3CK PART II

Question 1

Explain relationship between hyponatremia and thyroid

Answer 1

Hypothyroidism can cause hyponatremia due to decreased clearance of free water and increased release of antidiuretic hormone.

Euvolemic hyponatremia.

Question 2

Algorithm hyponatremia

Answer 2

DO

Question 3

Postpartum thyroiditis presentation

Answer 3

Is a variant of hashimoto

brief thyrotoxic phase, followed by a self-limited hypothyroid phase and eventual return to a euthyroid state.

If mild, no need of supplementation
If sever needs levothyroxine

Question 4

patient hypotense, tachycardi and blunt thoracic trauma , next step in management?

Answer 4

FAST! lead to detection of other causes that can be life threatening-pneumothorax, aortic dissection, hemoperitoneum, pericardial effusion leading to tamponade

• FAST is not only in abdomen
• Chest X rays are often done, but FIRST FAST

Question 5

What are the preferred Chest X rays in trauma?

Answer 5

bedside (ie, anteroposterior) chest x-rays are typically performed as obtaining posteroanterior and lateral chest x-rays requires patients to stand

Question 6

type I error, definition and ways that it is increased

Answer 6

rejecting a true null hypothesis [false positive]

increases as sample size increases

Question 7

type II error

Answer 7

probability of failing to reject a false null hypothesis [false negative

Question 8

2 ways in which Nonresponse increases the potential for bias

Answer 8

when nonrespondents differ from respondents in the outcome of interest; and it contributes to a decrease in statistical power given that the sample size has been reduced. However, a significant nonresponse rate in a study does not necessarily translate into bias.

Question 9

Patient with alcoholism that after treatment with intravenous glucose, thiamine and fluids develops weakness of arms

Answer 9

Its due to hypophosphatemia ( refeeding syndrome) which can lead to development of rhabdomyolisis due to myopathy.

• check CPK in this setting.

Question 10

Absolute iron deficiency is defined as

Answer 10

transferrin saturation <20% or ferritin <100 ng/mL.

Question 11

Causes of anemia in ESDR

Answer 11

MC decreased EPO production
BUT ALSO: 
iron deficiency ( blood loss, frequent blood testing, dyalisis, functional
severe hyperPTH( resistance to EPO)
Folate deficiency
systemic inflammation 
aluminium toxicity

Question 12

functional iron deficiency

Answer 12

Can occur in ESRD but these can also have the normal iron deficiency.

In functional-> unable to mobilize iron from stores.

Question 13

When do you start EPO in ESDR?What considerations are needed before starting it?

Answer 13

Hemoglobin < 10

The goal is to increase hemoglobin by 1.5-2 g/dL over 4-6 weeks to target hemoglobin to 10-11.5 g/dL.

Question 14

When do you supplement with iron in ESDR?

Answer 14

Iron supplementation is recommended for ESRD patients with transferrin saturation <30% and ferritin <500 ng/mL

** Think on the patient who despite receiving EPO keeps going with anemia.

Question 15

Stress urinary incontinence tto

Answer 15

Intrinsic sphincter deficiency and urethral hypermobility

Lifestyle modification
Pelvic floor exercises
Pessary
Urethral sling surgery

Question 16

Urgency urinary incontinence tto

Answer 16

Lifestyle modification
Bladder training
Antimuscarinic medications

Question 17

Overflow urinary incontinence tto

Answer 17

Intermittent catheterization

Correct underlying etiology

Question 18

Patients with an underlying neuropathy can develop overflow incontinence when additional risk factors (eg, antihistamines) result in exacerbation of symptoms

Answer 18

t

Question 19

Overflow incontinence- post void residual volume

Answer 19

> 150

Question 20

Presentation Genitourinary syndrome of menopause

Answer 20

urinary incontinence PLUS
vaginal atrophy
dyspareunia, 
vulvar irritation
pelvic organ prolapse

Question 21

Normal JVD

Answer 21

6-8

Question 22

notched (bifid) P waves in lead II

Answer 22

left atrial enlargement due to mitral stenosis

Question 23

Mitral stenosis in women think of

Answer 23

rheumatic fever

Question 24

hear murmur + dyspnea, orthopnea, hemoptysis , hoarseness

Answer 24

mitral stenosis

Question 25

Auscultation and ECG findings of MS

Answer 25

Auscultation: loud S1, loud P2if pulmonary hypertension Mid-diastolic murmur ECG: notched p wave atrial tachyarryhtmias, high R'S IN v1,v2

Question 26

Cardiac manifestations Noonan syndrome

Answer 26

pulmonic stenosis, atrial septal defects, and hypertrophic cardiomyopathy.

Question 27

Indications of IVC filters

Answer 27

In whom anti coagulation is contraindicated :recent surgery, hemorrhagic stroke, bleeding diathesis, active bleeding

Question 28

goal of IVC filters

Answer 28

inhibit progression of lower extremity clots through the IVC toward the lungs.

Question 29

Acute and long term complications of IVC filter placement

Answer 29

acute: acute insertion site thrombosis, hematoma, arteriovenous fistula long term recurrent DVTs andIVC thrombosis. IVC filters do not appear to affect overall mortality significantly. The filter can prevent clot progression to a pulmonary embolism, but it does not prevent future DVTs or treat the underlying thrombotic predisposition.

Question 30

heteroplasmy - mitochondrial disorders

Answer 30

mom passess diasease to both male and women, but then her female child is the only one able to pass to the offspring.

Question 31

Stroke + Seizures

Answer 31

MELAS

Question 32

MELAS presentation

Answer 32

Mitochondrial encephalomyopathy with lactic acidosis and stroke like episodes - stroke - seizures - weakness - hearing loss - lactic acidosis

Question 33

Corrected calcium formula

Answer 33

Corrected calcium in mg/dL = (measured total calcium) + 0.8 (4.0 g/dL - measured serum albumin in g/dL). calcium concentration decreases by 0.8 mg/dL for every 1 g/dL decrease in serum albumin concentration.

Question 34

ss hypocalcemia

Answer 34

oral paresthesias, carpopedal spasm, tetany, seizures

Question 35

tto hypocalcemia

Answer 35

Oral calcium citrate or carbonate mild acute hypocalcemia (corrected calcium of 7.5-8.5 mg/dL) or chronic hypocalcemia. for symptomatic : Intravenous calcium gluconate

Question 36

distribution of calcium in the body

Answer 36

albumin-bound calcium (45%), ionized calcium (40%), or calcium bound to inorganic and organic anions (15%).

Question 37

organism in chagas

Answer 37

PROTOZOAN-Tripanosoma cruzi

Question 38

Cardiac manifestations of chagas

Answer 38

- Ventricular apical aneurysm in the absence of coronary disease - Biventricular heart failure (R>L) with cardiomegaly - Mural thrombosis with embolic complications - Fibrosis leading to conduction abnormality ( heart block , ventricular tachycardia)

Question 39

Cardiac manifestations of lyme

Answer 39

atrioventricular conduction block. In rare cases, patients can also develop myopericarditis with dilated cardiomyopathy.

Question 40

Infection with human immunodeficiency virus has been associated with the development of dilated cardiomyopathy.

Answer 40

T

Question 41

Diagnostic criteria for C difficile

Answer 41

Characteristic symptoms – Watery diarrhea (≥3 loose stools in 24 hours) with or without lower abdominal pain, low-grade fever, and leukocytosis AND Positive stool testing Positive laboratory testing in the absence of symptoms is not sufficient for diagnosis as asymptomatic carriage is common.

Question 42

4 RF for C.difficile

Answer 42

PPIs – C difficile spores are acid-resistant, but proton pump inhibitors are thought to alter the colonic microbiome, which increases the risk of C difficile proliferation. Recent antibiotic use – Antibiotics disrupt the barrier function of normal colonic flora. Fluoroquinolones, clindamycin, and broad-spectrum penicillins/cephalosporins are most likely to cause CDAD. Hospitalization Advanced age

Question 43

Medications related to C. difficile

Answer 43

Fluoroquinolones, clindamycin, and broad-spectrum penicillins/cephalosporins

Question 44

Newborn with red sac in lumbar spine, dx?

Answer 44

Spina bifida = myelomeningocele

Question 45

Complications of spina bifida (4)

Answer 45

Motor/sensory dysfunction Neurogenic bladder/bowel ( urinary retention/constipation) Hydrocephalus Scoliosis

Question 46

tto spina bifida and its complciations

Answer 46

Surgical closure Clean intermittent catheterization Scheduled laxatives/enemas Bracing; correction of deformities Patients undergo urgent surgical repair, which results in hydrocephalus requiring a ventriculoperitoneal shunt in over half of infants.

Question 47

Presentation of transverse myelitis

Answer 47

Rapidly progressive weakness of the lower extremities following an upper respiratory infection, accompanied by sensory loss and urinary retention muscle flaccidity and hyporeflexia, but spasticity and hyperreflexia develop subsequently.

Question 48

type of patients that can present with epidural abscess

Answer 48

IV drug users

Question 49

crescent, hypoechoic lesions adjacent to the gestational sac

Answer 49

subchorionic hematoma abnormal collection of blood between the uterus and the gestational sac

Question 50

management of subchorionic hematoma

Answer 50

management is expectant; patients can be followed with serial ultrasounds to help provide reassurance. **DO NOT RECOMMEND HOSPITALIZATION OR BED REST- DOESNT CHANGE ANYTHING, AND INCREASES RISK OF DVT

Question 51

Kleihauer-Betke test

Answer 51

determines the amount of fetomaternal hemorrhage that occurred due to delivery, maternal trauma, or first-trimester bleeding in an Rh-negative mother. determines the amount of Rho(D) immune globulin to be administered.

Question 52

Pts with subchorionic hematoma are at higher risk of

Answer 52

``` Spontaneous abortion Abruptio placentae Preterm premature rupture of membranes Preterm delivery preeclampsia, fetal growth restriction, and intrauterine fetal demise ```

Question 53

RF for subchorionic hematoma

Answer 53

Infertility treatment Anticoagulation Uterine anomalies Recurrent pregnancy loss

Question 54

RF Placenta previa

Answer 54

prior placenta previa.,history of prior cesarean delivery, multiple gestations, multiparity

Question 55

RF Placenta accreta

Answer 55

previous cesarea

Question 56

Indication for Fetal fibronectin

Answer 56

cervicovaginal discharge of patients at <34 weeks gestation with preterm contractions not older than 34

Question 57

patient third trimester bleeding, fetus ok, next step?

Answer 57

transvaginal US- likely caused by placenta previa Transvaginal ultrasound and speculum examination are safe in placenta previa as neither the transvaginal probe nor the speculum enters the endocervical canal. DIGITAL EXAM IS CONTRAINDICATED

Question 58

Woman that after birth- shortness of breath, unresponsive, hypotension

Answer 58

Amniotic fluid embolism: Cardiogenic shock Hypoxemic respiratory failure Disseminated intravascular coagulopathy Coma or seizures

Question 59

Management of amniotic fluid embolism

Answer 59

Respiratory & hemodynamic support | ± Transfusion

Question 60

RF for amniotic fluid embolism

Answer 60

cesarean/operative delivery, placenta previa, and abruptio placentae.

Question 61

Peripartum cardiomyopathy

Answer 61

in the late third trimester or early postpartum period with symptoms of heart failure (eg, dyspnea, orthopnea, hemoptysis, pedal edema)

Question 62

Initial management of aspiration pneumonia:

Answer 62

blood and sputum cultures with initiation of broad-spectrum antibiotics with anaerobic coverage (eg, clindamycin).

Question 63

Patient diabetic with sinusitis, next step

Answer 63

depends on glycemic control: If adequate glucose: amoxi-clavulanate for 5-7 days If not control ( i.e DKA)- think of mucor - and admit to hospital for antifungals

Question 64

Acute bacterial rhinosinusitis tto

Answer 64

1st-line therapy: Amoxicillin-clavulanate (5-7d) Alternate agent: Doxycycline or fluoroquinolones Supportive care: Analgesics, decongestants, saline irrigation, topical glucocorticoids

Question 65

Dx Acute bacterial rhinosinusitis

Answer 65

>1 of the following is present: Persistent symptoms/signs of rhinosinusitis for >10 days Severe symptoms, high fever (>39 C [102.2 F]), purulent nasal discharge, and/or facial pain for >3 consecutive days "Double sickening" - initial improvement of viral upper respiratory symptoms for 5-6 days, followed by clinical deterioration (eg, worsened fever, headache, nasal discharge)

Question 66

MC organisms in bacterial rhinosinusitis

Answer 66

Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis.

Question 67

ST elevation

Answer 67

ST-elevation myocardial infarction (STEMI) is diagnosed by ECG showing >1 mm (0.1 mV) ST elevation (>2 mm in leads V2 and V3) in ≥2 anatomically contiguous leads.

Question 68

If suspicion of perforated peptic ulcer, next step

Answer 68

Chest and Abdomen X ray

Question 69

sudden-onset abdominal pain with significant tenderness and guarding

Answer 69

peritonitis

Question 70

management of peptic ulcer perforation

Answer 70

Fluids, antibiotics with coverage for gram negative, PPIs IN preparation for surgery

Question 71

cause of small intestinal obstruction in patients with a history of abdominal surgery.

Answer 71

adhesions

Question 72

Conditions associated with Down Syndrome

Answer 72

``` VSD/ASD duodenal atresia, Hirschsprung's disease, atlanto-axial instability, and hypothyroidism. ```

Question 73

Pts with Down syndrome on the long run are at increased risk of ..

Answer 73

``` Acute Leukemia Alzheimer ADHD Autism seizure disorder depression ```

Question 74

Management of dyspepsia

Answer 74

Age ≥60: Upper endoscopy Age <60: Testing and treatment for H pylori Upper endoscopy in high-risk patients (eg, overt GI bleeding, significant weight loss, >1 alarm symptom)

Question 75

presentation of dyspepsia

Answer 75

Epigastric pain often described as "burning" | ± Nausea, vomiting, epigastric fullness, heartburn

Question 76

pelvic organ prolapse

Answer 76

Weight loss Pelvic floor exercises Vaginal pessary Surgical repair

Question 77

rectocele presentation

Answer 77

posterior vaginal mass that increases with the Valsalva maneuver. pelvic pressure, lower back pain, constipation, and fecal incontinence.

Question 78

rectocele treatment

Answer 78

Pelvic floor exercises Vaginal pessary Surgical repair

Question 79

What findings are associated with poor prognosis in CLL

Answer 79

lymphadenopathy, organomegaly, and anemia/thrombocytopenia,

Question 80

erythrocytosis and hematuria

Answer 80

Renal cell carcinoma lank pain, hematuria, and palpable abdominal mass; h

Question 81

suspect renal ca, next step

Answer 81

CT scan of the abdomen

Question 82

JAK2 mutation is seen in which condition

Answer 82

Polycytemia vera

Question 83

polycythemia vera presentation

Answer 83

Erythrocytosis is the defining feature; patients also often | aquagenic pruritus, hypertension, and arterial or venous thrombus.

Question 84

CT scan of the abdomen reveals an enhancing mass of the kidney with thickened, irregular septa, raising strong suspicion for renal cell carcinoma, next step

Answer 84

referral to nephrology for nephrectomy!

Question 85

Polycystic kidney disease tto

Answer 85

ACE inhibitors- reduce risk of chronic renal insufficiency.

Question 86

management of kidney cysts.

Answer 86

Complex kidney cysts often require surveillance with repeat imaging

Question 87

viral conjunctivitis, when does it stop to be contagious?

Answer 87

when watery discharge resolves Other symptoms, such as morning crusting or eye redness, may persist longer than eye discharge but do not contribute to infectivity

Question 88

Difference between allergic vs nonallergic rhinitis

Answer 88

Allergic: earlier age (<20) with predominant eye symptoms (eg, watery eyes), sneezing, nasal congestion, and watery rhinorrhea. Patients usually can identify a trigger PE:normal or pale blue nasal mucosa with pallor and occasionally shows polyps TTO: allergen avoidance and intranasal glucocorticoids Non allergic after age 20 with nasal blockage, rhinorrhea, and postnasal drip.. throughout the year. PE:nasal mucosa can appear normal or boggy and erythematous on examination. topical intranasal glucocorticoids (eg, fluticasone) or intranasal antihistamine (eg, azelastine).

Question 89

Tto of allergic and nonallergic rhinitis

Answer 89

aLLERGIC: Avoid trigger, and intranasal glucocorticoids | NON ALLERGIC : topical intranasal glucocorticoids (eg, fluticasone) or intranasal antihistamine (eg, azelastine).

Question 90

When to consider allergy testing/IgE in rhinitis

Answer 90

reserved for differentiating between NAR and AR in patients who do not respond to initial treatment or in those being considered for immunotherapy.

Question 91

Elderly woman saying that sexual activity is no longer "pleasurable." cause?

Answer 91

vaginal atrophy- vaginal dryness and dyspareunia. *** if they describe interest then is not age-related libido

Question 92

treatment of postmenopausa

Answer 92

SSRIs, NSRIs ( Venlafaxine)

Question 93

Considerations before prescribing opioids

Answer 93

evaluate prescription history and use - Also check the prescription drug monitoring program ( identify undisclosed prescriptiosn, clarify prescription patters and see if patient has obtained prescriptions from multiple providers)

Question 94

Tto of seborrheic dermatitis

Answer 94

TOPICAL antifungals (eg, selenium sulfide SHAMPOO, ketoconazole) Topical glucocorticoids Topical calcineurin inhibitors (eg, pimecrolimus, tacrolimus) keratolytic agents (eg, salicylic acid) **Oral could be used but are NOT the first line

Question 95

organism involved in seborrheic dermatitis

Answer 95

Malassezia

Question 96

Griseofulvin is used in

Answer 96

tinea capitis

Question 97

Permethrin is used to

Answer 97

scabies

Question 98

Crusted scabies can cause large, scaly patches but is not pruritic and occurs most commonly in immunocompromised patients (eg, lymphoma, AIDS).

Answer 98

t

Question 99

long term management of seborrheic dermatitis/ prognosis

Answer 99

chronic, relapsing condition. Initial treatment -> significant improvement but no remission. SO: intermittent re-treatment. Typical regimens include topical ketoconazole or ciclopirox every 1-2 weeks.

Question 100

factorial design

Answer 100

STUDY arms in RCT

Question 101

Does psoriasis cause alopecia?

Answer 101

NO, usually no!

Question 102

well-demarcated, often round, non-scarred patch of complete hair loss

Answer 102

Alopecia areata: can be multiple patches! not only one. "exclamation point hairs" (hairs which are tapered near the insertion into the scalp), especially at the periphery of an alopecic plaque

Question 103

Nail pitting associated to alopecia areata

Answer 103

yes

Question 104

Nail pitting is seen in

Answer 104

Psoriasis | Alopecia areata

Question 105

prognosis of alopecia areata

Answer 105

self-limited but may be relapsing and remitting or chronic and progressive. increased risk -> autoimmune thyroid disease, vitiligo, and pernicious anemia.

Question 106

Tinea capitis vs alopecia areata

Answer 106

tinea capitis: erythema, scaling, "black dot" alopecia (secondary to breakage of hairs near the scalp), pustules, or boggy plaques with posterior alopecia areata: well emarcated, non-scarred, exclamation points around it.

Question 107

Tto of normal pressure hydrocephalus

Answer 107

Ventriculoperitoneal shunting ***no eviudence for acetazolamide

Question 108

Diagnosis of normal pressure hydrocephalus

Answer 108

Marked improvement in gait with spinal fluid removal: Miller Fisher (lumbar tap) test Enlarged ventricles out of proportion to the underlying brain atrophy on MRI

Question 109

ppt normal pressure hydrocephalus

Answer 109

``` Gait instability (wide-based) with frequent falls Cognitive dysfunction Urinary urgency/incontinence Depressed affect (frontal lobe compression) Upper motor neuron signs in lower extremities ( they can have tremor, rigidity-parecido a parkinson) ```

Question 110

lumbar tap test (Miller Fisher test)

Answer 110

Is for normal pressure hydrocephalus evaluates parameters such as gait speed, stride length, verbal memory, and visual attention before and after removal of 30-50 mL of CSF.

Question 111

red flags for a pathologic etiology in scoliosis

Answer 111

Back pain ( nocturnal awakening- concerning for tumor) Neurologic symptoms Rapidly progressing curvature (>10 degrees each year) Vertebral anomalies on x-ray ** degree of curvature is not associated with etiology

Question 112

suspect scoliosis, next step

Answer 112

X ray, although MRI is gold standard

Question 113

Anterior horn cells disorders

Answer 113

SMA ALS Paraneoplastic syndromes Polio

Question 114

UMN disorders

Answer 114

leukodystrophies vasculitis brain mass vit B12

Question 115

Pathogenesis of botulism

Answer 115

peripheral nerve endings to inhibit release of acetylcholine into the synaptic cleft.

Question 116

patient with shock that after resuscitation develops hyperactive reflexes

Answer 116

multiple transfusions can lead to hypocalcemia as Ca joins with citrate . ----citrate chelates with calcium hypocalcemia : hyperactive reflexes

Question 117

relation between hypomagnesemia and reflexes

Answer 117

hyporeflexia

Question 118

Patient in whom you suspect varicella zoster, next step

Answer 118

Treat with oral acyclovir/valacyclovir atients with localized herpes zoster who have had lesions <72 hours typically receive antiviral treatment with oral valacyclovir to reduce transmission risk, new lesion formation, and (possibly) risk of postherpetic neuralgia. Analgesics for acute neuritis are also typically required. No need for testing. testing is reserved for atypical lesions

Question 119

Healthcare precautions for patients with varicella zoster

Answer 119

Localized infection - standard precautions and lesion covering Disseminated infection - standard precautions plus contact and airborne precautions

Question 120

Definition of hypoglycemia

Answer 120

< 60 normal fasting blood sugar range is 70 to 100 mg/dL The target pre-meal blood sugar level in patients with diabetes is between 80 and 120 mg/dL.

Question 121

Whipple's triad

Answer 121

low blood glucose level symptoms of hypoglycemia symptomatic relief with the administration of glucose. Whipple's triad is strongly suggestive of true hypoglycemia.

Question 122

Hypoglycemic episodes during exercise

Answer 122

decreasing the insulin dose (NPH, glargine - not the regular that ggoes with each meal ), eating before exercising, and avoiding injections of insulin in the exercising limbs.

Question 123

unilateral facial nerve palsy, hepatomegaly (>2 cm below costal margin), and lymphadenopathy AND significant fatigue

Answer 123

extrapulmonary sarcoidosis

Question 124

suspect sarcoidosis, next step

Answer 124

a chest x-ray as >90% of patients have bilateral hilar or mediastinal adenopathy

Question 125

Löfgren syndrome

Answer 125

SARCOIDOSIS Erythema nodosum Hilar adenopathy Migratory polyarthralgia Fever

Question 126

Eye manifestations in sarcoidosis

Answer 126

Anterior uveitis (iridocyclitis or iritis) Posterior uveitis Keratoconjunctivitis sicca

Question 127

CNS/endocrine manifestations

Answer 127

Facial nerve palsy Central diabetes insipidus Hypercalcemia

Question 128

Herpes simplex meningitis presentation

Answer 128

can have focal signs, including nerve palsy but in 90% cases ALTERED MENTAL STATUS

Question 129

Patients with facial nerve palsy should undergo brain imaging if symptoms do not improve by 3 weeks or resolve by 4 months.

Answer 129

T

Question 130

Chest x-ray reveals bilateral hilar adenopathy and interstitial infiltrates, next step to confirm diagnosis

Answer 130

excisional lymph node biopsy- noncaseous granulomas usually a palpable lymph node or skin lesion. When there is no easily accessible lesion, fiberoptic bronchoscopy with transbronchial lung biopsy is often performed. *** Although ACE levels will be high in 75%, not recommended.

