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Internal Medicine > All Questions 201-400 > Flashcards

All Questions 201-400 Flashcards

1
Q

22yo F with abnormal Pap smear and no history of irregular menstrual, postcoital bleeding, or vaginal discharge.

A

Cervical carcinoma in situ.

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2
Q

29yo Vietnames F with nausea, vaginal bleeding, dyspnea, and hemoptysis.

A

Choriocarcinoma. Can develop during normal pregnancy, s/p hydatidiform mole, or previous spontaneous abortion. Elevated hCG.

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3
Q

45yo F with gross difference in size of her breasts with sensation of fullness but no pain. Exam reveals large, firm mass.

A

Cystosarcoma phyllodes. Less common benign tumor of breast. Mass tends to be mobile and is well circumscribed. Path = cystic spaces on cut section, producing recesses and longitudinal openings with ‘leaflike’ (phyllodes) appearance.

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4
Q

25yo W with amenorrhea for 6 weeks and development of pelvic pain for 1 day.

A

Ectopic pregnancy. Risk factors = previous tubal surgery, tubal ligation, endometriosis, previous ectopic pregnancy, ovulation induction, pelvic inflammatory disease. Test of choice = hCG and ultrasound (can get transvaginal US if needed).

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5
Q

60yo F with obesity presents with intermittent vaginal bleeding for three months. Has never had children.

A

Endometrial CA. Estrogen-dependent cancer. Rx: hysterectomy, radiation. Important to include in differential of postmenopausal bleeding.

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6
Q

27yo with inability to conceive, painful intercourse, and painful menses.

A

Endometriosis = extrauterine endometrial tissue. Can be located in various locations with unique symptoms , most frequently bilateral ovaries = chocolate cysts.

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7
Q

27yo F marathon runner with painful lump breast. Mammography reveals irregular mass with focal areas of calcification.

A

Fat necrosis. Indurated lesion with retraction of overylying skin. Unilateral localized process associated with trauma, breast biopsy, and radiation. Easy to confuse with CA… pain is the key distinguishing feature.

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8
Q

25yo F with right breast lump that is small, encapsulated, and freely moveable.

A

Fibroadenoma. #1 benign breast tumor in young women; sometimes enlarges during pregnancy or normal menstrual cycles. Mammogram = “popcorn calcifications”.

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9
Q

20yo F with chronic left lower quadrant pain and left adnexal mass on exam.

A

Follicular ovarian cyst. #1 cause of ovarian enlargement. Test = US to look for cyst. Rx: Follow-up ultrasound (many disappear spontaneously); laparoscopic removal if persistent.

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10
Q

52yo nulliparous F with painles lump in breast. PE reveals fixed, hard, nontender mass with retraction of overlying skin and palpable ispilateral nodes.

A

Infiltrating ductal CA = #1 breast cancer. Risk = family hx, estrogen “exposure”, atypical hyperplasia, previous breast cancer. Fibrosis with induration = desmoplastic reaction. Rx = surgery, tamoxifen if E receptor positive.

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11
Q

59yo F with pain and swelling in breast with erythematous overlying skin with peau d’orange appearance.

A

Inflammatory carcinoma of breast. Highly malignant with early and widespread metastases.

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12
Q

39yo F with heavy and frequent periods, occasionally painful.

A

Leiomyoma. #1 tumor of uterus, most common tumor in women. Estrogen-dependent. US reveals multiple heterogenous masses, 95% intramural myometrium location, round, firm, well circumscribed.

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13
Q

60yo F with foul-smelling, blood-tinged, purulent vaginal discharge. Tumor projecting from cervical os on speculum exam.

A

Leiomyosarcoma. CT = large complex mass in uterus. Biopsy = spindle-shaped cells with many mitotic cells. Rx: adriamycin, progestins, combination therapy. Aggressive malignant tumor of the myometrium, can arise from leiomyoma or de novo.

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14
Q

56yo F with history of breast CA with pelvic mass identified on routine physical exam.

A

Ovarian carcinoma. Serous type most common, often bilateral and advanced at diagnosis. Elevated CA-125, psammoma bodies.

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15
Q

68yo F with itchy, painless scaling and oozing of erythematous nipple.

A

Paget’s carcinoma. Characteristically a scally skin lesion of areola and nipple arising from ductal adenocarcinoma.

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16
Q

35yo F with bloody nipple discharge originating from one of the duct openings.

A

Papilloma of the breast. Benign proliferation of ductal epithelial tissue. #1 cause of serous / bloody nipple discharge.

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17
Q

88yo M with purpura over extensor aspect of both hands. CBC reveals not abnormality.

A

Senile purpura. Benign disease of elderly, characteristically extensor hand surfaces, forearms, and neck. Defect in collagen support of dermal cappillaries. No treatment available. Cosmetic consequence only.

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18
Q

18yo M with small purple skin lesions following URI two weeks ago.

A

ITP. Abrupt onset. Viral illnesses, drugs = thiazides, gold, carbamazepine, phenothiazines, quinine, rifampicin, valproate, sulphonamides, penicillins. Drug binds pltlt or drug binds plasma protein, forms immune complex, binds pltlt. Rx: steroids.

