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9 TIME Flashcards

1
Q

Where is the problem in primary adrenal insufficiency? what are the hormone levels?and what changes in electrolytes and renin do these cause?

A

most common cause is autoimmune.. primary adrenal insufficiency = injury to all 3 layers of the adrenal cortex!! (zona glomerulosa, fasciculata, and reticularis)
so patients have LOW cortisol (fatigue, loss of appetite, wt loss), LOW aldosterone (orthostatic hypotension), and LOW androgens (low libido in women), which leads to HIGH ACTH (hyperpigmentation)
Hyperkalemia, hyponatremia, and Elevated plasma renin activity (in response to low aldosterone)
**pts require replacement of both glucocorticoid (with hydrocortisone) and mineralocorticoid (with fludrocortisone)

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2
Q

what should you suspect in pts who develop fever, n/v, and vague abdominal pain 2-10 days after laparoscopic cholecystectomy? lab studies may show leukocytosis, elevated alk phos and mildly elevated bilirubin, with normal-appearing bile ducts on imaging.

A

Bile leaks

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3
Q

soon after birth, an child presents with an isolated patch of telangiectasias that proliferates into a bright red, raised nodule that increases in size over the course of a year. What is this? what is management for it?

A

Infantile hemangioma
Observation!!!!
-they typically involute and regress over subsequent years, during which they may appear patchy and deeper red-to-violet in color

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4
Q

what is treatment for bulimia nervosa?

A

SSRI (fluoxetine)!!! 1st line tx!!!
nutritional rehabilitation
cognitive-behavioral therapy

there is little evidence to support the use of pharmacotherapy as primary tx for anorexia nervosa

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5
Q

a new left bundle branch block on ECG is suggestive of what?

A

an acute MI

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6
Q

MI can lead to left ventricular systolic dysfunction and cardiogenic shock. Describe what effect this has on preload, cardiac output, and afterload.

A

cardiogenic shock:

  • preload INCREASED (RA pressure or PCWP)
  • Cardiac output DECREASED (stroke volume x HR = CO, pump function measured by cardiac index)
  • afterload INCREASED (systemic vascular resistance)
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7
Q

how does Candida appear on KOH prep?

A

Pseudohyphae with budding yeast forms (blastoconidia)

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8
Q

How should gout be treated in pts taking anticoagulants (eg, aspiring, clopidogrel, apixaban)?

A

Colchicine and/or glucocorticoids
**NSAIDs (eg, indomethacin) are contraindicated due to increased risk of bleeding in pts on anticoagulants
(also contraindicated in pts with renal failure)

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9
Q

how do you manage a pt with a threatened abortion?

A

threatened abortion = vaginal bleeding, closed cervical os, and fetal cardiac activity present

Manage expectantly with outpatient observation – serial Ultrasounds can be performed until either symptoms resolve or their is progression to complete abortion

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10
Q

how does ocular rosacea present?

A

can involve the cornea, conjunctiva, and lids and causes burning or foreign body sensation, blepharitis, keratitis, conjunctivitis, corneal ulcers, and recurrent chalazia
symptoms may or may not be concurrent with skin findings

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11
Q

is folic acid a vitamin?

A

Yes! Vitamin B9 is folate :)

fyi, anticonvulsants, like carbamazepine, can cause low folic acid levels (supplement w/ 4mg folic acid daily in pregnancy in pts taking it)

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12
Q

uncontrolled HTN and use of crack cocaine increase the risk of hypertensive vasculopathy, the most common cuase of spontaneous intracranial hemorrhage. what is the most common site of hemorrhage? if pt develops symptoms such as a dilated, nonreactive ipsilateral pupil and contralateral extensor posturing, what do you suspect has occurred?

A

Basal ganglia

Uncal herniation! - a potential consequence of basal ganglia hemorrhage

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13
Q

what analgesic medication has serotonergic activity and can precipitate serotonin syndrome if taken in conjunction with SSRIs/SNRIs?