Question 131

All patients with pulmonary sarcoidosis should undergo pulmonary function testing to evaluate for respiratory impairment

Answer 131

true, but this is not to confirm diagnosis. Diagnosis after chest X ray: excisional lymph node

Question 132

Management of bacterial conjuncitvitis

Answer 132

S.aureus, S. pneumonia, moraxella, H. influenza Erythromycin ointment Polymyxin-trimethoprim drops Azithromycin drops Preferred agent in contact lens wearers: fluoroquinolone drops (pseudomona)

Question 133

Management of viral conjunctivitis

Answer 133

Warm or cold compresses | ± Antihistamine/decongestant drops

Question 134

When keratitis is suspected, next step

Answer 134

ophthalmology referral diagnosis of keratitis is made by slit-lamp examination showing corneal ulceration. cultures are needed Keratitis can cause scarring or ulceration of the cornea and subsequent blindness if not aggressively treated.

Question 135

well-defined plaques covered by thick silvery scales

Answer 135

psoriasis

Question 136

Treatment of psoriasis

Answer 136

Mild-to moderate plaques: TOPICAL high potency steroids ( fluocinonide, augmented betamethasone dipropionate 0.05%) -topical vit D derivatives Severe plaques: phtototherapy or systemic agents(methotrexate)

Question 137

Pt who had runny nose, sore throat, tactile, then develops headache, vomiting confusion and focal neuro signs?

Answer 137

Viral meningoencephalitis

Question 138

Suspect viral meningoencephalitis

Answer 138

LP followed by vancomycin, ceftriaxone, and ACYCLOVIR

Question 139

MC causes of meningoencephalitis

Answer 139

enterovirus( coxsackie) herpes arbovirus(West Nile)

Question 140

role of dexamethasone in pneumococcal meningitis.

Answer 140

Prevents neurological complications

Question 141

loss of consciousness. He was standing in a crowded subway station when he felt lightheaded, had a pounding sensation in his chest, and passed out. On awakening, he felt short of breath for a little while and then was "completely fine." Causes?

Answer 141

Vasovagal syncope could be BUT CONSIDER -Tachyarrhythmia- WPW so look for it in the ECG

Question 142

Managemetn of WPW

Answer 142

Catheter ablation

Question 143

Altered mental status in patients with lithium, what to consider

Answer 143

Any new meds? volume depletion? CKD? Lithium has a very narrow therapeutic index and can interact with many drugs THIAZIDES ( chlortalidone) , ACEIs, NSAIDs increase levels of lithium.

Question 144

therapeutic and toxic levels of lithium

Answer 144

Therapeutic lithium levels are 0.8-1.2 mEq/L. | Serum lithium levels >1.5 mEq/L confirm toxicity, and levels >2.5 mEq/L require emergency management.

Question 145

Drugs that increase lithium levels

Answer 145

THIAZIDES ( chlortalidone) , ACEIs, NSAIDs

Question 146

Management of lithium toxicity

Answer 146

Lithium levels every 2-4 hours Intravenous hydration Bowel irrigation (asymptomatic acute overdose) Hemodialysis: >4 mEq/L >2.5 mEq/L with symptoms or renal failure Increasing level despite intravenous fluids

Question 147

presentation of lithium toxicity

Answer 147

Acute GI: Nausea, vomiting, diarrhea Neurologic findings occur much later Chronic Neurologic: Ataxia, confusion, agitation, neuromuscular excitability (tremor)

Question 148

Mammogram screening

Answer 148

Mammogram every 2 years for women age 50-74 Screening for patients age 40-49 is based on individual risk factors Breast cancer screening is not indicated in low-risk patients age <40.

Question 149

self manual exam is recommended annuallu

Answer 149

FALSE, Breast self-examination does not reduce breast cancer mortality. It has a high false-positive rate and leads to unnecessary biopsies; therefore, it is not recommended at any age.

Question 150

Management of acute diverticulitis

Answer 150

bowel rest | ciprofloxacin and metronidazole,

Question 151

Patient with diverticulitis on antibiotics who after 2-3 days persists with fever, abodminal pain, next step

Answer 151

if no improvement after 2-3 days repeat CT to evaluate for complications: colonic abscess, obstruction, and perforation.

Question 152

MC complication of diverticulitis

Answer 152

Colonic abscess (5-15%) require percutaneous drainage and intravenous antibiotics followed by elective partial colectomy several weeks later.

Question 153

When do you recommend colonoscopy in diverticulitis

Answer 153

patients with diverticulitis 6-8 weeks after the complete resolution of symptoms to rule out colon cancer.

Question 154

pithelial cells that have a stippled appearance but no ferning

Answer 154

Vacterial vaginosis

Question 155

Bacterial vaginosis

Answer 155

Clindamycin or MTZ

Question 156

Candida vaginosis presentation

Answer 156

thick, white, clumpy discharge and vulvar pruritus

Question 157

Why should be treat bacterial vaginosis in pregnancy

Answer 157

To relieve symptoms. ↑ Risk of preterm birth, BUT NOT IUGR

Question 158

lung cancer screening

Answer 158

55-80 Patient has ≥30-pack-year smoking history AND Patient is a current smoker or quit smoking within the last 15 years

Question 159

lung Ca screening termination

Answer 159

Age >80 OR Patient successfully quit smoking for ≥15 years OR Patient has other medical conditions that significantly limit life expectancy or ability/willingness to undergo lung cancer surgery

Question 160

Smoking cessation reduces the risk of developing lung cancer and COPD exacerbations, even in long-term heavy smokers.

Answer 160

true

Question 161

What organism is most commonly cultured from corneal foreign bodies in the eyes?

Answer 161

Staph aureus Other: Strep, hemophilus, pseudomona

Question 162

treatment for all foreign-body associated corneal abrasions

Answer 162

empiric broad-spectrum antibiotic eye drops or ointments (e.g., erythromycin, sulfacetamide, ciprofloxacin, ofloxacin).

Question 163

Pt comes for blood in urine, next step

Answer 163

hx of trauma or suspected stone: CT/US IF no: urianalysis even if you think is bladder cancer or you know the etiology need to confirm first

Question 164

The first step in evaluating hematuria is

Answer 164

urinalysis and culture

Question 165

acute onset of flushing, a throbbing headache, palpitations and abdominal cramps, after 30 min eating fish. Dx?

Answer 165

Scombroid poisoning can also have bitter taste skin erythema, wheezing, tachycardia and hypotension.

Question 166

Pufferfish poisoning

Answer 166

prominence of neurological symptoms (perioral tingling, incoordination, weakness, etc).

Question 167

Scombroid poisoning

Answer 167

acute onset of flushing, a throbbing headache, palpitations and abdominal cramps after 30 minutes of eating fish can also have bitter taste skin erythema, wheezing, tachycardia and hypotension.

Question 168

Carcinoid syndrome

Answer 168

characterized by diarrhea, flushing, dyspnea, and wheezing – may occur if a serotonin-producing tumor has metastasized to the liver, bypassing first-pass metabolism. Elevated 5-HIAA in the urine helps to establish the diagnosis

Question 169

Recommendations on exercise for pt with cerclage

Answer 169

Contraindicated

Question 170

Contraindications of exercise during pregnancy

Answer 170

Patients at risk for preterm delivery Cervical insufficiency Preterm labor during current pregnancy Preterm premature rupture of membranes Patients at risk for antepartum bleeding Placenta previa Persistent second- or third-trimester bleeding Patients with an underlying condition that could be exacerbated by exercise Severe anemia Hypertensive disorders of pregnancy (eg, preeclampsia) Restrictive lung disease Severe heart disease

Question 171

prognosis of night terrors

Answer 171

typically occurs between ages 4-12. The condition is usually benign and self-limiting, resolving spontaneously over 1-2 years. low-dose BZD at bedtime if episodes are frequent, persistent & distressing

Question 172

non-rapid eye movement (NREM) sleep disorders

Answer 172

night terrors, sleep walking ( do not remember)

Question 173

REM sleep-related behavior disorder

Answer 173

acts out the dreams

Question 174

MOA of SGLT2 inhibitors for DM

Answer 174

proximal tube, exchange sodium for glucose. So inhibit re absorption glucose canagliflozin, dapagliflozin, and empagliflozin

Question 175

SE SGLT2 inhibitors for DM

Answer 175

Vulvovaginal candidiasis Polyuria UTI * In the setting of glucosuria canagliflozin, dapagliflozin, and empagliflozin

Question 176

canagliflozin, dapagliflozin, and empagliflozin are what type of drugs

Answer 176

SGLT2 inhibitors for DM

Question 177

Dipeptidyl-peptidase 4 (DPP4) inhibitors

Answer 177

sitagliptin, saxagliptin, linagliptin, and alogliptin. increase incretin levels (GLP-1 and GIP)--> inhibit glucagon release, which in turn increases insulin secretion, decreases gastric emptying, and decreases blood glucose levels.

Question 178

DDP4 inhibitors SE

Answer 178

Pancretatitis, may cause hypersensitivity ( ie. angioedema)

Question 179

Schizoaffective disorder

Answer 179

Major depressive or manic episode concurrent with symptoms of schizophrenia Lifetime history of delusions or hallucinations for ≥2 weeks in the absence of major depressive or manic episode Mood episodes are prominent & recur throughout illness

Question 180

Schizoaffective disorder vs Major depressive or bipolar disorder with psychotic features:

Answer 180

Schizoaffective disorder: has concurrent mood symptoms with psychotic symptoms, PLUS ≥2 weeks of psychotic symptoms in the absence of a major depressive or manic episode. In the other disorder: Psychotic symptoms occur exclusively during mood episodes

Question 181

Schizoaffective disorder is distinguished from schizophrenia by

Answer 181

the presence of mood symptoms lasting a significant portion of the illness.

Question 182

treating friends and family is not always unethical

Answer 182

true, there may be emergency cases in which is needed

Question 183

Friend asking for a prescription of opioid, what to say

Answer 183

" I would like to help you but I feel uncomfortable prescribing to someone I do not treat

Question 184

Women in 50s with symptoms of amenorrhea, and increased vaginal bleeding, next step?

Answer 184

endometrial biopsy her bleeding is anovulatory, and there is risk of endometrial cancer due to unopposed estrogen production. ALL WOMEN>=45 with anovulatory bleeding need to have endometrial biopsy

Question 185

Indications for endometrial biopsy

Answer 185

- ALL WOMEN>=45 with anovulatory bleeding | - Women < 45 with RF ( POS, Obesity), failed management, persist with abnormal bleeding.

Question 186

Why does menopause occur? At what age? How is diagnosis made?

Answer 186

- loss of ovarian function (oocyte depletion, and abnormal follicular development) - oocytes fail to produce progesterone Usually by 51 Dx with >=1 year of amenorrhea

Question 187

Treatment of anovulatory bleeding in transition to menopause

Answer 187

``` First - do an endometrial biopsy! If normal: Other options: Cyclic progestin Low dose OCP DIU ```

Question 188

Is measure of FSH needed for diagnosis of menopause?

Answer 188

NO! Menopause is a clinical diagnosis and FSH is not required to confirm.

Question 189

MCC of viral meningoencephalitis

Answer 189

Enterovirus (Coxsackie) Herpes (HSV) Arbovirus( West Nile Virus)

Question 190

presentation of viral meningoencephalitis

Answer 190

fever, headache, altered mental status, nuchal rigidity.

Question 191

West Nile infection - time of the year and presentation

Answer 191

Summer and early fall meningitis, including fever, headache, photophobia, nuchal rigidity, and/or signs of encephalitis, such as confusion and focal neurologic findings (eg, hyperreflexia). - Rash can be present but not always patients may have excoriated mosquito bites,

Question 192

Dx of West Nile virus

Answer 192

West Nile IgM antibody in the cerebrospinal fluid

Question 193

Does Lyme cause encephalitis?

Answer 193

NO, most commonly meningitis, CN palsy, or peripheral neuropathy.

Question 194

Presentation of Duchenne

Answer 194

2-3 years old, X-linked myopathy developmental delay ( can have speech delays, late onset walking) proximal lower extremities weakness (unable to run, walk, jump) for a long time Dilated Cardiomyopathy Scoliosis Waddling gait pseudohypertrophy of calves -- as fat replaces degrading muscle. THEY CAN HAVE HYPOREFLEXIA of achilles tendon

Question 195

First step when suspecting Duchenne's myopathy

Answer 195

CK levels

Question 196

GOLD standard or CONFIRMATORY study for Duchenne?

Answer 196

Genetic testing showing deletion of one or more exons of the dystrophin gene Not muscle biopsy

Question 197

Most accurate diagnostic tool for Parkinson disease?

Answer 197

Clinical- physical examination Striatal dopamine transporter scan ( DATscan) can be considered when the diagnosis of Parkinson's disease is equivocal.

Question 198

Management of Parkinson

Answer 198

Initial treatment: < 65 : pramipexole, bromocriptine ( dopamine agonists) >65 : levodopa Levodopa concerns with prolonged use. It hastens destruction of substantia nigra cells and worsen symptoms in the long-term.

Question 199

Role of entacapone in parkinson

Answer 199

Entacapone by itself not helpful for PD. It helps prolong the effect of levodopa.

Question 200

Patients with untreated celiac disease are at high risk of

Answer 200

enteropathy-associated T-cell lymphoma (EATL) in the jejunum -- poor prognosis - 10 months.

Question 201

Foodborne illness- primarily emesis

Answer 201

S. aureus, B cereus | Norovirus (Norwalk)

Question 202

Foodborne illness-predominant watery diarrhea

Answer 202

``` C. perfringes Enterotoxin E.coli Enteric viruses Cryptosporidium Cyclospora Intestinal tapeworms ```

Question 203

Foodborne illness-predominant inflammatory diarrhea ( bloody)

Answer 203

- Shigella - Salmonella - Shiga toxin E.coli - Campylobacter - Enterobacter - Vibrio parahemolyticus - Yersinia

Question 204

Foodborne illness- Ciguatera toxin

Answer 204

paresthesia

Question 205

Foodborne illness- Scombroid

Answer 205

Flushing, urticaria

Question 206

Foodborne illness- Listeria

Answer 206

Meningitis

Question 207

Foodborne illness- Vibrio Vulnificus

Answer 207

Cellulitis, sepsis

Question 208

Foodborne illness- Brucellosis

Answer 208

Arthtralgias, fever

Question 209

Norovirus ( 3 types of presentation)

Answer 209

- Asymptomatic infection - Fever with watery diarrhea - non-inflammatory small-bowel process - Severe illness - fever, vomiting, headache, and other systemic symptoms Symptoms usually start suddenly and last 48-72 hours. Diagnosis is generally clinical, and most patients improve with supportive care. If needed, diagnosis can be confirmed by polymerase chain reaction or nucleic acid-based testing.

Question 210

Dx of campylobacter

Answer 210

Stool culture

Question 211

Pathogen of Traveler's diarrhea

Answer 211

Enterotoxigenic E coli

Question 212

The most common cause of gastroenteritis in children and adults

Answer 212

Norovirus

Question 213

Tto of asymptomatic bacteriuria or cystitis in pregnancy

Answer 213

Nitrofurantoin, Cephalexin, amoxi-clavulanate, or fosfomycin 3-7 days

Question 214

Are fluoroquinolones CI in pregnancy

Answer 214

Yes, risk of cartilage damage in the fetus

Question 215

First line of treatment for cystitis in non-pregnat

Answer 215

TMP-SMX In pregnant: Cephalexin, amoxi-clavulanate, or fosfomycin

Question 216

Why is Trimethoprim-sulfamethoxazole CI in pregnancy

Answer 216

irst trimester has been associated with neural tube defects due to the folate antagonist Late third trimester associated with kernickterus

Question 217

Management of pyelonephritis during pregnancy

Answer 217

Ceftriaxone, Cefepime IV Once afebrile can be transitioned to 10-14 days of oral antibiotics. After treatment completion- daily suppressive therapy (eg, low-dose nitrofurantoin or cephalexin) is initiated and is maintained until 6 weeks postpartum to prevent recurrence.

Question 218

Outpatient management of pyelonephritis is not recommended in pregnancy due to risk of complications ie. pulmonary edema

Answer 218

true

Question 219

Cholestatic pattern in labs

Answer 219

high conjugated bilirubin, high cholesterol, high ALP.

Question 220

Algorithm for high ALP

Answer 220

Check GGT, If GGT Normal- then ALP is likely bone origin If GGT elevated- liver If liver-- RUQ US and AMA!

Question 221

Suspect of primary sclerosing cholangitis, next step

Answer 221

ERCP intra and extrahepatic sclerosis- strictures alternating with dilation and beading.

Question 222

Primary biliary cholangitis/cirrhosis with AMA + or US abnormal , next step

Answer 222

Liver biopsy

Question 223

Complications of Primary biliary cirrhosis/cholangitis

Answer 223

Osteomalacia ( despite vit D levels normal), malabsorption, ADEK deficiencies

Question 224

PPT of Primary biliary cirrhosis/cholangitis

Answer 224

``` Fatigue & pruritus (most common) Inflammatory arthritis (40%-70%) Hyperpigmented skin (25%-50%) Right upper quadrant discomfort (10%) Xanthelasmata (10%) & xanthomata (5%) ```

Question 225

Alpha-1 antitrypsin deficiency

Answer 225

cirrhosis (with significant elevations in hepatic transaminases) and emphysema.

Question 226

Anti–smooth-muscle antibodies

Answer 226

type 1 autoimmune hepatitis, which typically causes elevation of hepatic transaminases. Alkaline phosphatase is usually normal or only mildly elevated.

Question 227

ppt hemochromatosis

Answer 227

elevations in transaminases, and often has additional findings including hyperpigmentation, diabetes mellitus, arthropathy, and cardiomyopathy.

Question 228

Treatment of primary biliary cholangitis

Answer 228

ursodeoxycholic acid , if not liver transplant Ca and Vit D supplementation

Question 229

Management of asthma exacerbation

Answer 229

Mild to moderate ( PEF or FEV >=40): SABA ( up to 3 doses in 1 hour), PO corticosteroids if no reposnse to SABA or prior response to Corticosteroids. O2 if Sat <90 Moderate to Severe ( PEF or FEV<40): SABA +ipratropium in 1 hour , PIV or pO corticosteroids, O2 for Sat<90 ``` Impending or actual respiratory distress - SABA +Ipratropium -IV corticosteroids + Mg - +/- SQ terbutaline or epi +/- intubation and admission to PICU ```

Question 230

Inhaled short-acting beta agonists are the first-line treatment IN ASTHMA regardless of severity.

Answer 230

TRUE

Question 231

Treatment of CML

Answer 231

tYROSINE KINASE INHIBITOR-- IMATINIB

Question 232

Management of chronic urticaria

Answer 232

nothing! unless systemic ss | 80-90% of urticaria is idiopathic

Question 233

Presentation of chronic urticaria

Answer 233

Episodes of urticaria > 6 weeks episodes of rash that can worsen over min to hours, and resolve really fast INTENSE PRURITUS that can extend throughout the night. 40% may associate with angioedema ( mast cell activation extends to subcutuaneous tissue and deeper layers)

Question 234

Causes of chronic urticaria

Answer 234

``` 80-90% idiopathic physical stimuli - cold, skin pressure NSAIDs stress systemic disorders ( vasculitis, autoimmunde diseases) ```

Question 235

C1 esterase inhibitor levels

Answer 235

hereditary angioedema angioedema of the throat, tongue, or lips without urticaria. Patients can also have abdominal pain due to angioedema of the intestinal mucosa.

Question 236

When do you do biopsy in urticaria

Answer 236

NOT RECOMMENDED, ONLY with lesions that last >24 hours, are painful, have associated petechiae or purpura, associated systemic symptoms (eg, fever), elevated erythrocyte sedimentation rate/C-reactive protein, or do not respond to treatment.

Question 237

1st and 2 nd generation H1 blockers

Answer 237

diphenydramine , chlorphenidramine and others for motion sickeness: mezicline hydroxycine, promethazine. 2nd generation :cetirizine, loratadine, desloratadine

Question 238

Management of acute urticaria < 6 weeks

Answer 238

Mild: 1st or 2nd generation H1 Moderate h1 +h2 blockers Sever: oral steroid

Question 239

Management of chronic urticaria > 6 weeks

Answer 239

daily 2nd generation H1 blocker If no improvement in 2 weeks consider increasing dosing, add a first generation, add a H2 blocker, anti-leukotriene, brief course of oral steroids. If no improvement consider hydroxycloroquine, omalizumab or tacrolimus.

Question 240

H2 BLOCKERS EXAMPLE

Answer 240

Ranitidine , cimetidine

Question 241

prognosis of chronic urticaria

Answer 241

most patients have spontanoeus resolution within 1-5 years . 1 (50%), at 5 years 70%

Question 242

Causes of acute pericarditis

Answer 242

``` Viral or idiopathic TB Uremia Autoimmune ( SLE) Post MI ( early ( Peri infarct)< 4 days, late ( Dressler)) ```

Question 243

Management of peri infarct pericarditis vs. viral/idiopathic pericarditis

Answer 243

Peri-infarct pericarditis: high dose aspirin 650 mgTID - small effect on myocardial healing Pericarditis idiopathic or viral: NSAIDs and colchicine NSAIDS to be avoided in peri-infarct as impair myocardial healing and risk of wall rupture .

Question 244

Long term prognosis of pulmonary sarcoidosis

Answer 244

Asymptomatic patients often require no treatment those with symptoms or pulmonary function impairment usually receive 12-24 months of oral glucocorticoids Most cases (~75%) resolve over time and do not recur.

Question 245

TB screening

Answer 245

Can be done with the tuberculin skin test or Interferon Gamma Interferon Gamma preferred in patients who had BCG.

Question 246

Patient tested positive for TB, asymptomatic and nothing on X ray

Answer 246

latent TB 6-9 months of isoniazid ( daily) OR Rifampin 4 months

Question 247

PFTs in asthma

Answer 247

``` In patients with active ss: obstructive pattern (reduced FEV1 and a reduced FEV1/FVC ratio (total lung capacity and diffusing capacity of the lungs for carbon monoxide [DLCO] are typically normal or sometimes elevated). In these patients, a bronchodilator (eg, albuterol) can be administered and should result in significant improvement in FEV1 (eg, >15% from baseline). ``` In pts without ss- normal PFT findings. The administration of methacholine in these patients is likely to cause >20% reduction in FEV1, ( so normal test but an obstructive pattern following methacholine challenge)!

Question 248

Mild, moderate, and severe lead toxicity . values

Answer 248

5-44 45-69 >=70

Question 249

TTO lead poisoning

Answer 249

5-44- no meds 45-69 - Meso-2,3-dimercaptosuccinic acid (DMSA, succimer) >=70Dimercaprol (British Anti-Lewisite) plus calcium disodium edetate (EDTA)

Question 250

Indications of statins

Answer 250

Atherosclerotic cardiovascular disease ( CABG, TIA, etc) LDL>=190 Age>-45 with DM 10 YEAR RISK OF CABG is >7.5-10%%

Question 251

cholestyramine, colestipol, colesevelam - what class

Answer 251

bile acid sequestrants

Question 252

5 Types of lipid lowering agents

Answer 252

1. Statins 2. Bile acid sequestrans ( cholestyramine, colestipol, colesevelam) 3. Ezetimibe 4. Fibrates( Gemfibrozil, fenofibrate) 5. Niacin (B3)

Question 253

MOA statins

Answer 253

Inhibit conversionof HMG-CoA to mevalonate, a precursor of cholesterol. Decreases mortality in CAD patients

Question 254

EA statins

Answer 254

Hepatoxicity (increases LFTs) | myopathy ( particularly when used with fibrates, or niacin)

Question 255

MOA Bile acid sequestrants

Answer 255

Prevent intestinal reabsorption of bile acids, liver must use cholesterol to make more

Question 256

EA Bile acid sequestrants

Answer 256

GI upset, decreased absorption of other drugs and fat soluble vitamins

Question 257

MOA Ezetimibe

Answer 257

Prevent cholesterol absorption at small intestine brush border

Question 258

EA Ezetimibe

Answer 258

Rarely increased LFTs, diarrhea

Question 259

Fibrates MOA

Answer 259

Upregulate LPL--> TG clearance. | Active PPAR alpha to induce HDL synthesis

Question 260

EA Fibrates

Answer 260

Mypathy ( if given with statins), gallbladder stones

Question 261

Niacin MOA

Answer 261

Inhibits lipolysis in adipose tissue , reduces hepatic VLDL syndthesis

Question 262

SE Niacin

Answer 262

Red, flushed face, which is decreased by NSAIDs or long term use Hyperglycemia, Hyperuricemia

Question 263

Which of the lipid lower agents decrease the most the TRG

Answer 263

Fibrates

Question 264

Which of the lipid lower agents increased HDL

Answer 264

Niacin

Question 265

1st degree block

Answer 265

constant PR prolonged.