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19
Q

Causes of purpura.

A

Senile, Osler-Weber-Rendu (hereditary haemorrhagic telangiectasia), giant cavernous hemangioma (can cause DIC), Ehler’s-Danlos, Marfan’s, HSP, scurvy, Cushing’s, steroid use, uremia, liver dx.

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20
Q

64yo M with testicular swelling.

A

Lymphoma of testis. #1 testicular neoplasm in elderly.

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21
Q

29yo M with painless lymph node in the axilla, normochromic, normocytic anemia, and elevated ESR. Next test?

A

Node biopsy. Hodgkin’s –> Reed-Sternberg. Non-Hodgkins’ –> spectrum small lymphocytic (low-grade) to large cell centroblastic (high grade). A2 staging; I=nodes 1 region II=2 regions, same side III=nodes both sides hemidiaphragm, IV=diffuse.

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22
Q

45yo F with anemia, bone tenderness, and abdominal distension. Smear demonstrates blasts at all stages of maturation. Recent DVT.

A

CML. Philadelphia chromosome 22 bcr-abl translocation 9:22 (95% of cases). Complications = hyperviscosity (rx with leukophoresis).

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23
Q

60yo F with diffuse lymph node enlargement and smear with increased lymphocytes, smudge cells.

A

CLL. Most common leukemia in US and Europe. Monoclonal transformation of B cells. Diagnosis = persistent lymphocytosis with increased lymphs. Warm antibody hemolytic anemia may result. No rx if asymptomatic.

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24
Q

Causes of asplenia (anatomic or functional).

A

SLE, sickle cell, celiac, lymphoma, post-surgical. Risk of infection with S. pneumo, H. flu, N. meningitidis, malaria.

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25
Q

34yo M with facial plethora (redness), conjunctival suffusion, and splenomegaly.

A

Polycythemia. True or d/t excess EPO –> polycystic kidneys, renal CA / cysts, chronic glomerulonephritis, liver disease, hepatocellular CA, overian CA, bronchial CA. Hypoxia, lung disease, congenital heart disease, smoking. Enlarged retinal vessels.

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26
Q

P. vera

A

Hyperuricemia (rx with allopurinol), thrombotic events (less risk in secondary dx), 20% progress to myelofibrosis. Rx with phlebotomy. High incidence of HTN, itching, hepatomegaly, gout.

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27
Q

Causes of warm antibody autoimmune hemolytic anemia.

A

Lymphoma, leukemia (CLL), SLE, HIV. Causes spherocytes (also seen in congenital spherocytosis). Rx: prednisolone may induce remission; consider splenectomy.

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28
Q

Causes of cold antibody autoimmune hemolytic anemia.

A

Infectious mononucleosis, mycoplasma pneumonia, malaria, idiopathic (IgM paraprotein).

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29
Q

Cigar shaped erythrocytes.

A

Hereditary elliptocytosis. Usually asymptomatic.

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30
Q

Spherocytes on peripheral smear.

A

Perform osmotic fragility test. Spectrin defect = hereditary spherocytosis.

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31
Q

2yo with frontal bossing and “hair-on-end” appearance on skull x-ray. Has painful swelling of the fingers.

A

Sickle cell. Salmon-patch retinal hemmorhages. Homozygotes affected, heterozygotes asymptomatic until exposed to low O2 tension. Test with Hb electrophoresis and sickling test.

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32
Q

25yo black M develops painful joints and severe stomach pain one day into ski trip in the French Alps.

A

Sickle cell trait. Crisis at low O2 tensions.

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33
Q

Drug induced aplastic anemia.

A

Chloramphenicol, chlorpropamide, chlorpromazine, carbimazole, carbamazepine, gold salts, methotrexate, phenytoin.

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34
Q

Most common cause of iron deficiency anemia worldwide.

A

Hookworm.

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35
Q

58yo F with recurrent episodes of thrombophlebitis in the legs and arms.

A

Pancreatic CA. Thrombophlebitis may preceed diagnosis by many months.

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36
Q

64yo peanut farmer with jaundice, weight loss, and right upper quadrant pain.

A

Hepatocellular CA. Test for alpha-fetoprotein. Ultrasound / CT to evaluate.

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37
Q

Causes of cirrhosis.

A

Glycogen storage, Fanconi’s, alpha-1-antitrypsin (neonatal hepatitis with cirrhosis in childhood), cardiac cirrhosis (late complication of R heart failure), methotrexate, hereditary hemorrhagic telangiectasias, ulcerative colitis and Crohn’s.

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38
Q

17yo M with tremor, athetoid movements, and elevated LFTs.

A

Wilson’s disease. Low ceruloplasmin. Kayer-Fleischer ring in cornea. Rx: penicillammine chelation therapy.

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39
Q

55yo F with pruritus and jaundice that progressed over 3 years.

A

Primary biliary cirrhosis. Anti-mitochondrial Abs. Assoc. c Sjogren’s, Raynaud’s, thyroid dx, Addison’s, RA, fibrosing alveolitis, dermatomyositis, scleroderma. Women 9:1, age 40-60. ERCP reveals normal intra/extrahepatic bile ducts. Gallstones common.

