14

Question 1

Pleural effusion with protein greater than 50% lymphocytes and glucose of 40

Answer 1

TB, it is an exudate because the protein is greater than 4- Will most likely be at least 50% of seeing him as normal serum protein is between 6 to 8
glucose is low as it is less than 60

Question 2

Headache, facial swelling, JVD and lung cancer patient think? What to do next?

Answer 2

SVC syndrome, radiation therapy

Question 3

SBP fluid diagnosis

Answer 3

PMNs more than 250
Protein less than 1 g/dL
SAAG more than 1.1 g/dL
(Serum – ascites albumin gradient)
Implies dilute fluid is pushed or pulled out due to liver pathology

Question 4

Polymyalgia rheumatica vs polymyositis

Answer 4

Polymyositis: muscle weakness, ^CK, aldolase, even AST??

Polymyalgia rheumatica: stiffness more than pain, associated with Temporal arteritis, elevated ESR, CRP, NOT CK

Question 5

Episode of blank staring, then afterwards confusion and dragging leg, think?

Answer 5

Complex partial seizure, a common causes Temporel lobe epilepsy
Postictal state present, and leg dragging suggest Todd’s paralysis

Question 6

IDM at risk for?

Answer 6

RDS, preterm delivery, macrosomia

Congenital heart disease, NTDs, spontaneous abortion only if DM in first trimester

Question 7

Hypertension, muscle weakness paresthesias caused by hypokalemic alkalosis think? And treat with?

Answer 7

Primary hyper aldosteronism, treat with spironolactone

Question 8

Patient with right upper quadrant pain following gastric bypass surgery, think?

Answer 8

Gallstone disease, due to rapid weight loss which promotes stone formation from increased bile concentrations of mucin and calcium

Question 9

Low calcium and high phosphate in the setting of chronic kidney disease, what will happen to the parathyroid gland?

Answer 9

Secondary hyper parathyroidism, as PTH tries to compensate for low calcium, results in parathyroid hyperplasia
Causes renal osteodystrophy: increased risk of fracture

Question 10

Urge versus overflowing treatment

Answer 10

Urge: overactive detrusor, treat with muscarinic antagonist and bladder training
Overflow: impaired detrusor contractility, treat with cholinergic agonist may need intermittent cath

Question 11

Precipitating factors of hepatic encephalopathy

Answer 11

G.I. bleed causing increased nitrogen load, infection, tips, electrolyte changes, hypovolemia, drugs

Question 12

If alveolar VQ mismatch is present, what will you see on ABG

Answer 12

Elevated PA CO2 as it is a respiratory acidosis with CO2 retention
If low PaCO2, I think primary metabolic acidosis caused by lactic acid in septic shock

Question 13

If recent viral infection and shortness of breath with fluid overload, Think?

Answer 13

Dilated cardiomyopathy caused by Coxsackie

Question 14

Severe abdominal pain, dizziness, vomiting bright red blood, diarrhea with dark green stools, think?

Answer 14

Iron toxicity: maybe green due to presence of disintegrated tablets, maybe bloody as iron is caustic to the G.I. tract
May lead to lactic acidosis, hepatotoxicity, bowel obstruction due to scarring

Question 15

Prognosis of astrocytomas is dependent on?

Answer 15

Degree of anaplasia, To my grade with increased atypia, mitosis, new vascularity, necrosis conveying a worse prognosis

Question 16

Hypovolemic hyponatremia maybe do two?

Answer 16

Extrarenal fluid losses due to secretion of ADH in retention a free water
Will have decreased serum osmolarity, decreased urine sodium concentration less than 20, findings of volume depletion
Maybe due to diarrhea, vomiting, burns, pancreatitis

Question 17

Advanced pancreatic cancer not amenable to surgery how to treat palliatively?

Answer 17

Endoscopic common bile duct stent placement to relieve the obstruction
Uraodeoxycholic acid may help but the obstruction needs to be relieved

Question 18

Factors suggesting vascular dementia over Alzheimer’s

Answer 18

Besides vascular risk factors and stepwise deterioration, prominent executive dysfunction in contrast Alzheimer’s typically presents with memory loss first

Question 19

Characteristics of fragile X

Answer 19

Delayed milestones, autistic behavior, intellectual disability, elongated face, large testes

Question 20

Elevated right heart pressure, elevated pulmonary artery pressure, low/normal PCWP, think?

Answer 20

Pulmonary embolism

Will also have low CO

Question 21

Elevated platelets, elevated INR, elevated LDH, elevated bilirubin, elevated reticulocyte count, in patient with breast cancer, think?

Answer 21

DIC, the most common coagulopathy in malignancy

Elevated LDH, retic, bilirubin is consistent with microangiopathic hemolytic anemia, seen in DIC

Question 22

Decreased breath sounds and dullness to percussion, difficulty breathing, hemodynamic instability after thoracentesis, think?

Answer 22

Hemothorax, potential complication of thoracentesis

Question 23

Neck and arm pain,Numbness and tingling and in the fourth and fifth digit, hemidiaphragm paralysis, think?

Answer 23

Pancoast tumor: symptoms in ulnar nerve distribution, involvement of phrenic nerve, may also see Horners and SVC syndrome

Question 24

4 yo with sore throat, low-grade fever, rhinorrhea, cough, vesicles in the mouth, think what?and what to do next?

