All COMLEX STEP 2 Q's Flashcards
What are Head CT findings in a 45 year old caucasian male w frequent sudden jerky movements of upper extremities. Irritability, does not visit family/friends, decline in professional performance. Father died in nursing home w similar symptoms.
What is tx for motor sx?
Huntington’s chorea - Atrophy of caudate nucleus
Tx for motor sx: Tetrabenazine
–“orphan drug” - only indication is huntington’s
What is dx?
Skin rash, joint pain, malaise, fatigue, hx of IV drugs, palpable purpura, hepatosplenomegaly
Urinalysis: hematuria, rbc casts, proteinuria
Serum: low complement, positive Anti-HCV
Mixed essential cryoglobinemia - palpable purpura, proteinuria, hematuria
- cryoglobinemia - protein ppt in refrigerated serum+plasma
- –palpable purpura, arthralgia, myalgia (small-medium vasculitis)
a/w hep C
what is the LDL goal in a patient with CAD? What is the normal
LDL < 100 mg/dL in CAD
100 - 129 in healthy pts
what are pathological q waves (what does it mean? how can you tell it’s pathological?)
Prior MI
Width > 1mm (1 small box)
depth >25% of QRS complex
What ECG findings are in a positive exercise stress test?
what other findings indicate a positive stress test?
ST segment depression = subendocardial ischemia
Decreased Thallium 201 (Dipyridamole) uptake, CP, Hypotension, Arrhythmias
What is the standard of care for Stable Angina?
Aspirin + B-blocker, nitrates for CP
How are Unstable angina and NSTEMI differentiated? How are they similar?
no elevated troponin or CK-MD in Unstable angina
both do not have elevated ST segments or pathological Q waves
What is the medical management of Unstable Angina?
Aspirin, Clopidogrel, B-blockers, LMWH (Enoxaparin), Nitrates, O2
What electrolyte abnormalities are often seen in unstable angina?
Hypokalemia
Hypomagnesemia
In what case can Troponin I be falsely elevated?
Renal failure
When do Troponin levels peak and return to normal levels?
increase within 3 to 5 hours
peak in 24 to 48 hours
returns to normal in 5 to 14 days
When do CK-MB levels peak and return to normal. How often should they be measured?
peaks in 24 hours
returns to normal in 48 to 72 hours
measured upon admission and taken every 8 hours for the next 24 hours
Which are the only agents shown to reduce mortality in MI?
Aspirin
B-blockers
ACE-i
What is Dx?
Pt w pmh of MI few months ago presents w fever, malaise, pericarditis, leukocytosis, pleuritis
what is Tx?
Dressler’s syndrome (immuno dz)
Tx: Aspirin, second line: Ibuprofen
What is most likely Dx:
Ovarian US - mass with thick septations, solid components, peritoneal free fluid
Ovarian malignancy
elevated CA-125
How is Hemothorax differentiated from Pulmonary contusion in a trauma patient?
Hemothorax - CXR shows PLEURAL EFFUSION
Pulmonary contusion - CXR shows ALVEOLAR OPACITIES
What is the probable cause of easy bruising/epistaxis in a cystic fibrosis patient? What will be found at decreased levels
Vitamin K:
Factors II, VII, IX, X, C, S
Increased PT, INR Normal PTT (unless severe deficiency)
What is the initial Tx of most symptomatic Systolic CHF patients?
ACEi + Diuretic (Furosemide or HCTZ)
ACEi - reduce mortality
Hyponatremia in CHF patients parallels severity of HF
What is the most common cause of death in CHF?
sudden death from Ventricular arrhythmias
–Ischemia provokes ventricular arrhythmias
Which medications are contraindicated in patients with CHF? (4)
- Metformin - can cause lethal lactic acidosis
- TZD’s (pioglitazone)- fluid retention
- NSAIDs - risk of CHF exacerbation
- Negative inotropic antiarrhythmics (Diltiazem, Verapamil, etc)
How is diastolic CHF managed? what should not be used?
B-blockers
Diuretics (lasix)
ACEi
should NOT: Digoxin, Spironolactone,
What is the most common cardiac manifestation of Marfan’s syndrome?
second?
- Mitral Valve prolapse
2. Aortic Root dilatation
What is the CHA2DS2-VASc Score?
Congestive Heart Failure Hypertension Her (female) Age >75 - 2 points Diabetes Mellitus Stroke Hx Vascular dz hx Age 65-74 - 1 point
What should the height and weight be of a 12 month old child relative to their birth weight and height?
weight should triple
height should increase by 50%
What are pediatric symptoms of DiGeorge Syndrome?
22q11.2 deletion
- Conotruncal heart defect (ToF, Truncus arteriosus, VSD, interrupted aortic arch)
- Hypocalcemia (muscle twitches)
- Cleft palate
- immunodeficiency
- renal abnormalities
- hypoplasia of thymus
Dx of 3 week old?
- large fontanelles
- poor feeding, decreased activity
- decreased stooling
- macroglossia
Congenital hypothyroidism
poor growth, dev delay, dry skin, hypotonia
What is dx in 3 month old male?
thrombocytopenia (hematochezia, melena, epistaxis), eczema, immunodeficiency
Wiskott- Aldrich (X-linked defect of WAsp gene)
–involved w cytoskeleton remodeling
tx: supportive, IVIG, steroids, platelet transfusions
* *Hematopoietic stem cell transplantation
What are complications of a twin-to-twin transfusion syndrome in monochorionic twins?
donor twin - hypovolemia, anemia, oligohydramnios (fetus appears stuck to uterine wall), small of gestational age
recipient twin - hypervolemia, plethora, polyhydramnios, CHF, JAUNDICE (excess rbc’s)
What is dx: sensorimotor neuropathy w stocking-glove distribution painful hypersensitivity, hyporeflexia hypo and hyper pigmentation of skin hyperkeratosis of palms and sole
Labs: anemia, elevated AST, ALT
what is the management?
Arsenic Poisoning
Tx: Dimercaprol, DMSA
What are the following reflexes:
- C5
- C6
- C7
- L4
- S1
- Biceps
- Brachioradialis
- Triceps
- Patellar
- Achilles
What are some ways you can differentiate Squamous Cell Ca with Basal Cell Ca
SCC: ulcerated, occurs more commonly in IMMUNOSUPPRESSED pts, NEURO invasion (Sx)
What is the next best step in management for:
- large burn that is black, dry, numb
- superficial, partial thickness burn
- immediate excision, skin grafting
2. silver sulfadizine, triple abx
Cirrhosis pt w ascites, 102 fever, Paracentesis shows pmn leukocyte count 350/mm^3
What is most appropriate management?
