UWORLD Practice Flashcards
1
Q
Itching worse at night and is mildly relived with OTC antihistamines. Did chagne her soap recently and does not use any hand cream.
Her husband had a similar a while ago.
Diagnosis and Treatment?
A
Usually made based on hx and distribution of the lesions alone, although confirmation can be made with skin scraping of the lesions.
Topical permethrin
2
Q
Treatment of Benign Paroxysmal Positional Vertigo
A
Head positioning exercsies, such as the Epley manuever
3
Q
Why does BPPV occur?
A
displaced otoliths within the posterior semicircular canal.
Since the normal function of the semicircular canal is to detect angular acceleration, an abnormal triggering of the canal can lead to the sensation of vertigo.
4
Q
What is considered normal grief?
A
tearfulness, insomnia poor appetite, weight loss, hallcucination of her recently decresed husband, and wish that she had died instead is normal grief.
If persvasive sadness, low self-esteem or suicdial ideation, then that would make more characterisitc of major depression.
5
Q
Gold standard for diagnosis of Hirsprung disease?
What will it reveal?
A
Rectal suction biopsy.
Can be performed at bedside without the need for general anesthesia
absence of ganglion cells and nerve fiber hypertrophy
6
Q
Diagnosis of BPPV
Treatment of BPPV
A
Provacation of vertigo with the Dix-Hallpike mnaeuver is diagnostic.
Treatment of BPPV consists of primarly of positioning exerices (such as Epley manuever) to reposition the otoliths
7
Q
Pharmaconkinetic profiles of common insulin preparation
(Short, regular and long acting)
A
Insulin Lispro - short acting analog that has a very rapid onset and a short half-life.
Often given in multiple daily doses, usually with long acting basal insluin formulation (ex: insulin glargine)
8
Q
Bugs and RBC
A
9
Q
Hydatid disease versus protozoal infection of the liver
A
Entamoeba histolytica - RUQ pain, fever and hypoechogenic hepatic cyst after 8-20 weeks after inoculation. Diagnosis is made with serology or antigen testing; aspiration is rarely needed.
From water
Hydatid cysts - due to tapeworm echinococus granulosus. Cysts tend to grow slowly over the years and remain asymptomatic until the size is >10 cm. Fever is rare without cyst rupture;
From dog feces
Hydatid cysts in liver, causing anaphylaxis if antigens released (surgeons preinject with ethanol to kill cysts before removal)
10
Q
Treatment of Entamoeba histolytica
A
Metrondiazole & intraluminal antibotic (ex: paromyomycin)
11
Q
Main with fever, dysuria, frequency, pyuria and bacteriuria.
What is the differential diagnosis?
Next step in management?
A
cystitis or acute bacterial prostatitis
DRE (gives definitive diagnosis)
THe presence of prostatic warmth, edema and tenderness indicates acute bacterial prostatitis, whereas a normal exmination more likely sugggests UTI with cysitits.
12
Q
Management of esophagel coin ingestion
A
13
Q
How do you tell the difference between a coin versus a button battery in a child?
A
Do a 2-view (posterior anterior PA and later) neck xray and chest xray.
It confirms the location of the foreign body and distinguishes btwn a coin and battery (the latter can cause performation in just a few hours).
Coin is seen a homogenous object with a sharp, crisp edge; the bilaminar structure of a button battery causes a “double-ring” sign)
14
Q
Child aspiration- battery versus coin?
A
Coin - homogenous with sharp crisp edge
15
Q
Child aspiration (coin or battery)?
A
button battery
“double-ring” sign
16
Q
WHen do you use emergency bronchoscopy versus endoscopy?
A
Emergency bronchoscopy would be appropriate for an airway foreign body causing respiratory distress.
This patient has no stridor, wheezing or respiratory distress and the lateral radiograph indicates the foreign body is in the esophagus rather than the airway.
In addition, an esophagel coin appears linear on lateral x-ray, a tracheal coin appears linear (project on end in the PA view) in the PA view.
17
Q
Coin in esophagus versus trachea
A
an esphagel coin appears linear on lateral x-ray, a tracheal coin appears linear (project on end in the PA view) in the PA view.
18
Q
Second most common cause of small bowel obstruction?
A
Hernias
The presence of a tender, non-reducible mass in the hernia sac is consistent with an incarcerated hernia
In an incarierated hernia, a portion of the small bowel becomes trapped.
The associated edema can compromise blood flow, leading to ischemia and infraction (aka strangulation). this this is an condition requiring urgent surgical management.
19
Q
How does small bowel obstruction present?
What are the commmon causes of SBO?
A
abdominal cramps, vomiting, high pitched bowel sounds and abdominal distention.
Post operative adhesions, hernias and tumors.
20
Q
Indications for parathyroidectomy
A
21
Q
T-score
-1 and above
Between -1 and -2.5
-2.5 and below
A
22
Q
Those with primary hyperparathyroidism who do not require parathyroidectomy require what?
A
regular follow up and serum calcium, creatinine and DXA testing
23
Q
A femur fracture in a nonambulating child
A
A femur fracture in a nonambulating child, particularly a spiral fracture, is suspicious for a twisting force on the thigh.
