UWorld Step3 Flashcards

Question

CYP 450 Inducers (7):

Answer 1

``` *These will decrease drug effects* Carbamezapine, phenytoin Ginseng, St. John’s Wort Oral Contraceptives Phenobarbital Rifampin ```

Answer 2

``` *These will increase drug effects* Acetaminophen, NSAIDs Abx/Antifungals (metronidazole) Amiodarone Cimetidine Omeprazole/PPIs Cranberry Juice, Ginko, Vit.E Thyroid hormone SSRIs (fluoxetine) ```

Answer 3

``` anion-gap Metabolic acidosis Respiratory acidosis Azotemia Hyperkalemia Hypergylcemia Elevated lipase Elevated Hct/Hemoconcentration Coagulopathy w/increased coagulation markers (INR and aPTT) Leukopenia/Thrombocytopenia ```

Answer 4

``` LVEF <40% NYHA class III-IV heart failure Prior peripartum cardiomyopathy Severe obstructive cardiac lesions Severe pHTN (Eisenmenger syndrome) Unstable aortic dilation >40mm ```

Answer 5

Hysteroscopic sterilization or subdermal progestin implant | Estrogen-containing methods are contraindicated d/t increased risk of thromboembolism

Answer 6

Previous spontaneous abortion Advanced maternal age Substance abuse Extremes in BMI

Answer 7

Calculates pretest probability for PE +3 points for: Clinical signs of DVT; Alternate dx less likely than PE +1.5 points for: previous PE or DVT; Heart rate >100; Recent surgery or immobilization +1 point for: Hemoptysis; Cancer Total Score = 4 is low pretest probability (PE unlikely); >4 is high pretest probability (PE likely)

Answer 8

Painful mucocutaneous ulcer (shallow, discrete, white base) | Generalized maculopapular rash that may include the palms and soles

Answer 9

A false negative The failure to detect a difference bw groups when one exists. The smaller a study the less power and higher likelihood of type II error

Answer 10

Done in symptomatic or asx (pts who plan to become pregnant or participate in competitive sports) young adults if the following criteria are met: Aortic Stenosis No significant AV calcification or AR Peak gradient >50mmHg

Answer 11

Presence of active internal bleeding Bleeding diathesis (platelets <100k) Hypodensity in >33% of an arterial territory on CT Presence of intracranial hemorrhage on CT Intracranial surgery in last 3mos BP > 185/110mmHg

Answer 12

Evidence of sacroiliitis

Answer 13

Apical pulmonary fibrosis/Restrictive lung disease Ocular: acute anterior uveitis, cataracts, cystoid macular edema Cardiac: aortic regurg, MVP Varicocele GI: ileal and colonic mucosal ulcerations Atlanto-axial subluxation --> spinal cord compression Cauda equina syndrome Nephrotic syndrome caused by IgA nephropathy and secondary amyloidosis

Answer 14

Smoking is a/w very bad px | Prolonged standing and exposure to cold conditions increase risk of disability

Answer 15

Verapamil – usually initiated at 240mg Should not be taken repeatedly, and should only be used as a preventive treatment started at the onset of a cluster period. Occasionally topiramate may be added to verapamil therapy. **Sumatriptan may be used in the acute setting but is not preventative**

Answer 16

Fungal infection of finger or toenails most commonly caused by dermatophyte Trichophyton rubrum 1st line: Terbinafine, Itraconazole 2nd line: Griseofulvin, Fluconazole, Ciclopirox

Answer 17

Both will have same lab values (decreased MCV, normal RDW, norm/high RBCs, norm/high Iron and ferritin) and same peripheral smear (target cells). Must distinguish w/Hb electrophoresis – will show increased HbA2 for B-minor and normal for a-thal

Answer 18

Confounding

Answer 19

A complication that can be seen following parathyroidectomy Caused by sudden withdrawal of PTH in pts w/severe hyperparathyroidism, causing an increased influx of Ca2+ from the circulation into the bone. Typically see signs/sxs of hungry bone syndrome 2-4 days post-op Pre-op risk factors: severe hyperparathyroidism, severe bone disease and VitD def. (all these conditions have v high bone turnover)

Answer 20

Relative hypoparathyroidism – suppression of normal parathyroid glands by high Ca2+ levels pre-op fail to respond to low Ca2+ levels post-op Hungry bone syndrome – when PTH levels fall post-op the dynamics of bone turnover shift from net efflux of Ca2+ from bone to net influx of Ca2+ into bone.

Answer 21

New pulmonary infiltrate on CXR plus one or more of the following: Increased work of breathing, cough, tachypnea, wheezing Temp >38.5C/101.3F Hypoxemia Chest pain

Answer 22

Ceftriaxone/Cefotaxime + Azithromycin IVF Pain control

Answer 23

If O2 sat is <92% Significant anemia Worsening sxs despite initial tx

Answer 24

Ineffective erythropoiesis causes hemolytic anemia and indirect hyperbilirubinemia

Answer 25

Lateral shoulder or deltoid pain aggravated by reaching or lifting the arms up. Seen in rotator tears and tendonitis, impingement syndrome and frozen shoulder

Answer 26

1. Collect Data 2. Create causal factor flow chart 3. Identify root causes 4. Generate recommendations and implement changes 5. Measure success of changes

Answer 27

Verapamil Quinidine Amiodarone Spironolactone

Answer 28

Diagnostic paracentesis w/either positive cultures or 250+ neutrophils in the ascitic fluid

Answer 29

With the MELD score Values used to calculate are serum BR, INR, and serum Creatinine. Na+ is sometimes added to the calculation

Answer 30

If there is no evidence of stone on CT then check BUN/Cr Only renal papillary injury will cause increases in BUN/Cr Stones will only lead to kidney injury if it is a solitary kidney or they are bilaterally obstructing.

Answer 31

May cause HTN and hypokalemia | Will likely see as a result a suppression of the RAAS system with low renin and aldosterone

Answer 32

Hepatic injury

Answer 33

When <32 weeks gestation | 32+ weeks it is contraindicated d/t risk of oligohydramnios and premature closure of ductus arteriosus.

Answer 34

``` To pts <34 weeks gestation Give CCBs (Nifedipine) when 32-34 weeks Indomethacin when <32 weeks ```

Answer 35

Doxycycline + Ceftriaxone

Answer 36

These pts need serial lumbar punctures until the sxs stop – often the yeast and capsular polysaccharides can clog the arachnoid vili and lead to markedly increased ICP which if not managed can cause herniation/death. In rare cases VP shunts need to be placed

Answer 37

1. Induction – amphotericin B + flucytosine for 2+ weeks (until sxs stop and CSF is sterile) 2. Consolidation – high dose oral fluconazole for 8wks 3. Maintenance – low dose oral fluconazole for 1+yr to prevent recurrence **This is the same tx strategy for disseminated/cutaneous cryptococcus**

Answer 38

Harm/injury caused by medical management, not by disease/condition

Answer 39

``` ALL adrenal masses should be worked up. Serum electrolytes Dexamethasone suppression testing 24-hr urine catecholamine Metanephrine VMA 17-ketosteroid measurement ```

Answer 40

``` All functional tumors (hormone secreting, etc.) All malignancies (which demonstrate characteristic heterogenous appearance on imaging) All tumors >4cm ```

Answer 41

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

Answer 42

The thalamus or cortex – loss in face and body on the same side, contralateral to the lesion **Contrast to lesions in the brainstem (medulla) involving the CNs, these will cause losses in ipsilateral face and contralateral body**

Answer 43

1st line are combined OCPs, but they should all receive progestins – these confer endometrial protection and help thin and reverse the hyperplasia thereby reducing the risk of cancer

Answer 44

1. Soft, single second heart sound (S2) – d/t delayed closure of the aortic valve 2. Pulsus parvus et tardus – delayed and diminished carotid pulse 3. Loud and late-peaking systolic murmur

Answer 45

Celiac disease

Answer 46

``` General: fatigue, weight loss Skin: dermatitis herpetiformis, vitiligo MSK: osteopenia/porosis, osteomalacia – high alk phos levels, low Ca2+, low PO4-, low Vit. D Heme: anemia (esp. Fe-deficient) Neuro: peripheral neuropathy, HAs Endocrine: AI thyroiditis, Type I DM Psych: depression, psychosis ```

Answer 47

Characteristics: Suppressed TSH, normal thyroid hormone levels, +/- hyperthyroid sxs Causes: Exogenous thyroid hormone, graves disease, nodular thyroid disease, inflammatory thyroiditis

Answer 48

``` If TSH is persistently <0.1 If TSH is 0.1-0.5 PLUS additional risk factor: Age 65+ Heart disease Osteoporosis Nodular thyroid disease ```

Answer 49

Oral or vaginal Metronidazole or Clindamycin **during pregnancy only symptomatic pts are tx’d; tx does not decrease cxs in asx pts**

Answer 50

In patients w/symptomatic carotid artery disease who have high grade stenosis (70-99%) and a life expectancy of 5+ years Risks outweigh benefits in pts who are poor surgical candidates or have shorter life expectancies.

Answer 51

1. Noncoronary atherosclerotic disease (carotid, PAD, AAA) 2. Diabetes 3. CKD

Answer 52

EEG showing bilateral polyspike and slow wave activity/discharges

Answer 53

Epileptic disorder of infancy characterized by symmetric spasms, developmental delay and hypsarrhythmia on EEG. Gold-standard tx: Corticotropin (ACTH) and Vigabatrin

Answer 54

``` Fe-deficiency anemia Uremia/ESRD/CKD DM MS or Parkinson Pregnancy Drugs – antidepressants, metoclopramide ```

Answer 55

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)

Answer 56

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

Answer 57

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

Answer 58

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

Answer 59

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.

Answer 60

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

Answer 61

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

Answer 62

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

Answer 63

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

Answer 64

LAD blocked | Some or all of V1-V6

Answer 65

``` Dry mouth Blurred vision Dilated pupils Flushing Hyperthermia Urinary retention ```

Answer 66

``` Cholinesterase inhibitors (donepezil) for cognitive impairment Carbidopa-levodopa for parkinsonism Melatonin for REM sleep behavior disorder ``` **antipsychotics may be used to tx functionally impairing visual hallucinations/delusions, but pts w/DLB are vv sensitive to antipsychotics and they can cause significant worsening of confusion, parkinsonism and autonomic dysfunction**

Answer 67

Low-potency 2nd gens like Quetiapine | High-potency 2nd gens (Risperidone) and 1st gens are a/w significant exacerbations of sxs

Answer 68

They inhibit acetylcholinesterase at the NMJ – causes CHOLINERGIC toxicity

Answer 69

Competitive inhibition of acetylcholine at muscarinic receptors – causes anticholinergic toxicity.

Answer 70

``` Muscarinic effects: “DUMBELS” Defecation/diarrhea Urination Miosis Bronchospasm/bradycardia Emesis Lacrimation Salivation Nicotinic effects: mm. weakness, paralysis, fasciculation CNS: respiratory failure, seizure, coma ``` **often caused by organophosphate poisoning**

Answer 71

``` Emergent resuscitation – O2, IVF, intubation Atropine & Pralidoxime Activated charcoal (if w/in 1hr of exposure) ```

Answer 72

``` Dry mucous membranes Flushing Mydriasis Urinary retention Decreased bowel motility ```

Answer 73

Multiple sexual partners

Answer 74

Brain: Tinnitus, dizziness, AMS, cerebral edema, seizures Lungs: tachypnea, pulmonary edema Heart: arrhythmia Liver: hepatitis Stomach: nausea, vomiting Systemic: fever/hyperthermia, metabolic acidosis/lactic acidosis

Answer 75

Alkalinization of serum and urine w/sodium bicarb Other options: supplemental glucose (dextrose 5% H2O), activated charcoal (if w/in 2hrs of ingestion), dialysis (if pt has pulm edema, fluid overload, AMS, renal failure, cerebral edema, severe acidosis or v high salicylate levels)

Answer 76

Thrombocytopenia Hyponatremia Increased AST and ALT

Answer 77

Doxycycline – even for children and pregnant women

Answer 78

Doxycycline for all late stages and early stage in everyone >8yo Amoxicillin for early lyme in children <8

Answer 79

When a pt. has persistent HoTN despite aggressive fluid resuscitation. Dopamine is the initial Rx of choice Dobutamine should be avoided as it can decrease PVR and worsen HoTN.

Answer 80

It is a paraneoplastic syndrome a/w intrathoracic malignancy + other pulm diseases (CF) Polyarthropathy a/w digital clubbing and periostosis (xs bone formation)

Answer 81

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

Answer 82

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

Answer 83

AI disorder w/variable features of: SLE, Systemic Sclerosis and Polymyositis Lab findings: Anti-U1 ribonucleoprotein, ANA, RF, anti-CCP, elevated CK, anemia/cytpoenias

Answer 84

PMR has pain and stiffness in muscles, but NO weakness. Have increased ESR 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

Answer 85

Sodium-glucose cotransporter-2 inhibitors (canagliflozin) can cause: Genitourinary infections – vulvovaginal candidiasis, UTIs Fluid loss – symptomatic HoTN, AKI Metabolic abnormalities: Hyperkalemia, hyperglycemia, euglycemic ketoacidosis Misc – low trauma fractures, amputation

Answer 86

The chance decreases with age: Perinatally acquired infections have 90% chance of progressing to chronic HBV Children age 1-5 have a 20-50% progression rate Adults have <5% progression rate **In contrast, HAV has an almost 0% progression rate, and HCV has a 75-85% progression rate**

Answer 87

Rhabdomyolysis 2/2 hypophosphatemia that is exacerbated/unmasked by refeeding

Answer 88

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

Answer 89

Folinic acid (Leucovorin) – more potent than folic acid, and can rescue RBCs by bypassing the block on DHFR

Answer 90

Neurocutaneous disorder w/benign tumors in multiple organs – intracardiac rhabdomyomas, renal angiomyolipomas Angiofibromas, ash-leaf spots and shagreen patches (thick leathery skin, dimpled like an orange peel)

Answer 91

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

Answer 92

Kids >10 w/nephrotic syndrome Kids of all age w/nephritic syndrome Patients <10 w/minimal change that don’t respond to steroids

Answer 93

Brain MRI/EEG – determine if there are any tumors or baseline seizure activity Abdominal US or MRI – evaluate for renal involvement (obstructive renal angiomyolipomas) **Neurologic impairment/epilepsy is the #1 cause of death in TSC and renal involvement is the 2nd**

Answer 94

Clinically (usually by 1-2yrs) + Brain MRI (shows periventricular leukomalacia, brain malformation, ischemia, BG lesions, etc.) EEG should only be done in pts who have seizure-like activity

Answer 95

Flushing, throbbing HA, palpitations, abdominal cramps, diarrhea, oral burning, skin erythema, wheezing, tachycardia, and HoTN Occurs when fish is stored improperly and histidine undergoes decarboxylation to form histamine

Answer 96

Primarily neurologic: perioral tingling, incoordination, weakness, etc.

Answer 97

Commonly seen 14-21 days after abdominal surgery Often have hx of abdominal surgery, swinging fever, leukocytosis, and cough and shoulder-tip pain may be the presenting sxs. Abdominal US is best diagnostic test

Answer 98

An anticonvulsant, it is used in the depressed phase and for maintenance therapy It is not effective for treating mania. **Quetiapine and Lurasidone are alternatives for bipolar depression**

Answer 99

``` If they have any 2 of the following: Increased sputum purulence Increased sputum volume Increased dyspnea Or if they require any type of mechanical ventilation (invasive or non) ```

Answer 100

Macrocephaly is head circumference >97th percentile for age Neuroimaging should be done to evaluate for pathologic processes when: Rapidly expanding HC (>2cm/mo in an infant <6mo) Neuro abnormalities (seizures etc) Developmental delay **Head US is best study in infants w/open anterior fontanelle**

Answer 101

Odds ratio should be used. It is the odds of an event occurring in exposed patients divided by the odds of an event in unexposed pts. (null value is 1) OR = (a/c) / (b/d) = (a*d)/(b*c)

Answer 102

Relative risk (null value is 1.0) RR = (a (a+b)) / (c (c+d)) = (risk of developing disease in the exposed group) / (risk in the unexposed)

Answer 103

Inter-rater reliability

Answer 104

1.0 | Ho = 1.0 for RR and HR as well.

Answer 105

Early diastolic collapse of the RV and RA – seen on echo Electrical alternans on EKG is also fairly specific for tamponade In contrast, low-voltage QRS on EKG, kussmaul sign, and pulsus paradoxus are all non-specific and can be seen in multiple other disease states.

Answer 106

Early signs: nausea, vomiting, slurred speech, ataxia, nystagmus, lethargy, kussmaul’s breathing/rapid and deep (d/t severe anion-gap metab acidosis) Later signs/further toxicity: tachypnea, agitation, confusion, flank pain, renal failure, pulmonary edema, AMS, eventual coma

Answer 107

If they have been taken for 3+ weeks, especially if they were taken at high doses or at night. Need a roughly 3 week tapering period

Answer 108

FLUOROQUINOLONES Hydroxychloroquine also increases risk

Answer 109

Tretinoins

Answer 110

Fistula formation – up to 50% of pts w/anal abscesses develop chronic fistula

Answer 111

HPV infection and therefore cervical cancer Ovarian and breast cancers – d/t higher rates of smoking and obesity, less freq screening, lower parity and less OCP use Bacterial vaginosis DM-II CVD

Answer 112

The clinical usefulness of a medication – it’s a measure of its possible benefit minus its harm

Answer 113

To preserve randomization

Answer 114

1. Central retinal a. occlusion – have pale fundus w/”cherry red spot” 2. Central retinal v. occlusion – fundus w/retinal hemorrhages and optic disc edema 3. Retinal detachment – fundus w/vitreous hemorrhages and marked elevation of retina 4. Vitreous hemorrhage – decreased red reflex, visible hemorrhage on fundoscopy

Answer 115

When pts w/rapidly progressive form of a disease are less likely to be detected by screening when compared to those w/slowly progressive disease Slowly progressive pts remain asx for longer and increase their chances of being diagnosed by screening measures.