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40
Q

31yo M with jaundice, pruritus, and RUQ pain. Markedly elevated AP with slight elevation in AST and ALT.

A

Primary sclerosing cholangitis. ERCP shows patchy dilatation and stricturing of biliary tree. High risk of ulcerative colitis. Progresses to hepatic cirrhosis. Risk = ascending cholangitis. HLA B8, DR2, DR3.

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41
Q

30yo F with hypothyroidism and rheumatoid arthritis develops jaundice.

A

Autoimmune hepatitis. Type I = history or family history of autoimmune disease. Type 2 = anti-liver and kidney microsomal autoantibodies, occurs in younger children. Type 3/4 = soluble liver antigen, type 4 ill-defined similar clinical as type 1.

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42
Q

31yo F with morbilliform rash and jaundice. Recently seen by a neurolgist for epilepsy.

A

Drug-induced hepatitis. Phenytoin (anti-epilepsy).

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43
Q

25yo with eosinophilia, chronic cough, and distal small bowel obstruction.

A

Ascaris lumbricoides. Larvae migrate to lung, small bowel obstruction are complications.

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44
Q

29yo HIV + F with eosinophilia, liver, heart, and renal failure.

A

Strongyloidiasis. Can result in systemic invasion in IC’d pts.

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45
Q

23yo M former aid worker in Guatemala has resolving bloody diarrhea nd develops stricturing and mucosal damage to colon.

A

Entamoeba histolytica. Don’t confuse with inflammatory bowel disease.

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46
Q

Diarrhea: viral

A

Rotavirus, Norwalk, Adenovirus.

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47
Q

Diarrhea: bacterial toxin

A

E. coli (enterotoxigenic), Vibrio cholerae, Staph aureus, Clostridium perfringens, Clostridium difficile, Clostridium botulinum, Bacillus cereus.

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48
Q

Diarrhea: bacterial invasive

A

E. coli (enteroinvasive), Shigella, Salmonella, Yersinia enterocolitica, Vibrio parahemolyticus, Campylobacter jejuni.

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49
Q

Diarrhea: parasites

A

Giardia lamblia, Cryptosporidium parvum, Entamoeba histolytica.

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50
Q

Diarrhea: drugs

A

laxatives, antacids with magnesium

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51
Q

Diarrhea: food toxins

A

puffer-fish, ciguatoxin, scombroid

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52
Q

Diarrhea: chronic GI disorders

A

Ischemic colitis, malabsorption, irritable bowel, inflammatory bowel disease

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53
Q

Diarrhea: secretory

A

Vibrio cholera, campylobacter, E. coli, Salmonella.

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54
Q

Diarrhea with systemic illness

A

Salmonella typi (enteric fever with diarrhea as late symptom)

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55
Q

64yo with CAD deficiency develops diarrhea, vomiting, and vague abdominal pain that rapidly progresses to hematochezia and severe abdominal pain.

A

Acute mesenteric ischemia.

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56
Q

48yo M with recurrent abdominal pain after eating. Also has hypercholesterolemia.

A

Chronic mesenteric ischemia (intestinal angina).

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57
Q

53yo M with abdominal pain and diarrhea with blood. Plain abdominal film reveals “thumbprinting” pattern in the descending colon and narrowing of the colonic lumen.

A

Colonic ischemia. More common than mesenteric ischemia, typically affects splenic flexure and other watershed areas.

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58
Q

55yo F previously treated for carcinoma of cervix, now with nausea, vomiting, and rectal bleeding.

A

Radiation colitis. Intestinal ischemia may develop due to endarteritis obliterans. Sometimes pseudo-obstruction. Barium study = thickening of mucosal folds, narrowing of lumen. Symptoms due to rapid transit time and malabsorption.

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59
Q

38yo F with celiac disease with chronic diarrhea and weight loss. Has been strictly adhering to gluten-free diet.

A

Intestinal lymphoma. Increased risk in celiac disease.

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60
Q

19yo F with diarrhea and bullous skin eruption.

A

Dermatitis herpetiformis. Gluten senstive enteropathy (celiac disease) + bullous skin eruption. Both may respond to gluten-free diet.

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61
Q

8yo M with chronic diarrhea, steatorrhea, abdominal distention, and failure to thrive.

A

Celiac disease (Gluten-sensitive enteropathy). Adult presentation more vague with megaloblastic anemia, diarrhea, vague abdominal symptoms. Abs include endomysial, gliadin, and reticulin. IgA endomysial Ab with high sensitivity and specificity.

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62
Q

Diagnosis of celiac disease?

A

Biopsy! Flattening of vili. Definative diagnosis requires trial of gluten-free diet.

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63
Q

Causes of malabsorption.

A

Stomach: post-gastrectomy dumping, ZE, pernicious anemia. Hepatic/biliary: bil. obstr. / cholestasis. Pancreas: CF, pancreatitis, CA. Sm. bowel: celiac, crohn’s, removal of sm. bowel, fistulae/blind loops, infection, radiation, lymphoma, drugs, whipple’s.

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64
Q

Approach to malabsorption?