WARNING SIGNS OF CHILD ABUSE
24
Q
Red flags for child abuse include?
A
Posterior rib fractures,
metaphyseal corner fracture (“bucket-handle”) and
fractures at various stages of healing.
25
All patients with \< or = 75 with established cardiovacular disease should be treated with what?
**high intensity statins _regardless_ of baseline LDL cholesterol levels.**
**High intensity statin** is provided by **daily use of atorvastin 40-80 mg or rosuvastatin 20-40mg.**
Lower doses of these 2 drugs and all doses of statin agents consitute low-moderate-intensity statin therapy.
26
Identify
**Erythema multforme** presents as a mutitude of **symmetric targetoid skin lesions** on the **extensor** surfaces of the **extremities, palms and soles.**
## Footnote
**HSV is the most common cause, with medication being the next most common cuase..**
27
Classic findings of acute rheumatic fever
28
What is this?
**Strep pyogenes** can lead to development of rheumatic fever.
**Erythema marginatum** is a manifestation of **rheumatic fever** and using has lesions with clearing in the center, but the lesions are usually larger and not as numerous (unlike eryhtema multiforme).
29
Erythema migrans
Erythema marginatum
Erythema nodosum
Erythema multorme
30
Neisseria meningitidis can cuase what type of rash?
petechial rash
31
Management of palpable breast mass
In women age \> or = 30, inital evaluation is with diagnostic mammography. If mammographic results are indeterminate or normal, an ultrasound is prefered to further characterize the lesion.
32
Management of uncomplicated low back pain?
In patients with low back pain, what are the red flags that make you consider a serious underlying diagnosis
**NSAIDS and close observation.**
**Imaging studies** are **indicated _only_ if the patin persists after a period of several weeks despite conservative therapy.**
**hx of cancer, unexplained weight loss, pain predominately at night, urinary symptoms, fever**
*\*symmetric decreased ankle reflexes (is a nonspecific findings)*
33
Plain xray in a 45 year old shows narrowing of L4-L5 and L5-S1 disc spaces, traction osteophytes and end plate scerlosis
degenerative disc disease
If uncompicated, management should include NSAIDS for pain and follow up evaluation in 4-6 weeks.
34
Postpartum hemorrhage is considered?
the **loss of \> or = 500 mL of blood** after **vaginal delivery** or **\> or = 1,000 mL** after **cesarean delivery** is an **obsteric emergency** and a leading cuase of maternal mortality.
35
What are the four differential diagnosis of postparum hemorrage?
What do you see on examination and what is the management?
36
Hx of HIV and sexual encounters with men has a verrucous, ulcerated anal lesion, indicates likely?
These patients have a history of?
**anal carcinoma**
Anal carcinoma is a rare GIT malgnancy typically liked to infection with **HPV (\>=90%).**
As such, patients often have a hx of:
**-Receptive anal intercourse**
**-Genital warts**
**-Men who have sex with men**
37
Bacterial pneumonia versus Pulmonary infarction
**Bacterial pneumonia** typically presents with **SOB, fever, and productive cough**; lack of sputum production in this patient makes the diagnosis less likely.
In addtion, **pneumonic consolidation** are typically **more centrally**, rather than peripherally, located (in bacterial infarction)
38
**Pulmonary infarction**
potential complication of?
How does it appear on CT?
is a **potiental complication** of **acute PE** and typically appears on CT scan as a **periperhally located hemispherical** consolidation abutting the pleura.
39
Bleomycin can cause?
What would be seen on CT scan?
**pulmonary fibrosis** in some patients who have received chemotherapy with the drug; however a **diffuse pattern of reticular septal thickening** **and honeycombing** would be expected on CT scan.
40
A liver mass in a patient with Hepatitis B and evidence of chronic liver disease is highly concerning for?
**Hepatocellular carcinoma (HCC),** a tumor that orginates from **hepatocytes**.
Allthough **serum AFP levels** are often elevated in patietns with HCC, up to 40% of patients with small tumors have normal AFP levels (**so don't exclude diagnosis).**
41
Cholangiocarcinoma versus HCC
**Cholangiocarcinoma** (bile duct cancer) is assocaited with **obstructive jaundice, abdominal pain and weight loss.**
A **mass lesion** may be seen on ultrasonography, but **dilation of the bile ducts is typically seen as well.**
42
Patients with prostate cancer are generally stratifed as very low-risk when the following features are present?
Mangaement of these patients?
Gleason score \< or = 6 with \<3 cores affected (\<50% involvement in each affected core)
Normal DRE
PSA\<10
**Active surveillance needed only - monitor serum PSA levels every 3-6 months, having a DRE yearly and a repeat biopsy at the end of year 1 to ensure high greade deiase was not missed on the original biopsy.**
43
High risk Prostate cancer treatement
Radiotherapy or radical prostatecomy
44
Inhalants can produce what symptoms?
beief transient euphoria, lethargy, poor coordination and loss of consciouness.
The effects can be immediate and typically last 15-45 minutes.
45
most signifcant finding ont he above ECG is **peaked T waves,** which are commonly associate dwith **Hyperkalemia.**
Can occur from **worsening renal failure, and can be precipated by certain medications including ACEI, ARBS or potassium sparing diuretics.**
46
Severe pulmonary disease results on a EKG
Right ventricular hypertrophy, which would cause tall R waves in V1 and V2 as well as deep S waves in V5 and V6.
