Deck 1

Question 1

Diffuse itching in absence of rash

Answer 1

Do general labs search for systemic cause (TFT, iron, CBC, CMP)
Liver dz, CKD, thyroid, HIV, IDA, age appropriate cancer screening

Question 2

Psoas sign

Answer 2

pain on extension of hip - lumbar plexus compression from iliopsoas hematoma

Question 3

FHx of mucocutaneous bleeding, no prolonged PTT, on OCP

Answer 3

vW dz

Question 4

Newly Dx DM2 - what to do to screen

Answer 4

Urine alb-Cr ratio now

Do not use MDRD (only in pts with CKD - not accurate with preserved glomerular fxn)

Question 5

Mycobacterium Avium Complex in middle aged woman with no pre-existing lung condition, has discrete nodules - exposed to soil in SW US, no smoking

Answer 5

Need to repeat sputum ctx for MAC - if still positive then BAL or video assisted thoraoscopy for bx

Question 6

COPD tx FEV<60%

Answer 6

1st recommendation - long acting broncodilator (tiotropium)

don’t use budesonide (ie inhaled corticosteroid) - no benefit compared to long acting broncodilator

Question 7

Depression screening

Answer 7

screen all adults as long as appropriate support available

Question 8

Hep B screening

Answer 8

not routinely recommneded except pregnant women

Question 9

Osteoporosis screening

Answer 9

Women > 65 or high risk (3 month corticosteroid, etoh, low body mass, smoking, dementia, anticonvulsant use)

Question 10

Screening for H pylori in setting of GIB or PPI current use or abx use

Answer 10

ONLY H. Pylori serology

Question 11

Cardiorenal syndrome

Answer 11

fluid overload from inpt saline/abx use decreases ability to excrete sodium - heart can’t compensate for inc’d preload in setting of CHF -> IV lasix (even with elev Cr)
Don’t use lisinopril, don’t use BB in setting of acute decompensated HF

Question 12

Vaginal atrophy - pale walls, petechiae, whiff neg, no clue cells - no response for vaginal itching from lubricants

Answer 12

low dose vaginal estradiol/ring

don’t use oral estrogen (inc’d r/o CVA, CAD, VTE, breast CA)

Question 13

Bacterial vaginosis

Answer 13

inc’d vaginal pH, clue cells, +whiff test, vaginal d/c

Tx: metronidazole

Question 14

Yeast infections

Answer 14

thick white d/c, KOH + with hyphae

Tx: vaginal clomitrazole

Question 15

Posterior mediastinal mass

Answer 15

schwannoma - benign neoplasm from NEURAL tissue - usually located in posterior mediastinum
could also be esophageal tumor/cyst
(cough, venous distention, hoarsness, CP, Back pain, asx)
Usually need removal if sx don’t regress or if dx in question

Question 16

Anterior mediastinal mass

Answer 16

thyroid, thymus, lymphomas

Question 17

Middle mediastinal mass

Answer 17

broncogenic cysts, pericardial cysts, LAD

Question 18

Allergic contact dermatitis

Answer 18

eczema caused by environmental exposure, unusual geographic pattern (ie oval, rectangular patch) -> edematous erythematous then vesices/bullae if severe -> chornic - > lichenified, scaly, hyperpigmented

Question 19

Ecthyma

Answer 19

saucer shaped ulcers, legs, feet -> strep

Question 20

Nummular dermatitis

Answer 20

pruritic eczematous - annular coin shaped erythematous plaque - pinpoint vesicles, honey colors serous crusting

Question 21

Pulmonary valve stenosis

Answer 21

JVD prominent A wave, RV heave, systolic thrill, ejection click (rapid opening of stenotic pulmonary valve leaflets) - click decreases with inspiration but INCREASES systolic murmur (R sided murmurs increase with inspiration) - 2nd LEFT ICS -> left clavicular region, dilated pulmary artery on CXR

Question 22

ASD

Answer 22

fixed split S2,

Question 23

Bicuspid aortic valve

Answer 23

with more AS, click less audible, diminished, delayed carotid pulsation (pulsus parvus et tardus), apical impulse sustained, late peaking murmur -> carotids, LVH

Question 24

MVP/regurg

Answer 24

early systolic click, mid systolic murmur - with valsalva murmur longer but click moves closer to S1

Question 25

VSD

Answer 25

holosystolic murmur at left lower sternal region

Question 26

DISH - diffuse idiopathic skeletal hyperostosis

Answer 26

male, obese, DM calcification of enthesis region (where tendons insert near bone) Osteophyes on at least 4 contiguous vertebrae (anterolateral)

Question 27

Ankylosing spondylitis

Answer 27

Younger patients sarcoilitis vertical bridging syndesmophytes

Question 28

Lumbar spinal stenosis

Answer 28

chornic lower back pain pseudocladication - pain radiating down both legs on walking better with rest - BUT ALSO RELEIVED leaning forward over shopping kart, walking uphill, climbing stairs Narrowing spinal canal on MRI

Question 29

Spondylolisthesis

Answer 29

subluxation of on vertebrae over another - lax or damaged ligaments - > anterior posterior movement