A
  1. confirm impaired absorption (fecal fat, Schilling test) 2. Identify specific deficiencies (CBC, Fe, iron, folate, B12, PT/PTT, vit D 3. establish cause.
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65
Q

34yo M with severe recurrent peptic ulcer, diarrhea, and weight loss.

A

Zollinger-Ellison. Gastrin producing tumor associated with MENI (usually pancreatic). Diagnosis = high gastrin level and high basal secretion of acid.

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66
Q

Upper GI bleeding?

A

GUMBLEEDING = Gastritis, Ulcer, Mallory-Weiss, B, L, Esophagitis, Esophageal varices, angioDysplasia, Infection, N, GERD.

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67
Q

Common causes of lower GI bleeding?

A

hemorrhoids, anal fissure, inflammatory bowel, diverticulitis, carcinoma, intussusception.

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68
Q

Test for bacterial overgrowth?

A

glycochocolate breath test, based on deconjugation of radiolabeled bile acid and exhalation of labeled CO2.

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69
Q

GI utility of US and CT?

A

Liver, pancreas, and biliary tract.

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70
Q

GI utility of plain film?

A

Demonstrate dilatation (toxic megacolon), obstruction.

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71
Q

GI utility of angiography?

A

GI bleeding of obscure cause or suspected mesenteric ischemia.

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72
Q

Unusual causes of lower GI bleeding?

A

AV fistulae, hereditary-hemorrhagic-telangiectasias (Osler-Weber-Rendu), angiodysplasia, vasculitis, amyloidosis. Meckel’s, blood disorders (hemophilia, thrombocytopenia), rupture of AAA into bowel.

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73
Q

Common causes of upper GI bleeding?

A

Duodenal ulcer > stomach erosions / gastritis > GERD > gastric ulcer > Mallory-Weiss > duodenal erosions > esophageal/gastric varices > stomach CA

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74
Q

Causes of sore tongue?

A

Systemic: folate/B12/Fe deficiency, collagen-vascular dx, diabetes. Local: smoking, fractured tooth/dentures/crowns, candidiasis, dry mouth.

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75
Q

Teeth and gums

A

Blue line at tooth/gum margin = lead; gingivae swollen and purplish = scurvy; hyperplastic gingivitis = phenytoin, cyclosporin, and calcium antagonists; yellow staining = tetracycline.

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76
Q

Apthous ulcers?

A

poor dental hygeine, gluten enteropathy, inflammatory bowel dx, Behcet’s.

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77
Q

Enlarged tongue?

A

Acromegaly, myxoedema, amyloidosis, motor neuron disease.

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78
Q

71yo M smoker with progressive dysphagia.

A

Esophageal CA

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79
Q

25yo M with progressive dysphagia and no past medical history.

A

Esophageal ring. Occur at or near GE junction. Cause unknown.

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80
Q

31yo M with HIV and odynophagia.

A

Esophagitis due to candidia, herpes, or CMV.

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81
Q

H. pylori infection.

A

Association with duodenal ulcer (100%) > gastric (80%) > duodenitis/gastritis. Increased risk of gastric cancer and MALT lymphoma. Test: serology or urease breath test.

82
Q

Gastritis causes?

A

Infectious = rotavirus, norwalk, E. coli, H. pylori. Drug/chemicals = aspirin and other NSAIDs, alcohol. Asymptomatic chronic = elderly persons often with H. pylori. Atrophic = autoimmune (positive parietal cell Abs) with pernicious anemia.

83
Q

38yo F presents with melena and epigastric pain. Barium study revealed rugal hypertrophy.

A

Menetrier’s disease (giant hypertrophic gastritis). Assoc. with protein-losing enteropathy.

84
Q

GI disease with finger clubbing?

A

malabsorption, small intestinal disease, and cirrhosis.

85
Q

Hormone:

A

Stimulation test and markers:

86
Q

ACTH and GH

A

Insulin hypoglycemia test: GH, cortisol, blood glucose

87
Q

ACTH and GH

A

Glucacon: GH, blood glucose

88
Q

TSH

A

Thyrotropin releasing hormone: TSH, T3, T4, prolactin, GH

89
Q

LH, FSH

A

Gonadotropin releasing hormone: FSH, LH, spermatogenesis, ovulation

90
Q

GH

A

GHRH: GH

91
Q

ACTH

A

CRH: ACTH, cortisol

92
Q

ADH

A

Fluid deprivation:

93
Q

11yo M with with color blindness, midline facial deformity, and anosmia.

A

Isolated gonadotropin deficiency = Kallman’s syndrome. Prepubertal onset, hypogonadal hypogonadism.

94
Q

28yo F with resolving meningitis develops polyuria.

A

Central diabetes insipidus. Most frequently associated with craniopharyngioma. Rarely with anterior pituitary disease. Test = water deprivation and measure urine osmolality.

95
Q

43yo M with thick skin, broad nose, and prominent supraorbital and nuchal ridges.

A

Acromegaly. Uncommon. May occur in MEN1. Large spade-like hands. Enlargement of the tongue. Hoarse voice. Cardiomegaly, heart failure, and malignancy causes death. Tufting of terminal phalanges on x-ray.

96
Q

Elevation of prolactin level due to physiolgic cause?