3rd gen cephalosporin (Cefotaxime)
Spontaneous bacterial peritonitis (SBP) - PMN count >250/mm^3
Pt w 2 week cough followed by vomiting or sweating. 99.3, normal cxr, leukocytosis
- what is dx, management?
- what is second line?
- Bordetella pertussis (whoop) - Azithromycin/macrolides
2. TMP-SMX - if pt allergic to macolides
What is the management of scabies?
Permethrin 5% cream applied to the neck down
or Oral Ivermectin
What is organism/tx?
profuse watery diarrhea, fevers, abd tenderness
stool culture: H2S negative, nonmobile, non-lactose-fermenting bacteria
Shigella - negative: motility, H2S, lactose fermentation
Tx: Ciprofloxacin, Azithromycin, Ceftriaxone
What empiric abx should be given to a CF child with a concurrent influenza infection and recurrent skin infections?
Vancomycin
–S. aureus is most common pathogenic organism in young children w CF
What time period should pt respond to antidepressants before switching meds?
what additional med can be added as augmentation?
8 weeks - lithium can be added
also - aripiprazole, olanzepine, quetiapine, etc
What tests should be run before prescribing lithium to a 29 year old female?
BUN
Cr
Thyroid fxn studies
pregnancy test
What is the first line treatment for OCD?
Cognitive Behavioral Therapy = Most effective
Paroxetine (SSRI) = first line medication
A schizophrenic on high doses of lithium and risperidone develops tardive dyskinesia. what is the next best step?
Switch to clozapine if pt is symptomatic with dosage reduction.
Which muscles should muscle energy be directed for the following ribs?
- first rib
- second rib
- 3-5
- 6-9
- 10-11
- Anterior Scalene
- Posterior Scalene
- Pec Minor
- Serratus Anterior
- Lat Dorsi
How is a Serum Ascites Albumin gradient interpreted?
Paracentesis
SAAG > 1.1 = portal hypertension is extremely likely to be cause of ascites (ie CHF)
What is most likely dx/affected structure:
Weightloss, cheilitis, hyperglycemia, elevated serum glucagon, decreased amino acids
Glucagonoma - pancreatic alpha cells
amino acids are reduced from gluconeogenesis from amino acids
US/CT scan
Sx relief - octreotide
What is the genetic disorder involved with Familial adenomatous polyposis?
when should screening begin in pts w a fam hx of FAP?
Autosomal dominant mutation in the tumor suppressor gene, APC, located on chromosome 5
Flexible sigmoidoscopy or Colonoscopy starting at PUBERTY
What is likely dx?
60 yr old w hoarseness, firm solitary nodule in thyroid gland, cervical lymphadenopathy
labs show elevated calcitonin
Medullary thyroid carcinoma - originates from parafollicular cells (C cells)
What endocrine disorder shows
low calcium
elevated phosphate
elevated PTH?
what is associated dx? how to differentiate?
Pseudohypoparathyroidism - target organ resistance to PTH
a/w
- Renal failure
- Albrights hereditary osteodystrophy (bone deformation)
what is the next best step in treatment for an afib pt who overdosed on their meds. INR level is 10.1
Vitamin K replacement
(II, VII, IX, X, C, S)
use Fresh Frozen Plasma if there is active bleeding
When is MATERNAL AFP measured? what is it used to determine?
What is the workup for elevated AFP?
15-20 weeks - detect open neural tube defects, multiple gestations, abdominal wall defects
–US
then amniocentesis for AFP, Acetylcholinesterase activity
What is the treatment choice for endometriosis?
NSAIDs + OCP
what is most likely dx:
17 year old w US findings of 8cm ovarian cyst w calcifications and hyperechoic nodules
what are pt’s at higher risk for?
Cystic Teratoma = Dermoid Ovarian Cyst
Ovarian Torsion
What is dx?
Fever, flank/abdominal pain, weight loss, generalized muscle ache, foot drop. lacy, red rash on extremities. arthralgia
elevated ESR, leukocytosis, Hep B Ag, proteinuria, elevated serum Cr.
Polyarteritis nodosa - systemic, abd pain, neuro, cardiac dz (chf, htn, arrhythmias), skin rashes
—vasculitis that affects small-medium vessels
-Strong association with Hep B*
which structure is at risk in a fracture of the humeral shaft?
Radial N (lies in radial groove) --wrist drop, extensor weakness, paresthesia on back of the hand.
What are electrolyte/hormonal serum findings in: (4)
55 year old smoker w 3 day hx of hematuria, fever, left flank pain. palpable flank mass. US reveals localized renal mass.
Renal cell Ca paraneoplastic syndromes:
- Polycythemia (increased EPO)
- Cushing’s
- HTN (increased renin)
- Hypercalcemia (PTH-like hormone)
What are withdrawal Sx of:
- cocaine
- opioids
- dysphoria, excessive sleep, hunger
2. Rhinorrhea, lacrimation, yawning, abdominal/leg cramping. piloerection, nausea, vomiting, diarrhea, dilated pupils
28 year old R breast mass. no fam hx. mass is 2cm, nontender, mobile, firm in RUQ.
- which test should be ordered?
- most appropriate diagnostic modality?
- next best step?
Fibroadenoma
- Ultrasound
- Fine needle biopsy/aspiration
- observe for 1 menstrual cycle
What are sx of spondylolisthesis
Anterior displacement of a vertebrae:
low back pain
waddling gait
tight hamstrings
What of Sx of cauda equina syndrome?
Sciatica Low back pain decreased DTR Saddle anesthesia bladder/bowel dysfunction motor/sensory deficits
Whens should colonoscopies begin i pts with Lynch syndrome (Hereditary non-polyposis colorectal cancer)
every 1 to 2 years beginning at 20-25 or
10 years prior to the earliest colorectal cancer dx in the family
HNPCC: colorectal, ovarian, gastric, biliary tract, brain, prostate, skin, ENDOMETRIAL
What are 4 manifestations of MEN Type IIB
- Marfanoid body habitus
- pheochromocytoma
- Medullary thyroid carcinoma
- Mucosal neuromas (ie tumor of the tongue)
How do you calculate Number needed to treat from Absolute risk reduction?