Question 30

Parkinson's dz - wearing off syndrome

Answer 30

wearing off motor flucutuations, drug induced dyskinesia -> indication for deep brain stimulation (can't use further meds will cause further wearing off symoptoms and more dyskinesia Subthalamic nucleus or globus pallidus DO NOT DO ACUTE DRUG HOLIDAY - can cause acute parkinsonian sx

Question 31

Functional hypothalamic ammenorrhea

Answer 31

stress, excessive weight loss, excessive excercise Tumor/infiltrative lesion, lymphoma, sarcoid Low FSH, normal prolactin, TSH Neg preg, neg progestin challenge (no withdrawal bleeding - estrogen low) Pit MRI no lesion

Question 32

PCOS

Answer 32

look for hyperandrogenism (hirsuitism) | PCOS has good estrogen levels so progestin challenge would cause withdrwawal bleeding

Question 33

Primary ovarian insufficiency

Answer 33

FSH would be elevated (trying to raise levels of estrogen)

Question 34

Ceftaroline IV

Answer 34

B lactam abx with activity against CA-MRSA (only 5th gen cephalosporin active against MRSA) complicated soft tissue infection

Question 35

Pregnant pt with VTE/PE

Answer 35

LMWH at least 6 months and 6 weeks post partum | NO WARFARIN - teratogenic

Question 36

Polymyositis

Answer 36

anti-Jo abs Tx: Prednisone, azathroprine r/o ILD - need HRCT and PFTs to dx (can have normal CXR) PFT restrictive defect with decreased DLCO If HRCT neg then check Echo (RHC) r/o PAH as cause of isolated dec in DLCO

Question 37

Primary adrenal insufficiency

Answer 37

nausea, wt loss, salt craving hypontremia, hyperkalemia, low cortisol, high ACTH hypopigmentation dec'd production of mineralocorticoid (hyponatremia, hyperkalemia) Dec'd prodxn androgens (low DHEA) Random cortisol inappropriately low for level of hypotension Random cortisol >17 would r/o primary adrenal insuff If ACTH >100 (random) then confirms dx Likely autoimmune given fhx thyroid, premature gray hair, scleroderma don't need MRI pituitary - high ACTH normal in response to low cortisol/DHEA etc Tx: hydrocortisone

Question 38

Calcium oxalate kidney stones

Answer 38

envelope shaped crystals s/p bypass surgery - dec'd fatty absortion (binds Ca in gut) inc'd oxalate absorbtion 2/2 dec'd Ca absorption Tx: low fat diet, CaCarbonate supp to dec oxalate absorbption, aggressive oral hydration

Question 39

Hypercalciuria

Answer 39

Thiazide diuretics

Question 40

Migraine with aura

Answer 40

unilateral, pulsatile, mod to severe intensity, nausea, photophobia -> visual sx = aura tx: if NSAIDs don't work -> sumitriptan Propranolol ONLY FOR PPX not tx (>10 attacks/month) Migraine MRI - white matter hyperdensities

Question 41

Molluscum contagiosum

Answer 41

Pox virus firm umbilicated pearly papules waxy surface sexually active adult Henderson-patterson' bodies on bx

Question 42

Bacterial folliculitis

Answer 42

pustules centered on hair follicles

Question 43

Large esolphageal varices

Answer 43

Needs ppx Primary tx: endoscopic ligation (NOT SCLEROTX) and/or non-selective BB (propranolol) No BB if contraindication (ie asthma) large varices >5mm despite air insulfation and red whale marks (inc'd r/o rupture)

Question 44

When to use TIPS

Answer 44

Varicieal bleeding - if no effect with endo ligation | Gastric bleeding - if balloon tamponade ineffective

Question 45

Prevent surgical site infection

Answer 45

abx 30-60min prior to incision - maintain therapeutic level thru procedure - no reason to continue 24 hrs after procedure Control/eliminate modifable risk factors - DM, obesity tob use, avoid shaving hair, chorohex prep, minizize traffick, check list

Question 46

Prevention of neonatal GBS

Answer 46

decolonization of strep in vagina/rectum, no role in sugical site infection prev

Question 47

hypoactive sexual disorder

Answer 47

Sex therapy lack of sexual thought, dec'd desire individual or couples therapy ok

Question 48

Lofgren sydrome

Answer 48

known sarcoid d/o =- fever, erythema nodosum - hilar LAD - usually spontanous resolution - no need for tissue dx

