answer 318

Testicular tms often met to the retroperitoneal LNs causing low back pain, and the lungs causing dyspnea/cough and pulmonary nodules on CXR. Should be suspected when a young patient presents w/these sxs.

Question 319

Tx of aFib in pts with WPW:

Answer 319

``` Cardioversion or antiarrhythmics like Procainamide AVN blockers (BBs, CCBs, Digoxin, Adenosine) are contra’d bc they can increase conduction through the accessory pathway. ```

Question 320

What levels of pro-insulin are expected to be seen in patients with insulinomas?

Answer 320

Increased levels >5 pmol/L

Question 321

What are some complications of heat stroke?

Answer 321

Rhabdomyolysis Renal failure ARDS DIC – which leads to coagulopathic bleeding and persistent epistaxis

Question 322

Ocular AEs a/w PDE-5 inhibitors:

Answer 322

Blue discoloration of vision | Nonarteritic anterior ischemic optic neuropathy

Question 323

Rx interactions w/PDE-5 inhibitors:

Answer 323

Antihypertensives along with these Rxs can cause severe HoTN, but especially a-blockers like Doxazosin and Nitrates. Both these classes should be avoided.

Question 324

Tx of E. histolytica:

Answer 324

Metronidazole + an intraluminal abx (Paromomycin- an aminoglycoside)

Question 325

When are smudge cells seen?

Answer 325

In cases of CLL – these are pathognomonic.

Question 326

Presentation of CLL:

Answer 326

Often asx, but can have extreme fatigue, B sxs, infection or weight loss. PE shows lymphadenopathy and splenomegaly.

Question 327

What suggests impending respiratory collapse in an asthma exacerbation?

Answer 327

A near normal pH and PaCO2 on ABG – indicates that the ongoing increased work of breathing is unable to maintain adequate ventilation. Resp. mm. fatigue and/or severe air trapping prevent meeting the demands of increased respiratory drive and suggest impending resp. collapse.

Question 328

What valvular pathology can occur 2/2 pacemaker placement?

Answer 328

Tricuspid regurge. | The RV lead passes through the SVC and RA through the tricuspid valve and can damage the valve leaflets.

Question 329

What causes Age-related macular degeneration?

Answer 329

Degeneration and atrophy of the central retina (macula), retinal pigment epithelium, Bruch’s membrane, and choriocapillaries.

Question 330

How will AMD present?

Answer 330

Age-related macular degeneration. Presents w/ progressive loss of central vision with peripheral fields and navigational vision maintained. May develop cataracts after a while.

Question 331

Presentation of Chronic Prostatitis/Chronic pelvic pain syndrome:

Answer 331

Pain in pelvis, perineum, and genitalia. Pain can radiate to the back. Irritative voiding sxs (urgency, hesitancy) Hematospermia, pain w/ejaculation Normal urinalysis and negative culture results Typically NO prostate tenderness.

Question 332

What causes Chronic Prostatitis/CPPS?

Answer 332

Unclear etiology – thought to be noninfectious chronic prostate inflammation.

Question 333

Tx for chronic prostatitis/CPPS:

Answer 333

Abx (quinolones) even though bacteria aren’t thought to cause it. a-blockers (tamsulosin) 5-a-reductase inhibitors (finasteride)

Question 334

How long does it take for Coccidioides to present?

Answer 334

Typically get sxs 7-14 days after inoculation w/ the fungus (mold).

Question 335

Incubation time for Blastomyces?

Answer 335

3-6 weeks!

Question 336

When do you begin tx for HoThyroidism?

Answer 336

When TSH >5

Question 337

Hetrophile antibody test:

Answer 337

Aka monospot – positive in infectious mononucleosis, but there is a 25% false-negative rate during the 1st week of illness.

Question 338

Manifestations of PCV:

Answer 338

``` HTN Erythromelalgia (burning cyanosis in hands/feet) Transient Visual distrubances Aquagenic pruritis Gouty arthritis Bleeding Facial plethora Splenomegaly ```

Question 339

Tx of PCV:

Answer 339

Phlebotomy or Hydroxyurea if increased risk of thrombus

Question 340

What should be given in cases of COPD exacerbation?

Answer 340

``` Inhaled bronchodilators (B2 agonists and anticholinergics), and systemic glucocorticoids. Supplemental O2, Abx, and ventilator support may also be needed. ```

Question 341

How to diagnose Leprosy:

Answer 341

Full-thickness biopsy of skin lesion from an active edge. | It is not culturable.

Question 342

Tx of Leprosy:

Answer 342

Dapsone + Rifampin | Add clofazime if severe/multibacillary

Question 343

What arthritis is non-erosive?

Answer 343

SLE arthritis. It is an inflammatory. All others destroy the bone.

Question 344

What is familial Mediterranean fever?

Answer 344

Genetic disorder causing recurrent episodes of fever often accompanied by pain in abdomen, chest and joints.

Question 345

Febrile Neutropenia common causes and treatment:

Answer 345

G-negs (P. aeruginosa especially) are most common infection in febrile neutropenia. Once blood cultures are taken monotherapy w/an anti-pseudomonal B-lactam should be started – cefepime, meropenem, pip-tazo.

Question 346

How do alcoholics get hypocalcemia?

Answer 346

Often they develop hypomagnesemia which then creates resistance to PTH and decreases PTH secretion leading to hypocalcemia and hypophosphatemia.

Question 347

What Rx is used to diagnose and manage narrow-QRS-complex tachycardia?

Answer 347

Adenosine. | It slows the sinus rate, increases AVN conduction delay or can cause transient AVN block.

Question 348

What should be expected/tested for in unexplained cytopenias?

Answer 348

Chronic HIV infection.

Question 349

What should all patients with presumed ITP be tested for?

Answer 349

HIV and HCV

Question 350

Features of Lewy Body Dementia:

Answer 350

Fluctuating cognition, bizarre, visual hallucinations, and Parkonsonism (giving DA antagonists, 1st-gen antipsychs and risperidone will exacerbate the condition).

Question 351

Most common cause of community-acquired bacterial meningitis:

Answer 351

S. pneumoniae | Can occur w/ or w/o concurrent pneumococcal pneumonia.

Question 352

What is one of the earliest signs of macular degeneration?

Answer 352

Distortion of straight lines so that they look wavy.

Question 353

Lab results of AML:

Answer 353

Cytopenias, elevated LDH, myeloblasts w/auer rods on peripheral smear.

Question 354

What should be thought of in a HIV patient with pulmonary, mucocutaneous and reticuloendothelial findings?

Answer 354

Progressive disseminated Histoplasmosis. Get systemic sxs (fevers, chills, malaise) Weight loss/cachexia Pulmonary – cough, dyspnea Mucocutaneous lesions (papules, nodules) Reticuloendothelial (Hepatosplenomegaly, Lymphadenopathy)

Question 355

Labs in disseminated histoplasmosis:

Answer 355

Pancytopenia Transaminitis Increased LDH + Ferritin

Question 356

Tx of Disseminated Histoplasmosis:

Answer 356

``` Amphotericin B (mod-severe disease) Itraconazole (mild disease/maintenance) ```

Question 357

Most common cause of spontaneous lobar hemorrhage:

Answer 357

Amyloid Angiopathy – most often involves the occipital and parietal lobes.

Question 358

What should pts w/chest pain and suspected ACS be given first in the ED?

Answer 358

Aspirin – as long as the risk of aortic dissection is low.

Question 359

Common AEs of Cyclosporine:

Answer 359

Nephrotoxicity – most common HTN from renal vasoconstriction and Na+ retention Neurotoxicity – HA, visual disturbances, seizure, tremors Glucose intolerance Infection Malignancy – SCC of skin and lymphoproliferative Gingival hypertrophy and hirsutism GI – anorexia, N/V/D

Question 360

Preferred initial test in patients with suspected DVT:

Answer 360

Compression ultrasonography

Question 361

What sites are affected in spondyloarthropathies?

Answer 361

The ligamentous insertion points (enthesitis). | Pain is worse at night and with rest.

Question 362

Causes of chemotx-induced peripheral neuropathy (CIPN):

Answer 362

Vinca alkaloids (Vincristine, Vinblastine) Pb-based analogs (Cisplatin, Carbaplatin) Taxanes (Paclitaxel)

Question 363

What is seen on autopsy of LBD?

Answer 363

Eosinophilic intracytoplasmic inclusions – accumulations of a-synuclein protein. Seen in neurons of the substantia nigra, locus coeruleus, dorsal raphe nucleus, and sustantia innominata.

Question 364

Tx of LBD:

Answer 364

Carbidopa-levodopa for Parkinsonism Cholinesterase inhibitor for cognitive impairement SECOND-gen anti-psychs for psychotic sxs. 1st gens create severe neuroleptic sensitivity in these pts.

Question 365

Euthyroid Sick Syndrome:

Answer 365

Abnormal thyroid fxn tests in any pt. w/an acute, severe illness (post-MI etc) Most common pattern is low free and total T3 with normal TSH and T4.

Question 366

Esophagus ulcers in HIV pts:

Answer 366

Large linear = CMV Vesicles and round/ovoid ulcers = HSV White plaques = Candida

Question 367

What will cause Hyperchylomicronemia?

Answer 367

Aka Type I familial dyslipidemia D/t a defective LPL or apoC-II Often presents with acute pancreatitis

Question 368

Phosphate levels in secondary hyperPTHism:

Answer 368

Normally caused by renal failure – leads to phosphate retention and improper clearing, so increased serum PO4 with decreased Vit D, and Ca2+ and increased PTH. 25-hydroxycholecalciferol (inactive Vit. D storage form) will increase.

Question 369

How should B12 be administered in Pernicious anemia pts?

Answer 369

IM injection – this bypasses enteral absorption which is impaired in these patients.

Question 370

Tx of PE:

Answer 370

Heparin or LMWH (Enoxaparin) then bridge to warfarin Can give tpa in some cases, but is contraindicated in post-op patients. IVC filters can be placed in pts if PE recurs or anticoagulation is strictly contra’d

Question 371

Major risk factors for HBV infection:

Answer 371

Multiple sexual partners and IVDU. HBV is much more likely to present with sxs than HCV. HBV is also much more commonly contracted through sexual contact than HCV.

Question 372

Molluscum contagiosum:

Answer 372

Skin infection from Poxvirus. Characterized by small, pruritic, skin-colored papules w/umbilicated centers. Imaired cell-immunity may lead to a prolonged course w/widely spread papules involving the face. HIV testing should be considered for patients w/MC.

Question 373

Severe cx of Nitroprusside therapy:

Answer 373

Cyanide toxicity – get AMS, lactic acidosis, seizures and coma. Most common in patients w/renal insufficiency.

Question 374

Post-ictal lactic acidosis:

Answer 374

Often follows seizures (esp. tonic-clonic). Raises serum lactic acid d/t skeletal mm. hypoxia. Typically transient/self-limited and resolves w/in 90 min. Mgmt is observation and repeat chemistry panel//ABG after ~2hrs.

Question 375

When should NaHCO3 be given for metabolic acidosis?

Answer 375

When pH < 7.1. | Anything higher may cause myocardial depression and increased lactic acid production.

Question 376

Features of Chronic arsenic poisoning:

Answer 376

Polyneuropathy, pancytopenia, mild transaminase elevation, hypo/hyperpigmentation and hyperkeratosis. Mees lines - horizontal striations of the finger nails is characteristic

Question 377

Tx of acute MS exacerbation:

Answer 377

Glucocorticoids (IV Methylprednisolone) | Plasmapheresis can be considered in pts refractory to steroids.

Question 378

Chronic maintenance tx of MS:

Answer 378

IFN-B or Glatiramer acetate. Both are disease modifying agents and used for chronic tx in pts. w/relapsing-remitting or secondary, progressive forms of MS.

Question 379

Auto-Abs in Scleroderma:

Answer 379

Antinuclear-Ab (most sensitive, but not specific) Anti-topoisomerase I (anti-Scl-70) Ab and anti-RNA pol III (most specific) Anticentromere-Ab (mostly in limited disease/CREST)

Question 380

What does skin infection involving the external ear most likely suggest?

Answer 380

Erysipelas – bc the external ear lacks a lower dermis level which makes cellulitis a v. unlikely diagnosis.

Question 381

Cause and presentation of erysipelas:

Answer 381

S. pyogenes (aka GBS) Warm, tender, erythematous rash w/raised, sharply demarcated borders. May have systemic sxs fever, chills, regional lymphadenopathy.

Question 382

Most common AE w/in 1-6hrs of transfusion:

Answer 382

Febrile nonhemolytic transfusion rxn. -- can be prevented with leukoreduction.

Question 383

When should cells be washed prior to transfusion?

Answer 383

If the pt. has IgA deficiency or had a prior allergic transfusion rxn.

Question 384

What should be given to transplant pts. to prevent opportunistic infections?

Answer 384

TMP-SMX. This prevents PCP, some Listeria and toxoplasma infections. Can be discontinued 6-12 months post-transplant. Some pts. may also receive Ganciclovir for pphx against CMV

Question 385

What is use dependence and what Rxs is it seen with?

Answer 385

It is enhanced pharmacologic effects of a drug during faster heart rates Seen with class I (esp. IC, less so IA) and class IV (CCBs) anti-arrhythmic agents. Class IC cause progressive decrease in impulse conduction w/faster HR – leads to increase in QRS duration. Class IV (CCBs) will see an increase in the PR interval, but no change in the QRS complex.

Question 386

First step in evaluation of Cushing syndrome:

Answer 386

Confirm hypercortisolism w/late-night salivary cortisol assay, 24-hr urine free cortisol, and/or low-dose dexamethasone test. - 2/3 of these tests needs to be + to dx If confirmed, then measure ACTH.

Question 387

Tx of Diffuse esophageal spasm:

Answer 387

CCBs. | Alternatives: Nitrates or TCAs

Question 388

Diagnostic requirements of acute liver failure:

Answer 388

Severe injury with elevated aminotransferases (often >1000) Signs of hepatic encephalopathy Impaired hepatic synthetic fxn (INR > 1.5) **Cirrhosis or underlying liver disease should not be present**

Question 389

Tx of Optic neuritis:

Answer 389

IV corticosteroids.

Question 390

Diagnostic study for suspected aortic dissection:

Answer 390

TEE or CTA – but can’t use CTA in renal disease.

Question 391

Presentation and diagnosis of oropharyngeal dysphagia:

Answer 391

History of difficulty initiating swallowing with cough, choking, or nasal regurgitation. Diagnose with Videofluoroscopic modified barium swallow.

Question 392

Mgmt of caustic ingestion:

Answer 392

Ingestion of alkali substances like sodium hydroxide (lye), can cause immediate chemical burn or liquefactive necrosis. Managed with decontamination and IV hydration. Upper GI endoscopy should be performed w/in first 12-24 hrs to determine extent of damage. Mild injury = supportive measures More severe = tube feedings and possible surgery.

Question 393

What is tonometry and when is it used?

Answer 393

It measures intra-ocular pressure and is used to asses acute ACG.

Question 394

Tx of Trigeminal Neuralgia:

Answer 394

Carbamezapine

Question 395

Preferred tx for hypovolemic hypernatremia:

Answer 395

IV 0.9% saline. | The fluid can be switched to 5% dextrose once the patient is euvolemic.

Question 396

DoC for Osteoporosis:

Answer 396

Alendronate Can’t give to pts. w/GERD so give Zolendronic acid bc its given IV and doesn’t cause reflux esophagitis like Alendronate.

Question 397

What cancers are likely to cause primarily solitary brain mets?

Answer 397

Breast Colon RCCa Lung and melanoma likely to cause multiple mets.

Question 398

Most common ca to met to the Brain?

Answer 398

Lung. Neoplastic cells travel through vasculature and lodge in small-caliber vessels at the gray/white matter jxn. Often cause vasogenic edema as well.

Question 399

MS v. Brain mets on MRI:

Answer 399

MS often has inflammatory white matter lesions. | Brain mets often well-circumscribed lesions at the gray/white matter jxns w/ vasogenic edema.

Question 400

What causes the cyclical fevers in malaria?

Answer 400

Plasmodium-induced RBC lysis.

Question 401

What are Heinz bodies and when are they seen?

Answer 401

Heinz bodies are oxidized/denatured Hb that occurs when there’s a G6PD deficiency (XL-recessive dx).

Question 402

Most frequent source of PEs:

Answer 402

Deep veins of the lower extremities. >90% PEs come from iliac, femoral or popliteal vv. **Exception is patients w/nephrotic syndrome – renal vv. are most common source of PE in these pts.

Question 403

Recommendations for Bladder cancer screening:

Answer 403

Currently there is recommendation against screening d/t its low incidence and poor PPV of current screening tests.

Question 404

Management of Hyperosmolar hyperglycemic state:

Answer 404

Aggressive hydration w/NS IV Insulin (NOT subQ) K+ supplementation.

Question 405

Sxs of ACL injury:

Answer 405

Pain, rapid onset Popping sensation at time of injury Significant swelling w/effusion or hemarthrosis (gross blood on aspiration of joint fluid) Joint instability

Question 406

Common cardiac finding in chronic ankylosing spondylitis:

Answer 406

Aortic Regurgitation.

Question 407

When do HCMP murmurs increase in intensity?

Answer 407

``` With Valsalva (straining phase), abrupt standing, nitroglycerin administration – all d/t decreased preload. They decrease with sustained hand grip, squatting, and passive leg raise. ```

Question 408

Pathogenesis and common causes of phototoxic drug rxns:

Answer 408

D/t production of ROS that then directly damage cell membranes and DNA. Sxs can be seen in both sun-exposed areas as well as non-exposed areas. Common causes: Abx (tetracyclines), Antipsychs (chlorpromazine), Diuretics (furosemide, thiazides), Amiodarone, promethazine, piroxicam.

Question 409

Most common cause of B12 deficiency and possible long-term complication:

Answer 409

Pernicious anemia. | Causes atrophic gastritis which increases risk of gastric cancer and gastric carcinoid tms.

Question 410

Mgmt of frostbite:

Answer 410

Rapid rewarming in 37-39C water bath. Analgesia and wound care Thrombolysis in severe, limb-threatening cases.

Question 411

What medication can help with stone passage?

Answer 411

Tamsulosin or a1-antagonists. They relax ureteral muscles and decrease intraureteral pressure – facilitate stone passage and reduce need for analgesics.

Question 412

Tx of PCT:

Answer 412

Serial phlebotomy or hydroxychloroquine along w/mgmt. of underlying causes (HCV).

Question 413

Tx plan for patients with RA:

Answer 413

All pts should be started on DMARDs as soon as possible to prevent further joint damage. Started on non-bio DMARDs first (MTX is DoC) and then if no improvement, step-up to a biologic DMARD after 6 mo. Then NSAIDs and glucocorticoids can be added for symptom relief.

Question 414

DMARDs:

Answer 414

Nonbiologic: MTX (Initial DoC), Hydroxychloroquine, sulfasalazine, leflunomide, azathioprine Biologics: Etanercept, infliximab, adalimumab, tocilizumab, rituximab.

Question 415

What can ingestion of home distilled liquor cause?

Answer 415

Lead poisoning. Often distill alcohol through parts w/lead soldering.

Question 416

Best tx of Anaphylaxis:

Answer 416

IM epinephrine

Question 417

What is likely to be the cause of NPH?

Answer 417

Decreased CSF absorption

Question 418

What is pathognomonic for rhabdomyolysis on urine analysis?

Answer 418

3+ blood with no RBCs on microscopy. Bc the myoglobin is making it positive for blood.

Question 419

What causes Graves ophthalmopathy?

Answer 419

T cell activation and stimulation of orbital fibroblasts by TSH-R auto-Abs leading to expansion of orbital tissues.

Question 420

What is a complication of supplemental O2 in advanced COPD patients?

Answer 420

CO2 retention and worsened hypercapnia d/t 1- Increased dead space perfusion – V/Q mismatch 2- decreased affinity of oxy-Hb for CO2 3- reduced alveolar ventilation. Can cause increased lethargy and confusion and lead to seizure.

Question 421

What should the goal O2 saturation be in pts. w/advanced COPD?

Answer 421

SaO2 90-93% or PaO2 60-70mmHg | Will decrease chance of CO2 retention.

Question 422

Heme abnormalities in Chronic renal failure:

Answer 422

Platelet dysfxn is the most common cause of abnormal hemostasis in pts. w/CRF. Get abnormal bleeding and bruising in uremic coagulopathy PT, aPTT, and platelet count will be normal, but BT is prolonged. DDAVP is DoC. **DON’T give platelet transfusion bc the new platelets will quickly become inactive

Question 423

What comorbidities are a/w PCOS?

Answer 423

``` Metabolic syndrome (diabetes, HTN) Obstructive sleep apnea Nonalcoholic steatohepatitis Endometrial hyperplasia/cancer **Scren for DM w/oral glucose tolerance tes ```

Question 424

Most common cause of Acute Liver Failure:

Answer 424

Acetaminophen toxicity

Question 425

What is the preferred tx for Diabetic gastroparesis?

Answer 425

Metoclopramide – it is a prokinetic and antiemetic.

Question 426

Tetrad that characterizes Neuroleptic malignant syndrome:

Answer 426

Mental status change Rigidity Fever Autonomic dysregulation

Question 427

How to differentiate b/w NMS and Rx-Induced Parkinsonism:

Answer 427

Only NMS will have autonomic instability and fever. Also more likely to see mental status changes. Both will have tremors, rigidity, and gait abnormalities.

Question 428

Pathophys of Cyanide toxicity:

Answer 428

Cyanide binds cytochrome oxidase and inhibits mitochondrial oxidative phosphorylation. Cells shift to anaerobic metab w/decreased ATP production – lactic acidosis. Thiocyanate accumulation causes the neuro sxs.

Question 429

Treatment of Cyanide toxicity:

Answer 429

Sodium Thiosulfate

Question 430

What would cause refractory hypokalemia?

Answer 430

Hypomagnesemia is one of the most common causes. Intracellular Mg inhibits K+ secretion by renal outer medullary K+ channels in the CT of the kidney; So when Mg is low K is secreted in xs.

Question 431

What lab values will be seen in hyperthyroidism d/t exogenous intake?

Answer 431

Low TSH High fT3 and T4 Low radioactive iodine uptake Low serum Thyroglobulin

Question 432

What thyroid condition will give you an elevated ESR?

Answer 432

Subacute (DeQuervain’s) thyroiditis.

Question 433

Most likely cause of Culture negative urethritis?

Answer 433

Chlamydia

Question 434

Effects of UGI bleeding on BUN/Cr:

Answer 434

Pts. w/upper GI bleeding, but not lower, may have increased BUN:Cr d/t increased urea production (from intestinal Hb breakdown) and increased urea reabsorption (d/t hypovolemia). No changes are seen with creatinine.

Question 435

Meningococcal vax schedule:

Answer 435

Regular – Primary vaccine age 11-12, then booster at age 16-21 High-risk patients – Vaccinate/booster even if age >18 for pts w/complement deficiency/asplenics, college students in residential housing (<21yo), military recruits, travelers to endemic areas, exposure to community outbreaks.

Question 436

When should epidural glucocorticoid injections be used for low back pain?

Answer 436

In patients with lumbosacral radiculopathy who haven’t responded to initial tx. NOT helpful for nonradicular pain.

Question 437

Heme effects of ParvoB19:

Answer 437

Transient pure red cell aplasia | Aplastic crises in pts w/underlying heme disease.

Question 438

Arthritis of ParvoB19:

Answer 438

Non-destructive (like SLE) | Acute, symmetric – affects hands (MCP, PIP, and wrists), knees, and ankles.

Question 439

Most common behavioral risk for TB:

Answer 439

Substance abuse

Question 440

Common findings in invasive aspergillosis:

Answer 440

Triad of fever, chest pain and hemoptysis Pulmonary nodules (yes plural) with halo sign (surrounding ground-glass opacities) Positive cell wall biomarkers (galactomannan, beta-D-glucan)

Question 441

Mgmt of DKA:

Answer 441

NORMAL (0.9%) saline and regular insulin infusion. Can add dextrose 5% once glucose is <200 mg/dL Add K+ if serum K+ is < 5.2 mEq/L

Question 442

AE of EPO therapy:

Answer 442

HTN – may lead to HTN crises esp. in pts who receive large doses or experience a rapid rise in Hb concentration.

Question 443

Dialysis disequilibrium syndrome:

Answer 443

D/t osmotic shifts during hemodialysis – causes changes in neuro status d/t cerebral edema. May cause HA and N.

Question 444

What is salvage therapy?

Answer 444

A form of treatment for a disease when a standard tx fails. | Ex: Radiation for prostate ca. recurrence after radical prostatectomy fails.

Question 445

Lab values in steroid abuse:

Answer 445

Erythrocytosis/increased erythropoiesis – elevated Hb Cholestasis Hepatic failure Dyslipidemia Slight elevation in Creatinine (d/t increased mm. mass)

Question 446

Lab values in Klinefelter syndrome:

Answer 446

Low/no testosterone High FSH and LH Azoospermia

Question 447

What risk is increased in pts w/plantar puncture wounds through footwear?

Answer 447

Osteomyelitis d/t Pseudomonas.

Question 448

What adjunctive therapy can be used to tx PCP?

Answer 448

In addition to TMP-SMX corticosteroids may be used and have been shown to reduce mortality in severe cases. Indications: PaO2 <70 or A-a gradient >35 on room air.

Question 449

What is an external hordeolum, what causes it, what is used to tx?

Answer 449

Hordeolum = stye. Its an acute inflamm. disorder of the eyelash follicle or tear gland. Often d/t S. aureus, but can be sterile. Tx: warm compresses. If it persists or is v. large may consider I+D.

Question 450

Typical features of cerebellar hemorrhage:

Answer 450

Occipital HA (may radiate to neck/shoulders) Neck stiffness (d/t extension of blood into 4th ventricle) N/V Nystagmus Ipsilateral hemiataxia

Question 451

First-line tx of Reactive arthritis:

Answer 451

NSAIDs. | Abx are not used.

Question 452

Pulse in severe aortic stenosis:

Answer 452

Pulsus parvus et tardus | Delyaed/Slow-rising and diminished/weak carotid pulse.

Question 453

Winter’s Formula:

Answer 453

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

Question 454

What are conduction abnormalities in pts. w/IE suspicious of?

Answer 454

Perivalvular abscess – most commonly seen with aortic valve involvement. These are seen in almost 30-40% of patients with IE.

Question 455

Postconcussive syndrome:

Answer 455

Follows TBI (hrs to days) Sxs: HA, confusion, amnesia, difficulty concentrating or multitasking, vertigo, mood alteration, sleep disturbance, and anxiety. Typically resolves w/in weeks to few months w/symptomatic tx.

Question 456

What Rx increase risk of Exertional heat stroke?

Answer 456

Anticholinergics, antihistamines, phenothiazines, and TCAs.

Question 457

Mgmt of exertional heat stroke:

Answer 457

Rapid cooling – ice water immersion preferred Fluid resuscitation Electrolyte correction No role for antipyretics

Question 458

Anticholinergic toxicity presentation:

Answer 458

Hyperthermia, tachycardia, dry skin, nonreactive mydriasis (Dilation w/ineffective accommodation), and decreased bowel sounds. MOF/dysfxn is uncommon

Question 459

What anti-DM medication is most likely to result in weight loss?

Answer 459

GLP-1 Receptor agonists (Exenatide, Liraglutide). | Pioglitazones (TZDs) and Sulfonylureas are likely to cause weight gain.

Question 460

How to differentiate diarrhea in AIDS pts:

Answer 460

All can cause weight loss Cyrptosporidium (CD4<180) – severe watery diarrhea, low fever Micro/Isosporidium (CD4<100) – watery diarrhea, crampy AbdP fever RARE MAC (CD4<50) – watery diarrhea HIGH FEVER (> 39/102) CMV (CD4<50) – small volume diarrhea, only one that can be bloody/hematochezia, AbdP, low fever

Question 461

When is asterixis seen?

Answer 461

Hepatic encephalopathy Uremic encephalopathy CO2 retention

Question 462

Indications for Urgent Dialysis:

Answer 462

AEIOU Acidosis – metabolic acidosis (pH < 7.1 and refractory to tx) Electrolyte abnorms – symptomatic/severe hyperkalemia (EKG changes, arrhythmias, K>6.5) Ingestion – toxic alcohols (MeOH, ethylene glycol), salicylate, Lithium, Na-valproate, carbamazepine Overload – V overload refractory to diuretics Uremia – symptomatic, encephalopathy, pericarditis, bleeding

Question 463

What is hemi-neglect syndrome?

Answer 463

Caused by a lesion to the R/non-dominant parietal lobe, responsible for spatial organization. Characterized by ignoring the L side of a space, and possible anosognosia

Question 464

What are common BRAF inhibitors?

Answer 464

Vemurafenib and Dabrafenib

Question 465

Adalimumab MoA and conditions it treats:

Answer 465

TNF-a inhibitor. | Txs IBD, RA, ankylosing spondylitis and psoriasis

Question 466

What dx procedure should be done for pts. w/painless, gross hematuria?

Answer 466

Cystoscopy – to evaluate for bladder cancer.

Question 467

Acid-Base abnormalities a/w salicylate toxicity:

Answer 467

Combined Respiratory alkalosis and an anion-gap metabolic acidosis

Question 468

Clinical associations with FSGS:

Answer 468

AfAm + Hispanic ethnicity, obesity, HIV, heroin use

Question 469

What post-MI cx is likely to cause biventricular failure?

Answer 469

Interventricular septum rupture aka VSD.

Question 470

Aminoglycoside toxicity:

Answer 470

Can damage the cochlear cells – ototoxicity Gentamicin especially can also damage the motion-sensitive hair cells in the inner ear to cause selective vestibular injury (vestibulopathy) w/or w/o ototoxicity.

Question 471

What should be done before initiating trastuzumab therapy?

Answer 471

Trastuzumab = HER2 inhibitor Baseline assessment of cardiac fxn by echo. It is cardiotoxic.

Question 472

2 Primary manifetations of Chagas disease:

Answer 472

Megacolon/megaesophagus and cardiac disease.

Question 473

What patients should metformin be avoided in?

Answer 473

Acutely ill pts w/ARF Pts predisposed for hypoxia (CVD, CKD, COPD) Liver failure Sepsis All these conditions increase risk of lactic acidosis

Question 474

Lab findings in PSGN:

Answer 474

UA: Protein+, Blood+, RBC casts +/- Serum: decreased C3 and C4, increased Anti-DNase B, anti-AHase (antihyaluronidase), ASO, and anti-NAD

Question 475

First line therapy for Raynaud?

Answer 475

Dihydropyridine CCBs (Nifedipine, Amlodipine) – just like vasospastic angina

Question 476

What criteria must be met to receive pphx for Lyme dx?

Answer 476

Must meet all 5! 1- Tick is adult or nymphal Ixodes scapularis 2- Tick attached for >36hrs or engorged 3- Pphx started w/in 72hrs of removal 4- Local B. burgdorferi infection rate >20% 5- No contra’d to doxycycline

Question 477

Effects of hypopituitarism on aldosterone:

Answer 477

There are no significant effects. | Adrenal aldosterone is mainly regulated by the RAAS and is not affected by low ACTH.

Question 478

Tx of toxic megacolon:

Answer 478

IVF, BS Abx, and bowel rest. | IBD-induced should be treated w/IV corticosteroids

Question 479

AEs of MTX:

Answer 479

Pancytopenia, folic acid deficiency, nausea, stomatitis, rash, hepatotoxicity, ILD, alopecia and fever.

Question 480

Difference b/w case control and retrospective cohort:

Answer 480

Case control compares a group w/disease v w/o and tries to find risk factors Retrospective cohort finds a group w/ a risk factor v a group w/o the risk and sees if the disease developed in each group.

Question 481

Most appropriate diagnostic tests for acute HBV infection:

Answer 481

HBsAg and anti-HBc bc they’re both elevated during initial infection, and anti-HBc will remain elevated during the window period.

Question 482

What is the most common tx of homocysteinemia?