47
Congestive Heart failure versus Chronic Renal disease on an EKG
CHF may results in worsening renal function, but would not cause hyperkalemia.
This patient's fluid overload is secondary to renal failure, not CHF
48
**Pertusus**
Clinical phases
Diagnosis
Treatment
PRevention
Gram negative bacillus that is transmitted by respitatory droplets.
The patietn and all clsoe contacts should receive a macrolide antibiottic (regardless of their vaccination status)
49
Inguinal hernias in children
**inguinal hernias** commly present with asymptomatic reducible groin mass that is more pronouced with maneuvers that increase the intraddmonial pressure.
**Prompt surgical conrrection** is required in all children to avoid potentally serious complications like incaration and strangulation.
50
Differential diagnosis of urinary incontinence
51
Effects of combined estrogen/progesterone menopasual homrone therapy
52
What is recommended for immunocompetent adults \> or = 60?
Who should it not be given to?
Herpes zoster vaccination
it is a live-attenutated vaccine, it should be not be given to patietns with impaired immunity.
53
When can an oral directive be honored?
if a patient is diagnosed with a terminal or irreversiable condition and the patient's wishes are declided to the attending physician in the presence of TWO witnesses.
54
Diagnosis of kawaki disease
**Fever \> or = 5 days PLUS \> = 4 of the following findings:**
- **conjuctivitis** - bilateral, nonexudative
- **Mucositits**: Injected/fissured lips or pharynx, strawberry tongue
**-Cervical lympahdenopahty**: \> or =1 lymph node \> 1.5 cm in diameter
- **rash**: Erythematous, polymourovus, genralized; perineal erythemia & desquamoation; morbiliform (trunk, extremities)
**-Ereythemia of the hand & Feet**
55
Incomplete (atypical) kawasaki disease
**\< or = 3 criteria** but have **elevated inflammatory markers** (C-Reactive protein and ESR) and other **supporting laboratory criteria** (leukocytosis, thrombocytosis, anemia, hypoalbuminia, elevated transaminases and bilirubin, sterile pyuria) reflecting multisystem inflammation.
These patients should receive the same management as those with classic KD.
56
Menieres disease
57
PT and PTT values in hemophilia A and B
Normal PT and prolonged aPTT
These x-linked recessive disorders result from deficiency of factor VIII or IX respectively.
58
What happens to the PTT, PT and platelet count in DIC?
Elevated aPTT, prolonged PT and low platelet count
59
TTP
FATRN = TTP = Plasma Exchange.
(TTP-adults = HUS children).
60
DIC
61
HIT
discontinue heparin products, start direct thrombin inhibitor (lepirudin).
HIT antibodies will be sent out; once stabilizd, he can be transitioned to Coumadin for 6 months.
Dabigatran is used for nonvalvulatr aFIB thromboprophylaxis
62
ITP
ITP is "not anything else but low platelets."
63
Leukocytoclastic vasculitis
is the **most common cutaneous vasculitis** and is characterized by a **neutrophil-predominant inflammation of dermal vessels.**
It produces **isolated purpura,** often on the legs and may be painful.
64
**Statin-induced myopathy**
when does it occur?
patients who are concurrently taking what medication are more suspectible to muscular damage?
myositits typically occur within the **first few months** of initating statin therapy, it can be precipitated by the use of **certain CYP34A4-inhibiting medications,** such as **cyclosporine and macrolide antibotics.**
65
First time patient is experiencing this for the past several weeks.
Management?
The rsik of systemic thromboembolism in A.flutter is the same to that of AFIB.
In patietns with new atrial flutter (or fibrillation) of unknown duration or \>48 hours, **\> or = 3 weeks of anticoagulation is required prior to cardioversion or cardiac ablation.**
**Tx with warfarin, an oral factor Xa inhibitor** (ex: apixaban or rivaroxaban) , **or an oral direct thrombin inhibitor** (ex: digatran) **is appropriate.**
66
What are common abnormalities seen in patients with scleroderma?
Skin involvement and scleroderma
**Intersitital pulmonary fibrosis and esophagel hypomotility**
Heart failure in scleroderma can occur either as a primary abnormality or secondary to the lung disease.
Patietns with scleroderma may have **limited skin involvement** (ex: telangiectasia around lips) **without the classic skin sclerosis;** these patietnts are said to have limited cuntaeous scleroderma and are **frequently positive for anti-centromere.**
67
**Antibodies specific for which disease**
Anti-double stranded DNA
Anti-smith
Anti-mitochondrial
antibodies to thyroid periodiase
_Anti-DS DNA & Anti-smith_ - SLE
_Anti-mitochondrial antibodies_ - PBC
_Antibodies to thyroid peroxidase_ - Hashimoto's thyroditis
68
Inflammatory breast cancer presentation?
May be confused with?
Diagnosis?
**rapidly develop breast pain, erythema and edema, often with peau d'orange appearance.**
These findings may be **confused with mastitis,** but patients with **IBC do not respond to antibiotics.**
Diagnosis requires a **core biopsy** with histopathologic demostration of tumor infasion of the dermal lymphatics.