Question 49

STEMI

Answer 49

``` If PCI facility >1.5 hrs away then give thrombolytics unless contraindication: prev IC hemorrheage Known CVA ischemic stroke 3 months suspected aortic dissection active bleeding significant closed head or facial trauma 3 months Relative contraindication HTN >180/110 ichemic strove >3monthas ago CPR/major surgery w/in 3 wks recent internal bleeding (2-4 wks) Previous steptokinase active PUD current use of A/C ```

Question 50

Manage life sustaining care in critiaclly ill pt

Answer 50

Pt needs dialysis acutely - said initially that didn't want to be on long term machines but wants to attend graduation in 3 weeks - wife willing to consent for HD - can always make decsision to stop ethically/legally - also pt can then participate in decision

Question 51

Obscure GI bleeding aw severe AS (angioectasia) - Heyde syndrome

Answer 51

AVR - mechanical disruption of vWF during non-laminar flow thru stenotic AV No need to repair diffuse angioectasis - resolves post AVR

Question 52

Hyperandrogenism in pt with neoplasm

Answer 52

TVUS r/o ovarian neoplasm first total testosterone elevated DHEA normal Rapid inc in sx and high testosterone suggest OVARIAN source, if neg then image adrenals (if adrenal mass then likely elevated DHEA

Question 53

Hemolytic uremic syndrome

Answer 53

microangiopathic hemolytic anemia, low plts, AKI E coli 0157 H7 Shiga toxin glomerular damage (erythrocytes/ertyrocyte casts) Trip to endemic country inc'd LDH, dec'd haptoglobin, schistocytes dysentery (bloody diarrhea, dec'd UOP, fever, chills)

Question 54

Post strep glom nephr

Answer 54

weeks after strep/staph infxn - dec'd complement

Question 55

Chemotx induced myeloblastic syndrome

Answer 55

ineffective hematopoesis and various cytopenias multiple chromosomal abnormalities lack of LAD, HSM hypercellular marrow, dyerythropoesis

Question 56

ALL

Answer 56

7th decade - lymphocytosis, neutropenia, anemia, throbocytopenia, LAD, HSM

Question 57

Parvovirus B19

Answer 57

NOT A/W cytogenic changes

Question 58

Recurrent Hodgkins lymphoma

Answer 58

2-12 years - palpable mass, lymphomas sx (fever, anorexia, wt loss, pruritis) - NO CHROMOsomal abn

Question 59

Post infarct VSD

Answer 59

p/w delayed STEMI acute respiratory distress New harsh holosystolic murmur LSB palpable thrill (thrill makes VSD more likely than acute MR)

Question 60

Acute aortic dissection

Answer 60

aw IWMI, asymmetric BPs, early diastolic murmur of AI

Question 61

Rupture ventricular free wall

Answer 61

``` electromech dissociation, hemopericardium Risk factors Female First MI Anterior infarct ```

Question 62

RV infarct

Answer 62

hypotension, clear lung fields elevated JVP | not likely with AWMI

Question 63

Acute ischemic MR

Answer 63

prominent V wave in PCWP from inc'd reguritant volume into LA - need TTE

Question 64

Acanthosis nigrans

Answer 64

DM pt (obese) - asx lesion velvety, hyperpigmented skin thickening in axilla/neck fold area - multiple skin tags (fibroepithelial polyps) Tx: wt loss, improved DM control

Question 65

Tinea corpis

Answer 65

scaling annular patches with erythema - pruritic

Question 66

Lichen simplex chroicus

Answer 66

thickening of skin with exencuation of normal skin markings - pruritic

Question 67

Inverse psoriasis

Answer 67

atypical psoriasis areas (axilla/groin) - raw pink patches

Question 68

Allergic contact dermatitis

Answer 68

pruritis, erythematous, well demarkated border

Question 69

Chronic thromboebolic pulm HTN (CTEPH)

Answer 69

recurrent small PE over extended time with progressive dyspnea - inc'd PAP, gas tx defect (low DLCO) Tx: long term A/C, pulm artery endarectomy NO NEED FOR D-dimer, CTA chest or LE Duplex

Question 70

Rheumatoid arthrtis

Answer 70

Can present with carpel tunnel syndrome (confirmed with EMG testing) prolonged morning stiffness >60min b/l wrist sx synovitis of wrists can cause entrapment of median nerve Pregnant women, thyroid dz, DM Overuse DOES NOT CAUSE carpel tunnel OA DOES NOT cause wrist sx typically (PIP/DIP)

Question 71

Renovascular HTN w/u

Answer 71

pt with resistent HTN and inc'ing Cr w/ b/l epigastric bruits -obtain renal doppler arteries underperfusion of kidneys - inc'd renin-angiotensin - sodium retention - HTN ALready on 3 drug HTN tx including a diuretic (do not do kidney angio - bad for kidneys and can dislodge plaque from aorta)

Question 72

Restrictive CM

Answer 72

dyspnea, edema, fatigue, Right sided failure, Echo restrictive ventricular filling, atria dilated - systolic fxn preseverved, small to normal size ventricles

Question 73

Cardiac hemochormatosis

Answer 73

cause of restrictive CM but if iron levels low can be ruled out

Question 74

Constrictive pericarditis

Answer 74

restrictive filling less severe atrial enlargement BNP only mildly elevated h/o acute pericarditis, TB, malignancy or chest radiation

Question 75

Male hypogonadism

Answer 75

First step is morning TOTAL testosterone (morning most accurate) if abn, 2nd test indicated before further w/u (no reason for free testosterone - not older or obese) (no reason for testicular US if testicles normal volume)

Question 76

Subacute cuteanous Lupus erythematosis

Answer 76

Anti Ro/SSA + (or anti la/SSB) erythematous circular papules with central clearing neck, trunk, extensor surfaces can be aw meds - HCTZ, CCB, ACEi, terbenafine 50% no systemic manifestation of SLE

Question 77

Levido reticularis

Answer 77

lacy, purple motling of skin - pt with cholesterol emboli syndrome, SLE, raynaud, antiphospholipid syndrome, worse with cold, better warm (decrased local skin blood flow with dilated cappillaries

