Block 1 Flashcards
1
Q
Recommendations for lung cancer screening
A
- Annual screening→low-dose CT in adults age 55 - 80 who have a 30-pack-year smoking history and currently smoke or have quit within past 15 years
- Discontinue Screening→Once a person has not smoked for 15 years or develops a health problem limiting life expectancy or ability/willingness to have curative lung surgery
2
Q
Best initial test to Dx acromegaly
A
Insulin-like growth factor-1 (IGF-1)→significantly ↑↑ level compared to the average for age-matched equivalents►positive screen
3
Q
Confirmatory test for acromegaly
A
GH after 100 g of glucose is given orally
- Positive if GH remains high (>5 ng/mL)
- Normally a glucose load completely suppress levels of GH
4
Q
Why don’t you have hyperkalemia and salt loss in secondary adrenal insufficiency caused by pituitary disease?
A
Aldosterone production is mainly dependent on the renin-angiotensin system→not aldosterone deficiency
*Salt wasting, hyperkalemia, and death are associated with aldosterone deficiency
5
Q
Use of Metyrapone test. How does it work?
A
- Assess ACTH production
- Blocks cortisol production→↑ ACTH levels.
- A failure of ACTH levels to rise→suggests pituitary insufficiency
6
Q
Most common cause of panhypopituitarism
A
Pituitary adenomas
7
Q
Best diagnostic study for evaluating and confirming the diagnosis of bladder cancer
A
Cystoscopy
8
Q
Most specific and sensitive test to evaluate celiac disease
A
IgA anti-tissue transglutaminase (anti-tTG) and antiendomysial antibodies (anti-EMA)►jejunal mucosal damage
*Serum antigliadin antibody no longer used routinely►lower sensitivity and specificity
9
Q
How do you diagnose celiac disease without small bowel biopsy?
A
- Positive serology (anti-tTG, anti-EMA) + confirmed dermatitis herpetiformis by Bx
- Small bowel biopsy is the most accurate test
10
Q
Most accurate test of celiac disease and its common findings
A
Small bowel biopsy→blunting of distal duodenal and/or proximal jejunal villi, crypt hyperplasia, intraepithelial lymphocytosis
*Always necessary to exclude bowel wall lymphoma
11
Q
How do you differentiate corticosteroid-induced vs statin-induced myopathy?
A
- Corticosteroid induced→muscle enzymes normal, EMG normal. Lower extremity weakness and proximal atrophy. No correlation with dosage or duration.
- Statin-induced→↑↑ CPK ten times upper limit, weakness
12
Q
Enough findings to diagnose Wilson disease. Most accurate test to Dx.
A
- Low ceruloplasmin concentration (<20 mg/dL), Keyser-Fleischer rings on slit-lamp examination
- Liver Biopsy
13
Q
Clinical hallmark of necrotizing fascitis
A
Rapidly progressive erythema with pain and tenderness significantly out of proportion of physical findings
14
Q
Most important and definitive treatment of necrotizing fascitis
A
Surgical debridement
15
Q
Difference of the diffusion capacity of the lung for carbon monoxide between emphysema and chronic bronchitis, and why?
A
- Low in Emphysema→loss of alveolar capillaries
- Normal in Chronic Bronchitis
16
Q
How do you differentiate Rotor vs Dubin-Johnson syndrome?
A
- Dubin-Johnson→lack elevation of urinary coproporphyrins, has darkly pigmented liver
- Rotor→milder in presentation without black liver, ↑urinary coproporphyrins
17
Q
When do you evaluate for liver transplantation?
A
Decompensated liver failure
- Portal hypertension
- ↓Synthetic function (variceal hemorrhage, ascites, encephalopathy)
- Liver biopsy→evaluate extent of structural damage to the liver and candidacy for liver transplantation
18
Q
Most common presentation of glucagonoma
A
- Glucose intolerance
- Necrolytic migratory erythema→annular erythematous dermatitis, blistering and erosions
- Weight loss
- Normocytic normochromic anemia
- Diarrhea, thromboembolism
19
Q
What is the differential diagnosis in a patient with polydipsia and polyuria? Initial steps in management.
A
- Diabetes insipidus, psychogenic polydipsia, Diabetes mellitus
- 1st step to evaluate→measure urine osmolarity
- 2nd step→Water deprivation test
20
Q
What do you do next when diagnosing megaloblastic anemia by vitamin B12 deficiency?
A
Confirm the etiology before treatment (better route is intramuscular)
*Dietary absence (vegans), pregnancy, malabsorption syndrome, ileal or gastric resection, pernicious anemia
21
Q
History suggestive of pernicious anemia. How do you confirm the diagnosis?
A
- History of dyspepsia, autoimmune condition (ex, diabetes type 1), elderly.
- Low B12 levels→confirm:
- Serum anti-intrinsic factor antibodies and anti-parietal cell antibodies
22
Q
In which patients do you perform a head CT scan before lumbar punction when suspect meningitis?
A
- Papilledema
- Immunocompromised state
- New-onset seizure (within one week of presentation)
- History of CNS disease (mass lesion, stroke, focal infection)
- Abnormal level of consciousness
- Focal neurologic deficit
23
Q
What is the therapy for Heparin-induced Thrombocytopenia (HIT)?