Question 266

2nd degree block MObitz I

Answer 266

PR prolonges before dropped beat

Question 267

2nd degree block MObitz Ii

Answer 267

Constant PR dropped beat

Question 268

Treatment of mobitz II and 3rd degree AV block

Answer 268

pacemaker

Question 269

Suspect appendicitis in pregnancy next step

Answer 269

graded compression abdominal ultrasound NO CT

Question 270

Appendicitis in pregnancy

Answer 270

atypical presentation, including right-sided abdominal pain with no peritoneal signs or McBurney point tenderness. abdominal pain, fever. high clinical suspicion

Question 271

Pylephlebitis, what is

Answer 271

infective suppurative portal vein thrombosis (THROMBOSIS, INFECTED) rare but devastating complication of untreated appendicitis or other intraabdominal or pelvic infections (eg, diverticulitis)

Question 272

pyelephlebitis is a rare complication of appendicitis or intraabdominal pathology.

Answer 272

TRUE

Question 273

negative predictive value

Answer 273

probability of not having a disease given a negative result on that test.

Question 274

likelihood ratio (LR)

Answer 274

expression of sensitivity and specificity that can be used to assess the value of a diagnostic test indepedently of prevalence.

Question 275

positive likelihood ratio (LR+)

Answer 275

represents the value of a positive test result. It is the probability of a patient with the disease testing positive divided by the probability of a patient without the disease testing positive.

Question 276

lR value

Answer 276

The smaller the LR, the less likely it is that the disease is actually presen

Question 277

negative likelihood ratio (LR-

Answer 277

he value of a negative test result.

Question 278

Psychosis can be the first presentation of SLE

Answer 278

Psychosis due to SLE may be treated symptomatically with antipsychotics, but symptoms usually respond well to oral steroids within 2-4 weeks.

Question 279

Metabolic causes of psychosis

Answer 279

``` Urea cycle disorders Acute intermittent porphyria Wilson disease Renal/liver failure Hypoglycemia Sodium/calcium/magnesium disturbances ```

Question 280

Systemic disorder causing psychosis

Answer 280

Systemic lupus erythematosus | Thyroiditis

Question 281

Labs in SLE

Answer 281

leukopenia!!, anemia, and/or thrombocytopenia

Question 282

Management of allergic rhinitis

Answer 282

``` Allergen avoidance is the first step! Intranasal corticosteroids ( fluticasone spray) ```

Question 283

Cat scratch disease

Answer 283

papule, nodule fever < 50% 1-2 weeks tender and erythematous LAD

Question 284

Treatment Cat scratch disease

Answer 284

Azithromycin Mild cases in healthy patients often self-resolve within 1-4 months; but azithro reduces severity and lenght. But if not very sure add clindamycin as empiric tto for s. aureus and strep

Question 285

standard caloric intake recommended for enteral feeding

Answer 285

30 kcal/kg/day, with a lower amount of calories and higher protein can be used for patients with severe preexisting malnutrition in order to prevent refeeding syndrome. A 1g/kg level of protein is appropriate for most patients.

Question 286

Leriche syndrome

Answer 286

lower-extremity claudication, absent or diminished femoral pulses, and ED. Erectile dysfunction- no erections in the morning

Question 287

Ankle-brachial index

Answer 287

highest ankle SB pressure/highest arm SBP =<0.9 abnormal 0.9-1.2- normal >1.2-suggestive of calcified or uncompressible vessels.additional vascular studies needed

Question 288

patients with testosterone deficiency can usually still achieve nocturnal penile erections.

Answer 288

true, and Testosterone deficiency can lead to a decrease in libido and erectile dysfunction

Question 289

Patients with Erectile Dysfunction and atherosclerotic risk factors should receive appropriate diagnostic testing (eg, ankle-brachial index, cardiac stress testing) prior to initiating specific therapy for sexual dysfunction.

Answer 289

T

Question 290

patient on chronic prednisone, advice for bone loss

Answer 290

Calcium and vit D If there is no osteoporosis, no need for alendronate

Question 291

How do corticoid cause bone loss

Answer 291

1. Decrease Ca absorption in the gut 2. Increased Renal Ca wasting 3. Anti-anabolic effect on bone 4. Decrease GnRH release-- central hypogonadism.

Question 292

stones, bones, groans, psychiatric overtones

Answer 292

"Stones" refers to kidney stones, nephrocalcinosis, and diabetes insipidus (polyuria and polydipsia). These can ultimately lead to renal failure. "Bones" refers to bone-related complications. The classic bone disease in hyperparathyroidism is osteitis fibrosa cystica, which results in pain and sometimes pathological fractures. Other bone diseases associated with hyperparathyroidism are osteoporosis, osteomalacia, and arthritis. "Abdominal groans" refers to gastrointestinal symptoms of constipation, indigestion, nausea and vomiting. Hypercalcemia can lead to peptic ulcers and acute pancreatitis. The peptic ulcers can be an effect of increased gastric acid secretion by hypercalcemia.[1] "Thrones" refers to polyuria and constipation "Psychiatric overtones" refers to effects on the central nervous system. Symptoms include lethargy, fatigue, depression, memory loss, psychosis, ataxia, delirium, and coma. Left ventricular hypertrophy may also be seen.[2]

Question 293

Causes of PTH independent hypercalcemia

Answer 293

``` Malignancy High vit A, VIT D Granulomatosis Milk-alkali syndrome Excess intake Ca immobilization thiazides thyrotoxicosis ```

Question 294

Causes of priamry hyperPTH

Answer 294

high urine Ca - Adenoma, hyperplasia, cancer ( high ALP,cAMP) - Osteitis fibrosa cystica - familial hypocalciuric hyperCa - Lithium

Question 295

Causes of secondary HYpert PTH

Answer 295

``` Renal failure ( high PO4) Vit D deficiency (low PO4) pseudohypoPTH Tumor lysis syndrome pancreatitis sepsis ```

Question 296

Causes of 1ary hypoPTH

Answer 296

Surgical resection Polyglandular autoimmune syndrome Infiltrative disease ( Wilson, hemochromatosis, metastasis) DiGeorge.

Question 297

Corrected Ca

Answer 297

measured calcium + 0.8 x [4 – albumin]

Question 298

Bisphosphonates are useful in decreasing bone resorption and may preserve bone mass in patients who are immobilized for extended periods.

Answer 298

t, can decrease bone turnover and preserve bone mass

Question 299

Saw palmetto, what is it, and what is it used for

Answer 299

herbal preparation, benign prostatic hyperplasia. Its use has not been shown to significantly improve urinary symptoms or flow measures. In addition, saw palmetto does not appear to affect prostate-specific antigen levels or prostate size.

Question 300

Kava kava, what is it, and what is it used for

Answer 300

anxiety and insomnia; however, its use is not recommended due to the potential risk of severe liver toxicity.

Question 301

St. John's wort ,what is it, and what is it used for

Answer 301

treatment of depression,insomnia, SE:Drug interactions: Antidepressants (serotonin syndrome), OCs, anticoagulants (↓ INR), digoxin Hypertensive crisis

Question 302

SE of saw palmetto

Answer 302

bleeding | mild abdominal discomfort

Question 303

Ginkgo biloba, what is it, and what is it used for , SE

Answer 303

memory enhancement, SE is bleeding

Question 304

Ginseng,what is it, and what is it used for , SE

Answer 304

improved mental performance, SE is bleeding

Question 305

Black cohosh,what is it, and what is it used for , SE

Answer 305

Post menopausal ss(hot flashes & vaginal dryness) | SE: Hepatic injury

Question 306

Licorice,what is it, and what is it used for , SE

Answer 306

Stomach ulcers Bronchitis/viral infections SE: Hypertension Hypokalemia

Question 307

Echinaceawhat is it, and what is it used for , SE

Answer 307

Treatment & prevention of cold & flu sE: Anaphylaxis (more likely in asthmatics)

Question 308

Ephedra

Answer 308

Treatment of cold & flu Weight loss & improved athletic performance Hypertension Arrhythmia/MI/sudden death Stroke Seizure

Question 309

Cells for diagnosis of Spontanoeus bacterial peritonitis

Answer 309

250 cells/mm3

Question 310

Hepatorenal syndrome

Answer 310

Patients with cirrhosis develop decreased peripheral vascular resistance secondary to splanchnic vasodilation, which can cause the decreased renal perfusion of hepatorenal syndrome.

Question 311

Suspect hepatorenal syndrome, next step?

Answer 311

A volume challenge would be an appropriate next step to confirm a diagnosis of hepatorenal syndrome in this patient. A failure to respond would be consistent with hepatorenal syndrome octreotide and midodrine or norepinephrine if no response albumin for 1-3 days.

Question 312

test of choice for evaluation of tension pneumothorax in the acute setting (eg, trauma bay, intensive care unit).

Answer 312

Bedside US- allows visualization of the parietal and visceral pleura; inability to detect lung sliding, the 2 pleural layers moving against one another during respiration, is consistent with pneumothorax. At PE will present with hyperresonance and no fremitus if highly suspected--tto is needle decompression or chest tube placement.

Question 313

What is the best screen question for unhealthy consumption of alcholo? - single item

Answer 313

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

Question 314

CAGE

Answer 314

Have you felt you should cut down on your drinking? Have others annoyed you by criticizing your drinking? Have you ever felt bad or guilty about your drinking? Have you ever taken a drink first thing in the morning (eye-opener) to steady your nerves?

Question 315

Audit C screen alcohol

Answer 315

How often do you drink alcohol? How many drinks do you have on a typical day when you are drinking? How often do you have 6 (4 for women) or more drinks on 1 occasion?

Question 316

DX sicca syndrome

Answer 316

``` secretory deficiency (e.g. Schirmer test) Anti Ro-, la, RF, ANA ```

Question 317

tto of Slipped capital femoral epiphysis

Answer 317

surgical pinning Delay in treatment (>24 hours in unstable SCFE) can lead to avascular necrosis and femoroacetabular impingement, which increase the risk of future degenerative arthritis.

Question 318

Dx scoliosis

Answer 318

Posteroanterior and lateral x-rays

Question 319

TTO scoliosis

Answer 319

treatment is generally unnecessary, and no follow-up is required for mild/moderate scoliosis (Cobb angle <40 degrees, as in this patient). severe scoliosis (Cobb angle ≥40 degrees) : orthopedic referral for surgical evaluation -- high risk of chronic pain, neuro ss, pulmonary complications

Question 320

Palivizumab ( Sinagis ) for prevention of bronchiolitis indications:

Answer 320

Preterm birth <29 weeks gestation Chronic lung disease of prematurity Hemodynamically significant congenital heart disease

Question 321

policies for physicians sponsored by pharmacy, lecturers vs. those who just attend to conferences.

Answer 321

Physicians attending conferences cannot accept subsidies from the industry for travel costs, lodging, or other personal expenses. However, it is permissible for faculty physician lecturers to accept reasonable honoraria and/or reimbursement for reasonable travel expenses. - They should full disclose conflicts of interest

Question 322

Causes of serotonin syndrome

Answer 322

- Serotonin drugs, especially in combination ( SSRIs, SNRIs, TCA, Tramadol) - Serotonin drugs in combination with MAOis ( phenelzine) or LINEZOLID - Drug overdose with Serotonin drugs - MDMA

Question 323

presentation of serotonin syndrome

Answer 323

Altered mental status Autonomic dysregulation( mydriasis, agitation, tachycardia, HTN, vomiting, diarrhea) can have fever tremor, hyperreflexia, myoclonus, rigidity

Question 324

difference between serotonin syndrome and NMS

Answer 324

SS: serotonin drug ( SSRIs, SNRIs, TCA, tramadol) + MAOs( phenelzine) or linezolid, or intoxication with SSRIs. altered mental status, autonomic dysregulation, hyperrefelxia, tremor, rigidity NMS: with antipsychotics ( haloperidol, risperidone). - dopamamine antagonists. bradykinesia and generalized "lead pipe" muscular rigidity,. NO INCREASED IN REFLEXES.

Question 325

Tto of serotonin syndrome

Answer 325

Discontinuation of all serotonergic medications Supportive care, sedation with benzodiazepines Serotonin antagonist (cyproheptadine) if supportive measures fail

Question 326

to avoid serotonin syndrome how is the washout period to introduce MAOis in a patient who was previously on SSRIs

Answer 326

5 weeks

Question 327

Dx of osteomyelitis

Answer 327

MRI with contrast of the bone

Question 328

Diabetic ulcer with polymicrobial swab detected and osteomyelitis, next step in treatment

Answer 328

bone biopsy with culture and sensitivity to guide treatment antibiotics > 6 weeks

Question 329

TTO of Diabetic ulcer with osteomyelitis

Answer 329

glucose control, surgical debridement, weight off-loading, revascularization (if needed), antibiotic therapy for >6 weeks. Serial inflammatory markers (eg, erythrocyte sedimentation rate) can help confirm treatment response.

Question 330

Blood cultures are often negative (>60%) in patients with osteomyelitis;

Answer 330

true

Question 331

TTO of sporotrichosis

Answer 331

cultures from aspirate fluid are typically obtained. Treatment with 3-6 months of itraconazole

Question 332

Diagnosis of Hirshprung's

Answer 332

Rectal suction biopsy-absence of ganglion cells after a contrast enema that delineates theobstruction

Question 333

What is associated with Hirshprungs

Answer 333

Up to 25% of patients with HD have another congenital anomaly (eg, renal) and approximately 10% of patients with HD have a chromosomal defect (eg, Down syndrome).

Question 334

pyloric stenosis,

Answer 334

nonbilious emesis without abdominal distension in infants age 4–8 weeks. Abdominal US

Question 335

Dx malrotation with volvulus

Answer 335

Upper gastrointestinal series

Question 336

Complication of compartment syndrome

Answer 336

AKI - rhabdomyolisis-- myoglobin

Question 337

How is myoglobin from rhabdomyolysis toxic for kidney

Answer 337

The released myoglobin is filtered and degraded in the kidney. Heme pigment from myoglobin degradation: Is directly toxic to proximal tubular cells Combines with Tamm-Horsfall protein to form tubular casts Induces vasoconstriction, reducing medullary blood flow

Question 338

Nex step if suspect compartment syndrome

Answer 338

lower extremity tissue pressure: Pressure >30 mm Hg or delta pressure (diastolic blood pressure − compartment pressure) <20-30 mm Hg indicates significant CS.

Question 339

tto compartment syndrome

Answer 339

fasciotomy

Question 340

CK needed in compartment syndrome?

Answer 340

``` NOT PRIORITY Creatine kinase (CK) levels may be elevated in patients with crush injury with or without CS and may be helpful for predicting possible renal injury. However, waiting for CK level results may unnecessarily delay the more important diagnosis of CS. ```

Question 341

SE of amlodipine

Answer 341

edema preferential dilation of precapillary vessels (arteriolar dilation), which leads to increased capillary hydrostatic pressure and fluid extravasation into the interstitium. other side effects of DHP CCBs: flushing headache edema

Question 342

Rinne and Weber tests interpretation

Answer 342

see phone

Question 343

Sudden hearing loss, no trauma, normal neuro exam

Answer 343

urgently by otolaryngology with a formal audiogram, MRI, and corticosteroid therapy.

Question 344

CI tPA (6)

Answer 344

Presence of active internal bleeding Bleeding diathesis (eg, platelets <100,000/µL) Hypodensity in >33% of an arterial territory on CT scan Presence of intracranial hemorrhage on CT scan Intracranial surgery in the last 3 months Blood pressure >185/110 mm Hg

Question 345

Window for tPA

Answer 345

3-4.5hrs

Question 346

ancillary studies for patients with stroke

Answer 346

Magnetic resonance or CT angiography of head and neck , OR dupplex carotid EKG ( arrhythmia) TEE Echo(presence of an intracardiac thrombus.) ** Hypercoagulability studies are NOT indicated in all patients with acute stroke. They should be ordered in those with a personal or family history of hypercoagulable disease, in young patients with no apparent etiology for stroke despite evaluation for vascular and cardiac sources, and in patients with clinical findings that suggest systemic lupus erythematosus.

Question 347

labs dermatitis atopic

Answer 347

High serum IgE | Eosinophilia

Question 348

management for atopic dermatitis (AD)

Answer 348

oral antihistamines, emollients to maintain skin hydration, and avoidance of excessively hot or dry environments. Low-potency agents (eg, hydrocortisone) may be adequate for mild symptoms. More significant symptoms may warrant moderate- to high-potency glucocorticoids (eg, triamcinolone, betamethasone).

Question 349

low potency and high potency topical glucocorticosteroids. in atopic dermatitis

Answer 349

Low-potency agents (eg, hydrocortisone) may be adequate for mild symptoms. More significant symptoms may warrant moderate- to high-potency glucocorticoids (eg, triamcinolone, betamethasone). severe AD may require UV light.

Question 350

Topical glucocorticoids are relatively contraindicated for Atopic dermatitis on the face, eyelids, or flexural areas;

Answer 350

calcineurin inhibitors (eg, tacrolimus) may be considered for use in these areas

Question 351

Indications for parathyroidectomy in tertiary hyperparathyroidism

Answer 351

1. Persistently elevated calcium (eg, >10.5 mg/dL), phosphorus, or PTH (eg, >800 pg/mL) levels 2. Soft tissue calcification or calciphylaxis (vascular calcification with skin necrosis) 3. Intractable bone pain or pruritus

Question 352

How CKD leads to secondary hyperparathyroidism

Answer 352

CKD leads to 1. Decreased conversion from 25 hydroxyvit D to 1,25 hydroxyvit D. 2. Decrease PO4 clearance. If low vit D, decreased absorption of Ca in the gut. And decreased clearance then increase PO4 that binds to calcium in the serum aLL THESE LEAD TO LOW Ca IN SERUM AND THEN COMPENSATORY pth ELEVATION

Question 353

secondary hyperPTH

Answer 353

elevated PTH levels, low/low-normal calcium levels, and low 1,25-dihydroxyvitamin D levels (despite adequate 25-hydroxyvitamin D stores).

Question 354

tertiary hyperparathyroidism

Answer 354

result of prolonged secondary hyperPTH autonomous PTH secretion unresponsive to rising calcium levels, resulting in hypercalcemia with very high PTH levels.bone disease with bone pain and an elevated bone-specific alkaline phosphatase (due to high bone turnover).

Question 355

Stroke patients, particularly those with symptoms of dysarthria, are often at risk for oropharyngeal dysphagia.

Answer 355

In the setting of acute stroke, such patients should be given nothing (eg, food, drink, medications) by mouth until a swallow evaluation can be performed.

Question 356

Patient with stroke passed the tPA window. Management?

Answer 356

evaluate swallow study aspirin Low-dose heparin or low-molecular-weight heparin to prevent stroke/DVT - particularly in those who have dense hemiparesis.

Question 357

Types of necrotizing fascitis

Answer 357

Type I : underlying diabetes and peripheral vascular disease. It is generally a polymicrobial infection; some commonly isolated organisms include Staphylococcus aureus, Bacteroides fragilis, Escherichia coli, group A Streptococcus, and Prevotella species. - here you see more crepitus ( anaerobic) type II: MC! usually occurs in individuals with no concurrent medical illness. Many patients report a history of laceration, blunt trauma, or a surgical procedure as a predisposing factor. It is typically caused by group A Streptococcus (Streptococcus pyogenes).

Question 358

Microorganisms causing necrotizing fascitis

Answer 358

usually due to minor trauma or underlying disease( DM, glucocorticoid use, alcohol or drug abuse) - S.pyogenes ( MC if no underlying disease, and just minor trauma) - S aureus - Polymicrobial - C. perfringens ( MC in diabetics or PAD)

Question 359

Presentation of necrotizing fascitis

Answer 359

Systemic ss: hypotension, fever, tachyardia severe pain out of proportion erythema can have crepitus ( if c. perfringens or B. fragilis) BULLAE

Question 360

Tto necrotizing fascitis

Answer 360

debridement and antibiotics.

Question 361

Drunk person who threat with suicide and now says no.

Answer 361

When there is concern that the patient may be suicidal, the physician must observe the patient and perform a suicide assessment when the patient is completely sober. Speaking with the boyfriend and contacting family members for collateral information would also be advisable.

Question 362

Lead poisoning ss

Answer 362

anorexia, decreased activity, irritability, vague abdominal pain and insomnia, PICA behavior

Question 363

if suspicion of lead poisoning

Answer 363

CBC, serum iron and ferritin levels, and reticulocyte count.

Question 364

actinic keratosis (AK) tto

Answer 364

due to sun exposure Topical 5FU cream for a period of 3–6 weeks. other include: cryotherapy or surgical excision

Question 365

Untreated AK is associated with?

Answer 365

Untreated AK has up to a 20% risk of progression to squamous cell carcinoma. For this reason, any AK lesions that are detected should be removed or destroyed

Question 366

selective deficiency of IgG3

Answer 366

more common in adult females and is associated with recurrent sinopulmonary as well as gastrointestinal infections.

Question 367

Alpha-1-antitrypsin deficiency

Answer 367

emphysema and liver damage, but does not increase the risk of recurrent infections.

Question 368

Cystic fibrosis manifests earlier in life and does not cause gastroenteritis.

Answer 368

``` defect in the CFTR gene leads to impaired chloride and water transport this causes viscous secretions in the respiratory tract exocrine pancreas sweat glands intestines genitourinary tract Associated conditions nasal polyposis infertility in men and subfertility in women pancreatic insufficiency ```

Question 369

ss in cystic fibrosis

Answer 369

a productive cough respiratory symptoms are more prominent in adulthood recurrent pulmonary infections S. aureus is more common in pediatric patients (treat with vancomycin) Pseudomonal spp. are more common in adults (treat with amikacin, ceftazidime, and ciprofloxacin) chronic sinusitis chronic productive cough dyspnea on exertion bronchiectasis gastrointestinal symptoms are more prominent in infancy chronic and frequent diarrhea greasy stool with flatulence from malabsorption secondary to pancreatic insufficiency can lead to rectal prolapse meconium ileus in infants (15%)

Question 370

How do you measure respiratory status in Guillain Barre

Answer 370

frequent measurement of vital capacity and negative inspiratory force. Tidal volume. Approximately 30% of patients with GBS ultimately require mechanical ventilation.

Question 371

Patients with GBS should receive plasma exchange or IVIG if:

Answer 371

Nonambulatory Within 4 weeks of symptom onset Those who are ambulatory and recovering generally do not require treatment.

Question 372

tto botulism

Answer 372

equine serum antitoxin and antibiotics.

Question 373

course of disease in Guillain Barre

Answer 373

The manifestations of Guillain-Barré syndrome (GBS) tend to evolve as follows: 2 weeks of progressive motor weakness that can lead to paralysis 2-4 weeks of plateaued symptoms Slow, spontaneous recovery over months

Question 374

prognosis Guillain Barre

Answer 374

slow recovery | weakness may resolve spontaneously but treatments shortness the time needed for recover.

Question 375

Measures to decrease rate of transmission

Answer 375

Contact precautions hand washing with soap and water is more effective in C difficile spore elimination than alcohol-based sanitizers. cleaning the patient's environment (eg, room, medical equipment) and limiting the use of certain antibiotics (eg, clindamycin, fluoroquinolones, cephalosporins).

Question 376

tto giardia

Answer 376

Metronidazole

Question 377

tto giardia outbreak

Answer 377

Symptomatic individuals require metronidazole therapy. Symptomatic students with positive stool do not need to be restrained from schoolunless they are incontinent. NO Recreational water venues. until symptoms have resolved for 2 weeks.

Question 378

Immune thrombocytopenia pathogenesis

Answer 378

Anti GpIIb/IIIa antibodies. Spleen macrophages consume the platelet-antibody complex. Commonly in viral illness.

Question 379

ITT pathogenesis

Answer 379

inhibition or deficiency of ADAMS13 ( vWF metalloproteinase)- so decreased degradation of vWF. large vWF --> increased platelet adhesion-->increased platelet aggregation and thrombosis Labs: schystocytes, LDH,

Question 380

ITT presentation

Answer 380

``` neurologic and renal ss fever thrombocytopenia microangiopathic hemolytic anemia. Petechial rash, abdominal pain ```

Question 381

ITT tto

Answer 381

plasmapheresis, steroids.