Answer 116

``` Sensitivity = True Positives / (TP + FN) or A / (A + C) Specificity = True Negatives / (TN + FP) or D / (B + D) ```

Answer 117

``` PPV = TP/ all(+) or A/(A + B) NPV= TN/ all(–) or D/(D + C) ```

Answer 118

Fluconazole – has limited activity against aspergillus and shouldn’t be used

Answer 119

Systemic glucocorticoids Antifungal therapy – itraconazole or voriconazole are DoCs Omalizumab may occasionally be used

Answer 120

Brain imaging showing basilar meningeal enhancement CSF showing: increased protein, low glucose, lymphocytic pleocytosis, elevated adenosine deaminase May also see choroidal tubercles (yellow-white nodules near optic disc) on fundoscopy

Answer 121

In patients taking other medications that cause leukopenia as that is also a risk of colchicine, and in patients w/renal failure

Answer 122

If they are symptomatic or >5cm – surgical resection | If asx and <5 then stop offending meds (OCPs)

Answer 123

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

Answer 124

It is lesion against the spinal cord and will present w/flaccid or spastic paraplegia or quadriplegia, sensory deficits +/- urinary or fecal retention/incontinence

Answer 125

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)

Answer 126

1-2wks of IV Voriconazole + an Echinocandin (Capsofungin) | Then can be transitioned to prolonged oral tx of Voriconazole alone

Answer 127

glucocorticoids

Answer 128

HIV and HCV

Answer 129

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)

Answer 130

``` #1: Coagulase negative staph. Others: S. aureus, gram negs. (Klebsiella, pseudomonas), and Candida ```

Answer 131

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

Answer 132

Pts on anticoagulants w/acute stress (sepsis) | Hemorrhagic necrosis w/systemic infections: meningococcemia or pseudomonas sepsis

Answer 133

Upper lung lobe involvement – CF is the main cause of bronchiectasis involving the upper lobes Infection w/Pseudomonas is also characteristic

Answer 134

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.

Answer 135

Lytic bone lesions (skull, jaw, femur) seen in diaphysis of long bones Skin lesions (purplish papules, eczematous rash) Lymphadenopathy, hepatosplenomegaly Pulmonary cysts/nodules Central DI

Answer 136

In children, S. aureus is the most common and Pseudomonas is in adults. S. aureus starts to decline around age 20 whereas pseudomonas begins to peak. Both pathogens should be covered in tx of pneumonia in CF children.

Answer 137

Membranous nephropathy. | Normally uncommon in children, but can occur in those w/HBV

Answer 138

Transposition – Single S2 +/- VSD murmur Tricuspid atresia – Single S2 + VSD murmur Truncus arteriosus – Single S2 + systolic ejection murmur

Answer 139

Transposition of the great vessels.

Answer 140

Fastidious gram neg bacilli Tx: Azithromycin; However, many cases are self-limiting and don’t require tx *may also add clindamycin if lymphadenopathy is present but dx is unclear

Answer 141

3-6mo of oral Itraconazole

Answer 142

How many times in the past year have you had 5 (4 for women) or more drinks in a day?

Answer 143

In pts w an estimated GFR <30 | Should be used w caution in those w/eGFR 30-45

Answer 144

Occurs d/t chronic pancreatitis destroying islet cells (alpha and beta) Tx: Metformin for mild hyperglycemia, Insulin for more severe or symptomatic hyperglycemia **these pts are prone to developing hypoglycemia d/t loss of glucagon-producing a-cells, but ketoacidosis is rare bc of this glucagon loss**

Answer 145

UGIB mostly presents as hematemesis or melena | LGIB is more commonly hematochezia or bright red blood from the rectum

Answer 146

Low CO and decreased perfusion P at baroreceptors and renal afferent aa. --> increased release of renin and NE + secretion of ADH. ADH binds to V2 receptors in collecting ducts and increases H2O reabsorption Renin and NE increase proximal Na+ and H2O reabsorption and limit water delivery to distal tubules This all leads to water retention and dilutional hyponatremia **Hyponatremia in CHF parallels the severity of HF and is a predictor of adverse outcomes**

Answer 147

If the patient develops sxs of hyponatremia or if they are asx in severe hyponatremia (Na+ <120) Initial tx is water intake restriction **Correction of hyponatremia doesn’t improve clinical outcomes a/w HF**

Answer 148

Macrolides: Azithromycin and Erythromycin | - often given as post-exposure pphx for pertussis to infants w/a sick contact

Answer 149

Nontypeable H. Influenzae | Causes concurrent otitis media and purulent conjunctivitis

Answer 150

Initial: Amoxicillin 2nd Line: Amoxicillin-clavulanate (given for recurrent AOM if pt already received amoxicillin w/in the same month) Penicillin-allergic: clindamycin or azithromycin

Answer 151

at 12-14 weeks gestation

Answer 152

ACEIs are the DoC (captopril esp.) bc they reverse the angiotensin-induced vasoconstriction If the pt. has malignant HTN w/CNS manifestations a 2nd agent may be added, like IV nitroprusside

Answer 153

Need morning plasma cortisol w/concurrent ACTH 1. Low cortisol + high ACTH – diagnostic for primary adrenal insufficiency 2. Low cortisol + low ACTH – secondary or tertiary adrenal insufficiency 3. If testing is indeterminate get further tests to assess pituitary fxn

Answer 154

Often asx w/hyperkalemia and mild metabolic acidosis

Answer 155

Fatigue, weight loss, myalgias, increased pigmentation, decreased axillary and pubic hair Labs: hyponatremia, hyperkalemia, hyperchloremic metabolic acidosis

Answer 156

Lymphadenopathy is common in mono especially and can be observed for 3-4 weeks or less if the pt. presents w/ signs of malignancy. After this time period they should be referred for biopsy

Answer 157

Aplastic crisis – reticulocytes go down (<1%); transient arrest of erythropoiesis, secondary to infection Splenic sequestration – reticulocytes increase; vaso-occlusion causes rapidly enlarging spleen, only occurs prior to autosplenectomy

Answer 158

If any of the following are present: 1. Severe sepsis 2. Hemodynamic instability 3. Evidence of metastatic infection (endocarditis) 4. Pus at the exit site of the catheter 5. Continued sxs >72 hrs after abx 6. Blood culture confirmation of: S. aureus, P. aeruginosa, or fungi (candida) All other pts should just have catheter changed over a guidewire once afebrile and stable

Answer 159

ARBs and ACEIs *Especially Losartan: has a mild uricosuric effect Most diuretics (thiazides, furosemide) decrease urate excretion and should be avoided

Answer 160

Only in the 2nd and 3rd trimesters It should never be the 1st imaging test ordered in pregnancy – start w/renal and pelvic US, if negative do transvaginal US, if negative either treat empirically for stone or can do MRU or low-dose CTU

Answer 161

Cefepime and Ceftazidime (cephalosporins) Amikacin and tobramycin (aminoglycosides) Carbapenems Levofloxacin, gemofloxacin (respiratory fluoroquinolones) Aztreonam Colistin (aka polymyxin E) Pip-tazo Ticarcillin-clavulanate

Answer 162

Aspiration pneumonia

Answer 163

Echo, EKG, and Stress testing or coronary angiography to assess for CAD

Answer 164

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.

Answer 165

Diverticulosis – barium enema is test of choice, may do colonoscopy Diverticulitis – Contrast CT is test of choice (barium enema and colonoscopy are contraindicated until rupture is r/o)

Answer 166

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.

Answer 167

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

Answer 168

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

Answer 169

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.

Answer 170

Etomidate – it inhibits 11B-hydroxylase

Answer 171

Topical anti-fungals (azoles are DoC) | If topical tx is ineffective or there is extensive disease, switch to oral azole

Answer 172

To diagnose suspected paroxysmal cardiac arrhythmias

Answer 173

1. Rash – inguinal folds, perineum, trunk 2. Nonexudative conjunctivitis 3. Swelling +/- erythema of palms/soles 4. Mucositis – erythema of lips, tongue, oral mucosa 5. Cervical lymph node >1.5cm All these must be present w/fever for 5+ days

Answer 174

If 3 or less criteria are met in a child w/5+ days of fever then CRP, or ESR should be measured, ibuprofen should be given and daily follow up should occur to monitor for more sxs If 4 criteria are met then you can diagnose KD and give aspirin + IVIG (only given until response is seen)

Answer 175

It is tx’d w/IVIG which interferes w/the body’s normal immune response to live vaccines and therefore live vaccines should be deferred for 11 months after receiving IVIG

Answer 176

None – it doesn’t cause dysphagia | If it transitions into malignancy the associated malignancy can cause obstructive dysphagia

Answer 177

Acute Dystonia – benztropine, diphenhydramine Akathisia – BB (propranolol), benzodiazepine (lorazepam), benztropine Parkinsonism – Benztropine, amantadine Tardive dyskinesia – valbenazine, deutetrabenazine

Answer 178

Initially non-operatively w/volume resuscitation and gaining hemodynamic stability If pts remain hemodynamically unstable despite adequate resuscitation cut em open

Answer 179

Acetaminophen NSAIDs Mesalamine, Sulfasalazine Opiates

Answer 180

Isoniazid Tetracyclines Metronidazole TMP-SMX

Answer 181

Valproate | Carbamazepine

Answer 182

Thiazides, furosemide | Enalapril, losartan

Answer 183

Lamivudine | Didanosine

Answer 184

Azathioprine, mercaptopurine | Corticosteroids

Answer 185

Spontaneous resolution w/in 2-5 years

Answer 186

New ST elevation at the J-point in 2+ anatomically contiguous leads w/the following threshold: - >1mm in all leads except V2 and V3 - 1.5+ mm in women, 2+mm in men 40+, and 2.5+mm in men <40 in leads V2 and V3 New LBBB w/clinical presentation consistent w/ACS

Answer 187

By 3mos/10wks of age | Rule of 10s: 10lbs of weight, 10wks of age, 10g of hemoglobin

Answer 188

Papillary muscle rupture – occurs d/t MI or trauma | Chordae tendineae rupture – can be 2/2 MVP, Infective endocarditis, Rheumatic heart disease, trauma

Answer 189

Both caused by bacteria and typically have purulent ear drainage (if tympanic membrane is ruptured in AOM) - Otitis externa almost always has pain on manipulation of the ear, and fever is generally absent - Otitis media almost always has fever, but pain is often absent once the tympanic membrane is ruptured

Answer 190

Onset w/contraction and 30+ seconds to the nadir | Often seen in setting of fetal hypoxia

Answer 191

<30 sec to nadir with variable depths, can have more than one between contractions Often caused by umbilical cord compression

Answer 192

Prostate Small cell lung Hodgkin lymphoma **evaluate w/radionuclide bone scan**

Answer 193

Myeloma Non-small cell lung Non-hodgkin lymphoma **evaluate w/XR, PET or PET/CT**

Answer 194

``` Nitrofurantoin is DoC (5-7d) Amoxicillin (3-7d) Amoxicillin-clavulanate (3-7d) Fosfomycin (single dose) Cephalexin (3-7d) **Tetracyclines, flouroquinolones and TMP-SMX are contraindicated** ```

Answer 195

When venous lead levels are >45 ug/dL Dimercaptosuccinic acid (succimer) is used when levels are 45-69 Dimercaprol (British anti-Lewisite) + EDTA is used in emergency when levels are >70 or there are signs of acute encephalopathy.

Answer 196

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

Answer 197

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

Answer 198

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

Answer 199

NNT = 1/ARR ARR = (% affected in control group) – (% affected in treatment group) = (c/(c+d)) – (a/(a+b))

Answer 200

PPV increases with increasing prevalence and increases with increased specificity NPV increases with increasing sensitivity

Answer 201

AR is the difference in risk b/w exposed and unexposed AR = (a/(a+b)) - (c/(c+d))

Answer 202

Prematurity Low birth weight **Smoking and EtOH use are NOT risk factors**

Answer 203

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

Answer 204

TEE or CTA – but can’t use CTA in renal disease. TTE should not be used

Answer 205

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

Answer 206

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

Answer 207

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

Answer 208

Asbestosis is one of the only pneumoconiosis that affects the LOWER lobes of the lungs Pneumoconioses that affect the upper lobes: Silicosis (a/w sandblasting and foundries, increases risk of TB) Berylliosis (a/w aerospace engineering, vv. high risk of lung ca.) Coal worker’s pneumoconiosis (aka black lung disease)

Answer 209

Nearly all pts on long-term PPIs will have hypergastrinemia (typically <400) 1st step to evaluate is withdrawal PPI and repeat gastrin levels; most pts will have normal gastrin levels after withdrawal If gastrin levels are still high after PPI d/c then evaluate for other causes: H. pylori, ZES, gastrinoma, etc.

Answer 210

Cannon waves are large a-waves seen on JVP tracings – d/t the RA contracting against a closed tricuspid valve Seen in heart block and ventricular tachycardia/AV dissociation

Answer 211

CCBs – diltiazem, verapamil | BBs – metoprolol, propranolol, esmolol, atenolol, timolol, carvedilol

Answer 212

SSRI is 1st line

Answer 213

Fruit juice – juice high in fructose or sorbitol increases the osmotic load and causes fructose malabsorption in the SI. Juices should be avoided until sxs of GE resolve.

Answer 214

PFT +/- TTE Should evaluate for pulmonary involvement as it is common in systemic sclerosis ILD is common in diffuse cutaneous systemic disease, and pHTN is common in CREST syndrome

Answer 215

Most antidepressants require a 14-day washout period before beginning another serotonergic med, but Fluoxetine has a long t1/2 and requires at least 5 weeks.

Answer 216

IVF and bowel rest Abx w/enteric coverage Colonic resection if necrosis develops

Answer 217

Bile acid-binding agents (cholestyramine) Iron Calcium Aluminum hydroxide PPIs Sucralfate **can try taking these at a different time of day than levothyroxine to avoid malabsorption**

Answer 218

``` Estrogen (oral not IUDs) Pregnancy Tamoxifen, raloxifene, HRT Heroin, methadone Acute hepatitis ```

Answer 219

``` Androgens Glucocoticoids/hypercortisolism Anabolic steroids Slow-release nicotinic acid Chronic liver disease Hypoproteinemia: nephrotic syndrome, starvation ```

Answer 220

Rifampin Phenytoin Carbamazepine

Answer 221

MRI – much more sensitive than XR

Answer 222

Age <50 Symptomatic hypercalcemia Cxs: Osteoporosis, nephrolithiasis/calcinosis, CKD (GFR <60) Elevated risk of cxs: Ca2+ 1+ above normal, urinary Ca2+ excretion >400mg/day

Answer 223

Cognitive impairment and behavioral problems can occur at levels as low as 10-20 Encephalopathy and hemolytic anemia only occur with severe toxicity (70+) Decreases in nerve conduction can also occur at low lead levels but peripheral neuropathy is uncommon.

Answer 224

``` Active, untreated TB HIV infection Herpetic breast lesions Active varicella infection Chemo or radiation therapy Active substance use disorder Galactosemia in the infant ```

Answer 225

37+ weeks gestation

Answer 226

Chest tube placement – needle decompression is appropriate in the emergency setting where tension physiology is present and they are at risk of cardiac arrest, but then should always be replaced with a chest tube. Needle decompression should not be done in a patient who is stable and has not yet developed tension physiology (tachycardia, JVD, tachypnea, hypoxemia, decreased/absent breath sounds)

Answer 227

Praziquantel

Answer 228

Intralesional glucocorticoids | Surgical excision can be considered if steroids fail

Answer 229

Sodium thiosulfate

Answer 230

``` CNS disturbance – stroke, hemorrhage, trauma Drugs – carbamazepine, SSRIs, NSAIDs Lung disease – pneumonia Ectopic ADH secretion – SCLC Pain and nausea ```

Answer 231

SIADH will have serum hypotonicity (<275 mOsm), inappropriately high urine osmolality (>100mOsm), high urine sodium (>40), and clinical euvolemia Excessive water ingestion will have low urine osmolality (<100mOsm) and euvolemic hyponatremia

Answer 232

2nd generation antipsychotics: Risperidone, aripiprazole, are preferred tx 1st generation antipsychotics: fluphenazine, pimozide, haloperidol, can also be used Other 2nd line options: a2-agonists (clonidine, guanfacine), and tetrabenazine (DA depleter)

Answer 233

Resolution of sxs without recurrence (~75%) | Many need no tx, but those who do typically are treated for 1-2 years with steroids and then they are discontinued

Answer 234

1st stop all heparin products 2nd start a direct thrombin inhibitor (argatroban) or fondaparinux (these are not oral) 3rd transition to warfarin (bc it is oral) after platelet count has recovered to >150k

Answer 235

Methimazole is preferred over PTU bc of the severe hepatotoxicity a/w PTU PTU is only preferred for women in the first trimester of pregnancy

Answer 236

A SERM – used for breast ca prevention and tx of osteoporosis

Answer 237

Repeating a primary analysis calculations after modifying certain criteria or variable ranges Used to determine if such modifications significantly affect the results initially obtained

Answer 238

Sudden cardiac death Arrhythmias – Vtach, aFib, etc. Strong a/w WPW which increases risks of SCD

Answer 239

``` BBs CCBs Digoxin Adenosine **AVN conduction should NOT be slowed in these pts. which all these Rxs do** ```

Answer 240

Wolf-Parkinson White | Friedreich ataxia

Answer 241

BPH | Side effects include mild GI sxs and increased bleeding risk

Answer 242

LR is the probability of a given test result occurring in a pt. w/a disorder compared to the probability of the same result occurring in a pt. w/o the disorder. Provides clinically useful information for individual patients and is not effected by prevalence +LR = sensitivity / (1- specificity) ; -LR = (1-sensitivity)/specificity LR>2 rules in the disease; LR<0.5 rules out the disease; LR 0.5-2 is equivocal

Answer 243

Narrow QRS-complex tachycardia Absence of organized P waves Irregularly irregular rhythm w/varying R-R intervals Tx w/an AVN blocking agent like a BB or CCB (diltiazem, verapamil); unstable pts need cardioversion Although adenosine is used to tx narrow-complex tachycardia it has no role in tx of aFib

Answer 244

Serum EPO level

Answer 245

``` Thiazides ACEIs/ARBs NSAIDs (but not aspirin) Abx: tetracycline and Metronidazole Also, volume depletion (often d/t the above stated Rxs) ``` **acetaminophen does not**

Answer 246

If levels are >4mEq/L >2.5 w/sxs or renal failure Increasing level despite tx w/IVF

Answer 247

``` HTN Hyperglycemia – newly diagnosed DM Osteoporosis Mood Swings Hypokalemia Metabolic Alkalosis ``` **Evaluate with overnight dexamethasone suppression test or 24hr urinary free cortisol**

Answer 248

Idiopathic or viral Cardiac surgery Radiation therapy TB pericarditis in endemic areas

Answer 249

Hepatic congestion that occurs 2/2 RHF that eventually leads to cirrhosis Often seen as a result of constrictive pericarditis

Answer 250

Topical or intralesional corticosteroids **side note: fingernail pitting is commonly a/w this condition**

Answer 251

IV insulin + aggressive IVF (NS) + Potassium supplementation if <5.2 Once serum glucose falls <200 the rate of insulin infusion should be halved and dextrose should be added to IVF to prevent hypoglycemia

Answer 252

SubQ insulin can be started for the following: pt is able to eat, glucose is <200, anion gap <12 and serum HCO3 is 15+ IV insulin and SubQ insulin should be overlapped by 1-2hrs

Answer 253

Between 40-50; 50 is recommended for general population but can start as early as 40 depending on individual and patient’s preferences

Answer 254

2 1st-degree relatives w/breast ca (1 before age 50) 3 first or second degree relatives w/breast ca (at any age) 1st or 2nd degree relative w/breast and ovarian ca 1st degree relative w/ bilateral breast ca Breast ca in a male relative Ashkenazi jews w/any 1st or 2nd degree relative w/breast or ovarian ca

Answer 255

7d of oral valacyclovir if they present <72hrs after rash onset If >72hrs after rash onset typically just get analgesia and topical rash care (zinc oxide cream) If IMCP’d or widespread disease – get IV acyclovir for 7+ days

Answer 256

May be asx, but can present w/variceal bleeding d/t isolated gastric varices – this is the hallmark of the disease May also see portal HTN, ascites and congestive splenomegaly Often a/w pancreatitis

Answer 257

At birth HBV vaccine and HBV-Ig should be administered Then HBV vax series should be completed at 2 and 6 months Serology should be taken at 9months – if no HBsAg at that time, infant is uninfected **liver function tests are not used in detection of infantile HBV**

Answer 258

``` Carotid a. atherosclerosis (most common) Cardiogenic embolism Sm. a. disease d/t DM +/- HTN Carotid a. dissection Hematologic disease (SCD, hypercoagulability) Vasculitis (giant cell arteritis) ``` **central retinal v. occlusion in contrast is usually not d/t embolic disease**

Answer 259

Axillary and inguinal freckling | They also have numerous, widespread café-au-lait macules (more numerous than the gen population)

Answer 260

Ophthalmologic evaluation – asses for bilateral optic pathway gliomas These are pathognomonic for NF1, but often initially asx

Answer 261

It’s not – personal or FHx is not a contraindication bc anaphylaxis is so rare Can be given in an inpatient setting though if they want

Answer 262

Overlapping areas may or may not imply a statistically significant difference Non-overlapping areas do imply a statistically significant difference.