A

tramadol

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14
Q

What is the classic triad of Serotonin syndrome?

A 
Mental status changes (anxiety, restlessness, agitated delirium)
Autonomic dysregulation (diaphoresis, tachycardia, HTN, hyperthermia)
Neuromuscular hyperactivity (hyperreflexia, tremor, rigidity, *myoclonus, *ocular clonus [slow, continuous, horizontal eye movements], b/l Babinski signs)

there are also serotonin receptors in the gut, resulting in hyperactive bowel sounds and diarrhea

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15
Q

an individual living in close contact (eg, school-going, military recruit) has symptoms of headache, malaise, sore throat, and cough for a week. labs show a subclinical hemolytic anemia (cold agglutinins), and CXR shows interstitial infiltrates (diffuse reticulonodular opacities). What do you suspect and what is empiric treatment?

A

Mycoplasma pneumoniae – causing an atypical pneumonia

empiric tx = Azithromycin (or a respiratory fluoroquinolone)

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16
Q

what pre-op intervention significantly reduces the post-op incidence of atelectasis and pneumonia and shortens the length of postop hospital stay in pts undergoing elective cardiac surgery?

A

preoperative physical therapy

smoking cessation is also helpful, but benefit may only be present when smoking is stopped >8 weeks prior to surgery

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17
Q

pt recently traveled to a developing country and developed diarrhea, bloody stool, and abdominal pain. what do you suspect and how do you dx and tx it?

A

Entamoeba histolytica
Dx with Stool microscopy for oval and parasites (for cysts or trophozoites) or with stool E histolytica antigen testing
Tx = Metronidazole and an intraluminal antibiotic (paromomycin)

*Pts may also have a liver abscess (RUQ pain, fever)

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18
Q

What is Thromboangiitis obliterans (Buerger disease)?

A

it is a nonatherosclerotic, inflammatory, vaso-occlusive disorder of small and medium-sized vessels that leads to ischemic ulcers and gangrene (usually of the distal lower extremities)
**seen in heavy smokers! pts age < 45
Tx = complete smoking cessation

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19
Q

what is the diagnostic criteria for bipolar II disorder?

A

it requires at least 1 episode of hypomania and 1 episode of major depression

In a Hypomanic episode; symptoms are less severe, lasts for 4 or more consecutive days, unequivocal, observable change in functioning from pts baseline, symptoms are not severe enough to cause marked impairment or necessitate hospitalization, no psychotic features

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20
Q

What is the Fetal Fibronectin test? what does it mean if it’s positive?

A

this test is used to determine whether a pt at < 34 weeks gestation w/ regular uterine contractions and no cervical change is in preterm labor
(FFN is a protein found at the interface of the chorion and decidua; contraction disrupt this interface and release FFN into vaginal secretions)
a POSITIVE FFN test is a STRONG PREDICTOR OF DELIVERY within the next week and an indication for administration of antenatal CORTICOSTEROIDS (eg, BETAMETHASONE)

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21
Q

What neoplasm is associated with Lambert-Eaton myasthenic syndrome and what imaging should you get to evaluate for it?

A

Small cell lung carcinoma
Individuals with risk factors for lung cancer (eg, smoking) should receive a Chest CT scan
*remember LEMS is muscle weakness caused by Abs against presynaptic voltage-gated Ca channels; isometric muscular contraction leads to increased strength and reappearance of reflexes

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22
Q

how do pts with Dementia with Lewy bodies typically present?

A

present with progressive dementia (usually before the onset of parkinsonism) with FLUCTUATING COGNITION/ATTENTION (eg, “good days and bad days”), well-formed visual hallucinations, and motor manifestations of parkinsonism (eg, rigidity, bradykinesia, POSTURAL INSTABILITY), which may lead to frequent falls
Deficits in attention and visual-spatial ability (clock drawing, navigating a familiar neighborhood) may be prominent early in the dz course; however, in contrast to Alzheimer dementia, memory is usually affected later

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23
Q

Ventricular aneurysm may occur as a late complication, up to 3 months after an acute ST segment elevation MI. What is present in up to 50% of pts with left ventricular aneurysm that can cause further complications?