Answer 482

Folate and B6. Need B6 as cofactor for cystathionine B-synthase which catalyzes homocysteine to cystathionine. If documented B12 deficiency then cobalamin is addcled.

Question 483

Diagnosis of Dermatomyositis:

Answer 483

Increased CPK, aldolase, LDH Anti-RNP, anti-Jo1 and anti-Mi2(anti-helicase) Abs Can do EMG or mm./skin bx if uncertain Should screen for malignancy once diagnosed.

Question 484

Typical features of CJD:

Answer 484

Rapidly progressive dementia, myoclonus, and sharp, triphasic, synchronous discharges in EEG.

Question 485

What are Hollenhorst plaques and when are they seen?

Answer 485

Bright, yellow, refractile plaques in the retinal a. seen on fundoscopy. These are seen in atheroembolism/cholesterol embolism and indicate a more proximal source (Internal carotid).

Question 486

What is a mediastinal mass w/elevated AFP and B-hCG diagnostic of?

Answer 486

A nonseminomatous germ cell tumor. | If found a testicular US should be performed to exclude a sm. primary tm there.

Question 487

What could pulsatile tinnitus in a young woman be concerning of?

Answer 487

Fibromuscular dysplasia with involvement of the carotid or vertebral aa. Or Idiopathic Intracranial HTN

Question 488

Treatment of Paget disease:

Answer 488

Bisphosphonates

Question 489

What conditions are a/w Pseudogout?

Answer 489

Hemochromatosis Hyperparathyroidism Trauma/Overuse/Surgery

Question 490

What is the main measure of association in case controls?

Answer 490

Exposure odds ratio

Question 491

When is prevalence odds ratio calculated?

Answer 491

In cross-sectional studies

Question 492

Tx for severe hypovolemic hypernatremia:

Answer 492

Isotonic 0.9% saline. Once the volume deficit has been restored pts can be switched to half-normal 0.45% saline to better replace the free water deficit. Goal rate of plasma Na+ correction is no more than 1mEg/L/hr to prevent cerebral edema. Less severe cases can be treated w/5% dextrose in 0.45% saline

Question 493

Most common cause of hypernatremia?

Answer 493

Hypovolemia

Question 494

What is Ichthyosis vulgaris?

Answer 494

Chronic, inherited skin disorder characterized by diffuse dermal scaling. Caused by mutations in flaggrin gene.

Question 495

Situational syncope:

Answer 495

Form of reflex/neurally mediated syncope a/w triggers – micturition, cough, defecation. Triggers cause alteration in ANS response and lead to cardioinhibitory, vasodepressor or mixed response. Increased PSNS and decreased SNS

Question 496

Aspirin-exacerbated respiratory disease:

Answer 496

Non-IgE mediated, psuedoallergic Rx reaction. Seen in pts. w/hx of asthma, chronic rhinosinusitis w/nasal polyposis. Characterized by bronchospasm and nasal congestion following aspirin ingestion.

Question 497

Post-exposure pphx in HBV unvax’d pts:

Answer 497

Immediate HB vaccine and HB immune globulin with follow up serology.

Question 498

HSV retinitits in an IMCP’d pt:

Answer 498

Rapidly progressing b/l necrotizing retinitis – “acute retinal necrosis syndrome.” Initial sxs: keratitis, conjunctivitis w/eye pain, followed by rapid vision loss. Fundoscopy: widespread, pale, peripheral lesions and central necrosis of the retina. VZV may also cause this same type of retinal necrosis.

Question 499

Most common cause of corneal blindness in the US:

Answer 499

HSV infection.

Question 500

CMV retinitis:

Answer 500

Most common ocular cx in HIV pts. Typically painless (unlike HSV) Fundoscopy: fluffy or granular retinal lesions near the retinal vessels and assoc. hemorrhages. No conjunctivitis or keratitis like in HSV.

Question 501

What is sympathetic ophthalmia?

Answer 501

“Spared eye injury” Immune-mediated inflammation of one eye after a penetrating injury to the other eye. Typically see anterior uveitis, but panuveitis, papillary edema, and blindness may develop. Pathophys is thought to be the uncovering of “hidden antigens.”

Question 502

Cxs of Subarachnoid hermorrhage:

Answer 502

``` Re-bleed (first 24hrs) Vasospasm (>3days – use nimodipine to prevent) Hydrocephalus/increased ICP Seizures Hyponatremia (from SIADH) ```

Question 503

Serum measurement of what has a high sensitivity of diagnosing CHF?

Answer 503

BNP. Elevated levels of BNP correlate w/the severity of LV dysfunction and help differentiate dyspnea 2/2 CHF from other causes.

Question 504

What conditions are a/w Nephrotic syndrome 2/2 AA amyloidosis?

Answer 504

Chronic inflammatory conditions: RA, IBD | Chronic Infections: Osteomyelitis, TB

Question 505

Risk factors for Fluoroquinolone associated tendinopathy:

Answer 505

Age >60, normal BMI, female, concurrent oral corticosteroid use, recent transplant.

Question 506

Anti-mitochondrial Abs:

Answer 506

Seen in PBC – high sensitivity and specificity

Question 507

Typical presentation of Idiopathic Intracranial HTN:

Answer 507

Holocranial HA Vision changes (blurry/diplopia) Pulsatile Tinnitus

Question 508

When is Papilledema a contraindication to LP?

Answer 508

Only when the pt has evidence of obstructive/non-communicating hydrocephalus +/- a space-occupying lesion, or midline shift.

Question 509

What does the pronator drift test assess?

Answer 509

UMN or pyramidal/corticospinal tract disease.

Question 510

What are signs of pyramidal tract injury?

Answer 510

Pronator drift, focal weakness, spasticity, hyperreflexia, and Babinski sign.

Question 511

What is most likely a/w pts describing a “curtain drawn down” over the eye?

Answer 511

Retinal detachment. | May also be seen in amaurosis fugax/central retinal a. occlusion.

Question 512

Lung cancer screening:

Answer 512

Can be done w/annual low-dose CT for patients 55-80 with >30 pack year smoking history. CXR has not been shown to reduce mortality as a screening method.

Question 513

Murmur heard in HCMP:

Answer 513

Harsh crescendo-decrescendo systolic murmur heard best at the apex and lower left sternal border.

Question 514

Valvular abnormalities a/w bicuspid aortic valve:

Answer 514

In younger patients: Aortic regurg | In older: aortic stenosis

Question 515

How to calculate the corrected Ca2+ level:

Answer 515

Corrected Ca2 = Measured Ca2 + 0.8 (4-Albumin)

Question 516

Tx for Syphillis in a Pen-Allergic patient:

Answer 516

Oral Doxycycline for 14 days | Pen desensitization should be avoided if possible.

Question 517

What abx therapy should be started in prostatitis while awaiting urine cultures?

Answer 517

TMP-SMX or Fluoroquinolone for acute | Fluoroquinolone for chronic.

Question 518

Role of PEEP in respiratory distress:

Answer 518

PEEP prevents alveolar collapse and may also reopen some alveoli that have already collapsed, reducing shunting. High PEEP will improve oxygenation and directly counteract a mechanism by which ARDS causes hypoxemia. High PEEP may improve mortality in pts. w/severe ARDS.

Question 519

When should hypercoagulability testing be done?

Answer 519

In pts <45 with a 1st time unprovoked DVT/PE Pts w/recurrent DVT/PE Pts w/unusual sites of thrombi (cerebral, mesentery, portal vv.)

Question 520

Manifestations of HITT:

Answer 520

Thrombocytopenia – normally with platelets <60K. d/t RES removal of ab-coated platelets. Thrombus – HIT Abs activate platelets and cause aggregation w/ release of procoagulant factors.

Question 521

What is required for dx of malignant HTN?

Answer 521

Severe HTN w/retinal hemorrhages, exudates, or papilledema. | Malignant nephrosclerosis is often seen, but not always present and not required for diagnosis.

Question 522

What differentials present with low DLCO?

Answer 522

Obstructive spirometry – Emphysema Restrictive – ILD, Sarcoidosis, asbestosis, heart failure Normal – Anemia, PE, pHTN

Question 523

What differentials present with Normal DLCO?

Answer 523

Obstructive – Chronic bronchitis, asthma | Restrictive – MSK deformity, Neuromuscular disease.

Question 524

What differentials present w/Increased DLCO?

Answer 524

Obstructive – asthma Restrictive – morbid obesity Normal – pulm hemorrhage, polycythemia

Question 525

What is the management for pts w/Epidural spinal cord compression?

Answer 525

Emergent MRI, IV glucocorticoids (given 1st before confirmation w/MRI), and Neurosurgery consult.

Question 526

Common presentation of pancreatic cancer:

Answer 526

Most occur in the head and compress the pancreatic duct and common bile duct --> painless jaundice. Backup of bile leads to intra- and extrahepatic biliary duct dilation and nontender distended GB. Jaundice can lead to pruritus, pale stools, and dark urine.

Question 527

What is Felty syndrome?

Answer 527

RA – erosive jt disease/deformity, rheumatoid nodules, vasculitis (mononeuritis multiplex, necrotizing skin lesions) Neutropenia Splenomegaly. Often are anti-CCP and RF +, have v. high ESR.

Question 528

What causes the myopathy a/w Cushing syndrome?

Answer 528

Direct catabolic effects of cortisol on sk.mm. which leads to muscle atrophy. NOT d/t an electrolyte imbalance.

Question 529

How to diagnose CO poisoning:

Answer 529

ABG – check carboxyHb levels, EKG and cardiac enzymes is Ischemia or CAD.

Question 530

How to diagnose acromegaly:

Answer 530

First test IGF-1, if elevated confirm w/ glucose suppression test – normal pts. glucose will rapidly suppress GH secretion. In acromegaly it will not decrease and may even have a paradoxical increase.

Question 531

Treatment of Neurosyphillis:

Answer 531

IV penicillin for 10-14d (Not IM PenG like primary)

Question 532

1st line tx for Chemo-Induced N/V:

Answer 532

5HT3R antagonists – odansetron

Question 533

Common precipitating factors for HHS:

Answer 533

Hyperosmolar hyperglycemic state Infection (most common) Meds (Steroids, thiazides, pentamidine, atypical antipsychs.) Injury/Acute Illness Interruption of insulin tx HHS typically develops over days – weeks.

Question 534

What causes the neurologic sxs in HHS?

Answer 534

Confusion to coma can occur and are primarily d/t the high serum osmolality (norm. >320 mOsm) HHS pts typically have pseudohyponatremia and therefore this is not a cause of neuro sxs

Question 535

Nephropathy with dense intramembranous deposits that stain for C3 but not Igs:

Answer 535

``` Membranoproliferative glomerulonephritis type 2 aka Dense deposit disease. IgG Abs (C3 nephritic factor) directed against C3 convertase of the alt. complement pathway lead to persistent complement activation and kidney damage. ```

Question 536

What type of ulcers are typically seen on plantar surface of foot/toes?

Answer 536

Diabetic foot ulcers – tested for w/monofilament test. | In contrast arterial ulcers are often at v tip of toes but not plantar surface.

Question 537

Causes and risk factors of GBS:

Answer 537

Most common cause is C. jejuni. Others – HHVs, Mycoplasma, H. influenzae. Pts. at higher risk: Lymphoma, Sarcoidosis, SLE, recent HIV infection, and recent immunization.

Question 538

Preferred tx for Pen-susceptible IE:

Answer 538

IV aqueous penicillin G or IV ceftriaxone for 4 wks. | PO abx aren’t recommended.

Question 539

Tx of Ethylene glycol poisoning:

Answer 539

Fomepizole (competitive inhibitor of Alcohol DH) or EtOH. These prevent further breakdown into toxic metabs. Bicarb can help alleviate acidosis Hemodialysis may be required.

Question 540

What does methylene blue tx:

Answer 540

Methemoglobinemia

Question 541

Osteitis deformans:

Answer 541

Paget disease

Question 542

Effect of serum albumin on Ca2+:

Answer 542

Decreases in albumin will cause a decrease in total serum Ca2+ bc about half of total blood Ca2+ is bound to it. Ionized Ca2+ is hormonally regulated though and remains stable, so Ca2+ levels must be corrected based on albumin levels.

Question 543

What Meds should always be considered in the differential dx of peripheral edema?

Answer 543

Dihydropyridine CCBs (Amlodipine and Nifedipine)

Question 544

How to differentiate embolic v. thrombotic ischemic strokes:

Answer 544

Thrombotic are a/w AS risk factors, and sxs may alternate w/periods of improvement. Emboli are a/w hx of cardiac disease and the onset is abrupt and normally maximal at the start. Will see multiple infarcts in different vascular territories.

Question 545

pH effects on serum Ca2+:

Answer 545

Increased extracellular pH (alkalosis) causes H+ to dissociate from albumin, freeing up space for more ionized Ca2+ to bind. This leads to a decrease in ionized Ca2+, though total Ca2+ levels remain unchanged. Causes signs/sxs of hypocalcemia – crampy pain, paresthesias, carpopedal spasm etc. Seen in pts w/PE for example who get resp. alkalosis from hyperventilation.

Question 546

What are the potential causes of hypocalcemia w/elevated PTH?

Answer 546

Endo: Vit.D def., CKD Inflammatory: Pancreatitis, Sepsis Oncology: Tumor lysis syndrome

Question 547

Rxs that cause hypocalcemia:

Answer 547

Ca-chelators, Bisphosphonates, phenytoin

Question 548

Features of Pyruvate Kinase deficiency:

Answer 548

Chronic hemolysis, hepatosplenomegaly, skin ulcers and pigmented gallstones. Not triggered by stress/drugs like G6PD. Seen as hemolytic anemia in a newborn.

Question 549

Attributable risk percent calculation:

Answer 549

The risk percentage that can be explained by a particular exposure or risk factor ARP = (Risk in exposed – risk in unexposed)/ Risk in exposed ARP = (RR-1)/RR (If a group has 4x risk w/an exposure the ARP=4-1/4=75%)

Question 550

Tx for Exercise Induced Bronchoconstriction:

Answer 550

SABA 10-20min before exercise | Those who exercise daily can try ICS or antileukotriene agents.

Question 551

What is Polymyalgia Rheumatica?

Answer 551

Seen commonly in pts w/temporal arteritis Presents w/morning stiffness, pain and decreased RoM in the shoulders, neck and hip girdle. Stiffness > Pain Have normal muscle strength Increase in ESR, normal CRP and creatinine kinase. Tx w/glucocorticoids.

Question 552

What are tophi?

Answer 552

Tumors formed in soft tissues by urate crystal deposition. | White in appearance and can ulcerate and drain a chalky material.

Question 553

Mgmt of Diabetic foot infections:

Answer 553

Wound debridement and empiric IV abx (pip-tazo + vancomycin) to cover the polymicrobial nature of these infections.

Question 554

Features of Interstitial cystitis:

Answer 554

Aka Bladder pain syndrome A/w psychiatric and pain disorder (fibromyalgia) Presents as bladder pain w/filling, relief w/voiding, increased freq, urgency and dyspareunia. Pain can be exacerbated by exercise, EtOH and sex Normal UA Tx: not curative, can give Amytiptyline, pentosane polysulfate sodium, and analgesics for acute exacerbations.

Question 555

Tx of Toxoplasmosis:

Answer 555

Sulfadiazine and Pyrimethamine + Leucovorin | PPhx w/TMP-SMX

Question 556

Endocrine causes of recurrent pregnancy loss:

Answer 556

``` Thyroid disease PCOS DM Hyperprolactinemia **Celiac (not an endocrine dx) can also cause it ```

Question 557

CA-MRSA Pneumonia:

Answer 557

A common cause of secondary bacterial pneumonia that complicates the flu. Often seen in young people. Get severe, necrotizing pneumonia that’s rapidly progressive and often fatal. Sxs: high fever, productive cough w/hemoptysis, leukopenia, and multilobar cavitary infiltrates. CXR: multilobar (often midlung) infiltrates b/l and thin-walled cavities.

Question 558

Behcet disease:

Answer 558

Seen in young adults of Turkish, middle east or Asian descent. Get recurrent painful oral aphthous ulcers, genital ulcers, eye lesions (uveitis), skin lesions (erythema nodosum, acneiform lesions) and thrombosis. May also get pathergy – exaggerated skin ulceration w/ minor trauma (needlestick)

Question 559

What Rx-Combo is likely to reduce the risk of CCB-assoc. peripheral edema?

Answer 559

CCB + ACEI

Question 560

Features of PCP:

Answer 560

Elevated LDH! With diffuse reticular infiltrates on imaging. Normally indolent in HIV but can cause acute respiratory failure in IMCP’d Presents w/fever, dry cough and decreased O2 levels.

Question 561

CVS manifestations of Primary HyperPTHism:

Answer 561

HTN, arrhythmias, ventricular hypertrophy and vascular/valvular calcification. Significant HTN a/w HyperPTHism should be worked up for MEN2 and pheochromocytoma.

Question 562

What should victims of smoke inhalation be treated for?

Answer 562

CN toxicity and CO toxicity.

Question 563

What is the likely mechanism of lactic acidosis in smoke inhalation victims?

Answer 563

CN toxicity – it binds Ferric iron in Cytochrome oxidase a3 of electron transport chain which blocks oxidative phosphorylation and promotes anaerobic metab – lactic acidosis.

Question 564

Features of Sideroblastic anemia:

Answer 564

Microcytic anemia w/dimorphic RBC population (both normo- and hypochromic RBCs) Will have normal Fe levels and decreased TIBC to differentiate from Fe-def anemia. Caused by B6/pyridoxine deficiency.

Question 565

Derm associated cx of M. penumoniae infection:

Answer 565

SJS

Question 566

What infection is a/w aged seafood?

Answer 566

Aka cured fish – get foodborne Botulism

Question 567

Tx of Botulism:

Answer 567

Equine serum heptavalent botulinum antitoxin

Question 568

Findings suggestive of severe AS:

Answer 568

Sxs of fatigue, exertional lightheadedness, syncope Diminished/delayed carotid pulse – parvus et tardus Mid to Late-peaking systolic murmur Presence of soft and single S2. Early peaking of the murmur suggests mild-mod AS – these pts are typically asx.

Question 569

Cxs of PBC:

Answer 569

Malabsorption, fat-soluble vitamin deficiencies Severe hyperlipidemia w/xanthelasmas Metabolic bone disease – osteoporosis, osteomalacia (w/normal levels of Ca and Vit. D - bone dx isn't from malabsorption) HCCa.

Question 570

Hyperlipidemia a/w PBC:

Answer 570

HDL elevation out of proportion to LDL. | Does not increase the risk of AS.

Question 571

Where is bile absorbed?

Answer 571

In the ileum. | Pts w/ileal disease (Crohn’s) can get bile salt malabsorption/bile salt diarrhea

Question 572

Effects of HoVolemia on Na+ values:

Answer 572

HoVolemia can cause hyponatremia as well, but many patients have normal serum Na+ levels, and some may even have hypernatremia. However all patients w/V depletion will have decreased urine Na+ d/t RAAS activation and aggressive Na+ reabsorption in the kidney.

Question 573

Most common causes of bloody diarrhea:

Answer 573

E. coli (esp. if fever is absent) Shigella (a/w fever) Campylobacter

Question 574

What types of shock will see an increase in SVR (afterload)?

Answer 574

Hypovolemic and Cardiogenic. Septic shock the SVR decreases Differentiate Cardio v. Hypovolemic based on increase in preload (RA pressure, and PCWP) in cardiogenic and decreased preload in hypovolemic.

Question 575

Mgmt of acetaminophen toxicity:

Answer 575

For pts who present early (<4hrs from ingestion) gastric decontamination (activated charcoal) and measurement of acetaminophen levels should be obtained. Then based on levels and time since ingestion it can be determined if N-acetylcysteine should be admin’d Pts can be asx during first 24hrs post-ingestion.

Question 576

Tx recommendations in pregnant women w/suspected APS:

Answer 576

PPhx w/Aspirin and LMWH to prevent arterial and venous thromboses and pregnancy loss.

Question 577

Tachycardia-mediated cardiomyopathy:

Answer 577

Presents w/progressive dyspnea, decreased exercise tolerance, aFib w/RVR, and LV systolic dysfxn. Dx: EKG, Echo, and exclusion of other causes of LV dysfxn. Tx: Aggressive rate or rhythm control

Question 578

Tx of Latent TB:

Answer 578

9 mo of Isoniazid + Pyridoxine | Latent TB is dx’d w/positive PPD and negative CXR/no sxs.

Question 579

What is Melanosis coli characteristic of?

Answer 579

Laxative abuse – seen on colonoscopy Dark brown discoloration of the colon w/pale patches of lymph follicles “alligator skin” Can disappear if laxatives are stopped. Histo will show pigment in the MPs of the lamina propria

Question 580

Tx for Giardia:

Answer 580

Metronidazole

Question 581

Features of Putaminal (BG) hemorrhage:

Answer 581

Putaminal hemorrhages almost always involve adjacent internal capsule – contralateral hemiparesis and hemianesthesia + conjugate gaze deviation toward side of the lesion (from damage to frontal eye field efferents in ant. limb) Common site of HTN intraparenchymal brain hemorrhage.

Question 582

Pontine hemorrhage features:

Answer 582

Deep coma and total paralysis w/in mins. Pinpoint reactive pupils.

Question 583

Primary Pphx of esophageal variceal hemorrhage:

Answer 583

Nonselective BBs (Propranolol/nadolol), or endoscopal ligation.

Question 584

Best investigation for pleural effusion:

Answer 584

Thoracocentesis, except in pts w/clear evidence of CHF – they undergo trial of diuretic therapy first.

Question 585

Characteristics of Acute Interstitial Nephritis:

Answer 585

Maculopapular rash, fever, new Rx exposure, +/- arthralgias. Mostly caused by Rxs – Pens (Naficilin common), TMP-SMX, cephalosporins, NSAIDs, omeprazole Labs: AKI, pyuria, hematuria, WBC casts, eosinophilia Renal bx: inflammatory infiltrates and edema

Question 586

Infectious causes of Acute Interstitial Nephritis:

Answer 586

Legionella, TB, Streptococcus | These are uncommon causes. Rxs are most common cause of AIN.

Question 587

Cxs of Paget disease:

Answer 587

Giant cell tm and osteosarcoma

Question 588

What can Beta-D-glucan be useful in diagnosing?

Answer 588

Fungal infections – esp. candida and aspergillus

Question 589

Cxs of Giant Cell arteritis:

Answer 589

Permanent vision loss d/t anterior ischemic optic neuropathy from arteritis and aortic aneurysm.

Question 590

How does prevalence affect PPV and NPV?

Answer 590

Increased prevalence increased PPV and decreases NPV | Decreased prevalence increases NPV and decreases PPV

Question 591

What are the contributing factors to orthostatic HoTN in the elderly?

Answer 591

Decreased baroreceptor sensitivity, arterial stiffness, decreased NE content of SNS nerve endings, and reduced sensitivity of the myocardium to SNS stimulation.

Question 592

Characteristics of Myasthenic crisis:

Answer 592

Increased generalized and oropharyngeal weakness, resp insufficiency/dyspnea Risk factors: Infection, surgery, pregnancy/birth, tapering immunosuppressants, Rxs – aminoglycosides, BBs. Tx: Intubation, Plasmapheresis, IVIG and corticosteroids. Daily AchEIs used in MG mgmt. should be held to prevent xs airway secretions and risk of aspiration.

Question 593

What are the features of De Quervain tenosynovitis and who is it commonly seen in?

Answer 593

Inflammation of the abductor pollicis longus and extensor pollicis brevis tendons – tenderness elicited w/direct palpation on the radial side of the wrist at the base of the hand. Finkelstein test may also elicit pain. Classically seen in new mothers who hold the babies w/ the thumb outstretched.

Question 594

Dx of Polymyositis:

Answer 594

Elevated m. enzymes – CK, aldolase, AST Auto-Abs – ANA, anti-Jo-1 Bx – Endomysial infiltrate and patchy necrosis

Question 595

Effects of RAI therapy in Grave’s disease:

Answer 595

Resolution of Hyperthyroidism in 6-18 weeks, but most develop permanent hypothyroidism in mos-yrs following. May also worsen Graves ophthalmopathy d/t increased titers of Thyroid stimulating Auto-Abs.

Question 596

What skin conditions are a/w HIV infection?

Answer 596

Sudden-onset severe psoriasis Recurrent herpes zoster Disseminated molluscum contagiosum Severe seborrheic dermatitis

Question 597

What conditions are a/w severe Seborrheic dermatitis?

Answer 597

HIV and Parkinson

Question 598

What are the indication for parathyroidectomy in PHPT?

Answer 598

Symptomatic hypercalcemia! Age <50 Cxs – osteoporosis, nephrolithiasis/calcinosis, CKD (GFR < 60) Elevated risk of Cxs – Ca2+ >1 mg/dL above norm., urinary Ca2+ excretion >400 mg/day

Question 599

What should be suspected in an elderly pt. w/anemia + thrombocytopenia?

Answer 599

CLL – esp. if lymphadenopathy and hepatosplenomegaly are present. Cxs: recurrent infections common, AIHA, Secondary malignancy (Richter transformation – AML) Dx w/flow cytometry

Question 600

How to differentiate b/w an adrenal and ovarian androgen producing-tm:

Answer 600

Testosterone and DHEAS levels. If only testosterone is elevated – ovaries (most common) If both elevated – Adrenals, DHEAS is only produced in adrenals. Testosterone is produced in both.

Question 601

Diagnosis of Parkinson:

Answer 601

Clinically – need 2/3 cardinal signs: Rest tremor, rigidity, bradykinesia.

Question 602

Mgmt to reduce liver damage in HCV:

Answer 602

Avoid EtOH, HBV/HAV vax.

Question 603

Most common murmur heard at 1st R-ICS and features associated:

Answer 603

Supravalvlar AS – normally d/t congenital LV outflow tract obstruction. Systolic murmur v. similar to normal AS. May present w/unequal carotid pulses, differential BP in upper extremities, and palpable thrill in suprasternal notch.

Question 604

Rxs used in HCV treatment:

Answer 604

Ledipasvir, Sofosbuvir

Question 605

1st line tx of Bullous Pemphigoid:

Answer 605

High-potency topical glucocorticoids – Clobetasol Topical is 1st choice even in extensive disease. Oral systemic steroids are not a/w with better outcomes and should be avoided unless topical is highly unpractical

Question 606

What does randomization of a trial prevent?

Answer 606

Confounding

Question 607

Middle Mediastinal masses:

Answer 607

Bronchogenic cysts, tracheal tms, pericardial cysts, lymphoma, LN enlargement, and aortic aneurysms of the arch. Thymomas are in the anterior mediastinum.

Question 608

Common presentation of HSV keratitis:

Answer 608

Dendritic ulcers are most common, corneal vesicles, pain, photophobia, blurred vision, tearing and redness. Common in pts w/xs sun exposure, outdoor occupations, fever or IMCPd.

Question 609

Features of Anterior Cord Syndrome:

Answer 609

Norm d/t anterior spinal a. trauma. Bilateral hemiparesis – damage to lateral corticospinal tract Diminished b/l pain and T – lateral spinothalamic tract (1-2 levels below injury bc decussation) Intact b/l proprioception, vibration and light touch – dorsal column intact bc supplied by posterior spinal aa.

Question 610

Mgmt of HCMP:

Answer 610

Avoidance of volume depletion, BBs and CCBs (Non-Dihydropyridines ONLY), and surgery for persistent sxs.

Question 611

What should patients with new-onset aFib be screened for?

Answer 611

Occult hyperthyroidism as an underlying cause – get TSH and free T4 levels.

Question 612

Most common cause of death in acute liver failure:

Answer 612

Cerebral edema – coma, brain stem herniation, death.

Question 613

Indications for liver transplant in patients w/ALF:

Answer 613

Grade III or IV hepatic encephalopathy PT > 100 Cr >3.4 mg/dL

Question 614

What type of conjunctivitis will have a reappearing discharge after wiping?

Answer 614

Bacterial | Viral and allergic conjunctivitis will not.

Question 615

Adult Still Disease:

Answer 615

uncommon inflammatory disorder – recurrent high fevers, arthritis/arthralgias, salmon colored macular or maculopapular rash. ESR may be v elevated

Question 616

Empiric abx tx for Bacterial meningitis according to risk group:

Answer 616

Age 2-50: Vanc (S. pneumo) + 3rd gen cephalosporin (N. men) Age >50: Vanc. + ampicillin (listeria coverage) + 3rd-gen cephalosporin IMCPd: Vanc + ampicillin + cefepime (GNR) Neurosurgery/Penetrating trauma: Vanc + Cefepime

Question 617

Malaria pphx:

Answer 617

Mefloquine started >2 weeks prior to travel, throughout and then 4 weeks after returning from an endemic country. Chloroquine-resistant countries: Mefloquine, Doxycycline or Primaquine Chloroquine-Sensitive (Carib/S.Am): Chloroquine

Question 618

Common causes of crystal-induced AKI:

Answer 618

``` Acyclovir Sulfas MTX Ethylene glycol Protease Inhibitors Uric acid – tm lysis syndrome Causes renal tubular obstruction ```

Question 619

Features of Lithium toxicity:

Answer 619

Tremor, hyperreflexia, ataxia, seizures, V/D

Question 620

Features of phenytoin toxicity:

Answer 620

Horizontal nystagmus, cerebellar ataxia, and confusion

Question 621

Senlie purpura:

Answer 621

aka solar or actinic purpura. Non-inflammatory disorder most common in elderly, but can present in younger w/xs sun D/t loss of elastic fibers in perivascular connective tissue. Have residual brownish discoloration from hemosiderin deposition and many ecchymotic areas.

Question 622

What is pseudobulbar palsy?

Answer 622

Regurgitate liquids through the nose – from b/l damage to corticobulbar pathways.

Question 623

Features of Osler-Weber-Rendu Syndrome:

Answer 623

Aka Hereditary hemorrhagic telangiectasia AD disease w/diffuse telangiectasis (ruby-colored papules that blanch w/pressure), recurrent epistaxis, and widespread AVMs.

Question 624

Why might pts w/Osler-Weber-Rendu have increased Hct?

Answer 624

If a pulmonary AVM is present. Will shunt blood from the R – L heart causing chronic hypoxemia, digital clubbing, and reactive polycythemia. Pulmonary AVMs can lead to massive, sometimes fatal hemoptysis.

Question 625

Treatment of Dermatitis herpetiformis:

Answer 625

Dapsone – has anti-inflammatory and immunomodulatory properties. Long-term tx is gluten-free diet.

Question 626

Mgmt of patients with thromboembolic events:

Answer 626

If there is a clear provoking factor or there is a family hx suggesting the source workup should be done for these. If there are no clear provoking factors then patients should undergo age-appropriate ca-screening to check for malignancy as the source of hypercoagulability.

Question 627

Light criteria for transudative pleural effusions:

Answer 627

Protein pleural/serum <0.5 | LDH pleural/serum <0.6; Pleural LDH <2/3 upper limit of normal serum LDH.

Question 628

Causes of transudative pleural effusion:

Answer 628

Hypoalbuminemia – cirrhosis, nephrotic synd. | CHF

Question 629

Causes of exudative pleural effusion:

Answer 629

Infection (parapneumonic, TB, fungal, empyema) Malignancy PE **Infectious or inflammatory causes – cytokine release and increased capillary permeability.

Question 630

Features of TB effusion:

Answer 630

Moderate lymphocytosis V. elevated protein >4g/dL Elevated LDH Tend to occur on the R and have low pleural pH and glucose.

Question 631

Shy-Drager Syndrome:

Answer 631

Aka multiple system atrophy – degenerative disease characterized by: Parkinsonism Autonomic dysfxn – postural HoTN, abnorm sweating, bowel/bladder disturbances, abnorm salivation/lacrimation, impotence, and gastroparesis Widespread neurologic signs – cerebellar, pyramidal or LMN.

Question 632

Diagnostic studies to asses for esophageal perforation:

Answer 632

CT – esophageal wall thickening, mediastinal air fluid level | CXR or CT (late) – wide mediastinum, pneumomediatinum, pneumothorax, air around paraspinal mm., pleural effusion

Question 633

What kind of Rx is Memantine and what is it used for?

