7

Question 1

the development of clubbing and acute joint pain in a chronic smoker, think ?

Answer 1

hypertrophic osteoarthropathy

associated with lung cancer, get a CXR

Question 2

abx for human bite wounds

Answer 2

augmentin

clindamycin does not get G- (Eikenella) and ampicillin or cipro do not get anaerobes

Question 3

proptosis in Graves is caused by ?

Answer 3

orbital tissue expansion via T cell activation and stimulation of orbital fibroblasts by thyrotropin (TSH) receptor antibodies

Question 4

pseudogout finding on XR

Answer 4

chondrocalcinosis: calcification of articular cartilage

Question 5

1 cause of M/M in PAD patients

Answer 5

cardiovascular disease, i.e. MI

Question 6

veins that are the most common source of symptomatic PE

Answer 6

proximal deep leg veins: femoral, iliac, popliteal

Question 7

elevated prolactin, low TSH, T4, LH, testosterone, think ?

Answer 7

pituitary adenoma
in contrast, hyperprolactinemia caused by meds i.e. antipsychotics (risperdone) will not alter other hormone levels (D2 antagonist, don’t alter HPA axis)

Question 8

how to dx ankylosing spondylitis

Answer 8

XR of sacroiliac joints

HLA-B27 is not sn/sp

Question 9

how to manage a macroprolactinoma (10mm+)?

Answer 9

dopamine antagonists i.e. bromocriptine, cabergoline

use transphenoidal resection if 3cm+ or increases in size on tx

Question 10

tx of choice for Paget’s disease of bone

Answer 10

bisphosphonates

inhibit osteoclasts and suppress bone turnover

Question 11

suspect what in pts with flash pulmonary edema, rise in Cr 30%+, diffuse atheroslcerosis, asymmetric kidney size

Answer 11

renovascular HTN
may have abdominal bruit
may have onset after 55
likely resistant to 3+ antihypertensives

Question 12

intracranial bleed vs thrombotic vs embolic vs lacunar stroke

Answer 12

IC bleed symptoms progressively worsen +/- signs of ^ICP: vomiting, headache, loss of alertness, bradycardia
thrombotic symptoms fluctuate with periods of improvement
embolic symptoms are maximal at onset
lacunar: have severe focal neuro signs like bleed but no s/s of ^ICP

Question 13

thoracentesis is tx of choice in patients with pleural effusion except in cases of ?

Answer 13

obvious CHF: fluid overload, pedal edema, crackles b/l

do trial of diuretics

Question 14

how to manage pts with severe hyperthyroidism

Answer 14

medical tx first with methimazole or PTU and B-blocker, then radioactive iodine or thyroidectomy

Question 15

during what studies are exposure and outcome measured simultaneously

Answer 15

cross-sectional study

Question 16

CML LAP?

Answer 16

low leukocyte alkaline phosphatase score

Question 17

why is NaHCO3- used in TCA OD?

Answer 17

the increase in pH and extracellular sodium alleviate cardio-depressant action on sodium channels
TCA cardiac toxicity: prolonged QRS 100ms+, ventricular arrhythmias

Question 18

COPDers should get home O2 treatment if ?

Answer 18

PaO2 less than 55mHg or SaO2 is less than 88%

Question 19

immunosuppressed pt develops pneumonia with elevated LDH, think ?
how to dx?

Answer 19

PJP

dx with sputum microscopy with specialized stains; bronchoalveolar lavage if necessary

Question 20

how does type 4 RTA manifest? who is it seen in ?

Answer 20

hyperkalemia, non-anion gap metabolic acidosis, mild-mod renal insufficiency
seen in poorly controlled DM

Question 21

hydroxychloroquine SE

Answer 21

retinopathy

Question 22

initial tests to do in adrenal insufficiency

Answer 22

AM cortisol and ACTH stim test

Question 23

normal TSH, T4 with low T3

Answer 23

euthyroid “sick” syndrome

Question 24

skin ulcer associated with a chronic scar, think ?

what to do?

Answer 24

Squamous cell carcinoma; increased risk metastasis (Marjolin ulcer)
biopsy

Question 25

how to calculate Number Needed to Treat (NNT)

Answer 25

inverse of Absolute Risk Reduction i.e. if risk decreased from 16% (control) to 12% (case) 0.16-0.12 = 0.04 1/0.04 = 25 people NNT

Question 26

peripheral edema, ^JVP, hepatomegaly, ascites, think ?

Answer 26

constrictive pericarditis

Question 27

what pts should get a statin regardless of LDL levels

Answer 27

DM pts age 45-70

Question 28

what can cause idiopathic intracranial hypertension?