Answer 263

Aka herpes gestationis It’s an autoimmune disease typically presenting in the 2nd or 3rd trimester w/pruritis that precedes a truncal rash Characteristic rash: begins periumbilical as urticarial papules and plaques – develop into vesicles and bullae Rash spreads over entire body but spares mucous membranes

Answer 264

High-potency topical steroids (triamcinolone) Antihistamines Typically resolves after delivery

Answer 265

If the patient has dysfunctional bowel/paralytic ileus, cardiac or neurologic complications

Answer 266

The probability of a gene or trait being expressed Aka will someone with a gene show any presence at all that they have the gene or will they be a silent carrier with no phenotypic expression

Answer 267

The variation in phenotypic expression

Answer 268

Small Bowel Obstruction: Causes – prior surgery (wks to years) PE – distended abdomen, increased bowel sounds Imaging – small bowel dilation present; Large bowel distention ABSENT; air-fluid levels Ileus: Causes – recent surgery (hrs to days), metabolic (hypokalemia), medication induced PE – possible distention, reduced/absent bowel sounds Imaging – small bowel AND large bowel dilation; gas in colon and rectum, no air-fluid levels

Answer 269

Cryptorchidism – #1 risk FHx HIV infection

Answer 270

Scrotal US PE – firm ovoid mass or unilateral swelling, absence of transillumination Tumor markers – AFP, B-hCG Staging imaging – CT scan, Chest XR

Answer 271

Australia Western North America **most cases caused by Rocky Mtn. Wood tick and American Dog Tick**

Answer 272

Neurotoxins in tick saliva are transmitted over 4-7days and then sxs start: Brief prodrome of fatigue and paresthesias Gait ataxia and ascending paralysis develop over hrs Absent DTRs Fever and sensation abnormalities are usually absent and Lab and imaging are typically normal

Answer 273

Meticulous skin examination to find and remove offending agent (tick) Most patients recover completely after this and have dramatic improvement in sxs w/in few hrs after removal of tick

Answer 274

A mixed-density pattern showing both acute (hyperdense) subdural bleeds on chronic (hypodense) subdural bleeds Accidental trauma is more likely to only show acute, hyperdense, bleeding

Answer 275

BE CALM: should be performed in this order B – breathe, do not push E – Elevate legs/flex hips (McRoberts) C – call for help A – apply suprapubic pressure L – enlarge vaginal opening w/episiotomy M – Maneuvers: deliver post. arm; rotate post. shoulder; adduct post. fetal shoulder; mother on hands and knees; all else fails replace fetal head and go for cesarean

Answer 276

Hx of chronic GERD (>5yrs) or frequent reflux sxs and 2+ of the following risk factors: Age >50 Male sex White Hiatal hernia Obesity/increased waist circumference (>102cm) Current or former tobacco use 1st-degree relative w/Barrett esophagus or esophageal adenocarcinoma

Answer 277

30 kcal/kg/d with 1g/kg of protein | lower amounts are used for pts w/severe malnutrition to prevent refeeding syndrome

Answer 278

Penicillin is preffered tx – should be given orally for 10d minimum Single dose IM Penicillin can be given to those who can't tolerate oral abx Azithromycin or Clindamycin may be given for 5d to those w/anaphylactic Pen allergies Cefazolin is given for mild pen allergies **abx are continued for this length of time to reduce risk of ARF and suppurative cxs**

Answer 279

Topical metronidazole – most commonly prescribed Others: Azelaic acid Topical clindamycin Benzoyl peroxide

Answer 280

``` Burning or foreign body sensation Blepharitis Keratitis Conjunctivitis Corneal ulcers Recurrent chalazion ```

Answer 281

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

Answer 282

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

Answer 283

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 aka if there are signs of STEMI on EKG.

Answer 284

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

Answer 285

Locally aggressive benign tm arising from fibroplastic elements w/in the muscle or fascial planes It has v. low potential for mets or differentiation Thought to be d/t abnormal wound healing or clonal chromosomal abnormalities causing neoplastic behavior Increased risk in patients w/familial adenomatosis polyposis (Gardner syndrome)

Answer 286

As deep seated painless, sometimes painful, masses in the trunk/extremity, intraabdominal bowel and mesentery, and abdominal wall. They have high rate of recurrence even after aggressive surgery removal

Answer 287

Cardiogenic syncope – d/t an underlying structural heart defect

Answer 288

LEFT – back up in the pulmonary a. leading into the LA will cause pulm edema

Answer 289

Reduced FEV1 Reduced FEV1/FVC ratio – bc FVC is typically normal TLC, and DLCO are typically normal but may be slightly elevated in asthma and DLCO is decreased in COPD.

Answer 290

FEV1 and FVC both decreased FEV1/FVC ratio normal or increased TLC and DLCO are also decreased

Answer 291

6+ mm in diameter – these need excisional/punch biopsies with 1-3mm margins

Answer 292

Loop diuretics – furosemide | CCBs – verapamil; but these Rxs are usually considered safe and Amlodipine is routinely used

Answer 293

K+ sparing diuretics (Spironolactone) | Theophylline

Answer 294

Many neurologic conditions such as dementia, Bipolar and MS

Answer 295

polycloncal B-cell activation and infiltration of the salivary glands leading to B-cell NH lymphoma Often detected as a submandibular mass

Answer 296

>3-3.5 g/d

Answer 297

Brugada – right bundle branch block and ST elevation in V1-V3 Long QT syndrome – QTc >450 msec in men and >470 in women

Answer 298

Common cause of SCD in young athletes May have premonitory sxs of exertional angina, lightheadedness or syncope; SCD may also occur without any prior sxs EKG and TTE are often nondiagnostic and appear normal CTA or coronary MRA are diagnostic tests of choice

Answer 299

By having both L and R coronary artery originate from only one aortic sinus the defect creates a sharp curvature for the anomalous artery and makes it less amenable to high-volume flow. The anomalous artery also passes between the aorta and pulmonary a. and makes it susceptible to external compression during exercise

Answer 300

Pseudoaneurysm – bulging, pulsatile mass with audible systolic bruit AVF – no mass, continuous bruit Both may present with localized pain to the area and can typically be diagnosed w/US

Answer 301

A measure used to determine if the occurrence of a disease in a small population is high or low relative to an expected value derived from a larger comparison population It is calculated by dividing the observed cases in that population by the expected number of cases

Answer 302

Pooled human immune globulin (IVIG) or therapeutic plasma exchange

Answer 303

Rewarming for hypothermia Abx for presumed systemic infection Rehydration – oral fluids preferred; IVF if in shock Refeed cautiously

Answer 304

Folate deficiency

Answer 305

Frequent measurement of Vital Capacity and negative inspiratory force

Answer 306

Mitral stenosis | EKG shows “P mitrale” (broad, notched P waves), atrial tachyarrhythmias, RVH (tall R waves in V1 and V2)

Answer 307

By the end of puberty with Tanner stage 5

Answer 308

Eye discharge – pts. are infective and should stay home from school/limit contacts until eye discharge has resolved. Eye redness and morning crusting may occur after discharge has stopped but these are not considered signs of contagiousness

Answer 309

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

Answer 310

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.

Answer 311

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, loss of P wave, QRS widening, sine wave w/vFIb).

Answer 312

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

Answer 313

Neural crest origin, involves adrenal medulla and sympathetic chain. Often presents <2yrs, w/abdominal mass. Can get Horner syndrome if in SNS chain Other features: periorbital ecchymoses (orbital mets), spinal cord compression from epidural invasion, opsoclonus-myoclonus syndrome (rapid vertical and horizontal nystagmus w/myoclonus), HTN, flushing and diaphoresis Dx: elevated CAs (VMA, HVA), n-myc amplification, small round blue cells on histo.

Answer 314

It’s a measure of excess risk Estimates the proportion of the disease in the exposed subjects that is attributable to exposure status ARP = (risk in exposed – risk in unexposed) / (risk in exposed) = (RR-1)/RR

Answer 315

It is a measure of excess risk in the total population, not only in exposed subjects PARP = (Risk in total population – Risk in unexposed) / (Risk in total population) = [(Prevalence)(RR-1)] / [(Prevalence)(RR-1) +1] Risk in total population = (risk in exposed)(proportion of exposed) + (risk in unexposed)(proportion of unexposed)

Answer 316

The Thompson test – squeeze the calf to see if there is plantar flexion; no plantar flexion is basically pathognomonic of complete rupture of Achilles tendon.

Answer 317

Loss of gastrocnemius-soleus motor function | Loss of plantar sensory function

Answer 318

Its encapsulated and they have deficits in opsonization, humoral immunity and macrophage/neutrophil fxn

Answer 319

If the patient has mixed incontinence or complicated incontinence.

Answer 320

Familial short stature – short stature will be seen with normal growth velocity and a normal bone age Constitutional delay of puberty – delayed bone age on xray with height and pubertal development correlated more closely with the bone age rather than chronological age

Answer 321

If no secondary sexual characteristics (testicular enlargement/breast development) are present by age 14 in boys and 12 in girls

Answer 322

A normal age-appropriate diet | A bland diet is no longer recommended and diets high in sugar and fats should be avoided until sxs resolve

Answer 323

If airway obstruction appears imminent – tonsillar enlargement is so large it will cut off the airway Or if pts are IMCP’d/experiencing other serious cxs: aplastic anemia, overwhelming infection, thrombocytopenia

Answer 324

Most common causes are viral; enteroviruses (coxsackie) are #1 and HSV is #2 However, empiric tx should be started Get LP right away and then start IV Acyclovir and abx (Vancomycin + 3rd gen Cephalosporin) Once HSV and bacterial infections are excluded can stop abx and acyclovir and tx supportively **Steroids are NOT useful in viral meningoencaphalitis**

Answer 325

A thiazide diuretic

Answer 326

1. Non-weight bearing 2. Fever >101.3 3. ESR >40 or CRP >2 4. Leukocytosis If peds patients have 3 or more than its most likely septic and joint aspiration needs to be done ASAP

Answer 327

S. aureus > S. pneumoniae > S. pyogenes These should be covered w/IV Vancomycin Can add a 3rd gen cephalosporin when there is suspicion for unusual pathogens (Kingella in a kid<3 w/oral ulcers; H influenzae in unimmunized kids; Neisseria in sexually active adolescents)

Answer 328

Pulmonary edema JVD Presence of an S3

Answer 329

If the patient has bradycardia or heart failure (may worsen pulmonary edema in ADHF)

Answer 330

Haloperidol | Lithium – should be continued if already started and can be initiated for severe mania

Answer 331

Major neurocognitive disorder (dementia) both vascular and Alzheimer types It is not a/w development of comorbid anxiety as is earlier development of depression

Answer 332

Insulin Oral agents that increase insulin secretion even when blood glucose levels are normal: Sulfonylureas – glyburide, glipizide, glimepride Meglitinides – nateglinide, repaglinide

Answer 333

Isolated pubic hair development | Patients will have normal bone age and no additional signs of adrenarche (acne, etc.)

Answer 334

Central is d/t early maturation of the hypothalamic-pituitary-gonadal axis Peripheral is d/t excess sex hormone production from the gonads, adrenal glands, or an exogenous source

Answer 335

Hydrocortisone

Answer 336

It is AR inheritance Decreased 21-hydroxlase activity leads to increased 17-hydroxyprogesterone levels and increased androgens Patients will have normal glucocorticoids and mineralocorticoids (aka no salt wasting like seen in classic CAH)

Answer 337

Early pubic/axillary hair growth Severe acne Hirsutism and oligomenorrhea in girls Increased growth velocity and bone age (makes tall children, but short adults) Typically no evidence of precocious pubertal testicular or breast development

Answer 338

On EKG will see intermittent non-conducted P waves (dropped beats not preceded by a change in the length of the PR interval) and regular PR intervals Often have significant bradycardia Need placement of permanent pacemaker as this commonly progresses to complete block

Answer 339

If patients become unstable and have Mobitz type II AV block or any other bradycardia they should receive IV Atropine. However, if a patient is stable then it should not be given in Mobitz bc it may worsen the bradycardia

Answer 340

Some bullshit reverse “café-au-lait” spots Basically hypopigmented spots, described like ash-leaf spots seen in TSC, but FHx will be significant for bilateral deafness which is not a feature of TSC

Answer 341

``` Bilateral acoustic schwannomas Juvenile cataracts Meningiomas Ependymomas Hypopgimented café-au-lait spots (reverse of whats seen in NF1) ```

Answer 342

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

Answer 343

VHL gene w/Von hippel-Lindau RET gene – MEN type 2 NF1 gene – Neurofibromatosis Type I Sturge-Weber Syndrome

Answer 344

Sturge-Weber

Answer 345

Congenital NON-inherited anomaly of neural crest derivatives d/t activating mutation of GNAQ Port wine stain in V1/V2 distribution (nevus flammeus) Leptomeningeal capillary-venous malformation Seizures +/- hemiparesis Intellectual disability Visual field defects Glaucoma

Answer 346

Osler-Rendu-Weber

Answer 347

Aka Hereditary hemorrhagic telangiectasia AD disease w/diffuse telangiectasis (ruby-colored papules that blanch w/pressure), recurrent epistaxis, and widespread AVMs. Pulmonary AVMs – can cause blood to shunt from R to L heart which causes chronic hypoxemia, clubbing, and reactive polycythemia Vascular lesions of the CNS

Answer 348

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.

Answer 349

Chiari II malformation aka Arnold Chiari malformation

Answer 350

``` Scuba diving Contact sports Exercise w/falling risk (horse-back riding, gymnastics) Skydiving Hot yoga (regular is fine) ```

Answer 351

Eye abnormalities – chorioretinitis Neuro findings – diffuse intracranial calcifications, hydrocephalus/macrocephaly Hearing impairment **Infection in mother often goes undetected and is common after eating undercooked meat, or fruits/veggies from contaminated soil; infection is highest in S America**

Answer 352

``` Congenital heart defects (PDA) Eye abnormalities (cataracts) Hearing impairment (sensorineural hearing loss) Infants are typically normocephalic and do not have intracranial calcifications ``` **Typically see at least mild symptoms in the mother during pregnancy (fever, rash)**

Answer 353

GAS (S. pyogenes) is #1 in healthy patients Others: S. aureus C. perfringens (almost always a/w crepitus and gas formation) Polymicrobial (mostly seen in pts w/underlying DM and PVD) Pseudomonas (in IMCP’d)

Answer 354

DM and PVD patients are more likely to have polymicrobial infections Common organisms: S. aureus, Bacteroides fragilis, E. coli, Group A Strep, Prevotella spp.