Question 382

Pregnancy is associated with an ADAMTS13 deficiency that becomes more pronounced with increasing gestational age and persists into the postpartum period and can precipitate TTP

Answer 382

t

Question 383

stress fx appear in X ray

Answer 383

Possible abnormalities on x-ray may take up to 4 weeks to become apparent and include bone sclerosis, cortical thickening, periosteal elevation, and visible fracture line

Question 384

tto of stress fracture

Answer 384

pneumatic splinting, reduced weightbearing, and a graduated exercise program. Most patients may resume full-intensity exercise within 12 weeks,

Question 385

Hungtington disease

Answer 385

CAG triplet repeat expansion in one allele of the HD (huntingtin) gene on chromosome 4 severity depends on the number of repeats > 39 repeats: full penetrance allele anticipation: number of repeats may increase with generations, presenting earlier. ``` Involuntary movements ( chorea, ataxia, tics) cognitive deterioration ( memory, language disability) psychiatric ss) ``` atrophy of caudate and putamen, as well as general cerebral atrophy fatal. death 20 years after ss onset.

Question 386

Treatment lyme

Answer 386

Doxy: non pregnant and children >8 years Amoxi or cefuroxime: pregnant, lactant or children < 8 no congenital defects from lyme to baby

Question 387

Types of lyme

Answer 387

Early localized:days to 1 m ( erythema migrans, headache, myalgias) Early disseminated days to months (carditis AV block, cardiomypathy, VII palsy, encephalitis, meningitis, migratory arthritis, conjunctivitis, ) Late or chronic m to years ( arthritis, polyneuropathy)

Question 388

why serology is not recommended in Lyme

Answer 388

very insensitive. IgM usually develop 1-2weeks and IgG antibodies typically after within 2-6 weeks. BUT SEROLOGY SHOULD BE PERFORMED IN PTS WITH SIGNS OF EARLY DISSEMINATED OR LATE DISEASE

Question 389

Indications for Lyme tto

Answer 389

must meet all 5 1.attached tick is adult or nymphal Ixodes scapularis 2. tick attached for >=36 hrs or engorged 3.prphylaxis started within 72 hrs of tick removal 4. endemic area >20% no contraindications to doxy

Question 390

iron def anemia

Answer 390

hemoglobin <11 g/dL, often accompanied by low mean corpuscular volume (MCV), elevated red blood cell (RBC) distribution width, and a low RBC count.

Question 391

Differentiate thalassemia from iron def anemia

Answer 391

Mentzer index (MCV/RBC) >13 is also suggestive of iron deficiency and can help differentiate it from thalassemia; Alpha and beta thalassemias are also microcytic but characterized by a Mentzer index <13

Question 392

Mentzer index

Answer 392

Differentiate thalassemia from iron def anemia Mentzer index (MCV/RBC) >13 is also suggestive of iron deficiency and can help differentiate it from thalassemia; Alpha and beta thalassemias are also microcytic but characterized by a Mentzer index <13

Question 393

testicular torsion

Answer 393

elevated, transverse testi is erythematous, edematous, firm, and tender elevating the scrotum does not tend to relieve the pain absent cremasteric reflex

Question 394

Timefram for surgery in testicular torsion

Answer 394

ideally within 6 hours

Question 395

Epididymitis,

Answer 395

commonly due to chlamydia in sexually active boys, causes scrotal pain and swelling, with increased blood flow to the inflamed epididymis evident on Doppler ultrasound. experience pain relief with scrotal elevation (Prehn sign),

Question 396

Indications for implantable cardioverter/defibrillator in hypertrophic cardiomyopathy

Answer 396

``` Family history of HCM Syncope ( w or w/o exertion) Hypotensive episode with exertion nonsustained VT on Holter monitoring Extreme LVH > 3 cm ```

Question 397

Although quitting at younger ages is associated with a larger absolute decline in premature mortality, cessation at age 60 or older has also been shown to lower the risk of all-cause mortality and cardiovascular events. This benefit can be seen within 5 years of quitting.

Answer 397

elderly people also benefit from quitting smoking. decrease mortality seen 5 years of quitting.

Question 398

5 A'sapproach of smoking cessation

Answer 398

``` Ask Assess readiness to quit Advice patient to quit Assist- pharmacologically or referral Arrangea quit date and a follow-up appt. ```

Question 399

risk of osteoporosis may decline 10 years after quitting smoking

Answer 399

true

Question 400

Dx of TB

Answer 400

First X ray: signs of active disease such as upper lobe cavitation (70%-80%), hilar lymphadenopathy, or pleural effusion. Then SPUTUM :Three single sputum samples (spontaneous or induced) are submitted in 8- to 24-hour intervals with at least 1 early-morning sample. Sputum should be sent for acid-fast bacillus smear, mycobacterial culture, and nucleic acid amplification testing.

Question 401

Tuberculin skin test VS. Interferon-gamma release assay

Answer 401

Tuberculin skin test High specificity in non-BCG-vaccinated patients Cost effective, requires training for interpretation Can diagnose latent but not active TB Return visit required in 48 hours for final result Interferon-gamma release assay Blood draw required, 1 patient visit High specificity with results in 16-24 hrs No interference with BCG vaccine Cannot differentiate between latent & active TB

Question 402

who to treat in TB

Answer 402

wall

Question 403

Patient in whom you suspect TB but the three sputu samples came back negative, next?

Answer 403

Do not rule it out - low sensitivity (45%-80%) so false negatives are common. -Additional testing with mycobacterial culture (takes 2-6 weeks)or nucleic acid amplification(<48hrs) is required for confirmation.

Question 404

Developmental dysplasia of the hip

Answer 404

abnormal acetabular development resulting in a shallow hip socket and inadequate support of the femoral head.

Question 405

ppt of Developmental dysplasia of the hip

Answer 405

DDH may be missed in the newborn period if classic symptoms and signs (eg, hip clunk, asymmetric leg creases) are absent or undiagnosed. adolescents and young adults may have a leg-length discrepancy and gait abnormalities such as toe-walking on the affected side or a Trendelenburg gait. activity-related pain in the front hip and groin, premature joint degeneration and osteoarthritis

Question 406

radiation proctitis.

Answer 406

A cute:diarrhea, mucus discharge, and tenesmus (ineffectual/painful straining on defecation) during or within 6 weeks of pelvic radiation Chronic/; >9 weeks to years after radiation therapy and is more commonly associated with strictures, fistula formation, and rectal bleeding.

Question 407

Colonoscopy in radiation proctitis.

Answer 407

lesions with pallor, friability, telangiectasias, and mucosal hemorrhage,

Question 408

Incidentaloma in adrenal glands, labs

Answer 408

serum electrolytes, dexamethasone suppression testing, and 24-hour urine catecholamine, metanephrine, vanillylmandelic acid and 17-ketosteroid measurement.

Question 409

Criteria for surgical manangement of incidentaloma

Answer 409

all functional tumors, all malignant tumors (which demonstrate a characteristic heterogenous appearance on imaging), and all tumors greater than 4 cm. * Rest can be observed with serial imaging and consider removal

Question 410

Hep B labs

Answer 410

elevated aminotransferases, positive hepatitis B surface ANTIGEN, hepatitis B IgM core antibody, hepatitis B e antigen (indicator of high infectivity), and detectable hepatitis B DNA.

Question 411

Management of acute Hep B

Answer 411

symptomatic patients are at very low risk of acute liver failure or other significant complications. most cases of acute HBV (even with marked elevations in aminotransferases) resolve spontaneously and can be managed with outpatient supportive care and close follow-up.

Question 412

Hospitalization criteria in Hep B ( not a common thing)

Answer 412

fever or hemodynamic instability, impaired hepatic synthetic function (eg, abnormal coagulation markers), or other signs of acute liver failure (eg, encephalopathy). age >50, have poor oral intake, or have minimal social support.

Question 413

Risk of progression from acute to chronic HBV according to age.

Answer 413

the risk of progression from acute to chronic HBV infection decreases with age. Perinatally acquired: 90% Acquired at 1-5 years :20-50% Adults: 5% *Hepatitis C has a much higher risk of progression to chronic infection (approximately 75%-85%)

Question 414

Urethral swab is performed, and Gram stain of the urethral fluid reveals many neutrophils but no organisms. NAAT for Chlamydia and gonorrhea. Empiric treatment with?

Answer 414

Azythromycin. (likely chlamydia) otherwise : Intracellular gram-negative diplococci

Question 415

Gonococcal vs. Non-Gonoccocal urethritis

Answer 415

Gonococcal: N. gonorrhea, purulent, Intracellular gram-negative diplococci, CEFTRIAXONE PLUS AZYTHRO Non-Gonococcal: Chlamydia trachomatis Ureaplasma urealyticum Mycoplasma genitalium Trichomonas vaginalis watery, scant Aseptic with leukocytes Azythromycin

Question 416

Patient with urethritis that continue to have ss after initial treatment and NAAT for gonorrhea/chlamydia negative.

Answer 416

The first diagnostic step is repeating the urethral fluid Gram stain to confirm ongoing urethritis (>2 leukocytes/hpf). If positive, patients should undergo nucleic acid amplification (NAAT) testing of the urine for Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, and Trichomonas vaginalis (if available). in this scenario -->azithromycin-insensitive organism. So possibly not Chlamydia but M. genitalium. -->moxifloxacin.

Question 417

tto of urethritis by M. genitalium.

Answer 417

moxifloxacin.

Question 418

PCOS tto

Answer 418

Weight loss (first-line) OCPs for menstrual regulation Progestins for endometrial protection Clomiphene citrate for ovulation induction

Question 419

Management of decompensated heart failure

Answer 419

LMNO Initiate with diuretics and intravenous vasodilators to reduce cardiac preload and relief ss. An urgent pulse oximetry, chest radiograph, and electrocardiogram (ECG)

Question 420

TTo of vericose veins.

Answer 420

leg elevation, compression stockings, sclerotherapy, and surgical ligation. Compression stockings should not be used in patients with an underlying arterial insufficiency.

Question 421

TTo of vericose veins.

Answer 421

leg elevation, weight reduction, compression stockings, sclerotherapy, and surgical ligation. Compression stockings should not be used in patients with an underlying arterial insufficiency.

Question 422

When is surgical ligation indicated in varicose veins

Answer 422

large symptomatic varicose veins with ulcers, bleeding, or recurrent thrombophlebitis of the veins.

Question 423

Risk factors for persistent breech presentation

Answer 423

``` uterine anomalies (eg, leiomyoma, bicornuate uterus), placental anomalies (eg, placenta previa), and fetal anomalies. ```

Question 424

risk of asphyxia and fetal injury. is associated with which complications?

Answer 424

risk of asphyxia and fetal injury.

Question 425

When is the best time to do an external cephalic version?

Answer 425

>=37 weeks

Question 426

Treatment of graves disease

Answer 426

ALWAYS B blocker - ATDs- Mild - Radioactive iodine - Thyroidectomy

Question 427

Treatment of graves disease

Answer 427

ALWAYS B blocker - ATDs- Mild - Radioactive iodine - Thyroidectomy - if patient has moderate to severe ophtalmologic ss prednisone.

Question 428

When is indicated antithyroid drugs in hypertyroidism

Answer 428

- Mild hyperthyroidism - Elderly who have low life expectancy - preparation of iodine or thyroidectomy - Pregnancy ( PTU in 1st trimester)

Question 429

When is indicated radioactive iodine in hypertyroidism

Answer 429

Moderate to severe hyperthyroidism( with or without ophtalmo) patient preference in mild hypothyroidism

Question 430

When is indicated thyroidectomy in hypertyroidism

Answer 430

1. very large goiter 2. suspicion of Ca 3. Coexisting primary hyperPTH 4. Pregnant patient 5. severe ophtalm. 6. retrosternal goiter with obstructive ss

Question 431

RAI may cause an exacerbation of symptoms of hyperthyroidism

Answer 431

true!

Question 432

RAI may cause an exacerbation of symptoms of ophtalmology in hyperthyroidism

Answer 432

true!

Question 433

Prednisone is recommended for patients with moderate to severe Graves ophthalmopathy (eg, exophthalmos, periorbital edema, vision changes) prior to definitive treatment with surgery or RAI.

Answer 433

tryue

Question 434

When do you evaluate thyroid function after initiated treatment?

Answer 434

4-6 weeks after initiation of antithyroid drug (ATD) treatment and then every 2-3 months. YOU ORDER , total T3 and free T4 . TSH is not often order as it may be suppressed for a long time even after initiation of therapy and would

Question 435

major SE of antithyroid drugs

Answer 435

agranulocytosis and hepatotoxicity(mainly with PTU). agranulocytosis -occurs within 90 days of initiation and presents with fever, chills, or sore throat. If patients on ATDs develop these symptoms, a white blood cell count with differential should be obtained. if confirm stop antibiotic

Question 436

Physician asked to treat a family member.

Answer 436

Treating family members is generally considered to be ethically problematic and potentially unsafe. Acute and limited care may be appropriate when no other physician is available.

Question 437

Immunosuppressed woman due to chemo with fever and a rash on her right thigh. Within a few hours, a pustule formed in the center of the lesion, rapidly evolved into a dark bulla, and then ruptured and formed an ulcer.

Answer 437

Ecthyma gangrenosum- pseudomona PAINLESS Skin examination shows a nontender, necrotic ulcer with an erythematous rim and yellow-green, purulent exudate on the right thigh. There is another lesion with a hemorrhagic dark-bluish bulla and surrounding erythematous, indurated skin.

Question 438

Ecthyma gangrenosum

Answer 438

pseudomona's bacteremia In immunosuppressed PAINLESS Skin examination shows a nontender, necrotic ulcer with an erythematous rim and yellow-green, purulent exudate on the right thigh. There is another lesion with a hemorrhagic dark-bluish bulla and surrounding erythematous, indurated skin. anogenital area, axilla, and extremities are most commonly affected, FEVER is often present

Question 439

Pyoderma gangrenosum

Answer 439

associated with inflammatory bowel disease or anarthritides. inflammatory nodules, pustules, or vesicles and quickly evolve to ulcers; however, they are usually quite painful.

Question 440

Clostridial myonecrosis,

Answer 440

aka gas gangrene. fever, severe muscle pain, and painful purple-colored bullae

Question 441

Management of ecthyma gangrenosum

Answer 441

IV antibiotics ( pip tazo, aminoglycoside)

Question 442

Dumping syndrome

Answer 442

Complication of gastrectomy- occurs when high amount of carbs are consumed Early:rapid onset, usually within 15 minutes. It is the result of rapid emptying of food into the small bowel. Due to the hyperosmolality of the food, rapid fluid shifts from the plasma into the bowel occur, resulting in hypotension and a sympathetic nervous system response. Patients often present with colicky abdominal pain, diarrhea, nausea, and tachycardia [65]. avoid foods that are high in simple sugar content and replace them with a diet consisting of high fiber, complex carbohydrate, and protein rich foods. Late : aka postprandial hyperinsulinemic hypoglycemia (PHH). dizziness, fatigue, diaphoresis, and weakness, usually occur one to three hours after ingestion of a carbohydrate-rich meal, typically months to years after surgery, and are associated with documented hypoglycemia

Question 443

Dumping syndrome tto

Answer 443

decreasing the speed of the passage of fluids and food into the small gut. A high-protein and low-carbohydrate diet is advised, as well as smaller but more frequent meals throughout the day.

Question 444

Amoxicillin administration in a patient with infectious mononucleosis classically causes a generalized maculopapular rash.

Answer 444

The rash will resolve spontaneously after withdrawal of the antibiotic and observation alone.

Question 445

Prognosis of infectious mononucleosis

Answer 445

supportive tto, avoid exercise for next 3 weeks symptoms will resolve spontaneously within weeks of onset. BUT persistent fatigue is common and may exist for months (with some patients experiencing chronic fatigue for >6 months).

Question 446

pyloric stenosis dx

Answer 446

abdominal us Nonbloody, nonbilious, projectile vomiting weight loss, dehydration olive shape peristaltic waves can be seen prior to vomiting

Question 447

complications of pyloric stenosis

Answer 447

hypokalemic and hypochloremic metabolic alkalosis results from volume contraction and the loss of gastric hydrochloric acid. Blood urea nitrogen and creatinine may be elevated due to prerenal azotemia.

Question 448

tto and diagnosis intussusception

Answer 448

air contrast enema 6-36 months with colicky abdominal pain, "currant jelly" stools, and emesis.

Question 449

RF for pyloric stenosis

Answer 449

3-6 weeks; first-born, preterm, and bottle-fed infants, erythromycin/azythromycin exposure( prophylaxis for pertussis)

Question 450

pt has pyloric stenosis , tto?

Answer 450

FIRST CORRECTION OF ELECTROLYTE ABNORMALITY they have hypokalemic and hypochloremic metabolic alkalosis After fluid resuscitation and stabilization, surgical correction with a pyloromyotomy is indicated

Question 451

Rotavirus and intussusseption.

Answer 451

Rotavirus increases peyer;s M patch --- increase intussusseption

Question 452

Anion gap formula

Answer 452

Na -( CL+HCO3)

Question 453

In diabetic patient with metabolic acidosis, AKI think of

Answer 453

metformin related lactic acidosis Although lactic acidosis is rare in patients with normal renal function, patients with impaired renal function are at increased risk, or in patients with hypovolemia.

Question 454

tto hypoparathyroidism

Answer 454

vit D and calcium in patients with borderline low serum calcium and high urinary calcium, as seen in the patient described in the vignette, the addition of a thiazide diuretic will not only decrease the urinary calcium, but also increase serum calcium levels.

Question 455

Complications systemic sclerosis

Answer 455

Lung: Interstitial lung disease, pulmonary arterial HTN Kidney: HTN, scleroderma renal crisis (oliguria, thrombocytopenia, MAHA) Heart: Myocardial fibrosis, pericarditis, pericardial effusion

Question 456

Labs systemic sclerosis

Answer 456

Antinuclear antibody Anti-topoisomerase I (anti-Scl-70) antibody Anticentromere antibody

Question 457

CREST syndrome,

Answer 457

limited cutaneous systemic sclerosis ``` Calcinosis Raynaud Esophageal dysmotility Sclerodactily Telangiectasis ```

Question 458

types os systemic sclerosis:

Answer 458

1. limited cutaneous systemic sclerosis(CREST) 2. diffuse cutaneous systemic scleroderma (which includes more diffuse skin involvement as well as involvement of the lungs, kidneys, and gastrointestinal tract)

Question 459

All patients with scleroderma should be screened with pulmonary function testing at diagnosis.

Answer 459

In patients with interstitial lung disease, there is a concordant decline in both total lung capacity (TLC) and diffusing capacity for carbon monoxide (DLCO), whereas in patients with pulmonary hypertension, there is a greater drop in DLCO and a relatively preserved TLC.

Question 460

PATHOLOGY OF systemic sclerosis:

Answer 460

Progressive tissue fibrosis | Vascular dysfunction

Question 461

Indications of HPV

Answer 461

All girls & women* age 11-26 (but may be given up to age 45) Boys & men age 11-21 (up to age 26 for men who have sex with men) Immunocompromised individuals (including HIV patients) age 11-26 Not indicated in pregnant women In children<15 only 2 doses In children> 15 3 doses a person should still get the vaccine even if they are already sexually active. This is because they are unlikely to have been exposed to all of the types of HPV contained in the vaccine

Question 462

Posion Ivy type of hypersensitivity reaction

Answer 462

type IV (cell-mediated) hypersensitivity reaction

Question 463

Tto poison Ivy

Answer 463

Removal of apparel and cleansing of areas to avoid spread cool compress, topical corticosteroids If severe we may consider oral corticosteroids

Question 464

scabiestto

Answer 464

ivermectin

Question 465

Concern for delayed speech, next step

Answer 465

Audiology eval

Question 466

threshold for blood transfusion in most stable patients with upper gastrointestinal bleeding is

Answer 466

hemoglobin level <7 g/dL as this is associated with fewer complications and reduced mortality A hemoglobin level >8 g/dL is recommended in patients with stable coronary artery disease or in those planning to undergo major surgery (eg, certain orthopedic procedures). Patients with acute coronary syndrome, severe thrombocytopenia, or cancer with a high bleeding risk may require a higher transfusion goal.

Question 467

when do you do surgery in pancreatitis caused by gallstones

Answer 467

IF mild disease (lack of both organ failure and local or systemic complications (eg, acute necrotic collection, heart failure), --> cholecystectomy within 7 days of clinical improvement (usually during the same hospitalization) -- if not they will have ecurrence rate of 30% in 6-8 weeks. Delayed cholecystectomy should be considered for patients with severe GP, which is characterized by persistent failure of one or more organ systems (eg, hypotension not responsive to fluid resuscitation) .

Question 468

gallstone pancreatitis : In addition to having a cholecystectomy, patients should also undergo evaluation of the biliary system via preoperative endoscopic retrograde cholangiopancreatography or intraoperative cholangiogram to ensure no gallstones remain.

Answer 468

true

Question 469

Immunocompromised with Multiple small papules with central umbilication. Some of the lesions have central necrosis and are covered with a hemorrhagic crust.

Answer 469

cutaneous cryptococcosis.- mainly head and neck

Question 470

cutaneous cryptococcosis. in HIV. At what CD4 count

Answer 470

Cryptococcus neoformans is an encapsulated yeast CD4<100 Although meningoencephalitis , pulmonary or disseminated are the most common

Question 471

Disseminated Mycobacterium avium

Answer 471

fever, night sweats, abdominal pain, diarrhea, and weight loss

Question 472

Tto of cutaneous cryptococcosis

Answer 472

>2 weeks of intravenous amphotericin B and oral flucytosine

Question 473

Dx of cryptococcosis

Answer 473

BIOPSY OF THE LESION *not fungal cultures

Question 474

In digital injuries, tendons are more likely to be injured than arteries, veins, or nerves due to their relative, vulnerable, anatomic location.

Answer 474

true

Question 475

Patient treated for pneumonia, who develops PE. Wife asks if that complication could have been prevented

Answer 475

Thrombosis can occur with or without prophylaxis, but your husband should have been placed on it to decrease risk. timely disclosure of errors help mitigate any potential to affect the patient-physician relationship.

Question 476

Sjogren is associated to other diseases?

Answer 476

Primary form: none Secondary: to rheumatologic conditions such as RA, SLE

Question 477

Complications of xerostomia

Answer 477

dental caries, Candida, chronic esophagitis

Question 478

Sjogren manifestations

Answer 478

Xerosis (ie, abnormal dryness) (see 'Xerosis' below) ●Purpura, associated with vascular or hematologic abnormalities ●Raynaud phenomenon ●Cutaneous vasculitis ●Annular erythema ●Other manifestations, including eyelid dermatitis and angular cheilitis

Question 479

What questions to ask if suspecting Sjogren

Answer 479

"Do you wake up at night feeling dry, and then drink some water?" or "Do you frequently drink water to help you swallow some dry foods?"

Question 480

Amlodipine SE

Answer 480

fluid retention and urticarial rash.

Question 481

ACEIs SE

Answer 481

angioedema and urticaria. | Occasionally, lisinopril can lead to aggravation of psoriatic rash.

Question 482

Which antihypertensive causes photosensitivity?

Answer 482

Thiazides

Question 483

Management of pelvic organ prolpase

Answer 483

If not surgical candidate (cardiovascular or pulmonary comorbidities) VAGINAL PESSARY Weight loss Pelvic floor exercises VAGINAL PESSARY Surgical repair(ysterectomy with prolapse repair): in those who do not improve despite conservative management.

Question 484

tto of stress urinary incontinence

Answer 484

mid-urethral sling procedure

Question 485

isolated elevation of anti-HBc, next step?

Answer 485

rare. 1st repeat testing with all the serologies. if remains order:HBc IgM AND LIVER TEST FUNCTION TO SEE IF ACTIVE INFECTION *If liver enzymes are abnormal with negative IgM anti-HBc, or if there is evidence of chronic liver disease, HBV DNA should be obtained to evaluate for chronic HBV infection TOTAL anti-HBc includes IgM and IgG

Question 486

3 occasions in which isolated anti HBc is present

Answer 486

1. Window period 2. Years after recovery 3. Chronic infection

Question 487

Normal CSF Parameters

Answer 487

Cells: 0-5 Glucose: 40-70 Protein < 40

Question 488

CSF parameters for bacterial

Answer 488

Cells :>1,000 Glucose < 40 Prot > 250 Normal: Cells: 0-5 Glucose: 40-70 Protein < 40

Question 489

CSF for TB

Answer 489

Cells :100-500 Glucose < 45 Prot 100-200 Normal: Cells: 0-5 Glucose: 40-70 Protein < 40

Question 490

CSF for Viral

Answer 490

Cells :10-500 Glucose 40-70 Prot <150 Normal: Cells: 0-5 Glucose: 40-70 Protein < 40

Question 491

CSF for Guillain Barre

Answer 491

Cells :0-5 Glucose 40-70 Prot 45-1000 Normal: Cells: 0-5 Glucose: 40-70 Protein < 40

Question 492

cryptococcal meningoencephalitis

Answer 492

Markedly elevated opening pressure, often >250-300 mm H2O Low leukocyte count (<50/mm3) (compared to other meningitides) with a lymphocytic predominance Elevated protein and low glucose Positive India ink preparation or cryptococcal antigen test

Question 493

tto cryptococcal meningoencephalitis

Answer 493

3 STAGES: Induction - amphotericin B and flucytosine for >2 weeks (until symptoms abate and CSF is sterilized) If negative cultures in LP: Consolidation - high-dose oral fluconazole for 8 weeks Maintenance - lower-dose oral fluconazole for >1 year to prevent recurrence Antiretroviral treatment should generally be initiated 2-10 weeks after beginning treatment for meningitis.

Question 494

tto neurosyphilis

Answer 494

aqueous crystalline penicillin G.

Question 495

In adults, the most common causes of bacterial meningitis

Answer 495

treptococcus pneumoniae and Neisseria meningitidis

Question 496

Empiric tto for bacterial meningitis

Answer 496

Ceftriaxone +Vancomycin In adults>50 ampicillin as they have an increased risk of Listeria monocytogenes meningitis

Question 497

CMV encephalitis in HIV tto

Answer 497

ganciclovir plus foscarnet.

Question 498

Why cryptococcal meningitis presents with increased ICP

Answer 498

The yeast and capsular polysaccharides can clog the arachnoid villi, which prevents cerebrospinal fluid outflow and increases intracranial pressure (ICP).

Question 499

Patient dx with cryptococcal meningitis and started treatment has worsening of headache, nausea, vomiting, next step?

Answer 499

Serial lumbar punctures-- signs of increased ICP **Mannitol is NOT EFFECTIVE Some patients may need more invasive tto such as VP shunt

Question 500

When is dexamethasone recommended in bacterial meningitis?

Answer 500

meningococcal meningitis) to reduce inflammation, morbidity, and risk of death.

Question 501

Organophosphates poisoning presentation

Answer 501