A
- Discontinuation of Heparin
- Lepirudin (anticoagulant)
*Continue anticoagulation with non-heparin medication (argatroban, fondaparinux)
24
Q
Esophagus manometry results in scleroderma. How do you suspect esophageal compromise?
A
- ↓Lower esophageal sphincter pressure, ↓esophageal peristalsis
- Gastroesophageal reflux disease (GERD) and dysphagia
25
What is motility-type dysphagia? example of a disease with that.
- Difficulty with liquids and solids from the onset of symptoms
- Diffuse esophageal spasm
26
Gradual luminal narrowing of the esophagus after many years of gastroesophageal reflux disease (GERD).
Peptic esophageal stricture
27
Which are the two aberrant electrical pathways of the Wolff-Parkinson-White (WPW) syndrome?
- Pre-excitation→involves the node itself►Supraventricular tachycardias (atrial fibrillation or atrial flutter)
- Electrical pathway→reaches out of the AV node, connects to the bundle of His in the ventricles→early electrical impulse to the ventricles while bundle of His is in refractory period►Ventricular tachycardia
28
Drugs of choice in acute WPW hemodynamically stable. Which drugs you must avoid?
- Drugs of choice: Procainamide or Amiodarone
- MUST avoid: Digoxin, calcium channel blockers➡block the normal AV node and force conduction into the abnormal pathway; Beta-blockers.
29
Gold standard treatment for chronic WPW syndrome.
Radiofrequency ablation
30
Most sensitive test to diagnose pheochromocytoma
Plasma free fractionated metanephrines
31
Risk factors to develop shingles
- Advancing age
- Immunosupression
- Trauma to the skin
32
What is acquired perforating keratosis (Kyrle disease)? and with what condition is related?
- Dome shaped and umbilicated papules with a central keratotic crust on legs or less often trunk, neck, arms or scalp. Early lessions→pustular. Late lessions→resemble prurigo nodularis (central keratotic scale)
- Chronic renal failure and Diabetes mellitus
33
How do you differentiate cardiac taponade vs right ventricle failure?
- Pulsus paradoxus►Cardiac taponade, NO in right ventricle failure
* Both have Beck's triad►muffled cardiac sounds, hypotension, jugular venous distention
34
What is Felty syndrome? Treatment.
- Rare complication (<1%) of rheumatoid arthritis:
* High titer rheumatoid factor
* Splenomegaly
* Neutropenia (<1500, <1000→↑risk of clinically significant infection)
- Gold, MTX (second-line Tx for RA). G-CSF for severe neutropenia or unresponsive to Tx for RA, when splenectomy is contraindicated or not possible
35
Most likely ECG pattern expected in a pulmonary embolism.
Non-specific ST segment T waves abnormalities and sinus tachycardia→70% of PE
*S1 Q3 T3, right axis deviation, Right bundle branch block, atrial fibrillation [right heart strain]→may suggest PE, but absence doesn´t rule out (20% of PE)
36
Most useful test for diagnosing pericarditis, which finding is more specific?
ECG→Diffuse concave ST elevation, PR depression (more specific finding), occasionally flipped T waves
*Echocardiogram→to rule out coexisting pericardial effusion or tamponade, often normal in acute pericarditis alone. Find small amount of fluid is not specific, seen in variety of conditions
37
Treatment of urinary uric acid stone (radiolucent)
- Hydration
- NSAIDs (pain killers)
- Potassium citrate or potassium bicarbonate→alkalinization of urine►uric acid stone dissolve in an alkaline medium
*Add allopurinol if stones don't resolve with initial treatment
38
Why you should avoid sodium bicarbonate for a uric acid stone treatment?
Extra salt load→volume expansion►hypercalciuria→formation of calcium stones
*Uric acid is a nidus for calcium oxalate stone formation
39
Findings in a mesenteric angiography of angiodysplasia. Clinical presentation. Treatment.
- Dilated, slow-flowing vein in the colon
- Lower GI bleeding
- Endoscopic ablation→ cauterization or laser coagulation (if fails, surgical removement of affected bowel)
40
Most common cause of lower GI bleeding.
1. Diverticulosis
| 2. Angiodysplasia
41
When beta-blocker and ACEIs are more efficient between them to reduce mortality in post-myocardial infarction patients?
- Beta-blockers→post-MI patients with normal ejection fraction (↓ O2 demand and ventricular arrhythmias)
- ACEI→post-MI in patients with reduced ejection fraction
42
Most effective method to diagnose dural sinus thrombosis and findings on it.
Cerebral venogram→bilateral infarcts along the posterior and anterior frontal lobes and parietal lobes, extending into the white matter (Sagital sinus infarcts)
*Example: Sagital sinus infarcts tend to cross arterial vascular territories and extend into the white matter
43
Which Beta-blockers you should avoid when treating Heart Failure and why?
Pindolol and Acebutolol→have sympathomimetic activity
44
Which electrolyte disturbance is caused by Bartter syndrome? Look like which pharmacologic effect?
- Reabsorptive defect in thick ascending loop of Henle→Affect K/Na/Cl cotransporter►hypokalemia, metabolic alkalosis, hypercalciuria
- Chronic loop diuretic use
45
Treatment for Bartter syndrome
- Spironolactone→antagonizes effect of ↑ aldosterone (↑ by the loss of electrolytes and intravascular volume in Bartter)
- NSAID→↓ excessive prostaglandins (in Bartter ↑PGE)
46
Specific findings at physical exam of Graves disease
- Ophtalmopathy-exophthalmos (proptosis)
- Periorbital edema
- Pretibial myxedema
47
How do you identify a pericardial effusion at chest x-ray? Important physical examination finding to suspect it.