A

a mural thrombus – systemic embolization of the thrombus can lead to acute arterial occlusion (Stroke, Mesenteric ischemia, and Acute upper or lower extremity ischemia)

*progressive LV enlargement and remodeling may also lead to mitral annular dilation with mitral regurgitation

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24
Q

what are the symptoms of vitamin C deficiency (scurvy) and what is a well known complication?

A

petechial and perifollicular hemorrhages, corkscrew hair, mucosal bleeding, and periodontal disease
symptoms are the result of decreased connective tissue strength, which can lead to fragility of capillary walls and POOR WOUND HEALING

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25
Q

a pt with untreated HIV has several months of anal pain and bleeding with evidence of an anal ulcer and painless LAD. what is this?

A

Anal cancer

  • develops primarily from squamous epithelial cells due to HPV infection
  • risk is greatest in men who have receptive anal intercourse and those with advanced HIV!
  • rectal bleeding is the most common manifestation, also common to have anal pain and/or a sensation of anal pressure
26
Q

What are contraindications for the copper IUD?

A

Wilson Disease
Copper allergy
HEAVY MENSTRUAL BLEEDING
acute pelvic infection

27
Q

When you suspect acute Mastoiditis, how do you treat it?

A

IV antibiotics!!! (must cover for pseudomonas if there is a hx of recent Abx use)
Drainage of the purulent material is also required

**can be diagnosed clinically in most cases!!! if the dx is uncertain – CT scan or MRI w/ contrast

28
Q

In antiphospholipid syndrome, will PTT and PT be prolonged or normal?

A 
Prothrombin (PT) time is normal.
PARTIAL THROMBOPLASTIN (PTT) TIME IS PROLONGED!*** (even though antiphospholipid syndrome is associated with thrombosis) -- this is likely due to binding of phospholipid reagents in the assay by antiphospholipid antibodies (lupus anticoagulant) -- mixing of pt plasma containing lupus anticoagulant with normal plasma will not correct the PTT (in contrast to pts with clotting factor deficiencies, in which the addition of normal plasma will supply the necessary factors to normalize the assay).

**APL syndrome = prolong PTT time (both 3 letters)

29
Q

what is the most common dermal sign of antiphospholipid syndrome?

A

Livedo reticularis

- a transient red or purplish, blotchy or latticelike rash that primarily affects the lower extremities

30
Q

an HIV positive woman presents with lower back pain, a hx of irregular periods and occasional spotting, and a CT scan reveals a lower uterine segment mass with associated hydronephrosis. what is this?

A

advanged-stage CERVICAL CANCER

  • early symptoms = irregular vaginal bleeding and postcoital spotting due to bleeding from the cervical lesion itself
  • as the tumor extends laterally through the parametrium and pelvis (low back pain), it can lead to obstruction of the surround blood vessels and lymphatics (lymphedema) and ureters (hydronephrosis)
  • *cervical cancer is an AIDS-defining illness
31
Q

What is a favorable prognostic factor in pts with schizophrenia, and why?

A

Positive psychotic symptoms (hallucinations, delusions) are a favorable prognostic factor because antipsychotics are more effective for treating positive psychotic symptoms

32
Q

lack of placental delivery 30 minutes after fetal delivery and excessive vaginal bleeding are hallmarks of what?

A

postpartum hemorrhage due to a RETAINED PLACENTA – this can prevent adequate myometrial contraction and cause hemorrhage
retained products of conception = the presence of residual fetal and/or placental tissue in the uterus after an abortion (spontaneous or elective) or term/preterm birth

Risk factors for retained placenta = gestational age 24-27 weeks and stillbirth

33
Q

how does Chronic bursitis (such as olecranon bursitis) present?