``` Inhibition of AChE DUMBBELSS Diarrhea Urination Myosis Bradycardia Bronchospasm Excitation of skeletal muscle and CNS Lacrimtion Salivation Swating ```

Question 502

Treatment of organophosphate poisoning

Answer 502

Atropine( competitive inhibitor) + Pralidoxime ( regenerates ACHe if given early) ``` Emergent resuscitation (eg, oxygen, fluids, intubation) Atropine & pralidoxime Activated charcoal (if within 1 hour of exposure) ```

Question 503

Antimuscarinic tto

Answer 503

Physostigmine! NOT Pyridostigmine

Question 504

Pyridostigmine use

Answer 504

Myasthenia Gravis

Question 505

urinary schistosomiasis

Answer 505

urinary symptoms, terminal hematuria, and peripheral eosinophilia

Question 506

urinary symptoms, terminal hematuria, and peripheral eosinophilia in young patient from Ghana

Answer 506

urinary schistosomiasis

Question 507

Dx urinary schistosomiasis

Answer 507

identification of eggs using URINE SEDIMENT MICROSCOPY

Question 508

TTO urinary schistosomiasis

Answer 508

praziquantel

Question 509

Chronic schistosomiasis can be associated with bladder cancer, which usually presents with intermittent, gross, painless hematuria that is present throughout micturition.

Answer 509

true

Question 510

Tetanus prophylaxis in wounds

Answer 510

If Clean wound: >=3 tetanus toxoid doses: Vaccine only if >=10 years, NO TIG unimmunized, unknown or < 3 tetanus toxoid: Vaccine , no TIG If Dirty: >=3 tetanus toxoid doses: Vaccine only if >=5 years, NO TIG unimmunized, unknown or < 3 tetanus toxoid: Vaccine plus TIG

Question 511

vaginal bleeding and a friable, exophytic cervical lesion., next step?

Answer 511

cervical biopsy

Question 512

Non stop epistaxis

Answer 512

Oxymetazoline . a squirt bottle or cotton pledget. topical vasoconstrictors should not be used for >3 days due to the risk of rebound congestion. Advice to humidify with saline or humidified air

Question 513

Location of Kiesselbach plexus

Answer 513

anteriorly,

Question 514

Athletes participating in intense training can develop nonpathologic cardiovascular changes, including resting sinus bradycardia with or without first-degree atrioventricular block and left ventricular hypertrophy detected on ECG.

Answer 514

In the absence of other findings suggestive of underlying cardiac disease (eg, unexplained symptoms, cardiac murmur), these patients should be reassured without further cardiac testing.

Question 515

Patient asking about reduction of melanoma risk with sunscreen.

Answer 515

Sunscreen use reduces the incidence of all 3 types of cutaneous carcinomas (basal and squamous cell, and malignant melanoma). RECOMMEND: 15-30 minutes prior to sun exposure; sunscreen should be reapplied every 2 hours or after water exposure. Sun protection factor (SPF) 15 (Choice D) is recommended for regular daily use and is often contained in facial lotions and cosmetics. SPF >30 is recommended for outdoor work or recreation, as those participating in outdoor activities tend to have less consistent sunscreen application.

Question 516

TANNING PRODUCTS

Answer 516

dihydroxyacetone which temporarily darkens or "bronzes" the skin. These are generally safe but the color does not protect from UV rays. Patients should also be discouraged from tanning bed and suntan lotion/oil use as these products increase exposure to UV light.

Question 517

Sunscreen use reduces the incidence of all 3 types of cutaneous carcinomas (basal and squamous cell, and malignant melanoma).

Answer 517

TRUE

Question 518

patient fell onto his outstretched hand and has acute pain at the wrist and tenderness

Answer 518

SCAPHOID FX , x-rays of the wrist in full pronation and ulnar deviation

Question 519

Management of scaphoid FX

Answer 519

If nothing is seen in imaging: wrist splint and imaging in a. week. Nondisplaced fractures should be treated with a short arm thumb spica cast, but other fractures should be referred to an orthopedic surgeon for evaluation.

Question 520

Colles fracture

Answer 520

distal radius fracture - deformity - dinner fork deformity order lateral radiography

Question 521

X-rays can initially be negative for nondisplaced scaphoid fractures.

Answer 521

Patients with suspected scaphoid fracture should be evaluated further with either an immediate MRI or CT scan, repeat x-ray in 7-14 days, or bone scan in 3-5 days.

Question 522

Inadequate management of scaphoid fracture lead to ?

Answer 522

nonunion and avascular necrosis. arterial blood supply to the scaphoid enters in the distal pole and travels to the proximal pole this is why these fractures require prolonged immobilizations: >12 weeks

Question 523

Dupuytren contracture, what is it? what is associated with?

Answer 523

progressive fibrosis of the palmar fascia of unknown etiology. ``` diabetes mellitus repetitive vibration to the hands, CRPS, alcohol malignancy. ```

Question 524

peak expiratory flow in asthma exacerbation;

Answer 524

a drop in peak expiratory flow >20% is consistent with the diagnosis.

Question 525

outpt tto asthma exacerbation;

Answer 525

``` b agonists oral steroids (eg, prednisone 40 mg daily for 5-10 days) ```

Question 526

chest x ray in asthma

Answer 526

Chest x-ray is not routinely obtained during an asthma exacerbation unless there is evidence of concurrent pneumonia

Question 527

RF urinary tract malignancy

Answer 527

gross hematuria, age >40, male gender, and smoking history. Other potential risk factors include history of pelvic radiation or exposure to aniline dyes

Question 528

suspect bladder cancer, next step?

Answer 528

cystoscopy

Question 529

Gross hematuria warrants evaluation of both the upper and lower urinary tracts.

Answer 529

upper with CT contrast- CI in renal disease, so US | lower with cystoscopy

Question 530

Dx of DM

Answer 530

HbA1C ≥6.5% = diabetes mellitus FASTING GLUCOSE: ≥126 mg/dL = diabetes mellitus Random glucose levels:≥200 mg/dL with symptoms of hyperglycemia = diabetes mellitus oral glucose tolerance test ≥200 mg/dL Asymptomatic patients with an abnormal screening test for diabetes require a repeat measurement with the same test to confirm the diagnosis. Patients with symptomatic hyperglycemia and abnormal screening tests can be diagnosed with diabetes without repeating confirmatory testing.

Question 531

Bicuspid aortic valve is associated with..

Answer 531

aortic dilation, aortic aneurysm, and aortic dissection, and should be screened with imaging of the aortic root and proximal aorta.

Question 532

Biscupid aortic valve manangement

Answer 532

Echo every 1-2 years Ballon valvoplasty or surgery They are at high risk of infective endocarditis, aortic dilation, stenosis or dilation.

Question 533

vitamin B12 deficiency,

Answer 533

increase in indirect bilirubin due to ineffective erythropoiesis, as well as pancytopenia or bicytopenia, as in this case. The neurologic presentation includes ataxia, dementia, and occasionally, delirium.

Question 534

Lab testing for dementia

Answer 534

Routine: CBC, vitamin B12, TSH, CMP Selective (specific risk factors): folate, syphilis, vitamin D level Atypical (early onset): CSF

Question 535

Patient who is having dementia, and alcohol abuse. wHAT LAB TO ORDER

Answer 535

Folate Although thiamine deficiency and subsequent Wernicke-Korsakoff syndrome may also lead to cognitive decline in patients with alcoholism, suspected cases are generally treated empirically as the utility of laboratory tests for thiamine is low.

Question 536

most frequent cause of asthma

Answer 536

house dust mite allergens other are cat allergens, dog allergens ** air pollution is not considered

Question 537

Wallenberg sx presentation

Answer 537

.

Question 538

Women with hypothyroidism + increased liver enzymes, next step?

Answer 538

autoimmune hepatitis - so order ANA AND Anti Smith antibodies slight elevation of ALT/AST normal bilirubin levels

Question 539

Antimitochondrial antibodies

Answer 539

primary biliary cirrhosis (PBC), lymphocytic infiltrate +granuloma destruction of intralobar ducts. Ursodeoxycholic acid elevated alkaline phosphatase level , high ALP, Bilirrubin.

Question 540

high gamma-glutamyl transferase (GGT)

Answer 540

cholestasis.

Question 541

TCA intoxication

Answer 541

Drowsy, delirium, coma seizures,respiratory distress tachycardia, HYPOTENSION, PROLONGED QT,PR,RR CAN PROGRESS TO VT OR VFIB Dry mouth, blurred vision urinary retention

Question 542

Why do you use sodium bicarb in TCA toxicity

Answer 542

prevent arrhythmia- can evolve to Vfib and Vtach increases serum pH and extracellular sodium. The increased pH (goal 7.50-7.55) modifies TCAs to their neutral (non-ionized) form, making them less available to bind to the rapid sodium channels.

Question 543

Tto of TCA toxicity

Answer 543

Oxygen, intubation IV fluids Activated charcoal if within 2 hours ( unless ileus is present) Intravenous sodium bicarbonate for QRS widening and/or ventricular arrhythmia

Question 544

How TCAs cause arrhythmia

Answer 544

inhibit fast sodium channels in the His-Purkinje tissue and the myocardium to decrease conduction speed, increase phase 0 depolarization, and prolong the refractory period. This can prolong the QRS interval (>100 msec) and cause arrhythmias (eg, ventricular tachycardia, ventricular fibrillation).

Question 545

Patient with TCA refractory to sodium bicarb, what are some options

Answer 545

magnesium or lidocaine.

Question 546

N-acetylcysteine is the antidote for

Answer 546

acetaminophen

Question 547

Salicylate toxicity tto

Answer 547

IV sodium bicarbonate to alkalinize the urine and promote salicylate excretion by trapping the salicylate in its ionized form.

Question 548

severe lactic acidosis with severe acidemia (serum pH <7.1) and serum bicarbonate <6 mEq/L., tto?

Answer 548

sodium bicarbonate

Question 549

Uses of sodium bicarb

Answer 549

- TCA poisoning:prevent arrhythmias - Salicylate tox: alcalinize urine and favor excretion - Severe lactic acidosis ph<7.1, serum bicarb < 6 - significant hyperkalemia

Question 550

What does cross sectional studies is able to measure

Answer 550

prevalence

Question 551

Measure of case control studies

Answer 551

OR

Question 552

Measure of cohort studies

Answer 552

RR

Question 553

Phase I study

Answer 553

healthy volunteers- safety, toxicity, pharmacodynamics/pharmacokinetics

Question 554

Phase II study

Answer 554

small number of patients with disease | Does it work? treatment efficacy, dosing, adverse events

Question 555

Phase III study

Answer 555

large population of patients with disease | Compares the new treatment to current standard of care-is it good or better

Question 556

measure to ruling out disease

Answer 556

Sensitivity

Question 557

The higher the sensitivity

Answer 557

ruling out disease and indicate a low false negative rate. High sensitivity test used for screening in disease with LOW prevalence SN N OUT: When negative rules out

Question 558

Specificicy

Answer 558

When high specificity and positive test rules in. SP P IN

Question 559

PPV and NPV are affected by the prevalence of the disease

Answer 559

yes

Question 560

Incidence

Answer 560

of cases during a period of time / # of people AT RISK

Question 561

Crude mortality rate

Answer 561

deaths/total size of population

Question 562

Cause specific mortality rate

Answer 562

of deaths from a specific disease/total population

Question 563

Case fatality rate

Answer 563

of deaths from a specific disease/total population affected by the disease

Question 564

SMR

Answer 564

observed deaths /expected

Question 565

Attack rate

Answer 565

of patients with disease/population at risk

Question 566

Maternity Mortality rate

Answer 566

#maternal deaths/number of live births

Question 567

Treatment of scabies

Answer 567

Topical permethrin or 2 doses of ivermectin. Permethrin should be applied from neck to feet soles, and washed out after 8-12 hours.

Question 568

Movements triggering BBPV

Answer 568

rolling head in the bed or looking up while standing

Question 569

Dx and treatment of BBPV

Answer 569

Dx: Dix Hall pike TTo: epley manueve

Question 570

Patient who had prolonged hospitalization, history of stroke and left hemiparesis, and that has troubles walking now. At exam has limited extension of the leg. Cause

Answer 570

Deconditioning, also some other things is that when he tries to walk has tachycardia. Its not contracture, as it may be related with prior stroke

Question 571

Critical illness neuropathy

Answer 571

limb and respiratory muscle weakness. Patients are very difficult to wean from ventilatory support, and have encephalopathy or coma

Question 572

Patient with insomnia and sadness following death of husband. Next step

Answer 572

Provide education of grief reactions and counsel sleep hygiene. BZDs are NOT HELPFUL

Question 573

BZDs in insomnia/sadness in the setting of grief

Answer 573

BZDs are NOT HELPFUL

Question 574

Bilious emesis, abdominal distension, hypoactive bowel sounds, failure to pass meconium in 48 hours

Answer 574

Hirshprung

Question 575

Dx of Hirshprungs

Answer 575

Suction biopasy- absence of ganglion cells and nerve fiber hypertrophy

Question 576

Patient with lispro and glargine that has high Bedtime glucose. how to modify the insulin dose

Answer 576

Increase the pre-dinner insulin

Question 577

Differential of hepatic abscess

Answer 577

Protozoa( Entamoeba- developing countries, poor sanitation, colitis(stool ova and parasites),liver abscess(serology), tto with MTZ and paramomycin, NO ORGANISMS IN GRAM STAIN ) Bacterial,Pyogenic ( pt with underlying disease DM, hepatobiliary disease, generally after surgery, GI infection, appendicitis)-GRAM STAIN OF ASPIRATE Hydatid(Ecchinococcus, contact with dogs, sheeps. Egg shells calcification of livery cyst, EOSINOPHILIA, Surgery under coverage with albendazole

Question 578

41 yo male with UTI ss in addition to fever, malaise, myalgias, PERINEAL DISCOMFORT

Answer 578

Has a UTI + either cystitis or acute bacterial prostatitis: UTI+ cystitis: older males, urinary tract abnormality or recent intrumentation Acute bacterial prostatitis: young male with normal anatomy. prostate warmth, tender. PERINEAL DISCOMFORT RECTAL EXAM IS NEEDED TO DIFFERENTIATE THE TWO

Question 579

Tto of uncomplicated UTI in men

Answer 579

Ciprofloxacin or TMP/SMX

Question 580

Tto of acute bacterial prostatitis

Answer 580

Ciprofloxacin or TMP/SMX for 6 weeks

Question 581

Management of coin ingestion > 24 hours or sympatomatic

Answer 581

FLEXIBLE ENDOSCOPY

Question 582

Management of coin ingestion < 24 hours AND Asymptomatic

Answer 582

Observation and Xray in 24 to 48 hours

Question 583

Imaging in coin ingestion

Answer 583

2 view chest x ray anteroposterior and lateral

Question 584

When to use emergent bronchoscopy

Answer 584

foreign body causing airway compromise

Question 585

Indications for AAA repair

Answer 585

1. Sympatomatic( abdominal or back pain) 2. > 5.5 cm 3. Growth of 0.5 or more in 6 months If not then monitor with US or CT scan every 6 months during 2 years

Question 586

Patient with abdominal cramping, emesis, hyperactive sounds and mass in the abdomen, next steps

Answer 586

small bowel obstruction-LIKELY BY INCARCERATED INGUINAL HERNIA , SURGERY ! given risk of strangulation

Question 587

MC of small bowel obstruction

Answer 587

Hernias, postoperative adhesions, tumors

Question 588

Mesenteric angiography

Answer 588

when suspecting mesenteric ischemia. some risk factors include atrial fibrillation, and presents with bloody stool and abdominal pain. no masses.

Question 589

Effect of PTH in Ca, Phosph, Cl

Answer 589

Hypercalciuria, Hypercalcemia HypoPhos HyperCl

Question 590

Indications of Parathyroidectomy

Answer 590

Age <50 Symptomatic ( muscle/bone pain, constipation, osteoporosis, kidney stones) Osteoporosis ( T score1 mg/dl above normal Urine Ca excretion >400

Question 591

Pt with hyperPTH who does not meet criteria for surgery, next step

Answer 591

Follow up with regular serum ca, creatinine, and DXA

Question 592

Spiral fracture in femur baby

Answer 592

Child abuse- other typical fractures posterior rib fractures, methaphysial corners, fractures at varios stages of healing

Question 593

How many cafe au lait spots need to be for NF dx

Answer 593

>=6

Question 594

Defect in osteogenesis imperfecta

Answer 594

Collagen, multiple fractures in NEONATAL period and blue sclera

Question 595

Two main factors contributing to foot ulcer development

Answer 595

1. Diabetic Neuropathy 2. Vascular disease ( decreased dorsalis pulse)

Question 596

Prevent diabetic foot ulcer

Answer 596

Tight glycemic control

Question 597

After MI what are the recommendations to return to work/sex, and who needs a stress test prior to resuming activities

Answer 597

Uncomplicated MI with no additional symptoms are ok to resume activities at 2 weeks Patients with intermediate risk ( stable angina, incomplete revascularization, LV EF<40) need a stress test prior Patients who have unstable angina, congestive HF need evaluation and stabilization prior to that - could be 3-4 months.

Question 598

Indications for statin therapy

Answer 598

Any stroke/MI/stable angina ( If=< 75 high intensity, >75 low intensity) LDL>=190 high intensity >40 +DM ( If risk >=20 high intensity, if risk < 20 low intensity) Risk >=75 High t moderate

Question 599

What statin is recommended after MI

Answer 599

HIGH INTENSITY - atorvastatin 40-80 or rosuvastatin 20-40

Question 600

Causes of Erythema multiforme

Answer 600

HSV, Mycoplasma antibiotics, allopurinol autoimmune diseases

Question 601

Prognosis erythema mutliforme

Answer 601

most resolve 1-2 weeks without intervention

Question 602

other symptoms that can occur with erythema multiforme

Answer 602

oral lesions(erythema, erosions, bullae) and flu likeprodrome

Question 603

Management of breast mass in =<30

Answer 603

FIRST US, +/- mammogram If simple cyst- FNA If complex/solid mass- Core biopsy

Question 604

Management of breast mass in>30

Answer 604

FIRST Mammogram! if benign or indeterminate do US to characterize lesions If mammogram shows complex or suspicious lesion core biopsy.

Question 605

When do you do excisional biopsy vs core biopsy in breast mass

Answer 605

when core biopsy cant be performed when cyst does not resolve with FNA When core biopsy shows indeterminate or atypical results ( carcinoma insitu, hyperplasia)

Question 606

Patient with lumbar pain + degenerative changes in X ray ( disc space narrowing, traction ostephytes, endplate sclerosis), next step

Answer 606

IF NO RED FLAGS( Hx of cancer, pain at night, fever, weight loss), then NSAIDs and follow-up in 6 weeks

Question 607

When do you order MRI in lumbar pain

Answer 607

progressive neuro symptoms, suspicion of cancer, pain persisting > 12 weeks

Question 608

Differential of postpartum hemorrhage

Answer 608

Uterine atony ( RF:prolonged labior, chorioamnionitis, enlarged uterus(macrosomia, twins,,polyhydramnios) boggy enlarged uterus ---- bimanual pelvic massagge and oxytocin Retained products of contraception ( succenturiate placenta, manual extraction, enlarged boggy uterus, placenta missing cotiledones, retained fragment----manual extraction Laceration Coagulopathy Uterine rupture: severe abdominal pain , hypotension, fetal parts sin abdomen

Question 609

Newly diagnosed HTN with no additional risk factors, next step?

Answer 609

FIRST non-pharmacologic measures: WEight loss(< 25 BMI), DASH diet (high fruits and vegetables, low fat), Exercise 30 min 5 times a day, Dietary Na <3 g/day , < 2 drinks a day in men and < 1 drink in women. pt may be observed up to a year, if BP further increases or does not normalize then initiate antihypertensive med

Question 610

Shortness of breath, pleuritic pain, sinus tachycardia, hypoxemia

Answer 610

Pulmonary embolism

Question 611

Potential complication of acute PE

Answer 611

Pulmonary infarct - in periphery of the lung ( irritate pleura and causes pleural pain)

Question 612

what does bleomycin causes in. the lung?

Answer 612

Fibrosis -diffuse pattern of reticular septal thickening and honeycombing.

Question 613

Patient with hepatitis B progressive fatigue, increased abdominal girth, decreased appetite and an US showing a 3 cm lesion in one of the hepatic lobes

Answer 613

Fibrosis -diffuse pattern of reticular septal thickening and honeycombing.

Question 614

Etiology of stress urinary incontinence

Answer 614

urehtral hypermobility , decreased tone of urethral sphincter

Question 615

etiology ofurge urinary incontinence

Answer 615

Hyperactivity of detrusor muscle

Question 616

etiology ofoverflow urinary incontinence

Answer 616

impaired detrusor activity, bladder outlet obstruction

Question 617

Relationship urinary incontinence overflow and diabetes

Answer 617

Patients with diabetic neuropathy may have urinary incontinence . Also look for other signs such as postural hypotension is an evidence of impairment of autonomic system in diabetics

Question 618

Dx overflow incontinence

Answer 618

> 200 mL

Question 619

Meds that can cause urinary retention

Answer 619

anticholinergics, opioids, alpha 1 agonists

Question 620

Common causes of overflow urinary retention

Answer 620

Diabetic neuropathy and BPH

Question 621

Tto of hot flashes

Answer 621

If no hysterectomy combined progesterone/estrogen. If hysterectomy estrogen. CI to these therapy include Breast Ca, Stroke, DVT, CHD, liver disease. In women < 60 is considered less risk and if no RF short period 3-5 years.

Question 622

Statin induced myositis medications

Answer 622

Macrolides, Gemfibrozile, HIV protease inhibitors Cyclosporine

Question 623

When do you give Hib vaccine?

Answer 623

Usually in < 5years, starting at 2 months.

Question 624

When do you give Hep vaccine

Answer 624

0,1,6 ( unless 2kg). If exposed vaccinated: no tto. If exposed unvaccinated: Ig and vaccine. Other : chronic liver disease and high risk ( men sex men, IV drugs, healthcare workers)

Question 625

When do you give meningococcal vaccine

Answer 625

11-12 years and booster 16-21.

Question 626

When do you give pneumococcus

Answer 626

``` 19-65 PPSV23: chronic heart, lung, liver disease, DM, Alcoholic, liver disease PCV13 PLUS PPSV23 ( high risk patients) CSF leak, cochlear implant Sickle cell , asplenia immunocompromised CKD ``` > 65 PCV13 plus PPSV23 WITH A 8 WEEK DIFFERENCE

Question 627

When to give herpes zooster vaccine

Answer 627

>=60 years CI:Immunocsuppressed, Ca, pregnant

Question 628

Patient that says to doctor No resuscitative measures , but doesnt sign anything.When it happens what to do?