Answer 633

A glutamate inhibitor of the NMDA receptor. | Used to tx mod-severe alzheimers

Question 634

What year did blood and organs start being screened for HCV?

Answer 634

1992 – anyone before this needs testing.

Question 635

When are BBs contra’d in the tx of acute MI?

Answer 635

When there is presence of pulmonary edema – acute decompensated HF.

Question 636

What is “ugly duckling sign?”

Answer 636

A lesion that is substantially different from others in a patient who has multiple pigmented lesions. Has ~90% sensitivity for melanoma

Question 637

Tx of Bacillary angiomatosis:

Answer 637

Doxycycline or erythromycin + ART

Question 638

Rxs that cause pill-esophagitis:

Answer 638

Abx – tetracyclines Anti-inflammatory agents – aspirin and many NSAIDs Bisphosphonates – alendronate, risedronate Others – potassium chloride, iron

Question 639

Endoscopic appearance of pill-esophagitis:

Answer 639

Circumferential deep ulceration w/relatively normal surrounding mucosa. Normally in mid-esophagus.

Question 640

Pupillary axn that can worsen glaucoma:

Answer 640

DILATION!!! | Anything that can dilate the pupil – ATROPINE – is contraindicated in glaucoma.

Question 641

Infections that can cause acute pancreatitis:

Answer 641

Legionella Aspergillus CMV Less common viruses: HSV, Mumps, HBV, Coxsackie

Question 642

Initial tx of chronic venous insufficiency:

Answer 642

Leg elevation, exercise, and compression stockings

Question 643

Plasma aldosterone:renin value suggestive of primary hyperaldosteronism:

Answer 643

>20

Question 644

Associated neoplasms of Lynch syndrome:

Answer 644

Colorectal ca., endometrial and ovarian

Question 645

Associated neoplasms of FAP:

Answer 645

Colorectal ca., desmoids & osteomas, brain tms.

Question 646

Associated neoplasms of von Hippel-Lindau:

Answer 646

Hemangioblastomas, RCCa (clear cell), Pheochromocytoma.

Question 647

Pulmonary effects of A1AT deficiency:

Answer 647

Causes panacinar emphysema with the majority of destruction involving the lower lobes. Likely to present w/progressive SoB and cough w/mucoid sputum. Worse w/exertion. CXR: b/l basilar lucency Smokers present in their 30s, nonsmokers in their 40s

Question 648

What is a common precipitant of SIADH?

Answer 648

Any type of pulmonary pathology. HIV pts are especially prone to develop SIADH – may occur after episode of PCP. Suspect in any patient w/hypotonic, hyponatremic, euvolemia. Infusion of NS may worsen hyponatremia in SIADH.

Question 649

What is acrochordon?

Answer 649

Skin tag

Question 650

Explanation for large amounts of blood on UA, but only few (0-1) RBCs on micro:

Answer 650

Myoglobinuria. | UA isn’t able to differentiate from Hb and Mb so use micro to distinguish between hemoglobinuria and myoglobinuria.

Question 651

Tx of cancer-related anorexia/cachexia syndrome:

Answer 651

DoC – Progesterone analogues (Megestrol acetate) 2nd line – corticosteroids Cannabinoids have benefit in HIV cachexia but not cancer related.

Question 652

Features of lateral Medullary syndrome:

Answer 652

aka Wallenberg syndrome – most sxs ipsilateral Vertigo, falling to side of lesion, diplopia, nystagmus, difficult sitting upright, limb ataxia Abnormal facial sensation or pain Dysphagia, aspiration, hoarseness Horner’s syndrome, hiccups, lack of autonomic respiration

Question 653

Earliest renal abnormality present in pts w/DM:

Answer 653

Glomerular hyperfiltration

Question 654

Risk factors for C. diff infection:

Answer 654

Recent abx Hospitalization PPIs – gastric acid suppression

Question 655

What immune complexes are seen in HCV-cryoglobulinemia?

Answer 655

Complexes are formed from: HCV, anti-HCV IgG, IgM anti-IgG Abs (Rheumatoid factor) and complement.

Question 656

What endocrine complication can TB lead to?

Answer 656

Chronic primary adrenal insufficiency

Question 657

Granulomatous diseases that can lead to adrenal insufficiency:

Answer 657

TB, Histoplasmosis, Coccidiomycosis, Cryptococcosis and Sarcoidosis

Question 658

DTR in polymyositis:

Answer 658

NORMAL! Differentiates it between other causes of muscle weakness – Hypothyroidism (delayed), and Lambert Eaton (absent)

Question 659

Features of Trichinellosis:

Answer 659

``` Intestinal stage (w/in 1wk of ingestion) – asx, or AbdP, N/V/D Muscle Stage (up to 4wks after) – myositis, fever, subungual splinter hemorrhages, periorbital edema, eosinophila, elevated CK and leukocytosis. Clinical dx w/characteristic triad of periorbital edema, myositis and eosinophilia ```

Question 660

Typhoid fever presentation:

Answer 660

Progressive 1st week – fever 2nd – abdominal pain and salmon-colored rash 3rd – hepatosplenomegaly and abdominal complication, intestinal bleeding/perforation.

Question 661

Effects on mixed venous O2 saturation in different types of shock:

Answer 661

Both Hypovolemic and Cardiogenic will have decreased MvO2 d/t decreased tissue perfusion. Septic shock will have increased MvO2 d/t hyperdynamic circulation and an inability of the tissues to adequately extract O2.

Question 662

What kind of shock can be seen in mineralocorticoid deficiency?

Answer 662

Distributive shock – norm from primary adrenal insufficiency. Will have HoTN from low aldosterone levels and low SVR a/w hyperkalemia and hyponatremia.

Question 663

Stroke therapy w/in 3-4.5hrs of onset:

Answer 663

IV Alteplase

Question 664

Tx for stroke pts w/out prior antiplatelet tx:

Answer 664

Aspirin

Question 665

Tx for stoke pts on aspirin:

Answer 665

Aspirin + Dipyridamole OR clopidogrel

Question 666

Tx for stroke pts w/aFib:

Answer 666

Long-term ACs – Warfarin, dabigatran, rivaroxaban

Question 667

What antiplatelet agents are effective in reducing the risk of early recurrence of ischemic stroke?

Answer 667

ONLY ASPIRIN | Should be given w/in 24hrs to all pts w/ischemic stroke

Question 668

Complicated v. Uncomplicated Parapneumonic effusions:

Answer 668

Parapneumonic effusion = neutrophil dominate pleural effusion Uncomplicated pleural analysis – pH > 7.2, Glucose > 60, WBC < 50K Complicated – pH <7.2, Glucose <60, WBC > 50K Both will have negative pleural fluid gram stain and culture Tx: abx for both, drainage also for complicated

Question 669

How to differentiate empyema v complicated parapneumonic effusion:

Answer 669

Empyema will have frank pus on paracentesis and gram stains are typically positive for them as well. Both require abx + drainage by chest tube

Question 670

Characteristics of pleural effusion 2/2 PE:

Answer 670

Exudative, and bloody. Typically have normal pH and glucose levels.

Question 671

Lab values a/w Chikungunya:

Answer 671

Lymphopenia, thrombocytopenia, elevated liver enzymes

Question 672

What does a positive hepatojugular reflux signify?

Answer 672

A failing right ventricle – it cant accommodate an increase in VR w/abdominal compression. Most common causes: Constrictive pericarditis, RV infarction, and restrictive cardiomypoathy

Question 673

When should abx be initiated in COPD exacerbations?

Answer 673

If they have 2+ cardinal sxs (increased dyspnea, increased cough, sputum production). Or if mechanical ventilation is required.

Question 674

What abx are used in COPD exacerbation?

Answer 674

Macrolides, respiratory fluoroquinolones (levofloxacin, moxifloxacin) or penicillin/B-lactamase inhibitors (amoxicillin-clavulanate)

Question 675

Dacrocystitis:

Answer 675

Infection of the lacrimal sac. Acute cases characterized by sudden onset pain and redness in the medial canthal region. Often can express purulent discharge from the area. S. aureus and GBS are the main causes.

Question 676

What should be suspected in a patient with a pure motor stroke?

Answer 676

Lacunar infarct – especially if they have HTN. | Lacunar infarcts are from a combo of microatheroma formation and lipohyalinosis.

Question 677

Primary pphx of esophageal varices:

Answer 677

Nonselective BBs. Endoscopic ligation can be done in pts w/contraindications to BBs Endoscopic sclerotherapy is used only for actively bleeding varices, not as pphx

Question 678

What causes an anaphylactic rxn post-transfusion?

Answer 678

Host autoIgG-Abs against IgA. Happens in IgA deficient individuals.

Question 679

Which COPD patients have a lower threshold to start LTOT?

Answer 679

Pts w/Cor Pulmonale, evidence of RHF, or Hct >55%

Question 680

Clinical associations of Minimal change disease:

Answer 680

NSAIDs and lymphoma

Question 681

Most common form of nephrotic syndrome in pts/w Hodgkin lymphoma:

Answer 681

Minimal change

Question 682

Most common form of nephrotic syndrome a/w malignancies:

Answer 682

Membranous glomerulopathy. | Except lymphoma – minimal change disease, and MM – amyloidosis.

Question 683

How to differentiate between primary and secondary adrenal insufficiency:

Answer 683

Primary – d/t AI destruction of adrenal gland will see hyperpigmentation and mineralocorticoid deficiency, HoTN etc. Eosinophilia and hyperplasia of lymphoid tissues (tonsils) are also common findings. Secondary – d/t destruction of the pituitary gland will not have these effects and will only present w/signs of glucocorticoid and androgen deficiency.

Question 684

First test to order in suspected SLE pts?

Answer 684

ANA titers – v. sensitive (95-100%) Should be first no matter what sxs they present with. If positive, then others can be ordered (anti-smith, anti-dsDNA etc)

Question 685

How does lymphoma lead to hypercalcemia?

Answer 685

Increased Vit. D. Will have increased Ca2+ absorption, decreased PTH, and increased PO4

Question 686

Tx of Uncomplicated cystitis:

Answer 686

Nitrofurantoin for 5d – avoid if suspected pyelo TMP-SMX for 3d Fosfomycin single dose If complicated use fluoroquinolones Only do Uculture if pts fail initial therapy

Question 687

Tx of Pyelo:

Answer 687

Outpatient – Fluoroquinolones | Inpatient – IV abx (fluoros, aminoglycosides +/- ampicillin)

Question 688

How to diagnose Patellofemoral syndrome:

Answer 688

Clinical – patellofemoral compression test. | Often see increased pain with squatting, running and using stairs.

Question 689

Tx for restless leg syndrome:

Answer 689

1st line – dopamine agonists (pramipexole) | 2nd – Alpha-2-delta calcium channel ligands (gabapentin enacarbil)

Question 690

Secondary causes of restless leg syndrome:

Answer 690

``` Fe-def anemia Uremia (ESRD, CKD) DM MS, Parkinson Pregnancy Rxs (antidepressants, metoclopramide) ```

Question 691

What Rx-combo should be added to reduce mortality in AfAms w/LVF?

Answer 691

Hydralazine and nitrates

Question 692

What does a hx of recent URI followed by sudden onset cardiac failure suggest?

Answer 692

Dilated cardiomyopathy most likely 2/2 acute viral myocarditis Coxsackie B is most common; Others – parvo, HHV6, adeno, and enteroviruses.

Question 693

What will be seen on echo of DCMP?

Answer 693

Dilated ventricles w/diffuse hypokinesia and a low EF (systolic dysfxn).

Question 694

How to differentiate b/w a stone in the cystic v. common bile duct based on labs:

Answer 694

Both will cause elevations in BR, AST, ALT and possibly amylase, but only common bile duct occlusion would be expected to cause obstructive jaundice w/scleral icterus and v. high AlkPhos levels.

Question 695

VIPoma v. Carcinoid syndrome:

Answer 695

Both cause very similar sxs, but VIPoma will be tm in pancreas, and Carcinoid is typically in the SI. Carcinoid more likely to cause bronchospasm and cardiac cxs.

Question 696

When should tetanus-Ig be given as post-exposure pphx?

Answer 696

Only if the wound is dirty or severe AND the pt is unimmunized, uncertain, or has < 3 tetanus toxoid doses as a child. All other cases only require Td booster

Question 697

Lab findings a/w atheroembolism:

Answer 697

aka cholesterol crystal embolism Elevated serum Cr, eosinophilia (d/t IL-5 activation), hypocomplementemia UA may also show eosinophiluria.

Question 698

Features and tx of TTP:

Answer 698

Decreased ADAMTS13 – uncleaved vWF multimers – platelet trapping and activation. Causes hemolytic anemia w/schistocytes, renal failure, neuro sxs and fever Tx w/plasma exchange, glucocorticoids, and rituximab

Question 699

Definition of Massive PE:

Answer 699

PE complicated by HoTN and/or acute right heart strain. Syncope tends to only occur w/massive PEs, and likely to see JVD and RBBB on EKG. Signs/sxs of cardiogenic shock common.

Question 700

CVS effects of acromegaly:

Answer 700

Cardiomyopathy, HTN – concentric LV hypertrophy, HF, valvular disease (mitral & aortic regurg)

Question 701

Pphx for migraines:

Answer 701

CCBs, propranolol, TCAs | Sumatriptans are used to abort episodes

Question 702

Rare cx in HIT:

Answer 702

Adrenal hemorrhage. Should be suspected in pts w/shock in the setting of a drop in Hb after being diagnosed w/HIT. Pts should undergo CT scanning right away.

Question 703

What differentiates HIT from other hypercoagulable states?

Answer 703

It effects both the arterial and venous systems. Others preferentially affect the venous system. *Anti-phospholipid syndrome also commonly effects both systems

Question 704

How to dx Necrotizing fascititis:

Answer 704

Urgent surgical exploration. Imaging is not adequate enough and shouldn’t delay surgical intervention.

Question 705

Tx of Babesiosis:

Answer 705

Atovaquine + Azithromycin for mild to moderate cases | Clindamycin + Quinine in severe cases

Question 706

Tx of H. pylori:

Answer 706

PPI + Clarithromycin + Amoxicillin | In pen-allergic pts, metronidazole is sub’d for amoxicillin

Question 707

Definitive diagnosis of diverticulitis:

Answer 707

CT w/ oral and IV contrast

Question 708

Nitazoxanide:

Answer 708

An antiparasitic used to tx C. parvum in immunocompetent hosts. Should only be used in HIV pts if they are already initiated on ART and their CD4 counts aren’t increasing and clearing the infection.

Question 709

What Rxs are used in HTN-urgencies to lower BP over hours?

Answer 709

Oral captopril, furosemide, or clonidine. | Nifedipine or IV meds like labetalol should be avoided bc they’ll lower it too quickly.

Question 710

How to calculate corrected Na+ in hyperglycemia:

Answer 710

Corrected Na+ = measured Na + (serum glucose – 100)/100 x 1.6

Question 711

First line tx of Torsades de pointes:

Answer 711

Magnesium sulfate

Question 712

Tx of perianal disease in Crohn’s:

Answer 712

Mild to moderate tx’d w/metronidazole | Mod-severe tx’d w/anti-TNFa Rxs like infliximab or adalimumab

Question 713

Initial test in suspected Paget’s disease:

Answer 713

Xray

Question 714

Tx of Goodpasture’s:

Answer 714

Plasmapharesis, then cyclophosphamide and steroids can be used to keep inflammation suppressed.

Question 715

How to differentiate spinal stenosis from herniated disc:

Answer 715

Radiculopathy is usually unilateral in disc herniation and b/l in stenosis.

Question 716

Most common renal stones in Hyperparathyroidism:

Answer 716

Calcium phosphate

Question 717

What should pts w/HIT be switched to instead of heparin?

Answer 717

Direct thrombin inhibitors like Bivalirudin

Question 718

Tx of DIC:

Answer 718

FFP – need for platelets and low fibrinogen level. | In pts w/normal fibrinogen and low platelets, platelet transfusion is enough.

Question 719

Tx of ITP:

Answer 719

glucocorticoids

Question 720

Tx of TTP:

Answer 720

plasma exchange

Question 721

Manifestations and mgmt. of tumor lysis syndrome:

Answer 721

Mostly in aggressive heme malignancies Severe electrolyte abnormalities – hyperkalemia, hyperphosphatemia, hyperuricemia and HYPOcalcemia AKI d/t uric acid/calcium phosphorus Cardiac arrhythmias Tx – continuous telemetry and aggressive electrolyte monitoring/tx Pphx – IVF, allopurinol or rasburicase

Question 722

MoA and AE of Hydroxychloroquine:

Answer 722

TNF and IL-1 suppressor. | Can cause retinopathy, pts need periodic eye exams while taking this Rx.

Question 723

Risk factors for Ascending v. Descending aortic aneurysms:

Answer 723

Ascending (60%) are d/t cystic medial necrosis (occurs w/aging) or CT disorders (ED and Marfan). Descending (40%) usually d/t atherosclerosis – risk: HTN, hypercholesterolemia & smoking

Question 724

Features and cause of Cauda Equina Syndrome:

Answer 724

Compression of spinal nerve roots, leads to LMN signs. B/l, severe radicular pain w/saddle hypo/anesthesia and hypo/areflexia Get asymmetric motor weakness. Contrast to conus medullaris syndrome w/symmetric motor weakness, hyperreflexia and perianal hypo/anesthesia

Question 725

Tx of CAP and HAP:

Answer 725

CAP – Ceftriaxone and azithromycin | HAP – Vancomycin and Pip-Tazo

Question 726

Manifestations of Chromium deficiency:

Answer 726

Impaired glucose control in Diabetics

Question 727

Manifestations of Cu deficiency:

Answer 727

Brittle hair, Skin depigmentation, Neuro dysfxn (ataxia, periph neuropathy), sideroblastic anemia and osteoporosis

Question 728

Manifestations of Selenium deficiency:

Answer 728

Thyroid dysfxn, Cardiomyopathy, immune dysfxn

Question 729

Manifestations of Zinc deficiency:

Answer 729

Alopecia, pustular skin rash (perioral and extremities), hypogonadism, impaired wound healing, impaired taste, immune dysfxn.

Question 730

Deficiency of what can cause impaired taste?

Answer 730

Zinc

Question 731

How to differentiate b/w Central and Nephrogenic DI:

Answer 731

Central typically don’t have an intact thirst mechanism so have decreased intake and significant hypernatremia >150 Nephrogenic have normal/near normal Na+ and intact thirst mechanism

Question 732

When are target cells seen?

Answer 732

Often in B-thalassemia. | B-thal minor pts are typically asx and require no tx.

Question 733

What is the most likely vessel occluded in a stroke pt w/urinary incontinence?

Answer 733

The anterior cerebral artery.

Question 734

Most common trigger of COPD exacerbation:

Answer 734

URI

Question 735

Pphx of Spontaneous bacterial peritonitis:

Answer 735

Fluroroquinolones | Tx when you already have it: 3rd gen ceph (cefotaxime)

Question 736

Classic EKG findings of PE:

Answer 736

S1Q3T3 Prominent S in lead 1, Q in lead III, and inverted T in lead III. Only occur in a minority of cases though. aFib is commonly a/w PE though

Question 737

Most common ear pathology in AIDS:

Answer 737

serous otitis media d/t auditory tube dysfxn, characterized by presence of middle ear effusion w/out evidence of acute infection. Otoscopy – dull tympanic membrane that is hypomobile Conductive hearing loss most common sx

Question 738

What is Ludwig Angina (causes, sxs, tx):

Answer 738

Rapidly progressive cellulitis of the submandibular space. Mostly d/t dental infections in the molar roots. Typically polymicrobial – need aerobic and anaerobic coverage Sxs: rapidly develop systemic sxs (fever, chills, malaise), and local compressive (mouth pain, drooling, dysphagia, muffled voice, airway compromise) May have crepitus. IV abx – amp-sulbactam, clindamycin and removal of infected tooth

Question 739

PE signs of pulmonary HTN:

Answer 739

L parasternal lift/RV heave Loud P2, right-sided S3 Pansystolic murmur of tricuspid regurgitation JVD, ascites, peripheral edema, hepatomegaly

Question 740

What is LVEDV?

Answer 740

PRELOAD!!! | Mitral regurg increases preload, and so does increased blood volume d/t renal Na+ and H2O retention in heart failure.

Question 741

Murmur heard w/Tricuspid regurgitation:

Answer 741

Holosystolic and increases in intensity w/inspiration.

Question 742

What differentiates R-sided systolic murmurs from all others?

Answer 742

Augmentation of intensity with inspiration. | Only R-sided systolic murmurs will change w/inspiration.

Question 743

What is central cord syndrome?

Answer 743

Often a result of hyperextension injuries in elderly w/pre-existing degenerative spinal changes. Characterized by weakness more pronounced in the upper extremities than lower. May have complete loss of movement and sensation in UEs.

Question 744

What is posterior cord syndrome?

Answer 744

A/w b/l loss of vibratory and proprioceptive sensation. Often w/weakness, paresthesias and urinary incontinence or retention. MS and vascular disruption are most common causes.

Question 745

How does Acetazolamide tx IIH?

Answer 745

It inhibits choroid plexus carbonic anhydrase which decreases CSF production.

Question 746

What studies are considered Observational, Experimental, Review?

Answer 746

Observational: Cohort, Corss-sectional, Case-control, Case-study Experimental: Randomized control, nonrandomized design Review: Meta-analysis

Question 747

What is considered a positive bronchodilator response?

Answer 747

>12% increase in FEV1

Question 748

Difference in immune response to the pneumococcal vaccines:

Answer 748

PPSV23 is a polysaccharide vax. It alone can’t be presented to T-cells so it induces a relatively T-cell-independent B-cell response. PCV13 is a conjugate vax and induces a T-cell-dependent B-cell response. PCV13 produces a more effective response.

Question 749

What is Metolazone?

Answer 749

A thiazide Diuretic

Question 750

What Thyroid tx will worsen ophthalmopathy?

Answer 750

RAI bc increased TRABs are released Pts. w/moderate to severe ophthalmopathy should undergo thyroidectomy instead of RAI. Glucocorticoids can prevent complications in pts w/mild ophtalmopathy

Question 751

Features of malignant biliary obstruction:

Answer 751

Conjugated hyperBRemia, elevated AlkPhos, painless jaundice, and systemic sxs.

Question 752

Organisms that alkalinize the urine:

Answer 752

Proteus and Klebsiella. Often have pH>8 | E. coli will not cause alkaline urine bc it doesn’t produce urease

Question 753

What is the tx for Cervicofacial Actinomyces?

Answer 753

Penicillin for 2-6mos | May need surgery if fistulas form

Question 754

What would increase the risk of HACEK IE?

Answer 754

Periodontal infection, poor dentition, and dental procedures.

Question 755

How to differentiate b/w glomerular and non-glomerular hematuria:

Answer 755

Glomerular will have microscopic > gross hematuria w/Blood and protein + RBC casts and dysmorphic RBCs on UA Non-glomerular has Gross > micro hematuria w/blood, no protein and normal appearing RBCs on UA.

Question 756

Differences in renal cysts:

Answer 756

On CT/MRI simple renal cysts will have absence of contrast enhancement and smooth thin walls. These do not require any tx (esp in asx pts) Malignant renal cysts will have irregular walls, contrast enhancement and need follow-up

Question 757

When are BBs contra’d in MI pts?

Answer 757

If they have bradycardia or cardiogenic shock

Question 758

What is a GI complication of uric acid stones?

Answer 758

Ileus d/t a vagal reaction caused by ureteral colic. Not just uric acid stones. Can be anything causing renal/ureteral colic. Should get CTabdo, US, or IV pyelography to dx underlying stones and tx to resolve ileus.

Question 759

Preventative migraine Rxs:

Answer 759

Topiramate, Divalproex sodium, TCAs, BBs

Question 760

Abortive migraine Rxs:

Answer 760

Triptans, NSAIDs, Acetaminophen, Antiemetics (metoclopramide, prochlorperazine), Ergots

Question 761

In pts w/suspected MG but negative acetylcholine-R Abs, what should be checked?

Answer 761

Muscle-specific TK Abs

Question 762

What type of acid-base disorder is likely seen in shock?

Answer 762

Primary metabolic acidosis d/t lactic acidosis 2/2 hypoperfusion.

Question 763

Nerve injuries a/w humeral fractures:

Answer 763

Spell ARM proximally to distally Axillary – humeral neck Radial – mid shaft or anterolaterally displaced supracondylar Median – anteromedially displaced supracondylar

Question 764

Main cause of traveler’s diarrhea?

Answer 764

ETEC | Presents w/bloating, watery nonbloody stools that are foul smelling

Question 765

Mgmt of esophageal full-thickness tears:

Answer 765

Operative repair.

Question 766

When do you hear S3?

Answer 766

Heard during rapid ventricular filling in diastole. D/t turbulent blood flow to the ventricles d/t increased volume Normal: Children, young adults, pregnancy Abnormal: Age >40, heart failure, RCMP, High-output states

Question 767

When do you hear S4?

Answer 767

Heard immediately after atrial contraction as blood is forced into a stiff ventricle. Normal: healthy older adults Abnormal: younger adults, children, ventricular hypertrophy, ACUTE MI!

Question 768

Mgmt of Hypovolemic hypernatremia:

Answer 768

Symptomatic pts get NS until euvolemic and then switch to 5% dextrose Asx pts get 5% dextrose from beginning If euvolemic they just get free H2O supplementation

Question 769

Most common cause of febrile neutropenia & tx:

Answer 769

GNR – esp Pseudomonas. | Tx w/Pip-Tazo

Question 770

What are the features of Milk-Alkali Syndrome?

Answer 770

Pathophys: xs intake of Ca leads to renal vasoconstriction and decreased GFR w/renal loss of Na+ and H2O and reabs of HCO3-. Sxs: N/V/Constipation, polyuria, polydipsia, neuropsych sxs Labs: Hypercalcemia, metab alkalosis, AKI, suppressed PTH Tx: NS then furosemide

Question 771

Most common electrolyte abnormality in primary adrenal insufficiency:

Answer 771

Hyponatremia - leads to increased renin activity Must be corrected w/a mineralocorticoid like Fludrocortisone

Question 772

Contraindications to the Yellow Fever Vaccine:

Answer 772

Egg allergy AIDS w/CD 4 <200 IMCP’d – especially those a/w thymus disorders or recent stem cell transplant Immunosuppressive therapy – TNF antagonists, high-dose steroids, etc

Question 773

What are PVCs and how are they treated?

Answer 773

Premature ventricular contractions – wide, distorted QRS. | Tx: asx pts do not need therapy. Those w/sxs need escalating doses of BBs or CCBs

Question 774

Features of PVCs (4):

Answer 774

QRS >0.12 seconds Bizarre morphology not resembling any conduction abnormality T wave in opposite direction of QRS axis Compensatory pause

Question 775

What is Calciphylaxis?

Answer 775

Aka calcific uremic arteriolopathy Arteriolar and soft tissue calcification Local tissue ischemia & necrosis NO vasculitis

Question 776

Risk factors of calciphylaxis (5):

Answer 776

``` ESRD Hypercalcemia, hyperphosphatemia Hyperparathyroidism Hypomagnesemia (Mg inhibits extraosseous calcification) Obesity/DM Oral anticoagulants (warfarin) Vitamin K deficiency ```

Question 777

Clinical manifestations of calciphylaxis:

Answer 777

Painful nodules and ulcers Soft tissue calcification on imaging Skin bx: arterial calcification/occlusion, subintimal fibrosis

Question 778

What is the most specific diagnostic test for osteomyelitis?

Answer 778

Bone bx and culture. | Should be done before starting abx

Question 779

What nerve is commonly compressed by the inguinal ligament?

Answer 779

The lateral femoral cutaneous nerve (L2, 3)

Question 780

What should be used to tx UTIs in children?

Answer 780

Typically 3rd gen cephalosporins – cefixime

Question 781

What are the common features/sxs of Sick sinus syndrome?

Answer 781

Bradycardia – fatigue, dyspnea on exertion, lightheadedness, confusion, and syncope/presyncope If atria is affected – aFib/atrial arrhythmias, or bradycardia-tachycardia syndrome.

Question 782

What causes Sick sinus syndrome?

Answer 782

Typically d/t age-related degeneration of the cardiac conduction system w/fibrosis of the SAN. Characterized by inability of the SAN to generate an adequate HR.

Question 783

What are the features of Benzo withdrawal?

Answer 783

Tremulousness, hallucinations, and elevated VS (HTN, tachycardia). Severe cases pts may develop seizures

Question 784

What is gamma gap, and what would a large one suggest?

Answer 784

Gamma gap Is the difference b/w total protein and albumin. | Large gamma gaps can be seen in Waldenstrom macroglobulinemia and Multiple myeloma.

Question 785

Major internal manifestations of Waldenstrom Macroglobulinemia:

Answer 785

Hyperviscosity syndrome Neuropathy Bleeding Hepatosplenomegaly Lymphadenopathy Cryoglobulinemia and renal insufficiency – a nephritic syndrome “sausage-link” (dilated, segmented, tortuous) retinal vv.

Question 786

Lab values a/w Waldenstrom Macroglobulinemia:

Answer 786

Anemia Gamma gap Elevated ESR **If cryoglobulinemia develops, may show hypocomplementemia**

Question 787

Screening test for Waldenstrom macroglobulinemia:

Answer 787

Serum electrophoresis – will show IgM spike. Peripheral smear will show rouleaux (like in MM) And BM bx will show >10% clonal B cells (differentiates from the >10% plasma cells in MM).

Question 788

Sxs experienced in Waldenstrom macroglobulinemia:

Answer 788

``` Vision changes Headaches (bi-temporal common) Vertigo Dizziness Ataxia Rarely stroke or coma may occur ```

Question 789

How is a urethral diverticulum likely to present?

Answer 789

As a tender anterior vaginal wall mass. May lead to dyspareunia or a palpable mass on pelvic exam. If urine and debris collect inside it can lead to a purulent discharge, dysuria, or postvoid dribbling. Diagnosis confirmed w/MRI.

Question 790

What is considered normal labor progression in the active phase of labor?

Answer 790

When the cervix dilates 1+ cm every 2hours.

Question 791

How is chronic bacterial prostatitis likely to present?

Answer 791

``` In young and middle age men Recurrent UTIs (w the same organism) +/- prostatic tenderness and swelling (often absent) Pain with ejaculation Hx of abx tx w/transient improvement ```

Question 792

How is Chronic bacterial prostatitis dx’d and tx’d?

Answer 792

Dx: pyuria & bacteriuria on UA. Bacteria in prostatic fluid. UA before prostatic massage has less bac than after massage Tx: Fluoroquinolones (Cipro) for 6wks

Question 793

What will cause xs collagen deposition in the bone marrow?

Answer 793

Myelofibrosis – deposits xs collagen or reticulin in the BM | Presents w/fatigue, fevers, and HPT-SP-megaly.

Question 794

What effect will Down syndrome have on muscle tone?

Answer 794

Babies are v hypotonic – possibly protruding tongue and floppy body and extremities.

Question 795

What are some common disorders that present with hypotonia in infancy?

Answer 795

``` Down Syndrome Cretinism/Hypothyroid Fragile X Prader-Willi Infantile Botulism ```

Question 796

What are the most common bacteria that cause Epiglottitis?

Answer 796

H. influenzae Strep. spp. (S. pneumo, S. pyogenes) S. aureus

Question 797

What is the tx of epiglottitis?

Answer 797

Broad spectrum abx: Ceftriaxone – targets H. influ and Strep. Spp. Vancomycin – targets S. aureus (including MRSA

Question 798

What is chronic exertional compartment syndrome?

Answer 798

Increased pressure within a muscle group during exercise – often seen in young athletes. Will not have point tenderness or bone tenderness.

Question 799

How will injury to the interosseous ligaments present?

Answer 799

Aka a high ankle sprain – presents w/acute anterolateral ankle pain often following rotational force on a dorsiflexed ankle. Often have associated fibular fracture

Question 800

What is medial tibial stress syndrome?