Answer 355

Anaerobic bacteria, most common are C. perfringens and B. fragilis

Answer 356

Urgent, aggressive surgical exploration (even if the patients are hemodynamically unstable) Broad spectrum abx: Pip-tazo or a Carbapenem – covers Group A Strep and Anaerobes Vancomycin – covers S. aureus (including MRSA) Clindamycin – added to inhibit toxin formation by streptococci/staphylococci **once culture confirms offending organism abx can be narrowed**

Answer 357

Bc of their anticholinergic effects they can worsen BPH | Diphenhydramine and others should be avoided in men w/BPH

Answer 358

Glucocorticoids decrease the intestinal absorption of Ca2+ and increase Ca2+ excretion in the urine They also accelerate bone resorption Patients taking chronic steroids should also be given supplemental Ca2+ and Vit. D Bisphosphonates can be added if osteoporosis risk is v high (esp. in post-menopausal women)

Answer 359

Patients who will be treated w/steroids for more than 3 months (or 6 if low doses) require a baseline densitometry and then it should be repeated each year for as long as the therapy continues to monitor for adverse skeletal effects

Answer 360

US > MRI >> CT

Answer 361

It is an infective (often polymicrobial), suppurative portal vein thrombosis Although rare, it is most commonly a complication of untreated appendicitis or other intraabdominal or pelvic infections (diverticulitis)

Answer 362

``` Acute or chronic onset of fever RUQ pain Jaundice Hepatomegaly Labs: elevations in alk phos, and GGT ```

Answer 363

Bowel ischemia Portal HTN Hepatic abscess **Need prolonged, broad spectrum abx to prevent these**

Answer 364

<34 weeks gestation (as opposed to <37 weeks in general population) Steroids can cause hyperglycemia in pts w/DM

Answer 365

To alleviate the compression of the umbilical cord that causes variable decels It is not given in the mgmt. of oligohydramnios as it cannot correct chronic placental insufficiency

Answer 366

If gonorrhea is suspected/cannot be ruled out – ceftriaxone + doxycycline Low risk of gonoccal infection – Fluoroquinolones (levofloxacin)

Answer 367

Mumps, Rubella, Parvo These are most commonly seen in children/adolescents and often involve extraurinary manifestations (parotitis, meningitis)

Answer 368

``` Smoking is #1 Male sex Older (>65) White FHx of AAA Atherosclerotic disease ```

Answer 369

``` Smoking cessation is most important Aspirin and statin therapy Elective repair for: Large (5.5+ cm) Rapidly enlarging (>0.5cm in 6 months) AAA a/w PAD or aneurysm ```

Answer 370

Medium (4-5.4cm): US every 6-12mos | Smaller (<4cm): US every 2-3 years

Answer 371

Infrarenal aorta

Answer 372

Osteoporosis/compression fracture Suspected malignancy Ankylosing spondylitis **If XR is abnormal then should proceed to MRI**

Answer 373

Sensory/motor deficits Lumbosacral radiculopathy/sciatica lasting >1month Cauda equina syndrome (urine retention, saddle anesthesia) Suspected epidural abscess/infection (fever, IVDU, concurrent infection, hemodialysis) Known malignancy

Answer 374

If the patient has indications for an MRI but they are not able to have an MRI

Answer 375

``` Constitutional sxs (fever, wt. loss) Age >50 IVDU Immune suppression Recent bacterial infection Nocturnal pain Hx of Malignancy ```

Answer 376

Premenopausal women – oligo/amenorrhea, infertility, galactorrhea, hot flashes, decreased bone density Postmenopausal women – mass effect sxs (HA, visual field defects/bitemporal hemianopsia) Men – infertility, decreased libido, impotence, gynecomastia

Answer 377

DA-agonists – Cabergoline, Bromocriptine | Surgery for those who don’t respond to meds

Answer 378

In patients who did not receive thrombolytic therapy BP up to 220/120 is acceptable as this allows appropriate perfusion to borderline ischemic areas in the brain. Patients who did receive thrombolytic therapy should be maintained at BPs <185/105 for at least 24hrs to minimize the risk of hemorrhage

Answer 379

Subsequent PE – therefore pts should be managed on SQ low-dose Heparin or LMWH as DVT pphx Pts who suffered hemorrhagic stroke should initially be managed w/mechanical DVT pphx (SCDs)

Answer 380

Aka familial tremor (AD inheritance) Intention tremor that is both present at rest and then worsens when reaching for something or completing an activity. Often effects both hands but is not a/w other neurologic sxs Tx: BB propranolol

Answer 381

Interferon-gamma release assay (IGRA) They often have a false positive to the PPD test Patients who have latent TB will have positive result to PPD and IGRA and should be assessed w/CXR

Answer 382

Isoniazid + Rifapentine weekly for 3 mo under direct observation (not recommended for HIV+) Isoniazid monotherapy for 6-9months Rifampin monotherapy for 4mos **healthcare workers recommended to receive Isoniazid for 9mo**

Answer 383

Renal involvement in SLE is d/t immune complex-mediated glomerular injury, and the immune complexes are composed primarily of anti-dsDNA antibodies These antibody complexes are deposited in the mesangial, subendothelial, or subepithelial space and cause inflammation and destruction of the kidney

Answer 384

anti-dsDNA antibody levels and complement levels anti-Smith Abs also become elevated in SLE renal disease, but they remain elevated even after the disease is no longer active and therefore are not useful in monitoring but may identify pts at risk of developing renal disease.

Answer 385

Anti-histone Abs

Answer 386

``` Isoniazid Hydralazine Procainamide D-penicillamine Minocycline anti-TNFa (etanercept, infliximab) ```

Answer 387

Ulceration/scarring Vision impairment if near eye Life-threatening if near airway Most regress and don’t need tx but can use topical BBs (propranolol) for ulcerated or cosmetically sensitive areas

Answer 388

Chronic oligoarthritis (worse in the morning) Daily fever (quotidian fever >2wks) Rash (pink, macular, worsens during fever) Possible lymphadenopathy and hepatosplenomegaly

Answer 389

With neuropsychiatric sxs, immune-mediated anemia (Coombs +), thrombocytopenia, arthritis, and nephritis

Answer 390

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

Answer 391

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

Answer 392

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.

Answer 393

Erosive variant (most common): Erosive, glazed lesions w/white border, vaginal involvement +/- stenosis, associated oral ulcers Papulosquamous variant: Small pruritic papules w/purple hue often seen near wrists, vulva or penis Both present in women age 50-60 w/vulvar pain or pruritus, and dyspareunia Associated with HCV when seen outside of GU region

Answer 394

Multiple chain LAD Hepatosplenomegaly Anemia and thrombocytopenia

Answer 395

Infection and Secondary malignancy (Richter transformation) | But typically have 10+ year survival rate

Answer 396

``` Macrosomia Hypocalcemia Hypoglycemia Hyperviscosity d/t polycythemia Respiratory difficulties Transient HCMP ```

Answer 397

Hypertrophic cardiomyopathy (typically transient and doesn’t require tx) – occurs d/t hyperinsulinemia that triggers glycogen synthesis and XS glycogen and fat are deposited w/in the myocardium (esp. the IV septum) This occurs d/t poorly controlled DM in the 2nd and 3rd trimesters (so more common among gDM pts and not pre-pregnancy DM). Congenital heart diseases (hypoplastic LH syndrome, etc) occur d/t hyperglycemia in the 1st trimester and therefore are only seen in pregestational DM mothers

Answer 398

Noonan syndrome – RV outflow obstruction may result in R to L shunting and cyanosis also a/w facial structure abnormalities, bleeding disorders and bone and rib cage malformations

Answer 399

Ebstein anomaly d/t malformed tricuspid valve

Answer 400

It quantifies mortality in a specific group compared to the general population SMR = observed # of deaths / expected # of deaths SMR < 1 means deaths are lower than expected; >1 deaths are higher than expected

Answer 401

Aortic – 2nd ICS to the R sternal border Pulmonic – 2nd ICS to the L sternal border Erb’s point – 3rd ICS to the L sternal border Tricuspid – 5th ICS to the lower L sternal border Mitral – apex, PMI and 5th ICS at Midclavicular line

Answer 402

Hypokalemia Treatment w/B12 causes newly forming RBCs to rapidly uptake K+ and can cause significant hypokalemia Patients should be monitored during the first 48hrs of tx Can lessen the risk by giving packed RBC transfusion prior to initiating B12 treatment

Answer 403

After they become secondarily infected after a URI which causes erythema and tenderness

Answer 404

Thyroid imaging – TDCs are commonly associated with ectopic thyroid tissue and the TDC may be the only site of functioning thyroid tissue. Therefore thyroid imaging needs to be done before definitive tx (resection is the only curative therapy and should be done to prevent recurrent infections)

Answer 405

Patients in sinus rhythm who meet ALL of the following should receive one: 1. LV ejection fraction <35% 2. NYHA class II, III, or IV HF sxs (essentially presence of any sxs) 3. LBBB with QRS duration >150msec

Answer 406

Malabsorption For prevention all patients should take lifelong supplementation of vitamins: B1, B12. Folic acid and Vitamin D; and minerals: iron, calcium, trace minerals Vitamin D should be supplemented in high levels 2000-3000+ U/d

Answer 407

Suppressed/absent LH and FSH with increased levels of the a-subunit These tumors are composed of gonadotropin-secreting cells and mainly just secrete the a-subunit of the gonadotrophs Large tumors can compress the pituitary stalk and block the normal inhibition of prolactin secretion causing mild prolactinemia (<200), but not high levels like prolactinomas (>200)

Answer 408

Splenectomy

Answer 409

>34 weeks | Risks of perinatal morbidity and mortality no longer outweigh risks of maternal tocolytic exposure after this point

Answer 410

Only if the renal mass is still confined within the renal capsule aka Stage I disease

Answer 411

In elderly patients with an acute exacerbation of underlying pulmonary disease First step is to correct underlying disturbance – ie give O2 or ventilation Other common causes are electrolyte disturbances: hypokalemia, hypomagnesemia – should replace electrolytes before initiating pharmacotherapy

Answer 412

End-organ resistance to PTH Will have elevated PTH which distinguishes it from hypoparathyroidism Chronic hypocalcemia (leading to cataracts and basal ganglia calcifications), elevated phosphorous and low vitamin D can be seen in both disorders

Answer 413

A subtype of psuedohypoparathyroidism Will have dysmorphic features – round facies, short stature, short 4th/5th metacarpals as well as the other features of psueohypoPTH (high PTH, high phosphorus, low Ca2+ and Vit. D)

Answer 414

Low-grade syphilis infection in the subarachnoid space – can affect the intracranial vessels and potentially result in stroke CSF is likely to show similar results to viral encephalopathies: Elevated WBCs with lymphocyte predominance, elevated protein, normal glucose +/- xanthochromia Tx with IV Penicillin

Answer 415

Colonic abscess – can occur in 15-50% of patients Need IV abx, bowel rest and most need urgent percutaneous drainage + partial colectomy several weeks later If pts w/diverticulitis don’t have improvement in sxs after 2-3 days they should have repeat CT to assess for abscess and other cxs (obstruction, fistula, perforation)

Answer 416

TOPICAL agents: Antifungals – selenium sulfide shampoo, ketoconazole Glucocorticoids Calcineurin inhibitors – pimecrolimus Salicylic acid May need treatment as often as every 1-2 weeks in order to prevent recurrence

Answer 417

Griseofulvin – it has no activity against malassezia spp. and can worsen SD

Answer 418

Urgent ENT evaluation – they need to do full audiologic testing + imaging, etc Steroids should also be given (orally and/or injected into middle ear)

Answer 419

Aka interaction bias It occurs when a variable/effect modifier changes the direction or strength of the effect that the independent variable (exposure or treatment) has on the dependent variable (outcome) Ex: age is an effect modifier on aspirin usage and reye syndrome development

Answer 420

Negative inotropic agents – BBs (metoprolol), Verapamil or Disopyramide Patients w/persistent sxs refractory to medical therapy can have alcohol septal ablation

Answer 421

Vasodilators – dihydropyridine CCBs (amlodipine, nifedipine) ACEIs and ARBs Nitrates **these can all decrease SVR which may worsen the LVOT gradient and sxs**

Answer 422

Schirmer test – confirms secretory deficiency | autoantibody screen – anti-Ro, anti-La, RF and ANA

Answer 423

Patients should be placed on contact and airborne precautions until all lesions have crusted over Hospitalized patients with localized infection can be held on standard precautions with lesion covering

Answer 424

``` Male sex Age >50 FHx Diabetes Tobacco and alcohol use ```

Answer 425

NSAIDS – in the setting of peri-infarction only Aspirin should be used, in the setting of viral or idiopathic Naproxen is best choice + Colchicine (aspirin should be tried as monotx in peri-infarction pericarditis, but colchicine can be added later if sxs persist. Colchicine should be used in combo w/Naproxen for viral/idiopathic)

Answer 426

In normally distributed (bell curves) the mean is most valid | In skewed or asymmetrical distributions, the median is most valid

Answer 427

CML has marked leukocytosis of predominately neutrophil origin CLL has marked leukocytosis of predominately lymphocyte origin

Answer 428

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**

Answer 429

Alprazolam – short t1/2

Answer 430

Recurrent infections and daily cough w/mucopurulent sputum production (often green-yellow and foul smelling) Can get hemoptysis from repeated mucosal inflammation leading to rupture of small blood vessels

Answer 431

ABG showing elevated levels of Carboxyhemoglobin Tx w/High flow O2; intubation/HBO for severe cases **Often seen after smoke inhalation**

Answer 432

When Fe-molecules in Hb are oxidized to form methemoglobinemia – prevents O2 binding and has increased affinity for cyanide May present w/cyanosis and chocolate colored blood Most common causes: Rxs (dapsone, benzocaine), and toxins (aniline dyes) Tx: methylene blue and vitamin C

Answer 433

Correctable causes of anemia – evaluate Fe stores, folate and B12 levels, reticulocyte count and FOBT; even if MCV is normal Fe-stores also should be checked at regular intervals while on EPO bc they can quickly become depleted from new RBC production.

Answer 434

Immediate removal of contaminated clothing, and gentle cleansing of exposed area (minimizes spread) Tx is then supportive – cool compresses, topical steroids; Oral steroids can be given in severe dermatitis or dermatitis that involves the face or genitals Antihistamines have NO ROLE as poison ivy dermatitis is not histamine-mediated (its Type IV HS)

Answer 435

Warfarin should only be used in the preconception and postpartum periods (breastfeeding) LMWH should replace warfarin in the 1st trimester and be continued throughout pregnancy UFH should replace LMWH in the last few weeks of pregnancy before delivery (it is quicker to reverse) **All anticoagulation should be discontinued at the onset of labor and before epidural anesthesia is started**

Answer 436

GBS + in current pregnancy Prior infant w/early-onset neonatal GBS infection Unknown GBS status in current pregnancy + any of the following: 1. <37 weeks 2. Intrapartum fever 3. Rupture of membranes for 18+ hours

Answer 437

Nodules >0.8cm need further workup or surveillance; those <0.6cm require no follow up Nodules >2cm have >50% chance of being malignant

Answer 438

If age 60+ they need upper endoscopy | Age <60 should be tested/treated for H. pylori, and upper endoscopy only for high risk patients

Answer 439

``` Progressive dysphagia Fe-def anemia Odynophagia Palpable mass/LAD Persistent vomiting FHx of GI malignancy **Patients with 1 or more of these should get upper endoscopy to evaluate for malignancy** ```

Answer 440

SNRIs (Venlafaxine), SSRIs, TCAs | Sodium oxybate can be considered but it is rarely used d/t abuse potential

Answer 441

CBC + serum Fe and ferritin levels + reticulocyte count | If chelation therapy is required need BMP + UA

Answer 442

Mycotic aneurysm rupture 2/2 infective endocarditis Most commonly seen in those w/IVDU Likely to present w/sxs of SAH (HA, lethargy, neck stiffness) + fever, petechiae, and a heart murmur

Answer 443

Renal infarction Glomerulonephritis Drug-induced AIN from IE therapy

Answer 444

As an expanding mass w/focal neurologic findings | May also remain asx until rupture w/stroke or SAH

Answer 445

Valvular insufficiency – common CoD Perivalvular abscess Conduction abnormalities Mycotic aneurysm – can occur in systemic circulation or cerebral

Answer 446

``` Acute-onset (<1week) fever HA Seizures AMS Focal neurologic findings – hemiparesis or CN deficits ```

Answer 447

``` Age 65+ Coagulopathy Drug or EtOH intoxication High-risk injury mechanism: Pedestrian struck by vehicle Ejection from vehicle Fall from height ```

Answer 448

Retrograde amnesia (30+ min before injury) Vomiting 2+ times Seizure Severe HA

Answer 449

Battle sign – mastoid/postauricular ecchymoses Rcacoon eyes – orbital ecchymoses CSF rhinorrhea or otorrhea Hemotympanum

Answer 450

Even after minor head trauma patients should immediately receive non-con CT and Factor 8 or 9 should be replaced asap

Answer 451

HPV can be vertically transmitted and c-section does not prevent this transmission, therefore expectant mgmt. and vaginal delivery should be planned.

Answer 452

C5-C7 | Have pronated forearm, flexed wrist and fingers

Answer 453

It has no change or may increase mortality

Answer 454

All should receive aspirin + warfarin: Aspirin 75-100mg/d + warfarin in all pts w/aortic or mitral valve replacement Patients who cannot take warfarin should have increased doses of aspirin: 75-325 Warfarin w/goal INR 2.0-3.0: for AV replacement w/no risk factors Warfarin w/goal INR 2.5-3.5: MV replacement, AV replacement +risk factors, in the first 3mo post-AV replacement **risk factors: aFIb, severe LV dysfxn (EF<30), prior TE, presence of hypercoagulability**

Answer 455

It is a monoclonal Ab – used to reverse anticoagulation from Dabigatran (direct thrombin inhibitor)

Answer 456

Other AI diseases: AI thyroid disease, vitiligo, pernicious anemia They often also have associated nail pitting

Answer 457

All children <24 months w/a febrile UTI needs a renal/bladder US to evaluate for hydro and ureteral dilation. Children >2 don’t need US if UTI sxs resolve w/treatment US should be performed after the acute illness has been tx’d to prevent false-+ results If US is abnormal – VCUG to look for VUR (also done if recurrent, febrile UTIs in a child)

Answer 458

``` Recurrent spontaneous miscarriages (even euthyroid women w/anti-TPO abs are at risk) Severe preeclampsia Preterm birth Low birth weight Placental abruption ```

Answer 459

Topiramate – inhibits renal carbonic anhydrase

Answer 460

``` Longstanding hypothyroidism Amyloidosis Acromegaly Mucopolysaccharidosis (Hurler and Hunter syndromes) MEN 2B ```

Answer 461

To assess publication bias Funnel plots should be symmetric in the absence of study heterogeneity and publication bias – aka there should be the same number of dots on both sides of the triangle at similar spots Asymmetry (all points on one side of the triangle, etc.) suggest publication bias

Answer 462

A small sample size/low power would lead to more studies/dots at the base of the triangle Studies with large sample sizes/high power would be at the top of the triangle

Answer 463

Renal duplex Doppler US, CT or MR angiography w/contrast can all be done, but v. important not to do contrast studies in those w/renal insufficiency, therefore US should be done 1st in these patients

Answer 464

Sinus tachycardia is most common finding. Others: all occur d/t RV strain New RBBB Atrial arrhythmias Q-waves or ST-segment changes in the inferior leads

Answer 465

RV dysfunction Decreased RV contractility Presence of RV thrombus Moderate/functional tricuspid regurg – d/t pHTN causing dilation of the TV annulus

Answer 466

AMS (fussy behavior) LoC Severe mechanism of injury (fall >3ft, high impact, MVC) Non-frontal scalp hematoma (aka occipital, parietal hematomas) Palpable skull fracture

Answer 467

Large (>3cm) parietal and temporal hematomas – highest risk of TBI/intracranial injury

Answer 468

Cellulitis – S. pyogenes (also main cause of Erysipelas) | Abscess – S. aureus

Answer 469

Fetal loss Preeclampsia gDM gHTN

Answer 470

House dust mites (responsible for 60-90% of asthma cases) Other allergens: cat, dog, and cockroach Air pollution doesn’t have an association with asthma

Answer 471

Pulmonary toxicity is the most serious and is responsible for the most deaths a/w amiodarone ``` Photosensitivity Skin discoloration Bone marrow suppression Thyroid dysfunction Abnormal liver fxn tests ```

Answer 472

Topical Tacrolimus If it is significantly effecting the face, eyelids, or flexural areas Otherwise topical corticosteroids should be used (hydrocortisone, triamcinolone, etc.)