Answer 24

Think herpangina: presence of cough and rhinorrhea and absence of tonsillar exudates is suggestive of viral pharyngitis
Treatment: observation and reassurance, as this is self-limited, centor criteria is unreliable in pre-adolescent

Question 25

Unique symptoms of Wegener’s GPA

Answer 25

Skin lesions: leukocytoclastic angiitis, urticaria, livedo reticularis, pyoderma
Upper respiratory involvement may include otitis, ear pain, hearing loss

Question 26

What can impetigo lead to?

Answer 26

Post strep glomerulonephritis but not rheumatic fever, which is only from GAS pharyngitis

Question 27

What leads to acidosis and clinical manifestations in DKA

Answer 27

Lack of insulin causing breakdown of fatty acids to ketones in the liver

Question 28

Teardrop cells may be seen in?

Answer 28

Myelofibrosis or beta thalassemia, especially after splenectomy

Question 29

What to do next with a pregnant patient with VQ scan showing low probability for PE?

Answer 29

Get the CTA, as she has high pretest probability of PE and only a NORMAL VQ scan can rule out PE, if low or moderate probability, further testing is needed, CTA

Question 30

Blunt chest trauma with widened mediastinum on CXR, think? What to do next?

Answer 30

Think traumatic rupture of the aorta, get a TEE or CT scan of the chest with contrast, TTE does not adequately visualize the thoracic aorta

Question 31

2 migraine abortive therapies that should not be given together as they are both serotonin agonists

Answer 31

Triptans and Ergots:
Sumatriptan and Dihydroergotamine, may result in prolonged vasospasm due to over activation of serotonin receptors, leading to HTN, MI, stroke

Question 32

Painless blurring of vision, worsening of distance vision – myopic shift, halos around lights, think? What will you see on optic exam?

Answer 32

Cataract

loss of red reflux, decreased visualization of retinal detail

Question 33

Flame hemorrhages, AV nicking, hard exudates, think?

Answer 33

Hypertensive retinopathy

Question 34

Tocolytics

Answer 34

Indomethacin, Nifedipine, terbutaline(B agonist) – less commonly used

Question 35

Palmer xanthomas, pancreatitis in the setting of alcohol consumption, think? How to treat?

Answer 35

Severe hypertriglyceridemia, secondary to familial dysbetalipoproteinemia
Treat with fibroids such as fenofibrate to lower triglycerides

Question 36

What are used for the prevention rather than acute inhibition of preterm labor?

Answer 36

Cerclage, progesterone

Question 37

OCP effect on female cancers

Answer 37

Decreases the risk of ovarian and endometrial cancer due to suppression of ovulation and endometrial proliferation
Long term use associated with slight increase in risk for cervical and breast

Question 38

Treatment for prolonged QT

Answer 38

Magnesium sulfate to prevent torsades

Not antiarrhythmics which can prolong the QT even further, such as amiodarone, procainamide, propafenone

Question 39

Painful unilateral vision loss that improves after several weeks, may worsen with heat exposure such as hot shower think?

Answer 39

MS, Uthoff phenomenon

Question 40

How to manage wide complex tachycardia, stable or unstable

Answer 40

Stable: amiodarone, procainamide, sotalol, lidocaine

Unstable or symptomatic or persistent: synchronized cardioversion

Question 41

How to treat patients with WPW who presented in a fib with RVR

Answer 41

Control of ventricular response with Procainamide if stable, electrical cardioversion if unstable
DO NOT use AV nodal blocking agents such as adenosine, beta blockers, CCB’s, digoxin may promote conduction across the accessory pathway and lead to V fib

Question 42

S3 can be heard in what conditions?

Answer 42

Chronic severe mitral regurgitation, chronic aortic regurgitation, heart failure, and sometimes in high output states such as pregnancy or thyrotoxicosis

Question 43

Wet lungs in a patient with aortic dissection, think?

Answer 43

Aortic regurgitation due to retrograde extension of the intimal tear involving the valve
NOT cardiac tamponade as this will present with hypotension pulsus paradoxus, elevated JVP, with CLEAR lung fields

Question 44

Complications after coronary artery stenting prevented how?

Answer 44

Dual antiplatelet therapy: aspirin and platelet P2Y 12 receptor blocker – clopidogrel (Plavix)
Without which there’s a high risk of stent thrombosis within the first 12 months

Question 45

Persistent ST segment elevation and deep Q waves after recent MI, think?

Answer 45

Ventricular aneurysm
May present with apical impulse displaced to the left, heart failure, refractory angina, ventricular arrhythmias, mural thrombus with systemic embolization, mitral regurgitation
Diagnosed by Echo

Question 46

What to do in acute MI with pulmonary edema?

Answer 46

After given aspirin, Plavix, Statin:
Diuretics: furosemide to alleviate symptoms of flash pulmonary edema
Beta blockers are contraindicated if pulmonary edema, (acute decompensated heart failure)

Question 47

Development of a new conduction abnormalities – AV block in a patient with infective endocarditis, think?

Answer 47

PeriValvular abscess, which may extend into the adjacent cardiac conduction pathways