NNT = 1/ARR
What is the most common sequela after bacterial meningitis?
sensorineural hearing loss - children should be followed up with audiometry
other less common sequela: seizures, cranial N palsies, cognitive deficits, ataxia
Which STI is associated with Nephropathy w renal bx showing IgG and C3 deposits at basement membrane w a spike-dome appearance?
Syphilis - Membranous Glomerulonephritis HBV HCV malaria malignancy SLE gold salts penicillamine
Tx: prednisone
What is the management of Torsades de pointes in:
- unstable pts
- stable and conscious pts
- defibrillation
2. IV magnesium
what is the treatment for post partum endometritis
Clindamycin + Gentamicin
-ampicillin
how is an exhalation dysfunction of rib 5 treated with muscle energy?
pt lays supine ipsilateral hand on forehead grab key rib angle posteriorly pt holds breath in full inhalation + push ipsilateral elbow towards contralat ASIS Raise key rib (push inf on rib angle)
Where would a chapman’s point be found in a pt with colon cancer?
ANTERIOR iliotibial band
What is dx?
Seizure, fatigue, jaundice. hx of bloody diarrhea. Febrile, lower extremity petechiae. Hgb 9.2, mcv 90 fL, platelet count 70,000, total bilirubin 3.0 (direct 0.3) Cr 4.5. peripheral blood smear shows schistocytes
Thrombotic thrombocytopenic purpura (TTP)/Hemolytic uremic syndrome (HUS)
FAT RN: fever, anemia, thrombocytopenia, renal dz, Neuro dysfunction
Pt has hx of spinal cord injury. He experiences diaphoresis, flushing, headache. Needs frequent catheterization.
Where is location of lesion?
T6 or above - autonomic dysreflexia/hyperreflexia
What is the USPSTF recommendation for mammography in pt w no fam hx?
ACOG recommendation?
mammogram every other year starting at 50-75
ACOG suggests annually at 40
What are risk factors for PPROM?
what is the management?
genital tract infection smoking grand multiparity polyhydramnios previous PROM/PPROM
- <34 weeks
- no signs of fetal compromise = Abx, steroids, surveillance
- fetal compromise = Abx, steroids, Mg if <32 wks, delivery - 34 to <37 weeks: Abx, +/- steroids, Delivery
what are the differences in findings in Rotor syndrome and Dubin Johnson?
Urinalysis?
Rotor - normal liver color, elevated urine coproporphyrin
–Coproporphyrin III makes up 80% of urine coproporphyrin
Dubin-Johnson - darkly pigmented liver
–Coproporphyrin I make up 80% of urine coproporphyrin
what is the most appropriate dx test in suspected multiple myeloma?
urine protein electrophoresis
what is the first line therapy for OCD?
CBT + clomipramine (TCA) or an SSRI
What is the treatment of GBS? what is it associated with?
a/w influenza vaccine
Tx: Plasmapheresis or IVIG
What medications are used to treat adrenal insufficiency (gluco/mineralo)
Hydrocortisone - replacement of mineralocorticoid and glucocorticoid
Fludrocortisone - replaces just Mineralocorticoid
Prednisone - replaces just glucocorticoid
What is the best management in a pt w a fam hx of colon cancer. recent colonoscopy shows over 400 polyps, bx shows adenomatous
Familial adenomatous polyposis - Autosomal dominant
–Total colectomy
What are the 5 components of the primary respiratory mechanism?
- Inherent motion of the brain and spinal cord
- Fluctuation of CSF
- Mobility of intracranial and intraspinal membrane
- Articular mobility of cranial bones
- involuntary mobility of sacrum between ilia
Which vertebral segments are treated with muscle energy using patient’s head?
T1-4
What is the work up for a low risk patient who has 2 cm centrally located nodule with calcifications in bullseye pattern seen on CT/
low risk pt (no smoking, under 50)
-2 years of serial chest CTs
What are components of MEN type 1 (Wermer’s syndrome)
Autosomal dominant
tumors of:
1. parathyroid (hyperparathyroidism)
2. pancreatic islet cells (insulinomas, gastrinomas)
3. pituitary gland (hyperprolactinemia, GH secretion, gynecomastia)
what is dx:
pt started on haloperidol three days ago presents w oculogyric crisis
Acute dystonia - hours to days after starting antipsychotic (neuroleptic) drugs
-extrapyramidal movement disorder
what is dx: pt on fluphenazine for 15 months w involuntary tapping of lower extremities, abnormal twisting movement of the right leg
Tardive dyskinesia
–TIMING is important (months or years after start of meds)
What are 3 adverse affects of oxytocin overdose?
- Uterine Tachysystole
- Hyponatremia - oxytocin has similar structure to ADH = water retention
- Hypotension
What are the indications/contraindications for:
- Tamoxifen
- Raloxifene
- decreases post menopausal osteoporosis, increases risk for endometrial carcinoma, Hot flashes
- same as tamoxifen, does NOT increase risk for endometrial carcinoma, also DECREASES breast cancer risk.
both are contraindicated if hx of thrombosis
Minimal change dz:
- Sx
- Light microscopy findings
- electron microscopy findings
- Tx
- edema, fatigue, abdominal pain, PROTEINURIA in children (usually <10)
- normal
- diffuse effacement of foot processes of podocytes (Tcell mediated)
- Corticosteroids (bx is reserved for steroid resistance)
What is the underlying mechanism of Tardive dyskinesia
A/w dopamine blocking agents (antipsychotics)
- dopamine receptor supersensitivity
what is the cause of an anion gap acidosis in a pt who just experienced a general tonic clonic seizure. What is the next step
Postictal lactic acidosis - from skeletal muscle hypoxia
–Observe and repeat labs in 2 hours, usually self limited
What does the following measure:
- PT, INR
- PTT
- Extrinsic system (Tissue factor, VII)
2. Intrinsic system (XII, XI, VIII, IX)
How is multifocal atrial tachycardia identified on EKG?
- 3 or more different P-wave morphologies in the same lead
- HR greater than 100 beats per minute
- irregularly irregular rhythm
What are CBC findings of Polycythemia Vera?
Increased phenotypically normal RBC’s, granulocytes, platelets
What are the viscerosomatic levels for lower ureters and bladder?
T11-L2
What is the gold standard for diagnosing RSV, parainfluenza?
Nasopharyngeal swab
what is the pathophysiology of Myasthenia gravis?