A

soft, rounded, well-demarcated swelling at the point of the elbow (can be huge!)
it is caused by pressure, friction, overuse, or autoimmune dz (RA)
overproduction of bursa fluid over time produces an enlarged, soft bursal sac, which can be easily visible in superficial bursae such as the olecranon bursa – the joint will have relatively normal, PAIN-FREE range of motion
*in contrast to acute bursitis due to trauma or crystalline arthropathy that can generate significant pain

34
Q

what does initial medical management of osteoarthritis consist of?

A

weight loss, regular moderate activity, and simple analgesics.
EXERCISE TO STRENGTHEN THE QUADRICEPS MUSCLE can reduce abnormal loading on the joint and protect the articular cartilage from further stress

35
Q

what is a chalazion?

A

a granulomatous reaction to a blocked meibomian tear gland
it is characterized by eyelid swelling and erythema that progress to a solitary (usually PAINLESS), rubbery, nodular lesion
often resolve spontaneously, but warm compresses can enhance drainage and speed healing

*in contrast to a hordeolum, an acute inflammatory nodule arising from an elelash follicle (external hordeolum[stye!]) or from a meibomian gland under the eyelid (internal hordeolum) – usually caused by Staph aurus, and usually Painful! and tends to develop closer to the lid margin.

36
Q

what is the cause of pulmonary HTN in pts with left heart disease (such as left ventricular systolic or diastolic dysfunction, mitral or aortic valve disease, and congenital cardiomyopathies)?

A

pulmonary HTN in these pts is due to elevated left atrial and ELEVATED PULMONARY VENOUS PRESSURES! (pulmonary venous HTN)

37
Q

What are risk factors for hyperemesis gravidarum (besides previous HG)?
if a pt presents with symptoms of HG and their LMP was 8 weeks ago, and bimanual exam reveals a 12-week-size uterus, what should your next step in evaluation be?

A

multifetal gestation and hydatidiform mole

Pelvic ultrasound! – to evaluate the pregnancy (bc a greater than expected uterine size suggests a multifetal gestation or hydatidiform mole)

38
Q

how does a post-op incisional hematoma present? what are risk factors for this to occur?

A

serosanguineous drainage and incisional pain = incisional hematoma (abnormal collection of blood at the incision site often due to inadequate surgical hemostasis)
Risk factors = obesity and hypocoagulability (eg, anticoagulation, coagulopathy)

**in contrast to FAscial dehiscence, which presents with a “popping” sensation followed by Copious serosanguineous drainage and an incisional bulge

39
Q

What is the gold standard for investigating a new palpable breast mass in a postmenopausal pt?

A

Diagnostic MAMMOGRAPHY!!! (even if a recent screening mammogram was negative)

***This should be done before an US.. US may not even be needed! If mammogram is suggestive of malignancy (eg, calcifications), a Biopsy must be performed!

40
Q

pts in whom a tx plan is selected based on the severity of their condition may have a worse outcome due to what bias, rather than due to the treatment itself?

A

Selection bias!

-this particular type of selection bias is called susceptibility bias

41
Q

uncontrolled maternal hyperglycemia leads to fetal hyperinsulinemia and may result in a large for gestational age (LGA) infant. these infants have what potential complications?

A

hypoglycemia
hypocalcemia
POLYCYTHEMIA!! (the fetus is in constant anabolism and the placenta is unable to meet the increased metabolic demands, leading to fetal hypoxemia. in an attempt to increase the oxygen-carrying capacity of RBCs, increased EPO production causes polycythemia)

42
Q

what is DRESS syndrome? what drugs can cause it and how is it treated?

A
  • D*rug – most commonly ALLOPURINOL and antiepileptics (phenytoin, carbamazepine)
  • R*eaction (Rash) – morbilliform eruption that starts on the face/upper trunk and becomes diffuse and confluent; facial edema is also common
  • E*osinophilia!!!
  • S*ystemic Symptoms – fever, malaise, and diffuse LAD… most pts also have involvement of 1 or more organ systems (Liver [transaminitis], kidney, lung)

DRESS syndrome has an unusually long latency period, it may take 2-8weeks from drug initiation to see manifestation of symptoms
Tx = IMMEDIATE CESSATION OF THE INCITING DRUG and supportive care

43
Q

pt recently had an orthopedic surgery and now has abdominal pain, distension, and n/v. A CT scan reveals colonic dilation (cecum and ascending colon) with oral contrast visualized throughout the colon, suggesting no anatomic obstruction. what is this?