- Enlarged and globular cardiac silhouette ("water bottle" heart shape)
- Clear lung fields
- Inability to palpate the point of maximal apical impulse
- If large pericardial effusion→cardiac tamponade►Beck's triad (hypotension, elevated JVP, muffled heart sounds)
48
Initial evaluation for coarctation of the aorta. Dx confirmation.
1. Simultaneous palpation of the brachial and femoral pulses→assess for brachial-femoral delay
2. Bilateral upper extremities (supine position) and lower extremities (prone position) blood pressure measurement→evaluate blood pressure differential
- Dx confirmation→Echocardiogram
49
Embolism that more commonly occur during vascular procedures such as peripheral angiography or interventions, guidewire or catheter manipulations during cardiac catheterization, intraaortic balloon pump insertion.
Cholesterol crystal embolism→disruption of atherosclerotic aortic plaques►systemic atheroembolism
50
Most common cause of sepsis in sickle cell disease.
Streptococcus pneumoniae→despite immunization, is due to non-vaccine serotypes
51
When do you use acute therapy for hyperkalemia?
- ECG changes
- K>7 mEq/L (with or without ECG changes)
- Rapidly rising K due to tissue breakdown
* Dialysis→renal failure or severe life-threatening hyperkalemia unresponsive to initial therapy
* Calcium gluconate and insulin with glucose
52
Which metabolic disturbance can be found on diabetic hyporeninism? why?
- Hyperkalemic metabolic acidosis
- Damage of the juxtaglomerular apparatus→hyporeninemic hypoaldosteronism►"aldosterone deficiency"→Renal tubular acidosis type IV (hyperkalemic RTA)
53
Pathophysiologic cause of renal tubular acidosis type IV (hyperkalemic RTA) and its metabolic consequence
- Aldosterone insufficiency→Diabetic hyporeninism, ACEI, ARBs, NSAIDs, heparin, cyclosporine, adrenal insufficiency
- Aldosterone resistance→K sparing diuretics, obstructive nephropathy, TMP/SMX
* *Impaired function of the cortical collecting tubule►retention of H and K→hyperkalemic Non-anion gap metabolic acidosis
*Preserved kidney function→at least 20-50 mL/min
54
Diagnostic gold standard for viral myocarditis. Most frequently the diagnosis is assisted by which study?
- Endomyocardial biopsy (lymphocytic infiltration) aided by viral polymerase (DNA or RNA)
- Cardiac MRI▶️late enhancement of the epicardium
55
What is the indication for mineralocorticoid receptor antagonists on heart failure?
- Left ventricular ejection fraction <40% with recent ST-elevation myocardial infarction
- Symptomatic heart failure
56
Tumors that cause approximately 75% of all malignant pleural effusions
Lung carcinoma, breast carcinoma and lymphoma
57
Differences between ascending and descending aortic aneurysms in location and etiology
- Ascending aneurysm→60% cases, origin anywhere from aortic valve to the innominate artery, cystic medial necrosis (aging) or connective tissues disorders (Marfan sx or Ehler-danlos sx)
- Descending aneurysm→40% cases, origin distal to the subclavian artery, atherosclerosis
58
Chest X-ray findings suggesting thoracic aortic aneurysm
- Widened mediastinal silhouette
- Increase aortic knob
- Tracheal deviation
59
Finding of ECG of acute pericarditis due to renal failure
- Nonspecific T wave abnormalities
| * Classic diffuse ST elevations are typically absent due to lack of myocardial inflammation
60
Difference between the pleural exudate of tuberculous effusion and malignancy etiology
- Tuberculous→usually lymphocytosis>70%
| - Malignancy→lymphocytosis is uncommon
61
Which electrolyte disturbance is associated with increase susceptibility of digoxin toxicity? Why?
Hypokalemia (may be associated with excessive diuretic use)→permissive for digoxin binding at K+ binding site on Na+/K+ ATPase
62
Best initial tests to diagnose pulmonary embolism. Which is most often the best next step or test to do after them?
- Chest x-ray, EKG, Arterial Blood Gas
- CT Angiogram (Spiral CT Scan)→standard of care to confirm PE
*Angiography is most accurate but 0,5% mortality (rarely done)
63
If you suspect a pulmonary embolism and the V/Q and spiral CT don't give a clear diagnosis, what do you do next?
Lower Extremity Doppler study
- Positive→no further test is needed (80% of PEs come from legs and the therapy won't change)
- Negative→Withhold Heparin
64
First choice test to confirm pulmonary embolism in pregnancy
V/Q scan
*Completely normal scan excludes a clot
65
When do you use thrombolytics in a pulmonary embolism?
- Hemodynamically unstable→hypotension (systolic BP<90, tachycardia, etc)
- Acute right ventricular dysfunction
*There is no specific time limit as in stroke or MI
66
What is Ludwig angina? Clinical presentation.
- Rapidly progressive cellulitis of the submandibular space→most cases arise from dental infections
- Rapidly systemic symptoms→fever, chills, malaise
- Local compressive→mouth pain, drooling, dysphagia, muffled voice, airway compromise
67
Findings in the physical examination of Ludwig angina
Mass effect from edema; tender, indurated submandibular area; elevated floor of the mouth; tongue displaced; crepitus
68
What is the first step to confirm the diagnosis of peripheral artery disease?