Answer 800

Shin splints

Question 801

How are anterior shoulder dislocations typically caused?

Answer 801

By a blow to the externally rotated and abducted arm.

Question 802

How do anterior shoulder dislocations often present?

Answer 802

With flattening of the deltoid prominence Protrusion of the acromion Anterior axillary fullness (bc humeral head is now here) Arm abducted and externally rotated

Question 803

What nerve is most commonly injured in shoulder dislocations and what deficits will be seen?

Answer 803

Axillary n. It innervates: Teres minor Deltoid – weakened abduction Sensory innervation of lateral shoulder – numbness

Question 804

What does the radial n. innervate and how is it most commonly injured?

Answer 804

Primary innervation of the wrist and digit extensors. Sensation to posterior arm, forearm and dorsolateral hand. Most commonly injured in mid-humeral fractures and from improperly fitted crutches.

Question 805

What is responsible for the biceps reflex?

Answer 805

Mediated by C5 and C6 spinal nerves, via the musculocutaneous n.

Question 806

Damage to what nerve causes scapular winging?

Answer 806

The long thoracic n. which innervates the serratus anterior.

Question 807

What would indicate neuroimaging in a child w/a HA?

Answer 807

Coordination difficulties Presence of numbness/tingling/focal neurologic signs Hx of HA that awakens from sleep Hx of increasing HA frequency

Question 808

1st line mgmt. of migraines in peds pts:

Answer 808

Acetaminophen or NSAIDs + counsel the fam.

Question 809

What will the crystals look like on UA in cystinuria?

Answer 809

Hexagonal crystals

Question 810

What does the urinary cyanide-nitroprusside test detect?

Answer 810

Elevated levels of cystine

Question 811

When is complete bedrest recommended in pregnancy?

Answer 811

NEVER – has not been proven to be effective and increases risk of thromboembolisms.

Question 812

What is the initial mgmt. of mixed incontinence?

Answer 812

A voiding diary – helps classify the predominant type of incontinence and determine tx.

Question 813

What are some of the features unique to Ehlers-Danlos syndrome?

Answer 813

Skin manifestations – transparent/hyperextensible skin, easy bruising, poor healing, velvety w/atrophy and scarring Abdominal and inguinal hernias Uterine prolapse High arched palate

Question 814

What are some of the features unique to Marfan syndrome?

Answer 814

``` Tall w/long extremities Pectus carinatum Progressive aortic root dilation Lens and retinal detachment Spontaneous pneumothorax ```

Question 815

Genetics a/w Ehlers-Danlos and Marfan syndromes:

Answer 815

Both AD inheritance ED – COL5A1 and COL5A2 mutations Marfan – FBN1 mutation

Question 816

What are the chronic cxs a/w Giardiasis?

Answer 816

Malabsorption – lactose intolerance Profound weight loss Vitamin deficiencies **NOT a/w GBS**

Question 817

How is CMV transmitted?

Answer 817

Through contact w/infected bodily fluids (urine, saliva, breast milk)

Question 818

What are the stimuli for ADH secretion?

Answer 818

``` Osmotic: Serum osmolality >285mOsm Nonosmotic: Nausea Pain Physical/emotional stress HoTN HoVolemia Hypoxia HoGlycemia ```

Question 819

What is Exercise-associated hyponatremia?

Answer 819

Phenomenon in athletes who participate in prolonged exercise – most often caused by ingestion of xs hypotonic fluids which triggers SIADH. Sxs: lethargy, N, seizures, profound confusion

Question 820

What are common associations with erythema multiforme development?

Answer 820

Infections – HSV and Mycoplasma Rxs – sulfonamides Malignancies Collagen vascular disease

Question 821

Rxs that often trigger hemolysis in G6PD deficiency:

Answer 821

``` Dapsone Isobutyl nitrite Nitrofurantoin Primaquine Rasburicase Sulfonamides TMP-SMX ```

Question 822

Presentation of Infantile botulism:

Answer 822

Age <12mos Constipation, poor feeding, hypotonia Oculobulbar palsies (absent gag reflex, ptosis) Symmetric, descending paralysis Autonomic dysfxn (decreased salivation, fluctuating HR/BP)

Question 823

What is herpes zoster oticus?

Answer 823

Aka Ramsay Hunt Syndrome – reactivation of VZV from geniculate ganglion w/spread to CN VIII 2 defining manifestations: erythematous, vesicular rash on the auditory canal or auricle and ipsilateral facial droop/paralysis Other sxs: vertigo, N/V, hearing/taste disturbances

Question 824

How to differentiate central from peripheral vertigo:

Answer 824

Peripheral – horizontal +/- vertical/torsional nystagmus; walking usually preserved, may have hearing loss or tinnitus. Central – purely vertical/torsional nystagmus, severe postural instability, no hearing loss/tinnitus, often has other neuro signs.

Question 825

Causes of central v. peripheral vertigo:

Answer 825

Central – Stroke, MS, migraine, CNS tm, cerebellar infarction Peripheral – BPPV, Meniere's, vestibular neuritis, acoustic neuroma

Question 826

What would gamma-tetramers on Hb-electrophoresis represent?

Answer 826

Alpha-thalassemia/Hb Barts

Question 827

What would lab evaluation in Hb Barts look like?

Answer 827

Low MCV Increased RBCs Target cells on peripheral smear

Question 828

What might prevertebral calcifications on a spinal XR indicate?

Answer 828

AAA – calcifications seen in the aorta.

Question 829

What cardiac cxs are a/w Turner syndrome?

Answer 829

Bicuspid aortic valve, aortic root dilation, aortic coarctation and HTN. Pregnancy increases risk of dissection in Turner pts.

Question 830

What are common sxs of snake bites?

Answer 830

Hemoglobinuria, bleeding, mm. paralysis, severe local pain and swelling, and discoloration w/in hrs of the bite.

Question 831

How to differentiate brown recluse from black widow bites:

Answer 831

Black widow – N/V w/in hrs of the bite, then muscle pain, abdominal rigidity, and muscle cramps. Ulceration uncommon. Brown recluse – deep skin ulcer w/an erythematous halo and necrotic center progressing to an eschar.

Question 832

What should pts with Restless Leg Syndrome be screened for?

Answer 832

Fe-def anemia

Question 833

What is the target BP reduction in HTN-emergencies?

Answer 833

Reduce BP by 20-25% or get DBP less than 100 mmHg within mins or hrs

Question 834

What are recommended agents for lowering BP over hrs in HTN-urgency?

Answer 834

Oral captopril, furosemide, or clonidine

Question 835

How does chlamydial pneumonia often present?

Answer 835

In infants 3-16wks. Often are sick for several weeks and appear nontoxic and afebrile, but are tachypneic w/prominent cough. Over 50% have conjunctivitis as well Often have eosinophilia on CBC

Question 836

What is the criteria for introducing a 5-a-reductase inhibitor to treat BPH?

Answer 836

Evidence of prostatic enlargement or PSA >1.5. | If these criteria aren’t met then use an a-blocker, PDE-5 inhibitor, or antimuscarinic for BPH

Question 837

Recommended tx for a mallet fracture (forced flexion injury of DIP):

Answer 837

Splinting the DIP in extension for about 8weeks.

Question 838

What is active phase protraction and what is the most common cause?

Answer 838

Active phase protraction is when the cervix dilates <1cm every 2 hrs. Commonly caused by cephalopelvic disproportion

Question 839

How do the two different types of Vulvar Lichen Planus present?

Answer 839

``` Erosive variant (most common): Erosive, glazed lesions w/white border, vaginal involvement +/- stenosis, associated oral ulcers Papulosquamous variant: Small pruritic papules w/purple hue Both present in women age 50-60 w/vulvar pain or pruritus, and dyspareunia ```

Question 840

What are some common Lab abnormalities seen in lead poisoning?

Answer 840

``` Anemia Elevated venous lead level Elevated serum zinc protoporhpyrin Hyperuricemia (from impaired purine metab) Elevated Cr (nephrotoxicity) Basophilic stippling on peripheral smear ```

Question 841

What is increased QRS-complex voltage consistent with?

Answer 841

LV hypertrophy

Question 842

What is retinal arteriovenous nicking, and what is it indicative of?

Answer 842

When the retinal venules are narrowed at the intersection points w/arterioles and then bulge on either side. Consistent w/hypertensive retinopathy

Question 843

What is isolated ambulatory HTN?

Answer 843

Aka masked HTN Pts often present w/normal BP readings in the clinical setting but have consistently high BP throughout the day and night. They are often only caught once there is evidence of HTN end-organ damage. Dx w/ambulatory pressure monitoring

Question 844

Who has greatest risk of developing osteosarcoma?

Answer 844

Pts w/mutations in RB1 or TP53 So typically have hx of previous ca. (Retinoblastoma in RB1 and leukemia, breast, brain, or adrenocortical tms in TP53/Li Fraumeni synd.)

Question 845

Tx of Spinal Epidural abscess:

Answer 845

BSA – vanc + ceftriaxone | Aspiration/surgical decompression

Question 846

Classic triad of Spinal Epidural Abscess:

Answer 846

Fever Focal/Severe back pain Neuro sxs – motor/sensory change, bowel/bladder dysfxn, paralysis

Question 847

Rx causes of Osteoporosis (7):

Answer 847

``` Glucocorticoids Heparin Phenytoin Carbamazepine PPIs Aromatase Inhibitors Medroxyprogesterone (depot) ```

Question 848

Endocrine causes of osteoporosis:

Answer 848

Hyperthyroidism (accelerated bone turnover) Hyperparathyroidism (PTH increases bone breakdown) Hypercortisolism (inhibit bone formation) Hypogonadism (decreased estrogen)

Question 849

What type of bone lesions would cause an increase in ALP?

Answer 849

Osteoblastic lesions Osteolytic lesions would not increase ALP and therefore there should not be a rise in disorders that cause pure osteolytic lesions – Multiple myeloma, RCCa

Question 850

Tx of Viral or Idiopathic acute pericarditis:

Answer 850

NSAIDs + Colchicine

Question 851

What virus causes Croup?

Answer 851

Aka Laryngotracheitis – caused by Parainfluenza virus

Question 852

What is mixed connective tissue disease and what are the lab findings?

Answer 852

AI disorder w/variable features of: SLE, Systemic Sclerosis and Polymyositis Lab findings: Anti-U1 ribonucleoprotein, ANA, RF, anti-CCP, elevated CK, anemia/cytpoenias

Question 853

What effect does chronic hyperglycemia have on the renal arterioles?

Answer 853

Causes dilation of the renal afferent arterioles and constriction of the efferent arterioles – glomerular hyperfiltration and Diabetic nephropathy.

Question 854

What could early deceleration in head growth signify?

Answer 854

Rett Syndrome These pts also have breathing abnormalities characterized by alternating episodes of hyperventilation and hypoventilation/apnea, and retropulsion (rocking back and forth).

Question 855

Features of anaphylactic blood transfusion rxn:

Answer 855

HoTN Rapid onset of shock, angioedema/urticaria & resp. distress Happens w/in sec-min of transfusion Caused by recipient anti-IgA Abs (seen in pts w/IgA deficiency) Tx: IM Epi, antihistamines, vasopressors +/- high-dose steroids

Question 856

Features of Transfusion-related acute lung injury:

Answer 856

HoTN, Resp. distress & signs of noncardiogenic pulmonary edema Happens w/in 6hrs of transfusion Caused by donor anti-leukocyte Abs

Question 857

Features of primary HoTN rxn caused by blood transfusion:

Answer 857

Transient HoTN often in pts on ACEIs Happens w/in min of transfusion Caused by bradykinin in blood products

Question 858

Features of transfusion-transmitted bacterial infection (TTBI):

Answer 858

Greatest in pts receiving platelet transfusions (bc platelets are stored at room temp) High fever (>39C), HoTN, rigors, tachycardia (>120bpm), DIC, septic shock Happens w/in approx. 30 min. of completing transfusion Tx: stop transfusion, IVF, blood cultures, and BSAbx

Question 859

How would Candidal otitis externa present and what is used to tx?

Answer 859

With pruritus and white flaky debris in the ear canal. | Tx: Clotrimazole

Question 860

DoC for acute otitis media:

Answer 860

Amoxicillin | If tx failure happens tx w/Amoxicillin-Clavulanate (Augmentin)

Question 861

What are common sxs of HME?

Answer 861

Human monocytic erlichiosis Nonspecific sxs – HA, myalgias, cough, rash Labs – leukopenia, thrombocytopenia, elevated transaminases Seen in S. US, caused by Lone Star tick Tx w/Doxycycline

Question 862

When should pts w/Hb between 8-10 be transfused?

Answer 862

If they meet any of the following criteria: Symptomatic anemia Acute and ongoing blood loss Acute coronary syndrome w/ischemia

Question 863

What would a combo of increased VLDL and TGs indicate?

Answer 863

Type IV familial dyslipidemia Caused by xs hepatic VLDL production. Often leads to acute pancreatitis

Question 864

What could create a false positive for amphetamines?

Answer 864

Atenolol/Propranolol Buproprion Nasal Decongestants

Question 865

What opioids will not show up on urine drug screens?

Answer 865

Semisynthetics – Hydrocodone, hydromorphone, oxycodone Synthetics – Fentanyl, meperidine, methadone, tramadol Only morphine and its metabolites (heroin, codeine) are detected

Question 866

What Rxs may create a false positive for PCP?

Answer 866

``` Dextromethorphan Diphenhydramine Doxylamine Ketamine Tramadol Venlafaxine ```

Question 867

What are common presenting sxs of C. neoformans infection?

Answer 867

Fever, malaise, umbilicated skin lesions (resembles molluscum) Increased ICP w/enlarged ventricles, HA/N/V, abducens n. palsy

Question 868

What is multifocal atrial tachycardia and what are its common causes?

Answer 868

Rapid, irregular pulse w/ 3+ P-wave forms and atrial rate >100/min on EKG Typically asx Common causes: exacerbation of pulmonary disease/COPD, electrolyte disturbance/hypokalemia, catecholamine surge (sepsis) Norm. tx is just to correct underlying issue

Question 869

What are the indications for aortic valve replacement?

Answer 869

Severe AS and 1+ of the following: Onset of sxs (angina, syncope, etc.) - symptomatic pts w/severe AS have a high risk of SCD LVEF <50% (regardless of sxs) Undergoing other cardiac surgery (CABG, etc.) Only pts. who are truly asx and have severe AS w/LVEF >50% can be monitored w/serial echos instead of undergoing valve replacement.

Question 870

Criteria to dx severe aortic stenosis:

Answer 870

Aortic jet velocity >/= 4.0 m/sec OR Mean transvalvular pressure gradient >/= 40mmHg *Valve area is normally <1 cm but this isn’t required to dx*

Question 871

What is the most common cause of vesicovaginal fistula worldwide?

Answer 871

Obstructed labor

Question 872

Features of delirium tremens:

Answer 872

Onset w/in 48-96hrs | Sxs: Confusion, agitation, fever, tachycardia, HTN, diaphoresis, hallucinations

Question 873

Differentiation of pseudoaneurysm from AV fistula:

Answer 873

AV fistula – no palpable mass, but continuous bruit and palpable thrill over the region. May have decreased distal pulses in the region. Pseudoaneurysm – pulsatile mass with an audible systolic (not continuous) bruit.

Question 874

What are the skin conditions often a/w HIV infection?

Answer 874

Sudden-onset severe psoriasis Recurrent herpes zoster Disseminated molluscum contagiosum Severe seborrheic dermatitis (also a/w Parkinson)

Question 875

What are the features of secondary varicocele?

Answer 875

Pathophys: extrinsic compression (renal or retroperitoneal mass) of the IVC; Or venous thrombosis Clinical features: “bag of worms” mass, persists when supine, Prepubertal onset on R (often Wilms), Older onset on L (often RCCa) Mgmt: Abdominal US in children, CT Abd in adults (investigate for cause – Wilms tm, RCCa etc.)

Question 876

Features of urethral stricture:

Answer 876

M>F Often caused by: urethral trauma (catheter), urethritis, or radiotherapy Sxs: weak/spraying stream, incomplete emptying, irritative voiding (dysuria, frequency) Will typically have normal UA and high PVR

Question 877

What are the features and mgmt. of superficial dehiscence?

Answer 877

Separation of the skin and subQ tissue w/intact rectus fascia. Often in overweight/obese pts. Have scant serosanguineous discharge without signs of infection Mgmt: regular dressing changes

Question 878

When should a toddler’s legs be straight?

Answer 878

By 18mos. From 6-18mos: physiologic genu varum 4yrs: physiologic genu valgum 7+yrs: straight legs

Question 879

Characteristics of nasopharyngeal carcinoma:

Answer 879

Endemic to Asia, and linked to EBV reactivation. Risks: diet (salty fish), smoking, genetics May present w/obstruction – congestion, epistaxis, HAs; CN palsies, otitis media; Neck mass – cervical LAD

Question 880

Surgical indications for severe mitral regurgitation:

Answer 880

Surgery if LVEF 30-60% regardless of sxs | Surgery is successful valve repair is highly likely in pts w/sxs & LVEF <30% or asx & LVEF >60%

Question 881

What is referred otalgia and what is it commonly a/w?

Answer 881

Ear pain without an otic origin. Often a/w: dental disease, TMJ disorders, and mucosal head and neck SCCa. Almost never due to a central CNS cause

Question 882

What is the most common cancer of late adolescence (15-19)?

Answer 882

Hodgkin lymphoma

Question 883

Xray findings in Osteoarthritis v RA:

Answer 883

OA – Narrowed joint space and osteophytes | RA – periarticular erosions and soft tissue swelling

Question 884

Ottawa ankle rules (when x-ray of the ANKLE is required):

Answer 884

If pain at the malleolar zone AND Tender at post. margin/tip of medial malleolus; or Tender at post. margin/tip of lateral malleolus; or Unable to bear weight 4 steps (2 on each foot)

Question 885

Ottawa ankle rules (when x-ray of the FOOT is required):

Answer 885

If pain at the midfoot zone AND Tender at the navicular; or Tender at the base of the 5th metatarsal; or Unable to bear weight 4 steps (2 each foot)

Question 886

What allows for severe chronic AR pts to remain asx in the short term?

Answer 886

Eccentric hypertrophy allows for increased LV compliance as well as increased LV contractility to sustain increased SV and maintain CO.

Question 887

What is blepharospasm?

Answer 887

A form of focal dystonia involving recurrent forceful contraction of the eyelid muscles – commonly affected by sensory input/triggered by bright lights. When a/w spasm of the lower face it’s called Meige syndrome

Question 888

What are the HTN guidelines for mgmt.?

Answer 888

Elevated BP (120-129)/<80 – only lifestyle changes Stage I HTN (130-139/80-89) – Lifestyle + 1 anti-HTN Rx Stage II HTN (140+/90+) – Lifestyle + 2 anti-HTNs

Question 889

Clinical features of Asbestosis:

Answer 889

Presentation – prolonged asbestos exposure, sxs developing 20+ yrs after exposure, progressive dyspnea, basilar fine crackles, clubbing. Diagnosis: pleural plaques on chest imaging; imaging, PFTs, and histo consistent w/pulmonary fibrosis

Question 890

What are the systemic manifestations a/w RA (7)?

Answer 890

Pericarditis Scleritis Felty syndrome – RA w/splenomegaly & neutropenia Still’s disease – RA w/fever, rash and splenomegaly Interstitial lung disease Caplan syndrome – RA plus pneumoconiosis Sjogren’s syndrome

Question 891

What is the most common tx of Pediatric UTIs?

Answer 891

3rd-gen Cephalosporin (Cefixime)

Question 892

What are some of the common features to suggest Cervical Myelopathy?

Answer 892

LMN signs at the level of the lesion – weakness and atrophy in the arms UMN signs below the lesion – gait dysfxn, and hyperreflexia in the legs

Question 893

What are common risk factors for PCP pneumonia?

Answer 893

HIV with low CD4 count | Chronic glucocorticoid

Question 894

What is the most common location for Epidural spinal cord compression?

Answer 894

Thoracic #1, then lumbosacral

Question 895

What are the AEs of MTX therapy?

Answer 895

Hepatotoxicity Stomatitis – painful oral ulcers Cytopenias

Question 896

Tx of Paget:

Answer 896

Bisphosphonates

Question 897

What is likely in a patient that can walk on their toes but not heels?

Answer 897

Peripheral n. compression of the common peroneal n. Will have: unilateral foot drop numbness/tingling over dorsum and lateral shin impaired ankle dorsiflexion and great toe extension (can’t walk on heels) preserved plantar flexion (can walk on toes)

Question 898

What are the AEs of the anti-thyroid Rxs?

Answer 898

Thionamides – agranulocytosis MTZ: 1st-trimester teratogen, cholestasis PTU: Hepatic failure, ANCA-associated vasculitis

Question 899

What are the hallmarks of secretory diarrhea?

Answer 899

Larger daily stool volumes (>1 L/day) Diarrhea that occurs even during fasting and sleep Reduced stool osmotic gap

Question 900

What are the common txs of acute migraine episodes?

Answer 900

SubQ tripans (contraindicated in CAD) Antiemetics (D2 antagonists – Prochlorperazine) ** BBs have no role in abortive/acute mgmt. of migraine **

Question 901

Injury to which nerve will cause numbness and burning pain over the lateral aspect of the thigh?

Answer 901

Lateral femoral cutaneous n. Often compressed by the inguinal ligament No motor fibers, so no weakness Risks: obesity, increased lumbar lordosis (pregnancy), DM

Question 902

What is Chromogranin A a marker for, and when will it be elevated?

Answer 902

It is a marker for well-differentiated neuroendocrine tms. | Can be elevated in: carcinoid tms, hyperthyroidism, chronic atrophic gastritis, and chronic PPI tx.

Question 903

What kind of arrhythmia is Carotid massage used for?

Answer 903

Helps to terminate PSVT – a regular, narrow-complex tachycardia. It increases PSNS activity which helps directly slow AVN conductivity Not used in the tx of aFib Contraindications: recent TIA/stroke, carotid bruit

Question 904

What are risk factors for atraumatic splenic rupture?

Answer 904

Heme malignancy – leukemia/lymphoma Infection – CMV, EBV, Malaria Inflammatory diseases – SLE, pancreatitis Splenic congestion – cirrhosis, pregnancy Medications – anticoagulation, G-CSF

Question 905

How is gallstone pancreatitis managed?

Answer 905

ERCP | Elective cholecystectomy should be performed but only after the pancreatitis and cxs are cleared.

Question 906

Findings of anterior cord syndrome:

Answer 906

B/l hemiparesis at level of cord injury and below – damage to lateral corticospinal tracts Loss of b/l pain and temp. – lateral spinothalamic tract injury Intact b/l proprioception, vibration and light touch

Question 907

Difference b/w narrow and wide-complex tachycardia:

Answer 907

Narrow complex = supraventricular tachycardia | Wide complex = ventricular tachycardia

Question 908

EKG features of Narrow-complex tachycardia:

Answer 908

aka SVT | Have narrow QRS complexes w/no discernable P-waves bc they’re buried w/in the QRS complex.

Question 909

How to dx diverticulitis:

Answer 909

CT w/contrast

Question 910

What age should mammogram start being the diagnostic imaging test of choice for breast lesions?

Answer 910

30 and older! | Women under 30 should get US first.

Question 911

What parasite is a/w rectal prolapse?

Answer 911

Trichuriasis or Whipworm When there is a heavy parasite load it can cause rectal prolapse. Heavy loads can also affect a child’s growth and cognition

Question 912

What are some cxs a/w Enterobiasis infection?

Answer 912

In high worm burden can get abdominal pain.fullness or N/V | Rare cxs: UTIs/vulvovaginal pruritus in girls, eosinophilic enterocolitis and appendicitis.

Question 913

What is considered a wide QRS complex?

Answer 913

QRS >.12s or 3 small boxes on EKG strip

Question 914

What is the LDL goal in patient with KNOWN coronary artery disease?

Answer 914

LDL <100mg/dL Known CAD = previous MI, angina, etc. Disease equivalents to known CAD = DM, Cerebrovascular disease, AAA, PAD.

Question 915

Difference in site of pain for testicular torsion and inguinal hernia:

Answer 915

Torsion – Scrotal pain Hernia – Groin pain Both can be from increased abd pressure, exercise, etc. Site is one of main differences

Question 916

What is a cx of testicular torsion and how is it identified?

Answer 916

Testicular necrosis can occur w/ >12hrs torsion/ischemia – can lead to nonviability. Will be seen as heterogenous echotexture on US.

Question 917

Most common cause of community-acquired bacterial meningitis:

Answer 917

S. pneumoniae | Often secondary to dissemination, and may occur w/or w/out pneumococcal pneumonia

Question 918

What are some common sites for SCC of the skin to arise in?

Answer 918

Within chronically wounded, scarred or inflamed skin | Overlying a focus of osteomyelitis, radiotherapy scars, and venous ulcers

Question 919

What kind of infection is ringworm?

Answer 919

It is a Dermatophyte infection – Tinea Corporis Aka this is a fungal, NOT parasitic infection and needs to be tx’d 1st line w/topical anti-fungals (Clotrimazole, terbinafine) Dermatophyte infection involving the scalp (tinea capitis), diffuse or refractory cases are tx'd w/oral anti-fungals (griseofulvin, terbinafine)

Question 920

Tx of Polymyalgia Rheumatica:

Answer 920

Low-dose corticosteroids

Question 921

Indications for gastric bypass:

Answer 921

BMI >40 | BMI >35 + comorbid conditions

Question 922

What is the cause of physiologic hydronephrosis in pregnancy?

Answer 922

High progesterone levels cause ureteral dilation and decreased peristalsis. As the uterus enlarges it also compresses the ureters at the pelvic brim worsening the hydronephrosis.

Question 923

Signs of pHTN:

Answer 923

L parasternal lift, RV heave Loud P2, R-sided S3 Pansystolic murmur of tricuspid regurg, JVD, ascites, peripheral edema, hepatomegaly

Question 924

How to differentiate LVF from RVF based on S3:

Answer 924

RVF S3 is best heard at the L-lower sternal border on end-inspiration LVF S3 is best heard at the apex on end-expiration

Question 925

What are the common manifestations of Tumor Lysis Syndrome?

Answer 925

Severe electrolyte abnormalities – increased PO4, K+, uric acid, and v. high LDH Hypocalcemia (d/t the hyperphosphatemia binding all the Ca2+) AKI – d/t uric acid/calcium phosphorus Cardiac arrhythmias

Question 926

Pphx of Tumor Lysis Syndrome:

Answer 926

IV fluids and Allopurinol or Rasburicase

Question 927

When would you see pencil cells on peripheral smear?

Answer 927

Iron deficiency

Question 928

What are the features and triggers of Microscopic colitis?

Answer 928

MC is a chronic, immune-mediated colitis. Features: watery, non-bloody diarrhea (secretory), fecal urgency & incontinence, nocturnal diarrhea (classic sign) Less common sxs: abdP (50%), fatigue and wt. loss. Triggers: smoking, Rxs – NSAIDs, PPIs, SSRIs, Ranitidine

Question 929

How to dx Microscopic colitis and differentiate the 2 types:

Answer 929

Dx w/colonoscopic bx – lymphocytic infiltration of lamina propria Collagenous type – thickened subepithelial collagen band Lymphocytic type – high levels of intraepithelial lymphocytes (>20 for every 100 epithelial cells)

Question 930

Mgmt of Microscopic colitis:

Answer 930

Remove possible triggers, antidiarrheal Rxs, Budesonide

Question 931

What thyroid cancer arises from the parafollicular cells?

Answer 931

Medullary thyroid carcinoma – overproduces calcitonin Calcitonin levels correlate w/the risk of metastasis and recurrence and should be measured at the time of dx and then serially after tx. CEA also correlates w/disease progression and should be monitored w/calcitonin

Question 932

What should be the first step in evaluation of hypospadias?

Answer 932

Karyotype analysis. It is often indicative of a disorder of sex development (androgen receptor mutation, etc.). May represent virilization of an XX female, or undervirilization of an XY male.

Question 933

What are the common pulmonary features of RA?

Answer 933

Interstitial lung disease w/pulmonary nodules | Exudative pleural effusions – v. low glucose (<50mg/dL), v. high LDH (>700), and low pH resembling bacterial empyema.

Question 934

What are the most common causes of pleural effusions w/very low glucose (<50)?

Answer 934

RA Empyema Malignancy TB

Question 935

Common risk factors of brain abscess:

Answer 935

``` Cyanotic heart disease (ToF) Sinusitis Mastoiditis Otitis media Dental Infection **most commonly caused by S. aureus or S. viridans** ```

Question 936

How to differentiate Viral v. Bacterial acute rhinosinusitis:

Answer 936

Viral – no fever, or early resolution of fever Mild sxs (mild facial pain, etc.) Improvement & resolution by day 5-10 Bacterial – fever 3+ days, OR New/recurrent fever after initial improvement, OR Persistent sxs 10+ days

Question 937

Tx of acute rhinosinusitis:

Answer 937

Intranasal saline, saline irrigation, NSAIDs | Need abx if bacterial

Question 938

Most common causes of a positive hepatojugular reflux:

Answer 938

Constrictive pericarditis RV infarction Restrictive cardiomyopathy

Question 939

What does leukocyte esterase in the urine signify?

Answer 939

Significant pyuria

Question 940

What does nitrite positive urine signify?

Answer 940

Presence of enterobacteriacae (converts urinary nitrates to nitrites)

Question 941

What is the expected dipstick finding in acute pyelonephritis?

Answer 941

Pyuria, significant bacteriuria – positive for nitrites and esterase

Question 942

Tx of Actinomyces:

Answer 942

Penicillin (oral) is DoC; Severe cases may require IV pen or surgery

Question 943

What causes the diarrhea/steatorrhea in Zollinger-Ellison syndrome?

Answer 943

Excess gastric acid in the SI causes diarrhea and then steatorrhea can develop d/t inactivation of pancreatic enzymes and injury to the mucosal brush border.

Question 944

How to calculate and interpret the SAAG:

Answer 944

Serum-to-ascites albumin gradient Calculated by subtracting peritoneal fluid albumin from serum albumin SAAG >/= 1.1: Indicates portal HTN – cardiac ascites, cirrhosis, Budd-Chiari syndrome SAAG < 1.1: absence of portal HTN – TB, peritoneal carcinomatosis, pancreatic ascites, nephrotic syndrome

Question 945

Tx of Bell’s Palsy:

Answer 945

Oral Corticosteroids

Question 946

When should topical/rectal Mesalamine be used in tx of UC?

Answer 946

In patients with mild disease that doesn’t extend beyond the mid-sigmoid colon.

Question 947

What is pathognomonic for Chediak-Higashi syndrome?

Answer 947

Peripheral smear showing giant granules in the neutrophils.

Question 948

Tx of tension HAs:

Answer 948

NSAIDs are 1st line | HAs refractory to NSAIDs, or rebound HAs can be treated with TCAs

Question 949

Mgmt of ASCUS in a patient 21-24:

Answer 949

Immediate HPV testing/reflex HPV testing or repeat pap in 1 year.

Question 950

How long must pts be on PPIs before considered refractory to tx?

Answer 950

12 weeks!

Question 951

Tx of Lyme disease in a child <8yrs:

Answer 951

Amoxicillin or Cefuroxime

Question 952

How long should Fluoxetine be dc’d before initiating another serotonergic med?

Answer 952

5 weeks – has longer t1/2 than the other SSRIs which only need 2 weeks

Question 953

What arteries are commonly affected by FMD?

Answer 953

Preferentially affects the renal and internal carotids Less common the vertebral, iliac, or mesenteric are affected. Leads to arterial stenosis, aneurysm or dissection

Question 954

Most common presenting sx of FMD:

Answer 954

Recurrent HA – d/t carotid a. stenosis or aneurysm

Question 955

What PE maneuvers can assess for appendiceal abscess?

Answer 955

Psoas sign, obturator sign, and rectal tenderness. Obturator and rectal tenderness also test for pelvic appendix Psoas sign also tests for retrocecal appendix. All of these maneuvers assess the deep abdominal spaces

Question 956

Which benzo is most likely to result in seizures following abrupt dc?