Question 78

Colonoscopy screening UC pts

Answer 78

Dx'd with UC beyond rectum Colonoscopy 8-10 years after dx and every 1-2 years with bx (UC arises from mucosa - inc'd risk of adneoCA) If flat low grade dysplasia noted - colectomy or at least more frequent surveilalnce colonoscopy warranted

Question 79

Colonoscopy screening normal

Answer 79

General - age 50 then q10yr Pt with 1st deg relative colong CA after age 60 (or two 2nd deg relative) - age 40 then q10yr Pt with 2 first deg relatives with colon CA or one 1st dg relative with colon cA before age 60 - age 40 or 10 years prior to youngest affected relative then Q5yr HNPCC fhx - 25y or 10 years yonger than youngest affected relative then q2yr up to age 40 then q1yr FAP - sigmoidoscopy age 12 q1-2 yr Post colonoic resection for Colon CA - start 1 yr post, then 3yr then q5 yr UC/Crohns - colonscopy 8yr after dx then q1-2 yrs

Question 80

Extrapulmonary blastomycosis

Answer 80

Mild disseminated - oral itraconazole - verricus lesion -> central clearing -> scar formation -> depigmentation (broad based budding yeast) also osteoarticular, genitourinary and CNS manifestations Severe dz - CNS, mod to severe pulm, disseminated - tx with amphotericin B/lipid formulation Fluconazole DOES NOT WORK WITH BLASTO No reason for surgical exicision

Question 81

Suspected melanoma

Answer 81

``` ABCDE Asymetry borders irregular Color varied Diameter >6mm Evolving Dx: Excisional bx - breslow depth analysis ```

Question 82

Prevent pressure ulcers in elderly

Answer 82

Pressure distributing mattress and position changes high risk for ulcer - limited mobility, low albumin, ascites Stage I pressure ulcer - non-blanching erythematous plaque

Question 83

Tx of pt with acute DVT in post op period with renal insufficiency

Answer 83

Use Unfractionated heparin in pt with low GFR (cleared by reticuloendothelial system not kidneys) and reversible by protamine so good in post op setting) Only add warfarin after heparin therapeutic since initially aw hypercoagulablity - warfarin skin necrosis No fonduparinux with low GFR (cleared by kidney) Enoxiparin - not entirely reveersible so not good in post op setting and 80 BID too high dose for low GFR

Question 84

DVT dx

Answer 84

Pt with high pre-test probability of VTE given immobility, age, tachycardia so NO D DIMER CTA Chest high cost and uneccearly exposes to contrast US Duplex legs best and most cost effective test

Question 85

Non-dermatophyte (fungus) onchymycosis

Answer 85

thickened yellow or white nail with scaling DX: KOH or PAS staining of nail clipping Candida, yeast Usual tx terbinafine, fluconazole, itraconazole Can be non-fungal cause (trauma, psoriasis,lichen planus) so need nail clipping PAS

Question 86

Aplastic anemia in young patient

Answer 86

Aplastic anemia dx ANC < 20, Tx: if age 40yo or no HLA matched or medically fit for tx then tx is anti-thymocyte globulin and cyclosporin/corticosteroid No growth factors

Question 87

High risk NSTEMI

Answer 87

TIMI>4 - (age>65, >3 risk factors, ST seg dev, +CE, >2 anginal episodes in 24 hrs, ASA in last 7 days) A/C heparin, Plavix, ASA, lopressor, SLN + lipitor and IIb/IIIa (eptifiptide - block final common pathway of plt aggregation) and early invasive approach NO PPX LIDOCAINE (use BB instead) NO throbolytics with NSTEMI (tenecoplase) - ok for STEMI if no PCI available but no dec'd mortality with NSTEMI

Question 88

Respiratory failure in pt with COPD

Answer 88

tachycardic, hypoxic despite 6L O2, CP, clear CXR - CTA Chest r/o PE

Question 89

Evaluate pt for TB that has been treated with BCG for bladder CA, vaccine or unlikely to return for f/u of TB skin test

Answer 89

use IFN gamma release assay if + then assess sign's sx and CXR, sputum Two step TST only in pt with remote TB infection or remote BCG (not recent)

Question 90

Diagnose secondary h/a

Answer 90

unstable or progressive temporal sx - long h/o migraine with aura - new neuro sx of blurring vision - more frequent recently Obtain brain MRI Not medication overuse as pt with new and more frequent sx Before LP need to r/o mass lesion in brain

Question 91

Evaluate pt with high BP

Answer 91

If see end organ damage in eye then check EKG check for LVH or q waves, check for microalbumuria 1st line tx without other factors would be thiaizide ACEi, arb, CCB in gen non-black pop In Blacks thiazide or CCB Age >60 goal <150/90 Secondary HTN Primary hyperaldo - spontaneous hypokalmeia - check aldo, plasma renin activity

Question 92

Chronic pelvic pain - interstitial cystitis

Answer 92

noncyclic pain >6 months DDX: Interstitial cystitic pelvic adhesions - no h/o surgeries or STDs endometriosis - no masses or TVUS neg, no cyclic pain Irritable bowel syndrome - no GI sx Pt here with persistent urinary sx -> interstitial cystitis - Ctx and U/A can be neg Tx: stress management, diet modification PT oral meds (TCA, cimididiene, hyroxazine)

Question 93

Type I cryoglobulinemic vasculitis

Answer 93

monoclonal immunoglobulins complication of monoclonal paraproteins - seen in Sjogren's pts +palpapable purpura, mononeuritis complex, low C3/4, immune complex glomerulonephropathy

Question 94

Microscopic polyangiitis

Answer 94

p-ANCA No immune depostis L

Question 95

Lupus associated Glom nephritis

Answer 95

immune complex GN, dec'd complememnt - need clinical features of systemic lupus

Question 96

Type II cryoglobulinemic vaculitis

Answer 96

active Hep C (RNA +)

Question 97

Painful DM neuropathy

Answer 97