Ankle-brachial index→<0,9►diagnostic of occlusive PAD with a 90% sensitivity and 95% specificity in symptomatic patients
*Arterial ultrasound of the lower extremities→less sensitive and specific than ABI►localize site and severity of vascular obstruction
69
How are the potassium deposits in DKA and why?
Excess of glucagon→hyperglycemia, ketonemia, osmotic diuresis►net renal loss of K+→depletion of total body K+ stores
*Despite reduction in K+ stores→serum [K+] may be ↑ due to acidemia and ↓insulin activity►redistribution of K+ to the extracellular fluid compartment
70
Major risks factors for Clostridium difficile infection
- Recent antibiotic use (fluoroquinolones, clindamycin, cephalosporins, penicillins)
- Advanced age (>65 years)
- Gastric acid suppression (Ex, PPI)
71
Gold standard for diagnosis Herpes encephalitis
PCR of HSV DNA in CSF
*Highly sensitive and specific. Replacing brain biopsy.
72
Best initial test in acute exacerbation of asthma
- Peak expiratory flow (PEF)→approximation of the FVC
| - Arterial blood gas (ABG)→↑ A-a gradient
73
Most accurate test for asthma in an asymptomatic patient
>20% decrease in FEV1 with use of methacholine or histamine
*Less likely to find an ↑ in FEV1 using a SABA (albuterol)→false negative
74
Findings in the pulmonary function testing in asthma
- ↓ FEV1, FVC and FEV1/FVC
- ↑>12% and 200 mL in FEV1 with albuterol
- ↓>20% in FEV1 with methacholine or histamine
- ↑ Diffusion capacity of the lung for Carbon monoxide (DLCO)
75
When do you use anticholinergics in chronic asthma management?
If SABA, LABA and inhaled corticosteroids at maximum doses are not sufficient
*Iptratropium, Tiotropium
76
Typical presentation in acute asthma exacerbation in arterial blood gas. Which finding suggests the patient is getting worse?
- Hyperventilation→Respiratory alkalosis
- ↑ work of breathing→respiratory muscle fatigue→inability to maintain adequate ventilation (hyper)►normal pH and PaCO2 (normalized or elevated from respiratory alkalosis)►impending respiratory collapse
77
Which are the 3 most common causes of chronic cough? What is chronic cough?
- Chronic cough→lasting >8 weeks
- Upper airway cough syndrome (postnasal drip)
- Asthma
- Gastroesophageal reflux disease (GERD)
78
What is a solitary pulmonary nodule? What is the first step when evaluating it?
- Rounded opacity, <3cm, completely surrounded by pulmonary parenchyma, No associated with lymph node enlargement
- Determine if nodule is low, intermediate or high malignancy risk
79
Which is the management of high, intermediate and low malignancy risk solitary pulmonary nodule?
- High risk→surgical excision
- Intermediate risk→FDG-PET, serial CT scans or Bx depending radiographic findings
- Low risk→serial CT scans
80
Which disease result in C1 inhibitor deficiency? Which products of the complement cascade are elevated?
- Hereditary angioedema
- Edema producing factors→C2b, bradykinin
* C1q levels are normal, ↑in acquired angioedema forms
* ↓C4 in all forms of angioedema
81
How do you differentiate hyperthyroidism due to thyroiditis and exogenous thyroid hormone use (factitious thyrotoxicosis)? What do they have in common?
- Common→Radioactive iodine uptake (RAIU) decreased
- Differentiate:
* ↑Thyroglobulin→thyroiditis (subacute or silent), iodide exposure
* ↓Thyroglobulin→Factitious thyrotoxicosis
82
Which electrolyte disturbance can occur due to immobilization and its mechanism?
- Hypercalcemia
- ↑Osteoclastic bone resorption
*Onset around 4 weeks, patients with chronic renal insufficiency develop it in about 3 days
83
Hallmark of Paget's disease and underlying breast condition
- Painful, itching, eczematous, and/or ulcerating rash on the nipple that spreads to the areola
- Adenocarcinoma
84
Where is the most common location of the VIPoma? How do you confirm the diagnosis?
- Pancreatic tail
| - VIP level >75 pg/mL
85
Most common electrolytic disturbances in VIPoma syndrome
- VIPoma syndrome (pancreatic cholera)►secretory, watery diarrhea and ↓ gastric acid secretion→hypokalemia and hypo or achlorhydria
86
Mechanisms by which Beta-adrenergic agonists cause hypokalemia
- Stimulate Na-K ATPase pump and the Na-K-2Cl cotransporter→potassium shift into the intracellular space
- Release of Insulin→promotes intracellular K+ shift
87
Two major exposure associations of Squamous cell carcinoma. How do you call an SCC arising from a burn wound?
- Ultraviolet sun exposure
- Chronically wounded, scarred, or inflamed skin
- Marjolin Ulcer
*Within skin overlying a focus of osteomyelitis, radiotherapy scars, venous ulcers
88
First line inpatient non-ICU treatment for community-acquired pneumonia
- Fluoroquinolone: Respiratory→moxifloxacin, levofloxacin
| - Beta-lactam + macrolide
89
Best initial and most accurate diagnostic test for COPD?