Answer 956

Alprazolam – short t1/2

Question 957

Difference b/w diagnostic tests of choice for Diverticulitis v. Diverticulosis:

Answer 957

Diverticulosis – barium enema is test of choice | Diverticulitis – Contrast CT is test of choice (barium enema and colonoscopy are contraindicated until rupture is r/o)

Question 958

Difference in presentation of Proximal v. Mid/Distal SBOs:

Answer 958

Proximal – present w/early vomiting, abd discomfort, and abnorm contrast filling on XR Mid or distal – present as colicky abd pain, delayed vomiting, prominent abd distention, constipation-obstipation, hyperactive BS, and dilated loops of bowel on abd XR

Question 959

What are Ladd’s bands?

Answer 959

Congenital adhesions seen in children

Question 960

What causes the bleeding and possible anemia in Meckel diverticulum?

Answer 960

Ectopic gastric mucosa secretes HCl acid which causes surrounding small-bowel ulceration and subsequent bleeding.

Question 961

What is one way to differentiate Niacin from Riboflavin deficiency?

Answer 961

Both cause dermatitis and glossitis. Only riboflavin will cause normocytic-normochromic anemia Only niacin will cause neuro and GI sxs

Question 962

What is the timeline for fat embolism?

Answer 962

24-72 hrs following the inciting event

Question 963

Risk factors of cerebral palsy:

Answer 963

Prematurity | Low birth weight

Question 964

Why does prematurity increase the risk of Cerebral Palsy?

Answer 964

Premature infants are more likely to have periventricular leukomalacia (white matter necrosis from ischemia/infarction) and intraventricular hemorrhage Both of these are a/w CP

Question 965

Time course of post-MI cxs:

Answer 965

RVF – Acute Papillary muscle rupture – acute, or w/in 3-5 days Interventricular septum rupture – acute or w/in 3-5 days Free wall rupture – w/in 5 days-2 weeks LV aneurysm – up to several mos.

Question 966

What findings on CXR would suggest Bronchiectasis?

Answer 966

Linear atelectasis Dilated and thickened airways Irregular peripheral opacities

Question 967

How is VUR diagnosed?

Answer 967

Voiding cystourethrogram

Question 968

Abx used for GBS+ patients w/penicillin allergy at low-risk for anaphylaxis?

Answer 968

Cefazolin

Question 969

What patients require immediate defibrillation?

Answer 969

Vfib or pulseless ventricular tachycardia | VT w/a pulse needs cardioversion not defibrillation

Question 970

When should atropine be given to pts w/bradycardia?

Answer 970

If persistent bradyarrhythmia + one: HoTN or signs of shock Acute mental status changes Chest discomfort concerning for cardiac ischemia Acute heart failure If no response to atropine: transcutaneous pacing, IV dopamine or IV epinephrine

Question 971

What are the main organisms that cause central line-associated bloodstream infections?

Answer 971

``` #1: Coagulase negative staph. Others: S. aureus, gram negs. (Klebsiella, pseudomonas), and Candida ```

Question 972

How to differentiate Obesity hypoventilation syndrome from ILD:

Answer 972

OHS will have a normal DLCO whereas ILD will have decreased DLCO Only ILD will have cough and bibasilar crackles

Question 973

What are the NOACs?

Answer 973

Non-vitamin K antagonist oral anticoagulants Rivaroxaban Dabigatran Apixaban Edoxaban **Should be given to patients w/aFib and a mod-high risk of thromboembolic events**

Question 974

Tx of Spontaneous bacterial peritonitis:

Answer 974

``` Empiric abx (3rd gen cephalosporins – Cefotaxime) Fluoroquinolones are used for pphx ```

Question 975

Precipitating factors of Hepatic Encephalopathy:

Answer 975

``` Drugs (sedatives, narcotics) Hypovolemia (diarrhea) Electrolyte changes (hypokalemia) Increased Nitrogen load (GI bleed) Infection (pneumonia, UTI, SBP) Portosystemic shunting/TIPS ```

Question 976

What type of shock would be seen in acute Fe poisoning?

Answer 976

All three can occur Hypovolemic shock – from GI losses Distributive shock – vasodilation Cardiogenic shock – direct injury to myocardium

Question 977

Complications of acute Fe poisoning:

Answer 977

Hepatic necrosis Shock GI bleeding – scarring and obstruction

Question 978

What are the most important prognostic factors for astrocytomas?

Answer 978

Patient age Functional status Tumor grade – increased atypia/anaplasia, mitoses, neovascularity and necrosis are all considered worse prognoses

Question 979

What is the worst astrocytoma?

Answer 979

Grade IV – aka Glioblastoma multiforme | It has neovascularity and necrosis w/a high degree of anaplasia and many mitoses

Question 980

Most common brain tm in adults?

Answer 980

Astrocytoma (subcategory of glioma)

Question 981

How to differentiate CML from CLL:

Answer 981

CML has marked leukocytosis of predominately neutrophil origin CLL has marked leukocytosis of predominately lymphocyte origin

Question 982

Where do you see smudge cells?

Answer 982

CLL “crushed little lymphocytes”

Question 983

What preceding infection is likely to cause a brain abscess in the temporal lobe or cerebellum?

Answer 983

Otitis media or mastoiditis

Question 984

What preceding infection is likely to cause a brain abscess in the frontal lobe?

Answer 984

Sinusitis or dental infection

Question 985

What effects will renal tubular necrosis have on volume status?

Answer 985

It can be seen in pts w/severe HoTN and impaired renal perfusion – HYPERvolemic hyponatremia w/urine Na>20

Question 986

How to differentiate between types of Hypovolemic Hyponatremia:

Answer 986

Must have serum Na < 135 and signs/sxs of Hypovolemia 1. Extrarenal losses (D/V, burns, pancreatitis): urine NA <20 2. Renal losses (diuretics, mineralocorticoid deficiency): urine Na >20 3. Decreased effective circulating volume (CHF, cirrhosis)

Question 987

Conditions which require pphx against bacterial endocarditis:

Answer 987

High-risk cardiac conditions: Prosthetic heart valve Previous IE Structural valve abnormality in a transplanted heart Unrepaired cyanotic congenital heart disease Repaired CHD w/residual defect

Question 988

First step in evaluating dizziness:

Answer 988

Classification of sxs into 1/3 categories: Vertigo – sensation of spinning Presyncope – feeling like about to faint Disequilibrium – a sense of imbalance

Question 989

Most common UA findings in pts w/Multiple Myeloma:

Answer 989

UA will often be normal with little/no proteinuria (it detects albumin but not the monocloncal protein)

Question 990

Most common cause of renal insufficiency in pts w/MM:

Answer 990

Myeloma cast nephropathy – the monoclonal light chains clog the renal tubules and cause intratubular cast formation and toxicity.

Question 991

What does the PCWP measure?

Answer 991

It reflects L atrial pressures

Question 992

What would the results of cardiac catheterization in a patient w/a PE show?

Answer 992

``` Cardiac output: decreased RA pressure: increased RV pressure: increased Pulmonary a. pressure: increased PCWP: normal ```

Question 993

Who is likely to get septic arthritis from gram negative bac?

Answer 993

IVDU Severe IMCP Advanced age Sexually active young adults (N. gonorrhea)

Question 994

Most common coagulopathy in malignancy:

Answer 994

DIC | Often in gastric, breast and lung cancer pts.

Question 995

What valvular abnormality is caused by chordae tendonae degeneration?

Answer 995

Mitral regurgitation | NOT aortic regurg.

Question 996

When would hyposegmented neutrophils be seen on PBS?

Answer 996

In Myelodysplastic syndrome | Get granulocytes – hyposegmented/hypogranular NPs and ovalomacrocytosis – dysplastic RBCs

Question 997

What investigation should be done in pts. w/widened mediastinum on CXR post-trauma?

Answer 997

A TEE or Chest CT w/contrast to look for ruptured aorta | A TTE will not adequately visualize the thoracic aorta and should not be performed

Question 998

What is thyroid acropachy?

Answer 998

Nail clubbing in the setting of hyperthyroidism | Uncommon, but specific finding of Graves disease (like ophthalmopathy)

Question 999

How is lid lag described on PE?

Answer 999

Sclera seen above the iris on downward gaze

Question 1000

Respiratory effects of opioid poisoning:

Answer 1000

Decreased RR and tidal volume – decreased minute ventilation and CO2 retention – respiratory acidosis

Question 1001

What causes ovarian hyperstimulation syndrome?

Answer 1001

Overexpression of VEGF in the ovaries leads to b/l enlarged and cystic ovaries w/increased vascular permeability (increased Doppler flow) which causes 3rd spacing – ascites and pulmonary edema

Question 1002

Conditions associated with Pyoderma gangrenosum:

Answer 1002

IBD Inflammatory arthritis/RA Malignancy

Question 1003

Malignancies that may secrete PTHrP and lead to hypercalcemia:

Answer 1003

``` Squamous cell of: lung, head and neck Renal cell carcinoma Breast Bladder Ovarian ```

Question 1004

What is drug-induced acne and what are common causes of it?

Answer 1004

``` Acute papular inflammatory rash – has monomorphic papules and lacks comedomes. Seen in any age group Rxs: Glucocorticoids/steroids Androgens Immunomodulators (azathioprine, EGFR inhibitors) Anticonvulsants (phenytoin) Antipsychotics Anti-TB Rxs (Isoniazid) ```

Question 1005

Cxs of cardiac myxoma:

Answer 1005

Embolization – stroke, acute limb or mesenteric ischemia, etc. Sudden cardiac death d/t impaired CO.

Question 1006

How does b/l choanal atresia present?

Answer 1006

Shortly after birth with cyanosis that worsens during feeding and improves when crying. May also have noisy breathing/stertor Unable to pass a catheter from the nares into the oropharynx. Often a/w CHARGE syndrome

Question 1007

How does unilateral choanal atresia present?

Answer 1007

As chronic nasal discharge during childhood.

Question 1008

What are the sxs of a Left ventricular aneurysm?

Answer 1008

Progressive enlargement of the LV can cause: Heart failure Refractory angina Ventricular arrhythmias Mural thrombus w/systemic arterial embolization Mitral annular dilation w/MR

Question 1009

When is Clopidogrel used?

Answer 1009

Clopidogrel and ticlopidine are ADP-R inhibitors – inhibit platelet aggregation. These are only used to tx arterial thromboses – MI and Stroke. They have no use in the tx of venous thrombosis (DVT, PE)

Question 1010

What bug is most commonly a/w pediatric seizures in the setting of acute bacterial gastroenteritis?

Answer 1010

Shigella spp. The seizures are typically self-limited with a quick return to baseline (unlike seizures a/w Reye syndrome or hyponatremia) If the seizure occurs a week after the diarrhea has resolved, likely HUS

Question 1011

What are the long term cxs of Mitral Stenosis?

Answer 1011

MV narrowing causes LA enlargement which causes increased LAP during ventricular diastole This leads to elevated pulmonary artery pressure and pHTN Ultimately causes RHF

Question 1012

What abnormalities would be seen on PBS in CMV infection?

Answer 1012

Atypical lymphocytes - -have granulated LCs

Question 1013

Difference between pitting and non-pitting edema:

Answer 1013

Pitting edema is caused by low protein in the ISF – Liver failure (hypoalbuminemia), nephrotic syndrome, and Congenital/Congestive HF Nonpitting edema is d/t high protein in the ISF – lymphatic network dysgenesis/congenital lymphedema

Question 1014

How should minimal bright red blood per rectum be managed?

Answer 1014

<40y/o and no red flags – anoscopy 40-49 w/out red flags – sigmoidoscopy or colonoscopy >50 or red flags – colonoscopy

Question 1015

By what age do most SCD patients have functional asplenia?

Answer 1015

5 years old

Question 1016

What are helmet cells?

Answer 1016

Schistocytes

Question 1017

Recommended tx for splenic abscess:

Answer 1017

Splenectomy Abx alone have 50% mortality rate If poor surgical candidate may consider percutaneous drainage instead

Question 1018

Tx of severely enlarged tonsillitis/pharyngitis in Infectious Mononucleosis:

Answer 1018

Corticosteroids – decreases the airway edema and risk of acute airway obstruction

Question 1019

What are children who develop premature adrenarche at risk for?

Answer 1019

PCOS, type 2 DM, and metabolic syndrome – risk increases in obese children. Obesity is also a risk factor for premature adrenarche – adipose triggers xs insulin production which stimulates adrenals to produce androgens

Question 1020

Tx of gallstone ileus:

Answer 1020

Surgical removal of stone and simultaneous or delayed cholecystectomy

Question 1021

How to distinguish b/w gallstone ileus and emphysematous cholecystitis:

Answer 1021

Both will have penumobilia Gallstone ileus – colicky, diffuse abdP, bloating, distention, inability to pass flatus or stool, HoTN. These patients will have HYPERactive bowel sounds d/t mechanical obstruction Emphysematous cholecystitis – RUQ pain, fever, septic sxs These patients may have HYPOactive bowel sounds d/t paralytic ileus

Question 1022

What age group is at increased risk for developing Listeria meningitis?

Answer 1022

Those >50 years | Must add Ampicillin coverage for anyone >50 (in addition to the normal Vancomycin + 3rd gen-ceph)

Question 1023

What should be added to the tx regimen of Meningitis in addition to empiric abx?

Answer 1023

Dexamethasone – helps prevent the neuro cxs (deafness, focal deficits) a/w S. pneumo meningitis in adults and H. influenzae in children If cultures r/o s. pneumo or H.flu as the cause it should be dc’d

Question 1024

When should Cefepime be part of the tx regimen for meningitis?

Answer 1024

If the person is IMCP’d or it occurs after neurosurgery/penetrating skull trauma It’s a 4th gen-ceph and covers: S. pneumo, N. meningitidis, GBS, H. influenzae, MSSA and Pseudomonas

Question 1025

What is one of the leading causes of new-onset urinary incontinence in the elderly?

Answer 1025

UTIs – may cause concurrent delirium w/o systemic signs/sxs (fever, etc.) Should obtain UA to r/o this before other investigations

Question 1026

B vitamins:

Answer 1026

``` B1 – Thiamine B2 – Riboflavin B3 – Niacin B5 – Pantothenic acid B6 – Pyridoxine B7 – Biotin B9 – Folate B12 – Cobalamin ```

Question 1027

What causes the pulmonary edema seen in preeclampsia/HELLP syndrome?

Answer 1027

``` Systemic HTN leads to: Increased afterload – increased pulmonary capillary P Decreased renal function Increased vascular permeability Hypoalbuminemia ```

Question 1028

What are the current guidelines recommended for PCI in pts w/acute STEMI?

Answer 1028

Reperfuse w/PCI if: W/in 12hrs of symptom onset AND w/in 90min from first medical contact to device time at a PCI capable facility OR w/in 120min from first contact to device time at non-PCI capable facility

Question 1029

What is dead space ventilation?

Answer 1029

It is the ventilation of areas of the lung that are not perfused with blood – effected in PE, etc. Pneumonia does not interfere w/pulmonary vasculature and does not cause significant alterations in dead space ventilation.

Question 1030

When is a tube thoracostomy not enough to manage hemothorax?

Answer 1030

In patients who have: An initial bloody output >1.5L Persistent hemorrhage – >200mL/hr for >2hrs Continuous need for blood transfusion to maintain hemodynamic stability **Patients with any of these factors need emergent thoracotomy**

Question 1031

What is the current recommendation for Td/Tdap vaccination in adults?

Answer 1031

Adults should get Td booster every 10 years, with a one-time dose of Tdap in place of the Td booster. Pregnant women should get Tdap with every pregnancy.

Question 1032

Lab values seen in G6PD deficiency:

Answer 1032

Hemolysis – decreased Hb and haptoglobin, increased BR and LDH PBS – bite cells and Heinz bodies Negative Coombs test Decreased G6PD levels, but may be normal during an attack!

Question 1033

What causes the short stature in Turner’s and how is it tx’d?

Answer 1033

Short stature is caused by absence of X chromosome | Tx’d w/GH even though GH levels are typically normal

Question 1034

What may be seen on US in a threatened abortion?

Answer 1034

Subchorionic hematoma

Question 1035

How should hemodynamically stable v. unstable pts w/evidence of renal trauma be evaluated?

Answer 1035

Stable patients: US and contrast-CT of abdomen and pelvis. | Unstable: IV pyelography prior to surgical evaluation

Question 1036

What are the risk factors of chronic venous stasis?

Answer 1036

Obesity Advanced age Varicose veins Hx of DVT

Question 1037

What will be seen on imaging in a patient w/Complex regional pain syndrome?

Answer 1037

XR: Patchy demineralization/osteopenia | Bone scintigraphy: increased uptake in the affected limb

Question 1038

What is sialadenosis and what patients are at risk for it?

Answer 1038

It is a benign, non-tender, non-inflammatory swelling of the salivary glands – a/w abnormal autonomic innervation of the glands w/accumulation of secretory glands in the acinar cells. Patients at risk: Advanced liver disease (alcoholic and non), altered dietary patterns and malnutrition (DM, bulimia) No mgmt. necessary except to tx underlying condition

Question 1039

Tx of Neurocysticercosis:

Answer 1039

Antiparasitics – albendazole Corticosteroids Antiepileptics – phenytoin if seizures

Question 1040

When should a CT be ordered in a patient w/vertigo?

Answer 1040

Vertigo may indicate an underlying stroke or hemorrhage, so a noncontrast CT is needed if patients have 1+ of the following: Prominent stroke risk factors – hyperlipidemia, HTN, DM New-onset HA Neurologic signs/sxs

Question 1041

Most common congenital heart defect in Down Syndrome:

Answer 1041

Complete AV septal defect—failure of endocardial cushions to merge

Question 1042

How should warfarin anticoagulation be reversed prior to urgent surgery?

Answer 1042

1 – Immediately dc warfarin 2 – administer Prothrombin complex concentrate (contains vitK-dependent cofactors + normalizes INR <10 min) 3 – Give IV vitamin K **If PCC is unavailable can give FFP (IV colloid) but it is less effective**

Question 1043

What are the sxs of Pelvic congestion syndrome?

Answer 1043

A dull, ill-defined pelvic ache that worsens w/intercourse or long periods of standing. Pain is often relieved by menses

Question 1044

What causes Friedrich ataxia?

Answer 1044

Trinucleotide expansion (normally GAA) in the frataxin gene

Question 1045

What is acute cerebellar ataxia?

Answer 1045

Typically post-infectious – presents w/acute onset of ataxia, nystagmus, and dysarthria 1-3wks post-viral illness. Reflexes, proprioception and vibration NOT affected. Most commonly in children <6 Used to be highly a/w varicella but is decreasing now w/vaccine (can occasionally see it after getting VZV vaccine). Coxsackie and herpes viruses most common Usually resolves w/supportive care in <2 weeks

Question 1046

Tx of Friedrich ataxia:

Answer 1046

Supportive – PT and psychosocial support. No Rxs to tx it

Question 1047

Most common organisms to cause brain abscess:

Answer 1047

S. aureus S. viridans Less commonly – anaerobes

Question 1048

What causes aFib in patients with Mitral stenosis?

Answer 1048

Dilated left atrium and increased pressures within it.

Question 1049

What is the problem in factor V Leiden?

Answer 1049

It causes a resistance to activated protein C Most common thrombophilia in white people (2nd most common is mutation in prothrombin)

Question 1050

What is a common imaging finding in pts w/Idiopathic intracranial HTN?

Answer 1050

Empty sella

Question 1051

What are some common causes of functional asplenia where you would see Howell-Jolly bodies?

Answer 1051

Sickle cell disease Sarcoidosis – and other infiltrative disorders of the spleen Splenic congestion – thrombosis, etc.

Question 1052

Typical presentation of Friedrich ataxia:

Answer 1052

Neurologic dysfxn – spastic weakness, loss of vibration and proprioception, ataxia Cardiomyopathy – HCMP Diabetes (frataxin is highly expressed in the pancreas) Skeletal abnormalities – kyphoscoliosis, pes cavus (high arched feet)

Question 1053

Difference in mgmt. of exertional v. non-exertional heat stroke:

Answer 1053

Exertional – rapid cooling, ice-water immersion, IVF, etc. | Non-exertional – evaporative cooling: spraying lukewarm water and blowing w/fans etc.

Question 1054

Cxs of Zenker diverticulum:

Answer 1054

Tracheal compression Ulceration w/bleeding Regurgitation Pulmonary aspiration

Question 1055

Who is at greatest risk for developing Cholangiocarcinoma and what lab values will be seen?

Answer 1055

Risk is greatest in pts w/fibropolycystic liver disease and primary sclerosing cholangitis (90% a/w UC) Labs will show cholestatic liver enzyme pattern: Hyperbilirubinemia, mild increase in ALT/AST, increased ALP & GGT, and often CEA and CA 19-9 are elevated

Question 1056

What will be seen on abdominal imaging in Cholangiocarcinoma?

Answer 1056

Intrahepatic or common bile duct dilation. Common bile duct may be normal depending on the level of the lesion. EUS or ERCP are needed for tissue bx after this is seen

Question 1057

Clinical signs of traumatic AV fistula:

Answer 1057

Widened pulse pressure Strong peripheral arterial pulsation (brisk carotid upstroke) Systolic flow murmur Tachycardia Flushed extremities/site affected will be erythematous and more flushed LVH w/displaced PMI

Question 1058

Physiologic changes in a patient w/traumatic AVF:

Answer 1058

The fistula shunts large amounts of blood and causes: Decreased SVR Increased preload Increased CO This will cause a compensatory increase in HR and SV to meet O2 requirements of peripheral tissues. Ultimately leads to high output heart failure`

Question 1059

What are the common lab values seen in HCC?

Answer 1059

Large increases in AFP and ALP (esp. if mets to the bone) | AST/ALT may be normal or mildly elevated.`

Question 1060

What type of bone lesions are a/w HCC?

Answer 1060

HCC mets to the bone cause a mixed osteolytic and osteoblastic pattern

Question 1061

Clinical features of Langerhans cell histiocytosis:

Answer 1061

Lytic bone lesions (skull, jaw, femur-often diaphysis) Skin lesions (purplish papules, eczematous rash) LAD, hepatosplenomegaly Pulmonary cysts/nodules (present w/cough) Central DI May have recurrent otitis media w/mass involving mastoid bone

Question 1062

What are the common infectious complications seen in atopic dermatitis?

Answer 1062

Impetigo Eczema herpeticum Molluscum contagiosum Tinea corporis

Question 1063

What is hepatopulmonary syndrome and what are the likely findings?

Answer 1063

Syndrome that results from intrapulmonary vascular dilations in the setting of chronic liver disease. Patients often have platypnea (increased dyspnea when upright) and orthodeoxia (decreased O2 saturation when upright)

Question 1064

What is postoperative endophthalmitis and how will it present?

Answer 1064

Most common form of endophthalmitis – bacterial or fungal infection w/in the eye (mostly the vitreous) Occurs w/in 6wks of surgery Presents w/swollen eyelids and conjunctiva, hypopyon, corneal edema, exudates in the anterior chamber and decreased visual acuity.

Question 1065

Risk factors and complications of Hidradenitis suppurativa:

Answer 1065

Risks – Obesity, tobacco use and Fhx | Cxs – Contractures, lymphatic obstruction, fistula

Question 1066

How to differentiate b/w rotator cuff tear and impingement/tendinopathy:

Answer 1066

Impingement or tendinopathy will have pain w/abduction and external rotation, subacromial tenderness and normal ROM w/positive impingement tests Tear will present similar but may have less pain and more weakness – weakness w/abduction and external rotation and positive drop arm test

Question 1067

What are the common cxs of PPROM?

Answer 1067

Preterm labor Intraamniotic infection Placental abruption Umbilical cord prolapse

Question 1068

When would you not use B-agonists to tx hyperkalemia?

Answer 1068

If the patient has active coronary artery disease (angina etc.) – they can cause tachycardia and precipitate angina.

Question 1069

Cxs of cholesteatomas:

Answer 1069

Hearing loss Cranial n. palsies Vertigo Infections – brain abscess, meningitis

Question 1070

Common causes of cylothorax:

Answer 1070

Tramua – cardiothoracic surgery Congenital malformations Syndromes – Down syndrome, Noonan syndrome Malignancy

Question 1071

Major AEs of Metoprolol:

Answer 1071

``` Bradyarrhythmias Acute worsening of HF Bronchoconstriction Fatigue Depression Weight gain Sexual dysfxn ```

Question 1072

What enzyme is deficient in hereditary fructosemia and how will it present?

Answer 1072

Aldolase B deficiency Presents in infancy after the introduction of fruits and vegetables leads to accumulation of fructose-1-phosphate Sxs: V, poor feeding and lethargy. May lead to seizures or encephalopathy if fructose isn’t removed from the diet

Question 1073

Enzyme deficient in Galactosemia and presentation:

Answer 1073

Galactase-1-phosphate uridyl transferase in RBCs Presents in first few days of life w/jaundice, hepatomegaly and failure to thrive after consumption of breast milk or formula

Question 1074

What are the current screening guidelines for DM in asx pts?

Answer 1074

Screen in pts w/sustained BP >135/80 (whether tx’d or untx’d) Screen in all pts 45+ and those at any age w/addn’l risk factors (BMI >25, hx of gDM, Fhx, etc)

Question 1075

What is responsible for the development of male external genitalia and prostate?

Answer 1075

DHT which is converted from testosterone via 5-a-reductase 5-aR deficiency will therefore lead to normal internal male genitalia (testes) and external female (blind-ending vagina) which become virilized during puberty (clitoromegaly)

Question 1076

Why don’t patients w/5 a-R deficiency have breast development?

Answer 1076

Because they still have responsive androgen receptors (unlike AIS) so the increased levels of testosterone bind and inhibit estrogen from binding and stimulating breast proliferation.

Question 1077

What are the sxs of hypokalemia?

Answer 1077

Sxs depend on the severity but may include: Weakness, fatigue, and mm. cramps Flaccid paralysis, hyporeflexia, tetany Arrhythmias (K <2.5 norm) – aFib, TdP, Vfib can all occur

Question 1078

How do the nasal polyps a/w CF appear on PE?

Answer 1078

Translucent shiny, grey or yellow masses that obscure the nasal turbinates. Present bilaterally

Question 1079

What GI complications can occur in CF?

Answer 1079

Blockage of pancreatic ducts – pancreatic insufficiency and CF-related diabetes Blockage of the biliary tree – biliary cirrhosis from increased pressure and subsequent fibrosis

Question 1080

What does peak airway pressure in a ventilated patient measure?

Answer 1080

Total airway resistance + plateau pressure | plateau pressure inversely measures lung compliance and = elastic pressure + PEEP

Question 1081

What would cause an increase in peak pressure without a change in plateau pressure in a ventilated patient?

Answer 1081

``` Increased peak and normal plateau means total resistance has increased Causes: Bronchospasm Mucus plug Biting endotracheal tube ```

Question 1082

What would cause an increase in both peak and plateau pressure in a ventilated patient?

Answer 1082

``` Increase in plateau signifies decreased lung compliance or increased elasticity Causes: Pneumothorax Pulmonary edema Pneumonia Atelectasis R mainstem intubation ```

Question 1083

How are plateau pressure and PEEP measured?

Answer 1083

Plateau is calculated by performing the end-inspiratory hold maneuver PEEP is calculated by performing the end-expiratory hold maneuver

Question 1084

What are the cofactors for PTH secretion?

Answer 1084

Magnesium and Vitamin A | In alcoholism there is hypomagnesemia which leads to decreased PTH and therefore hypocalcemia

Question 1085

What causes Hypocalcemia in alcoholism?

Answer 1085

Alcoholics have decreased magnesium which leads to decreased PTH secretion and ultimately hypocalcemia

Question 1086

What causes Myasthenia Gravis?

Answer 1086

Abs against the acetylcholine Rs on the motor endplate – plenty of Ach gets released, but it cannot bind to the Rs bc they’re blocked. *Lambert eaton blocks release of Achth*

Question 1087

How to diagnose HTN in pediatric population:

Answer 1087

Measure BP on 3 separate occasions at least 1 week apart.

Question 1088

Defect in which cells will leave a child at greatest risk for TB?

Answer 1088

T cells, specifically Th1 cells. | Often seen in IL-12 receptor deficiency – unable to produce/activate Th1 cells

Question 1089

What causes acne?

Answer 1089

``` Pilosebaceous follicles (holocrine glands) on the face have increased sebum, keratin and bacteria that lead to: Obstruction – causing comedomes Inflammation – causing papules/pustules, nodules and cysts ```

Question 1090

What are apocrine glands and where are they found?

Answer 1090

They are sweat glands found in the axilla, groin and areola | They are scent glands – why we smell when we sweat

Question 1091

What is the most common cause of acquired ataxia and how will it present?

Answer 1091

Alcoholic cerebellar degeneration It effects LE > UE and leads to gait resembling EtOH intoxication “reeling from one side to the other” MRI will show atrophy of cerebellar vermis

Question 1092

Most frequent pathogens to cause infection in Multiple Myeloma:

Answer 1092

S. pneumoniae | Gram negatives

Question 1093

What will be seen on fundoscopy in optic neuritis?

Answer 1093

Pallor of the optic disc or hyperemia and swelling | Depends on time of exam

Question 1094

When should cervical conization be done?

Answer 1094

When CIN grade 2 or 3 is found on colposcopy | In young women observation is preferred for CIN-2

Question 1095

What is anemia of prematurity and how will it present?

Answer 1095

Seen in preterm infants d/t impaired EPO production, short RBC lifespan and iatrogenic blood sampling Normally asx, but may have tachycardia, apnea, and poor weight gain

Question 1096

Lab findings in anemia of prematurity:

Answer 1096

Low Hb and Hct Low reticulocytes (bc decreased EPO) Normocytic, normochromic RBCs Tx: minimize blood draws, Fe supplements, transfusions

Question 1097

What pediatric patients are at risk for Wilm’s tm. and hepatoblastoma?

Answer 1097

Patients with Beckwith-Wiedemann syndrome, as well as those with isolated Hemi-hyperplasia (WAGR complex and Denys-Drash are also at risk for Wilm’s tm.) Both need to undergo frequent screening w/US and AFP measurements

Question 1098

What are the features of Denys-Drash syndrome?

Answer 1098

Early-onset nephrotic syndrome (diffuse glomerulosclerosis) leading to kidney failure in childhood Male pseudohermaphroditism or ambiguous genitalia w/undescended testes in 46XY pts - Females typically have normal genitalia Wilms tumor (develops in 90% of cases)

Question 1099

What malignancy is commonly a/w Sjogren syndrome?

Answer 1099

Non-hodgkin lymphoma

Question 1100

What signs should raise suspicion of HIT?

Answer 1100

Heparin exposure >5d and any of the following: Platelet count reduction >50% from baseline Arterial or venous thrombosis Necrotic skin lesions at heparin injection sites Acute systemic (anaphylactoid) reactions after Heparin *sxs may manifest sooner in pts previously exposed to Heparin*

Question 1101

Causes of Hyperthyroidism w/decreased RAI uptake:

Answer 1101

Painless/silent Thyroiditis (nontender goiter) Subacute/granulomatous thyroiditis aka De Quervain (tender goiter) Iodide exposure Exogenous thyroid hormone

Question 1102

What is the MoA of hyperthyroidism with decreased RAIU?

Answer 1102

It is d/t release of preformed thyroid hormone, so the thyroid gland is underworking in these states and not being stimulated.

Question 1103

What is the most common congenital cyanotic heart disease in the neonatal period?

Answer 1103

Transposition of the great vessels

Question 1104

What is the only cyanotic congenital heart disease that might present w/o a murmur?

Answer 1104

Transposition of the great vessels It requires a VSD, PDA or PFO to survive in the neonatal period, and a VSD and PDA will both present with murmur but if the patient has a PFO then there will be no murmur

Question 1105

What conditions are a/w Erythema Nodosum?