``` better glucose control+ TCA (Desipramine) + capsacin cream Remyelination can occur with better glucose control NO SSRI Nerve conduction studies NOT needed ```

Question 98

Acute stroke

Answer 98

even if hemorrhage suspected - Do CTH first impaired conciousness and h/a suggest cerebral mass lesion with elevated ICP No LP until mass lesion r/o

Question 99

Post Roux en Y gastric bypass abn CBC elev MCV

Answer 99

B12 deficinecy macrocytic anemia mild neutropenia low retic lack of IF production from bypasesed gastric tissue Monitor b12 post op and supplement (500-1000 oral daily or 1000 q monthly IM) Also check ferritin, folate, vit D, Ca q6month first 2 years NO BM bx (too early) NO suspicion for GIB or CRCA with guiac neg stool,no fhx, MACROcytic anemia

Question 100

Excercise induced broncospasm

Answer 100

short acting B2 agonist 15 min prior to excerise Mild intermittent asthma aw excercise only Normal baseline FEV (>80) with drop after excercise

Question 101

Inhaled corticosteroids

Answer 101

>twice daily sx, weekly nightime sx

Question 102

Type A acute aortic dissection

Answer 102

proximal aorta through arch to desecending with diastolic murmur, distant heart snds, CP-> back Not necesarily divergent BP in arms Emergency surgery evaluation (not stenting) Bicuspid Aortic valve aw dilated prox asc aorta - inc'd risk aneurysm or dissection No IABP - worsens AI

Question 103

Histoplasmosis

Answer 103

``` Bat droppings Ohio river valley Hilar LAD with infiltrates SE US/ohio river valley bird/bat droppings Asx, or flu like sx, dyspnea ```

Question 104

Blastomycosis

Answer 104

NO hilar LAD aw soil exposure with decaying vegetation - NOT BATS/BIRD droppings Ohio river valley

Question 105

Coccoidomycosis

Answer 105

SW US | Acute pulmonary, erythema nodosum, joint pain

Question 106

Flat warts

Answer 106

HPV autoinnoculation from shaving flat, flesh colored

Question 107

Actinic keratosis

Answer 107

PRE-cancerous -> SCC erythematous with overlying hyperkeratosis irregular edges, gritty

Question 108

Lichenoid keratosis

Answer 108

inflammed sebhorrhic keratosis (benign - stuck on, do not resolve)

Question 109

Dermatofibromas

Answer 109

firm dermal nodules - button hole when pinched - legs adult women

Question 110

Hypoparathyroidism

Answer 110

s/p thyroid surgery perioral anesthesia - muscle cramping tx: first oral Ca+ Eventual calcitriol since with lack of PTH no conversion of 25 to 1,25 D3

Question 111

Treat pt with kidney stone

Answer 111

inc chance of kidney stone 10 mm won't pass without intervention) Urine collection and analysis only several weeks after stone passage for w/u of nephrolithiasis May require intervention if no stone passage after period of time

Question 112

Cancer of unknown primary site

Answer 112

Tx for GI cancer - primarily abdominal districtuion (liver, ascietes) NOT germ cell tumor (undiff) if ID'd as adenoCA - platnum chemo NOT neuroendocrine (would be poorly differentiated) - platnum chemo NOT prostate (bony mets/ elevated PSA) - anti androgen tx NOT lung (would be distrubed over diaphragm)

Question 113

Manage carpel tunnel

Answer 113

EMG and nerve conduction first (+- NSAIDs) sx - parasthesia hand, weakness grip strength, loss of sensation in median nerve territory, thenar atrophy Wrist splint/conservative measures If all this fails and after EMG/nerve studies- consider surgical release

Question 114

Tx pt with recurrent chemo sensitive diffuse b cell lymphoma

Answer 114

Initial tx - RCHOP recurrent high dose chemo, autolougous stem cell tx no radiation, not just recurrent chemo

Question 115

Hypercalciuric patient with nephrolithiasis

Answer 115

U Ca >300 (normal serum Ca+) FHx nephrolithisis Tx: distal reabsorbption of Ca+ with Thiazide don't use Ca citrate - will exacerbate calciuria (if want to alkalzye urine - use POTASSIUM CITRATE) Don't restrict CA (makes Ca Oxilate worse)

Question 116

CAP in outpt

Answer 116

Tx with azithromycin (H.Pneumo, H.flu, mycoplasma, chlamydia) NEVER USE CIPRO (poor activity against S. Pneumo) Risk factors for drug resistant age >65, B lactam tx in last 3 months, medical comorbidies, immunocompromised

Question 117

Pt with advanced HF

Answer 117

Pt with end stage cardiac failure refractory to tx - mechanical support and cardiac tx indicated Relatively young, no other comorbidities IF QRS OK then no indication for BIVICD upgrade

Question 118

Pusatile tinnitis

Answer 118

pt with whooshing sound in ear louder when excerciseing - listen over r eye, ear, neck for bruits for vasc abnormality (tumor, stenosis) -> confirm with doppler or MRA If no cause found - external noise generator

Question 119

Pull test

Answer 119

quick pull - pt should compensate by stepping backward if not predictive of future falls

Question 120

Dix Halpike

Answer 120

peripheral vs central verigo

Question 121

Abnormal proprioception

Answer 121

do not fall backward - have abnormal gait | loss of proprioception - peripheral neuropathy, spinal cord dz, severe hemicranial cortex dz

Question 122

Rhomberg test

Answer 122

ataxia and proprioception loss - cerebellum, cerebellar, vestibular issue

Question 123

Utricarial Vasculitis

Answer 123

Lesions that last > 24hrs and resolved with bruising concerning for vasculitis SKIN BX NEEDED 50% have underlying SLE No role for RAST (no clear allergin)

Question 124

Malignant pleural effusion

Answer 124

former smoker - pw sx concerning for malignancy (cough, wt loss, unilateral effusion) Pleural fluid cytology used for dx - if neg first then repeat (inc's with serial taps) If nothing then pleural bx

Question 125

Evaluate GIB with endoscopy

Answer 125