- Best initial: chest x-ray
| - Most accurate: Pulmonary Function Test
90
Most appropriate initial step in the management of Hyperkalemia with ECG changes
Calcium gluconate
91
Most appropriate next step when suspect clinically amebic liver abscess
EIA test - antibodies for Entamoeba histolytica
*The role of microscopic stool examination is limited. Less than 30-40% of patients with amebic liver abscess have concomitant intestinal amebiasis, and 10% of the population is infected with the nonpathogenic strain of E. dispar
92
Most likely causal organism of a macular rash involving abdomen, chest, back, extremities and soles without fever and pruritus
Treponema pallidum
93
Why are the thyroid antibodies (antithyroid peroxidase/antithyroglobulin) important to evaluate hypothyroidism?
If TSH is less than double the normal and antibodies are positive→replace thyroid hormone
94
Ventricular apical ballooning, history of myocardial infarction after a stressful situation and normal coronary angiography. Disease and its mechanism?
- Tako-Tsubo cardiomyopathy
| - Massive catecholamine discharge
95
When do you use Exercise Tolerance Testing to evaluate chest pain?
Etiology is not clear and EKG is not diagnostic
96
Why the EKG in an Exercise Tolerance Testing may not be suitable to read and interpret?
Baseline EKG abnormality→Left bundle branch block, left ventricular hypertrophy, pacemaker use, effect of digoxin
97
Which antiplatelet drugs are preferred in addition to aspirin in a patient undergoing angioplasty and stenting? and why?
- Prasugrel or Ticagrelor
| - Restenosis of stenting is best prevented
98
Medication that offers the best mortality benefit in chronic angina
Aspirin and Beta blockers
99
Which other medications can be used instead of ACEI/ARB in systolic dysfunction to decrease mortality? in what situation could you switch them?
- Hydralazine (arterial vasodilator→↓ afterload) and Nitrates (dilate coronary arteries) - Reduce mortality in african-american
- Hyperkalemia by ACEI or ARB
100
Which are the most common liver metastases?
Primary tumors from gastrointestinal tract (colon), lung and breast
101
Most important clues to recognize a Valley Fever. Which is the etiology?
- Valley Fever
1. Desert Southwest (Ex, Arizona or California)
2. Symptoms onset 7-14 days after inoculation, subclinical, >50% Community acquired pneumonia (fever, chest pain, dry or productive cough, lobar infiltrate)
3. Often accompanied: arthralgias, erythema nodosum or erythema multiforme
- Coccidioides immitis
102
Best first-line treatment for acute multiple sclerosis exacerbation
1. Glucocorticoids
| 2. Plasmapheresis - MS flares refractory to corticoid therapy
103
Screening indications for Diabetes mellitus
- USPSTF→patients with sustained blood pressure (treated or untreated) >135/80
- ADA→all patients >45 years,and at any age with risk factors for diabetes
104
Which EKG finding in the context of acute coronary syndrome has the worst prognosis?
ST elevation in V2-V4 leads or Anterior Wall Miocardial Infarction
*If untreated - 30 to 40% mortality in 1 year
105
Most important measure in decreasing the risk of restenosis of the coronary artery after PCI
Placement of drug-eluting stent (paclitaxel, sirolimus)
106
When do you suspect a perivalvular abscess?
Symptoms of infective endocarditis + New conduction abnormalities (ex, 2:1 second-degree atrioventricular block with syncope)
107
Which symptom is more specific when suspecting beta-blocker intoxication?
- Beta-blocker intoxication→bradycardia, atrioventricular block, hypotension (ex, present also in CCB, digoxin, cholinergic intoxication)
(+) Wheezing more specific
108
In an ST-segment depression acute coronary syndrome, which is the best next step in the management after aspirin is given? Which of them is best in terms of mortality?
- Heparin
| - Low molecular weight heparin superior to unfractionated heparin
109
Most accurate test in diagnosing congestive heart failure. In which case do you use it?
- Multiple-gated acquisition scan (MUGA) or nuclear ventriculography
- Ex: Patient receiving chemotherapy with doxorrubucin
110
Best initial treatment for beta-blocker poisoning. Best next step if there is no improvement after the initial treatment.
- Initial Tx→secure airway, isotonic fluids, atropine
| - Next best step→Glucagon (⬆cAMP➡Tx for BB and CCB toxicity) in profound refractory hypotension
111
How can you suspect Hypoparathyroidism induced by low magnesium?
- Low Calcium
| - Low Phosphorus (different from other causes of hypoparathyroidism➡High Phosphorus)
112
Mechanism by which hypomagnesemia induce hypocalcemia
↓Mg→⬆resistance to PTH and ⬇PTH secretion
113
Causal agent and treatment of Bacillary angiomatosis
- Bartonella
| - Oral Erythromycin
114
Most common cause of Glomerulonephritis in adults
IgA Nephropathy
115
Earliest findings of macular degeneration. Risk factors.
- Distortion of straight lines (look wavy)→Grid test to screen
- Driving and reading first activities affected
- Ophtalmologic exam: drusen deposits in macula
- Increase age, smoking
116
Which arterial blood gas result would you find in a carbon monoxide poisoning?
- Lactic acidosis→↓ bicarbonate, ↓pH (tissue hypoxia)
| - ↑ Carboxyhemoglobin levels
117
Which finding do you expect to find in cell blood count in a patient with chronic carbon monoxide poisoning?