Answer 473

``` Fatigue and pruritus are most common Inflammatory arthritis Hyperpigmented skin RUQ discomfort Xanthelasmata and xanthomata ``` **increased risk if there is FHx**

Answer 474

Dx – elevated ALP, positive anti-mitochondrial Abs, liver biopsy if AMA is negative Tx – Ursodeoxycholic acid; Liver transplant in advanced cirrhosis **AST, ALT and BR levels may all be normal or mildly elevated**

Answer 475

Autoimmune Hepatitis

Answer 476

Metabolic bone disease – osteopenia/porosis | Vitamin D levels are typically normal though

Answer 477

HTN crisis – give IV nitroprusside, phentolamine or nicardipine HoTN (d/t decreased CAs after tm removal) – give NS bolus + pressors if unresponsive Hypoglycemia (increased insulin secretion after tm removal) – give IV dextrose Tachyarrhythmias (from increased CA release from adrenal gland handling) – IV lidocaine or esmolol

Answer 478

TSH 10+ uU/mL: treat all patients TSH 7-9.9: Age <70 – treat Age 70+ – tx if convincing hypothyroid sxs TSH upper limit of normal (6.9): Age <70 – tx if convincing hypothyroid sxs, enlarging goiter, or elevated anti-TPO titer Age 70+ – do not treat, may cause harm

Answer 479

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**

Answer 480

``` Cardiac output: decreased RA pressure: increased RV pressure: increased Pulmonary a. pressure: increased PCWP: normal ```

Answer 481

Can be done w/annual low-dose CT for patients 55-80 with >30 pack year smoking history + current smoker or quit w/in last 15 years CXR has not been shown to reduce mortality as a screening method.

Answer 482

Autoantibodies attacking the acetylcholine receptors at the NMJ

Answer 483

Manual disimpaction followed by enema or suppository to empty the colon Increased dietary fiber + stool softeners should then be started after disimpaction

Answer 484

Cutaneous T-cell lymphoma Has highly variable appearance – may present as papules, plaques or hyper-/hypo-pigment patches May have subQ tumors Extradermal spread can cause regional LAD, infiltration of the lung, liver or spleen and occasionally can cause bone marrow and CNS involvement

Answer 485

Premature discontinuation of dual antiplatelet therapy: aspirin and P2T12 Receptor blocker (clopidogrel, prasugrel, ticagrelor)

Answer 486

That the patient has a low risk (<1%) for cardiac events in the near future (w/in the next year) It does not exclude the possibility that the patient has CAD as it could be nonobstructive or microvascular

Answer 487

Augmentation of evaporative cooling – naked patient sprayed w/water mist or covered w/a wet sheet while large fans circulate air

Answer 488

Toxin-mediated myocarditis, neuritis, and kidney disease

Answer 489

Insulin, metformin and glyburide can all be used if diet doesn’t control gDM Glyburide has higher risk of neonatal hypoglycemia than insulin though

Answer 490

Most common in young/middle-age women Often have other autoimmune manifestations: arthritis, erythema nodosum, thyroiditis, pleurisy pericarditis, anemia and sicca syndrome Labs: increased AST, and ALT; typically have normal/near-normal ALP and BR Common auto-Abs: ANA, and anti-smooth muscle Abs (against actin)

Answer 491

Cholestasis | Can also help differentiate if ALP elevations are from liver pathology or bone

Answer 492

Anaphylaxis to neomycin Anaphylaxis to gelatin Immunodeficient state – congenital immunodefs., long-term immunosuppressive tx, heme or solid tms, severe HIV infection

Answer 493

Close monitoring for a vaccine-associated VZV rash – this is contagious to immunocompromised individuals If a rash develops then the IMCP’d individual needs VZV-Ig asap (w/in 10d of initial exposure), but otherwise they do not require Ig if they previously were vaccinated for VZV

Answer 494

Erythromycin ointment Polymyxin-TMP drops Azithromycin drops Fluoroquinolone drops – preferred in contact wearers bc higher risk of Pseudomonas

Answer 495

Bacterial keratitis – more common in contact wearers

Answer 496

With photophobia, blurred or impaired vision, foreign body sensation w/difficulty opening the eye Needs urgent Ophtho evaluation

Answer 497

Acute dissection of the ascending aorta w/carotid a. involvement – causes cerebral ischemia Need CTA, MRA or TEE asap

Answer 498

With a baseline Radionuclide ventriculography (aka MUGA) and then repeat before each subsequent chemo dose A decrease in EF by 10+ % may warrant discontinuation of therapy, and those w/baseline EF <30% cardiotoxic agents are contraindicated

Answer 499

SOM is a middle ear effusion – commonly occurs after an episode of AOM Watchful waiting can be done for up to 3mos in a unilateral effusion If SOM persists >3mos or is bilateral then further therapy should be considered

Answer 500

When considering if statin therapy should be started

Answer 501

There’s a non-statistically significant difference between the two

Answer 502

1 – diseases w/decreased RBC production 2 – hemolytic disorders w/increased RBC destruction Need reticulocyte count to differentiate – elevated retics mean hemolysis, low means decreased production

Answer 503

Tendons – bc they run on the anterior surface of the phalanges Veins, arteries and nerves run along the sides

Answer 504

Aka bloody diarrhea Most commonly caused by bacterial enteritis Most common pathogens: Salmonella, Shigella, E. coli (enterohemorrhagic or enteroinvasive), Campylobacter, Yersinia Tx: fluid repletion (abx only needed for IMCP’d pts, or invasive disease/sepsis) **STEC must be excluded before giving abx bc they can predispose to HUS**

Answer 505

Corrected calcium = (measured serum Ca2+) + 0.8(4.0 – measured serum albumin)

Answer 506

Penicillin – if the patient is allergic they need to become desensitized and then get penicillin

Answer 507

Universally at first prenatal visit If positive then they must get repeat screening in 3rd trimester (28-32wks) – a 4-fold or greater decrease in serologic titer indicates treatment success; Anything less needs re-treatment

Answer 508

They need a 24hr esophageal pH monitoring to reevaluate the diagnosis

Answer 509

In all postmenopausal women w/a DEXA T-score -2.5 or less, or those w/a hx of low-trauma hip or vertebral fractures regardless of T-score Other recommendations are when 10-yr FRAX is >20% for major osteoporotic fractures or >3% for a hip fracture

Answer 510

14-21 days of Amoxicillin or Cefuroxime

Answer 511

Small artery erosion d/t colonic mucosal outcropping

Answer 512

Only second trimester and early third First trimester – increased risk of neural tube defects Late third – increased risk of neonatal kernicterus Should avoid altogether

Answer 513

G+ and anaerobes | Has no gram negative coverage – v. little role in GU infections

Answer 514

Need hospitalization w/IVF hydration IV abx w/broad-spectrum B-lactams – ceftriaxone, cefepime Once afebrile for 48hrs can switch to oral abx for 10-14d and then daily suppressive tx w/low-dose Nitrofurantoin or Cephalexin until 6wks post-partum

Answer 515

Pain control – morphine IV BBs – esmolol +/- Sodium Nitroprusside (if SBP >120mmHg; but monotx is contraindicated) Emergent surgical repair for ascending dissection

Answer 516

Stone 10+mm need Uro consult for removal Stone <10mm should be managed w/hydration, pain control, a-blockers and strain urine If pts have uncontrolled pain or no stone passage w/in 4-6 weeks consult Uro Patient w/any stone size that have urosepsis, ARF or complete obstruction – uro for surgery

Answer 517

1st recurrence – Vancomycin PO (even if used in the initial episode) or Fidaxomicin if Vanc was used in initial episode 2nd recurrence – Same as first recurrence, or Vanc PO followed by rifaximin, or fecal transplant

Answer 518

Only in fulminant disease (HoTN/shock, ileus, megacolon) – IV metronidazole + high-dose IV Vanc and surgical eval

Answer 519

Immune complex formation (Type III HS) Antibiotics – B-lactams, sulfa Acute HBV infection

Answer 520

Serum-sickness like reaction Polyarteritis nodosa Glomerulonephritis – normally membrane nephropathy, less commonly membranoproliferative glomerulonephritis

Answer 521

DM-2 – at the time of diagnosis | DM-1 – beginning 5 years after initial diagnosis (no matter the age at diagnosis)

Answer 522

Statin – for both Type I and II DM Should also calculate their 10-yr ASCVD risk to determine intensity of statin (moderate or high), but all DM patients 40+ need a statin regardless of their ASCVD risk

Answer 523

Traumatic LP – RBC count >6,000, elevated WBC count (typically 1 WBC per 750-1000 RBCs), elevated protein and glucose Xanthochromia will be absent in traumatic LP and will be present in >90% of SAH w/in 12hrs and starts to show up w/in 2-4hrs **A WBC/RBC ratio <0.01 has an almost 100% NPV for meningitis (viral or bacterial)**

Answer 524

Caused by protozoan Trypanosoma cruzi (most common in Mexico, Central and S. America) Cardiac Manifestations – can have any or all of the following: 1. Biventricular HF (R>L) w/cardiomegaly 2. Ventricular apical aneurysm (LV apical aneurysm is pathognomonic for chagas CMP) 3. Mural thrombosis w/embolic complications 4. Fibrosis leading to conduction abnormalities (heart block, VTach)

Answer 525

Progressive dilation of esophagus and colon – megacolon | Caused by T. cruzi

Answer 526

Lyme disease

Answer 527

Rare form of idiopathic myocarditis – thought to be AI-mediated Echo can show LV dilation w/segmental and/or global LV systolic dysfunction

Answer 528

Dilated cardiomyopathy

Answer 529

Prodromal sxs – fever, fatigue, cough, coryza (stuffy nose), and conjunctivitis Koplik spots often appear after the onset of prodromal sxs and resolve when rash appears After 2-4d of prodromal sxs the patient typically looks very ill and a maculopapular rash starts on the face and spreads cephalocaudally sparing the palms and soles Often have cervical LAD as well Tx: supportive (IVF, antipyretics); hospitalized patients/severe cases get Vitamin A

Answer 530

HHV-6 Often does not have a prodrome of sxs and presents w/high fevers (possible to provoke seizures) for several days and then followed by a diffuse macular (often described as lacy) rash once the fevers resolve **will not have fever and rash at same time**`

Answer 531

Parvovirus | Have nonspecific prodrome (fever, cough) followed by rash “slapped cheeks” with spread to trunk

Answer 532

An atypical presentation of hyperthyroidism seen in older patients – characterized by lethargy, confusion and depression. May coincide with dementia which makes diagnosis more difficult. Other sxs that may be present: tachycardia, tremor, decreased appetite, constipation, etc.

Answer 533

When the mean values of a continuous variable in several groups (categorical variable) are being compared

Answer 534

Thyroiditis Iodide exposure * *if both were low it would be d/t exogenous hormone** * *high/high would be d/t toxic adenoma, goiter or Graves**

Answer 535

High-potency topical corticosteroids – fluocinonide, augmented betamethasone dipropionate 0.05% Low-potency (1% hydrocortisone) can be used on the face or intertriginous areas

Answer 536

Pituitary enlargement and hyperpigmentation following bilateral adrenalectomy for Cushing’s disease. Pituitary enlargement is d/t loss of feedback by adrenal glucocorticoids – the tm development is aggressive and needs surgery or pituitary radiation

Answer 537

Alcohol intake (even modest 2-3/d) – possibly d/t its effect on folate absorption Cigarette smoking – typically in current, long term smokers (30+ years) Obesity Low-fibre diet **Regular NSAID use, hormone replacement tx and high-fiber offer protection against CRC**

Answer 538

Coma, respiratory failure and death w/in weeks Once sxs manifest tx is primarily palliative Post-exposure Pphx w/rabies Ig and vaccine can help prevent the disease if there are no clinical manifestations but it has no use once clinical manifestations occur

Answer 539

Don’t transfuse unless Hb is <7 In pts w/CVD Hb should be maintained above 8 In unstable patients transfusion may need to occur at higher levels d/t an inaccurate reflection of the Hb at time of lab tests

Answer 540

Oligoclonal IgG bands

Answer 541

IV or oral corticosteroids can be used, unless optic neuritis is present, then IV need to be used Oral steroids have an increased risk of recurrent optic neuritis Plasmapheresis can be considered in glucocorticoid-refractory patients

Answer 542

Disease-modifying agents – B-interferon and glatiramer acetate Long-term steroids are typically not recommended

Answer 543

Fatigue – amantadine or stimulants If sleep hygiene and regular exercise fail Neuropathic pain – gabapentin or duloxetine

Answer 544

Atypical glandular cells on pap test

Answer 545

AUB plus: Unopposed estrogen (obesity, anovulation) Failed medical mgmt. Lynch syndrome (HNPCC)

Answer 546

AUB or postmenopausal bleeding

Answer 547

Aka atypical glandular cells. May be d/t either cervical or endometrial adenocarcinoma. Investigated w/colposcopy, endocervical curettage and endometrial bx – allows evaluation of ecto- and endo cervix and endometrium

Answer 548

1 – Transdermal patch and gum or lozenge (no contra’s) 2 – Varenicline (an a-4 B-2 nicotinic Ach-R partial agonist). Contra’s: recent suicidality and unstable psych disorders; relative – preexisting CVD. It increases risk of CVS events in these pts. 3 – Buproprion (NE-DA reuptake inhibitor) Contra’s: seizure disorders, active bulimia or anorexia

Answer 549

Seizure hx – bc buproprion lowers seizure threshold Psych hx – varenicline is a/w increased risk of suicide and neuropsych side effects (can’t use in unstable psych pts or those w/recent suicidal ideation)

Answer 550

Pulseless electrical activity – different than normal symptomatic bradycardia Need to tx based on ACLS – continuous CPR + Epi every 3-5min; atropine not used in bradycardia a/w PEA

Answer 551

Defibrillation + CPR and Epi | Unlike pulseless bradycardia this is a shockable rhythm

Answer 552

Aka “chicken skin” looks like goosebumps Benign condition of retained keratin plugs in the hair follicles, most commonly presents w/small painless papules, and a roughened skin texture; Can become pruritic in cold, dry weather Posterior upper arm is most common location Often a/w eczema and asthma Tx: topical keratolytics – salicylic acid or urea cream (help soften papules)

Answer 553

1st line – SSRIs +/- CBT | 2nd line – Clomipramine +/- CBT

Answer 554

if the patient is asx w/a tumor <10mm in diameter and <3mm depth/thickness Should reexamine in 3mos and then every 6mos If the tm becomes larger than that or the patient has associated sxs then radiotherapy is the preferred tx (brachytx or EBRT)

Answer 555

common after a gastrectomy Change in diet to high protein, and fractionated, smaller but more frequent food portions usually relieves the sxs Metoclopramide should be avoided as it increases gastric emptying

Answer 556

Pregnancy – it causes an ADAMTS13 deficiency that becomes more pronounced w/increasing gestational age

Answer 557

28d or less – Ampicillin + Gentamicin or Cefotaxime (E. coli and GBS most common) >28d – Ceftriaxone or Cefotaxime +/- Vanc if meningeal involvement is suspected (S. pneumo and N. meningitidis most common)

Answer 558

>28 days – before this it can displace albumin-bound BR and increase risk of kernicterus

Answer 559

Dextrose is 1st line, but Octreotide (a SST analog) can also be used in pts w/persistent hypoglycemia, as it decreases insulin secretion

Answer 560

anti-dsDNA these are the most sensitive (about 70%) and specific ANA are very sensitive but not specific Anti-Smith are very specific but not very sensitive (only about 25%)

Answer 561

It is particularly effective at improving arthralgias, serositis, pleurisy, and cutaneous sxs

Answer 562

If they have serious manifestations such as nephritis, CNS involvement or vasculitis

Answer 563

IM Benzathine penicillin G for: Primary and secondary stages, latent infections, unknown durations of infection and gummatous/CV syphilis IV aqueous crystalline penicillin G for: Neurosyphilis and congenital infections

Answer 564

Cryotherapy, electrosurgery and radiation therapy

Answer 565

Measures amniotic fluid volume surrounding the fetus. Normal AFI is 5-23cm AFI <5cm – oligohydramnios AFI 24+ cm – polyhydramnios

Answer 566

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

Answer 567

ACL or possibly PCL injury | V unlikely meniscal injuries would cause this

Answer 568

To maintain a mild hyperthyroid state (up to 1.5x normal serum values) Overtreatment can result in fetal hypothyroidism and goiter

Answer 569

Biopsy of the lesion for histopath exam and staining

Answer 570

Phlebotomy or Hydroxychloroquine | IFa can be used in those w/HCV

Answer 571

Reduce cardiac preload w/diuretics and IV vasodilators (in pts w/o HoTN) – will reduce pulmonary edema and dyspnea

Answer 572

High Risk: 1. Prior preeclampsia 2. CKD 3. Chronic HTN 4. DM 5. Multiple gestation 6. AI disease Patients at high-risk for preeclampsia should take daily low-dose aspirin starting at 12 weeks

Answer 573

BSA w/penicillin-resistant anaerobic coverage Most common: Clindamycin + Gentamicin Clindamycin – aerobic G+ cocci and pen-resistant anaerobes (can use amp-sulbactam too) Gentamicin – G- and some G+ (staph)

Answer 574

Ampicillin + Gentamicin **No anaerobic coverage in this combo**

Answer 575

Cefoxitin + Doxycycline

Answer 576

Vancomycin

Answer 577

Vancomycin

Answer 578

C-section (biggest risk factor, esp if started after onset of labor) Chorioamnionitis GBS colonization Prolonged rupture of membranes Operative vaginal delivery BV during pregnancy (but not candidiasis) Preterm (<37wks) and Post-term (42+wks) gestations

Answer 579

Fever >24hr postpartum Uterine fundal tenderness Purulent lochia

Answer 580

An organized cardiac rhythm (sinus bradycardia, aFIb) unable to generate sufficient CO to create a measurable BP or palpable pulse Aka bradycardia w/o pulse or aFIb w/o pulse These are NON-SHOCKABLE rhythms and need immediate, continuous, CPR w/Epi