A

Sleep, stress, nipple stimulation, coitus, pregnancy, suckling.

97
Q

Most common cause of Cushing’s syndrome?

A

ACTH overproduction by pituitary 60% > ectopic ACTH (15%) > adrenal adenoma (15%) > adrenal carcinoma (10%). Cushing’s disease usually pituitary microadenoma (90%) more frequently in women.

98
Q

48yo F with develops increasing pigmentation following bilateral adrenalectomy for Cushing’s disease.

A

Nelson’s syndrome. May follow adrenalectomy if ACTH production continues in excess.

99
Q

Diagnosis of Cushing’s syndrome.

A

Low dose 48hr dex suppression. Screening with overnight dex suppresion test or 24hr urinary free cortisol. If plasma ACTH is undetectable, usually adrenal tumor. Pituitary-dependent disease suppresses, whereas adrenal tumors and ectopic ACTH does not.

100
Q

Ectopic ACTH tumors?

A

Bronchial carcinoma, carcinoid.

101
Q

29yo F with SLE and history of DVTs develops increased skin pigmentation and profound hypekalemia.

A

Primary adrenal insufficiency. Antiphospholipid syndrome can destroy adrenal glands.

102
Q

31yo M with fatigue, weight loss, GI disturbances, and dark spots on the inside of his cheeks.

A

Addison’s disease. Autoimmmune or rarely TB, granulomatous disease, metastases. Other causes of adrenal insufficiency include withdrawal of steroid therapy, Waterhouse-Friderichsen, anticoagulant therapy. Hyponatremia, hyperkalemia, vitiligo.

103
Q

Poor growth syndromes?

A

Rare congenital syndromes, nutritional/emotionald deprivation, GH deficiency (fat with immature facies and genitals), hypothyroidism, Cushing’s. “Fat and short” likely endocrine. Turner’s 45XO, and Noonan’s (45XO/XY mosaic).

104
Q

34yo F with short stature, large head, prominent forehead and disproportion of body and limbs.

A

Achondroplasia. Autosomal dominant. #1 short stature with abnormal proportions.

105
Q

15yo F found on pelvic exam to have bilateral masses in the labia. LH levels is high.

A

Testicular feminization syndrome. XY male with X-linked deficiency of androgen receptors.

106
Q

Newborn with ambiguous genitalia, clitoral hypertrophy, and partial fusion of labioscrotal folds.

A

Congenital adrenal hyperplasia. 21-hydroxylase defiency. Excess androgenic cortisol precursors.

107
Q

18yo M with small firm testes, gynecomastia, and female distribution of body hair.

A

Klinefelter’s. Infertile, may be unusually tall, 47XXY.

108
Q

Common causes of amenorrhea?

A

Hyperprolactinemia, weight loss, anorexia nervosa, autoimmune associated ovarian failure (Addison’s or other).

109
Q

24yo obese F with menstrual irregularity, hirsutism, and acne.

A

Polycystic ovarian syndrome. Stein-Leventhal syndrome = obesity, amenorrhea, and hirsutism. DM2 develops in 40% by age 40. Labs = incr LH, +/- incr T, normal FSH, prolactin and TSH. Pelvic

110
Q

61yo M with new onset atrial fibrillation, heart failure, and 20lb weight loss over 12 months.

A

Masked hyperthyroidism. Commonly due to toxic multinodular goiter. Lacks typical Grave’s features.

111
Q

44yo F with diffuse goiter, pretibial myxoedema, and tachycardia.

A

Grave’s. IgG antibodies against TSH receptor = thyroid stimulating Abs (TSAb). Exopthalmos, lid lag, periorbital puffiness, increased lacrimation, conjunctival edema, ophthalmoplegia, loss of visual acuity.

112
Q

53yo F with hyperlipidemia, puffy face, and coarse hair, and hair loss.

A

Hypothyroidism: Spontaneous atrophic, postsurgical, radioactive I, Hashimoto’s (thyroid peroxidase and thyroglobulin Abs in 90%). Dry skin, coarse hair, facial edema, effusion, ascites, cardiac dilatation. Assoc c pernicious anemia and carpal tunnel.

113
Q

Most common goitrous hypothyroidism?

A

Hashimoto’s. Women&raquo_space; Men. Older women > younger.

114
Q

58yo F from central Africa with large goiter.

A

Endemic goiter. Can be euthyroid. Due to iodine deficiency.

115
Q

73yo F with hypothermia and altered mental status and history of hypothyroidism.

A

Myxedema coma. marked by hypothermia, cardiac failure, altered MS, convulsion. Mortality 50%.

116
Q

46yo M with painful itchy ear following family vacation to lake. Experiences pain when tragus is pressed during exam.

A

Otitis externa. Symptoms inlcude pain, pruritus, hearing loss, and fullness. Tragus = semicircular cartilage in front of ear canal. Staph and pseudomonas.

117
Q

51yo diabetic M with painful itchy ear. Physical exam reveals inflammation and swelling of the pinna.

A

Cellulitis. Differentiate from otitis externa.

118
Q

47yo HIV positive M with “boring” ear pain and long-standing ear infection that has not responded well to treatment.