Answer 628

Follow next kin desire. Patient had needed to sign it. If oral advaced directive is done needs the physician plus two witnesses.

Question 629

Tto of kawasaki

Answer 629

Aspirin + IgG

Question 630

Kawasaki ppt

Answer 630

Rule of 5: 90% < 5 years. Fever >=5 + 4 of the following: 1. Bilateral conjunctitivs, nonexudative 2. Cervical LAD >=1 of 1.5cm, 3. mucositis 4. Rash, 5. erythema and edema of the hands. Patients < 6 months have often atypical kawasaki =<3 criteria but have inflammatory markers CRP, ESR

Question 631

intrinsic pathway disorders

Answer 631

Hemophilia A and B( def of factor presents early) , Von Willebrand disorder, acquired coagulation factor inhibition( presents late)

Question 632

tto Aflutter

Answer 632

Same as Afib. If <48 hrs cardioversion. If > 48 hours: warfarin, rivaroxaban or dabigatran >=3 weeks of anticoagulants is needed prior to think on cardioversion.

Question 633

anti mitochondrial antibodies

Answer 633

primary biliary cirrhosis

Question 634

Pulmonary and cardiac manifestations of scleroderma

Answer 634

Pulmonary fibrosis presenting as angina, shortness of breath HF: prominent heave in the lower sternum

Question 635

Peu d'orange,erythema, lymph node involvement dx and tto

Answer 635

"inflammatory breast cancer Do a core needle biopsy / Is often confused with mastitis-- MASTITIS THAT DOESN’T IMPROVE AFTER ABCS. "

Question 636

recurrent infections of the lower extremity, and evidence of no DVT,

Answer 636

Cellulitis is often the first, but if recurrent think of: fungal infection (Tinea pedis)- ESPECIALLY IN THOSE WHO HAD SAPHENECTOMY , lymphedema or chronic venous insufficiency.

Question 637

Types of acne and tto

Answer 637

CIN Comedonal -Topical retinoids, salicilic, glycolid acid Inflammatory- Mild: topical retinoids + benzoyl peroxidase Moderate: Topical antibiotics ( erythromycin, clindamycin) Severe: oral antibiotics Nodulo cystic- Moderate: topical retinoids + benzoyl peroxidase+ topical antibiotics Severe:add oral antibiotics Refractory: ISOTRETINOIN

Question 638

Frequent UTIs in the setting of chronic diarrhea, lower abdominal pain, chronic back pain, weight loss

Answer 638

THINK OF INFLAMMATORY BOWEL DISEASE --enterovesical fistula. - think of E.coli, bacteroides fragilis. Pneumaturia can also be seen

Question 639

46 yo with intermenstrual bleeding and new onset heavy bleeding

Answer 639

Think about fibroids and endometrial cancer and hyperplasia.-- endometrial biopsy is needed

Question 640

First line treatment for hypertension in patients with gout

Answer 640

ARBs-- losartan, uricosuric event and you can add Ca channel blockers ( amlodipine) thiazide should be avoided

Question 641

Positive psoas sign

Answer 641

psoas abscess, retroperitoneal hemorrhage

Question 642

Patient with sudden onset abdominal pain in right lower quadrant , hypotense, psoas sign positive. Afib noted., next steps

Answer 642

Retroperitoneal hematoma, CT scan

Question 643

Patient with retroperitoneal hemorrhage in warfarin, tto

Answer 643

intravenous K and fresh frozen plasma

Question 644

WaRrfarin anticoagulation

Answer 644

vit K and FFP

Question 645

Pt with Minimental score 25/30 ( normal>=26) that is able to understand consequences but still refuses to tto

Answer 645

RESPECT WISHES- COMPREHENSION, CONSEQUENCS, CHOICE

Question 646

Prior to prescribing antidepressve in depression screen for:

Answer 646

Maniac episodes

Question 647

Mom with ADHD ASKS IF THEY CAN HAVE SPECIAL ACCOMODATIONS

Answer 647

YES

Question 648

Treatment scabies

Answer 648

Topical permethrin or 2 doses of ivermectin. Permethrin should be applied from neck to feet soles, and washed out after 8-12 hours.

Question 649

Dx of scabies

Answer 649

often clinically, but skin scraping

Question 650

Movements triggering BBPV

Answer 650

rolling head in the bed or looking up while standing

Question 651

Dx and tto of BBPV

Answer 651

Dx: Dix Hall pike TTo: epley manueve

Question 652

Patient who had prolonged hospitalization, history of stroke and left hemiparesis, and that has troubles walking now. At exam has limited extension of the leg. Cause

Answer 652

Deconditioning, also some other things is that when he tries to walk has tachycardia. Its not contracture, as it may be related with prior stroke

Question 653

Critical illness neuropathy

Answer 653

limb and respiratory muscle weakness. Patients are very difficult to wean from ventilatory support, and have encephalopathy or coma

Question 654

Patient with insomnia and sadness following death of husband. Next step

Answer 654

Provide education of grief reactions and counsel sleep hygiene. BZDs are NOT HELPFUL

Question 655

Bilious emesis, abdominal distension, hypoactive bowel sounds, failure to pass meconium in 48 hours

Answer 655

Hirshprung

Question 656

Dx of Hirshprungs

Answer 656

Suction biopsy - absence of ganglion cells and nerve fiber hypertrophy

Question 657

Patient with lispro and glargine that has high Bedtime glucose. how to modify the insulin dose

Answer 657

Increase the pre-dinner insulin

Question 658

Differential of hepatic abscess

Answer 658

Protozoa( Entamoeba- developing countries, poor sanitation, colitis(stool ova and parasites),liver abscess(serology), tto with MTZ and paramomycin, NO ORGANISMS IN GRAM STAIN ) Bacterial,Pyogenic ( pt with underlying disease DM, hepatobiliary disease, generally after surgery, GI infection, appendicitis)-GRAM STAIN OF ASPIRATE Hydatid(Ecchinococcus, contact with dogs, sheeps. Egg shells calcification of livery cyst, EOSINOPHILIA, Surgery under coverage with albendazole

Question 659

41 yo male with UTI ss in addition to fever, malaise, myalgias, PERINEAL DISCOMFORT

Answer 659

Has a UTI + either cystitis or acute bacterial prostatitis: UTI+ cystitis: older males, urinary tract abnormality or recent intrumentation Acute bacterial prostatitis: young male with normal anatomy. prostate warmth, tender. PERINEAL DISCOMFORT RECTAL EXAM IS NEEDED TO DIFFERENTIATE THE TWO

Question 660

Treatment of uncomplicated UTI in men

Answer 660

Ciprofloxacin or TMP/SMX

Question 661

Treatment of acute bacterial prostatitis

Answer 661

Ciprofloxacin or TMP/SMX for 6 weeks

Question 662

Management of coin ingestion > 24 hours or symptomatic

Answer 662

FLEXIBLE ENDOSCOPY

Question 663

Management of coin ingestion < 24 hours AND Asymptomatic

Answer 663

Observation and Xray in 24 to 48 hours

Question 664

Imaging in coin ingestion

Answer 664

2 view chest x ray anteroposterior and lateral

Question 665

When to use emergent bronchoscopy

Answer 665

foreign body causing airway compromise

Question 666

Indications AAA repair

Answer 666

1. Sympatomatic( abdominal or back pain) 2. > 5.5 cm 3. Growth of 0.5 or more in 6 months If not then monitor with US or CT scan every 6 months during 2 years

Question 667

Patient with abdominal cramping, emesis, hyperactive sounds and mass in the abdomen, next steps

Answer 667

small bowel obstruction- LIKELY BY INCARCERATED INGUINAL HERNIA, SURGERY ! Given risk of strangulation

Question 668

MC of small bowel obstruction

Answer 668

Hernias, postoperative adhesions, tumors

Question 669

Mesenteric angiography

Answer 669

when suspecting mesenteric ischemia. some risk factors include atrial fibrillation, and presents with bloody stool and abdominal pain. no masses.

Question 670

Effect of PTH in Ca, Phosph, Cl

Answer 670

Hypercalciuria, Hypercalcemia HypoPhos HyperCl

Question 671

Indications parathyroidectomy

Answer 671

Age <50 Symptomatic ( muscle/bone pain, constipation, osteoporosis, kidney stones) Osteoporosis ( T score1 mg/dl above normal Urine Ca excretion >400

Question 672

Pt with hyperPTH who does not meet criteria for surgery, next step

Answer 672

Follow up with regular serum ca, creatinine, and DXA

Question 673

Spiral fracture in femur baby

Answer 673

Child abuse- other typical fractures posterior rib fractures, methaphysial corners, fractures at varios stages of healing

Question 674

How many cafe au lait spots need to be for NF dx

Answer 674

>=6

Question 675

Defect in osteogenesis imperfecta

Answer 675

Collagen, multiple fractures in NEONATAL period and blue sclera

Question 676

Two main factors contributing to foot ulcer development

Answer 676

1. Diabetic Neuropathy 2. Vascular disease ( decreased dorsalis pulse)

Question 677

Prevent diabetic foot ulcer

Answer 677

Tight glycemic control

Question 678

After MI what are the recommendations to return to work/sex, and who needs a stress test prior to resuming activities

Answer 678

Uncomplicated MI with no additional symptoms are ok to resume activities at 2 weeks Patients with intermediate risk ( stable angina, incomplete revascularization, LV EF<40) need a stress test prior Patients who have unstable angina, congestive HF need evaluation and stabilization prior to that -- couldbe 3-4 months

Question 679

Indications for statin therapy

Answer 679

Any stroke/MI/stable angina ( If=< 75 high intensity, >75 low intensity) LDL>=190 high intensity >40 +DM ( If risk >=20 high intensity, if risk < 20 low intensity) Risk >=75 High t moderate

Question 680

What statin is recommended after MI

Answer 680

HIGH INTENSITY - atorvastatin 40-80 or rosuvastatin 20-40

Question 681

Causes of Erythema multiforme

Answer 681

HSV, Mycoplasma antibiotics, allopurinol autoimmune diseases

Question 682

Prognosis erythema mutliforme

Answer 682

most resolve 1-2 weeks without intervention

Question 683

other symptoms that can occur with erythema multiforme

Answer 683

oral lesions(erythema, erosions, bullae) and flu likeprodrome

Question 684

Management of breast mass in =<30

Answer 684

FIRST US, +/- mammogram If simple cyst- FNA If complex/solid mass- Core biopsy

Question 685

Management of breast mass in>30

Answer 685

FIRST Mammogram! if benign or indeterminate do US to characterize lesions If mammogram shows complex or suspicious lesion core biopsy.

Question 686

When do you do excisional biopsy vs core biopsy in breast mass

Answer 686

when core biopsy cant be performed when cyst does not resolve with FNA When core biopsy shows indeterminate or atypical results ( carcinoma insitu, hyperplasia)

Question 687

Patient with lumbar pain + degenerative changes in X ray ( disc space narrowing, traction ostephytes, endplate sclerosis), next step

Answer 687

IF NO RED FLAGS( Hx of cancer, pain at night, fever, weight loss), then NSAIDs and follow-up in 6 weeks

Question 688

When do you order MRI in lumbar pain

Answer 688

progressive neuro symptoms, suspicion of cancer, pain persisting > 12 weeks

Question 689

Differential of postpartum hemorrhage

Answer 689

Uterine atony ( RF:prolonged labior, chorioamnionitis, enlarged uterus(macrosomia, twins,,polyhydramnios) boggy enlarged uterus ---- bimanual pelvic massagge and oxytocin Retained products of contraception ( succenturiate placenta, manual extraction, enlarged boggy uterus, placenta missing cotiledones, retained fragment----manual extraction Laceration Coagulopathy Uterine rupture: severe abdominal pain , hypotension, fetal parts sin abdomen

Question 690

Anal cancer is associated with HPV

Answer 690

Is higher in patients with HIV

Question 691

Newly diagnosed HTN with no additional risk factors, next step?

Answer 691

FIRST non-pharmacologic measures: WEight loss(< 25 BMI), DASH diet (high fruits and vegetables, low fat), Exercise 30 min 5 times a day, Dietary Na <3 g/day , < 2 drinks a day in men and < 1 drink in women. pt may be observed up to a year, if BP further increases or does not normalize then initiate antihypertensive med

Question 692

Dx of DM

Answer 692

fasting glucose > 126 or Hb >=6.5

Question 693

Shortness of breath, pleuritic pain, sinus tachycardia, hypoxemia

Answer 693

Pulmonary embolism

Question 694

Potential complication of acute PE

Answer 694

Pulmonary infarct - in periphery of the lung ( irritate pleura and causes pleural pain)

Question 695

what does bleomycin causes in. the lung?

Answer 695

Fibrosis -diffuse pattern of reticular septal thickening and honeycombing.

Question 696

Pulmonary infarct in CT

Answer 696

peripherally located, Hemispherical consolidation that abutts the pleura.

Question 697

Patient with hepatitis B progressive fatigue, increased abdominal girth, decreased appetite and an US showing a 3 cm lesion in one of the hepatic lobes

Answer 697

Hepatocellular Carcinoma!!- liver parenchyma. It arrives from the hepatocytes not the intersticial liver cells.

Question 698

AFP relation with liver

Answer 698

AFT is elevated in 60% of hepatocellular carcinoma

Question 699

Presentation of cholangiocarcinoma

Answer 699

jaundice, bile duct dilation, abdominal pain, weight loss.

Question 700

Role of physician in organ donation

Answer 700

Physician may initiate the process of organ donation with family if he is trained for doing that or the organ procuremetnt organization staff member

Question 701

Gleason score

Answer 701

The Gleason score is calculated by adding together the two grades of cancer cells that make up the largest areas of the biopsied tissue sample. The Gleason score usually ranges from 6 to 10. The lower the Gleason score, the more the cancer cells look like normal cells and are likely to grow and spread slowly.

Question 702

Prognosis of prostate Ca

Answer 702

Patients with very low risk ( PSA <10, Normal rectal exam, gleason score <6) have excellent 10 year survival and active surveillance should be made. --PSA every 3-6 months, yearly rectal exam, and repeat a biopsy by the end of year 1. in high risk patients: radiotherapy or radical prostectomy-- GI irritation and erectyle dysfunction.

Question 703

Inhalants presentation

Answer 703

Euphoria,PUPILARY DILATION, lethargy, uncoordination, loss of consciousness . Effects last15-45 min, dermatitis in nose, carrhtyhtmias. INHALANTS ARE NOT IN THE MEDICAL DRUG SCREEN

Question 704

Drugs causing hyperK

Answer 704

1. Non selective b blockers( labetalol, carvedilol, propanolol, nadolol) 2. ACEis 3. ARBS 4. K sparing diuretics- spironolactone 6. Digoxin 7. NSAIDS 8. Heparin 9. Succinylcholine

Question 705

Treatment for pertussis

Answer 705

Azythromycin, and treat all close contacts regardless of the immunization status. Incompletely immunized contacts should receive also the vaccine.

Question 706

Phases of pertussis

Answer 706

Catarrhal(1-2 weeks) mild cough, rhinitis, Paroxysmal ( 2-6 weeks) inspiratory whoop, cough with postusive emesis, APNEA IN INFANTS, Convalescent: chronic ocugh.

Question 707

bilateral reticular opacities, enlarged hilium, irregular thickening of the bronchovascular bundles predominantly affecting UPPER LUNGS.

Answer 707

Sarcoidosis

Question 708

Besides hyperCa, bilateral hilar lymph nodes how does sarcoidosis presents

Answer 708

shortness of. breath, malaise, cough , weight loss, african american

Question 709

Silicosis presentation

Answer 709

sandblasting, mines, eggshell calcification of the hilar lymph nodes . CXray nodular opaicities. risk of TB, Bronchogenic cancer.

Question 710

Dx of sarcoidosis

Answer 710

non caseating granulomas in transbronchial biopsy

Question 711

Management of inguinal hernia

Answer 711

If asymptomatic: surgical repair 1-2 weeks. If asymptomatic: surgery.

Question 712

Direct vs Indirect hernia

Answer 712

Direct: medial to epigastric vessesls, wekaness of abdominal wall, behind the inguinal ring. Indirect: lateral to epigastric vessels, same course as the spermatic cord, can pass to the scrotum or labia mayora. PATENT PROCESSUS VAGINALIS

Question 713

prognosis of hydroceles

Answer 713

resolve by age 1

Question 714

When do you repear cryptorchisdism?

Answer 714

wait until 6 months

Question 715

urine leak/overflow

Answer 715

incomplete bladder emptying

Question 716

Etiology of stress urinary incontinence

Answer 716

urehtral hypermobility , decreased tone of urethral sphincter

Question 717

etiology ofurge urinary incontinence

Answer 717

Hyperactivity of detrusor muscle

Question 718

etiology ofoverflow urinary incontinence

Answer 718

impaired detrusor activity, bladder outlet obstruction

Question 719

Relationship urinary incontinence overflow and diabetes

Answer 719

Patients with diabetic neuropathy may have urinary incontinence . Also look for other signs such as postural hypotension is an evidence of impairment of autonomic system in diabetics

Question 720

Dx overflow incontinence

Answer 720

> 200 mL

Question 721

Meds that can cause urinary retention

Answer 721

anticholinergics, opioids, alpha 1 agonists

Question 722

Common causes of overflow urinary retention

Answer 722

Diabetic neuropathy and BPH

Question 723

Tto of hot flashes

Answer 723

If no hysterectomy combined progesterone/estrogen. If hysterectomy estrogen. CI to these therapy include Breast Ca, Stroke, DVT, CHD, liver disease. In women < 60 is considered less risk and if no RF short period 3-5 years.

Question 724

Statin induced myositis medications

Answer 724

Macrolides, Gemfibrozile, HIV protease inhibitors Cyclosporine - CYP 3A4 system

Question 725

When do you give Hib vaccine?

Answer 725

Usually in < 5years, starting at 2 months.

Question 726

When do you give Hep vaccine

Answer 726

0,1,6 ( unless 2kg). If exposed vaccinated: no tto. If exposed unvaccinated: Ig and vaccine. Other : chronic liver disease and high risk ( men sex men, IV drugs, healthcare workers)