Answer 1105

``` Strep Infection Sarcoidosis TB Endemic fungal diseases – Histoplasmosis IBD Behcet disease ```

Question 1106

Mgmt of Toxic megacolon (d/t C. diff):

Answer 1106

Bowel rest, NGT Aggressive abx tx: Oral vancomycin and IV metronidazole d/c anything that contributes to decreased GI motility (opiates) Lack of response/deterioration often need surgery – subtotal cholectomy

Question 1107

What is iliotibial band syndrome and how will it present?

Answer 1107

It is an overuse injury and will cause lateral pain w/tenderness at the lateral femoral condyle

Question 1108

What are the effects of Na+ on Ca2+ absorption?

Answer 1108

Increased Na+ intake enhances Ca2+ excretion in the urine – hypercalciuria and increases the risk of developing calcium stones. Low Na+ intake promotes Na+ and Ca2+ reabsorption. Therefore pts w/renal calculi should be advised to follow a low-Na diet w/normal dietary Ca2+ intake

Question 1109

What would promote hyperoxaluria and Ca-Oxalate stone formation?

Answer 1109

``` Decreased Ca2+ intake – leads to free Oxalate absorption in the gut and hyperoxaluria Increased Vitamin C intake Malabsorption syndromes (Crohn, CF) that have increased intestinal FAs that form salts w/Ca2+ and lead to increased Oxaluria reabsorption ```

Question 1110

When is amnioinfusion contraindicated?

Answer 1110

In a patient w/prior uterine surgery

Question 1111

How to differentiate Histoplasma from Coccidioiomycosis based on CXR:

Answer 1111

Histoplasma is typically bilateral, focal, reticulonodular or miliary infiltrates and b/l hilar or mediastinal LAD Coccidiodes is typically a unilateral infiltrate w/ipsilateral hilar LAD

Question 1112

When do hemothoraces require emergent surgical thoracotomy?

Answer 1112

If chest tubes (tube toracostomy) put out immediate bloody drainage >1.5L

Question 1113

Preferred imaging modality to assess for an empyema:

Answer 1113

Chest US – can assess volume and location of fluid + presence or absence of loculated fluid.

Question 1114

Most common cause of acute v. subacute unilateral LAD in children:

Answer 1114

Acute – S. aureus and S. pyogenes (tender LN) Subacute – MAC and other non-TB mycobacteria (non tender LN) *acute in poor dentition is most commonly caused by anaerobes (prevotella)*

Question 1115

Most common cause of acute v. subacute bilateral LAD in children:

Answer 1115

Acute – Adenovirus and other URIs | Subacute – CMV and EBV

Question 1116

What is the difference b/w PMR and Polymyositis?

Answer 1116

PMR has pain and stiffness in muscles, but NO weakness. Have increased ECR and CRP, but CK, aldolase, etc are all normal Polymyositis has severe weakness, but pain is mild/absent and no stiffness. Will have increased CK, aldolase, AST and ANA/Anti-Jo-1 Abs. Need muscle bx to dx this but not PMR

Question 1117

Tx of Peri-infarction pericarditis:

Answer 1117

Aka early post-MI pericarditis (not Dressler) Tx is supportive – should avoid anti-inflammatory meds (NSAIDs, steroids) bc they’ll disrupt healing and increase risk of other cxs (free wall rupture, etc)

Question 1118

What kind of malabsorption is Lactose intolerance?

Answer 1118

Carbohydrate malabsorption | No problems w/fat absorption in these pts so have negative acid steatocrit tests

Question 1119

What is the most common cause of hearing impairment in children?

Answer 1119

Conductive loss d/t repeated ear infections

Question 1120

What effect does hyperthyroidism have on Ca2+?

Answer 1120

Increased Thyroid hormone increases osteoclast activity and bone resorption – hypercalcemia and decreased PTH. Ultimately leads to hypercalciuria as well and increases risk of Ca-stones.

Question 1121

DoC for tocolysis <32 weeks gestation:

Answer 1121

Indomethacin | Contraindicated >32 weeks d/t risk of closing the PDA

Question 1122

What causes febrile non-hemolytic transfusion rxn and how does it present?

Answer 1122

Small amounts of leukocytes remain in red cell concentrate after being separated from whole blood and plasma, and when stored the leukocytes release cytokines that cause sxs when transfused. Sxs: transient fevers, chills, and malaise w/o hemolysis Will have negative Coombs/direct antiglobulin test and negative free Hb

Question 1123

What is the timeline for acute hemolytic transfusion rxns and how will they present?

Answer 1123

Presents w/in 1 hour of transfusion w/fever, chills, flank pain, and hemoglobinuria which can progress to renal failure and DIC. Will have a positive direct coombs/antiglobulin test and plasma free Hb >25

Question 1124

Using whole blood increases the risk of what kind of rxn?

Answer 1124

Whole blood contains lots of leukocytes and increases the risk of febrile non-hemolytic rxn It is rarely used bc of this, and normally only for cases of acute massive hemorrhage (trauma)

Question 1125

What do plasma mixing studies tell you about increased PT or aPTT?

Answer 1125

In patients w/prolonged pt or aptt plasma mixing studies differentiate b/w coagulation factor deficiencies or coagulation inhibitors: Coagulation corrects w/mixing study – there is a deficient coagulation factor Coagulation does not correct w/mixing – there is an inhibitor present

Question 1126

What is one of the most common coagulation inhibitors in females?

Answer 1126

Lupus anticoagulant – a type of antiphospholipid Ab. | It prolongs the aPTT and will not correct w/plasma mixing studies, but will correct w/the addition of phospholipids

Question 1127

What coagulation study would be prolonged in pts taking Xa inhibitors?

Answer 1127

Thrombin time (PT and aPTT should be normal)

Question 1128

How should patients with long QT syndrome (Jervell-Lange-Nielsen, etc.) be treated?

Answer 1128

BBs + Pacemaker – if hx of syncope or sxs (lightheadedness, palpitations, etc.)

Question 1129

How will pts w/Galactokinase deficiency present?

Answer 1129

With cataracts – otherwise asx

Question 1130

When is diagnostic peritoneal lavage used?

Answer 1130

Typically only in unstable pts w/equivocal FAST results, or if CT/US are unavailable

Question 1131

What is the significance of endometrial cells being found on Pap test?

Answer 1131

Endometrial cells on pap test mean that the endometrial lining is shedding. In women <45yrs this is not reported on results bc it’s a normal finding esp if in the 1st 10 days of the menstrual cycle Women >45 yrs this is concerning for an abnormality and might signify endometrial hyperplasia/ca and these women need an endometrial bx to investigate

Question 1132

Tx of Invasive Aspergillosis:

Answer 1132

1-2wks of IV Voriconazole + an Echinocandin (Capsofungin) | Then can be transitioned to prolonged oral tx of Voriconazole alone

Question 1133

Predominant MoA for ventricular arrhythmias in the immediate post-MI period:

Answer 1133

Reentry – most commonly leads to Vfib and sudden cardiac arrest These are called phase 1a ventricular arrhythmias and occur w/in 10min of coronary occlusion

Question 1134

What are the immunologic responses seen in IE?

Answer 1134

Positive Rheumatoid factor (possibly d/t Ab production) Immune complex-mediated glomerulonephritis (get hematuria and RBC casts) Cutaneous lesions – osler nodes (painful fingertip nodules) Roth spots – edematous/hemorrhagic lesions of the retina

Question 1135

What needs to occur in pregnant women w/a non-reactive NST?

Answer 1135

Must be followed up w/a BPP or CST – they are equivalent to each other, but CST is contraindicated in any woman where labor is contraindicated (placenta previa, prior myomectomy, etc.)

Question 1136

What are the cxs of Biliary cysts?

Answer 1136

Cysts may transform into cholangiocarcinoma and require surgical resection. Older children may present w/the normal sxs (jaundice, acholic stools, dark urine, abd pain, etc.) with pancreatitis superimposed on top of it.

Question 1137

What effects will maternal Listeria infection have on a baby?

Answer 1137

If infection during 1st trimester – often causes fetal death, may lead to premature birth Perinatal – can cause newborn infections that are typically severe w/fever, Granulomatosis infantiseptica: disseminated abscesses in multiple organs (liver, spleen, lungs, kidneys, brain) and skin lesions.

Question 1138

When would you see a pendular knee reflex?

Answer 1138

In cerebellar degeneration – commonly seen in EtOH-induced cerebellar degeneration

Question 1139

What kind of lesion would the presence of clonus suggest?

Answer 1139

Lesion in the pyramidal tracts – UMN lesion

Question 1140

When should a baby be able to sit unsupported?

Answer 1140

By 7mos | At 6mos they should be able to sit propped on their hands and unsupported for a few moments

Question 1141

What features of ureterolithiasis would warrant a Urologic consult?

Answer 1141

``` Signs of urosepsis – fever, chills, tachycardia, etc. Anuria Acute kidney injury Pain refractory to analgesics Large stones (10+ mm) Stones that do not pass w/in 4-5 weeks ```

Question 1142

What are the 3 main categories of Diabetic Retinopathy?

Answer 1142

1. Background/Simple retinopathy: consists of microaneurysms, hemorrhages (dot & blot), exudates (hard) and retinal/macular edema (what causes visual impairment) 2. Pre-proloferative: w/cotton wool spots 3. Proliferative/malignant: consists of newly formed vessels

Question 1143

What is erythromycin use in neonates a/w?

Answer 1143

Pyloric stenosis | Should avoid use in all children <1mo.

Question 1144

What are the risk factors for ovarian cancer?

Answer 1144

Endometriosis and Fhx | delayed menarche and early menopause are protective

Question 1145

What causes unilateral pain in the middle of the menstrual cycle?

Answer 1145

Mittelschmerz – rupture of the ovarian follicle releases the egg and the small amount of blood released at this time can irritate the peritoneum. Typically occurs on days 10-14 of the menstrual cycle (this starts counting from the 1st day of the previous menses)

Question 1146

What are the common adult causes of osteomalacia?

Answer 1146

``` Malabsorption (IBD, CF, etc.) Bypass surgery Celiac sprue Chronic liver disease Chronic kidney disease (RTA type 2) ```

Question 1147

Most common skin malignancy in pts on chronic immunosuppressive tx:

Answer 1147

SCC – esp. if they’re on immunosuppressants for organ transplant Often aggressive w/local recurrence, regional mets, and perineural invasion

Question 1148

What are broad casts and when would they be seen?

Answer 1148

Seen in chronic renal failure Arise in the dilated tubules of enlarged nephrons that have undergone compensatory hypertrophy in response to reduced renal mass. Waxy casts (shiny, and translucent) are also seen in chronic renal disease

Question 1149

When are RBC casts found in the urine?

Answer 1149

In glomerulonephritis or vasculitis (malignant HTN, etc.)

Question 1150

What does the progesterone withdrawal test evaluate for?

Answer 1150

Secondary amenorrhea – will determine if amenorrhea is from low estrogen (no withdrawal bleed).

Question 1151

Characteristics of the tremor a/w Parkinson’s:

Answer 1151

Resting tremor that decreases w/voluntary movement. | Also have pill-rolling tremor

Question 1152

What type of tremors will be worse w/goal-directed movement?

Answer 1152

Essential tremors | Intention tremors d/t cerebellar dysfxn.

Question 1153

What causes the bounding peripheral pulses in septic shock?

Answer 1153

The Cardiac Index and SV both increase to compensate for the intravascular hypovolemia and this creates an increased pulse pressure which manifests as bounding peripheral pulses (like in AR) This happens in the early phase of sepsis/the hyperdynamic phase

Question 1154

What Rxs should be used to treat patients w/accessory pathways (WPW)?

Answer 1154

``` Class IA – Procainamide, Quinidine, Disopyramide Class III (K+ channel blockers) – Amiodarone, Sotalol, Dofetilide, Ibutilide ```

Question 1155

What is likely the cause of a painless corneal abrasion?

Answer 1155

Abrasion in a patient who has damage to the V1 (ophthalmic) branch of the trigeminal n. Common causes of trigeminal dysfxn: tumor, trauma, prior zoster infection.

Question 1156

How would a corneal abrasion be expected to present?

Answer 1156

Severe eye pain (from V1 sensory innervation), photophobia w/reluctance to open the eye, and possible sensation of foreign body in the eye. May have decreased visual acuity and pupillary dysfxn. Will see corneal staining defect on fluorescein exam

Question 1157

How should patients w/neurogenic bladder be managed to avoid catheter-assoc. UTIs?

Answer 1157

Clean intermittent catheterization – decreases risk of infection, performed every 4-6 hours Another option is subrapubic catheterization

Question 1158

What medications can be used to tx Kleptomania?

Answer 1158

SSRIs, opioid antagonists, lithium and anticonvulsants. | Should also use CBT

Question 1159

How would cholecystitis and cholangitis be differentiated on US?

Answer 1159

Cholecystitis will show gallbladder wall thickening and edema/pericholecystic fluid (no obstruction, just inflammation) Cholangitis will show dilation of the intrahepatic ducts and common bile duct (obstruction leading to infection)

Question 1160

What is a common complication of gallstone pancreatitis?

Answer 1160

Acute cholangitis – should be suspected in anyone w/gallstone pancreatitis who has fevers, RUQ pain, jaundice, AMS, and HoTN. Must do ERCP stat to relieve obstruction to prevent development of sepsis and death

Question 1161

Who is at highest risk of developing severe infections with Vibrio vulnificus?

Answer 1161

Patients with liver diseases (cirrhosis, hepatitis) as well as DM. Hemochromatosis is especially a risk bc the free iron is a growth catalyst for the bacteria

Question 1162

How will infection w/V. vulnificus present and how is it tx’d?

Answer 1162

It is rapidly progressive and presents in <12hrs most of the time with: Septicemia – septic shock and bullous lesions Cellulitis – hemorrhagic bullae and necrotizing fasciitis (much quicker presentation than most causes of nec.fasc. – s.aureus/s.pyogenes) Tx: IV ceftriaxone + doxycycline in anyone w/even suspected illness bc highly fatal

Question 1163

What are the major and minor criteria for Acute rheumatic fever?

Answer 1163

Major: (JONES) Joints- migratory arthritis (esp. in the wrists, ankles and knees) <3 – Carditis (friction rub, long PR, diffuse ST elevation) Nodules – subcutaneous/erythema nodosum Erythema marginatum Sydenham chorea Minor: Fever, arthralgias, elevated ESR/CRP, prolonged PR interval

Question 1164

Why do OCPs cause HTN?

Answer 1164

Estrogen causes increased angiotensinogen synthesis during hepatic 1st-pass metabolism

Question 1165

Why does a-Thalassemia major cause Hydrops fetalis?

Answer 1165

These fetuses have no a-chains for Hb and instead form gamma tetramers (HB Barts) y-tetramers have >10x more affinity for O2 than normal HbA and bind all the O2 and don’t release it to the tissues This causes severe hypoxemia leading to high-output HF and subsequent hydrops fetalis

Question 1166

What conditions are a/w Hydrops fetalis?

Answer 1166

``` Achondroplasia Turner syndrome Parvo B19 infection a-Thalassemia major/Hb Barts Rh alloimmunization ```

Question 1167

Diseases a/w the different gene losses in a-Thalassemia:

Answer 1167

1 gene loss (aa/a-): a-Thalassemia minima – asx, silent carrier 2 losses (aa/--) or (a-/a-): a-Thal minor – mild microcytic anemia 3 losses (a-/--): Hb H disease – chronic hemolytic anemia 4 losses (--/--): Hb Barts/Hydrops fetalis – High-output HF, anasarca, death in utero can only get babies like this from 2 parents w/cis losses (aa/-- or a-/--)

Question 1168

How does secondary syphilis often present?

Answer 1168

Weeks to months after initial exposure: Systemic sxs – fever, malaise, sore throat, HAs Widespread LAD – cervical, axillary, inguinal, epitrochlear Oral lesions – often seen as grey mucous patches Condylomata lata – raised grey genital papules Diffuse maculopapular rash – begins on trunk and spreads to extrems. and involves palms and soles

Question 1169

How to differentiate Syphilis from RMSF based on the rash:

Answer 1169

Secondary syphilis – will have a centrifugal rash that starts on the trunk and spreads out to involve palms and soles RMSF – will have centripetal rash that starts on extremities and palms/soles and then moves in to involve the trunk

Question 1170

What is chronic hyperthyroid myopathy?

Answer 1170

Myopathy that manifests as proximal muscle weakness weeks to months after the onset of hyperthyroidism May have muscle atrophy early on, but usually there is no muscle tenderness Tx of the hyperthyroidism often improves the myopathy **May also see myopathy in Hypothyroidism**

Question 1171

What stage of labor can neuraxial anesthesia have an effect on?

Answer 1171

It can lengthen the second stage – 10cm dilation until fetal delivery It will have no effect on the first stage/latent and active phases

Question 1172

What post-MI pts are at greatest risk for SCD?

Answer 1172

Those w/prior MI complicated by LV systolic dysfxn and ejection fraction <30% These patients often have normal systolic fxn or improved fxn w/proper therapy, but those who do not improve w/meds and still have <30% EF need an implantable cardioverter-defibrillator

Question 1173

What are the common manifestations of cardiac sarcoidosis?

Answer 1173

``` Conduction defects – complete AV block is most common Restrictive CMP (early manifestation) Dilated CMP (late) Valvular dysfxn Heart failure ```

Question 1174

When should oral abx be given to children w/AOM?

Answer 1174

All children <6mo | 6+ mos only need abx if they have: high fever, severe pain, or bilateral disease

Question 1175

What are the extraarticular features a/w Ankylosing spondylitis?

Answer 1175

Patients may develop: Anterior uveitis IBD Cardiac involvement w/aortic regurgitation

Question 1176

What are the characteristics of the rash in disseminated gonoccal infection?

Answer 1176

Vesiculopustular rash – rarely involves the face

Question 1177

When is rouleaux formation seen?

Answer 1177

In conditions that cause elevated serum protein – MM, Waldenstrom, Connective tissue diseases, etc.

Question 1178

How long post-partum before women can be prescribed combined OCPs?

Answer 1178

3+ weeks | Cannot prescribe <3 weeks

Question 1179

How does the disease course differ for PCP in HIV pts v.non-HIV IMCP’d?

Answer 1179

Typically causes an indolent disease in HIV pts. Immunosupressed pts w/o HIV often develop acute respiratory failure w/tachypnea, dyspnea, hypoxia leading to respiratory alkalosis, dry cough and fever Pts on prolonged glucocorticoid tx (esp if combined w/other immunosuppressants) should be on TMP-SMX pphx

Question 1180

Where would lesions be expected to be seen in Korsakoff syndrome?

Answer 1180

Anterior and medial thalami, and corpus callosum

Question 1181

What neuropathologic findings are seen in Wernicke encephalopathy?

Answer 1181

Mamillary body atrophy and dorsomedial thalamic neuron loss

Question 1182

What is the mgmt. of prepatellar bursitis?

Answer 1182

Must do fluid aspiration for cell count, gram stain and culture. About 1/3 of cases are infectious and need abx If infection is r/o then can manage w/NSAIDs

Question 1183

What will be seen in exercise testing of a patient w/Sick sinus syndrome?

Answer 1183

Chronotropic incompetence – inadequate HR response to exercise These patients need pacemakers

Question 1184

What infections are patients w/Hemochromatosis at increased risk for?

Answer 1184

Listeria V. vulnificus Yersinia enterocolitica

Question 1185

What are the msk, endocrine and cardiac manifestations of Hemochromatosis?

Answer 1185

MSK: arthralgia, arthropathy, choncrocalcinosis Endo: DM (“bronze diabetes”), Hypothyroidism, secondary hypogonadism Cardio: Restrictive or Dilated CMP, and conduction abnormalities (sick sinus syndrome)

Question 1186

What are the PDA-dependent congenital heart diseases (5)?

Answer 1186

``` Coarctation of aorta Transposition of the great arteries Hypoplastic LH syndrome Total anomalous pulmonary venous connection Tricuspid atresia ```

Question 1187

What extrarenal features are seen in AD-PCKD?

Answer 1187

``` Cerebral aneurysms Hepatic and pancreatic cysts Mitral valve prolapse, aortic regurg, HTN Colonic diverticulosis Ventral and inguinal hernias ```

Question 1188

Risk factors for Psoas abscess:

Answer 1188

HIV, IVDU, DM, Crohn’s | Diverticulitis and vertebral osteomyelitis are also risk factors bc they can be causes of direct spread.

Question 1189

What are the risk factors and common findings in chronic pulmonary aspergillosis?

Answer 1189

Risks: lung disease/damage (cavitary TB) Findings: 3+ months of wt. loss, productive cough (may have blood-tinged sputum), hemoptysis, and fatigue. Cavitary lesions may contain debris and fluid, or a fungus ball – Aspergilloma Dx: positive aspergillus IgG serology

Question 1190

How to differentiate Type I Cryoglobulinemia from Mixed (Types II and III):

Answer 1190

Type I: often asx, may have hyperviscosity (blurry vision), thrombosis (Raynaud), skin findings (Livedo reticularis, purpura) - Seen in lymphoproliferative or heme diseases (MM) - NORMAL complement levels, and negative RF Mixed: Often have systemic sxs, renal (HTN, glomerulonephritis), Pulm (dyspnea, pleurisy), Skin (palpable purpura, leukoclastic vasculitis), and liver involvement - Seen w/chronic HCV, HIV, and SLE - LOW complement, often v. low C4, elevated transaminases, and positive RF

Question 1191

Tx of Essential tremor:

Answer 1191

1st line: BBs – Propranolol Anticonvulsants – Primidone (can be used alone or in combo w/the BBs) Small amounts of EtOH Benzos – Clonazepam

Question 1192

What will be seen on CXR in Takayasu arteritis?

Answer 1192

Aortic dilation and widened mediastinum – CT/MRI will show wall thickening and narrowing of the lumen

Question 1193

What will be the lab findings in acute mesenteric ischemia?

Answer 1193

Leukocytosis Elevated amylase and phosphate Metabolic acidosis (d/t elevated lactate) Elevated Hb (hemoconcentration)

Question 1194

What is spondylothisthesis and in what age is it most common?

Answer 1194

It is a fracture of the pars interarticularis (spondylosis) and then slippage of a vertebral body. Most common in adolescents (10-19) during growth spurts d/t increased physiologic lumbar lordosis and decreased bone mineralization. Pain w/extension of spine, and athletes w/repetitive extension (gymnastics, ballet, diving) are at greatest risk

Question 1195

How should billous emesis be managed in children?

Answer 1195

Stop feeds, NGT decompression, IVF then do AbXR – if no evidence of free air, distal obstruction (dilated loops of bowel) or duodenal atresia (double bubble) then need to get an upper GI series/barium swallow

Question 1196

What are common causes of asterixis?

Answer 1196

Hepatic encephalopathy Uremic encephalopathy Hypercapnia Each requires unique mgmt. and careful review of labs and hx should be done to determine the cause before initiating tx.

Question 1197

What screening tests are part of the routine newborn care?

Answer 1197

Comprehensive newborn screen – metabolic/genetic disorders Hyperbilirubinemia Hearing screen Pre and Post-ductal pulse ox (tests for CHD) Hypoglycemia in select populations

Question 1198

What antidote may be used as a mucolytic in CF patients?

Answer 1198

N-acetylcysteine

Question 1199

What is required to diagnose Bipolar II?

Answer 1199

``` Hypomanic episode(s) and at least 1 MDE No psychotic features (requirement to be hypomanic) if psychotic features are present it is automatically mania/BP-I MDE may happen in BP-I but is not required for the diagnosis ```

Question 1200

What will be heard on cardiac auscultation in aortic dissection?

Answer 1200

New aortic regurgitation

Question 1201

What would be the expected clinical presentation of a lesion in the vertebrobasilar system?

Answer 1201

Vertebrobasilar vessels supply the brain stem – lesions would cause: Alternate syndromes w/contralateral hemiplegia and ipsilateral cranial n. involvement Possible ataxia

Question 1202

What is the difference in presentation of a stroke involving the MCA of the dominant v. non-dominant lobe?

Answer 1202

``` Both will present w/contralateral motor and somatosensory deficits worse in the face/UEs, and homonymous hemianopia/quadrantanopia Dominant lobe lesions (L) often present w/aphasia Nondominant lobe (R) often present w/hemineglect or anosognosia (lack of awareness of illness) ```

Question 1203

What is the most common electrolyte abnormality in chronic alcoholism?

Answer 1203

Hypomagnesemia

Question 1204

How might hypophosphatemia present?

Answer 1204

Typically only have sxs in severe deficit but may cause weakness, rhabdomyolysis, paresthesias, and respiratory failure.

Question 1205

What is the tx of actinic keratosis?

Answer 1205

Fluorouracil cream

Question 1206

What would the results of a Hb electrophoresis show in a and B thalassemia minors?

Answer 1206

a-minor will show normal results | B minor will show increased HbA2

Question 1207

What is the Mentzer index and how can it differentiate b/w types of anemia?

Answer 1207

Mentzer index is the ratio of MCV/RBC Mentzer index < 13 is seen in a- and B-Thal minors (decreased MCV/normal or high RBCs) Mentzer index > 13 is seen in Fe-def anemia (decreased MCV/decreased RBCs)

Question 1208

What can be used as an alternative antidote to Methylene blue?

Answer 1208

Methylene blue is the antidote for methemoglobinemia, but is sometimes unavailable or contra’d (G6PD def.) High-dose ascorbic acid/Vit. C can be used in these cases

Question 1209

What are periarticular erosions on XR indicative of?

Answer 1209

RA

Question 1210

What drugs might cause pancreatitis?

Answer 1210

``` Diuretics – furosemide, thiazides IBD rxs – sulfasalazine, 5-asa Immunosuppressants – azathioprine, 6-MP HIV rxs – didanosine, pentamidine, PIs, NRTIs Abx – metronidazole, tetracycline, sulfas Anti-epileptics – valproate GLP-1 agonists (exenatide/liraglutide) Cannabis (only illicit drug to cause it) ```

Question 1211

What lab value will suggest biliary pancreatitis?

Answer 1211

ALT > 150 | This is helpful when no stone is seen on US (in cases where the stone may have already passed)

Question 1212

What is the most likely cause of statin-induced myopathy?

Answer 1212

Statins decrease coenzyme Q10 synthesis involved in muscle cell energy production which most likely causes the myopathy a/w these Rxs

Question 1213

What would cause loss of pain and temp in the ipsilateral face and contralateral trunk and limbs?

Answer 1213

Wallenberg/lateral medullary syndrome – d/t occlusion of the PICA - Will have motor function of face intact, but will have bulbar sxs Lateral pontine syndrome – d/t occlusion in the AICA - Will have loss of facial motor function, but no bulbar sxs Both vessels are brs. of vertebral a.

Question 1214

A lesion in what vessel is the only one that will cause hoarseness and dysphagia as part of the stroke syndrome?

Answer 1214

Lesion in PICA (br. of vertebral a.) – these effects are d/t its supply of the nucleus ambiguus Only a lesion of the PICA will cause loss of gag reflex, hoarseness and dysphagia

Question 1215

When should coronary angiography be done as the first diagnostic test?

Answer 1215

In patients w/high (>90%) pretest probability of ischemic heart disease: Typical angina in men 40+ or typical angina in women 60+

Question 1216

What is required to classify typical/classic angina?

Answer 1216

Must have all three of the following: 1. Typical location (substernal), quality and duration 2. Provoked by exercise or emotional stress 3. Relieved by rest or nitroglycerin Atypical is 2/3 and <2 is considered non-anginal

Question 1217

What kind of heart failure is prolonged HTN a risk for?

Answer 1217

Diastolic LHF

Question 1218

What are the ocular cxs of PDE-5 inhibitors?

Answer 1218

Blue discoloration of vision | Nonarteritic anterior ischemic optic neuropathy

Question 1219

What is the BP goal in diabetics?

Answer 1219

DM w/signs of nephropathy: <130/80 DM w/o signs of nephropathy < 140/90 - this is also the goal BP for all pts age <60, or who have CKD all pts age 60+ goal is <150/90 whether they have DM or not

Question 1220

What is the etiology of serum sickness-like reaction?

Answer 1220

It is a type III HS rxn w/immune-complex formation Occurs 1-2 wks after tx w/B-lactams (penicillin, amoxicillin, cefaclor) or TMP-SMX May also be seen in acute HBV infection

Question 1221

Most common cause of gross lower GI bleeding in adults:

Answer 1221

Diverticulosis

Question 1222

What is the diagnostic test of choice when CLL is suspected?

Answer 1222

Flow cytometry – will show a clonality of mature B cells | LN or BM biopsy are typically not needed, but can help dx HL and NHL

Question 1223

What is the early-morning cortisol test used for?

Answer 1223

Primary adrenal insufficiency – will show low or low-normal levels This test is NOT useful in assessing hypercortisolism in suspected Cushing’s

Question 1224

What are the features and tx of Chronic prostatitis/chronic pelvic pain syndrome?

Answer 1224

Non-infectious chronic prostate inflammation (separate dx from chr. bac. prostatitis) Sxs: pain in low back, pelvis, perineum and genitalia; irritative voiding sxs, hematospermia, and pain w/ejaculation Will have no/mild prostate tenderness and a sterile UCx Mgmt: a-blockers, abx (Cipro – esp. if hx of UTI), and 5-a-reductase inhibitors

Question 1225

What neurotransmitters does tetanus toxin prevent release of?

Answer 1225

Inhibitory neurotransmitters GABA and glycine

Question 1226

What is the timeline of presentation in order for a patient to be considered for alteplase therapy?

Answer 1226

Must present w/in 3-4.5hrs of sx onset and not have any contraindications to thrombolytic therapy

Question 1227

What is the recommended mgmt. of a Hydatidiform mole?

Answer 1227

Suction curettage and then weekly B-hCG levels until it is undetectable. - if these levels increase or plateau = gestational trophoblastic neoplasia Once undetectable check monthly levels for 6mo (must use contraception during this time) - if B-hCG becomes detectable again = gestational trophoblastic neoplasia Once clear for 6mo pts can attempt pregnancy again

Question 1228

What is the therapeutic Magnesium range for treating preeclampsia?

Answer 1228

5-8mg/dL | Mg2+ becomes toxic at concentrations >8`

Question 1229

What are the Centor criteria and who are they used for?

Answer 1229

Centor criteria predicts likelihood of Strep throat in adults only, should NOT be used in preadolescents and children. Criteria: fever by hx, tender anterior cervical LAD, tonsillar exudates, absence of cough 0-1 – no testing or tx for strep 2-3 – rapid strep test (pen or amox if +) 4 – Empiric penicillin or amoxicillin or do rapid test

Question 1230

What Rxs are a/w causing exacerbations of Myasthenia Gravis?

Answer 1230

Abx: Fluoroquinolones, aminoglycosides, azithromycin Anesthetics: neuromuscular blocking agents Cardiac meds: BBs, procainamide Others: Mag sulfate, penicillamine Tapering immunosuppressants can also cause exacerbations

Question 1231

What surgery is a particular risk for exacerbation of Myasthenia Gravis?

Answer 1231

Thymectomy – aka one of its tx options

Question 1232

What are the common clinical findings in neonatal HSV infection?

Answer 1232

Pathogenesis: vertical transmission intrauterine, perinatal, or postnatal Skin/membranes: mucocutaneous vesicles, keratoconjunctivitis - cutaneous sxs may be absent in CNS or disseminated infections CNS: seizures, fever, lethargy, temporal lobe hemorrhage/edema Disseminated: sepsis, hepatitis, pneumonia

Question 1233

What patient population is Otosclerosis most likely to effect?

Answer 1233

Young adults 20s-30s w/female predominance | abnormal remodeling of the otic capsule – stapes becomes fixed to the oval window

Question 1234

What are the common sxs a/w Herpetic whitlow?

Answer 1234

Norm. have mild prodrome of fever/malaise, and then development of grouped vesicles on an erythematous base typically on the hand – often have tingling, burning and pain Some pts have epitrochlear and axillary LAD

Question 1235

What are common findings in burn wound sepsis?