69
Hematochezia versus hematesis and melena
hematochezia - bright red blood per rectum or maroon colored stools; is nearly always due to LGIB
Hematemesis and emlena are more common in UGIB, although UGIB can sometimes present with hematochezia if bleeding is particular brisk.
70
Mgmt of hematochezia
*Need to give bowel preparation (ex: laxatives) followed by colonoscopy*
71
Patient has this and also yellowed thicken nail - what is this evidence of?
What is typically associated with this and treatment?
Dermatophyte infection with **tinea pedis** (scaling, fissuring between toes) and **tinea unguium** (yellow, thickened nail)
**Recurrent cellultiis** (acute lower extremity erythema, edema and pain the setting of leukocytosis and negative doppler studies)
**Treatment with topical antifungals** (ex.topical terbafine cream) is likely to reduce risk of recurrent cellulitis episodes.
72
Tratement of acne vulgaris
Severe oral antibiotics are for **widespread acne**: **tetracyclines** (tetracycline, doxycycline, minocycline), **macrolides** (erythromycin, azithromycin) and **trimethroprim-sulfamethoxazole.**
73
What may form as a complication of Chronh's diease?
**Enterovesical fistulas.**
Patients develop **recurrent UTI** caused by gut pathogens like **E.coli and bacteroides fraglis.**
**Pneumaturia (air in the urine)** can also be seen in patietns with an enterovesical fistula.
74
Enterovesical fistula presentation in Chronhs disease versus somatization disorder
Somatization disorder can cause many of the systemic and GI symptoms seen in this patient.
However, findings of the current UTIs is more suggestive of an organic cause of her complaints.
75
First line treatment in patients with Gout
HTN must be managed caustiously in patients with gout.
**Diuretics** decrease the fractional excretion of urate and should be **avoided** when possible.
The **angiotensin II receptor blocker Losartan** has **mild uriosuric effect** and is efective as **first-line treatment for HTN** in **patietns with gout.**
76
Patient on warfarin therapy in the therapeutic range and back pain or positive psoas sign
All patients on long-term anticoagulantion are at risk for developing severe and potenitally life-threatening treatment from a variety of scources, one which involves **bleeding into the retroperitoneal space, even if their INR is within the theurapetic range.**
The most appropriate i**nital imaging study** in patients iwth a **suspected retroperitoneal hemorrage is a CT scan of the abdomen**.
*\*These pateients commonly present with severe lower quadrant abdominal pain (similar to this patient) or back pain. In addition, PE often demostrates a positive psoas sign, which refers to pain that worsens with active flexion of the high at the hip,*
77
Patient on warfarin who develops serious bleeding require what?
prompt reversal of anticoagulant.
**warfarin should be discontinued and both IV vitamin K and FFP should be administered.**
78
Preferred treatment of patietns who develop bleeding while on heparin?
Protamine sulfate
79
Acute HYPOcalemia presentation
**neuromuscular irriability and/or tetany, manifested by paresthesias, muscle cramps and perioral numbness.**
IT typically causes **prolonged QT** on ECT
80
Presentaiton of HYPERcalemia
**acute neuropsychiatric symptoms** (ex; confusion) and a **shortened QT interval**
Other signs include **weakness, constipation, dimiished reflexes**
81
Patient with NSTEMI and negative first set of serum cardiac biomarkers - Management
**first set** of serum cardiac biomarkers is **typically normal** in patients with STEMI patietns early after symptoms onset as cardiac troponin concnetrations **usually begin to rise 2-3 hours after the onset of MI.**
Therefore serial ECGs, cardiac biomarkers, echocardiogram or admission to the ICU are not appropriate. This patient should be **managed with emergency coronary angiography or primary PCI.**
82
Patietns with intussception should first be managed with
**first stablize with IV isotonic fluids followed by attempted enema reduction** (air or saline contrast under sonographic or fluorscopic guidance)
83
What are some clues that support the diagnosis of C. diff infection?
clinical detoriation after improvement in pneumonia symptoms
high fever, leukocytosis, elevated platelet count (inflammatory response to infection), nausea, loose stoools and use of antiboiotics are known to predispose to CDI.
84
Common causes of C.Diff
broad-spectrum penicillins, cephalosporins, clindamycin and fluoroquinolones
85
The diagnostic test of choice for C.Diff
bacterial toxin detection, typically with PCR.
PCR is highly sensitive, easy to perform, results available within a few hours.
86
Most likely cause of this patient's syncope
**cardiac tamponade**
**Electrical alternans,** which descriibes alternativing amplitude of the QRS complexes on ECG likely due to changes in the ventricular axis as the heart moves within the excess fluid of the pericardial space, is a poorly senstive but specific finding for cardiac tamponade.
87
Cardiac tamponade results from?
excessive accumulation of pericardial fluid, leading to **compression of the right-sided heart chambers** and r**educed systemmic venous return** (cardiac preload)
Hypotension, sometimes syncope can result due to a marked decreased in cardiac output.
88
How do you tell the difference between cardiac tamponade from severe impairement in left ventricular contractilitiy from chemotherapy?