Question 727

When pneumococcus

Answer 727

``` 19-65 PPSV23: chronic heart, lung, liver disease, DM, Alcoholic, liver disease PCV13 PLUS PPSV23 ( high risk patients) CSF leak, cochlear implant Sickle cell , asplenia immunocompromised CKD ``` > 65 PCV13 plus PPSV23 WITH A 8 WEEK DIFFERENCE

Question 728

When to give herpes zooster vaccine

Answer 728

>=60 years

Question 729

Patient that says to doctor No resuscitative measures , but doesnt sign anything.When it happens what to do?

Answer 729

Follow next kin desire. Patient had needed to sign it. If oral advaced directive is done needs the physician plus two witnesses.

Question 730

tto of Kawasaki

Answer 730

Apirin +Ig

Question 731

Kawasaki ppt

Answer 731

Rule of 5: 90% < 5 years. Fever >=5 + 4 of the following: 1. Bilateral conjunctitivs, nonexudative 2. Cervical LAD >=1 of 1.5cm, 3. mucositis 4. Rash, 5. erythema and edema of the hands. Patients < 6 months have often atypical kawasaki =<3 criteria but have inflammatory markers CRP, ESR

Question 732

Complications kawasaki

Answer 732

Coronary aneurysms, infarct.

Question 733

Intrinsic and extrinsic pathways

Answer 733

intrinsic TENET, PTT, HEPARIN…............ Extrinsic tissue factor, VII, PT, Warfarin

Question 734

intrinsic pathway disorders

Answer 734

Hemophilia A and B( def of factor presents early) , Von Willebrand disorder, acquired coagulation factor inhibition( presents late)

Question 735

Management atrial flutter

Answer 735

Same as Afib. If <48 hrs cardioversion. If > 48 hours: warfarin, rivaroxaban or dabigatran

Question 736

Pulmonary and cardiac manifestations of scleroderma

Answer 736

Pulmonary fibrosis presenting as angina, shortness of breath HF: prominent heave in the lower sternum

Question 737

Peu d'orange,erythema, lymph node involvement dx and tto

Answer 737

inflammatory breast cancer Do a core needle biopsy / Is often confused with mastitis-- MASTITIS THAT DOESN’T IMPROVE AFTER ABCS.

Question 738

Types of acne and tto

Answer 738

CIN Comedonal -Topical retinoids, salicilic, glycolid acid Inflammatory- Mild: topical retinoids + benzoyl peroxidase Moderate: Topical antibiotics ( erythromycin, clindamycin) Severe: oral antibiotics Nodulo cystic- Moderate: topical retinoids + benzoyl peroxidase+ topical antibiotics Severe:add oral antibiotics Refractory: ISOTRETINOIN

Question 739

Frequent UTIs in the setting of chronic diarrhea, lower abdominal pain, chronic back pain, weight loss

Answer 739

THINK OF INFLAMMATORY BOWEL DISEASE --enterovesical fistula. - think of E.coli, bacteroides fragilis. Pneumaturia can also be seen

Question 740

46 yo with intermenstrual bleeding and new onset heavy bleeding

Answer 740

Think about fibroids and endometrial cancer and hyperplasia.-- endometrial biopsy is needed

Question 741

First line treatment for hypertension in patients with gout

Answer 741

ARBs-- losartan, uricosuric event | and you can add Ca channel blockers ( amlodipine) thiazide should be avoided

Question 742

Positive psoas sign

Answer 742

psoas abscess, retroperitoneal hemorrhage

Question 743

Patient with sudden onset abdominal pain in right lower quadrant , hypotense, psoas sign positive. Afib noted., next steps

Answer 743

Retroperitoneal hematoma, CT scan

Question 744

WaRrfarin anticoagulation

Answer 744

Tvit K and FFP

Question 745

Pt with Minimental score 25/30 ( normal>=26) that is able to understand consequences but still refuses to tto

Answer 745

RESPECT WISHES- COMPREHENSION, CONSEQUENCS, CHOICE

Question 746

Prior to prescribing antidepressve in depression screen for:

Answer 746

Maniac episodes

Question 747

Hypothyroidism + mildly elevated transaminases, next step?

Answer 747

ANA ( homogeneous staining) and anti-smooth abs( against actin)- Autoimmune hepatitis - normal ALP, normal bilirubin

Question 748

antimitochondrial antibodies seen in

Answer 748

Primary biliary cirrhosis - high ALP

Question 749

Pt with anemia of chronic disease and signs suggesting RA, management of anemia?

Answer 749

Underlying cause- anti TNF factors. Caused by Suppression of hematopoiesis by cytokines

Question 750

Iron and ferritin in anemia of chronic disease

Answer 750

low iron, high ferritin, normal transferrin

Question 751

Characteristics catatonia

Answer 751

psychomotor disturbance seen in very ill psychiatric patients. Posturing against gravity, mutism, negatitivity, immobility-- examiner puts arm up and he leaves it up.

Question 752

Tto catatonia

Answer 752

BZDs- lorazepam or Electroconvulsive therapy. Lorazepam challenge test confirms diagnosis of catatonia- temporary relief 5-10 minutes after

Question 753

Acute dystonia tto

Answer 753

Benztropine or diphenhydramine

Question 754

Akathisia tto

Answer 754

betablocker ( propanolol) or BZD

Question 755

Parkinsonism

Answer 755

Benztropine or amantadine

Question 756

Tardive dyskinesia

Answer 756

no definitive tto but clozapine may help

Question 757

Dantrolene

Answer 757

Neuroleptic malignant syndrome - fever, altered mental status, muscle rigidity, autonomic instability

Question 758

difference serotonin syndrome and NMS

Answer 758

serotonin: vomiting diarrhea, autonomic instability, can have fever, NO RIGIDITY but YES TREMORS, HYPERREFLEXIA, CLONUS. IMAO ( phenelzine) AND SSRI

Question 759

Strict glycemic control in DM effects on micro, macro, mortality

Answer 759

Macro ( MI):No change short term. Micro ( nephropathy, retinopathy): iMPROVE. Mortality : no change or increased.

Question 760

Etiology of serum sickness disease

Answer 760

immune complex mediation. B lactams/sulfas. Acute Hep B infection

Question 761

Hep B infection causing serum sickness disease

Answer 761

1-2 weeks after exposure. pain in ankle, feet, hands. Then rash can also have purpura areas, fever, polyarthralgia. -- polyartheritis nodosa and glomerulonephtritis

Question 762

tto serum sickness reaction

Answer 762

retire offending agent, supportive, steroids or plasmpaheresis if needed.

Question 763

What is the best initial approach to stablish trust with an schizophrenic patient

Answer 763

maintain interpersonal distance and avoid challenging patients belief. DO NOT NEED TO BE FRIENDLY ALL THE TIME THAT IS SUSPICIOUS.

Question 764

Patient in whom you suspect HIV, and pt refuses to testing. Next step?

Answer 764

First step is always to explore the reasoning behind it.

Question 765

Patient positive for HIV, hesistant to tell wife. Next step

Answer 765

encourage and support to tell the wife. Physicians are not required to disclose results with third parties but new cases should be reported to the Department of public health.

Question 766

management PCP

Answer 766

Lorazepam- restless patient, nystagmus, aggressive behavior, altered mental status. PCP is an NMDA receptor antagonist.

Question 767

Patient with pancreatitis, which type of drug is related?

Answer 767

Thiazides ( hydrochlorothiazide, chlorthalidone) and LOOP diuretics ( Furosemide) - ischemia due to increased intravascular volume, and increased viscosity of pancreatic secretions.

Question 768

Medications that can cause pancreatitis

Answer 768

Heart failure or hypertension (ACE inhibitors, angiotension II receptor blockers, diuretics) Autoimmune disease (azathioprine, mesalamine, corticosteroids) Chronic pain (acetaminophen, opiates, nonsteroidal anti-inflammatory drugs) Seizure disorder (valproic acid, carbamazepine) HIV (lamivudine, didanosine, trimethoprim-sulfamethoxazole)

Question 769

VSD

Answer 769

Holosystolic murmur. Not continuous ( THAT ONE IS PDA)

Question 770

Acute limb ischemia

Answer 770

6Ps:pain, pallor, paresthesia, pulselessness, paralysis, poikylothermia

Question 771

Management limb ischemia

Answer 771

Depends: 1. if capillary refill intact-catheter based or surgical revascularization. 2. If no pulses, cold- emergent revascularization.-given risk of myonecrosis in 4-6 hours 3. Non viable - amputation. ALL OF THESE WITH HEPARIN BOLUS FOLLOWED BY INFUSION

Question 772

pain in leg can be

Answer 772

DVT OR ACUTE ISCHEMIA!!!

Question 773

Definition of priapism

Answer 773

>4 hours persistent painful erection. Common risk factors for ischemic (low-flow) priapism include phosphodiesterase-5 inhibitors (eg, sildenafil), intracavernosal injections (eg, alprostadil), certain medications (eg, trazodone), and sickle cell disease.

Question 774

Dxand management of priaprism

Answer 774

blood gas analysis of a corporeal aspirate. If mild ( urination and col compressess help) if > 4 hours aspiration of corpa cavernosa ( with irrigation saline), or PHENYLEPHRINE

Question 775

When is angiographic embolization indicated in priaprism

Answer 775

treatment of choice for nonischemic (high-flow) priapism, which is significantly less common than ischemic priapism and is often due to a traumatic fistula from the cavernosal artery.

Question 776

Patient on SSRI that complains of sexual dysfunction, next step

Answer 776

Can switch to bupropion or mirtazapine. Patients who are SSRI responders may benefit from addition of sildenafil, or buproprion.instead of switching. SSRIs:decreased libido in women and men, anorgasmia in women, and delayed ejaculation in men

Question 777

Physician that notices that multiple pts have dyspareunia after procedure of same doctor. Next step

Answer 777

Report state medical board, report obstetritian and adverse outcomes

Question 778

When to test for H.pylori

Answer 778

diagnosis of peptic ulcer disease, which typically presents with postprandial epigastric pain and early satiety.

Question 779

Girl with abdominal pain > 4 months, inespecific. No other ss, next step

Answer 779

Symptoms diary. Likely functional abdominal pain > 2 months, normal examination

Question 780

Management spinal epidural abscess

Answer 780

MRI with gadolinium- patient with fever, urinary incontinence, neuro deficit, tachycardia,. IMMEDIATE SURGICAL DECOMPRESSION. STEROIDS ARE NOT GIVEN IN THIS SETTING

Question 781

Organism in spinal epidural abscess

Answer 781

Staph aurerus

Question 782

Patient with stroke who received tPA, with elevated BP NEXT steo

Answer 782

iV labetalol.Strict control with intravenous medications such as labetalol, nitroprusside, or nicardipine is recommended to keep blood pressure <185/105 mm Hg to avoid the risk of hemorrhagic transformation.

Question 783

patient that will undergo bariatric surgery, considerations pregnancy

Answer 783

bariatric surgery is recommenddedbut pregnancy would need to be delayed for at least a year

Question 784

Bariatric ssurgery indications

Answer 784

 obesity class II (BMI ≥35 kg/m²) with at least 1 comorbidity (eg, diabetes mellitus, hypertension, sleep apnea) or for those in class III (BMI ≥40 kg/m²).  Bariatric surgery is recommended in reproductive-age women as it reduces the risk of long-term adverse health consequences and reduces several obstetric complications (eg, preeclampsia, gestational diabetes mellitus) - delay pregnancy for at least a year after bariatric surgery to achieve weight loss goals and stabilize nutritional status -- babies can have neural tube defects or preterm delivery.

Question 785

Bariatric surgery does NOT increase risk of miscarriages and is NOT an indication for cesarea

Answer 785

True

Question 786

preservation of finger

Answer 786

container should have ice mixed with saline or sterile water 50/50. goal temperature of 1-10 C (33.8-50 F). However, the body part should not be cooled below this range to avoid inducing frostbite.

Question 787

tto rosacea

Answer 787

Patients with only erythema and telangiectasias: brimodinine. If pt have papular or pustular lesions : topical metronidazole or azelaic acid. Oral antibiotics (eg, metronidazole, tetracyclines) are sometimes required for more severe cases.

Question 788

most common complications rosacea

Answer 788

ocular manifestations:burning or foreign body sensations, blepharitis, keratitis, conjunctivitis, corneal ulcers, and recurrent chalazion. Patient with ocular chalazion should have ophtalmology consult

Question 789

Actinic keratoses is precursor of

Answer 789

squamous cell carcinoma

Question 790

Fistulous tracts are a complication of

Answer 790

Actinomycosis

Question 791

Cerebral venous thrombosis can be a complication of mucormycosis.

Answer 791

true

Question 792

Gingo biloba

Answer 792

Memory enhancement- increased bleeding risk

Question 793

Gingseng

Answer 793

Memory enhancement- increased bleeding risk

Question 794

Saw palmetto

Answer 794

BPH- GI issues and increased bleeding

Question 795

Black cohosh

Answer 795

postmenopausal symptoms- hepatic injury

Question 796

kava kava

Answer 796

anxiety- hepatic injury

Question 797

St.Johns wort

Answer 797

Depression,insomnia- hypertension, serotonin sydrome, increased bleeding risk, digoxin

Question 798

Licorice

Answer 798

stomach ulcers,bronchitis- hypertension, hypokalemia

Question 799

echinacea

Answer 799

flu symptoms- analhylaxis particularly in asthma

Question 800

Ephedra

Answer 800

flu, weight loss, athletic performance - HTN, arrhythmia/MI/Sudden death syndrome/Stroke.

Question 801

Which is the most effective intervention that decreases likelihood expansion of aortic aneurysm

Answer 801

SMOKE CESSATION!!!! MORE THAN BP control

Question 802

Which is the most common part of aorta that is affected in aortic aneurysm

Answer 802

infrarenal aorta

Question 803

whom do you screen for abdominal aortic aneurysm

Answer 803

Abdominal US in men 65-75 who have ever smoked

Question 804

3 Indications for surgical repair of aneurysm

Answer 804

> 5.5 cm , >0.5 cm expansion in 6 months, AAA associated with PAD or aneurysm-ss.

Question 805

tto of adbominal aortic aneurysm

Answer 805

smoking essation, aspirin, statin. Possibly surgery If large, rapidly expanding or sympomatic.

Question 806

18 year old with recurrent UTIs, one sexual partner. Currently with UTI, next step in manangement.

Answer 806

ANTIBIOTIC PROPHYLAXIS ( TMP/SMX,Fluoroquinolones, nitrofurantoin) in addition to postcoital void and cranberry juice. Abcs could be given continuously for several years or only post coital. NOT ABDOMINAL US- ANATOMIC ABNORMALITIES WOULD NOT BE EXPECTED AT THIS AGE.

Question 807

When to give antibiotic prophylaxis for UTI

Answer 807

more than two UTI in six months, more than 3 in one year.

Question 808

Pt recently treated with amoxicillin for acute otitis media, presents to clinic with no ss and serous otitis media (retracted tympanic membrane with fluid), next step

Answer 808

If patient is asymptomatic do not treat. Serous otitis media can persist up to 3 months after treatment - so watchful waiting. If patient is symptomatic, effusion is bilateral, or effusion persists in > 3 months then treat with amoxicillin clavulonate.

Question 809

Tourette syndrome diagnosis

Answer 809

Multiple motor tics and >=1 vocal tic ( not necessarily concurrent, > 1 year) , and age of onset < 18.

Question 810

Tourette syndrome management

Answer 810

behavioral training ( habit reversal training), RISPERIDONE, ARIPIPRAZOLE ( ANTIPSYCHOTICS), TETRABENAZINE ( Dopamine blocker), ALPHA 2 ADRENERGIC RECEPTOR AGONISTS( Clonidine, guanfacine)

Question 811

Organism in severe intertrigo

Answer 811

Candida- miconazole, terbinafine, nystatin

Question 812

Erythrasma

Answer 812

in skin fold regions, leaves a dark mark - Corynebacterium minuttism.

Question 813

neurocardiogenic (vasovagal) syncope

Answer 813

education and reassurance, physical counterpressure manuevers like leg crossing, tensing arms with clench fist.

Question 814

Management of PAD

Answer 814

ESCALATED APPROACH: 1st step: smoking cessation, DM and BP control , aspirin and statin treatment. 1b. Supervised exercise program. 2

Question 815

Patient with signs of meningitis that gram stain is negative, and CSF fluid consistent with meningitis

Answer 815

they still can have bacterial meningitis even though the gram stain and culture are negative particularly if they had recent antibiotic therapy.

Question 816

Pregnant women after vehicle collision presents with uterine tenderness, baby with accelerations but no decelerations, and increased contractions. 27 weeks.AND MOM RH -Next step?

Answer 816

Kleihauer Betke test to detect and quantify the amount of fetomaternal hemorrhage to determine how much IGD should be given - and continue fetal monitoring.

Question 817

Patient pregnant, uterine tenderness, anemic,

Answer 817

always think of contained abruptio of placenta.

Question 818

Patient with COPD who has signficant weight loss and some depressive ss. What is the most common cause of weight loss?

Answer 818

Pulmonary cachexia syndrome ( BMI <20%, or weight loss> 5 %). Caused by 1. increased work of breathing ( increased calorie use), systemic inflammation( decreased appetite and skeletal muscle wasting), skeletal muscle hypoxia.

Question 819

Primary ovarian insufficiency causes

Answer 819

Turner syndrome, fragile X syndrome, chemotherapy, radiation, galactosemia

Question 820

tto of primary ovarian insufficiency

Answer 820

estrogen plus progesterone( if intact uterus)- ideally until 50s or when menopause was supposed to be . Helps with hot flashes and to decrease bone loss. SO NO NEED OF BIPHOSPHONATES

Question 821

Use and SE of Raloxifen

Answer 821

for postmenopausal osteoporosis BUT WORSEN HOT FLASHES

Question 822

DKA Management.

Answer 822

draw

Question 823

Tight glycemic control benefits

Answer 823

nePHROPATHY ( proteinuria, CKD), and retinopathy. NOT PAD, MI, Stroke. Target < 7

Question 824

Thyroid nodule management

Answer 824

draw

Question 825

Management of medullary carcinoma

Answer 825

Before thinking about resection think of other places for metastasis- check calcitonin, CEA Ag, neck US, abdominal US, plasma free metanephrines, 24 hr metanephrines, catecholamines , RET mutation

Question 826

Patient with cushings characteristics. How to differentiate primary and secondary- management for each

Answer 826

Primary ( Adrenal) - high cortisol levels, no suppression with dexamethasone test, suppressed ACTH. - DO CT OF ADRENAL GLANDS- CT and MRI have same sens/spes. Seconday: high cortisol, ACTH should be high or normal.

Question 827

Management of primary enuresis

Answer 827

urinalysis, lifestyle modification, enuresis alarm, desmopressin

Question 828

Blood glucose in DKA VS. HHS

Answer 828

>250 vs. 600

Question 829

Alcoholic ketoacidosis

Answer 829

anion gap acidosis, increased osmolal gap, ketonemia or ketonuria and variable blood glucose levels. Blood glucose levels are generally higher than 250 mg/dL in patients with diabetic ketoacidosis.

Question 830

Management of alcoholic ketoacidosis

Answer 830

IV fluids and THIAMINE. THERE IS NO NEED TO GIVE INSULIN IN THESE CASES

Question 831

Signs of hypercalcemia

Answer 831

If mild ( < 12) no symptoms. If more than this: stones (nephrolithiasis), bones (bone pain, arthralgias), abdominal groans (abdominal pain, nausea, vomiting), and psychiatric overtones (anxiety, depression, fatigue)

Question 832

Signs of hypocalcemia

Answer 832

Chvostek, and hyperreflexia. numbness and/or tingling of the hands, feet, or lips, muscle cramps,muscle spasms,seizures,facial twitching,muscle weakness, ightheadedness, and.slow heartbeat.

Question 833

21 alpha hydroxylase

Answer 833

ambiguous genitalia, hypotension, cerebro perdedor de sal, hypoNA, hyperK, hypoglycemia, 46 XX

Question 834

11 b hydroxylase

Answer 834

ambigous genitalia, hypertension

Question 835

17 alpha hydroxylase

Answer 835

all are phenotypically female, hypertension

Question 836

Baclofen and anticholinergic can cause urinary retention

Answer 836

TRUE Immediate bladder decompression using urethral or suprapubic catheter is required to prevent progression and acute renal failure. For most patients, urethral catheterization is attempted prior to consideration of suprapubic catheterization.

Question 837

Mc Cune albright syndrome

Answer 837

irregular café au lait spots, precocious puberty peripheral, fibrous dysplasia of the bone.

Question 838

Management of renal cell carcinoma

Answer 838

If contained within capsule- partial nephrectomy. If extends through the capsule but not the Gerota's fascia is stage II, and RADICAL NEPHRECTOMY. Radical nephrectomy also for Stage III where there is invasion of major veins, abdominal lymph nodes and adrenal glands. CHEMO/IMMUNOTHERAPY just for metastasis

Question 839

Hyponatremia in CHF

Answer 839

CHF-low cardiac output and poor perfusion-ADH secretion-- reabsorption of water. MANAGEMENT IS TO WATER RESTRICT!! TOLVAPTAN (VASOPRESSIN ANTAGONIST ) CAN BE USED IN SYMPTOMATIC CHF, OR IN PATIENTS WITH SEVERE HYPONATREMIA < 120.

Question 840

Patient with DM , coming for hypoglycemia, hypotension, weakness, fatigue, weight loss. Labs consistent with hypoglycemia, hypoNatremia, hyperK, EOSINOPHILIA

Answer 840

Think adrenal insufficiency- to cosyntropin test( ACTH) and measure cortisol before and after. It should increase if normal. iF INSUFF no response.

Question 841

Patient with hematuria due to exercise, next step

Answer 841

repeat urinalysis in 1 week.

Question 842

Hmaturia due to rhabdomyolysis, next step

Answer 842

CPK and serum myoglobin

Question 843

2-step approach is involved in screening for GDM.

Answer 843

glucose challenge test (GCT) 50-g glucose load. A blood glucose level >140 mg/dL is an indication for the second step, a 3-hour glucose tolerance test (GTT). The GTT is a diagnostic test that consists of a fasting blood glucose and blood glucose levels measured 1, 2, and 3 hours after a 100-g glucose load. GDM is diagnosed when >2 of the GTT values are elevated

Question 844

Targets of glucose in GDM, and management

Answer 844

Fasting <95, 1 hour < 140, 2 hour <120. Insulin should be started to reduce risk of shoulder dystocia if these are not met. Metformin and glyburide are other options. BUT first line insulin. After failure of lifestyle modifications

Question 845

Hyperthyrodism in elderly - apathic hyperthyroidism

Answer 845

lethargy, apathy, decreased appetite, and weight loss (often termed "apathetic hyperthyroidism") or have muscle weakness (myopathy). atrial fibrillation and heart failure can be readily triggered by thyrotoxicosis, but tachycardia may be absent due to concurrent medications (eg, beta blockers) or underlying cardiac conduction system disease.

Question 846

Type I diabetic that is on glargine and aspart. He is admitted to the hospital for vomiting and dehydration. How to adjust the regimen of insulin

Answer 846

Decrease the basal insulin ( long acting) as they often eat less during hospitalization. And give short term insulin based on the status of glycemia. The goal is to maintain 140 -180 levels.

Question 847

Polyruia, polydipsia, hypertension and hypoK

Answer 847

Primary hyperaldosteronism ( Conn syndrome) -- measure plasma aldosterone to renin ratio--a ratio of 30 or more is suggestive of excessive aldosterone secretion from the adrenal gland

Question 848

Assess Conn's syndrome

Answer 848

plasma aldosterone to renin ratio

Question 849

Recent bariatric surgery, HyperPTH, back pain, normal calcium, hypophosphatemia,

Answer 849

Vit D deficiency. paTIENTS WITH BARIATRIC SURGERY NEED at least 2000-3000 units of cholecalciferol (vitamin D3) per day to maintain vitamin D levels of 30-50 ng/mL,

Question 850

Diabetic neuropathy presentatio and DX

Answer 850

bilateral sensory changes, feel burning pain , changes in vibration and proprioception. TUNING FORK TEST IS A GOOD FIRST STEP. -- NERVE STUDIES DIAGNOSE IT BUT ARE EXPENSIVE

Question 851

fiRST LINE TREATMENT FOR DIABETIC NEUROPATHY

Answer 851

Duloxetine ( SNRIs), gabapentin pregabalin, TCAs. Topical capsaicin. While tricyclic antidepressants are effective pain control agents for diabetic neuropathy, SSRIs are not

Question 852

Patient with normal TSH, normal T4, LOW T3

Answer 852

"low T3 syndrome" and is thought to be primarily the result of decreased conversion of T4 to T3. Causes: acute illness,inflammatory cytokines (eg, tumor necrosis factor), starvation, and certain medications (eg, glucocorticoids, amiodarone). REPEAT IN 8 WEEKS.

Question 853

hypocalcemia after transfusion-ACUTE HYPOCALCEMIA TTO

Answer 853

An ionized calcium level is required for diagnosis, as serum calcium is often normal. Give CA gluconate or chloride

Question 854

fASTING GLUCOSE IN DM DX

Answer 854

Normal fasting glucose <100. If 100-126 impaired fasting glucose and puts you at risk for CAD( even with normal lipid profile). Fasting glucose of > 126 DM

Question 855

Management of asymptomatic bacteriuria in pregnancy

Answer 855

cephalexin for 3-7 days, amoxicillin-clavulanate for 3-7 days, or fosfomycin as a single dose.

Question 856

maNAGEMENT OF Pyelonephritis in pregnancy

Answer 856

Patients with acute pyelonephritis during pregnancy receive a treatment course of antibiotics. Once treatment is completed, they receive daily antibiotic suppression until 6 weeks postpartum to prevent recurrence. During the first trimester, nitrofurantoin is a second-line antibiotic due to potential associations with congenital defects. It is contraindicated at term due to an increased risk of hemolytic anemia in the newborn.

Question 857

First line tto of cystitis in non pregnant

Answer 857

TMP-SMX

Question 858

Treatment of asymptomatic bacteriuria during pregnancy decreases the risk of maternal (eg, pyelonephritis) and fetal complications (eg, preterm birth, low birth weight, perinatal mortality).

Answer 858

TRUE

Question 859

Newborn to DM mother with respiratory distress and murmur.

Answer 859

Hypertrophic interventricular septum- insulin triggers glycogen synthesis, glycogen gets stored in the myocardium particularly in the septum - they will present with signs of congestive HF - pulmonary edema- tachypnea and respiratory distress

Question 860

Prognosis of hypertrophic cardiomyopathy in newborns of diabetic mom

Answer 860

Most cases resolve without surgery

Question 861

RF for hypoplastic left ventricle

Answer 861

Mothers with pregestational DM- babies present with cyanosis, and is often recognized in the second trimester.

Question 862

Congenital pulmonary valve stenosis

Answer 862

Noonan synrome

Question 863

Delayed puberty in boys

Answer 863

lack of testicular enlargement >=4mL by 14 yo. Always test for FSH, LH, Testosterone, prolactin,.Prolactin and TSH tests should also be ordered, as increased levels interfere with GnRH secretion.

Question 864

Brain death algorithm

Answer 864

draw. Patients with brain death can have spontaneous movements originating from peripheral nerves or the spinal cord.

Question 865

suicidal patient

Answer 865

Patients who are actively suicidal and refusing treatment should be placed on 1:1 observation and hospitalized under involuntary status.

Question 866

TTO IMMUNE THROMBOCYTOPENIA

Answer 866

Mild - asymptomatic or cutaneous bleeding (eg, petechiae, purpura) - watch Moderate/severe - mucosal bleeding (eg, gingival bleeding, epistaxis), internal hemorrhage (eg, hematochezia, intracranial hemorrhage)- < 30,000 -IVIG

Question 867

Dr. that doesn’t want to take care of a patient, what is the next step

Answer 867

Ask him to care for him until he has a new doctor. Ensuring continuity of care is fundamental to patient safety.

Question 868

Immunizations in HIV

Answer 868

Tdap followed by Td every 10 years, Annual influenza( not the intranasal one as it is alive), PCV13 followed by PPSV3 8 weeks later and then every 5 years after, Hep A and B. Live vaccines are contraindicated except for MMR, Varicella, and Zoster only I if their CD4+ cell counts are >200/mm3 and they have no history of an AIDS-defining illness.

Question 869

septic aborption management

Answer 869

Blood & endometrial cultures Broad-spectrum antibiotics Suction curettage Hysterectomy

Question 870

septic aborption complications

Answer 870

``` Myometrial infection/necrosis Sepsis Acute respiratory distress syndrome Disseminated intravascular coagulation Death ```

Question 871

antibiotics for septic abortion

Answer 871

gentamicin plus clindamycin

Question 872

when do you consider hysterectomy in septic abortion

Answer 872

no response to antibiotic or curretage, pelvic abscess and clostridial myonecrosis (eg, pelvic tissue crepitus, radiographic evidence of air within the uterine wall).