Answer 581

5 Hs and 5Ts H's: 1. Hypovolemia, 2. Hypoxia, 3. H+ ions (acidosis), 4. Hypo or hyperkalemia, 5. Hypothermia T's: 1. Tension pneumo, 2. Tamponade, 3. Toxins (narcotics, benzos), 4. Thrombosis (PE/coronary), 5. Trauma

Answer 582

For supraventricular tachycardia (aFib w/RVR) in a hemodynamically unstable patient w/a pulse (if they lose the pulse it becomes PEA and need CPR)

Answer 583

Infundibulopelvic/suspensory ligament of the ovary (houses ovarian blood supply) Utero-ovarian ligaments

Answer 584

Hypothyroidism Celiac disease Learning disabilities (although normal intelligence is expected) Should be screened for every few years in childhood and neuropsych testing prior to school entry

Answer 585

Echo and 4-extremity BP measurements for coarctation – can cause neonatal cardiogenic shock May also identify bicuspid aorta although this is not threatening for the newborn Renal US to identify horseshoe kidney – can predispose to UTIs **Turner is caused by sporadic event and is not considered an inherited syndrome – risk is same as general population in subsequent pregnancies and regardless of maternal age**

Answer 586

``` Narrow, high-arched palate Low hairline Posteriorly rotated ears Small maxilla Short, webbed neck Cubitus valgus (elbows bent outward) Short stature Congenital lymphedema (hands and feet swollen at birth) ```

Answer 587

``` Developmental regression Microcephaly Epilepsy Stereotypic hand movements **Girls w/Rett appear normal at birth and have no dysmorphic features** ```

Answer 588

The ratio of MCV to total RBC count In Fe-def anemia the Mentzer index is typically high >13 In thalassemias mentzer index is typically <13 as they have high numbers of RBCs

Answer 589

``` Lead poisoning Sideroblastic anemia Myelodysplastic syndromes Alcoholism Thalassemias ```

Answer 590

Reticulocyte count will first increase w/in 1-2wks and then Hb and Hct will begin to normalize within about a month. Ferritin will not rise until after the Hb has normalized

Answer 591

Only if a patient has persistent severe hyponatremia after water restriction, salt intake and loop diuretics have all failed

Answer 592

Cxs include: Infections, hepatic encephalopathy and renal failure Infections are most important though and occur in up to 50% of pts.; Can develop – UTIs, SBP, resp. infections, aspiration pneumonia or primary bacteremia Can help to prevent infections w/pphx abx – preferred regimen is fluoroquinolone for 7-10d

Answer 593

Prophylactic antibiotics to prevent infectious cxs (SBP, UTI, pneumonia, bacteremia) Fluoroquinolone (Cipro, ofloxacin or norfloxacin) for 7-10d

Answer 594

``` Hydatidiform mole Preeclampsia Anemia Operative vaginal delivery Postpartum depression ```

Answer 595

``` Gastroschisis Omphalocele Preterm birth (risk does not continue w/ subsequent pregnancies after the teenage years) Low birth weight Perinatal death ```

Answer 596

Gastroschisis has no membrane covering intestines and the umbilical cord is found to the L of the defect Omphalocele has membrane covering defect and umbilical cord is attached to that membrane at the apex

Answer 597

All of the following are associated with more severe disease or increased risk of death: Older age Obesity Hematocrit (>44%) CRP – >150 and rising slower than other acute markers (Hct, BUN) a/w severe AP 24-48hrs after admission BUN – 20+ on admission increases risk of death

Answer 598

Oral factor Xa inhibitors (Rivaroxaban) for 3+ months for those who do not have cancer In patients w/underlying malignancy LMWH is considered superior (then must bridge to warfarin)

Answer 599

SSRIs or SNRIs

Answer 600

AD mutation of MEN1 (menin – tm suppressor gene) 3 Ps: Parathyroid adenomas/hyperplasia (most need parathyroidectomy) Pituitary adenomas (prolactin or GH) Pancreatic endocrine tms (ZES, Insulinomas, VIPomas, Glucagonomas) May also have multiple cutaneous lipomas

Answer 601

AD mutations in RET gene (TK receptor gene) MEN2a: Parathyroid hyperplasia, MTC, Pheochromocytomas MEN2b: MTC, pheochromocytomas and Marfan habitus/Mucosal neuromas (oral/intestinal ganglioneuromatosis)

Answer 602

Exercise is contraindicated in pts w/cerclage placement as well as those w/cervical insufficiency, preterm labor during current pregnancy, PPROM, placenta previa or persistent 2nd or 3rd trimester bleeding

Answer 603

Erythrasma

Answer 604

DM – has highest risk of developing and is typically the quickest to occur (w/in months) Subclinical Hypothyroidism Osteoporosis RCC in the native kidney

Answer 605

Mild hypermagnesemia may have decreased DTRs and severe hyperMg causes loss of DTRs Hypomagnesemia can cause increased DTRs (most commonly d/t alcoholism)

Answer 606

Hypocalcemia – occurs d/t volume expansion and hypoalbuminemia or bc of citrate in pts w/massive blood transfusions Causes increased DTRs

Answer 607

SAAG = Serum albumin – Ascitic fluid albumin; >1.1 indicates presence of portal HTN SAAG 1.1+ – CHF, Cirrhosis, EtOH Hepatitis, Budd-Chiari SAAG <1.1 – peritoneal carcinomatosis (ovarian cas), peritoneal TB, nephrotic syndrome, pancreatitis, and serositis

Answer 608

Herbal supplement to tx Anxiety and Insomnia | Can cause severe liver damage

Answer 609

Ginkgo biloba Saw palmetto Ginseng **Besides mild GI upset from saw palmetto this is the only main AE of these supplements**

Answer 610

Insulin resistance, obesity, overt diabetes, metabolic syndrome Pregnancy Crohn disease – seen perianally

Answer 611

Anyone w/asx LVSD (EF 40% or less) Can delay onset of symptomatic HF and improve long-term morbidity and mortality **Once suitable ACEI dose has been achieved a BB should be added**

Answer 612

``` Drugs (sedatives, narcotics) Hypovolemia (diarrhea) Electrolyte changes (hypokalemia) Increased Nitrogen load (GI bleed) Infection (pneumonia, UTI, SBP) Portosystemic shunting/TIPS ```

Answer 613

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

Answer 614

Sensitivity – the probability of a diseased person testing positive Specificity – the probability of a nondiseased person testing negative

Answer 615

Anterior uveitis – characterized by pain, redness, variable visual loss and a constricted and irregular pupil Will see leukocytes in the anterior segment which contains the aqueous humor May also see hazy “flare” which is indicative of protein accumulation secondary to damaged blood-aqueous barrier Tx: antimicrobials for bacterial and viral causes, topical steroids for noninfectious causes

Answer 616

Uvea = Iris, pars planus, choroid and ciliary body Anterior uveitis – iritis; see leukocytes in the anterior segment which contains aqueous humor Intermediate uveitis – pars planitis Posterior uveitis – choroiditis and/or retinitis **May also have hypopyon (pus in anterior chamber) and conjunctival redness**

Answer 617

With severe photophobia and difficulty keeping the eye open | Penlight exam will show corneal opacity or infiltrate

Answer 618

``` ICU admission Fevers >102.2 Severe illness Sepsis CNS infection – meningitis ```

Answer 619

If a patient does not have known diabetes and does not meet diagnostic criteria for DM then it is most likely stress hyperglycemia w/ketoacidosis DM-I patients who present w/DKA as their first sign will still have signs of chronic hyperglycemia – HbA1c 6.5% or greater DM criteria: Random plasma glucose 200+ w/classic sxs of hyperglycemia OR HbA1c 6.5% or more OR Fasting glucose 126+ OR 2hr glucose 200+ during oral glucose tolerance test

Answer 620

Increase Levothyroxine dose 30% at time of positive pregnancy test Measure TSH every 4 weeks after that and adjust dose to trimester-specific TSH norms

Answer 621

Bedside US – much higher sensitivity and specificity (>90%) than portable CXR (50%) Will visualize the parietal and visceral pleuras and the inability to detect lung sliding, the 2 pleural layers moving against each other during respiration, is diagnostic of pnx **In patients w/high suspicion of tension pnx, diagnostic confirmation isn’t needed and treatment (decompression/tube placement) shouldn’t be delayed for it**

Answer 622

HIV – presence of trichomonas increases rates of HIV transmission So both patient and partner need to be treated regardless if they have sxs or are asx

Answer 623

When results from an atypical population are extrapolated into the entire population

Answer 624

Presentation is extremely variable. If it is at all suspected just give IM Epi Any or all of the following sxs may be present: HoTN (often the only symptom) GI distress – N/V, diarrhea, crampy abdominal pain Swelling of lips and tongue Rash, itching, hives Respiratory distress

Answer 625

Glucocorticoids Phenytoin, Carbamazepine PPIs

Answer 626

If there is absence of specific historical or examination findings suggesting an underlying cause initial evaluation should begin with: Spirometry and CXR

Answer 627

aFib – RR intervals will be regular and equal, the baseline b/w RR will be irregular and no discernible P-waves will be identified aFlutter – RR intervals will be regular and equal, baseline will show sawtooth pattern w/back-to-back atrial depolarizations and typically a 4:1 sawtooth to QRS pattern SVT – RR intervals will be regular and equal, mostly see narrow QRS-complexes, have retrograde P waves seen as pseudo S and pseudo R waves. Baseline b/w RR will be regular.

Answer 628

Different types of SVT – sinus tach, AVNRT, AVRT, aFIb and aFlutter In hemodynamically stable pts first identify type of SVT by giving IV Adenosine or w/vagal maneuvers – these will slow AVN conduction and help differentiate the cause of the SVT **In unstable patients they need immediate synchronized direct-current cardioversion**

Answer 629

If there is an obvious deformity on exam or an abnormal scoliometry – spinal rotation 7+ degrees (or 5+ in overweight children)

Answer 630

Cobb angle <10 – considered normal variant, f/u only if new findings (pain, neuro sxs) develop Cobb angle 10+ degrees – observation or back brace Cobb angle 40+ degrees – severe scoliosis, need surgical evaluation **Once puberty/skeletal maturity are complete no tx is needed unless severe deformity is present**

Answer 631

Give Bisphosphonates or Calcitonin in those who can’t tolerate bisphosphonates Symptomatic disease – intolerable pain, etc. Involvement of weight-bearing bones (femur) Neurological involvement Rare indications: Hypercalcemia Hypercalciuria CHF

Answer 632

X-linked recessive for both A and B

Answer 633

This is considered dyspepsia even if there is no associated pain – H. pylori testing first if <60y/o

Answer 634

Endoscopic US and aspiration – will differentiate cyst v. malignancy and guide tx

Answer 635

Secondary bile acids cause colonic stimulation and diarrhea Common post-cholecystectomy, post-ileal resection and in short bowel syndrome Tx w/Cholestyramine (bile salt-binding resin)

Answer 636

No CAD or structural heart disease – Flecainide or Propafenone CAD w/o HF – Dronedarone or Sotalol LV Hypertrophy – Dronedarone or Amiodarone HF – Amiodarone or Dofetilide aFib refractory to meds – radiofrequency ablation

Answer 637

Aka Laryngotracheitis Mild (no stridor at rest) – humidified air (softens secretions) +/- corticosteroids (oral or IM) Moderate/Severe (stridor at rest) – Corticosteroids + Nebulized Epi **Nebulized SABAs (albuterol) have no role in management**

Answer 638

Parainfluenza Bronchiolitis is caused by RSV

Answer 639

Always carotid a. dissection until proven otherwise Occurs in younger patients (~45) Tx: Thrombolysis if w/in 4.5hr of onset; Antiplatelet tx +/- anticoagulation Should get CT or MR angiography right away

Answer 640

Occurs at 20+ weeks gestation, but can occur up to 12 weeks postpartum Tx is the same for postpartum preeclampsia – Mag sulfate + BP control

Answer 641

Series should be completed at 2, 4 and 6 months with an additional dose at 15-18mos and again at 4-6 years Boosters should then be given every 10 years and w/every pregnancy at 28wks **Only contraindications are encephalopathy after previous dose or anaphylaxis to a vaccine component; Immunosuppression of any kind is not a contraindication**

Answer 642

Carcinoid tumor – obstruction can lead to recurrent pneumonia and infection + scarring Can occur at any age but is especially seen in younger non-smokers

Answer 643

Flexible bronchoscopy | CT should be obtained first, but CT cannot diagnose, only a tissue biopsy can

Answer 644

PCI – for refractory angina in patients w/severe single or two-vessel CAD not involving the proximal LAD CABG – superior in pts w/multivessel CAD (especially involving the LAD) and LV dysfunction

Answer 645

Step 1A: Risk factor mgmt. – smoking cessation, BP and DM control, antiplatelet (aspirin) + Statin therapy Step 1B: Supervised exercise therapy Step 2: Cilostazol (PDE3 inhibitor) Step 3: Revascularization for persistent sxs

Answer 646

Almost identical to a leiomyoma – enlarged and irregular uterus w/a mass seen May often also see ascites as free fluid in posterior cul-de-sac Commonly met to the lungs and cause pleural effusions Need hysterectomy urgently to diagnose, stage and treat Should be suspected in postmenopausal patients w/pelvic radiation or tamoxifen use

Answer 647

Often present the same: abdominal pain, fever, leukocytosis | Choledocholithiasis usually also has common bile duct dilation on US, elevated BR and ALP

Answer 648

FSH, LH, testosterone, TSH and prolactin levels | Bone age radiograph

Answer 649

Primary hypogonadism – will have elevated FSH/LH Klinefelter syndrome Secondary hypogonadism – will have low/normal FSH/LH constitutional, chronic illness, malnutrition Hypothyroidism Hyperprolactinemia Kallmann syndrome Craniopharyngioma

Answer 650

Dantrolene

Answer 651

Either fecal antigen testing or urea breath test, but neither should be done until 4 weeks after completion of therapy.

Answer 652

Horizontal lacerations of upper lateral eyelid – may involve the orbital septum and levator palpebrae muscle as well as the lacrimal gland Medial lacerations of the eyelid likely to injure canaliculi as well as the punctum, nasolacrimal duct and lacrimal sac

Answer 653

Rectal mucosal suction biopsy – will show absence of ganglion cells Commonly a/w Down syndrome

Answer 654

Causes decline of LVEF and although usually asx may lead to overt clinical HF However, there is typically complete recovery of cardiac fxn after trastuzumab is dc’d **It is not dose-related as is the irreversible cardiotoxicity a/w anthracyclines (doxorubicin)**

Answer 655

At B-hCG levels >1500

Answer 656

Stool culture Immunoassay for Shiga toxin Fecal leukocyte count

Answer 657

Preschool age or focal lung findings – most common cause S. pneumo; tx w/high-dose amoxicillin Older child or well-appearing w/bilateral lung findings – most common cause M. pneumo; tx w/Azithromycin

Answer 658

Naltrexone – can be initiated while still drinking, but is contraindicated in those taking opioids, or who have acute hepatitis or liver failure Acamprosate can also be used as 1st line therapy

Answer 659

With total T3 and free T4 – TSH may remain suppressed for several mos after initial therapy and therefore does not accurately reflect thyroid functional status

Answer 660

Capnography w/persistent waveform w/ventilation

Answer 661

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.

Answer 662

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

Answer 663

Preeclampsia (increased BP + urine proteins after 20 wks) Nausea/vomiting RUQ abdominal pain

Answer 664

New-onset HTN (SBP 140+ and/or DBP 90+) at 20+ weeks gestation PLUS proteinuria &/or end-organ damage

Answer 665

``` SBP >160 or DBP 110 (2x 4hrs apart) Thrombocytopenia Increased Creatinine Increased Transaminases Pulmonary edema Visual or cerebral sxs (hyperreflexia/clonus) ```

Answer 666

W/out severe features – delivery at 37+ weeks W/severe features – delivery at 34+ weeks Mag sulfate for seizure pphx + Anti-HTNs should be started first in regardless of gestation *C-section is not indicated unless there is a contraindication to labor, or there's a non-reassuring FHR*

Answer 667

Mag sulfate – given immediately on diagnosis and continued for 24hrs after delivery.