A

Acute colonic pseudo-obstruction (Ogilvie syndrome)

more common in men > 60, usually presents 3-7 days after surgery. predisposing conditions = nonoperative trauma, severe illness, and surgery, particularly in combo w/ metabolic abnormalities (eg, hypokalemia) or medication administration (eg, opioids)

44
Q

what is the dominant species of malaria outside of Africa? and what is unique about it that requires two drugs to treat (and what are those drugs)?

A

Plasmodium vivax is the dominant species outside of Africa – it has a DORMANT HEPATIC PHASE that may cause recurrent parasitemia weeks or months after initial infection!
Tx requires combination of antimalarial drugs that target both the erythrocyte phase (CHLOROQUINE) and the dormant hepatic phase (PRIMAQUINE!!)

45
Q

pt had a spontaneous abortion less than 6 months ago, and now presents with abnormal uterine bleeding/amenorrhea, pelvic pressure, an enlarged uterus, and a friable (vascular) vaginal lesion. This is concerning for what?

A

Choriocarcinoma!! – a type of gestational trophoblastic neoplasia (GTN)

  • -most commonly develops after a complete hydatidiform mole but can follow any type of pregnancy (including a spontaneous abortion)
  • -most aggressive type of GTN and is characterized by rapid metastases, most commonly to the lungs and VAGINA
  • -symptoms of vaginal mets = bloody or purulent vaginal discharge*
46
Q

what is sarcoma botryoides?

A

aka embryonal rhabdomyosarcoma
typically presents in infancy and early childhood as non-friable nodules protruding from the vagina that have an appearance resembling a cluster of grapes

47
Q

what causes translocational hyponatremia?

A

high serum osmolality (hypertonic hyponatremia) – a shift of fluid from the intracellular to the extracellular spaces occurs due to an excess of an osmotically active substance in the bloodstream, like glucose!

48
Q

If you suspect coarctation of the aorta in a young pt with brachial-femoral pulse delay (strongly suggestive!), HTN with a hx of frequent headaches, and a cardiac exam that reveals a sustained apical impulse (due to LV hypertrophy), what study is appropriate to get next, and will make the diagnosis?

A

Echocardiogram!!!

*pts with coarctation of the aorta may also have a systolic or continuous murmur best heard in the left interscapular area

49
Q

what are the nail findings assocaited with psoriasis?

A 
distal onycholysis (distal separation of the nail plate from the nail bed)
nail pitting (focal areas of abnormal keratinization of the nail plate)
50
Q

Microscopic colitis is characterized by watery and nocturnal diarrhea, fecal urgency, and incontinence. Risk factors include age > 50, female sex, smoking, and possibly NSAID use. what does colonoscopy typically show?

A

biopsy reveals inflammatory infiltrates with monocytic predominance
(the bowel mucosa is macroscopically normal)

51
Q

an older pt with a previous hx of chemo/radiation presents with fatigue and weakness. PE shows scattered ecchymoses, there is NO hepatosplenomegaly or LAD present. labs shows a normocytic/macrocytic anemia with insufficient reticulocytosis. Leukopenia with immature neutrophil precursors and thrombocytopenia. peripheral blood smear shows dysplastic erythrocytes (ovalomacrocytosis) and granulocytes (reduced segmentation and decreased granulation of neutrophils). what is this?

A

Myelodysplastic syndrome

*Bone marrow biopsy is required for diagnosis, and shows hypercellular marrow
Tx = transfusions, chemo, and stem cell transplant

52
Q

a cirrhotic with recurrent hepatic encephalopathy is already taking an appropriate amount of lactulose to reduce her serum ammonia levels. What would be the most appropriate next step to lower serum ammonia levels?