Autoantibodies against NICOTINIC post-synaptic acetylcholine receptors
What type of psychiatric medication can cause hyperprolactinemia?
Antipsychotics - especially typical
–ie fluphenazine
What is the mechanism involved in symptoms relief with parkinson’s medication?
supplement dopamin
decrease cholinergic activity
(Benztropine + trihexyphenidyl = anticholinergic)
What is the difference between ethylene glycol and methanol poisoning
methanol - optic disc hyperemia, eye damage
ethylene glycol - kidney damage
What is the mechanism of thyrotoxicosis in a new born to a mother with graves disease?
Transplacental TSH-receptor ANTIBODY
–Methimazole + B blocker is given to symptomatic pt’s until condition self resolves in few weeks/months
Which vitamin deficiency can result in neutropenia
hypochromic anemia
Copper deficiency - occurs in premature infants, absorption disorders, genetic disorders
Sx: anemia, osteoporosis, leukopenia
What is a dx of a 45 year old pt w depressed mood for a year after her son moved out. Weight gain, sleep for 15 hours. briefly cheers up when son visits her.
Atypical Depression - mood reactivity + 2 of the following:
–weight gain, increased appetite, hypersomnia, leaden paralysis, sensitivity to rejection
What is dx:
45 year old female w abd pain, diarrhea, steatorrhea, cholelithiasis and diabetes mellitus
Somatostatinoma - somatostatin secreting tumors of the duodenum of delta cells of pancreas
What is dx:
35 year old pt w 7 year hx of ocp use has 2 cm hepatic tumor. No abd pain. US shows central scar on tumor
Focal nodular hyperplasia - “CENTRAL SCAR”
benign - continue oral contraception
What occurs at each axis of the sacrum:
- superior transverse axis
- Middle transverse axis
- Inferior transverse axis
- respiratory and inherent sacral motion
- postural motion (bending over)
- innominate rotation
What is the empirical treatment of bacterial meningitis in a nonimmunocompromised host? Close contacts? Where are organisms usually carried in close contacts
Neisseria = Petechial rash
Vancomycin
Ceftriaxone
Steroids
Ciprofloxacin, Ceftriaxone, or Rifampin for close contacts - organisms in NASOPHARYNX
What is the causative organism of Tinea Versicolor? KOH findings?
Tx?
Malassezia globosa
-Spaghetti & meatball pattern of hyphae and yeast
Tx: topical ketoconazole, topical terbinafine, selenium sulfide lotion/shampoo
or oral -azole
5 year old pt w enlargement of clitoris. puberty tanner stage 4. Lab studies show hyponatremia, hyperkalemia. What is the most appropriate test to order?
21-hydroxylase deficiency
–order Serum 17-hydroxyprogesterone level
What is dx classification and treatment? 17 year old w cough that occurs throughout the day and awaken at night every night. Pt is dx w asthma
Severe Persistent Asthma
Tx: inhaled high dose glucocorticoids, inhaled LABA, SAB2A
What is the appropriate next step in a 52 year old male that has 2 cm central nodule in L lung, 3 cm central nodule in R lung. Bx shows Small cell carcinoma
Chemotherapy - SCLC located centrally, considered a systemic disease
(surgical tx is uncommon cause SCLC is usually spread
What is most likely organism:
5 year old male w maculopapular rash that started on face, spreading to neck and extremities. Says he is experiencing “bone pain” Suboccipital lymphadenopathy
Rubella (Togavirus/German measles)
- -suboccipital/postauricular lymphadenopathy
- -maculopapular rash that starts on the face and spreads caudally.
- -Arthralgias
What is the likely organism:
3 year old w high fever given supportive therapy. Fever resolves 3 days later, and child returns w maculopapular rash that started on the trunk w spreading to neck
HHV6 (Roseola infantum, exanthem subitum, sixth dz)
-2-5 day self limiting fever, followed by maculopapular rash that starts on trunk and spreads to neck/extremities
How are Niemann-Pick and Tay-Sachs dz differentiated?
Hepatosplenomegaly is NOT present in Tay-Sachs
N-P: sphingomyelinase deficiency
TS: hexosaminidase A deficiency
How is a exhalation dysfunction of the first, second, third ribs on the left treated w muscle energy?
look straight ahead and pt lifts head anteriorly. physician grasps rib angle posteriorly and resists anterior head movement
What is the difference between bulimia and anorexia?
what is first line treatment for Anorexia?
anorexia = body weight < 85% expected, fear of gaining weight, distorted body image, amenorrhea
—Tx: Nutritional rehab + Psychotherapy
bulimia = patient of normal weight/overweight
What are pts w klinefelters at higher risk for? most common type? Sx?
extragonadal germ cell tumor
- -Mediastinal nonseminomatous germ cell tumor = most common!
- —–mediastinal mass = chest pain, chronic cough, SVC syndrome, Horner syndrome
What is most appropriate management of Variant Angina (Prinzmetal)
Calcium channel blockers (diltizem, etc)
Long acting nitrates
What is first workup step in pt w syncope?
Electrocardiogram
What is the next step in a pt already on metformin with an A1C of 7.9%?
Add sulfonylurea (Glyburide, etc) if A1C is b/w 7 and 8.5
Why is HVLA contraindicated in Down Syndrome patients?
weakness of the alar and transverse ligaments = can result in dens moving posteriorly = quadriplegia
What is:
- Colles Fracture
- Boxer’s Fracture
- Monteggia’s fracture
- Galeazzi’s fracture
- Nightstick fracture
- distal end of radius is bent dorsally (dmg to median nerve)
- fx of fifth metacarpal (tx: closed reduction and splint)
- fx of ULNAR shaft w dislocation of RADIAL head
- Diaphyseal fracture of DISTAL RADIUS w DISRUPTION of radioulnar joint
- fx of ulnar shaft
What are symptoms of roseola infantum
rash that starts on trunk and spreads peripherally AFTER fever typically
What are Sx of Erythema Infectiosum
Parvovirus B19 (5th dz)
- -fever, nasal, congestion that last for a few days
- -followed by “slapped cheeks” then ery thematous rash begins on arms and spreads to trunk and fades in lace like pattern.
Acute Arthralgia/arthritis (resemble RA)
What is the management of a scaphoid fracture w a normal radiograph?
casting for 10 days and REIMAGING (signs of healing should appear)
-surgical exploration if displacement >1mm
What are serum changes in Wilson dz?