Kidney responds to tissue hypoxia→↑EPO→Secondary polycythemia
118
Which sodium disturbance you may find secondary to a pulmonary pathology and why?
Hypotonic Euvolemic Hyponatremia
- Pulmonary pathology (Pneumocystis pneumonia, Ex)→ SIADH
* Infusion of normal saline - worsen hyponatremia
119
What potassium level do you expect in a hyperglycemic crisis (DKA or HHS)? Why?
- Normal or slightly elevated serum potassium
- Insulin deficiency→put K+ out of cells
- Osmotic diuresis→excessive urinary K+ loss
*Total body potassium deficit (3-5 mg/kg)
120
Which is the implication of a total body potassium loss in a Hyperglycemic Hyperosmolar State?
Insulin therapy→abruptly decrease K+ - severe hypokalemia
| *K+ reposition during initial insulin therapy
121
Colonoscopy recommendations for colon cancer screening in inflammatory bowel disease
- 8-10 years after diagnosis (12-15 years if only left colon)
- Repeat every 1-3 years
122
Colonoscopy recommendation for colon cancer screening in lynch syndrome (HNPCC)
- Age 20-25 years
| - Repeat every 1-2 years
123
Colonoscopy recommendations for colon cancer screening in classic familial adenomatous polyposis
- Age 10-12 years
| - Repeat anually
124
Colonoscopy recommendations for colon cancer screening family history of adenomatous polyps or CRC
- Age 40 or 10 years before the age of diagnosis of the relative
- Repeat every 5 years
125
Kartagener syndrome screening test
Decreased nasal nitric oxide
126
Most common cause of endocarditis in a patient with associated nosocomial urinary tract infection
Enterocci species, Ex Enterococcus faecalis
*Recent instrumentation can yield the bacteremia
127
Which germs that cause endocarditis or bacteremia are associated with colon pathology? What test you should perform?
- Clostridium septicum>Streptococcus bovis
- Perform colonoscopy➡rule out colon cancer
*Tumor cells undergo anaerobic glycolysis➡adequate environment for C. septicum spores germination; damage colonic mucosa➡bacteria translocation into bloodstream
128
How do you treat endocarditis secondary to staphylococcus aureus on a protestic valve?
Oxacilin, Nafcilin or Cefazolin + Rifampin for 6 weeks
129
Strongest indication of surgery in acute endocarditis
Acute valve rupture and congestive heart failure
130
Most common bacteria causing endocarditis when culture is negative
- Coxiella
| - Bartonella
131
Pathognomonic sign of syphilis
Epitrochlear lymphadenopathy→2-handed "sailor's handshake"
132
When do you consider an adequate or successful treatment of syphilis?
4-fold decrease in serologic titers at 6-12 months
133
What is the endemic typhus? Clinical presentation.
Louse-borne rickettsial infection→abrupt onset of fever, severe headache, malaise and centrifugally-spreading macular or maculopapular rash (sparing palms and soles)
134
How is the rash of the Rocky Mountain spotted fever?
Maculopapular rash that spreads centripetally toward the trunk. Includes palms and soles. Petechial over time.
135
Treatment of tertiary syphilis
Intravenous Penicillin for 10-14 days
| *Desensitize if penicillin allergy
136
What must you do with a pregnant woman with syphilis or a patient with neurosyphilis to treat them?
Penicillin desensitization
137
What is the long-term outcome of nonalcoholic fatty liver disease (NAFLD)?
- Hepatic Fibrosis 40%
| - Cirrhosis 10-15%
138
Since hepatic steatosis is similar between NAFLD and alcoholic liver diseases, how can you differentiate both?
- NAFLD→AST/ALT ratio <1
- Alcoholic liver disease→AST/ALT ratio 2:1
*Off course ask for severe alcohol exposition
139
Extrarenal complications of autosomal dominant polycystic kidney disease. What is the most common?
1. Hepatic cyst
2. Intracranial berry aneurysm (5-15%)
3. Valvular heart disease (most often mitral valve prolapse and mitral regurgitation)
4. Colonic diverticula
5. Abdominal wall and inguinal hernia
140
Treatment for anticholinergic toxicity
Physostigmine►cholinesterase inhibitor
141
Most common sources of exposure for cyanide intoxication
- Dermal: partial immersion in liquid cyanide or cyanide solutions or contact with molten cyanide salts
- Inhalational: Hydrogen cyanide, product of combustion from nitrogen-containing synthetic polymers (foam, cotton, paint, silk, etc)►Faster onset of symptoms
- Intestinal: ingestion of amygdalin (cyanogenic glucoside in apricot seeds), cyanide directly
142
Which empiric treatment should be done in unconscious victims of smoke inhalation?
Cyanide toxicity→Hydroxicobalamin►forms Cyanocobalamin; Sodium thiosulfate or Nitrites►induce methemoglobinemia
*Prevent cardiorespiratory arrest and permanent neurologic disability
143
Two major products of combustion in closed spaces
Hydrogen cyanide (HCN) and Carbon monoxide (CO)
144
Best initial management of altered mental status of unclear etiology (suspecting intoxication)
- Opiate antagonist→Naloxone (give immediately, opiate overdose is fatal)
- Dextrose
145
Keys on clinical presentation to diagnose aspirin overdose
- Tinnitus and hyperventilation
- Respiratory alcalosis
- Metabolic acidosis with ↑ Lactate
146
Best initial test when suspect tricyclic antidepressant toxicity and why?