Answer 668

Paradoxical abdominal wall retraction during inspiration while lying supine Patients often have SoB worse while supine that can be mistaken for a cardiac origin of dyspnea

Answer 669

Adverse drug events; Second is hospital acquired infection In patients undergoing an operation/procedure then operative/post-procedure adverse events become the most common; These include wound infections, bleeding and DVTs

Answer 670

First apply direct compression w/nostril pinching, if this fails add topical vasoconstrictor (Oxymetazoline) via squirt bottle or cotton pledget. If this fails next step is chemical (silver nitrate) or electrical cautery, then anterior nasal packing w/bacitracin covered sponge if there is continued bleeding. **If bleeding appears to be posterior then nasal packing needs to be done, but this is much less common**

Answer 671

With methylene blue instillation into the bladder – positive test will turn tampon in the vagina blue d/t leakage through the fistula

Answer 672

Urethral hypermobility – >30-degree angle of movement during Valsalva is diagnostic

Answer 673

If the patient has otitis w/a completely occluded ear canal

Answer 674

Differentiated epithelial thyroid cancer = Papillary and Follicular Small, low-risk tms: Target TSH 0.1-0.5 for 6-12mo and then kept at low normal range (0.5-1ish) Intermediate risk: Target TSH 0.1-0.5 Large, aggressive tms: Target TSH <0.1 and should be continued at this level for several years **Suppressing TSH will decrease risk of recurrent disease**

Answer 675

Lesions should be removed/destroyed at time of detection Individual lesions – liquid nitrogen cryosurgery, surgical excision or curettage Numerous lesions – field therapy w/5-FU cream (best), imiquimod cream, topical diclofenac or photodynamic therapy

Answer 676

Age and FEV1 (<40% indicates severe disease) | After adjusting for age, FEV1 is the single most important factor to determine prognosis

Answer 677

aka those w/SLE, organ transplant, etc. | Screening should start at onset of sexual intercourse and should occur annually w/pap and HPV cotesting

Answer 678

Enodcardial cushion defect

Answer 679

``` Acute leukemia Alzheimer-like dementia Autism ADHD Atlanto-axial instability Depressive disorder Duodenal atresia Seizure disorder Hypothyroidism ```

Answer 680

Maternal – PPROM, preterm labor, postpartum endometritis | Fetal – neonatal conjunctivitis and neonatal pneumonia

Answer 681

Difficulty in copying simple line drawings, most commonly seen in patients who have damage to their nondominant parietal lobe May also have confusion and dressing apraxia (difficulty in wearing cloths, and getting dressed) as these are also common in parietal lobe lesions

Answer 682

Visual disorders – homonymous upper quadrantanopia | Auditory agnosia – impaired perception of complex sounds

Answer 683

Often occurs w/damage to the dominant parietal lobe Patients can have acalculia (difficulty performing simple math), finger agnosia (inability to name individual fingers), agraphia, and R/L confusion (difficulty identifying the R from L side of the body)

Answer 684

Anti-hyperglycemic therapy should be stopped after delivery of placenta Obtain fasting glucose at 24-72hr and then do 2hr 75g GTT at the 6-12 week postpartum visit These patients should also undergo DM screening every 3 years as they are at increased risk

Answer 685

All patients w transferrin saturation 30% or less and ferritin 500 or less These patients may have normal iron stores but can’t mobilize them, also ferritin is an acute phase reactant and can be increased d/t the inflammation a/w ESRD therefore it is a poor indicator of Fe-status in patients w/ESRD

Answer 686

Often in childhood after an oxidative stress w/jaundice, pallor, dark urine + abd/back pain May also occur in neonatal period w/jaundice and anemia on day 2-3 of life and rapid increase in unconjugated BR (differentiated from ABO incompatibility based on timing, ABO <24hrs, and other physiologic jaundice by the presence of anemia which is not seen in physio jaundice) X-linked disease

Answer 687

Cat bites are considered high risk for infection and always require abx regardless of the cleanliness or benign appearance of the wound Tx: amoxicillin-clavulanate

Answer 688

Labor protraction: cervical dilation 1cm or less/2hr during the active phase of labor (6cm-10cm cervical dilation) Tx: Oxytocin + amniotomy (artificial rupture of membranes) are first line therapies

Answer 689

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

Answer 690

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

Answer 691

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

Answer 692

No long-term sequelae but they are at increased risk for subsequent febrile seizures and have slight increased risk of epilepsy (~1%)

Answer 693

Metaplasia but no dysplasia: PPI + surveillance endoscopy in 3-5 years Low-grade dysplasia: PPI + surveillance endoscopy 6-12mo OR endoscopic eradication High-grade dysplasia: Endoscopic eradication therapy (ablation, mucosal resection)

Answer 694

Alloantibodies – most commonly seen in pts w/multiple transfusions (SCD, myelodysplasia) **Side note: RBCs do not express HLA antigens**

Answer 695

Features: Amenorrhea at age <40 Hypoestrogenic sxs (hot flashes) Increased FSH (increased/normal LH), decreased Estrogen Tx: Estrogen therapy + progestin if patient has an intact uterus (reduces risk of endometrial ca) Continue therapy until around normal age of menopause (50) and then dc

Answer 696

``` Turner syndrome (45,XO) Fragile X Autoimmune oophoritis Anticancer drugs Pelvic radiation Galactosemia ```

Answer 697

aka Parinaud syndrome – specific manifestation of cat-scratch disease Presents w/lymphadenitis (often chronic, >2wk) of the preauricular or cervical nodes with involvement of the conjunctivae – conjunctivitis w/clear drainage Typically self-resolving but sometimes the LNs can suppurate and drain onto the skin (needle-aspiration can prevent rupture and relieve sxs) Tx not always indicated but Azithromycin can accelerate recovery

Answer 698

Limited plaque psoriasis – topical glucocorticoids or Vit. D derivatives (calipotriene) Extensive plaques or joint involvement/arthritis – methotrexate or other biologics

Answer 699

IV abx that cover Pseudomonas – anti pseudomonal B-lactam (pip-tazo) + aminoglycoside Others that can be used: select cephalosporins, monobactams, fluoroquinolones and carbapenems Usually does not require surgery/debridement like nec fasc which it commonly resembles – can differentiate based on pain – ecthyma gangrenosum is typically painless

Answer 700

Typically resemble Type II DM and is characterized by insulin resistance rather than insulin deficiency like seen in type I. DKA is very uncommon in these patients

Answer 701

Stress-induced hyperglycemia | Type-I DM

Answer 702

Peripheral nervous system: Schwann cells (implicated in acoustic neuromas) Central nervous system: Oligodendrocytes

Answer 703

When a patient develops petechiae after BP cuff inflation on their arm for 5 min Often seen in Dengue hemorrhagic fever

Answer 704

If a mass is identified and is persistent, has complex features (septations), and/or is >10cm in diameter Surgery should be done in the early second trimester to prevent complications.

Answer 705

EHLERS-DANLOS!!!!!! | Not Marfan, they get aortic dissection and lens dislocations and shit

Answer 706

Psychosocial intervention w/social skills training Meds so far have not shown proven benefits in targeting negative sxs and mood stabilizers should not be added as negative sxs are not the same as depression.

Answer 707

``` Migraine w/aura 15+ cigs/d AND age 35+ HTN >160/100 Heart disease DM w/end-organ damage Hx of thromboembolic disease Antiphospholipid-Ab syndrome Hx of Stroke Breast ca Cirrhosis and liver ca Major surgery w/prolonged immobilization Use <3wks postpartum ```

Answer 708

New onset fever, increased secretions, new/worsening pulmonary infiltrates and increased requirement for ventilatory support in a patient ventilated for 48+ hrs Commonly occurs as a complication of ARDS Other signs: leukocytosis, tachypnea, and decreased oxygenation **respiratory sampling (tracheobronchial aspirate/BAL) is necessary for culture and microscopy to tailor abx**

Answer 709

Often caused by: E. coli, Strep spp., MRSA, Pseudomonas (microaspiration of virulent oropharyngeal organisms) Tx: Imipenem or meropenem, pip-tazo or cefepime, gentamicin AND vancomycin or linezolid - Tracheobronchial aspiration or BAL must be done for culture/microscopy to tailor abx regimen d/t increased resistance of VAP-associated organisms

Answer 710

Cariogenic syncope – can happen in any age, but commonly in elderly w/structural heart disease. Often have no signs/sxs by time of presentation to ED or office Can be exertional (d/t AS or HCM), have preceding sxs like fatigue/dizziness (sick sinus syndrome), or nonexertional w/no preceding sxs (Vtach, TdP) These patients need inpatient monitoring w/tele to detect the arrhythmia + echo to look for structural heart disease

Answer 711

``` Folate deficiency – #1 Pregestational DM Maternal fever in 1st trimester Maternal obesity Genetic factors ```

Answer 712

NTDs require urgent neonatal surgical repair, and over half of infants who undergo repair of an NTD get hydrocephalus requiring a VP shunt

Answer 713

If the pregnant mother had an episode of acute pyelonephritis – they need immediate IV abx during the episode and then once it has resolved require daily abx suppression until after delivery to prevent pyelo-associated cxs (preterm labor, sepsis, ARDS)

Answer 714

Side Effects: unscheduled bleeding (most common), weight gain, HA Contraindication: progesterone receptor+ breast cancer This is the most effective form of contraception (even higher than sterilization and IUDs)

Answer 715

Initial test should be for detection of Anti-IF Abs (anti-parietal Abs are not commonly tested for as they’re much less specific than anti-IF in diagnosing pernicious anemia) Schilling can be done as a 2nd-line if anti-IF is negative

Answer 716

Pernicious anemia is a/w autoimmune metaplastic atrophic gastritis (AMAG) – immune response mainly directed against oxyntic cells and IF. There are 3 main components of AMAG: 1. Absent rugae in the fundus and sometimes body/glandular atrophy 2. Intestinal metaplasia 3. Inflammation The gastric body and fundus are the main areas affected; typically see little/no changes in the antrum

Answer 717

``` n-REM disorders (sleep walking, sleep terrors), occur during the first 1/3 of sleep/slow wave sleep, the patients have amnesia of the event REM disorders (nightmares), occur during second ½ of sleep, the patients have detailed dream recall or act out their dreams during the event Don’t need tx unless episodes are frequent, persistent & distressing – give low-dose benzo ```

Answer 718

Often in neutropenic patients, those w/CVCs used for TPN, and in severely ill pts in the ICU Sxs: fever, decreased visual acuity, and eye pain Fundoscopy: focal, glistening white, mound-like lesions on the retina that may extend into the vitreous w/resultant vitreous haze

Answer 719

Vitrectomy + intravitreal antifungal injection + systemic antifungal (amphotericin B; can consider using fluconazole or voriconazole instead, but not ketoconazole)

Answer 720

With fever, cough, pleurisy and weight loss Thoracentesis often shows lymphocyte-predominate, exudative effusion w/elevated ADA Often require pleural biopsy to diagnose as pleural fluid smear is usually aseptic

Answer 721

HIV patients w/high or normal CD4 counts typically present as expected w/apical cavitary lesions Patients w/low CD4 counts cannot mount a sufficient cell-mediated defense to create cavitations and often present w/lobar, pleural, or disseminated infections.

Answer 722

Physiologic genu varum from 6mos up to 3yrs (after 3 yrs need investigation) Straight legs are typical around age 2 Physiologic genu valgum from 4yrs on Straight legs by >7yrs, if not need imaging and investigation

Answer 723

Aneurysms of the posterior communicating a. or rarely cavernous-carotid aneurysms SAH d/t rupture of these aneurysms is typically what causes the palsy, but can get prodromal sxs (diplopia) from their mass effects prior to rupture

Answer 724

Primary is caused by an intrinsic defect of the MV apparatus – leaflets, chordae tendineae (MVP is one of the most common causes) Secondary/Functional occurs d/t a disease process involving the LV (MI, DCMP, etc.)

Answer 725

Most healthy patients LVEF 50% or less is considered impaired systolic function In patients w/severe, chronic MR, LVEF 60% or less is considered impaired function

Answer 726

In the presence of associated sxs – dyspnea on exertion, HF Or specific echo findings – LA and LV enlargement, regurgitant jet prominence LVEF <60% is considered systolic dysfunction in these patients bc a large portion of the LVEF flows back into the LA and underestimates the EF.

Answer 727

``` Subacute (de Quervain, subacute granulomatous) thyroiditis Silent (painless) thyroiditis Postpartum thyroiditis Surreptitious thyroid hormone abuse Iodine-induced thyroiditis ```

Answer 728

Typically NSAIDs are enough, and relieve the associated pain; may give glucocorticoids for severe or refractory cases BBs can also be added to minimize the sxs (sweating, palpitations) Anti-thyroid meds (PTU, MTZ) have no role

Answer 729

Graves and nodular thyroid disease

Answer 730

Metformin **In contrast, sulfonylureas will worsen obesity and do not improve lipid profiles**

Answer 731

Pre-exposure pphx: Rabies vaccine on days 0, 7 & 21 or 28 Post-exposure pphx; unvaccinated: Rabies vax on days 0, 3, 7 & 14 + Rabies Ig on day 0 Post-exposure pphx; previously vaccinated: Rabies vax on days 0 & 3

Answer 732

Can have any or all of the following: Meningitis – HA, confusion, N/V, stiff neck, photophobia (more subacute presentation than bacterial meningitis) Ocular – posterior uveitis, decreased visual acuity, photophobia Meningovascular – infectious CNS arteritis causing ischemia and/or infarction Otosyphilis – tinnitus, sensorineural hearing loss (often unilateral) Cranial neuropathies – most commonly of the optic, facial or auditory nerves **These most commonly occur during the secondary stage of syphilis and will also see signs of this – generalized maculopapular rash involving palms/soles, LAD**

Answer 733

Osmotic laxatives Stimulant laxatives can be used for acute disimpaction as well as enemas but these should not be used everyday as part of a long-term therapy

Answer 734

Often leads to misclassification of exposure

Answer 735

First: clinical criteria – imaging evidence, absence of confounding factors, etc. Second: neuro exam showing coma w/absent cerebral and brainstem reflexes Third: apnea test to confirm brainstem failure If all of these are positive then brain death can be diagnosed; if any are inconclusive then ancillary testing should be performed (EEG, CTA, transcranial Doppler, etc.)