Decreased total serum copper Increased free copper decreased ceruloplasmin Hypoalbuminemia elevated aminotransferases
What is the most appropriated test to confirm dx of Cardiac tamponade?
Transthoracic echocardiogram
What is dx in newborn: polydactyly meningomyelocele rocker-bottom feet cleft palate eye malformations GI/cardiac/renal dz
Trisomy 13 - Patau syndrome
What is dx in newborn: intellectural disability microcephaly micrognathia clenched fist prominent occiput rocker-bottom feet hypertelorism
Trisomy 18 - Edward’s syndrome
What are liver manifestations of oral contraceptive use? what other risk factors? management?
Hepatic adenoma - OCPs, Anabolic steroids, glycogen storage dz
- Tx:
1. Discontinue OCPs
2. Surgical resection IF SYMPTOMATIC
How is Cdiff dx’d?
C diff toxin PCR
(EIA assay has lower sensitivity but higer specificity) - slower test, often used in conjunction
When should umbilical hernias be treated in children?
if it has not spontaneously reduced by 4 years old
dx? Tx?
16 year old w maculopapular rash, allergic rhinitis, asthma, positive for p-ANCA
Churg-Strauss (allergic granulomatosis)
Tx: glucocorticoids + immunosupressive drugs
What is a medication that may be used to reduce incidence of PUD a/w NSAIDs? sidefx?
Misoprostol
side fx = abd pain, diarrhea
(NSAIDs inhibit prostaglandin synthesis)
What are the two DIAGNOSTIC tests for syphilis?
- Dark field microscopy
2. direct fluorescence antibody testing of lesion tissue
Upon itiating abx for Group A strep, the patient is considered contagious for how long?
1-2 days on abx
What are 3 first line drugs for maternal hypertensive crisis?
- IV Hydralazine - vasodilator
- IV Labetalol - DONT use w bradycardia (<60bpm)
- PO Nifedipine - difficult to use w emesis
*Methyldopa is used for chronic maternal htn
How do you treat an acute psychotic episode in a pt that has previously responded to haloperidol but experienced extrapyramidal symptoms?
Second generation antipsychotics:
- ziprasidone (low metabolic risk)
- Olanzapine (high metabolic risk)
- Lurasidone
- Aripiprazole
Dx? Immediate management?
Newborn w resp distress. Prenatal US shows polyhydramnios. O2 sats 82%. Exam shows nasal flaring, grunting, barrel shaped chest. Absent breath sounds on L. Normal aeration of R side. Heart sounds are loudest in R chest. Abdomen is Scaphoid
Congenital Diaphragmatic Hernia - polyhydramnios can occur from esophgeal compression.
- concave abdomen
- barrel shaped chest
Management - Emergency intubation (mask ventilation risks aerating stomach, further compromising lungs)
What is the cause of decreased total calcium in a patient w nephrotic syndrome?
Decreased Albumin = decreased total calcium (bound to albumin) Q Ionized Ca (physio active form) are still at normal levels
What is the management of uncomplicated chronic low back pain?
Chronic > 12 weeks
Tx: Exercise therapy
What is dx:
50 yr old postmenopausal female w 2 day hx of vaginal spotting. Phys exam shows thin female w large adnexal mass. US shows endometrial thickening. No evidence of hirsutism/virilization
Granulosa-theca cell tumor
–hormonally active = hyperextrogenism
(Sertoli-Leydig = androgen = virilization)
What is most common cause of pancreatitis in children/adolescents?
Blunt trauma to abdomen
-Sx: epigastric pain radiating to back + N/V
What is difference b/w postpartum blues and postpartum depression?
Blues - appear within first weeks and remit by end of 2 weeks postpartum
Depression - delayed from 2 weeks to 12 months
What is causative organism:
24 yr old breast feeding pt presents w pain in left nipple. No fevers, chills, fatigue. Nipple is erythematous, shiny, w flaky skin at areola. No erythema of breast.
Candida albicans - pain, burning, redness of NIPPLE, shiny appearance
- -Azole cream for nipple
- -Check infants mouth for thrush, give oral azole to infant
(S. aureus causes nipple cracks/fissures)
What is most common cause of primary hyperparathyroidism? Second most common? Tx? Localization technique?
- Parathyroid adenoma
- Parathyroid hyperplasia
Surgical excision - localize w Sestamibi scan
What are 3 relative contraindicatiosn to lymphatic omm treatments?
Metastatic Cancer
Disseminated/Febrile infections
Chronic infections
How is the diagnosis of boerhaave syndrome made? (2 ways)
Chest CT
Iodinated contrast esophagram
What are 3 indications for long term oxygen therapy in COPD patients?
- SaO2 < 88%
- PaO2 <55 mmHg
- PaO2 55-59 mmHg if right sided HF or erythrocytosis are present
When is excisional bx of a breast mass indicated?
- All palpable dominant breast masses in women over 50
- Masses that persist after FNA (except fibroadenomas)
- Bloody aspirate
What level are somatic visceral changes present in a pt w UC in the sigmoid colon? what other organs share this visceral level
T12-L2
- distal 1/3 of transverse colon, descending, sigmoid colon, rectum
- prostate
- lower ureter
- bladder
What is likely dx:
30 year old smoker w nonproductive cough, SOB. CXR shows bilateral nodules/cysts, Lytic lesions of the ribs.
what protein will be expressed on these cells?
Langerhans cell histiocytosis
- -proliferation of specialized bone marrow-derived Langerhans cells.
- -Dyspnea, Non-productive cough, fatigue, weight loss.
- -CXR = bilateral nodules, cysts, honey combing (interstitial), boney lesions of ribs
*CD1a is used to identify
what is the dx test for infantile botulism?
Stool C. botulinum toxin assay
What is dx? most specific lab test?
35 yr old female w fatigue, white finger tips in cold weather. dysphagia, small blood vessels on her body. Skin has hard nodular type lesions on upper extremities, tightness of skin
CREST syndrome: Calcinosis Raynaud's Esophageal dysmotility Sclerodactyly Telangiectasias
Anti-centromere Abs
What is the first line tx of tourettes? What are 4 comorbidities?
Typical Antipsychotics (haloperidol, fluphenazine)
Comorbidities
- ADHD
- OCD
- learning disorders
- conduct disorder
What is the workup for elevated prolactin levels?