A

Necrotizing external otitis. Occurs in ICd pts. Refer to otolaryngology.

119
Q

28yo F with diffusely swollen and tender pinna.

A

Perichondirits. IV antibiotics, serious condition.

120
Q

31yo M with circumscribed swellings in the external canal with tenderness on exam.

A

Furunculosis. Rx with topical ABs.

121
Q

82yo M with pruritus of the external canal. Whitish exudate with black spots on exam.

A

External mycotica (otomycosis). Aspergillus niger causes black spots over white.

122
Q

44yo construction worker with dizziness, tinitus, and conductive hearing loss in the right ear.

A

Cerumen impaction.

123
Q

Complications of sinusitis?

A

Osteomyelitis, periorbital infections (pain with eye motion, ptosis, proptosis), cavernous sinus thrombophlebitis (CN III, IV, VI palsies), brain abscess, meningitis.

124
Q

Persistent sinusitis?

A

Consider Wegener’s granulomatosis, cystic fibrosis, Kartagener’s, and TMJ syndrome. Need CT scan to rule out obstruction.

125
Q

25yo F develops high fever, myalgias, rhinorrhea, and sore throat.

A

Common cold, due to: influenza virus, rhinovirus, coronavirus, adenovirus, parainfluenza. Rule out bacterial sinusitis, pharyngitis, and allergic rhinitis (history of itchy eyes, nose, and throat).

126
Q

25yo F develops high fever, myalgias, and palpable tender neck nodes.

A

Bacterial pharyngitis. No cough or rhinorrhea. Tonsillar exudate may be present. Viral pharyngitis much more common (90%). Group A strep&raquo_space; other strep, mycoplasma, chlamydia, and neisseria gonorrhea. Diptheria with grey-white pseudomembrane.

127
Q

25yo F with itchy eyes, nose, and throat. Pale edematous nasal mucosa.

A

Allergic rhinitis. Seasonal or allergic pattern. Tearing. Mucosa is not erythematous.

128
Q

25yo F with purulent nasal discharge, tender face, and toothache.

A

Bacterial sinusitis. Treat with amoxicillin.

129
Q

Findings suggestive of Group A strep pharyngitis.

A

Recent exposure, history of infection in past yr, absence of cough, hoarseness, or rhinorrhea, temp > 101, tonsillar exudate, anterior cervical lymphadenopathy.

130
Q

Causes of secondary hypertension (5% of all HTN, primary/essential HTN 95%)

A

Aortic coarctation, intrinsic renal dx, renal artery stenosis (young = fibromuscular, old = athero), primary hyperaldosteronism (suspect if hypokalemic and not on diuretic), Cushing’s, Pheo,

131
Q

1 anatomic, two renal, three adrenal, and four CENTs cause HTN.

A

CENTs = hyperCalcemia, Ethanol or Estrogen (oral contraceptives) most common causes, Neurologic disease = increased ICP, Thyrotoxicosis.

132
Q

21yo F develops dramatic increase in creatinine after starting ACE inhibitor therapy for hypertension.

A

Consider renal artery stenosis!

133
Q

31yo M with mental status changes and blood pressure of 225/124

A

Hypertensive emergency. Hypertensive urgency = systolic BP > 220. Hypertensive emergency = Urgency + End-organ damage: encephalopathy (ms changes), intracranial hemorrhage, aortic dissection, MI, unstable angina, hypertensive nephropathy.

134
Q

HTN treatment: uncomplicated, DM1, CHF systolic, CHF diastolic, isolated systolic HTN, CAD or MI, BPH, pregnancy.

A

beta blocker or diuretic; ACE or diuretic; beta blocker, diuretic, or CCB; diuretic; beta blocker; prazosin; methyyldopa.

135
Q

18yo M with painful swollen knee and ipsilateral leg lower leg edema.

A

Ruptured popliteal cyst.

136
Q

54yo F with inguinal lymphadenopathy, pelvic symptoms, weight loss and bilateral lower extremity edema. Dry and scaly skin on feet.

A

Lymphedema.

137
Q

43yo F with painless edema worse at the end of the day. Varicose veins present. Improves with elevation.

A

Chronic venous insufficiency.

138
Q

54yo F with painful thighs and bilateral lower extremity edema following knee replacement surgery.

A

Bilateral DVTs.

139
Q

45yo F with tachycardia, bilateral lower extremity edema, and tremor.

A

Pretibial myxedema (Grave’s disease)

140
Q

12yo M with leg length discrepancy since childhood and ipsilateral lower extremity edema.

A

Congenital venous malformation.

141
Q

24yo F with SLE presents with bilateral lower extremity edema.

A

Nephrotic syndrome.

142
Q

28yo M with taut, shiny skin and extreme sensitivity to touch of right leg. Edema in the right leg on exam.

A

Reflex sympathetic dystrophy.

143
Q

43yo M with lots of tatoos develops peripheral edema and necrotic skin lesions.

A

HCV is associated with cryoglobulins and membranoproliferative glomerulonephropathy.

144
Q

45yo F with recurrent infections, nonhealing leg ulcers, history of RA, and splenomegaly on examination.

A

Felty’s syndrome.