Severe impairement in left ventircular contractility (heart failure) may cause syncope due to loss of cardiac output and anthracylcines (ex: dosxorubicin) can cuase dilated cardiomyopathy, leading ot heart failure.
However, **pulmonary edema, manifests as crackles** on lung auscultation **and prominanet lower extremity** would expected (unlike trace in cardiac tamponade and clear lungs)
89
Acute PE versus cardiac tamponade
Acute PE leads to increased pulmonary vascular resistance and decreased venous return to the L.A; it also causes syncope.
However, this patietns **subacute prsentation with fatigue preceding the syncope** is less consistent with acute PE. In addition, **electrical alternans** on ECG does not occur with PE.
90
What is commonly seen during winter months when men with BPH are treated symkptomaically for upper respiratory infections?
**Sympomimetic and anticholienergic medications** (such as dihenphydrame) are common precipitants of **acute urinary retention** in **postoperative patietns** and in those with bladder outlet obstruction such as elderly men with **BPH.**
## Footnote
*\*reduces detrusor contractility*
91
PMR versus RA
can be distinguished by the site of musculoskeletal involvement
PMR has proximal muscle symptoms, while RA preferentially involves the smaller, more distal joints.
92
What do you need to look for in PMR?
The absence of headaches, jaw pain and vision probelms are pertinent negatives as there is a high association of PMR with giant cell artritis.
the abscence of clinical findings suggestive of giant cell arteritis, the treatment of PMR consits of glucocorticoids for symptomatic relief of pain.
93
Patients with PMR are generally?
over 50 and complain of proximal muscle achiness and stiffness that is worse in the morning
there is no muscle weakness or sensory loss.
94
Patients with CKD who have GFR of what should receive education on renal replacement therapy?
What is considered the best therapeutic option.
Less than 30 as extensive perepartion is often required prior to intervention.
Kideny transplant is considered the best therapeutic option.
THose who are poor candidates for transplant often receive hemodialysis or peritoneal dialysis.
95
What suggests a diagnosis of multiple myeloma?
hyper**C**alcemia
mild **R**enal insufficency
normocytic **A**nemia
chronic **B**ack pain
**\*CRAB**
*The neoplastic proliferation of plasma cells in the bone marrow causes bony destruction and pathologic fractures that cause bone pain, likely explaining this patient's chronic back pain.*
96
How do you confirm diagnosis of Multiple myeloma?
presence of monoclonal protein in the serum and/or urine, as detected by a serum or 24-hour urine protein electrophoresis.
97
What is varicocele?
**tortous dilation of veins** in tthe pampiform plexus surrounding the spermatic cord and testis.
It presents as a **soft, irregular mass (**bag of worms) that **increase in size with standing and valsalva.**
Varioceles can **cause elevated scrotal tempteratures,** increasing the **risk for infertility and testicular atrophy.**
98
How doe you diagnosis varicocele?
confirmed by ultrasound which can show retrocgrade venous flow and dilation of the pampinform plexus.
99
Treatement of varicocele
Asymptomatic patietns do not require treatement.
* **Gonadal vein ligation** (boys & young men with testicular atrophy)
* **Scrotal support & NSAIDS** (older men who do not desire more children)
100
Varicocele versus Hydrocele
Hdyroceles are caused by the collection of peritoneal fluid between the layers of tunica vaginalis and typically present as cystic scrotal masses.
The irregular character of this patietns mass and changes with valsalva and position are more consistent with varicocele.
101
Why are varicoceles more common on the left side?
A right sided varocele is a sign of and warrants what?
The **left spermatic vein drains in the left renal vein,** which then passes between the superior mesenteric artery and aorta.
**Compression between the SMA** (nutcracker effect) can lead to increased pressure in the spermatic vein and venous dilation.
For this reason, varioceles are more common on the left side.
In contrast the **right spermatic vein drains directly in the IVC** and right sided varicoceles are relatively rare.
A **right sided varcicele** can be a **sign of malignant compression** (ex: RCC) and therefore warrants **CT imaging**.
CT Scan is not recommeneded for workup of an isolated, left sided varicele.
102
What is choanal atresia caused by?
Bilateral versus unilateral choanal atresia?
caused by **narrowing or obstruction of the posterior nasal passages,** preventing communication between the nasal cavity and nasopharynx
_Unilateral_ (most common): chronic nasal discharge during childhood
_Bilateral_: noisy breathing (stertor); cyanosis that worsens with feeding & improves with crying
103
How do you diagnosis chroanal atresia?
- inabilty to pass cather past nasopharynx
- confirmation with CT scan
104
Choanal atresia versus Tacheoesophageal fistula?
Infants with **TEF** can have **increased secretions of coughing, choking and respiratory distress after feeding**, symptoms are not prsent in this infant.
When TEF is suspected, **atttempted insertion of a gastric catheeter followed by CXR** is the first step in determining whether the esophagus is patient, a **catheter terminating in the esophageal pouch** suggests esophagel atreasia as indicated by the _white arrow_ on the x-ray. _Red arrow_ indicates mild ateletctasis and _green arrow_ indicates umbilical venous cather in its expected location.
105
How do you diagnosis H type TEF
An upper GI series can be used to diagnosis H-type TEF, in which the esophagus and trachea are both fully patent but have a distal connection.