EKG➡look for cardiac toxicity
- Widening of the QRS complex➡⬆risk ventricular arrhythmia
- Prolongs QT→Torsade de Pointes
147
Severe symptoms of carbon monoxide poisoning and most appropriate treatment
- Severity: CNS symptoms, Cardiac symptoms, Metabolic acidosis
- Treatment: Hyperbaric oxygen
*No severe treat with 100% Oxygen
148
Best initial and most effective therapy for Methemoglobinemia
- Best initial: 100% Oxygen
| - Most Effective: Methylene blue (↓ half-life)
149
Treatment for Lead poisoning
- Oral: Succimer
| - Parenteral: Ethylenediaminetetraacetic acid (EDTA) and dimercaprol (BAL)
150
Most accurate test and best initial test for Lead poisoning
- Most accurate: Lead level
| - Best initial: Level of free erythrocyte protoporphyrin
151
Describe the clinical presentation and lesions of pityriasis rosea
- Viral prodrome: headache, malaise, fever.
- Lesions: First herald patch→erythematous annular lesion, scaly around edge. In 1 week→clusters of small, scaly, erythematous oval lesions on the trunk in "Christmas tree" pattern (back). Mild pruritus.
152
Best initial test and their results when suspect idiopathic intracranial hypertension
- MRI→Normal or empty sella (70%)
- MRV→Normal
- Lumbar puncture→Opening pressure >250 mmH2O
153
Risk factors for splenic infarction
- Hypercoagulable disorder
- Source of embolic disease (atrial fibrillation)
- Myeloproliferative neoplasm
- Hemoglobinopathy (sickle cell disease)
154
Most probable diagnosis in a patient with chest/back pain, fever, vomiting and pleural effusion. Most common etiologies.
Esophageal perforation or rupture
- Effort rupture (ex, self-induced vomiting, Boerhaave syndrome)
- Instrumentation (ex, endoscopy), trauma
- Esophagitis (infection, pills, caustic)
155
Best diagnostic test for esophageal perforation and expected finding
Esophagography or CT scan with water-soluble contrast (no barium, it is inflammatory)→Leak from perforation
156
Diagnosis of Hepatitis C Virus chronic infection
- Hepatitis C virus antibody→Positive serology
| - HCV PCR→confirmatory molecular test (Do this because HCV may clear in up to half of patients)
157
What is "Lone Atrial Fibrilation"? Treatment.
- Paroxysmal, persistent or permanent AF + No evidence of cardiopulmonary or structural heart disease
- Usually <60 years, CHA2DS2VASc=0→No treatment needed
158
Most common cause of megaloblastic anemia in chronic alcoholics
Folate deficiency
*Alcohol impair enterohepatic cycle and absorption of folate, may develop anemia in 5-10 wks (body stores are limited)
159
Which types of acid-base disorder may cause acute kidney injury and why?
- Non-anion gap metabolic acidosis⇦impaired acid excretion, ammonia generation or bicarbonate reabsorption
- Anion gap metabolic acidosis⇦retention of unmeasured uremic toxins
160
COPD patient with acute-on-chronic respiratory acidosis
Hypoventilation→CO2 narcosis
161
Typical MRI/CT finding of high-grade (ex, IV grade) astrocytoma (glioblastoma)
Butterfly appearance with central necrosis, heterogenous serpiginous contrast enhancement
162
Diseases associated with erythema nodosum
- Streptococcal infection
- Sarcoidosis
- Tuberculosis
- Endemic fungal disease (Histoplasmosis)
- Inflammatory Bowel Disease
- Behcet Disease
163
Therapy for hemodynamically stable atrial fibrillation with rapid ventricular response
Beta blockers, Calcium channel blockers (Diltiazem), Digoxin
164
How do you identify by auscultation the tricuspid valve compromised by infective endocarditis? Why?
- Tricuspid valve endocarditis (Regurgitation)→⇧holosystolic murmur with inspiration (differentiates right sided murmurs from all others)→Carvallo's sign
- ↑Venous blood flow on inspiration→↑stroke volume of right ventricle in systole→↑blood from right ventricle to the right atrium
165
Measure of aortic valve area on echocardiogram to cause left ventricular hypertrophy and symptoms of angina
Aortic valve area<1cm2→severe stenosis
166
Measure of aortic valve area to diagnose aortic stenosis
Valve area<3cm2
167
When do you suspect Renovascular Hypertension?