145
Q

Calcinosis, Raynaud’s, Esophageal dysmotility, Sclerodactyly, Telangiectasias.

A

CREST

146
Q

45yo F with history of PBC with skin thickening of the fingers and difficulty swallowing.

A

CREST. Associated with PBC and primary pulmonary hypertension.

147
Q

Causes of chronic cough

A

Postnasal drip > GERD > asthma. Also cigarette use +/- COPD. Less common causes include bronchiectasis, CHF, ACE-I, post-pertussis cough, malignancy, chronic infection usually c systemic symptoms, and psychogenic cough.

148
Q

Headache and jaw claudication.

A

Giant cell arteritis. Diagnosis with biopsy, start steroid rx immediately. Large vessel vasculitis.

149
Q

26yo Asian F with finger ischemia and arm claudication.

A

Takayasu’s arteritis. “Pulseless disease”. Diagnosis with aortic arch angiogram.

150
Q

32yo M with skin ulceration, hematuria, abdominal pain after eating, joint pain, and right hand weakness.

A

Polyarteritis nodosa (PAN). Necrotizing vasculitis of small and medium muscular arteries. 1/3 associated with HBV, also with HCV. No pulmonary findings!

151
Q

35yo M with shortness of breath, fever, maculopapular rash, palpable purpura, and cutaneous nodules. CBC reveals eosinophilia.

A

Churg-Strauss. Granulomatous reaction in medium sized vessels.

152
Q

28yo M with recurrent sinusitis, hematuria, and hemoptysis. Has had recurrent fevers, weight loss and arthralgias.

A

Waegener’s granulomatosis. C-ANCA positive vasculitis of small arteries. Upper and lower respiratory infections.

153
Q

Drug causing palpable purpura.

A

Hypersensitivity vasculitis.

154
Q

45yo M with abdominal pain, swollen joints, purpuric rash, and hematuria following URI four days ago.

A

Henoch Schonlein Purpura. Definition = IgA nephropathy plus abdominal pain, join pain, and purpura.

155
Q

24yo F with history microscopic hematuria and microalbuminuria, now with gross hematuria following URI.

A

IgA nephropathy

156
Q

34yo M with hemoptysis and hematuria.

A

Goodpasture’s syndrome. Anti-glomerular basement membrane antibody. (Anti-GBM).

157
Q

50yo M with CLL presents with blurry vision, finger ischemia, headache, and lethargy.

A

Monoclonal cryoglobulinemia. Rx with plasmapheresis.

158
Q

60yo M with history of IVDA now with arthralgia, purpura, glomerulonephritis, and neuropathy.

A

Mixed cryoglobulinemia. Result of immune complex deposition. Associated with HCV, lupus, and RA.

159
Q

35yo M with one year progressive dyspnea. Oxygen saturation drops with ambulation.

A

Idiopathic pulmonary fibrosis or PCP pneumonia. Hallmark of interstitial lung disease.

160
Q

Dermatomyositis patients have increased risk of what?

A

Malignancy: colon, lung, breast, and prostate.

161
Q

Causes of wheezing

A

CARES: Cardiac asthma (CHF), Churg-Strauss, Allergic bronchopulmonary aspergillosis, Reflux esophagitis (GERD), Exposures (irritants, meds), Embolism, Sinusitis, Strongyloides.

162
Q

Causes of obstructive lung disease?

A

Asthma, COPD, bronchiectasis, cystic fibrosis.

163
Q

Causes of restrictive lung disease?

A

Pleural fibrosis, Interstitial (idiopathic, fungal infection: histoplasmosis, sarcoid), neuromuscular (myasthenia gravis, myopathy, Guillain-Barre), alveolar edema or inflammation, BOOP, pleural effusion, kyphoscoliosis, pregnancy, obesity.

164
Q

What causes most cases of acute bronchitis?

A

Viral > atypical bacteria (Mycopl, Chlamydia, Legionella) > typical bacteria rarely (s. pneumo, h. flu, morexella) > allergic. Acute onset of cough and sputum production s hx of chronic pulm dx and no evidence of pneumonia or sinusitis. No Abs needed.

165
Q

Most common immunodeficiency?

A

Selective IgA deficiency. Caused by anti-IgA IgG. Recurrent sinopulmonary infections.

166
Q

Low IgA, IgG, and IgM. Normal numbers of B cells. Pts 15-30yrs old.

A

Common variable immunodeficiency. Associated with autoimmune disease and lymphoid malignancies.

167
Q

Recurrent pyogenic infections of skin and lower respiratory tract. Pruritus, coarse facies, keratotic nails.

A

Job’s syndrome. Hyper-IgE. Autosomal recessive. Abscess, empyema, staph. aureus.

168
Q

Thrombocytopenia, eczema, and recurrent infections.

A

Wiscott-Aldrich. Depressed cell-mediated immunity, high IgA.

169
Q

Low set ears, opportunistic and viral infections, severly sick after live viral vaccine, hypokalemia and hypocalcemia.

A

DiGeorge syndrome. Congenital immunodeficiency with no thyroid or parathyroid. 3rd and 4th pharyngeal pouch.