The other types can be confirmed with a CT scan.
106
The presence of malignant pleural effusions in patients with non-small cell lung cancer indicates what?
What is the management?
incurable disease and warrants a palliative treatment approach.
**Large-volume thoracentesiss followed by chemical pleurodesis** is an appropriate pallative intervention in patients who are symptomatic from recurrent, rapidly accumulating pleural effusion.
*\*obliterating the pleural space by inducing pleural inflammation and fibrosis using a sclerosing agent (ex: talc)*
107
What is this patients syncope due to?
Long QT \>450 msec in male patients and \>470msec in females
108
What is this Prolonged QTc patient at increased risk for?
What are the two most common causes of acquired long QT syndrome?
**torsades de pointes,** a form of polymorphic ventricular tachycardia.
**Electrolyate abnormalities** (ex: hypomagnemia, hypokalemia) and **drug therapy** (ex; fluoroquinolones, anti-psychs) are the 2 most common causes of acquired long QT syndrome.
109
What is a common cause of pneumonia in patients with advanced HIV?
How does it manifest?
What does the chest xray reveal?
What is the first line diagnostic test?
**Pneumocysitis jiroveci**
**indolent onset of fever, cough and SOB**
CXR shows **diffuse intersitital or alveolar infiltrates**
**Induced sptum** is the first line, due to low cost, min. invasiveness and reasonable sensitivity.
110
Patietns with moderate or severe Pneumocystis pnemonia may have what during the few days of antimicrobial treatment?
What do they require?
**Respiratory decompenstaiton** due to an inflammatory response to organism lysis.
THose with respiratory distress, tachypnea, or hypoxia require **ABG** analyiss to dtermine if concomitant corticosteriods are required **(partial pressure of oxygen \<70 mm Hg or an alveolar-arterial gradient \>35 mm Hg on room air)**
111
Candiduria management in hospitalized patients
**Candiduria is** **common** in hospitalized patients who have indwelling bladder catheter or have received recent antibiotic therapy.
Most cases represent **asymptomatic colonization** and require **no treatement other than changing bladder catheters and limiting antibiotic medications.**
Patients with **symptoms, neutropenia or systemic signs of infection** are more likely to have an active infection and often **require antifungal treatment.**
112
Patietns who have ankle pain following an inversion injury may have what?
What does the Ottawa Ankle Rules state?
simple sprain or fracture of the distal fibula and/or tibia
patietns who have pain near the malleoli and either an inability to bear weight or bony tenderness at the malleoli should have **plain standard films** taken.
113
A large pulmonary mass in a patient with a history of Hodgkin Lymphoma and smoking is usually?
Primary lung cancer.
Lymphoma typically presents as enlarged lymph nodes in the mediatstinum or hila, whereas infectious eitologies do not usually present with large, solitary masses
114
Treatment of Acute acetaminophen toxicity
Actiavated charcoal
- N-acetylcysteine if 4 or \> to prevent heaptotoxicity.
115
What is the single greatest risk factor for developing pancreatic cancer?
**cigarette smoking** which increases relative risk \>2 fold.
116
Indications for implantable cardioverter-defibrillator placement
Prior MI & LVEF \< or = 30%
NYHA Class II or III with LVEF \< or = 35%
117
Cardiac resynchronization therapy
used in patietns with moderate to severe heart failure, and LVEF \< or = 35 and a widened QRS (\>120msec)
118
What should be suspected in any young healthy patient who has a blood clot without any udnerlying precipating factor?
What is the most common cause?
inherited thrombophilia
Activated protein C resistance caused by Factor V Leiden
119
When is medication for weight loss indicated?
for patietns who fail inital dietary modification and are obese (BMI \> or = 30) and overweight (BMI 25-29.9) with obesity related complications.
Orlistat has excellent safety profile
120
Delusional disorder versus somatic symptom disorder
Delusional disorder is characterized by fixed delusions without other symptoms of psychosis and intact functioning (apart from the impact of the delusion)
Patietns with somatic symptom disorder typically have excessive anxiety about multiple physical symptoms but are not delusional.
121
Patients receiving immunosuppressive agents after a kidney transplant are at risk for developing what?
risk of developing nephritiis as a result of infection with BK virus, a polyomavirus.
BK-induced nephritis is characterized by fever, worsening renal function, urinalysis onsistent with intersitial nephritis and biopsy findings of renal tubular damage and prominent basophilic intranuclear inclusions.
122
Infant of diabetic mother - complications
123
Differential diagnosis of Myopathy
124
First line migrane prophylaxis
beta blockers (ex: metoprolol), TCA (ex: amitriptyline) and anticonvuslants (ex: valproate)
125
What is this?
Lichen planus
pruritic, planar, polygonal and purple
wickham's straie are white, lacelike patterns that are sometimes seen on the surface of these papules.
126
The initation of positive pressure mechanical ventilation can cause what?
Management?
acute increase in intrathoracic pressure, which, especially in patients with intravascular volume depletion, can cuase a marked decrease in venous return and cardiac output.
The resulting hypotension is best treated with a bolus of IV fluids or if possible, by lowering the positive end expiratory pressure.
127
Patients with severe nephrotic syndrome are predisoposed to?
thrombotic events, particularly venous thromboses in the renal veins and deep veins of the legs.