``` Neg NGT does NOT r/o UGIB First resucitate then EGD (first) if neg then colonoscopy then tagged RBC scan then video capsule ```

Question 126

PCOS

Answer 126

PCOS - irreguular menses, elevated testosterone, hirsuitism, tx: estrogen-progesterone OCP - dec'd LH, inc'd sex binding hormone-> dec's avaiable testosterone

Question 127

Prolactinoma

Answer 127

tx'd with bromocriptine

Question 128

Congential adrenal hyperplasia

Answer 128

17 hyroxyprog abn - tx with dexamethasone - reduces hyperplasia and reduces prodxn of testosterone

Question 129

Non-purulent cellulitis - B hemolyitic strep

Answer 129

B lactam agent - Cephalexin CAMRSA (doxy/bactrim)

Question 130

Apraxia

Answer 130

inability to perform previously learned motor task despite intact motor and sensory systems, clear comprehension, full cooperation (need to r/o parkinsons, severe wk etc)

Question 131

Hemiparkinsonianism

Answer 131

``` asymmetric rigidity, bradykinesia, dystonia Corticobailiar degeneration (hemiparkinson combined with hand moving independent of voluntary control = alien hand syndrome) ```

Question 132

Asomatognosia

Answer 132

pt doesn't recognize body part as part of himself (R parietal cortex)

Question 133

Routine f/u in breast CA survivor

Answer 133

Early stage breast CA survivors Routine clinical f/u - no intensive lab surveillance H&P, Mammo in otherwise asx patients

Question 134

Humoral hyperCa of malignancy

Answer 134

severe hyperCa in setting of lung mass Tumor prodcution of PTHrP - acts on skeletal Ca release Usually SCC Lung

Question 135

Sx PAD tx

Answer 135

Best therapy - supervised excercise program 30 min/day 3 days x 12 wks - inc pain free walking time and distance Cilastoazole - contraindicted EF<40% Surgery (bypass) only for limb thretening ischemia - or severe life limiting dz on maximal medical tx

Question 136

Miliaria

Answer 136

Heat rash - skin get hot and occulded exocrine sweat glands - need active cooling measures - hospitalized pt with rash limited to dependent parts of body (vesicles, papules, pustules) No need for oral steroids

Question 137

Fibromuscular dysplasia

Answer 137

``` Angiogram - beads of strings MC women 15-30 nonatherosclerotic, noninflammatory (suspicious in pt with severely resistant HTN, high renin/angiotensin) TX: PTCA Don't use drugs in this young patient ```

Question 138

Obese patient needing weight loss

Answer 138

reduce calories by 500-1000/day 1-2 lbs/week (excercise alone will not work) (Bariatric only BMI>35 with comorbidity (DM, OSA, joint dz) or >40 anyone Med supplement is secondary ie orlistat (lipase inhibitor)

Question 139

Manage acute PE

Answer 139

Unfractionated heparin Only throbolysis if still hypotensive after fluid bolus (alteplace) DOn't use LMWH if with CKD or possible need for revesal (ie if need to thrombolyse)

Question 140

Dyspepsia

Answer 140

with no alarm sx (wt loss, blood) -> PPI empiric tx

Question 141

If H. pyori

Answer 141

test and treat ok if no heartburn, alarm sx or area of high h pylori prevenlance If alarm sx then EGD (onset after 50, aemia, odynophagia, dysphagia, wt loss fhx GI malignancy, h/o PUD, abd mass, LAD)

Question 142

Thiamine deficiency s/p gastric bypass

Answer 142

wernike's encephaloptahy (nytagumus, opthalmoplegia, ataxia, confusions) - needs IV thiamine - can have irreversible damage - thiamine depletes quickly much faster than B12 gets deficient (starts with parasthesia/ataxia