170
Q

5yo M without tonsils, recurrent URIs and skin infections, and asymmetric arthritis.

A

Bruton’s congenital agammaglobulinemia.

171
Q

Recurrent staph and strep infections in albino child.

A

Chediak-Higashi.

172
Q

34yo M with slow onset of cough and pleuritic chest pain several days following resolution of URI.

A

Pneumococcal pneumonia. Usually abrupt presentation occurs insidiously following viral respiratory tract infection.

173
Q

57yo M with COPD develops pleuritic CP and worsening cough.

A

H. flu pneumonia.

174
Q

88yo F develops cough, fever, and pleuritic CP.

A

S. aureus pneumonia. Seen in ICd and nursing home pts.

175
Q

54yo alcoholic presents with productive cough, fever, and lobar consolidation on CXR.

A

Aerobic GNR pneumonia.

176
Q

19yo F with mild pneumonia and hemolytic anemia.

A

Mycoplasma. Prominent extrapulmonary symptoms including: erythema multiforme, myocarditis, erythema nodosum, bullous myringitis, neurological abnormalities.

177
Q

23yo M with mild pneumonia and hoarseness with severe pharyngitis.

A

C. pneumoniae. Distinguishing feature = hoarseness with severe pharyngitis.

178
Q

Atypical pneumonias?

A

Legionella, Moraxella, Chlamydia, Mycoplasma.

179
Q

Pneumonia requiring hospital admission?

A

Two or more lobes, increased A-a gradient or tachypnea, mental status changes, vulnerable patient, homeless patient, very high/low white count.

180
Q

45yo M with pedal edema, nocturia, and morning headache.

A

Sleep apnea. Symptoms include snoring, daytime hypersomnolence, morning headache, impotence, nocturia or enuresis, pedal edema, exercise fatigue. Exclude hypothyroidism and acromegaly.

181
Q

Abdominal Pain due to metabolic / systemic disorders: Puking My Very BAD LUNCH

A

Porphyria, Mediterranean fever, Vasculitis, Black widow, Addison’s / Angioedema, DKA, Lead, Uremia, Neurogenic (diabetes, syphillis, spinal nerve impingement), hyperCalcemia, Herpes zoster.

182
Q

Abdominal pain: RUQ

A

liver, gallblader

183
Q

Abdominal pain: Epigastric

A

stomach, pancreas, duodenum, abdominal aorta

184
Q

Abdominal pain: LUQ

A

spleen

185
Q

Abdominal pain: lower quadrants

A

appendix, intestine, ovary, fallopian tubes, testes, kidney, ureters

186
Q

Abdominal pain: periumbilical

A

small intestine, appendix, abdominal aorta

187
Q

Abdominal pain: suprapubic

A

bladder, uterus, ovaries, fallopian tubes

188
Q

Causes of secretory diarrhea that persists despite fasting?

A

Thyrotoxicosis, carcinoid syndrome, colon cancer, colonic polyps, durgs.

189
Q

Drugs causing diarrhea?

A

Colchicine, Mg-containing antacids, antibiotics, theophylline, lactulose, laxatives.

190
Q

Causes of osmotic diarrhea?

A

Drugs, pancreatic insufficiency, celiac disease, lactose/fructose intolerance, laxatives.

191
Q

Causes of exudative diarrhea?

A

(Protein, blood, mucus) Stools with leukocytes and blood. Causes include: Lymphoma, Whipple’s disease, collagenous colitis, IBD, ischemic colitis.

192
Q

Intestinal motility disorders associated with?

A

IBS, DM, narcotic use, systemic sclerosis, fecal impaction, surgery (post-gastrectomy dumping, post-vagotomy syndrome).

193
Q

Causes of malabsorption?

A

Radiation enteritis, bacterial overgrowth, enteric fistula, ileal resection, short bowel syndrome.

194
Q

Diarrheas associated with immunodeficiency?

A

Isospora belli, Microsporidia, Cryptosporidium parvum, Giardia lamblia, Strongyloides stercoralis, Entameba histolytica, Mycobacterium-avium-intracellulare complex, Clostridium difficile, CMV.

195
Q

What accounts for 50% of cases of diarrhea referred to gastroenterologists?

A

Functional diarrhea. No organic cause.

196
Q

34yo M presents with low back pain worse with rest and bloody diarrhea.

A

Crohn’s disease.

197
Q

67yo M with CAD and familial hypercholesterolemia presents with bloody diarrhea.

A

Ischemic bowel.

198
Q

31yo F with diarrhea, weight loss, and skin rash.

A

Celiac disease with dermatitis herpetiformis.

199
Q

Anion gap metabolic acidosis?

A

MUDPILES: Methanol, Uremia, Diabetic ketoacidosis, Paraldehyde, Iron/INH, Lactic acidosis, Ethylene glycol, Salicylates.

200
Q

Causes of constipation?

A

Neoplasia, strictures, adhesion/rectoceles, drugs (tricyclics, opiates, neuroleptics, antihistamines, CCBs, iron supplements, antacids without Mg), DM, hypothyroid, hypokalemia, hypomagnesemia, uremia, neurologic disorders, IBS, amyloid, scleroderma.

Internal Medicine (4 decks)

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