Nephrotic syndrome patients are also at increased risk for infection, although the infections are usually caused by typical organisms such as the pneumococcos, not opportunistic organisms.
128
Parvovirus B19 infection in adults versus pregnant patients and management?
Parvovirus B19 infection typicallly presents in adults as a flulike illness, ocassionally accompanied by rash and arthralagias.
Although most patients recover without sequelae, preganant patients require special consideration given the associated risk of complications, including fetal anemia, hydrops fetalis, and fetal demise, and they require periodic ultrasound assessements.
129
Medication induced esophagitis
Certain medicaitons (ex: doxycycline) can cause localized chemical injury to the esophagus if there is prolonged mucosal contact; ingeston of these medications with minimal water or at bedtime increases the risk.
When medication-induced esophagitis occurs, it is best treated with discontinuation of the offending drug.
130
Management of acute exacerbation of COPD
131
What is commonly seen in patients taking glucocorticoids?
Psychiatric symptoms and can include mood changes, psychosis and anxiety.
They occur more commonly in patietns taking high doses for prolonged periods but can occur any time.
132
First line treatment for bulimia nervosa?
What is contraindicated?
**Cognitive behavior therapy**
**SSRI**, especially fluoxetine, are also a component of treatment.
**Buproprion is contraindicated.**
*\*congitions (thoughts and beliefs about body weight and shape) and behavoral disturbnances (ex: binging, compensatory behaviors) that perpetuate the disorder.*
133
When is inpatient care required for bulimia nervosa patients?
in-patient care is ually required only if the patient is suicidal, has several weight loss with food refusla or has comorbid psychaitric conditions requiring hospitalization.
134
Treatment
Furuncles (one hair follicle) and carbuncles (multiple) are types of subcutaneous involving hair follicles.
The majority are caused by S.Aureus, with many isolates being methicllin resistant.
Oral antibotics against MRSA include clindamycin, TMP and doxycyline
135
Cohort study
study in which a group of patients who are similar except for a single variable are followed over time.
After a certain amount of tiem, the incidence of a chose end point is compared between the grops to compute a relative risk.
136
S.Aureus blood stream infections are commonly associated with?
All patients with S aureus bacteremia require?
who is at high risk?
vertebral osteomyelitis and infectious endocarditis.
transthoracic or TEE to evaluate for infectious endocarditis.
Those with valvular disease at particularly high risk
137
A major cause of death in patients with granulomatois with polyangitis is?
diffuse aveloar hemorrhage
Wegeners is a systemic vasculitis that primilary involves the Upper respiratory tract, lower respirtoary tract and the kidneys.
138
Primary scloersing cholangitis is a common condition seen in patients with?
causes what lab pattern?
UC
causes cholestatic pattern of laboratory abnormalities including elevated bilirubin and Alkaline phosphatase.
The diagnosis is confirmed by endoscopic cholangiogram, which is charateristically demonstrate multifocal stricture and dilation sof the intra-and extrahepatic bile ducts.
139
conjunctivitis types
140
THere are a limited number of explantions for metabolic alkalosis with hypokalemia - they are?
What can distinguish among these diagnosis?
**vomiting, diuretic use, or abnormal sodium handling in kidney** as is seen in Gtitelman's and bartter's syndrome.
**Urine chloride value**
Patients with gastric losses (**vomiting**) will need to reaborb chloride from the urine due to volume depletion and hypochloremia, leading to **low urinary choloride.**
In contrast, patietns who are on **diuretics or have gitleman's or batter's syndrome** are unable to reasborb cholride and it will be lost in the urine **(high)**
141
Second generation antipsychs are often used for what?
Their side effects include?
such as olanzapine are often use to augment antidepressants in patients with treatment resistant depression.
Their side effects include weight gain and metabolic effects that can contribute to new-onset DM.
142
When do you suspect hypoplastic left heart syndrome in neonates?
**neonates with mild cyanosis at birth who develop progressive respiratory distress and shock a few day slater with closure of the ductus arterosius**
Patients with HLHS typically ahve stenosis or atresia of the mitral and aortic valves and therfore are dependent on PDA for systemic circulation.
On closure of teh Ductus arteriosis, affected neonates rapidly develop shock and aciodiss as a result of decreased systemic perfusion.
143
A positive titer for anti-Rh(D) antibodies indicate what?
Management?
that the mother has undergone alloimmunization, and as such, any subsequent Rh(D)-positive fetuses may be affected by hemolytic disease of the newborn.
Anti-D immune globulin is effective only if given before alloimmunization has occured.
144
What strongly correlates with obstructive sleep apnea, especially in men?
increased neck circumference.
OSA is suggested by neck circumference \>43.2cm (17 in) in men and \>41 (16 in) in women
145
Confounder versus effect modification
Confounder is correlated with both dependent and independent variables and can serve to alter the results of the study if it is not controlled for.
Effect modification occurs when the risk of a certain condition is present only within a certain subgroup of the population studied.
146
Umbilical hernia
is a common congental malformation and usually resolves without treatment.
It is at very low risk for incarceration and stragulation
147
Gaucher disease
is a AR lysosomal storage disase caused by deficiency of glucoerebrosidase, resulting in a building of glycolipids.