Answer 736

``` Benzos Antipsychotics (haloperidol) can be used if benzos fail but should not be first line ```

Answer 737

Cause: ABO incompatibility (more common in those requiring multiple transfusions – can develop Abs to common Rh, Kell, or other blood group Ags) Timing: within 1hr of transfusion start Features: fever, flank pain, hemoglobinuria, + Coombs test Cxs: DIC, renal failure (d/t immune complex deposition) Tx: stop transfusion and aggressively hydrate w/NS (not ringers or dextrose) – treats HoTN and prevents renal failure

Answer 738

To increase the amount and activity of ADAMTS13, a plasma metalloprotease

Answer 739

Both will cause thrombocytopenia, bruising and petechiae, but only TTP will cause MAHA leading to schistocytes on PBS, elevated direct BR, LDH and aminotransferases

Answer 740

TTP – auto antibodies against ADAMTS13, a metalloprotease, that cleaves vWF ITP – auto antibodies against platelet antigens

Answer 741

In high doses often needed in chemo patients it can cause EPS and drug induced parkinsonism

Answer 742

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.

Answer 743

Itchy rash, worse at night, involvement of the webbed-spaces on the hand May also be seen on the forearms, elbows, axilla, waist, genitalia, knees, thighs and feet Tx: topical permethrin (1 application) or 1-2 doses oral ivermectin

Answer 744

Often d/t protozoal infection w/Entamoeba histolytica Manifestations begin 8-20wks after inoculation and include: fever, RUQ pain, nonspecific systemic sxs (malaise, nausea); May or may not have recent hx of dysentery US will show round, well-defined hypoechoic mass in the R hepatic lobe. Dx w/blood serology and antigen detection; aspiration not required to diagnose but often resembles “anchovy paste” (thick, dark brown fluid) and is aseptic w/neg gram stain

Answer 745

Both typically present w/the same sxs and appear similar on imaging Differentiation must be done w/E histolytica serologic or antigen testing If testing is negative aspiration can be done – pyogenic abscesses will typically have positive cultures and gram stains, whereas amebic abscesses will likely be negative and aseptic

Answer 746

Ingestion time <24hrs AND asymptomatic – observation + repeat XR in 12-24hrs Ingestion time 24+hrs, or unknown OR symptomatic – endoscopic coin removal

Answer 747

Post-op adhesions, hernias (incarcerated), and tumors

Answer 748

For those who do not have indications for surgery, the mgmt. should be close monitoring of the serum Ca2+, creatinine and DEXA testing

Answer 749

Atorvastatin and Rosuvastatin

Answer 750

Erythematous plaques w/central clearing; Usually begins on the extremities Most occur d/t underlying infections (>90%), common causes: HSV (#1 cause), M. pneumoniae Other causes: drugs (sulfas, B-lactams, phenytoin), cancers and AI diseases

Answer 751

HCC arises from hepatocytes/liver parenchyma | Liver interstitial cells play no role in the development of HCC

Answer 752

Lymphocyte-dominant leukocytosis – aka will look like virus but needs abx (macrolide)

Answer 753

Asymptomatic – elective surgery in 1-2wks (regardless of age) Immediate surgical repair for incarceration

Answer 754

Age 50 or greater to all immunocompetent individuals

Answer 755

Presence of coagulation factor inhibitor – antibodies against coagulation factors Common Abs: antiphospholipid Abs, inhibitors of factors VIII, IX, and XI VIII inhibitors cause “acquired hemophilia” and lab results will mimic inherited hemophilia. Just as dangerous These can occur independently or be a/w malignancy, pregnancy, lymphoproliferative disorders or rheumatic disease

Answer 756

Retroperitoneal bleed – can have acute, severe RLQ pain and +psoas sign Hemorrhage can occur even if the INR is w/in the therapeutic range Need a CT abdomen STAT

Answer 757

Protamine sulfate

Answer 758

Hypercalcemia – shortened interval | Hypocalcemia – prolonged interval

Answer 759

Unilateral (most common) – chronic nasal discharge and sxs begin in childhood Bilateral – cyanosis that worsens w/feeding, improves w/crying, noisy breathing (stertor), sxs present shortly after birth Both may be a/w CHARGE syndrome Dx by inability to pass catheter past nasopharynx; confirm w/CT or nasal endoscopy

Answer 760

Malignant effusions automatically makes the cancer stage IV/incurable and therefore care should be palliative – recurrent thoracocenteses for slow accumulating effusions, chemical pleurodesis for more aggressive/rapidly accumulating effusions. Pleural catheter is another option but has risk of infection.

Answer 761

Ventricular arrhythmias

Answer 762

Prolonged PR interval

Answer 763

Cigarette smoking

Answer 764

Primary prevention: Prior MI w/LVEF 30% or less NYHA class II or III sxs w/LVEF 35% or less Secondary prevention: Prior VF or unstable VT w/o reversible cause Prior sustained VT w/underlying cardiomyopathy

Answer 765

Those with moderate-severe HF, an LVEF 35% or less, and a widened QRS (>120msec)

Answer 766

Activated protein C resistance caused by Factor V Leiden | Account for about 50% of all inherited thrombophilias

Answer 767

Sodium Bicarb is the #1 choice to stabilize the cardiac membrane and decrease QRS, but Lidocaine may also be used is Sodium bicarb is ineffective Mag Sulfate is often used to decrease QRS prolongation but is not first line, can be added later if there is persistent arrhythmia Physostigmine is used in isolated anticholinergic toxicity, but TCAs have mixed MoAs and therefore it is contraindicated as it can cause cardiac arrest in TCA toxicity Flecainide is contraindicated and will worsen QRS prolongation

Answer 768

NE and Serotonin reuptake inhibitors (antidepressant effects) Antihistamines (results in sedation) A1-antagonists (results in HoTN, worsens BPH/BOO) Cardiac Na+ channel blockers (results in conduction delay/QRS prolongation) Anticholinergics (dry mucous membranes, pupillary dilation)

Answer 769

Mag Sulfate – will decrease QRS prolongation

Answer 770

Hx and sxs of obesity and obesity related cxs: Back pain, OA, atherosclerotic CD, sleep apnea Biometric measurements: BP and pulse, Weight, BMI, Waist circumference Lab studies: Glucose (or HbA1c), TSH, lipids, hepatic enzymes **must assess for complications and reversible causes when overweight/obesity is diagnosed**

Answer 771

Step 1: lifestyle modifications – exercise 20-30min/d, 5-7d/wk, diet low in calories and fat or Mediterranean diet, decrease portion sizes *If fail to lose wt + have BMI 30+ or 27-29 and have comorbidity move to step 2 Step 2: Drug therapy options – orlistat (often 1st line), phentermine/topiramate, buprorion/naltrexone, liraglutide **If fail to lose wt and have BMI 40+ or 35+ and comorbidity proceed to step 3 Step 3: Bariatric surgery

Answer 772

If a patient is obese (BMI 40+ or 35+ and has a comorbidity) and has already failed lifestyle modifications and drug therapy **comorbidities/obesity-related cxs include: HTN, impaired glucose tolerance, DM, dyslipidemia, sleep apnea**

Answer 773

Both will present w/dysentery and abdominal cramps EHEC is often afebrile and is a/w animal exposure (farms, petting zoos), or ingestion of undercooked beef Shigella is commonly febrile and is not a/w animal exposure, but is contracted through contaminated food or water **both will have shiga toxin present**

Answer 774

Salmonella – a/w pets, poultry and turtles; often does not produce dysentery and is seen as non-bloody diarrhea, but can be bloody EHEC – a/w farms, petting zoos, etc.; almost always bloody and afebrile

Answer 775

EHEC does NOT ferment sorbitol which is evident by growing it on sorbitol-MacConey agar

Answer 776

If they have proven infection with EHEC – increased chance of developing HUS

Answer 777

Aka TIBC 20%-50% In Fe-deficient anemia levels typically drop below 10%

Answer 778

Increased Hepcidin in setting of inflammation leads to decreased release of Fe from macrophages and decreased Fe absorption from the gut. Most often it is normocytic but can become microcytic Always nonhemolytic so will have normal BR levels Labs: decreased Fe, decreased TIBC (opposite of Fe-def), and increased ferritin (acute phase reactant) **Only time it should be treated is in setting of CKD – give EPO, otherwise just correct underlying disease; Fe plays no role in tx as they have normal iron stores they just can’t mobilize them properly**

Answer 779

Radiation and Drugs – benzene, chloramphenicol, alkylating agents, antimetabolites, phenytoin Viruses – parvoB19, EBV, HIV, hepatitis viruses Faconi anemia – DNA repair defect leading to bone marrow failure Idiopathic **All cell lines will be deficient, but will have normal cell morphology on PBS**

Answer 780

Hairy Cell leukemia – fibrosis of bone marrow Aplastic anemia – fatty infiltration of bone marrow Both will cause pancytopenia and have all cell lines down

Answer 781

circular, naked, dsDNA viruses JC virus – causes PML in HIV pts BK virus – common in transplant patients, attacks kidneys and causes nephritis Has basophilic intranuclear inclusions like CMV and HSV

Answer 782

Children comprise about 50% of enrollees but only about 15% of the expenditures Elderly and disabled comprise much smaller percentages but consume a disproportionately larger portion of expenditures. **Medicare is only for 65+ and disabled, low-income adults and children are not covered**

Answer 783

If they have an estimated fetal weight >9.9lb by US – do C-section at 39 weeks to avoid risks of shoulder dystocia

Answer 784

BBs (Metoprolol), TCAs (amitriptyline), and anticonvulsants (valproate)

Answer 785

Dopamine antagonsits (metoclopramide, chlorpromazine) – help w/N, V and pain Ergotamines +/- caffeine or analgesics Selective serotonin agonists – Triptans (sumatriptan)

Answer 786

**Goal is to sustain PaO2 at 55-80, and O2 saturation 88-95%** Low tidal volume is most important – prevents alveolar overdistention and barotrauma FiO2 should be lowered <60% as quickly as possible to prevent O2 toxicity High PEEP (up to 15-20) – prevents alveolar collapse and improves oxygenation when FiO2 is <60% Higher respiratory rates (35 or less) to maintain adequate minute ventilation Plateau pressure 30 or less

Answer 787

DM Secondary hypogonadism – see low/normal testosterone and decreased sex drive Hypothyroidism

Answer 788

Vaginal clotrimazole, miconazole and nystatin – all are safe in all trimesters

Answer 789

Urine chloride level Appropriately low urine Cl levels (<20): External loss of gastric acid – vomiting, NG suctioning Inappropriately elevated levels: Diuretic therapy, Inherited sodium wasting disorders – Gitelman and Bartter syndromes

Answer 790

Furuncle is infection of one single hair follicle, carbuncle involves multiple and often has systemic sxs as well. Most common cause is S. aureus and often MRSA Abx w/MRSA coverage are required: Clindamycin, TMP-SMX, or doxycycline I&D is also warranted a well

Answer 791

TTE or TEE to assess for IE Even if the patients have clear evidence of osteomyelitis, biopsy of bone for culture is not warranted, but echo is always needed

Answer 792

Endoscopic cholangiogram or MRCP Often though lab abnormalities are enough – show cholestatic pattern w v. high ALP and BR 90% of pts. w/PSC have UC

Answer 793

Hypoplastic left heart syndrome Severe coarctation of the aorta Differentiate by cyanosis and HoTN in all extremities in HLHS v. only lower extremities in coarctation **ToF and Truncus arteriosus are also cyanotic defects but are not ductal dependent and will not worsen w/its closure around day1 of life**

Answer 794

Severe necrotizing pneumonia caused by S. aureus Often presents w/acute pulmonary sxs, rapid decompensation and a lower lobe infiltrate + cavitation Common TNF inhibitors: etanercept, adalimumab, certolizumab, infliximab, golimumab

Answer 795

If a pregnant woman has any type of positive anti-Rh(D) Ab titer (even as low as 1:1, 1:2) then alloimmunization has already occurred and therefore they should not receive anti-D Ig as it will not be effective at preventing alloimmunization

Answer 796

It is an AR inherited lysosomal storage disorder d/t glucocerebrosidase deficiency Glycolipids (glucocerebrosides) accumulate w/in the lysosomes of macrophages, which infiltrate and disrupt various organs Type I GD is most common and has varying severities which can present at any time from early childhood to late adulthood.

Answer 797

Maple syrup urine disease and phenylketonuria Can present in infancy w/acute decompensation after protein feeding or later in childhood w/developmental delay or regression

Answer 798

Lesch-Nyhan Gout ADA deficiency

Answer 799

To prevent postherpetic neuralgia

Answer 800

Eosinophilia and eosinophiluria – help differentiate it from contrast-induced nephropathy Will not see the cholesterol crystals a/w atheroemboli as they remain in the blood vessels and don’t enter the urine

Answer 801

RCCa – often palpable in the flank region or abdomen, nontender and moves w/respiration In contrast, colon and ovarian masses may be palpable in similar areas, but typically do not move w/respiration.

Answer 802

Need a urate-lowering drug – allopurinol is DoC While initiating therapy patients should also be placed on a prophylactic drug to prevent flares during this period – low dose colchicine is 1st line, but NSAIDs can also be used

Answer 803

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)

Answer 804

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

Answer 805

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

Answer 806

Cell-free fetal DNA – has high sensitivity and specificity. If the results of this are abnormal then the more invasive chorionic villus sampling can be taken and confirm the diagnosis w/fetal karyotyping.

Answer 807

Second trimester (15-20 weeks)

Answer 808

First trimester (10-13 weeks)

Answer 809

First trimester (10+ weeks) in patients at risk for aneuploidies (>35)

Answer 810

Decreased AFP Increased hCG Decreased estriol Increased inhibin A

Answer 811

Decreased AFP Decreased BhCG Decreased estriol Normal or low inhibin A

Answer 812

Contraindicated in pts w/PUD and should be avoided in renal failure

Answer 813

CPP: early maturation of HPG axis; see typical pubertal sequence w/breast or testicular development first, followed by pubic and axillary hair development PPP: d/t excess sex hormone; see pubic and axillary hair development first, and often no development of breast or testes. Often have other features of adrenarche such as acne or hirsutism and oligomenorrhea in girls. **Both present w/advanced bone age**

Answer 814

``` Nonclassic CAH Estrogen-secreting ovarian cysts Exogenous estrogen exposure DHEAS producing adrenal tms. Aromatase excess McCune-Albright syndrome Leydig-cell testicular tms. (produce androgens or estrogen) ```

Answer 815

Hypothalamic or pituitary tms. Idiopathic precocious puberty Primary Hypothyroidism (TSH activates FSH) Tuberous sclerosis (d/t brain hamartomas) NF1 (rare, but optic gliomas can effect the hypothalamus)

Answer 816

2x/d NPH insulin or 1x/d insulin glargine at bedtime. | If a patient is experiencing hypoglycemic episodes it is likely these that will need to be adjusted

Answer 817

NO! Only organs, bone marrow, and platelets

Answer 818

When the control group in a controlled trial unintentionally receives the tx or intervention, thereby reducing the difference in outcomes b/w the control and treatment groups. Not a bias seen in observational studies

Answer 819

Mitral facies – pink/purple patches on cheeks Loud S1, loud P2 if pHTN is present Opening snap (high-freq early diastolic sound) Mid-diastolic rumble (low-pitched, best heard at apex) Sxs reported: dyspnea, orthopnea, PND, hemoptysis, aFib, thromboembolisms, hoarseness from RLN compression d/t LA enlargement

Answer 820

Serum calcitonin and CEA measurements Neck US Genetic testing for RET mutations: if positive need metanephrine measurements before thyroidectomy to rule out pheo and cxs it can cause during surgery

Answer 821

Salicylate toxicity – the sedation and paralysis in prep for intubation can acutely worsen acidosis and exacerbate the toxicity. In addition normal ventilation strategies often cannot mimic the high RR providing beneficial alkalosis in these patients. Intubation should be reserved for those w/significant hypoventilation and respiratory failure

Answer 822

A PDE-3 inhibitor – aka antiplatelet | Can be used in PVD and intermittent claudication when lifestyle and exercise interventions fail

Answer 823

Hyperthyroidism may cause mild hypercalcemia as a result of the increased bone turnover a/w hyperthyroidism

Answer 824

Q fever – caused by coxiella burnetii; spores inhaled as aerosols and a/w cattle or sheep amniotic fluid May also present as pneumonia

Answer 825

Macrocytic anemia and B12 deficiency | Will also have +Lactulose breath test

Answer 826

Dapsone + Gluten-free diet

Answer 827

In the setting of malingnancy or trauma | They are NOT recommended in the setting of suspected infection/epidural abscess

Answer 828

It is the number of new cases of disease occurring in a specified population in a given period IR = (# of new cases of disease during a period) / (Total person times contributed by the at-risk population)

Answer 829

Most commonly seen in young patients Those w/conduction abnormalities (Brugada, Congenital long QT) are more typically to suffer from non-exertional SCD Those w/structural abnormalities (HOCM, AAOCA) often experience exertional SCD

Answer 830

Associated w/Sarcoidosis – get erythema nodosum, hilar adenopathy, migratory polyarthralgia and fever

Answer 831

Facial n. palsy Central DI Hypercalcemia Can also cause adrenal insufficiency

Answer 832

Serotonin release assay

Answer 833

Mycoplasma genitalium – tx w/moxifloxacin

Answer 834

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)

Answer 835

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

Answer 836

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)

Answer 837

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

Answer 838

Needs referral to ortho for tx – most need hip in brace that flexes and abducts it for 3+mos, but needs close monitoring by ortho for cxs of this harness position Most infants who are tx’d early have no long term sequelae but need monitoring until skeletal maturity to monitor for recurrent dysplasia

Answer 839

Labyrinthitis is vestibular neuritis + hearing loss | Often post-viral

Answer 840

Intranasal glucocorticoids – often cause epistaxis, can be prevented by adding nasal saline rinses

Answer 841

Croup has short prodrome of rhinorrhea and fever followed by abrupt onset of stridor, hoarseness and harsh, barking cough Pertussis has longer prodrome (10-14d) of rhinorrhea, cough +/- fever followed by weeks of increasingly severe cough. Not likely to have stridor or abrupt onset of cough.

Answer 842

If ARS does not improve w/in 7-10d of symptomatic tx or if it worsens acutely after initial improvement

Answer 843

Basically the same as any other cause of ADHF First initiate loop diuretic to get prompt symptom relief Then need to decreased both preload and afterload Direct arterial dilator (Hydralazine) decreases afterload Long acting nitrate (isosorbide mononitrate) decreases preload These will lessen contractile demands of left ventricle **Once the acute decompensation is adequately treated a BB should be added, and digoxin can be used for conduction abnormalities or persistent sxs despite adequate diuresis and vasodilator tx**

Answer 844

Psychogenic polydipsia – check serum Na+ levels for possible hyponatremia causing the delirium, may also lead to seizures although this is uncommon

Answer 845

Hydroxychloroquine | MTX, leflunomide, cyclophosphamide and mycophenolate are all contraindicated

Answer 846

Anti-SSA (Ro) and anti-SSB (La) – these also increase risk of congenital heart block

Answer 847

Analgesics + supplemental oxygen | Common in young males w/hx of lung disease, respiratory infection or hx of inhalational drug use

Answer 848

Proteinuria – higher urine protein concentrations are a/w more rapid decline in renal function HTN, hyperglycemia and African American and Asian decent are also risk factors

Answer 849

Impaired H+ excretion causes hyperchloremic, hypokalemic non-anion gap metabolic acidosis. Hypercalciuria from chronic acidosis and a urine pH >5.5 predispose to recurrent stones

Answer 850

HSV and H. ducreyi | lymphogranuloma venereum and syphilis are PAINLESS

Answer 851

If it is cyclic, bilateral and diffuse, patients can be observed unless a mass is palpated, then get imaging If it is noncyclic, unilateral and focal w/o a mass – need imaging; if mass is present then biopsy and refer to breast surgeon

Answer 852

IVF to increase renal excretion + calcitonin for short-term reductions Long-term need to be treated w/bisphosphonates (zolendronic acid)

Answer 853

If the hypospadias is accompanied by cryptorchidism – do pelvic US to look for uterus and karyotype to identify sex chromosomes If accompanied by other organ system abnormalities (CHD, cleft lip) then need upper tract imaging w/renal US

Answer 854

Miliary TB Will see multiple organs effected – pulmonary (cough, night sweats), liver (RUQ pain, vomiting, increased transaminases), CNS and adrenal glands can also be involved **More common in recently incarcerated individuals**

Answer 855

Trancranial Doppler US – assess risk of stroke Done from age 2-16 Those w/high TCD velocity need chronic transfusion therapy to prevent stroke

Answer 856

Resistant HTN Coronary artery disease Cardiac arrhythmias (aFib, bradycardia, ventricular ectopy) HF

Answer 857

Tidal volumes and respiratory rate affect ventilation – will optimize the pH and PaCO2 FiO2 and PEEP affect oxygenation – will change the PaO2 and O2 sat FiO2 >60% can cause oxygen toxicity, tidal volumes >8mL/kg predicted weight can cause alveolar overdistention and barotrauma

Answer 858

If they are able to maintain adequate ventilation (pH >7.25) and oxygenation (PaO2 55-80) w/minimal ventilator support (FiO2 40% or less, and PEEP 8 or less)

Answer 859

Decreased bone mineral density | Increased total cholesterol and TGs

Answer 860

First step is aggressive IVF resuscitation (NS or Ringers) After resuscitation can give pRBCs to return Hct to normal but should not be first step as RBCs will release back into circulation w/IVF and over-transfusing can cause HF Splenectomy can be done electively after recovery from the initial event

Answer 861

Lower intraocular P w/topical BBs (timolol), miotic agents (pilocarpine), and a2-agonsits (apraclonidine) + oral or IV acetazolamide and IV mannitol **Pts may present w/o increased intraocular P, but still need tx**

Answer 862

IV ceftriaxone is DoC (cefotaxime and Pen G are alternatives) until AV block resolves, then tx w/3-4 wk course of Doxy or amoxicillin

Answer 863

Opiates – particularly morphine; this is part of comfort care when patients are DNR/DNI

Answer 864

Primarily occurs in critically ill patients Signs/Sxs: unexplained fever, jaundice, leukocytosis, RUQ pain, increased ALP, BR and transaminases See GB wall thickening w/o stones on CT or US Tx: percutaneous cholecystostomy (aka GB drainage) + abx; cholecystectomy if perforation or necrosis occurs

Answer 865

Senna + Docusate or Lactulose alone | Methylnaltrexone can be used to tx refractory OIC but is not a preventative

Answer 866

Glucose and BR – can develop hypoglycemia and hyperbilirubinemia d/t increased RBC volume. May require tx w/IVF, glucose and partial exchange transfusion in symptomatic newborns, but most are asx and do not require tx

Answer 867

``` Hematuria/papillary necrosis Hyposthenuria Splenic infarction (esp. at higher altitudes) Venous TE Priapism Exertional rhabdomyolysis ```

Answer 868

Typically occur once phosphate drops below 1 Generalized weakness, diminished reflexes, paresthesias, ileus, and/or metabolic encephalopathy IV Phosphate for symptomatic pts, oral for asx

Answer 869

Coagulopathy (DIC) after several weeks of fetal retention

Answer 870

Dominant temporal

Answer 871

If BR climbs >12; >25 needs exchange transfusion and intensive phototherapy BR <12 needs q8h serum total and indirect BR checks and can be monitored

Answer 872

``` Lactose free diet High fibre diet Loperamide Biofeedback Reassurance Relaxation exercise ```

Answer 873

1. Oropharyngeal dysphagia – difficulty initiating a swallow, often a/w coughing, drooling or aspiration. May also have referred ear pain. Need Nasopharyngeal laryngoscopy assessment or barium esophagram 2. Esophageal dysphagia – delayed sensations of food sticking in the upper or lower chest. Need EGD assessment.

Answer 874

Adeno – more likely in mid to distal, caused by Barrett’s | Squamous – more likely in upper esophagus, caused by tobacco and alcohol

Answer 875

1: add ACEI or ARB if ACEIs are not tolerated 2: Diuretic therapy (furosemide) BB (once euvolemic, if EF is 40% or less) Spironolactone (if EF is 35% or less), plus continue above Defibrillators (for EF <30%), plus continue above 3: Isosorbide dinitrate + Hydralazine (if AfAm) Digoxin (if sxs w/spironolactone) Cardiac resynch is QRS >150 4: Transplant/VAD evaluation

Answer 876

ONLY if the patient is >28d old and there is suspicion of meningeal involvement **Ceftriaxone should also not be given before 28d, can cause kernicterus**

Answer 877

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

Answer 878

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

Answer 879

0-4 days: dichorionic, diamniotic (25%) 4-8 days: monochorionic, diamniotic (most common – 75%) 8-12 days: monochorionic, monoamniotic (rare) >13 days: conjoined monochorionic, monoamniotic (rare) **All types will have 2 cords**

UWorld Step3 Flashcards

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