A

add a nonabsorbable antibiotic – RIFAXIMIN!

Antibiotics are thought to act by decreasing ammonia-producing bacteria in the colon

53
Q

what is the area of the aortic valve when aortic stenosis typically is considered “Severe,” and becomes symptomatic (exertional dyspnea, angina, presyncope/syncope)?

A

aortic valve area < 1 cm^2

pts with severe symptomatic aortic stenosis should be referred for aortic valve replacement

54
Q

what is the cause of testicular torsion?

A

caused by twisting of the spermatic cord due to INADEQUATE FIXATION of the lower pole of the testis to the tunica vaginalis – this leads to compression of the pampiniform plexus of the testicular vein and reduced venous outflow

55
Q

In SIADH, what is the serum osmolality, urine osmolality, and urine Na excretion?

A

LOW serum osmolality (<275)
HIGH urine osmolality (>100)
HIGH urine Na excretion (>40)

hyponatremia due to SIADH is characterized by serum hypotonicity, inappropriately high urine osmolality, and euvolemia (eg, moist mucous membranes, absence of peripheral edema). the urine Na concentration is typically high bc the kidneys do not aggressively retain Na in the setting of euvolemia.

56
Q

what is the cause of uric acid kidney stone formation in a patient with chronic diarrhea?

A

chronic diarrhea leads to GI losses of bicarbonate and water, which results in making the urine acidic and hyperconcentrated – this promotes the formation of uric acid stones

management of uric acid stones involves urine alkalinizaton with K+ bicarb or K+ citrate

57
Q

acute PE may present with syncope… what is the reason for syncope?

A

right ventricular dysfunction and sudden loss of CO
cardiac arrhythmia induced by RV strain and ischemia
or vasovagal response

*massive PE can lead to sudden occlusion of >50% of the pulmonary arterial circulation, causing a rapid increase in pulmonary vascular resistance and right ventricular pressure load

58
Q

what causes ~85% of malignant cavitary lung lesions?

A

Squamous cell lung carcinoma!

59
Q

what changes occur with thyroid hormones and binding globulins in pregnancy and why?

A

Thyroid hormone production increases during pregnancy to cope with metabolic demands. 2 mechanisms:

  1. ESTROGEN stimulates synthesis of TBG and decreases TBG clearance (ELEVATED TBG), leading to an increased pool of bound thyroid hormone. pts w/ . normal thyroid reserve subsequently INCREASE THYROID HORMONE PRODUCTION to maintain FREE hormone levels
  2. beta-hCG (which shares a common alpha subunit with TSH and a very similar beta subunit) directly stimulates TSH receptors. this results in INCREASED THYROID HORMONE PRODUCTION and feedback that DECREASES PITUITARY TSH RELEASE

net effect = increased total T3 and T4, normal/mildly elevated free T4, and decreased TSH

60
Q

pt has a severe, sudden-onset, generalized headache that became unbearable in seconds. her vision became blurry, which caused her to stumble and almost fall. what’s the best next step?

A

noncontrast CT scan of the head!

sounds like a subarachnoid hemorrhage

61
Q

Describe Direct inguinal hernias. and who are they most common in?

A

Direct inguinal hernias are due to WEAKNESS OF TRANSVERSALIS FASCIA (inguinal canal floor)
contents protrude through Hesselbach triangle; and travel medial to inferior epigastric vessels
most commonly occur in older men

62
Q

how do you treat condylomata acuminata? specifically what is first-line tx in pregnancy?

A

aka genital warts
first line tx in pregnancy = topical TRICHLOROACETIC ACID
(liquid nitrogen, laser ablation, and electrocautery may also be used during pregnancy)

Imiquimod and podophyllin resin may be used in normal people, but are CONTRAINDICATED IN PREGNANCY due to potential teratogenicity

Step 2 CK (9 decks)

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