MRI of the brain
what is the most common cause of PUD? what is the most common blood type associated?
H. pylori infection
G”A”stric ulcers - Type A
Du”O”denal ulcers - Type O
What 2 lab findings are used to monitor response of osteomyelitis to therapy?
ESR and CRP
What is the time period required for a diagnosis of schizophrenia?
6 months
What are the 3 most common risk factors for spontaneous pneumothorax?
- Smoking
- fam hx
- Marfans
What is most likely dx:
2 year old w bloody nose. Has unilateral nasal discharge w foul smell.
Foreign body
What is first line treatment of Fibromyalgia?
What is first line med?
What are other three drugs that are approved for management.
Initial: pt edu, regular aerobic exercise, good sleep hygiene
First line med: TCA’s (Amitryiptline)
Others if nor responding to TCA:
- duloxetine (SNRI)
- milnacipran (SNRI)
- pregabalin
What are treatments for acute mania/psychosis?
Antipsychotics (Olanzapine is IM and has rapid onset)
Lithium
Anticonvulsant mood stabilizers (valproate)
What is most likely congental heart defect?
1 week old w central cyanosis. ECG shows left axis deviation. holosystolic murmur at left lower sternal border. fam hx has maternal uncle who dies from hypoplastic left heart syndrome
Tricuspid valve atresia
What is cause? what should be done?
COPD pt has exacerbation. He is given inhaled bronchodilators, systemic steroids, high-flow facial mask oxygen, IV lorazepam. He becomes lethargic and confused and experiences a general tonic-clonic seizure
Carbon dioxide retention
- -high flow oxygen causes loss of compensatory vasoconstriction = worsens V/Q mismatch
- -Increase in oxyhemoglobin reduces uptake of CO2 from Haldane effeect
- -decrease respiratory drive/minute ventilation
*O2 sats should be titarted to 90%-94%
or paO2 between 60-65
What is the most common congenital heart defect in children w Edwards?
Trisomy 18
- VSD
- microcephaly, micrognathia
- absent palmar creases
- rocker bottom feet
What is management of Community-acquired pneumonia? Criteria and treatment
CURB-65: Confusion Uremia (BUN > 20) Resp rate > 30 BP < 90 systolic or < 60 diastolic Age > 65
Scoring:
<2 outpt w Macrolides (azithromycin, clarithromycin, erythromycin) or Doxycycline
=2 inpt w respiratory fluoroquinolone or Macrolide w Beta-lactam
>3 ICU w B-lactam/resp fluoroquinolone or B-lactam/Macrolide
What is the treatment choice for Acute Otitis Media in a child?
Amoxicillin (S.pneumo, M. cata, H. flu)
Augmentin - if pt had amoxicillin within past 30 days. or Sx dont improve after 48 to 72 hrs on high-dose amoxicillin
What are the classifications of Scoliosis?
- Mild: 5-15, treated w OMT, PT
- Moderate: 20-45, tx orthotics, PT, OMT
- Severe: >50 - surg intervention
> 50: Resp compromise
75: Cardiac compromise
What is dx: 30 yr old male w scrotal mass: 2 cm cystic, transilluminates located superior and posterior to testis
Spermatocele
Hydrocele are Ant + Lat
What should happen before administering Rh(D) immune globulin in a pt w placental abruption
Rh(D) typing
What is dx:
40 yr old recently visited Wisconsin. Cough, fever, chest pain, severe arthralgia. Non-pruritic verrucous/ulcerating skin lesions
Tx?
Appearance?
Blastomycosis
- Midwest/Southcentral States
- Fever, cough, CP, weightloss, painless VERRUCOUS/Ulcerated skin lesions
- Bone lesions
- CNS disease
KOH: broad based budding
Tx: Itraconazole, Amph B if dissemiated/HIV
What is the management of a
- pleural effusion
- empyema
- therapeutic thoracentesis for large or symptomatic transudative/malignant exudative
- Chest tube + empiric IV Abx
What is dx:
1 month old w jaundice, hepatosplenomegaly, cataracts, cardiac murmur, hearing loss
Rubella Virus
- cataracts
- hearing loss
- “blueberry muffin” rash
- hepatosplenomegaly
- intellectual/dev disability
What is management of bat bite in pt:
- vaccinated
- unvaccinated
Vaccinated: irrigation + 2 doses of rabies vaccine prophylaxis
Unvaccinated: irrigation + passively immunized + 4 doses of rabies vaccine prophylaxis
What is dx? most specific test?
70 year old pt w nasal congestion, shortness of breath, hemoptysis
ESR 60 mm/hr and WBC 11,000. Urine has red cells, red cell casts
Granulomatosis w polyangiitis (Wegeners)
–C-ANCA (abs against proteinase-3)
-Upper + Lower Resp Sx + Glomerulonephritis
What is most effect Tx for pt w rhinitis during the fall. pt’s father was dx’d w atopic conjunctivitis
Dx: Allergic rhinitis (most significant risk factor = fam hx of atopy or asthma)
Tx: Intranasal corticosteroid
What is first line treatemtn of hemodynamicaly unstable pt w confirmed or highly suspected pulmonary embolsm?
tPA
How is Meckels diverticulum diagnosed? Tx?
Technetium-99m pertechnetate scan
Tx: Surgical exicision
-can lead to intestinal obstruction, volvulus, intussusception
What is dx and next workup step in 54 yr multiparous woman w 5 month hx of urinary incontinence. admits to urinary frequency, dribbling, hesitancy. second step shows large postvoid residual volume.
What is appropriate tx?
Overflow incontinence - Urinalysis
Tx - Self-catheterization and treating underlying cause
What is dx:
32 year old at 38 weeks gestation. hx of cesarean delivery. intially at 6cm dilated 60% effaced, fetal head at 0 station. She experiences intense lower abdominal pain. moderate vaginal bleeding, cervix is 6cm dilated, 60% effaced, fetal head at -3 station. Fetal heart rate is tachy w variable decelerations
Uterine Rupture
- loss of fetal station is pathognomonic
- occurs at scar of prior cesasean delivery
70 year old pt has BP of 165/75. ECG shows LVH. What is cause of HTN?
Rigidity of arterial wall
- isolated SYSTOLIC HTN (sys>140, dia<90)
What is the dx criteria fro Adjustment disorder w depressed mood? Tx?