Question 873

Patient calling for dysuria. Has a history of UTI, next step?

Answer 873

Prescribe TMP/SMX x 3 days if acute uncomplciated- history alone is enough. No need to do urinalysis /urine culture . Alternative is 5 days of nitrofurantoin . IF PATIENT WERE TO BE PREGNANT, WITH S OF VAGINAL INFECTION OR PYELO NEED TO BE SEEN.

Question 874

WHAT IS partial small bowel obstruction.

Answer 874

Pt with vomiting, X ray cosnsitent with small bowel obstruction but there is air in colon

Question 875

Management of partial small bowel obstruction

Answer 875

observation and supportive care, if patient is not able to to improve in 12-24 hours then surgery.

Question 876

Electro convulsive therapy indications

Answer 876

Conditions treated Unipolar & bipolar depression Catatonia Bipolar mania Specific indications Treatment resistance Psychotic features present Emergency conditions Refusal to eat or drink Imminent risk for suicide Pharmacotherapy contraindicated due to comorbid medical illness or poor tolerability Pregnancy when pharmacotherapy is undesirable or ineffective History of ECT response No absolute contraindications Increased risk Severe cardiovascular disease, recent myocardial infarction Space-occupying brain lesion Recent stroke, unstable aneurysm

Question 877

pregnant women with hx of poorly controlled bipolar, suicidal, risk of hurting child

Answer 877

ECT, Lithium is associated with a slightly increased risk of cardiac malformations (Ebstein anomaly) but can be used during pregnancy in patients with severe bipolar illness.

Question 878

hidradenitis suppurativa (HS) (also known as acne inversa), TTO

Answer 878

General (all patients) Weight loss, smoking cessation Daily skin cleansing of affected area Hurley stage I (mild disease) Topical clindamycin Intralesional steroids or oral antibiotics for flare-ups Hurley stage II (moderate disease with nodules, sinus tracts & scarring) Oral tetracyclines (preferred)- doxycycline Oral clindamycin + rifampin in refractory cases Hurley stage III (severe disease with diffuse involvement & extensive sinus tracts) Biologic TNF-alpha inhibitors (eg, infliximab) Oral retinoids (eg, acitretin) Surgical excision

Question 879

myocardial ischemia due to acute cocaine intoxication

Answer 879

benzodiazepines and nitroglycerin to improve the mismatch of myocardial oxygen supply and demand. Patients with persistent ST elevation despite medical therapy should undergo coronary revascularization without delay.

Question 880

Funduscopic examination shows a small, densely pigmented lesion with irregular borders in the peripheral right choroid. The lesion is about 8 mm in diameter and is minimally raised (1 mm).

Answer 880

ocular melanoma from choroid pigmented nevus- Asymptomatic patients with small pigmented lesions (diameter <10 mm, thickness <3 mm) follow-up in 3-6 months. If > 10mm, thickness> 3 mm -- RADIOTHERAPY

Question 881

When to do enucleation in ocular melanolma

Answer 881

tumors are very large, have extrascleral extension, or severe associated pain. - not the best as it has multiple morbidities

Question 882

Sickle cell trait

Answer 882

Hbs A 40 and Hbs S 60. Trait,asymptomatic and does not cause anemia.

Question 883

Alpha thalassemia

Answer 883

Hb Barts (4 gamma chains) on electrophoresis,, or HBH ( 3 DELETIONS)

Question 884

B thalassemia

Answer 884

mutations in the beta globin genes- Point mutation. HbA>3.5. mild or severe. Target cells

Question 885

Postexposure HIV prophylaxis low and high risk

Answer 885

high risk: exposure to blood, semen, mucuous membranes , vaginal secretions , breast milk. LOW RISK ( NO NEED OF PROPHYLAXIS): urine, nasal secretions, saliva, sweat, tears

Question 886

postexposure HIV prophylaxis

Answer 886

within 72 hours, for 28days. Triple drug therapy ( tenofovir, emcitirabine, raltegravir). TEST IN 4-6 WEEKS

Question 887

Tuberous sclerosis genetics and ppt

Answer 887

AD, TSC 1 ( hamartin) or TSC 2 ( tuberin). Hamartonas in skin and CNS, Angiofibromas in skin, Mitral regurgitation, Ash leaf spots, Cardiac Rhabdomyoma, tUB/AD,Mental retardation, Shagreen spots, renal angyiolipoma.

Question 888

Initial management of childrens who ha seizures and you suspect Tuberous sclerosis

Answer 888

utaneous examination, funduscopy, and a brain MRI to evaluate for hamartomas. An electroencephalogram

Question 889

comorbidities is the predominant cause of death in patients with tuberous sclerosis?

Answer 889

epilepsy - brain MRI and electroencephalogram always whensuspecting it . Second most common cause is renal falure.

Question 890

pt requesting staying more days at the hospital

Answer 890

I understand your concerns, unfortunately nsurance only cover xtra days that are medically necessary

Question 891

lichen sclerosus can evolve to vulvar cancer

Answer 891

do a biopsy if lesion seems vulvar cancer single, raised plaque or ulcer covering the labia majora. Treatment of vulvar cancer is with surgical excision and possible chemoradiation.

Question 892

tto lichen sclerosus

Answer 892

topical corticosteroids

Question 893

atrophic vaginitis

Answer 893

thinned vulvar skin and fusion of the labia minora - estrogen

Question 894

patient with hx of raynaud, GERD, with hypertensive crisis. Most common cause?

Answer 894

scleroderma renal crisis . ALWAYS CHECK BP IN SCLERODERMA PATIENTS.

Question 895

pHARMACOTHERAPY FOR HTN CRISIS IN SCLERODERMA

Answer 895

ACEIs ( Captopril) and intrvenous nitroprusside if CNS manifestations or papilledema present.

Question 896

Best prognostic factor in primary cns lymphoma

Answer 896

the degree of immunosupression- so increase in CD4 count better outcome

Question 897

primary CNS lymphoma tto in HIV

Answer 897

radiation, corticosteroids, and HAART

Question 898

Pregnant woman 19 weeks, with vaginal pressure and spotting. Bulging of amniotic fluid through cervix 3 cm dilated

Answer 898

Cervical incompetence

Question 899

Prognosis of cervical incompetence with cerclage

Answer 899

If cerclage is done prophylactically at 12-14 weeks the prognosis is good. However, if cerclage is done later, and the patient presents with bulgin og amniotic bag through cervix, POOR prognosis and there is no point in doing cerclage.

Question 900

ould provide the greatest benefit for decreasing this patient's risk of an ischemic cerebrovascular accident

Answer 900

control of bp

Question 901

Suspicion of epididymitis, next step

Answer 901

order urine analysis and culture, NAAT for gonorrhea and chlamydia. In < 35 is likely STIs, in > 35 due to E.coli

Question 902

Tto of epididymitis

Answer 902

Antibiotics- if gonorrhea suspicion ( Ceftriaxone + doxy), if not levofloxacine

Question 903

Presentation of viral orchitis, or when to suspect

Answer 903

children/ adolescents - viral meningitis, mumps, bilateral orchitis

Question 904

Management of HIT 2

Answer 904

Stop heparin, give argatroban, fondaparinux, . And given that these are not oral patient will need to transition to warfarin once platelets are > 1500

Question 905

acute heart failure due to acute mitral valve regurgitation

Answer 905

Pt with sudden onset of short breath, diaphoresis, pulmonary edema, hypotension, late systolic murmur

Question 906

acute heart failure due to acute mitral valve regurgitation tto

Answer 906

bedside echo, and emergent surgical intervention

Question 907

When do you see acute heart failure due to acute mitral vavlve regurgitation.

Answer 907

Ehler Danlos, Marfan have both mitral valve prolapse but velvety skin with atrophic scarring is consistent with EDS. EDS Abdominal & inguinal hernias Uterine prolapse

Question 908

dX AND MANAGEMENT OF MUCORMYCOSIS

Answer 908

Sinus endoscopy with biopsy and culture. Management is surgical debridement and amphotericin B

Question 909

Pulmonary embolism

Answer 909

Sudden shortness of breath, pleuritic pain, pleural friction rub, tachycardia, pleural effusion. IF V/Q mismatch is low probability and you still suspect it don’t let if fool you!

Question 910

Wells criteria

Answer 910

3 DVT, alternate diagnosis. +1.5 Previous PE or DVT, tachycardia > 100, surgery/immbolization. Wells> 4 probability high A12

Question 911

Early signs of compartment syndrome

Answer 911

AT EXAM TIGHTNESS AREA, PAIN WITH PASSIVE STRETCHING OF THE MUSCLE, MUSCLE WEAKNESS

Question 912

Later stages of compartment syndrome

Answer 912

pulse.

Question 913

management of compartment syndrome

Answer 913

Compartment pressures should be measured, and pressures >20-30 mm Hg typically require fasciotomy as definitive therapy to relieve high compartment pressure. T

Question 914

complications of transurethral resection of the prostate.

Answer 914

retrograde ejaculation

Question 915

Strongest RF for PID

Answer 915

FIRST MULTIPLE SEXUAL PARTNERS, THEN PRIOR PID

Question 916

PID tto

Answer 916

CEFTRIAXONE PLUS DOXY . If inpatient: Cefoxitin + doxy

Question 917

Infantile botulism

Answer 917

inhibition of ACH release - honey, living in farms/rural areas

Question 918

Degeneration of anterior horn cells

Answer 918

spinal muscular atrophy,

Question 919

management of infantile botulism

Answer 919

otulism immune globulin

Question 920

Pooled human immune globulin

Answer 920

tto for Guillain Barre

Question 921

Vertebrobasilar insuffiency

Answer 921

vertigo, dizziness, dysarthria, diplopia, and numbness.

Question 922

prognosis of febrile seizures

Answer 922

o long-term sequelae ↑ risk of subsequent febrile seizure Slight ↑ risk of epilepsy (~1%)

Question 923

increased risk preoperatively for anesthetic and operative drug reactions.

Answer 923

multiple drugs

Question 924

Immunocompromised patient with pneumonia, organism? Tto?

Answer 924

PCP, tmp/smx + corticosteroids. Hypoxia, ground grass opaicites on chest x ray

Question 925

Vaginal spotting in elderly-

Answer 925

SEVERE ORGAN PROLAPSE can cause it!! . If cervical cancer, you would be able to see something in the speculum . severe prolapse cause vaginal erosions that lead to abnormal vaginal bleeding (eg, postmenopausal bleeding, postcoital spotting). Treatment of prolapse is via pessary or surgical correction; erosions can be treated with vaginal estrogen.

Question 926

Intussusspetion

Answer 926

AIR OR SALINE ENEMA . NOT BARIUM-- RISK OF PERITONITIS

Question 927

intussuseption is a medical emergency!!

Answer 927

if not available someone to consent-- do it without consent/

Question 928

Pt that underwent air enema for intussusspetion, and one hour later has severe abdominal pain

Answer 928

order Abdominal X rays- to evaluate for perforation .

Question 929

pregnant woman with HPV lesiosn, in labor. Next step

Answer 929

expectant manangement and vaginal delivery . Unless the lesions are too big that obstruct birth canal

Question 930

Treatment of hemochromatosis

Answer 930

therapeutic phlebotomy

Question 931

Wilsons disease tto

Answer 931

Penicillamine

Question 932

Hemochromatosis can present with

Answer 932

infertility, diabetes, bronze skin

Question 933

Patient with symptoms of renal stone, CT negative, and history of analgesic use for a lot of time, and has BUN AND CREAT HIGH

Answer 933

Anaglesic nephropathy-- causes papillary necrosis and can present similarly

Question 934

Turner syndrome has normal intelligence?

Answer 934

YES , low set ears, micrognathia, streak ovaries, they have normal IQ but are at risk of learning disabilitis

Question 935

Turner syndrome genetic defect

Answer 935

NONDISJUNCTION 45 X, sporadic event. - probability to have another pregnancy with that is similar to rest of population

Question 936

BACTERIAL ENTERITIS- BLOODY IN KIDS-NEXT STEP AFTER OBTAINING CULTURE

Answer 936

FLUID EVEN IF NOT DEHYDRATED. ALWAYS THINK OF E.COLI , SALMINELLA, SHIGELLA. , E.COLI, Plain water may exacerbate electrolyte disturbances and lead to dangerous hyponatremia or hypoglycemia. Juice is also not recommended as its high sorbitol content can exacerbate diarrhea.

Question 937

Causes of transient PSA elevation

Answer 937

Urinary retention, mild acute prostate inflammation or infection, urologic procedure ( cystoscopy) ,digital recta exam ( minimal elevation of PSA), recent ejaculation --- recheck in 6-weeks

Question 938

Persistent elvations of PSA

Answer 938

bph, prostate cancer, or severe prostatitis

Question 939

tto of keloids

Answer 939

intralesional glucocorticoids, but risk of recurrence so sometimes may require surgical excision

Question 940

pt with ALS complaining of difficulty sleeping, orthopnea, dysphagia, dyspnea, and has fasciculations,

Answer 940

diaphragmatic paralysis

Question 941

tto of salmonella

Answer 941

NO ANTIBIOTIC USE!!!! SUPPORTIVE TREATMENT IN IMMUNOCOMPETENT AND OLDER OF 12 MONTHS.

Question 942

treatment of subclinical hypothyroidism, and when do you treat

Answer 942

treat if: 1. . TSH >10 2. Antithyroid peroxidase abs positive 3. Pregnancy +, infertility or ovulatory dysfunction, goiter, symptoms, abnormal lipid profile ( hypercholesterolemia) tto : levothyroxine

Question 943

When do you screen for thyroid disease

Answer 943

is controversial:( 2 pts of view) 1. all patients > 40 2 >50 women with ss

Question 944

in patients who present with HTN < 30 years of age, or aa worsening of HTN after being controlled for a long time, think of

Answer 944

secondary HTN In the second case, renovascular HTN

Question 945

Patient with controlled HTN with 2 meds and everything has been the same in his life, that now has increased BP., decreased peripheral pulses, carotid bruitNEXT STEP

Answer 945

Think of renovascular HTN ( IN THE SETTINGOF ATHEROSCLEROSIS) NEXT STEO-- MR angiography of renal vasculature

Question 946

do inhakled corticosteroids for asthma cause hyperglycemia

Answer 946

NO. the dosing , and appropirate use with spacers should not cause hyperglycemia. It is most commonly seen with oral corticosteroids

Question 947

patient with fever> 39, nausea and diarrhea. Dehydrated somnolent. Labs with hyperglycemia 200, ketones in urine, hb A1C 5.6. What is the cause of hyperglycemia?

Answer 947

``` stress hyperglycemia ( caused by high circulating stress hormones) seen with fever > 39 severe illness sepsis meningitis ICU ``` * not DM because no typical ss of polyuria, polydipsia, weight loss. Hb A1C not show long time DM

Question 948

16 yo with tiredness, weigh loss, amenorrhea, decreased appetite, multiple freckles, patchy brown spots on mucosa, and lips, decreased amount of axillary and decreased axillary and pubic hair. labs with hyponatremia and hyperK, next step?

Answer 948

suspect Addison's disease or adrenal insuff order cortisol with ACTH with cosyntropin

Question 949

Hypoaldosteronism does not present with hyperpigmentation

Answer 949

hyperpigmentation is not seen as there is no increased production of ACTH/melanocyte-stimulating hormone.

Question 950

Patient IV user who has malaise, nausea, mjaundice, RUQ pain, elevated LFTs, hep B labs negative, Hep C antibodies negative, hep A antibody negative. Cause?

Answer 950

it is highly suspicious for HEPATITIS. Hep C antibodies are not useful to detect infection in earlier stages as they appear only 2-6 months after exposure. SO ORDER HCV RNA BY PCR BECAUSE THIS CAN BE DETECTED WITHIN DAYS.

Question 951

67 yo smoker, COPD, who had pneumonia 3 weeks ago, now presenting with pneumonia. next step?

Answer 951

CT chest! in the setting of non-resolving pneumnia particularly on the same place and in a smoke think of endobronchial neoplasm. Other things that the CT will be helpful to rule out are: abscess and empyema.

Question 952

factors associated with euthanasia request

Answer 952

MC: - loss of autonomy and control of dying process - fears of future suffering others include: - loss of dignity - inability to engage in pleasurable activities " WHEN THEY REQUESTED: ASK PLEASE TELL ME MORE ABOUT WHY YOU FEEL THAT WAY"

Question 953

ASCITIS FLUID ANALYSIS- SAAG

Answer 953

SAAG: Serum albumin- Ascitic fluid albumin SAAG>=1.1 : Indicates portal hypertension : CHF, hepatic cirrhosis, alcoholic hepatitis, Budd Chiari SAAG< 1.1 : Peritoneal carcinomatosis, peritoneal TB, nephrotic Sx, pancreatitis, serositis.

Question 954

patient with ADHD who will need medication. Has a family hx of substance abuse and he has tried a couple of times alcohol. any risks with ADHD medication and substance abuse?

Answer 954

NO. THERE IS NO DATA SHOWING THAT ADHD MEDS INCREASE RISK FOR SUBSTANCE ABUSE

Question 955

Elderly alcoholic with abdominal pain after feeds that improve with sitting, postprandial bloating and discomfort, and large stools that require multiple flushes. next step?

Answer 955

MR cholangiopancreatography or an abdominal CT scan Chronic pancreatitis- so this image will show calcifications which is patognomonic . other signs: ductal dilation, eudocysts. they also may develop diabetes. **amylase and lipase may be a little bit elevated but are freq normal

Question 956

tto of chronic pancreatitis

Answer 956

``` alcohol and smoking cessation pain management frequent small meals pancreatic enzymess f/u in 1-2 months. ```

Question 957

Fat embolism

Answer 957

after fx shortness of breath hypoxemia petechial rash confusion dx:presence of fat droplets in urine or intra-arterial fat globules on fundoscopy Serial X-rays: increasing diffuse b/l pulm. Infiltrates within 24-48 hours of onset of clinical findings

Question 958

What can be done to prevent fat embolism

Answer 958

early immobilization and correction of fracture.

Question 959

tto fat emboslism

Answer 959

supportive.

Question 960

wat to ask about suicide

Answer 960

ideation, intent and plan

Question 961

brief psychotic disorder>

Answer 961

>1 day and < 1 month. sudden onset and full return to function.

Question 962

schizophrenifrom disorder

Answer 962

> 1 m and < 6 months. Same as schizophrenia , functional decline not required

Question 963

schizophrenia

Answer 963

> 6 months ( includes at least 1 month of active ss, and can include prodromal and residual periods), requires functional decline

Question 964

schizoaffective disorder

Answer 964

concurrent mood episode + ss of schizophrenia | and at least 2 week lifetime hx of delusions/hallucinations in the abscence of mood ss

Question 965

Cannabis can lead to psychosis?

Answer 965

High-potency cannabis has been associated with paranoia, depersonalization, and hallucinations. -Some experts suggest that early cannabis use may be a causal factor in developing schizophrenia in those with susceptibility

Question 966

cocaine can lead to psychosis

Answer 966

ocaine intoxication and withdrawal can also present with acute psychotic symptoms.

Question 967

kid with psychosis hx of substance abuse and family hx of of schizophrenia

Answer 967

always rule out substance induced psychosis and consider timing to dx schizphrenia

Question 968

tto PTSD

Answer 968

SSRIS trauma- focused psychotherapy fOR nightmares: prazosin

Question 969

always screen for PTSD in veterans

Answer 969

individuals experiencing new-onset anxiety, insomnia, interpersonal conflicts, or escalating substance use.

Question 970

Elderly with torsaides de pointes. Causes?

Answer 970

bradyarrhythmias. ``` Also think of ABCDE Electrolyte disturbancesHypoMg, HypoK, HypoCa hypothermia Sinus dynfucntion , AV blocks, hypothyroidism starvation ```

Question 971

Electrolyte disturbances causing Long QT syndrome

Answer 971

hypoK, HypoMg, HypoCa

Question 972

tto torsaides de points independent of the cause

Answer 972

First give IV Mg then if not helpful temporary transvenous pacing

Question 973

Can ABO incompatibility - acute hemolytic reaction occur in a patient who has been transfused multiple times?

Answer 973

Yes-Patients who require chronic red cell transfusions (eg, African American patients with sickle cell anemia) may form multiple antibodies to common Rh, Kell, or other blood group antigens.

Question 974

tto of acute hemolytic reaction

Answer 974

stop transfusion and IV NS ( do not give LR) to treat hypotension and prevent renal failure

Question 975

Febrile nonhemolytic transfusion reactions can be prevented?

Answer 975

no, Premedication with antihistamines and acetaminophen does not prevent blood transfusion reactions

Question 976

Patient who developed peripartum cardiomyopathy, and now is pregnant with the second baby and wants to know the risk ?

Answer 976

Some patients can have spotaneous resolution of ss,however, there is a risk of recurrence, with patients with LVEF <20% at diagnosis at highest risk. Patients with persistent PPCM are at risk for further LV function decline and death in subsequent pregnancies. REGARDLESS OF RESOLUTION OF SYMPTOMS THESE MOMS ARE FOLLOWED WITH SERIAL ECGS and if there is further LV dysfunction they are recommended to avoid pregnancy

Question 977

presentation of peripartum cardiomyopathy

Answer 977

36 weeks gestation and 5 months postpartum. Risk factors include maternal age >30, multiple gestation, and preeclampsia. Patients present with left heart failure symptoms (eg, dyspnea), left ventricular ejection fraction (LVEF) <45%, and no other cause of heart failure (ie, diagnosis of exclusion).

Question 978

Management. ofperipartum cardiomyopathy: Hydralazine, nitrates and delivery based on mom stability . Adter delivery how should it be managed?

Answer 978

serial TTE

Question 979

PPT AND PATHOPHYSIOLOGY OF SEBORREIC KERATOSIS

Answer 979

proliferation of immature keratinocytes. after 50s well-demarcated, pigmented, round or oval, and have a dull or verrucous surface with a "stuck-on" appearance. Typical locations include the face, upper extremities, and trunk. CAN ITCH OR NOT Explosive onset of multiple pruritic SKs (Leser-Trélat sign) has been associated with malignancies (especially lung and gastrointestinal tumors).

Question 980

Tto of seborreic dermatitis

Answer 980

reassurance, is a benign tumor If symptomatic or cause cosmetic problems cryotherapy or removed by curettage/shave excision or electrodessication

Question 981

tto of expanding neck hematoma- tracheal deviation, hoarseness

Answer 981

intubation

Question 982

malignant otiis media

Answer 982

purulent drainage, ear pain in diabetes/HIV | pseudomona

Question 983

Ramsay Hunt syndrome

Answer 983

(also known as herpes zoster oticus) | ear pain, external auditory vesicles, and ipsilateral facial paralysis.

Question 984

TTO OF MALIGNANT OTITIS EXTERNA

Answer 984

CIPROFLOXACIN IV and once ESR/CRP normalize can transition to oral. to complete 6-8 weeks of therapy is recommended. Other options: anti-pseudomonals: piperacilin, ticarcilin third generation cephalosporins: ceftazidime

Question 985

pt with prostate cancer and mestastasis to lumbar spine, in managementt with narcotics but still ver painful. no bladder/rectal incont or neuro abnorm. next step

Answer 985

External beam radiation therapy should be used for pain alleviation in patients with single or few focal bone metastatic lesions due to hormone-refractory prostate cancer. *surgery only indicated if neuro abn

Question 986

Woman 55 yo concerned about Colon Ca. Her sister was recently diagnosed. She is asymptomatic and had a colonoscopy 5 years ago which was normal.

Answer 986

a patient at average risk should have a repeat colonoscopy every 10 years.

Question 987

Patients at average risk colon cancer -screening

Answer 987

Start screening at age 50. Options include: ``` Colonoscopy every 10 years gFOBT or FIT every year FIT-DNA every 1-3 years CT colonography every 5 years Flexible sigmoidoscopy every 5 years (or every 10 years combined with annual FIT) ```

Question 988

Patients at risk colon cancer -screening

Answer 988

Colonoscopy at age 40 or 10 years before the age of cancer diagnosis in a relative (whichever comes first) Repeat every 3-5 years