Answer 1235

``` May have some or all of the following: Temperature <97.7 or >102.2 Progressive tachycardia >90bpm Progressive tachypnea >30/min Refractory HoTN (SBP <90) Oliguria AMS Unexplained hyperglycemia Thrombocytopenia ```

Question 1236

What is the tx of TCA overdose?

Answer 1236

O2 and intubation if necessary IVF Activated charcoal if pts present w/in 2 hrs and there are no signs of ileus IV Na-HCO (alleviates depressant axn on myocardial Na channels)

Question 1237

What finding a/w Raynaud is suggestive of the presence or future development of a CTD?

Answer 1237

Abnormalities such as dilated or dropout vessels in the nailfold capillaries

Question 1238

Who should undergo carotid endarterectomy?

Answer 1238

Symptomatic pts (previous TIA or stroke in distribution of affected vessel w/in last 6 mos) w/high-grade carotid stenosis (>70%) Asymptomatic pts w/stenosis >80% Everyone else should get aspirin + other meds to control their risk factors (including asx pts w/stenosis up to 80%)

Question 1239

How to differentiate XLA from CVID:

Answer 1239

XLA – low B cells (lymphocytes – Tcells) and low numbers of all immunoglobulin classes Presents in infancy/early childhood CVID – normal B cells w/decrease in all immunoglobulin classes Presents w/less severe sxs than XLA and after adolescence

Question 1240

What is the best way to secure an airway in an unstable cervical spine injury?

Answer 1240

Still orotracheal intubation – can stabilize the neck w hand during procedure, its quick, and there isn’t that much movement

Question 1241

What is the pathophys of secretory diarrhea and what are its common causes?

Answer 1241

Occurs when luminal ion channels are disrupted in the GIT and results in a state of active secretion Common causes: bacteria (Cholera), viruses (Rota), congenital disorders of ion transport (CF), early ileocolitis, and postsurgical changes

Question 1242

What cxs can occur in pts w/only sickle cell trait?

Answer 1242

Hematuria/papillary necrosis (most common) Hyposthenuria Splenic infarction (esp. at high altitudes) Venous thromboembolism Priapism Exertional rhabdomyolysis Will have normal Hb, retic count, RBC indices and morphology

Question 1243

Renal cxs in sickle cell trait:

Answer 1243

``` Hematuria – mostly from papillary ischemia or necrosis Renal medullary carcinoma UTIs Hyposthenuria Distal renal tubular acidosis ```

Question 1244

What are the features of postdural puncture HA?

Answer 1244

Occurs after LP or neuraxial anesthesia – dural puncture causes CSF leakage, low CSF pressure and slight herniation of brain/brainstem Positional HA worse when upright, improves when supine Neck stiffness Photophobia, diplopia Hearing loss and tinnitus *mostly self-limited but severe sxs can be tx’d w/epidural blood patch*

Question 1245

What is alcoholic neuropathy and how does it present?

Answer 1245

EtOH is a neurotoxin and results in axonal neuropathy w/a reduction in the number of small myelinated and unmyelinated fibers. May occur alone or a/w thiamine def. Features: symmetric distal polyneuropathy in stocking glove pattern, paresthesia, burning pain, numbness, loss of DTRs (starting w/ankle), low of light touch and vibration, and gait ataxia Tx: EtOH cessation, thiamine to prevent secondary neuropathies, gabapentin and TCAs for pain

Question 1246

What will be seen on imaging in Colonic ischemia?

Answer 1246

CT scan: Colonic wall thickening and fat stranding (although may have only nonspecific findings) Endoscopy: Edematous and friable mucosa

Question 1247

Difference between colonic and mesenteric ischemia:

Answer 1247

Colonic – mostly d/t low blood flow/HoTN or non-occlusive ischemia w/underlying atherosclerotic disease. Effects watershed regions most (splenic flexure and rectosigmoid jxn) Mesenteric – d/t atheroembolic or thrombotic events causing occlusive ischemia of the small bowel typically (jejunum, ileum, duodenum)

Question 1248

What Rxs are used to tx Frontotemporal Dementia?

Answer 1248

SSRIs and Trazodone can both help the neuropsychiatric sxs

Question 1249

What should be done in patients w/suspected blunt cardiac injury?

Answer 1249

Continuous cardiac monitoring w/echo (TTE or TEE in intubated/unstable pts) and EKG for 24hrs to detect arrhythmias that may occur

Question 1250

What are the CVS hemodynamic effects of Thyrotoxicosis?

Answer 1250

Systolic HTN and increased PulseP Increased contractility and CO Decreased SVR Increased myocardial O2 demand

Question 1251

What is one of the most common causes of acute renal failure in hospitalized patients?

Answer 1251

CONTRAST INDUCED NEPHROPATHY!!! always pay attention when there is imaging done in pts w CKD and then worsening of renal failure Can prevent w/IVF pre-procedure and by holding NSAIDs

Question 1252

What are the 2 main toxic products of combustion that can harm pts w/inhalation smoke injuries?

Answer 1252

``` Hydrogen Cyanide (aka cyanide toxicity) Carbon monoxide – carboxyhemoglobin **methemoglobinemia does NOT occur 2/2 inhalational smoke exposure and is actually used to tx the cyanide poisoning that may occur** ```

Question 1253

What will be seen on coagulation studies in severe B12 def causing pancytopenia?

Answer 1253

Normal results. | Severe deficiency can cause decrease in all cell lines, but coagulation will be normal

Question 1254

Cardiac causes of hemoptysis:

Answer 1254

Mitral stenosis/acute pulmonary edema

Question 1255

Timeline difference b/w Crystal-induced AKI and AIN:

Answer 1255

Crystal-induced typically occurs w/in 24-48hrs of starting a drug and is often asx AIN usually occurs 7-10d after starting a Rx and rash + eosinophilia, etc.

Question 1256

What kind of infections does Kingella kingae cause and what abx is often used to treat them?

Answer 1256

Septic arthritis, osteoarthritis, bacteremia and endocarditis Most infections are found in children They are aerobic gram neg. and often tx’d w/Ceftriaxone

Question 1257

What cx of appendicitis is significantly increased after laparoscopic procedures v. laparotomy?

Answer 1257

Intra-abdominal abscess – often found sub-phrenic causing hiccups, pleural effusions and SoB

Question 1258

What is the mgmt. of Primary Ovarian Insufficiency?

Answer 1258

Estrogen therapy and Progestin added if there is an intact uterus

Question 1259

What is the most common mechanism of leukopenia and thrombocytopenia in SLE?

Answer 1259

Immune-mediated destruction

Question 1260

How can a large PE be differentiated from RV MI?

Answer 1260

PE is more likely to cause tachycardia, dyspnea, and syncope RVMI is more likely to cause bradycardia and arrhythmias Both can cause RV dysfxn, increased CVP and decreased LV preload and CO

Question 1261

When should Penicillin desensitization be done to tx Syphilis?

Answer 1261

If other txs (Doxycycline) are contraindicated – like in pregnancy If it has progressed to Neurosyphilis/Tertiary stage (CVS/aortitis effects, gummas) All other pts. w/severe penicillin allergies can receive Doxycycline instead

Question 1262

What does the Secretin stimulation test diagnose?

Answer 1262

Gastrinoma/ZES Normal G cells in the stomach are inhibited by Secretin, but gastrinoma cells are stimulated by it. Secretin will not cause a rise in gastrin levels in any other causes of hypergastrinemia besides ZES/gastrinoma

Question 1263

How is Seborrheic dermatitis tx’d?

Answer 1263

Topical antifungals (ketoconazole, selenium sulfide) – malassezia spp. are thought to play a role in its pathogenesis

Question 1264

What stroke syndrome is least likely to cause Hemiparesis?

Answer 1264

Cerebellar – almost all others will cause paresis/paralysis

Question 1265

What stroke syndrome is most likely to cause seizures?

Answer 1265

Cerebral lobar strokes

Question 1266

What are the most common causes of Steppage gait?

Answer 1266

L5 radiculopathy or neuropathy of the common peroneal n.

Question 1267

What are the soft signs of extremity vascular trauma?

Answer 1267

``` Hx of hemorrhage Diminished pulses Bony injury Neurologic abnormality These should be investigated w/imaging (CT, US, Angio) if the pt. is stable and there are no hard signs present ```

Question 1268

Mgmt of Neonatal Varicella exposure:

Answer 1268

Give VZIG if exposure or if mother developed infection 5d pre- or 2d post-delivery If varicella infection develops tx w/Acyclovir (safe in pregnancy and infancy)

Question 1269

What renal pathology does HBV infection increase the risk for?

Answer 1269

Membranous nephropathy – a nephrotic syndrome. Thought to be d/t HBeAg deposits in the glomeruli (membranoproliferative glomerulonephritis has also been a/w HBV but is much less common)

Question 1270

What is a common source of nosebleeds in pregnancy?

Answer 1270

Pyogenic granulomas of the anterior nasal septum. Pregnant women have an increased incidence of these.

Question 1271

Most common organisms cultured from peritoneal fluid in SBP:

Answer 1271

E. coli and Klebsiella

Question 1272

Risk factors for Hydatidiform mole:

Answer 1272

Extremes of maternal age Previous Hx of mole Vitamin A def. (seen post Roux-en-Y surgery)

Question 1273

How will viral myocarditis likely present?

Answer 1273

Post-URI w/fatigue, dyspnea, elevated JVP and cardiomegaly on CXR Typically have audible S3 and bibasilar rales w/pulmonary vascular congestion on imaging.

Question 1274

What is seen on UA in hemoglobinuria?

Answer 1274

Will be dipstick positive for blood but there will be absent RBCs on microscopy bc the heme is lysed from the RBCs and excreted in the kidneys but the whole RBC is not intact in the urine (hematuria)

Question 1275

Anti-DM Rxs used in pregnancy:

Answer 1275

Insulin is 1st choice, but Metformin and Glyburide may also be used, but these both cross the placenta

Question 1276

Mgmt of Aortic Dissections:

Answer 1276

``` Pain control w/Morphine, and IV BBs should be started right away, then: Type A (involving the ascending aorta) need immediate surgical repair Type B (only descending involved) can be managed w/pain and tight BP control unless there are signs of organ malperfusion, (mesenteric ischemia, etc.) then these need surgery asap as well ```

Question 1277

What are the common lab findings and mgmt. of acute mesenteric ischemia?

Answer 1277

Labs: leukocytosis, elevated amylase and phosphate, elevated Hb (hemoconcentration) and metabolic acidosis (elevated lactic acid) Mgmt: immediate operative evaluation, or dx w/CT-angio. Then need bs-abx and anticoagulation

Question 1278

What kind of arthritis does Lyme disease cause?

Answer 1278

A mono-articular migratory arthritis. Most commonly involves the knee, but only involves 1 joint at a time and then may resolve and affect another joint later.

Question 1279

What is EPO?

Answer 1279

A cytokine

Question 1280

Endocrine causes of recurrent pregnancy loss:

Answer 1280

Thyroid disease (anti-TPO Abs a/w miscarriage in both euthyroid and hypothyroid women) PCOS DM Hyperprolactinemia Celiac dx (not an endocrine cause, but remember it)

Question 1281

How long should a pt. be seizure free before considering dc of anti-epileptics?

Answer 1281

>2 years | Must slowly taper and then dc

Question 1282

What is the tx of Carcinoid syndrome?

Answer 1282

Octreotide for sxs and prior to surgery/anesthesia | Surgery for liver mets

Question 1283

What products do carcinoid tms secrete?

Answer 1283

Histamine 5-HT and 5-HIAA VIP

Question 1284

What are the CVS features of DM-autonomic neuropathy?

Answer 1284

Tachycardia, impaired exercise tolerance | Postural HoTN w/loss of diurnal BP variation

Question 1285

What is the role of ADH in ADPCKD?

Answer 1285

Tubular destruction leads to a mild nephrogenic DI which then increased ADH levels. The high ADH levels may promote renal cyst growth, so Vasopressin-2-R antagonists (tolvaptan) have been shown to slow progression of the disease.

Question 1286

What causes aFlutter?

Answer 1286

Reentrant circuit around the tricuspid annulus

Question 1287

What are the clinical features of Neurofibromatosis 1?

Answer 1287

Café-au-lait macules (1st cutaneous finding-often in infancy), axillary and inguinal freckling, Lisch nodules and neurofibromas Pseudoarthrosis Pheochromocytoma These pts are at increased risk for neurologic disorders: cognitive deficits, learning disabilities, seizures, intracranial neoplasms (astrocytomas, brainstem gliomas), and optic pathway gliomas

Question 1288

What are the features of Tuberous sclerosis?

Answer 1288

Neurocutaneous disorder w/benign tumors in multiple organs – intracardiac rhabdomyomas Angiofibromas, ash-leaf spots and shagreen patches (thick leathery skin, dimpled like an orange peel)

Question 1289

What are the features of Sturge-Weber syndrome?

Answer 1289

Triad of port-wine stain on the face, ocular disease (visual deficits or glaucoma), and leptomeningeal capillary-venous malformations. Often have seizures from the malformations

Question 1290

When does renal biopsy need to be performed in the pediatric population?

Answer 1290

Kids >10 w/nephrotic syndrome Kids of all age w/nephritic syndrome Patients <10 w/minimal change that don’t respond to steroids

Question 1291

How should pulseless electrical activity be managed?

Answer 1291

This is a rhythm on the monitor w/o a palpable pulse or measurable BP Mgmt: CPR x 2min, IV access, Epi every 3-5min, possible advanced airway. Continue this until there is a shockable electrical rhythm or the underlying causes have been reversed

Question 1292

What is Lemierre Syndrome?

Answer 1292

Infection caused by Fusobacterium necrophorum – affects young immunocompetent pts. Typically starts w/tonsillitis (but may be 2/2 dental work or mastoiditis) then the bacterium invades the lateral pharyngeal space and causes IJV thrombosis and infection

Question 1293

What is the typical presentation of Lemierre syndrome?

Answer 1293

A prolonged duration (1+ week) of sore throat w/high fever, rigors, dysphagia and neck pain w/swelling along the SCM (IJ thrombosis) Once the IJ is infected septic thromboembolic can seed other organs – esp. the lungs, see nodules and cavitation on imaging

Question 1294

What are the common effects of Growth Hormone?

Answer 1294

``` Hyperglycemia Sodium retention HTN Swollen hands Joint and muscle pain ```

Question 1295

What would be the expected hormone levels in exercise-induce hypothalamic amenorrhea?

Answer 1295

Decreased: GnRH, LH, FSH and Estrogen | Normal TSH and PRL

Question 1296

What would be used to make the diagnosis of Mallory-Weiss syndrome?

Answer 1296

Upper GI endoscopy – can confirm dx and tx persistent bleeding This is a mucosal tear w/bleeding (contrast to Boerhaave which is transmural and EGD is contraindicated)

Question 1297

How is thyroglobulin used as a tumor marker?

Answer 1297

Thyroglobulin is produced by normal thyroid tissue and differentiated thyroid cancer – papillary, follicular Once patients have undergone Thyroidectomy w/RAI tx they should have no Thyroglobulin production. A rise in its concentration would signify recurrence of the cancer

Question 1298

What is often used as bs-coverage in PID?

Answer 1298

Cefoxitin + Doxycycline | Metronidazole may also be used as part of the regimen

Question 1299

Patients with what condition have increased sensitivity to lactate infusions?

Answer 1299

Patients w/Panic Disorder | Lactate infusion can provoke panic attacks in susceptible pts.

Question 1300

What should be suspected in a neonate w/direct hyperbilirubinemia and hepatomegaly?

Answer 1300

Biliary atresia

Question 1301

Tx of Bacterial Vaginosis in pregnant pts:

Answer 1301

Metronidazole or Clindamycin is the tx regardless of pregnancy status

Question 1302

What are the characteristics and common locations of Tophi?

Answer 1302

Tophi are nodular deformities filled w/chalky material, often found on the ears, tendons and periarticular tissues of the digits. Unlike acute gout tophi are normally painless. In pts w/gout who develop tophi a urate-lowering Rx (allopurinol) is required

Question 1303

What is the gold standard for diagnosing DM in pts w/PCOS?

Answer 1303

Oral glucose tolerance test | This is more sensitive for detecting glucose intolerance than the standard DM screening tests (fasting glucose, HbA1c)

Question 1304

When is BRCA mutation testing indicated?

Answer 1304

In pts w/Fhx of ovarian ca. at any age and a personal or Fhx or breast cancer <50. Not indicated for Fhx of endometrial cancer

Question 1305

What are the most common inciting factors of Hepatorenal syndrome?

Answer 1305

Spontaneous bacterial peritonitis | GI bleeding

Question 1306

What is the tx of Hepatorenal syndrome?

Answer 1306

``` Address precipitating factors and return liver fxn to normal Liver transplantation Splanchnic vasoconstrictors (Midodrine, octreotide, NE) and albumin ```

Question 1307

Most common cause of chronic mitral regurg in developed countries?

Answer 1307

MVP – murmur may be more consistent w/severe mitral regurg (holosystolic radiating to axilla) in late stage instead of the classic mid/late systolic click

Question 1308

How will changes in K+ affect patients w/cirrhosis?

Answer 1308

Hypokalemia is a common precipitant to hepatic encephalopathy and even slight decreases require prompt repletion. This commonly occurs after the initiation of diuretics which deplete K+ and cause low intravascular volume despite total volume overload Metabolic alkalosis (increased HCO3-) is often a/w hypokalemia which also exacerbates HE by increasing conversion of NH4+ to NH3

Question 1309

What are the common inherited forms of Pheochromocytoma?

Answer 1309

VHL gene w/Von hippel-Lindau RET gene – MEN type 2 NF1 gene – Neurofibromatosis Type I

Question 1310

What test can be performed to assess ovarian fxn?

Answer 1310

Day 3 FSH testing – during the follicular phase As ovarian reserve and fxn decline, estradiol and inhibin dencrease – negative feedback leads to increased FSH as ovarian fxn decreases

Question 1311

When would hypertrophic osteoarthropathy be seen?

Answer 1311

It is a paraneoplastic syndrome a/w intrathoracic malignancy + other pulm diseases (CF) Polyarthropathy a/w digital clubbing and periostosis (xs bone formation)

Question 1312

Important diagnostic clues for Psoriatic arthritis:

Answer 1312

Involvement of the DIPS and nail changes – pitting and onycholysis (separating of the nail from nailbed) Often presents as asymmetric oligoarthritis or symmetric polyarthritis May have seronegative spondyloarthritis or aggressive/destructive arthritis mutilans Psoriatic arthritis manifestations are increased in pts positive for HLA-B27 or w/involvement of the nails

Question 1313

Tx of acne:

Answer 1313

Always start w/topical retinoids, salicylic or glycolic acid For mild inflammatory can start topical retinoids + benzoyl peroxide Next step add topical abx Next add oral abx Last resort for unresponsive severe nodular/cystic acne can replace other Rxs w/oral isotretinoin

Question 1314

What clinical picture should a biliary leak be suspected with?

Answer 1314

A patient w/low-grade fever, RUQ tenderness, N/V, leukocytosis and obstructive-appearing liver enzymes (elevated BR and ALP) w/normal-appearing biliary ducts or mild dilation on imaging 2-10d post-cholecystectomy (or other biliary surgeries)

Question 1315

How to tell if there’s a statistically significant difference b/w 2 groups based on CIs:

Answer 1315

If the CIs of 2 different groups do not overlap (A = 1-2 and B = 3-4) then that suggests there is a statistically significant difference b/w the two groups

Question 1316

Manifestations of early Lyme disease:

Answer 1316

Erythema Migrans Systemic sxs: malaise, fatigue, arthralgia Regional LAD Neuro: meningitis, CN palsy (often b/l facial n. palsy), radiculoneuritis CVS: AV block **most pts 1st present w/erythema migrans (80%) but some may present w/early disseminated signs such as Neuro signs and/or carditis** All of these sxs may occur alone or in combinations

Question 1317

What should be suspected in a patient w/flu-like sxs and b/l facial palsy?

Answer 1317

Lyme disease

Question 1318

What tm markers are commonly increased in testicular cancer?

Answer 1318

AFP and B-hCG

Question 1319

Common causes of Intertrigo:

Answer 1319

Candida #1 (will also form satellite lesions w/vesicles, papules or pustules) S. aureus + others

Question 1320

What will present as segmented hyphae on KOH prep?

Answer 1320

Dermatophyte infections

Question 1321

What is the most common congenital infection worldwide?

Answer 1321

CMV – it is also one of the only ones a/w microcephaly

Question 1322

What are some relative contraindications to NSAIDs in acute gout attacks?

Answer 1322

Pts. taking anticoagulants (increase risk of bleeding) and those w/heart failure (can acutely worsen HF) In these pts. Colchicine or steroids should be used for acute attacks But shouldn’t use colchicine in elderly or w/severe renal dysfxn, and steroids are not preferred in DM

Question 1323

How does ocular rosacea present and how is it treated?

Answer 1323

It is seen in the majority of pts w/rosacea and may appear on its own w/out skin findings. Involves the cornea, conjunctiva and lids and often has recurrent chalazia Sxs: burning or foreign body sensation/”dirt in eyes sensation", blepharitis, keratitis, conjunctivitis, and corneal ulcers Tx: Mild – lid scrubs, topical abx (metro, erythro), and ocular lubricants; Severe may require systemic abx and topical immunosuppressive agents

Question 1324

What is seen in the clinical presentation of Acute Liver Failure?

Answer 1324

Generalized sxs – fatigue, lethargy, anorexia, N RUQ abd pain Pruritus and jaundice – from hyperbilirubinemia Renal insufficiency Thrombocytopenia Hypoglycemia Signs of HE – somnolence, disorientation, asterixis

Question 1325

What is the most common neural tube defect?

Answer 1325

Myelomeningocele

Question 1326

What might be the fetal effects of maternal cigarette smoking?

Answer 1326

FGR, intra-uterine fetal demise, and cleft lip/palate

Question 1327

What is a severe cx of basal ganglia hemorrhages?

Answer 1327

Uncal herniation – hemorrhage compresses part of the temporal lobe (uncus) laterally and downward against the tentorium cerebelli.

Question 1328

What are sxs of an uncal herniation?

Answer 1328

Aka transtentorial herniation CN-III palsy – dilated, nonreactive pupil ipsilateral to the side of herniation (d/t direct compression) Contralateral extensor/decerebrate posturing, coma and respiratory compromise (d/t compression of the midbrain) Often occur after hemorrhagic strokes 2/2 HTN

Question 1329

What are sxs of a cerebellar tonsillar herniation?

Answer 1329

Neck tilt, flaccid paralysis, coma, BP instability, and respiratory arrest all d/t tonsillar herniation and compression of structures through the foramen magnum

Question 1330

What can be done in pts w/increased risk for pulmonary cxs in the post-op period to decrease their risk?

Answer 1330

Pre-op PT w/aerobic exercise, and inspiratory muscle training can significantly reduce the risk of atelectasis and pneumonia Smoking cessation 8+ weeks pre-op is also of benefit

Question 1331

Besides infections, what are some cxs of Wiskott-Adrich syndrome?

Answer 1331

Bc they have microthrombocytopenia they are at increased risk for bleeding. May have just petechiae/purpura or more severe bleeding like hematuria, hematochezia, or intracranial hemorrhage

Question 1332

What are the features of Chediak-Higashi syndrome?

Answer 1332

Lysosomal defect – impaired phagocytosis | Signs/Sxs: Albinism, peripheral neuropathy, recurrent skin and soft-tissue pyogenic infections, giant granules in NPs

Question 1333

Why might pts w/Hypercalcemia present w/signs of dehydration?

Answer 1333

Hypercalcemia induces nephrogenic DI – polyuria and volume depletion. This is why NS is the first line tx of hypercalcemia – restores intravascular volume and promotes urinary Ca2+ excretion

Question 1334

When should glucocorticoids be used to tx hypercalcemia?

Answer 1334

When the hypercalcemia is d/t extrarenal calcitriol production – Lymphomas and granulomatous diseases (sarcoid)

Question 1335

What are the target INR ranges for pts taking Warfarin w/a mechanical prosthetic valve?

Answer 1335

Mitral valve: INR 2.5-3.5 | Aortic valve: INR 2.0-3.0

Question 1336

What are the clinical features of mechanical prosthetic valve thrombosis?

Answer 1336

Inadequate coagulation (#1 risk factor) Mitral valve risk > aortic valve Obstructive thrombus mimics valvular stenosis—get rapid onset dyspnea, pulm edema w/crackles, lightheadedness HF, cardiogenic shock Systemic thromboembolic events (stroke, limb ischemia)

Question 1337

Most common cause of persistent nasal obstruction in childhood:

Answer 1337

Adenoid hypertrophy – have signs/sxs of chronic upper airway obstruction: Nasal congestion refractory to medical mgmt., recurrent sinus and ear infections, mouth breathing, sleep disturbances/snoring d/t apnea May also have mucopurulent nasal discharge, postnasal drip, and elongated/flattened facial features Concurrent tonsillar hypertrophy is common

Question 1338

What are the cxs of Ventricular aneurysms post-STEMI?

Answer 1338

``` Progressive LV enlargement – HF Refractory angina Ventricular arrhythmias Systemic arterial embolization – stroke, mesenteric ischemia, UE or LE ischemia Mitral annular dilation – MR ```

Question 1339

What are the features of Beriberi?

Answer 1339

High-output heart failure and peripheral neuropathies | Caused by Thiamine/B1 deficiency

Question 1340

Contraindications to the two types of IUD:

Answer 1340

Levonorgestrel – active liver disease, breast ca., active pelvic infection Copper – Wilson disease, Cu allergy, Menorrhagia, Acute pelvic infection

Question 1341

Risk factors and most common causes of Pyelonephritis in pregnancy:

Answer 1341

Risks – asx bacteriuria, DM, age <20, Tobacco use | Common pathogens – E. coli (most common), Klebsiella, Enterobacter, GBS

Question 1342

What are signs of cervical ca. tm extension?

Answer 1342

Low back pain from pelvic extension Lymphedema from obstruction of lymphatics and BVs Hydronephrosis from obstruction of ureters

Question 1343

What are potential cxs of chronic hypoparathyroidism?

Answer 1343

Nephrocalcinosis Cataracts Deposition of Ca2+ in the basal ganglia (may cause EPS) *cxs are higher in those w/hyperphosphatemia and a Calcium x Phosphorus product >55, this increases risk of soft tissue calcification*

Question 1344

What are the risk factors for retained placenta?

Answer 1344

Gestational age 24-27wks Stillbirth Placenta accreta Hx of prior retained placenta

Question 1345

What is the difference b/w Type I and II Chemo-induced cardiomyopathy?

Answer 1345

Type I: a/w anthracyclines (Doxorubicin). Causes myocyte necrosis and destruction w/fibrosis. Causes asx decline in LV systolic fxn which progresses to overt HF. Unlikely to be reversible Type II: a/w Trastuzumab. Causes myocardial stunning/hibernation w/o myocyte destruction. Get asx LV systolic dysfxn. Often reversible when Rx is dc’d

Question 1346

Risk factors for penile cancer:

Answer 1346

Age >60, HPV, phimosis, cigarette smoking | Most are SCC

Question 1347

What is pulmonary cachexia?

Answer 1347

Phenomenon of loss of lean muscle mass a/w chronic pulm. Disease (mostly advanced COPD) Suggested by BMI <20 or >5% wt. loss Occurs in 20-40% of COPD pts and leads to impaired balance, increased susceptibility to lung infections and increased mortality. Development of the disorder correlates w/disease severity.

Question 1348

What is pHTN and what are the causes of pulmonary venous HTN?

Answer 1348

pHTN = mean pulm. arterial P 25+ at rest Causes of venous pHTN: L heart disease (LV dysfxn, AR/S, MR/S, etc.), chronic lung disease/hypoxemia, chronic thromboembolic disease, other – hematologic, systemic or metabolic disorders

Question 1349

What kind of pHTN do connective tissue diseases cause?

Answer 1349

CTDs (SLE, RA, sclerosis) cause narrowing and obliteration of the small arterioles and alveolar capillaries which leads to pulmonary ARTERIAL HTN.

Question 1350

What is an osteoclastoma?

Answer 1350

Giant cell tumor

Question 1351

What is the likely presentation and outcome of a constitutionally small infant?

Answer 1351

Prenatally will be seen as estimated fetal wt. <10% for gestational age, but then will have normal Doppler a. US during follow-up and appropriate interval growth via US Outcome is normal neonatal course and no adverse outcomes. Often seen in women w/low pre-pregnancy wt. and short stature

Question 1352

What are the long-term cxs of infants w/FGR?

Answer 1352

Neuro cxs: delayed cognitive development, motor dysfxn, behavioral probs (ADHD) Growth failure Childhood obesity and Metabolic syndrome

Question 1353

What value is considered small for gestational age in a term infant?

Answer 1353

2500g or 5lb 8oz

Question 1354

How is incisional hematoma managed?

Answer 1354

For large symptomatic hematomas the incision needs to be opened to evacuate the clot, obtain hemostasis and then reclosed. Incisional hematomas can be a nidus for bacterial growth, bc of their stagnant fluid, and increase the risk of surgical site infection (cellulitis, abscess)

Question 1355

What ophthalmologic disease is a/w gradual peripheral vision loss?

Answer 1355

Open-angle glaucoma | On fundoscopy see: Enlargement of the optic disc/cupping, increased cup:disc ration, and elevated IOP

Question 1356

What are the cxs seen in infants of DM mothers w/hyperglycemia in the 1st trimester?

Answer 1356

Congenital heart disease Neural tube defects Small L colon syndrome Spontaneous abortions

Question 1357

What are the cxs seen in infants of mothers w/Hyperglycemia in the 2nd and 3rd trimesters?

Answer 1357

Polycythemia Organomegaly Neonatal hyperglycemia Hypocalcemia (d/t PTH suppression, but norm asx) Macrosomia – shoulder dystocia, brachial plexopathy, clavicle fracture, perinatal asphyxia

Question 1358

Most common causes of DRESS syndrome?

Answer 1358

Allopurinol and Anti-epileptics (Phenytoin, Carbamazepine) Less commonly abx – sulfas, minocycline, vancomycin Long latency from Rx initiation to rxn – 2-8wks Possible cross-reactivity b/w herpesvirus lymphocytes and drug antigens – most pts have Ab evidence of HHV6 reactivation during DRESS syndrome

Question 1359

How will Ogilvie syndrome present on imaging?

Answer 1359

Aka acute colonic pseudo-obstruction | Colonic dilation w/oral contrast visualized throughout the entire colon – suggesting no anatomical obstruction

Question 1360

What will be the clinical presentation of Ogilvie syndrome (acute colonic Pseudo-obstruction)?

Answer 1360

Abdominal distension, pain, N/V Constipation/obstipation or paradoxical diarrhea Increasing dilation may lead to ischemia/perforation – guarding, rigidity, extreme tenderness Partial/total colonic dilation w/o anatomic obstruction on CT

Question 1361

What spp. of Malaria have a dormant phase?

Answer 1361

P. vivax – seen in Non-african countries. Need tx w/Chloroquine and Primaquine (kills hepatic hypnozoites) P. falciparum – seen in Africa doesn’t have a dormant phase

Question 1362

Where is Choriocarcinoma most likely to met?

Answer 1362

Lungs – dyspnea/ARDS | Vagina – bloody or purulent vaginal discharge, vascular/friable nodule on pelvic exam

Question 1363

Features of chronic ischemic colitis:

Answer 1363

Chronic abd pain, bloody diarrhea, weight loss, and colonic strictures May see mucosal atrophy and granulation tissue on colonic biopsy

Question 1364

What are the risk factors and features of Myelodysplastic syndrome?

Answer 1364

Hematipoietic stem cell neoplasm Risks: advanced age, hx of chemo or radiation Causes dysplasia and cytopenias – typically decrease in all cell lines Anemia – weakness and fatigue Granulocytopenia – infections and hyposegmented NPs Thrombocytopenia – bleeding and bruising Cx: transformation to AML

Question 1365

How to differentiate Hairy cell leukemia from the chronic leukemias:

Answer 1365

All may cause massive splenomegaly Hairy cell – pancytopenia (d/t fibrosis of bone marrow: dry tap) CLL – lymphocytosis CML – leukocytosis **Myelofibrosis may also cause massive splenomegaly w/pancytopenia**

Question 1366

What pulmonary sxs does Listeria cause?