Question 143

CMV after kidney tx

Answer 143

pt with seroneg for CMV, seropositive donor - few months after tx (after CMV ppx completeted) - so CMV is correct pw low grade fever, body aches, cytopenia, colitis, hepatitis, pneuonitis (CMV), leukopenia, thrombocytopenia

Question 144

Polyoma BK virus post tx

Answer 144

LATE complication of tx, p/w neuropathy, organ rejection, uteretral strictirues - decoy cells (with intranuclear inclusions)

Question 145

Listeria mono post tx

Answer 145

usually causes meningitis, h/a, MS change

Question 146

EBV post tx

Answer 146

usually pw LAD

Question 147

hemodynamically stable WC tachycardia

Answer 147

regular wctachy with LBBB w/ AV dissociation -> VT (h/o cad or CM) cannon a waves from AV dissociation (atria contracting against closed TV) Tx: IV amiodarone -2nd line procainamide, sotolol, lidocaine If unsuccessful - cardioversion DO NOT GIVE BB/CCB - > can deteriorate in VT Will need ICD for 2ndary prevention

Question 148

Breast CA with mets to brain (>1) and inc'd ICP

Answer 148

corticosteroids and radiation - reduce ICP h/a sx of inc'd ICP, papilledema on exam also sz, focal neuro findings, cognitive changes Will need chemo, not surgery (>1 lesion) NO LP

Question 149

Axial spondyloarthritis

Answer 149

Dx: pt with inflamm back pain without radiographic evidence of sarcoilliitis or spondylitis, clean MRI Dx of spondyloartritis without radio evidence - HLAB27+ and two of the following with elevated CRP, fhx spondyloartritis, good response to nsaids, crohn/UC, dacyliasis, psoriasis, NO RF + in spondyloartritis

Question 150

Centor criteria

Answer 150

Fever>100.5, sore throat, tonsillar exudate, tender cervical LAD 2 criteria - obtain rapid strep antigen testing 0-1 risk factors - no abx or culture 2 or 3 - throat culture/antigen test and tx if + 4 or 5 - treat empirically (and get ctx)

Question 151

Plasma osmolality

Answer 151

Sz caused lactic AG met acidosis Dec'd breathing from etoh intoxication caused respiratory acidosis + etoh ketoacidosis If pt improves with supportive measures - no HD or fomizpezole Fomipezole if pt has methanol or ethylene glycol poisoning (competitive inhibition of etoh dehydrogenase) - prevent conversion to toxic metabolites 2x [Na]+ glucose/18+ BUN/2.8+ ethanol/3.7 if present Supplemental bicarb if pH <7.15 HD if severe ethylene glycol or methanol poisoning, severe propylene glycol poisoning, severe isopropyl -

Question 152

Delayed hypoglycemia in pt with Type I DM

Answer 152

Need to eat complex carbs at bedtime to avoid nighttime hypoglycemia after evening excercise - etoh reduced ability of liver to release glucose into blood (no need to avoid evening excercise, omit insulin in evening or light beer only)

Question 153

Lichen planus

Answer 153

white reticulated network on buccal mucosa (wickham striae) - does not scrape off - can ulcerate also affects skin, scalp, nails incd with liver dz, hcv or drug induced (BB, diuretics, ACE, PCNamine, lasix) autoimmune Skin - small violacious papules

Question 154

Candidiasis

Answer 154

Usually immunocompromised or corticosteroid use | scrapes off

Question 155

Oral hairy leukoplakia

Answer 155

aw HIV | lateral tongue - adherent doesn't remove from scraping - no ulceration

Question 156

MAP

Answer 156

2x DBP + SBP) /3 - if < 65 -> or CVP < 8-12 - if fluid resucitation does not get MAP>65 then vasoactive agent (norepi) ok If that doesn't work - hydrocortisone next step

Question 157

Invasive aspergillosis in pt with leukemia after chemo

Answer 157

``` halo sign on CT galactomannan antigen immunoassay + BAL or TT percutaneous bx, VATS Tx: Voriconazole Salvage Tx: amphotericin, itraconazole, caspofungin/micofungin (echinocandin) ```

Question 158

Toxic epidermal necrolysis

Answer 158

Drug reaction (bactrim) Stop bactrim or offending drug Burn unit - wound care, supportive care Fluids Skin bx DO NOT USE SYSTEMIC STEROIDS - worsens mortality No role for ppx abx (only if evidence of infxn)

Question 159

A/C preg pt with mechanical MVR

Answer 159

Warfarin - despite teratogenicity | or LMWH or UFH

Question 160

VTE after intracranial hemorrhage stroke

Answer 160

UFH low dose or LMWH after day 4 if no ongoing bleeding | IVC filter only if absolute contraindication to heparin

Question 161

Axial Spondyloarthritis

Answer 161

Inflamm back pain, Tx: NSAID (diclofenac) only after several diff NSAIDS - then try etanercept

Question 162

Evaluate obscure GIB

Answer 162

If pan endoscopy neg - repeat EGD (or colon) whichever more likely source If neg then other modality (wireless capsule, single balloon enteroscopy)

Question 163

Asess for recurrent PE

Answer 163

A/C x 3 months f/u D-dimer 3-4 weeks after dx if elevated inc'd risk for recurrent PE Restart A/C

Question 164

Manage hyperparathyroid in CKD

Answer 164

CKD with low 25OHD3 and high PTH-> maybe be just vit D deficient If this does not work and 25OHD3 >30 (normal) with PTH still high then give 1,25OHD3 (calcitriol)

Question 165

Febrile neutropenia

Answer 165

Begin broad spectrum abx (zosyn, cefepime) - G pos and neg coverage Only start antifungals after 4-7 days of no response to zosyn cefepime

Question 166

Chronic pain in elderly

Answer 166

First line tylenol (chronic non-cancer pain) if no underlying liver problems No TCA NO NSAID if h/o PUD

Question 167

Metabolic syndrome

Answer 167