Onsent within 3 months of identifiable stressor
Marked distress &/or functional impairment
Tx: psychotherapy
What is the cause of swelling in hands and feet of a newborn w Turner’s syndrome?
Lymphatic network dysgenesis
–severe obstruction can result in cystic hygroma
What are the first 4 steps in early neonatal care in an uncomplicated pregnancy?
- Initial physical assessment (APGAR)
- removal of airway secretions
- drying infant, keep warm
- early preventatie measures (silver nitrated eye drops, vitamin K)
How long should a patient continue antidepressant tx after achieving remission of depressive symptoms
continue for an additional 6 months in a pt w single-episode unipolar major depression.
What is difference between Marfan’s syndrome and Homocystinuria
Marfan’s: Autosomal dominant, Fibrillin abnormality, Long fingers, Scoliosis, ECTOPIC LENTIS, LOOSE JOINTS
Homocystinuria: marfanoid habitus, Mental retardation, Osteoporosis, LENS SUBLUXATION, TIGHT JOINTS
What is the appropriate management for:
- cleft lip
- cleft palate
- Surgical repair by 3 months
2. Special nipple for feeding + surgical repair at 9 months
What is the most common cause of meningitis in a 7 month old? What are characteristics of the organsim?
S. pneumoniae
-most common cause:
3 months - 9 years
after 30 yrs old
-Lancet-shapted
gram positive
alpha-hemolytic
encapsulated
What is dx:
50 year old w new fever and weightloss
Labs: WBC 54,000, HgB 14, hematocrit 42%, increased leukocyte alkaline phosphatase.
Bone marrow bx: hypercellularity
Leukemoid reaction
- secondary to infection
- Increased leukocyte alkaline phosphatase
- –CML has DECREASED leukocyte alkaline phosphatase
What is the dx:
neck pain, hyperthyroid sx, hx of sinusitis, elevated ESR, T4, decreased TSH level
Iodine uptake?
Tx?
Subacute GRANULOMATOUS thyroiditis (de Quervain’s)
- Decreased iodine uptake
- NSAIDs
**subacute lymphocytic thyroiditis is PAINLESS
What is the definitive diagnostic test for Fanconi anemia? what is the patient at greater risk for?
chromosome breakage test
-greater risk for AML, liver tumors, other malignancies
What is dx:
2 day old child w chorioretinitis. Mother admits to ingesting raw meat during pregnancy. Jaundice
What will head CT show?
Toxoplasmosis
- hydrocephaly
- chorioretinitis
- jaundice
- hepatosplenomegaly
- mental retardation
- microcephaly
CT - intracranial calcifications (especially Basal Ganglia)
What causes variable deceleration in fetal heart rate monitoring?
Umbilical cord compression
What causes early deceleration in fetal heart rate monitoring?
Fetal head compression
What causes late deceleration in fetal heart rate monitoring?
uteroplacental insufficiency
What is the next step after establishing an airway in a child w epiglotitis? What is the most common cause?
Administer antibiotics
-empiric = 3rd gen cephalosporin + vancomycin/clindamycin
mostly caused by H flu (most common), then S.pneumo, Group A strep, S aureus
What is Dx, Cause, Tx?
40 yr old w bipolar dz has polyuria, dehydration. Urine osmolality is extremely low, slight response w vasopressin.
Nephrogenic DI - caused by Lithium
Tx: Sodium restriction and Thiazide +/- Amiloride
What is dx?
11 year old girl w 15 lb weight loss over past month. Frequent melanotic diarrhea, abd pain. Aphthous oral ulcers, perirectal skin tag
Crohn’s disease
What is dx:
child w/ episodes of depersonalization followed by lip smaking. EEG shows three per second spike and wave discarges
Absence seizure idsorder
What are the following:
- Curling’s ulcer
- Cushing ulcer
- Marjolin’s ulcer
- Marginal ulcer
- Buruli ulcer
- Curling: Duodenal ulcer that occurs acutely after a burn
- Cushing: gastric/duodenal ulcer caused by elevated intracranial pressure
- Marjolin - malignant transformation of CHRONIC wound (most commonly a burn)
- Marginal ulcer - jejunal ulcer after gastrojejunostomy
- Buruli - manifestation of mycobacterium ulcerans
What is dx? etiology?
15 year old boy w progressive weakness. Increasing difficulty making facial expressions, swallowing, ptosis, temporal wasting, thin chees, inverted V-shaped upper lip, testicular atrophy
Mytonic dystrophy
-autosomal dominant expansion of CTG in DMPK gene on chromosome 19
What is the tx for candida vulvovaginitis
Oral Azole (fluconazole) Intravaginal Nystatin
What electrolyte abnormality can be caused by TMP-SMX?
hyperkalemia - TMP blocks epithelial sodium channel in collecting tubule
What are renal changes observed in normal pregnancy? what are the lab findings?
Increased: Renal blood flow, GFR, Renal basement membrane permeability
Labs: Decreased Serum BUN, CR, increased renal protein excretion
What is the location of dysfunction:
36 year old woman w pronator drifty?
Pyramidal/Corticospinal tract
Upper motor neuron
What is dx? What 3 things will be positive in serology test?
49 yr old woman w swelling/stiffness in hands, raynauds, fatigue, gerd, lungs have bibasilar fine inspiratory crackls
Systemic Sclerosis
- Anti-topoisomerase I Abs (anti-Scl-70)
- Antinuclear Ab
- Anticentromere Ab
Sx: Fatigue, weakness, Telangiectasia, sclerodactyly, digital ulcers, calcinosis, arthralgias, dysphagia, raynaud, interstitial lung dz
How do you differentiate Amaurosis Fugax with Central retinal vein occlusion?
CRVO - Retinal hemorrhages more common, cotton wool spots, optic disk swelling = “blood and thunder”
What is the initial management?
71 yr old w acute substernal cp, dyspnea, bp is 78/57, pulse 102, jvd is present, pulm auscultation shows prominent rales in all lung fields w faint wheezes
Dopamine - flash pulmonary edema, cardiogenic SHOCK
–give catecholamine vasopressor - increasee cardiac contractility + vasoconstriction
–then MONA BASH
What type of HTN medication can be useful in pts with osteopenia, osteoporosis?
Thiazide diuretics - decreases calcium excretion - causes hypercalcemia
What is the treatment choice for symptomatic sarcoidosis?
oral corticosteroids
What does a sinusoidal heart rate pattern indicate in fetal heart rate monitoring?