Patients with resistant hypertension and:
- Diffuse atherosclerosis
- Asymmetric kidney size
- Recurrent flash pulmonary edema
- ↑Creatinine >30% from baseline after initiate ACEI or ARB's
- Continuous abdominal bruit (high specificity)
168
Auscultations findings of severe mitral regurgitation
- Blowing and high-pitched holosystolic murmur at the apex
- S3 gallop→sudden cessation of blood flow into dilated LV during filling phase of diastole
*Absence of S3 helps rule out severe chronic MR
169
Effect of brussels sprouts, broccoli and green tea on warfarin
↓Effect→↑Thrombosis risk NO bleeding risk
170
Effect of acetaminophen on warfarin
↑Effect→↑Bleeding risk
171
Signs and symptoms of malignant hyperthermia
- Hypercarbia (↑cell metabolism)→Tachypnea
- Sinus tachycardia
- Masseter/generalized muscle rigidity
- Myoglobinuria (rhabdomyolysis)
- Hyperthermia→later manifestation, not usually present initially
172
Cause of malignant hyperthermia
Autosomal dominant or sporadic skeletal muscle receptor disorder→excessive calcium release→sustained muscle contraction
*Triggered by volatile anesthetics, succinylcholine, excessive heat
173
Neuropsychiatric manifestations of Wilson disease
- Psychiatric→Depression, personality changes, psychosis, mania, anxiety
- Neurologic→parkinsonism, dysarthria, choreoathetosis, ataxia
174
Risk factors of Multiple Sclerosis
- Female, caucasian, HLA-DRB1
- Location: USA, Europe, cold climate
- Low Vitamin D levels
- Smoking
- EBV
175
Most common cause of mitral and aortic stenosis
- Mitral stenosis→rheumatic fever (most common immigrants in USA)
- Aortic stenosis→congenital bicuspid valve or calcification by aging
176
Treatment of mitral and aortic stenosis
- Mitral stenosis→dilation through balloon valvuloplasty with catheter
* Valve replacement when ballon cannot be done or fails
- Aortic stenosis→surgical replacement
177
Unique features of mitral stenosis clinical presentation
Dysphagia, Hoarseness, Atrial fibrilation (stroke) [Big LA], Hemoptisis
178
Etiology of Mitral Regurgitation
- Any reason that dilated the heart
- Hypertension
- Endocarditis
- MI with papillary muscle rupture
179
First line of treatment of regurgitant lesions (mitral and aortic regurgitation)
Vasodilators: ACEIs or ARBs or nifedipine→delay the progression
180
Valve replacement indication for mitral regurgitation
When heart starts to dilate→LVESD>40mm or EF<60% *Operatively or with catheter placing a clip or sutures
181
Most common presentation of mitral valve prolapse
Atypical chest pain, palpitations and panic attack
182
Heart compensatory mechanisms of the asymptomatic phase of chronic volume overload (AR, MR, Ischemic disease, dilated cardiomyopathy)
Eccentric hypertrophy→↑Left ventricle compliance (have additional LV volume) and ↑Left ventricle contractility (sustain stroke volume)
183
Most common cause of sick sinus syndrome
Age-related degeneration of the cardiac conduction system→fibrosis of the sinus node
184
ECG findings of sick sinus syndrome
- Sinus bradycardia
- Sinus pauses (delayed P waves)
- Sinoatrial nodal exit block (dropped P waves)
185
Clinical presentation of sick sinus syndrome
- Bradycardia→fatigue, dyspnea, dizziness, syncope
- Palpitations:
+Bradycardia-tachycardia syndrome→bradycardia alternating with supraventricular tachycardia
+Atrial arrhythmias (ex, atrial fibrillation)
186
Most common arrhythmia on hyperthyroidism and its treatment
- Thyroid hormone ↑beta-adrenergic receptor expression ↑sympathetic activity→Atrial fibrillation (5-15%)
- Beta-blockers (propranolol, atenolol)→continue until hyperthyroidism is well treated
187
Pathologic causes of sinus bradycardia
Sick sinus syndrome, myocardial ischemia, obstructive sleep apnea, hypothyroidism, ↑intracranial pressure, medications (b-blockers, CCB excess)
188
Best initial therapy for hypertrophic obstructive cardiomyopathy and ordinary hypertrophic cardiomyopathy
Beta-blockers
*Strong negative inotropic drugs are useful - Verapamil, Disopyramide
189
Contraindicated medications in HOCM
Diuretics, ACEIs do not help (may worsen symptoms), digoxin, hydralazine
*Diuretics may help in ordinary hypertrophic cardiomyopathy symptoms
190
Distinctive feature of chronic constrictive pericarditis
Chronic pericarditis→fibrosis and calcification of pericardium►Calcification on x-ray (Best initial test)
191
Presumed etiology of idiopathic pericarditis
Coxsackie B virus
192
Treatment of idiopathic pericarditis
NSAID and colchicine
193
What is the Kussmaul sign and when it is most likely associated?
- ↑JVD on inhalation (normally neck veins go down on inspiration)
- Constrictive pericarditis
194
Most appropriate study for pericardial tamponade
Echocardiogram→right atrial and ventricular diastolic collapse
195
EKG findings on pericadial tamponade
Electrical alternans→different heights of QRS complexes between beats
196
Best initial test for aortic dissection
Chest x-ray→widening of the mediastinum
*Source MTB2
197
Screening test and indication for aortic aneurysm
Men who ever smoked >65 years with ultrasound
198
What is peripartum cardiomyopathy? In which stage during pregnancy is most commonly developed?
- LV dysfunction secondary to antibodies against the myocardium in a pregnant woman
- After delivery in most cases
199
Best initial test for hemodynamically stable and unstable patients in those who suspect aortic dissection
- Stable→CT angiography, MRA if contrast is contraindicated
- Unstable→Transesophageal echocardiogram
*Source First aid 2CK
200
Differences between the treatment of the type A and B aortic dissection
- Type A (ascending)→proximal to left subclavian artery (may involve descending aorta)►all patients should have surgery
- Type B (descending)→distal to left subclavian artery (no involve ascending aorta)►BP, heart rate control; surgery if leakage, rupture, or compromised organs