Answer 1366

NONE! You’re thinking of legionella, they’re different Listeria = GI and Neuro; G+ aerobic rod Legionella = GI then pulmonary; G- aerobic rod

Question 1367

What are the clinical features and tx of Legionella?

Answer 1367

G- aerobic rod, a/w travel and hospital Spreads via aerosolized water droplets from contaminated source (ac, ventilator) Get GI sxs first (D/V, cramps), then fever (>101.8), relative bradycardia for fever (70s norm) and then pulmonary sxs are delayed and show last Often have Hyponatremia and patchy unilobar or interstitial infiltrates Tx: Resp fluoroquinolone (levo) is DoC, newer macrolides (azithro) are 2nd choice

Question 1368

AEs of oral Isotretinoin tx:

Answer 1368

``` Teratogenic – spontaneous abortion, fetal malformations Hyperlipidemia Chelitis (dry, cracked lips), dry skin Myalgias Pseudotumor cerebri ```

Question 1369

What causes testicular torsion

Answer 1369

Twisting of the spermatic cord d/t inadequate fixation of the lower pole of the testis to the tunica vaginalis – compression of pampiniform plexus and reduced venous outflow

Question 1370

When will women start menstruating post-partum?

Answer 1370

Formula feeding: 8-14 weeks | Exclusive breastfeeding: >6mos (variable)

Question 1371

Common causes of SIADH:

Answer 1371

CNS disturbance – stroke, hemorrhage, trauma Meds – Carbameazepine, SSRIs, NSAIDs, Cyclophosphamide, Lung disease (pneumonia) Ectopic ADH secretion (SCLC) Pain and/or nausea

Question 1372

Most common type of fibroid to cause heavy/prolonged menstrual bleeding:

Answer 1372

Submucosal; Intramural may as well, but less common. Subserosal will not.

Question 1373

What is the best diagnostic step to confirm uterine fibroids?

Answer 1373

Sonohysterography – saline infusion US

Question 1374

What does omental caking on CT signify?

Answer 1374

Intra-abdominal carcinomatosis

Question 1375

What are common causes of Uric acid stones?

Answer 1375

Uric acid stones are relatively uncommon (5-10%) Increased serum uric acid levels: gout, tumor lysis syndrome Chronic HCO3- loss: diarrhea, dehydration

Question 1376

What is the tx of Waldenstrom macroglobulinemia?

Answer 1376

Plasma exchange – to remove the xs serum IgM

Question 1377

When would ultrafiltration be used?

Answer 1377

In pts. w/massive volume overload whose condition doesn’t respond to aggressive diuretics

Question 1378

What is the most common form of lung cancer?

Answer 1378

Adenocarcinoma

Question 1379

How to tell different types of lung ca. based on CXR:

Answer 1379

Squamous cell – often a single, upper lobe, cavitary lesion. Typically the only type to cause a cavitary lesion Adenoca. – peripheral nodule Bronchoalveolar – typically a solitary peripheral nodule, but may have multiple nodules or lobar consolidation SCLC – central (hilar, perihilar) mass, often w/mediastinal LAD

Question 1380

What type of hernia may extend into the scrotum?

Answer 1380

Indirect inguinal – protrudes through deep inguinal ring into inguinal canal d/t patent processus vaginalis (lat. to inferior epigastrics) Direct – protrude through weakness in transversalis fascia/inguinal canal floor (med. To inferior epigastrics). Has no route into the scrotum.

Question 1381

What is the tx of Condylomata accuminata in pregnancy?

Answer 1381

Topical trichloroacetic acid Imiquimod and podophyllin resin are contraindicated d/t teratogenicity Excisional removal is avoided d/t increased anesthetic and surgical risks Viral culture does not need to be done bc it won’t change mgmt.

Question 1382

What pattern of pain suggests Ureterolithiasis obstruction at the UVJ?

Answer 1382

Severe flank pain that radiates to the perineum, penis, scrotum, or inner thigh

Question 1383

What imaging studies should be done when Pancreatic ca. is suspected?

Answer 1383

If jaundice is present – abdominal US | No jaundice – CT

Question 1384

What is likely to cause jejunal atresia and how will it present?

Answer 1384

Jejunal and ileal atresia likely d/t vascular insults in utero that cause necrosis and resorption of fetal intestine Common causes: maternal vasoconstrictive meds, tobacco or cocaine abuse Presents w/bilious emesis, abdominal distension and “triple bubble” sign on xray and gasless colon typically w/in first 24hrs

Question 1385

Tx of Acute Cholangitis:

Answer 1385

Abx covering enteric bacteria | ERCP drainage w/in 24-48hrs

Question 1386

What are common secondary causes of RLS?

Answer 1386

``` Fe-def anemia Uremia – ESRD, CKD DM MS or Parkinson Pregnancy Drugs – antidepressants, metoclopramide ```

Question 1387

Tx of RLS:

Answer 1387

DA-agonists (Pramipexole, Ropinirole) are 1st line a-2-d calcium channel ligands (Gabapentin) may be preferred in pts w/comorbid insomnia, chronic pain syndrome or anxiety Opioids are last choice for refractory sxs

Question 1388

What are the features of Medication overuse HA?

Answer 1388

Near-daily HA in the setting of regular use of acute HA medications Occurs in pts w/a preexisting HA disorder (migraine) and sxs must be present for 3+ mos The pts underlying HA disorder may worsen or they may develop a new HA pattern Sxs frequently mimic tension-type or migraine-type HA and are commonly present upon awakening

Question 1389

What are the feats. and tx of tissue-invasive CMV disease?

Answer 1389

Mostly affects immunosuppressed, esp. after solid organ transplant Can cause: pneumonitis, gastroenteritis (w/hematochezia), hepatitis, and meningoenceohalitis Tx: dc any immunosuppressants and start anti-virals – IV ganciclovir for severe disease, oral valganciclovir for pts w/minimal signs

Question 1390

What are the 2 ways to improve oxygenation in pts on ventilators?

Answer 1390

Needs to be done in pts who have PaO2 <60: Increase PEEP – prevents alveolar collapse and decreases hypoxemia Increase FiO2 – delivers higher amounts of O2 to the lungs, but should be decreased to <60% as soon as possible

Question 1391

What are the ways to improve ventilation in pts. on ventilators?

Answer 1391

Should be done in pts w/high levels of PaCO2: Increase the respiratory rate Increase the tidal volume Both will increase the minute ventilation and decrease the PaCO2

Question 1392

1st line therapy for pts w/RAS:

Answer 1392

1st line for both unilateral and bilateral RAS is ACEIs or ARBs b/l RAS should only dc ACEIs if there is >30% increase in Cr after starting the Rx Revascularization should be avoided and only done in refractory cases

Question 1393

Neurovascular injuries seen in supracondylar humeral fractures:

Answer 1393

Most common pediatric elbow fracture – FOOSH w/elbow hyperextension Anterolateral displacement – radial n. injury Anteromedial displacement – brachial a. or median n. injury Posteromedial displacement (rare) – ulnar n. injury; happens w/fracture during elbow flexion

Question 1394

Mgmt of acute v. chronic hyponatremia:

Answer 1394

Acute (<48hrs) – poorly tolerated and pts at high risk for brain herniation. Pts w/ANY sxs of elevated ICP should get 3% NS boluses to rapidly correct serum Na+ (neural adaptations haven’t occurred at this point, so low risk of osmotic demyelination) Chronic (48+ hrs) – better tolerated so 3% NS is reserved for severe hyponatremia (<120), severe sxs, or concurrent intracranial pathology (mass, stroke, etc)

Question 1395

What is the difference in pathology of the types of pHTN Systemic sclerosis can cause?

Answer 1395

Primary paHTN d/t hyperplasia of the intimal sm. mm. of the pulm. aa. The lung parenchyma will be unaffected w/normal FEV1 and FEV1/FVC ratio as well as a normal CXR -This type is more common in the limited cutaneous type/CREST syndrome Secondary pHTN caused by ILD (alveolar spaces filled w/fibroblasts) may also occur and will present w/a restrictive pattern on spirometry and reticular opacities on CXR - More common in the diffuse cutaneous type

Question 1396

First line tx of Idiopathic intracranial HTN:

Answer 1396

Acetazolamide +/- Furosemide

Question 1397

What are common PE and lab findings in vertebral osteomyelitis?

Answer 1397

PE: Exquisite focal tenderness on percussion of affected spinous processes, increased muscle spasm and decreased ROM, +/- fever Labs: WBC count may be normal or elevated, BCx positive in majority of pts, ESR and CRP usually v. elevated

Question 1398

What are some disorders that increase the risk of pediatric thromboembolic events?

Answer 1398

Homocystinuria – presents w/Marfan habitus, fair complexion, developmental delay, lens dislocation, and hypercoagulability. Cystathionine synthase def. Fabry disease – presents w/angiokeratomas, peripheral neuropathy, asx corneal dystrophy, increased risk for renal and heart failure as well as thromboembolic events. a-Galactosidase def.

Question 1399

What are the common lab findings in Hodgkin Lymphoma?

Answer 1399

CBC and PBS are often completely normal, however Reed-Sternberg cells, when seen, are pathognomonic

Question 1400

What is the only type of pathology that will cause increased breath sounds on auscultation?

Answer 1400

``` Consolidation (lobar pneumonia) – will cause increased tactile fremitus as well as increased breath sounds seen as crackles and egophony present Everything else (pleural effusion, pneumothorax, emphysema, atelectasis, etc) will cause decreased or absent breath sounds and decreased tactile fremitus ```

Question 1401

When should congenital fetal heart block be suspected?

Answer 1401

In pts w/SLE or Sjogren syndrome w/anti-Ro (anti-SSA) Abs. | These may cross the placenta and cause heart block presenting as fetal bradycardia (<110) on NST.

Question 1402

Tx and most common causes of acute bacterial rhinosinusitis:

Answer 1402

1. Nontypeable H. influenzae (~50%) 2. S. pneumoniae (~25%) 3. Moxarella catarrhalis Tx: Amoxicillin +/- Clavulanate

Question 1403

Bacteremia with what bacteria should prompt a screening colonoscopy?

Answer 1403

Clostridium septicum – can cause bacteremia and acalculous cholecystitis Streptococcus bovis (group D strep.) – this should also prompt TTE d/t risk of IE These are both a/w colon cancer and when found should prompt screening colonoscopy

Question 1404

What type of screening exams should be prompted after finding Candida bacteremia?

Answer 1404

Ophthalmologic evaluation – even in asx pts bc it commonly causes fungal endophthalmitis

Question 1405

What are the neurotropic effects of the Mumps virus?

Answer 1405

Aseptic meningitis (norm benign) and sensorineural hearing loss (often transient but may lead to deafness)

Question 1406

Common acid-base disturbance seen in Laxative abuse:

Answer 1406

Metabolic alkalosis – unlike most other causes of diarrhea that cause metabolic acidosis Facticious diarrhea can also cause acidosis, but the finding of alkalosis in a pt. w/diarrhea should raise suspicion for laxative abuse

Question 1407

What Rxs are known to increase Lithium levels?

Answer 1407

ACEIs, NSAIDs, Tetracyclines, Metronidazole, Thiazides | + anything that decreases renal perfusion will decrease Li clearance and increase risk of toxicity.

Question 1408

What are common causes of constrictive pericarditis?

Answer 1408

``` Idiopathic pericarditis Prior cardiac surgery (CABG, valve surgery) Mediastinal irradiation TB Malignancy Uremia ```

Question 1409

What will be seen on imaging of constrictive pericarditis?

Answer 1409

Pericardial calcifications and thickening of the pericardium

Question 1410

What is a pericardial knock?

Answer 1410

Mid-diastolic sound heard in constrictive pericarditis

Question 1411

How will pts likely present w/Constrictive pericarditis?

Answer 1411

Fatigue and dyspnea on exertion Signs of RHF: peripheral edema, ascites, increased JVP, may have hepatic congestion and hypoalbuminemia May hear pericardial knock (middiastolic murmur) on auscultation Pulsus paradoxus, Kussmaul’s sign

Question 1412

What causes Vasovagal syncope?

Answer 1412

Abrupt PSNS activation leads to a cardioinhibitory response that manifests as bradycardia w/sinus arrest This causes abrupt decrease in cerebral perfusion leading to syncope

Question 1413

What protein is coded for by the NF2 gene?

Answer 1413

Merlin | NF1 tumor suppressor gene encodes protein neurofibromin

Question 1414

What is retinitis pigmentosa?

Answer 1414

Inherited degenerative disease of retinal photoreceptor cells that causes b/l tunnel vision and eventually binocular blindness usually begins w/night blindness and may lead to scotoma (central vision loss) a/w A-betalipoproteinemia Fundoscopy: bone spicule-shaped deposits around maucla

Question 1415

What are the cxs of McCune Albright Syndrome?

Answer 1415

It causes overproduction of all pituitary hormones: Peripheral precocious puberty (LH, FSH) Thyrotoxicosis (TSH) Acromegaly (GH) Cushing syndrome (ACTH) Recurrent fractures d/t polyostotic fibrous dysplasia

Question 1416

What are the common features of Tick-Borne paralysis and how is it differentiated from GBS?

Answer 1416

Progressive ascending paralysis over hrs-days; may be more localized/pronounced in one extremity Sensory exam is usually normal No fever or prodromal illness (GBS has this) CSF analysis is normal (contrast to GBS – high protein few cells) Caused by neurotoxin release from a tick, must feed for 4-7d before toxin release Search for and removal of tick results in improvement w/in an hr and complete recovery w/in days NO ANS dysfxn (tachycardia, urinary retention) like seen in GBS

Question 1417

Sxs of GVHD:

Answer 1417

Typically develop w/in 100d of transplant (bone marrow is highest risk) Maculopapular rash – can be painful and become confluent, may resemble SJS Profuse, watery diarrhea – secretory pattern (persistent, occurs at night, even when fasting) Liver inflammation – damage to biliary tract epithelium w/increased BR, ALP and transaminases

Question 1418

How to differentiate HCCa caused by a Hepatic adenoma and Cirrhosis:

Answer 1418

Hepatic adenomas rarely undergo malignant transformation, but when they do there is no associated decompensated liver failure bc only one small part of the liver has lost its fxn Cirrhosis caused HCCa will have liver failure bc the entire organ has been affected Both can have a palpable liver nodule and cause cachexia, anorexia, wt. loss, etc.

Question 1419

At what gestational age do tocolytics become contraindicated?

Answer 1419

34+ weeks At this point in time the risks of the tocolytics for the mother and fetus outweigh the risks of premature delivery Pts in preterm labor <37wks and >34 wks need steroids, abx, and delivery (route depends on status of fetus and mother) They are always contraindicated in PPROM though, if membranes rupture prior to onset of labor (regular contractions) they can’t be given

Question 1420

What are the features of Stress-induced CMP?

Answer 1420

Aka Takotsubo CMP/apical ballooning syndrome/broken heart syndrome Transient systolic dysfxn of apical/mid segments of the LV w/hyperkinesis of the basal segments Causes balloon-like appearance of the LV in systole Seen in older adults in response to intense physical/emotional stress or acute medical illness

Question 1421

What is the only MEN syndrome that would cause parathyroid adenomas?

Answer 1421

MEN1 | MEN2 only causes primary hyperparathyroidism by parathyroid hyperplasia, MEN1 can cause adenomas or hyperplasia

Question 1422

What conditions should Succinylcholine be avoided in and why?

Answer 1422

Succinylcholine is a depolarizing NM blocker and binds post-synaptic Ach-Rs to cause influx of Na+ and efflux of K+ Pts w/upregulation of Ach-Rs or who are already at risk for hyperkalemia should not receive this bc can cause cardiac arrhythmias Exs: Crush Injuries (rhabdo), Burn injury, Disuse muscle atrophy, denervation – stroke, GBS, critical illness polyneuropathy **use non-depolarizers for these pts (vecuronium, rocuronium)**

Question 1423

What anesthetic can lead to adrenal insufficiency?

Answer 1423

Etomidate – it inhibits 11B-hydroxylase

Question 1424

What pts should Propofol be avoided in?

Answer 1424

Those w/ventricular systolic dysfxn | It can cause severe HoTN d/t myocardial depression

Question 1425

What would be seen on FHR tracing w/a nuchal cord?

Answer 1425

Variable decels

Question 1426

What would Benzene exposure cause?

Answer 1426

Aplastic anemia d/t chromosomal breakage. | Benzene is found in solvents, polishes and gasoline

Question 1427

Cxs of Severe Pancreatitis:

Answer 1427

``` Severe acute pancreatitis = pancreatitis + 1 or more organ failure Pseudocyst Peripancreatic fluid collection Necrotizing pancreatitis ARDS GI bleeding Acute renal failure ```

Question 1428

What is the mgmt. of CIN3?

Answer 1428

If age >25 and not pregnant need immediate: Cone biopsy +/- LEEP and cryoablation Then need pap w/HPV test 1 and 2 yrs post-procedure

Question 1429

What are the risks a/w Porphyria cutanea tarda?

Answer 1429

``` HCV HIV Xs EtOH Estrogen use Smoking ```

Question 1430

How will porphyria cutanea tarda present?

Answer 1430

Mostly skin mainfestations – blisters, bullae and scarring on sun-exposed skin, increased skin fragility on the dorsal surfaces of the hands, and facial hypertrichosis May have hypo/hyperpigmentation Scarring and calcification similar to scleroderma Mild elevation of liver enzymes and Fe overload

Question 1431

How would paraneoplastic myelopathy present?

Answer 1431

It is lesion against the spinal cord and will present w/flaccid or spastic paraplegia or quadriplegia, sensory deficits +/- urinary or fecal retention/incontinence

Question 1432

What is the most common cause of gastric MALTomas?

Answer 1432

H. Pylori infection!!!! Causes 90% of tms All pts w/MALTomas should be tested for H. pylori and undergo eradication tx, for those w/early-stage, which causes most tms to go into complete remission *Sjogren and Hashimoto also increase risk of MALToma*

Question 1433

What kind of cancers are pts. w/Pernicious anemia at risk for?

Answer 1433

Gastric adenocarcinoma and gastric carcinoids | NO risk for MALTomas

Question 1434

How will the UA differ in glomerular v. nonglomerular hematuria?

Answer 1434

Glomerular have microscopic > gross hematuria and will have blood and protein on UA w/RBC casts and dysmorphic RBCs Nonglomerular have gross > micro hematuria and UA will have blood, no protein and normal appearing RBCs (non-glomerular is more common)

Question 1435

Most common causes of nonglomerular hematuria:

Answer 1435

``` Nephrolithiasis Cancer (RCCa, prostate) PCKD Infection – cystitis Papillary necrosis ```

Question 1436

Common causes of renal papillary necrosis:

Answer 1436

``` Mnemonic: NSAID NSAIDs Sickle cell Analgesic abuse (long-term abuse) Infection (pyelo) Diabetes ```

Question 1437

What characteristic of CF bronchiectasis helps differentiate it from other causes?

Answer 1437

Upper lung lobe involvement – CF is the main cause of bronchiectasis involving the upper lobes Infection w/Pseudomonas is also characteristic

Question 1438

Mothers with what blood types are capable of causing a neonatal ABO incompatibility?

Answer 1438

A (against baby B or AB blood), B (against A or AB), or O (against everything) AB mothers have no Abs against the other bloodtypes and will not cause hemolysis

Question 1439

What are the common presenting features of Thyroid lymphoma?

Answer 1439

Mostly occurs in pts w/Hashimoto and high anti-TPO Abs Rapidly progressive thyroid enlargement +/- mild tenderness, hoarseness and dysphagia Retrosternal extension is common and compresses surrounding vasculature – get JVD, and facial plethora, worse w/raising the arms. B sxs may also be present – night sweats, fatigue, wt. loss, fever

Question 1440

What might be seen on imaging in a mitral stenosis?

Answer 1440

EKG – “p mitrale” (broad, notched P waves), atrial tachyarrhythmias (aFib), RVH (tall R waves in V1 and V2) Echo – MV thickening and calcification, decreased mobility and coexisting MR

Question 1441

What test should be done to diagnose suspected tracheobronchial ruptures?

Answer 1441

Bronchoscopy CT scan can detect large injuries but misses small tears Most pts require surgery

Question 1442

What are the sxs of Trochanteric bursitis?

Answer 1442

Unilateral hip pain that is worse w/external pressure to the upper lateral thigh (like when you sleep on your side) external rotation and with resisted hip abduction

Question 1443

What bugs should be suspected when urine pH is >8?

Answer 1443

Urease producing: Proteus (most common) and Klebsiella

Question 1444

What is the recommended workup for a thyroid nodule?

Answer 1444

First get TSH levels Low – do RAI scan low uptake requires further workup (FNA, US) high uptake just tx hyperthyroidism High or Normal – do US and consider FNA based on the findings

Question 1445

What are common precipitants of recurrent episodes of Herpes simplex keratitis?

Answer 1445

Excessive sun exposure/outdoor occupation, fever or immunodeficiency

Question 1446

How should oligohydramnios be managed in late and post-term pregnancies?

Answer 1446

Oligohydramnios or a non-reactive NST individually are indications for immediate delivery Position of fetus, and status of it and the mother determine method – vag v c-section

Question 1447

How to differentiate sepsis/infection post liver-transplant and acute rejection:

Answer 1447

Infection is more likely to cause rapid-onset hemodynamic instability, high fever and significant leukocytosis Rejection occurs <90d post-transplant and will cause fever, RUQ pain, and elevation in liver fxn tests but leukocytosis and rapid hemodynamic instability are less common

Question 1448

Timeline of infections post-liver transplant:

Answer 1448

<1mo: Bacteria from op-cxs (hepatic abscess, biliary leak, wound infection) or hospitalization (catheter, external drain) Months 1-6: Opportunistic pathogens (CMV, Aspergillus, TB) >6mo: Immunosuppressants at lower doses so typical community acquired infections most common

Question 1449

What is ventricular remodeling and what can prevent it post-MI?

Answer 1449

Remodeling gradually causes dilatation of the LV w/thinning of the ventricular walls. Get globular shaped LV Prevent w/ACEIs started w/in 24hrs of an MI

Question 1450

What are the common presenting features of Gaucher disease?

Answer 1450

Onset may be delayed and present in mid-late adolescents Bone marrow infiltration – anemia and thrombocytopenia Splenomegaly – typically severe and more prominent than hepatomegaly Bony pains d/t skeletal involvement – often mistaken for “growing pains” May have osteopenia and pathologic fractures following minimal trauma Failure to thrive – height and weight <5th percentile Delayed puberty (tanner stage I in a 16yo)

Question 1451

How will an infant w/posterior urethral valves present?

Answer 1451

In the neonatal period with decreased/absent urine output Distended abdomen and weight gain (rather than the normal loss) d/t retained urine Postnatal respiratory distress d/t lung hypoplasia from oligohydramnios in utero Often missed in those who don’t follow-up prenatal care

Question 1452

Most common causes of Duodenal ulcers:

Answer 1452

H. pylori | NSAIDs

Question 1453

What causes the myopathy a/w Cushing syndrome?

Answer 1453

Catabolic effects on skeletal muscle which leads to muscle atrophy Get progressive proximal mm. weakness and atrophy w/o pain. LE more involved ESR and CRP will be normal

Question 1454

What diseases will have a decreased absorption of D-xylose?

Answer 1454

Small intestinal mucosal disease (Celiac) | malabsorption d/t enzyme deficiencies will have normal absorption (CF, lactose)

Question 1455

What is the inheritance pattern and comorbidities a/w Myotonic dystrophy?

Answer 1455

AD inheritance of trinucleotide repeat (CTG) Comorbidities: arrhythmias, cataracts, balding, testicular atrophy/infertility Presentation: onset 12-30; facial weakness, hand grip myotonia, dysphagia (risk of aspiration pneumonia). May have ptosis, frontal balding, and generalized muscle wasting

Question 1456

Common causes of adrenal hemorrhage:

Answer 1456

Pts on anticoagulants w/acute stress (sepsis) | Hemorrhagic necrosis w/systemic infections: meningococcemia or pseudomonas sepsis

Question 1457

What causes adrenoleukodystrophy?

Answer 1457

Accumulation of VLCFAs within the adrenal glands leads to adrenal insufficiency Only affects males, females are carriers

Question 1458

What electrolyte disturbances are seen in refeeding syndrome?

Answer 1458

Increased insulin occurs d/t carbohydrate ingestion (IV or enteral) This causes increased cellular uptake and decreased serum levels of: K+, PO4, Mg2+, and Thiamine Phosphate is the primary deficient electrolyte bc its needed to make ATP Deficiencies in Mg2+ and K+ cause cardiac arrhythmias Thiamine deficiency causes Wernicke Aggressive nutrition w/o adequate electrolyte replacement – cardiopulmonary failure

Question 1459

Lab/Imaging findings in ILD:

Answer 1459

CXR – reticular/nodular opacities CT – fibrosis, honeycombing, traction bronchiectasis PFTs – normal or increased FEV1/FVC, decreased DLCO, decreased TLC, decreased RV Resting ABG – normal or mild hypoxemia; Exertion will cause significant hypoxemia V/Q mismatch and Increased A-a gradient

Question 1460

What is Miller-Fisher syndrome and how will it present?

Answer 1460

It is a variant of GBS and will also present post-infection w/the same organisms It is d/t Anti-Gq1b Abs (highly sensitive for MFS) that attack peripheral nerves Will cause rapid-onset ophthalmoplegia, diplopia, ptosis, cerebellar-like ataxia (dysmetria) and areflexia Ophtho signs may be unilateral with the areflexia and extremity weakness bilateral Paralysis is less common in MFS than classic GBS CSF analysis and mgmt. are the same as classic GBS

Question 1461

What would cause decreased or absent response to vaccination in an adult?

Answer 1461

CVID

Question 1462

Who is most at risk for CA-MRSA and how is it tx’d?

Answer 1462

CA-MRSA preferentially attacks young patients w/influenza – severe, destructive, secondary necrotizing pneumonia Often causes leukopenia instead of leukocytosis Most pts need to be tx’d in the ICU w/IV abx – Vancomycin or Linezolid

Question 1463

What are common abx used for anaerobe coverage (esp. in aspiration pneumonia)?

Answer 1463

Clindamycin Metronidazole + Amoxicillin (high failure when metro is used as monotx) Amoxicillin + Clavulanate Carbapenems

Question 1464

How to differentiate Tabes Dorsalis from Subacute Combined Degeneration:

Answer 1464

Both affect dorsal columns – sensory ataxia from decreased proprioception and vibration sense w/+Romberg Tabes dorsalis – Argyll robinson pupils + nerve root involvement: decreased Pain/T and hypo/areflexia SACD – lateral corticospinal tract involvement: spastic paresis and hyperreflexia

Question 1465

How to tell cauda equina and conus medullaris syndromes apart:

Answer 1465

Cauda equina – asymmetric motor weakness, hypo/areflexia and b/l severe radicular pain Conus medullaris – symmetric motor weakness, hyperreflexia and sudden-onset severe back pain **contrast both to Spinal cord compression when there is typically no pain and numbness can begin higher up – umbilical area, etc.**

Question 1466

What Rxs are contraindicated or should be avoided in pts w/RVMI?

Answer 1466

Nitrates – decrease RV preload and cause profound HoTN and cardiogenic shock Diuretics – volume depletion and HoTN Opiates – venous dilation and decreased RV preload BBs – sometimes appropriate, but contraindicated in pts w/bradycardia or cardiogenic shock

Question 1467

When should amyloid cardiomyopathy be suspected?

Answer 1467

In pts w/unexplained CHF, proteinuria (>300mg/d), and LV hypertrophy w/o hx of HTN This is a cause of restrictive CMP and RHF sxs seem to predominate Echo: concentric LV hypertrophy, nondilated LV cavity, LA enlargement and preserved EF Other sxs: anemia, thrombocytopenia, hepatomegaly, thickened skin, peripheral neuropathy

Question 1468

Difference in mgmt. of hernias:

Answer 1468

All symptomatic hernias should undergo surgical resection Asx femoral hernias – elective surgical resection (high risk of incarceration and strangulation) Asx inguinal hernias – can be reassured and observed (low risk of incarceration)

Question 1469

Mgmt of hepatic adenomas:

Answer 1469

asx and <5cm – stop OCPs | Sxs or >5cm – surgical resection

Question 1470

What are common lab findings in Wilson disease and how is it tx’d?

Answer 1470

Increased AST and ALT only may occur – w/AST being almost 2x higher than ALT ALP, BR, and GGT may all be completely normal Tx: Chelators – D-penicillamine, trientine; Zinc – will interfere w/Cu absorption

Question 1471

How will CNS tms manifest based on their location?

Answer 1471

Supratentorial: Increased ICP, weakness, sensory changes, and seizures - Astrocytoma, Glioblastoma, Craniopharyngioma ``` Posterior fossa (infratentorial): Increased ICP, cerebellar dysfxn – dysmetria, ataxia, clumsiness - Astrocytoma, Ependymoma, Medulloblastoma ``` Brainstem: ataxia, clumsiness, CN palsies Spinal cord: back pain, weakness, abnormal gait - Ependymoma (much less common than post. fossa)

Question 1472

What are the most common posterior fossa tms in children and what structures do they arise from?

Answer 1472

``` #1 – Ependymoma: arises from the ependymal cell lining of the ventricles and spinal cord. #2 – Medulloblastoma: arises from the cerebellar vermis ```

Question 1473

What causes Meniere’s disease?

Answer 1473

Elevated endolymphatic pressure and volume, likely d/t defective resorption of endolymph Sxs: low-freq tinnitus in affected ear, episodic vertigo (may have N/V, lightheaded), sensorineural hearing loss in affected ear

Question 1474

Most common cause of urethritis in men:

Answer 1474

Gonococcus – contrast to chalmydia being most common in women

Question 1475

Tx of bacterial vaginosis:

Answer 1475

Metronidazole or Clindamycin (topical or oral)

Question 1476

What are the sxs of an uncal herniation?

Answer 1476

Compression of contralat. crus cerebri – ipsilateral hemiparesis (same side of hemorrhage) Compression of CN III – mydriasis (early), ptosis and down-n-out gaze (late) of ipsilateral eye Compression of PCA – contralateral homonymous hemianopsia (opposite eye of CN III defects) Compression of reticular formation – altered level of consciousness, coma **seen in basal ganglia hemorrhages 2/2 HTN and epidural hematomas**

Question 1477

What should be suspected in Non-pupil sparing CN III palsies?

Answer 1477

Non-pupil sparing palsies are most often caused by mass effect. They should be assumed to be d/t aneurysm until proven otherwise and need immediate MRA or CTA of the head Pupil-sparing (doesn’t affect the PSNS fibers on the outside of the n., only motor in the center) Are most often d/t microvascular ischemia – DM, HTN. HLD, advanced age. These can be observed in most cases and worked up by risk factors

Question 1478

Abnormal proliferation of what type of cells leads to epithelial ovarian ca.?

Answer 1478

It can be d/t abnormal proliferation of: ovarian, fallopian/tubal, or peritoneal cells. All three will cause lg. ovarian tm. causing ascites and solid mass w/thick septations on US

Question 1479

How will Phenytoin toxicity present?

Answer 1479

Acute toxicity: signs of cerebellar dysfxn – horizontal nystagmus, ataxia/wide-based gait, dysmetria, slurred speech, paresis; N/V and hyperreflexia Severe toxicity: AMS (lethargy, confusion), coma, paradoxical seizures (unlike most anti-epileptic toxicities), and death Rapid phenytoin infusion can also result in HoTN and bradyarrhythmias **susceptible to toxicity in renal or hepatic dysfxn or when taken w/Valproate, and Rxs that inhibit CYP-450**

Question 1480

What will be seen on echo in LV aneurysm?

Answer 1480

Thin and dyskinetic myocardial wall