Type I gaucer disase is the most common form, and results in heaptoplenomegaly, anemia, thrombocytopenia, osteopenia and pathologic fractures
148
Women with PCOS are at increased risk for and require what screening?
type 2 DM and screening with oral glucose tolerance test is recommended.
Other comorbidities icnlude nonalcohoic steatoheaptis, OSA and increased risk for endometrial cancer.
149
Joint aspiration can help narrow the diff. diagnosis of joint pain.
What is expected in OA versus RA & Gout versus infectious arteritis?
A synoval fluid leukocyte count of less than 2,000 cells is seen in patients with noninflammatory conditions such as OA.
Leukocyte counts between 2,000 to 75,0000 are seen in innlammatrory conditions like RA and gout.
Counts over 100,000 sugggestes infectious arthritis
150
Early antiviral treatment in patietns with herpes zoster does what
reduces the risk and severity of postherpetic neuralgia and promotes healing of vesticular lesions
treatment should be initiated within 72 hours
\*postherpetic neuralogia - persistent pain in hte distribution of the vesticular eruption that lasts 3-4 months or more folllowing resolution of the rash
151
femoral hernia
uncommon type of hernia usually seen in elderly women
passes below the inguinal ligament and lies medial to the femoral nerve, artery and vein
A higher incdience of incarceration and stragulation is assocated with femoral hernias (as compared to inguinal hernias)
152
Indirect inguinal hernias
pass through the inguinal ring and descend into the scrotum
153
indirect and direct versus femoral hernias
indirect and direct pass above the inguinal ligament
femoral hernias pass below
154
Infertility is defined as
155
Disseminated gonoccocal infection can present as
purulent monoarthris or as a triad of tenosynovitis, dermatitis or polyarthralgias.
Patients with possible disseminated gonococcus should be evaluated with blood cultuers, NAAT of urine and supsected primary sites, and synovail fluid analysis
156
PEG tube placement in severly demented hospitalized patients
have not shown to oimporve outcomes
157
After the removal of a cortisol producing adrenal adenoma, patients are at risk for
developing adrenal crissi because atrophy of the remaining adrenal cortex secondaryto negative feedback inhibition of CRH and ACTH
158
**Sick sinus syndrome**
Most commonly seen in what type of patients?
caused by?
When is a pacemaker required?
elderly patients with multiple comorbid medical conditions
caused by chronic SA node dysfunction and typically causes alternating episodes of tachycardia and bradycardia
pacemaker placement is indicated for patients who develop symptoms secondary to sinus bradycardia.
159
Both aortic atheroembolism and contrast-induced nephropathy can lead to what after cardiac catehrizaiton?
Aortic atheroembolism is more likely causative agent in patients who have?
acute renal failure
atherosclerosis, skin changes in the lower extremities, and elevated serum and urine eosinophils
* \*fragments can emoblize to distal sites resulting in livdeo reticularis or the "blue toe" syndrome*
* \*elevations in blood and urine eospinophils help in differentiaing atheroemboli to the kidneys from contrast-induced nephropathy*
160
Muddy brown casts are seen in?
Acute tubular necross, which can occur secondary to renal ischemia or contrast-induced nephropathy.
161
Proteinuria and waxy casts are seen in?
patietns with nephrotic syndrome
162
Current guidelines for acute pancreatitis in terms of nutrition
In acute pancreatitis, **oral and enteral nutrition is perferred** over the parenteral support.
**Oral nutrition should be initated as soon as the patient has a return of appetite.**
Otherwise, in severe cases, enteral nutrition support should be pursued via a nasojejunal or nasogastric feeding tube within 72 hours of hospitalization.
163
Chronic managemetn of gout
Urate lowering therapy (ex: allopurinol) is indicated for patietns with current gouty attacks.
However, changes in uric acid levels during initation can trigger an acute flare of gout.
Therefore patients should also receive colchiine or a NSAID to prevent acute gout durnig the initation and titration of treatment
164
What is the most significant risk factor for the development of a recurrent stroke?
a prior cerebral vascular event (previous stroke)
165
What is most likely responsible for this person's hypotension?
**tension pneumothorax**
cardiovascular collpase can occur due to compression of the vena cava and marked derease in venous return.
166
Polycythemia vera is?
chronic myelodysplastic disorder, and is principally characterized by an elevated red blood cell mass.
The majority of patients with PV hav eelevations of all three major cell lines on presentation
167
What is highly suggestive of polycytehmia vera?
Affected patients also have what?
Diagnosis is best confirmed by?
abnormal thrombotic event and splenomegaly in the presence of elevated red blood cell mass
leukocytosis, thrombocytosis, and a decreased serum erythropietin level
genetic mutation analysis demostrating the JAK2 mutation..
168
**Thyroiditis**
Three types
Clinical features
Diagnostic Testing
Postpartum thyroiditis is similar to silent thyrodiitis but by definition occurs within one year of pregnancy
169
Postpartum thyroidits typically follows what type of course
triphasic course, with a hyperthyroid phase follwed by transietn hypothyroidism and an eventual recovery to euthyroid state.
However, some patietns may develop persistent or recurrent hypothyroidism with a palpable goiter.