Severe fetal anemia = RH isoimmunization or severe hypoxia
what is dx:
3 year old w 7 day hx of 101.2 fever. fissuring of lips, erythema and desquamation of palms and soles. Bilateral conjunctivits. Inflamed “strawberry” tongue
complications?
Tx?
Kawasaki (mucocutaneous lymph node syndrome)
- -fever >5days
- -bilateral conjunctivis
- -uveitis
- -strawberry tongue
- -cracked lips
- -erythematous desquamation of trunk, hands, feet
a/w coronary artery aneurysms
Tx: IVIG, High dose aspirin
What is dx:
35 yr old male w swelling and solid mass on R testicle. Labs shows elevated B-HCG, normal AFP. Histology shows well defined cell membranes w clear cytoplasm “fried egg” appearance
what are risk factors for this condition?
Seminoma
- -normal AFP
- clear cytoplasm, round nuclei = “fried egg”
Risk: Cryptorchid testis, infertility, Klinefelter, fam hx
What is most likely dx:
25 yr old w hypercortisolism. Low dose dexamethasone test does not cause cortisol reduction (above 1.8). High dose dexamethasone causes cortisol to be supressed
What is Tx?
Pituitary tumor - ACTH excretion (Cushing’s disease)
Tx: tumor removal + replacement glucocoriticoid
4 month old born at 28 weeks gestation is seen for wellness check up. what is the appropriate action to prevent infection of RSV?
Palivizumab in high risk pts:
high risk =
- infants <24months w hemodynamically congenital heart defects, chronic lung dz
- born prior 29 weeks
- <24month and immunocompromised
What is the typical presentation of Wernicke encephalopathy?
“ACE” triad
Ataxia
Confusion
Eye disorders
Korsakoff refers to long term dementia that can develop - imaging will show mammillary body lesions
What is dx? Tx?
chronic alcohol abuse has fatigue, abd pain, conjunctival pallor. Iron, ferritin levels are elevated, normal TIBC. Bone marrow bx shows erythroblasts w stainable deposits of iron in cytoplasm.
Sideroblastic anemia - bx shows ringed sideroblasts
–causes: alcohol, isoniazid, chloramphenicol, lead poisoning
Labs:
increased iron, ferritin
normal TIBC
Tx: removal of offending agent + Pyridoxin (B6)
What is dx:
35 yr old male experiences cramping pains and numbness in left arm and becomes dizzy w double vision when he exercises by punching bag.
Subclavian steal syndrome - obstruction of left subclavian artery prox to origin of vertebral artery. - backflow of blood from vertebral artery to distal subclavian
dx: duplex US, MRI, MRA
How is relative risk calculated?
(A/(A+B)) / (C/(C+D))
What is the management of a hepatic cavernous hemangioma that is incidentally found on US?
Stop hormonal therapy
- -watch expectantly
- followed by imaging, hemangiomas over 5cm or symptomatic is managed surgically
What are 3 ways DM T2 is diagnosed?
- Fasting glucose > 126 mg/dL
- Random glucose > 200 + symptoms
- HbA1c > 6.5%
What is dx and tx?
40 year old female w pruritis, scleral icterus, jaundice, hepatomegaly. Labs have elevated alk phos, serum antimitochondrial abs
Primary Biliary Cirrhosis
- -Cholestyramine, Cholestipol for pruritis
- –Ursodeoxycholic acid to slow dz progression
What is the skin manifestation a/w celiacs? Tx?
Dermatitis herpetiformis
Tx = Dapsone + gluten free
What is the tx for neuroleptic malignant syndrome? (3)
Stop meds + IV fluids first
- -if sever or sx continue:
1. Dantrolene
2. Bromocriptine
3. Amantadine
Pt w hx of afib on warfarin has INR of 2.1. He presents w an acute abdomen, abdominal xray shows free air under diaphragm, what is next step?
Fresh frozen plasma to reverse INR for surgery.
–in acute setting (ie hemorrhagic stroke) use Prothrombin complex concentrate (PCC) + Vitamin K
What is the most common site for the origin of atrial fibrillation
pulmonary veins
What kind of medication should children w sickle cell disease be taking?
Children <5 yrs old w SCD should be on prophylactic penicillin
S. pneumo - most common cause of sepsis in fxnal asplenia
What are the two definitions of active phase labor arrest? what is next step?
active phase begins >6cm dilation
- no cervical change >4 hrs w adequate contractions
- no cervical change >6 hrs w/o adequate contractions
Cesarean delivery
What is Alport syndrome? what are microscopy findings?
“Cant See, Pee, Hear High C”
-Renal dz, sensorineural hearing loss, ocular abnormalities
abnormalities of Type IV collagen
Microscopy = Thinning/Splitting of glomerular basement membrane
When should a colonoscopy be offered in a pt with Ulcerative colitis or Crohn’s w colonic involvement?
8-10 years after diagnosis (12-15 if dz only in L colon)
-repeat every 1-3 years
What are hormonal findings in Turner Syndrome patients?
Ovarian dysgenesis (streak ovaries) -
Low estrogen + progesterone
elevated LH + FSH
Psyche pt w depression and psychosis has symptoms controlled on medication. She has infertility and erratic menstrual periods. What medications is she probably on?
Antipsychotics
First gen: Haloperidol, Fluphenazine
Sec gen: Risperidone, paliperidone
–Dopamine 2 blockers = increase prolactin
=galactorrhea, menstrual irregularities, infertility
What is dx? Additional findings? how is it dx’d?
2 day old fails bilateral hearing screen. born at 37 weeks via csection due to fetal growth restriction. Mother had brief febrile illness while traveling during first trimester. She reported joint paint 5-7 days after fever. Infants weight, length, head circ is <5th percentile. child has loud murmur over left second intercostal space.
Congenital Rubella
- Sensorineural hearing loss
- Cataracts = Leukocoria (white pupillary reflex)
- PDA
Dx: Serology (Infant IgM)
What is dx? what will confirm dx?
1 month old male has poor feeding and “floppiness” since birth. Sx have been progressive. Hypotonia, generalized weakness, lack of head control. Eyes have active movment.
Werdnig-Hoffman disease (Spinal muscular atrophy type 1)
- -Genetic testing -Autosomal recessive (SMN1 gene)
- –Survival motor neuron gene 1 (SMN1) - encodes protein that arrests apoptosis of motor neurons
–Extraocular + sphincter muscles are spared