Answer 28

(besides being an obese female) | growth hormone, tetracyclines and vitamin A derivatives (isotretinoin)

Question 29

fatigue, arthralgias and porphyria cutanea tarda, think ?

Answer 29

Hepatitis C

Question 30

digitalis causes what cardiac effects leading to what EKG manifestations

Answer 30

ectopy and increased vagal tone leading to atrial tachycardia with AV block

Question 31

megaloblastic anemia, atrophic glossitis (shiny tongue), vitiligo, thyroid disease, neuro abnormalities in northern European think

Answer 31

pernicious anemia

Question 32

a common cause of Addison's disease (primary adrenal insufficiency) in endemic areas metabolic derangements

Answer 32

TB | non-anion gap metabolic acidosis and hyperkalemia

Question 33

cauda equina (spinal nerve roots) vs conus medullaris syndrome

Answer 33

``` cauda equina (nerves separated): typ. b/l, radicular pain, saddle anesthesia, asymmetric motor weakness, hypo/areflexia conus medullaris: sev. back pain, perianal anesthesia, symmetric motor weakness, hyperreflexia (UMN and LMN) ```

Question 34

tx of botulism

Answer 34

horse-derived antitoxin

Question 35

feature of low back pain that suggest an inflammatory cause | examples: ankylosing spondylitis, psoriatic arthritis, reactive arthritis, IBD-associated arthritis

Answer 35

gradual onset, younger than 40, pain at night that does not improve with rest, improvement with activity

Question 36

what site do immune mediated spondyloarthropathies affect

Answer 36

ligamentous insertions (enthesitis)

Question 37

tendency of study population to affect the outcome since they are aware they are being studied

Answer 37

Hawthorne effect

Question 38

deposition of calcium and phosphorus in the skin-->whitish papules, plaques, nodules

Answer 38

calcinosis cutis

Question 39

``` what is affected? chondrosarcoma OA Rheumatoid nodules Chronic tophaceous gout ```

Answer 39

chondrosarcoma: pelvis, femur, humerus OA: DIPs and PIPs Rheumatoid nodules: elbow, proximal ulna Chronic tophaceous gout: urate crystals can be deposited in skin, resulting in tumors with a chalky white appearance

Question 40

metabolic derangement in hyperaldosteronism

Answer 40

metabolic alkalosis ^aldo, decreased renin HTN, mild hypernatremia, hypokalemia

Question 41

thrombolytics in DVT?

Answer 41

reserved for hemodynamically unstable pts with PE, less commonly for massive proximal DVT with significant symptomatic swelling =/- limb ischemia

Question 42

alternative to warfarin in tx of acute DVT/PE

Answer 42

direct Xa inhibitors: rivaroxaban, apixaban | do NOT use in severely impaired renal function or DVT/PE secondary to malignancy

Question 43

immunocompromised pt with fever, pleuritic CP and hemoptysis think ?

Answer 43

invasive aspergillosis CT scan: pulmonary nodules with surrounding ground-glass opacities ("halo sign") tx: voriconazole and an echinocandin (caspofungin) (PJP rarely has hemoptysis or productive cough)

Question 44

small vs large nerve fiber injury

Answer 44

small: POSITIVE s/s: pain parenthesis, allodynia large: NEGATIVE s/s: numbness, loss of proprioception/vibration sense (ataxia, +Romberg), diminished ankle reflexes, weakness of intrinsic feet muscles (hammer toe deformity)

Question 45

progressive DOE and fatigue 2 weeks following MI

Answer 45

ventricular aneurysm

Question 46

what findings on EKG with ventricular aneurysm? (post-MI)

Answer 46

persistent ST-segment elevation PLUS deep Q waves

Question 47

what to do with PPD 8mm in asymptomatic HIV pt

Answer 47

greater than 5mm is positive, in absence of active TB symptoms, tx with 9 months INH and pyridoxine if CD4+ less than 200 may have false negative

Question 48

acid-base disturbance in ASA toxicity

Answer 48

``` low PaCO2 (resp. alkalosis), low HCO3- (metabolic acidosis) pH typically in the NORMAL range due to mixed picture eventually metabolic acidosis will predominate if untreated ```

Question 49

tx of neutropenic fever

Answer 49

anti-pseudomonal agents: cefepime, meropenem, pip-tazo (zosyn)

Question 50

SOB, productive cough, destruction of lower lung lobes (decreased breath sounds, basilar lucency on CXR), think ?

Answer 50

alpha-1 antitrypsin deficiency panacimar emphysema results in greater destruction of lower lobes (consider in younger patient, minimal smoking hx, basilar COPD, unexplained liver disease)