``` 3 of 5 Waist circumference >40 men, >35 F SBP >130>85 HDL< 50 F TG>150 Fasting glucose>110 ```

Question 168

Tx for severe etoh hepatitis

Answer 168

Should add corticosteroid unless contraindictated (GIB, kidney failure, active infection (has this - SBP)) Maddrey discriminant score >32 Add pentoxyfyline

Question 169

Reactive arthrtiis

Answer 169

acute arthritis + urinary symptoms Despite not being sexually active in one month - check urine for gonnorhea and chlamydia -> symptoms point to DIG (arthritis, urethritis, conjunctivitis) - sx 2-4 wks after infxn Sexual partners should be dx and treated

Question 170

Infection control in pt with strep pyogenes (invasive)

Answer 170

necrotizing fasciitis and TSS clinda + PCN CLose contacts can get infected so-> CONTACT PRECAUTIONS needed PCN ppx for household contacts at high risk (Age>65, DM, cardiac dz, varicella, CA, HIV, coriticosteroid use, IVDA)

Question 171

Airborne precautions

Answer 171

TB, avian influenza, disseminated zoster, smallpox

Question 172

Droplet precaustions

Answer 172

>5micrometer droplets 3 to 10 feet | Neiserria meningitidus, pneumonic plague, diptheria, H flu b, pertussus, influenza, mumps, parvo b19

Question 173

Erythema Multiforme

Answer 173

``` INfections or drug rxn target/iris lesions palms, soles, mucous membranes Tx: suppressive acyclovir (doesn't shorten course) (if also respiratory sx then consider mycoplasm pneuoniae -> tx with azithro) ```

Question 174

Erythema migrans

Answer 174

``` hallmark cutaneous lesion of lyme centrifical spreading ring - bullseye much bigger than erythema multiforme lack of mucosal invovlement amoxicillin or doxy ```

Question 175

Erythema nodosum

Answer 175

strep infection | PCN tx

Question 176

Recurrent breast CA with possible bony mets

Answer 176

first bx bone to see HER2neu and hormone status | Tx: IV bisphosphonate -

Question 177

Hypothyroid during pregnancy

Answer 177

thyroid supp requirement inc'd by 30-50% | Goal first trimester <2.5 TSH (less fetal complications)

Question 178

AL Amyloidosis

Answer 178

``` frequently affects kidney and heart progressie HF from restrictive CM Nephrotic syndrome Hepatomegaly (congestion from RHFx painful b/l sensory neuropathy (distal) monoclonal light chain - lambda DX: fat pad bx congo red stain rectal or kidney bx if non dx SPEP/UPEP detect monoclonal light chains 20% have concurrent MM or lymphoprolif dz ```

Question 179

Polyarteritis nodosa

Answer 179

fever, abd pain, arthraliga, mononeurtis multiplex, livido reticularis

Question 180

Occupational lung dz

Answer 180

ground glass diffuse nodules on CT, SOB cough, low grade fevers no exposures, no relief with abx Always get detailed history of current work exposures, timing of ezposure to symptoms, if co-workers also getting affected, MSDS Metal workers - lipoid PNA, hypersensitivity pneumonitis, occupational asthma

Question 181

Cardiovascular risk in elderly women

Answer 181

Start ASA in women 55 to 79 with several risk factors (older age, DM2, HTN) - dec's risk of stroke, MI, CV death - outweighs risk of GI hemmorhage

Question 182

Stroke risk reduction

Answer 182

ASA alone Plavix slightly more effective or if allergic to ASA ASA + dipyramidole even more effective ASA + plavix - high bleeding risk

Question 183

Myopericarditis

Answer 183

Acute pericarditis with +CE unrelated to MI Regional ST elev with new global or seg WMA Prodromal URI or other sickness (fever, etc) could have effusion

Question 184

Cardiac tamponade

Answer 184

SOB complication of pericarditis JVP, pulsus paradoxus RV/RA collapse during diastole

Question 185

Post myocardial infarction syndrome

Answer 185

Pericardidits preceeded by cardiac injury (ST e MI) | Does not usually cause HF

Question 186

Takutsubo's CM

Answer 186

Chest pain, STE on EKG, LV dysfxn, normal cornoaries - deg of biomarker elev mild compared to myopericardiits - ballooned apex, hypokinetic base

Question 187

Concurrent primary cancers - cancerization field effect

Answer 187

H&N cancer rare mets to lung - lung mass found can be another early stage primary - need to bx to find out Chemo and radiation spares voice

Question 188

Dx Male infertility

Answer 188

1st step: Semen analysis (abstain 2-3 days) | 2nd step: if semen analysis abn - FH, LSH, total testosteroine (asess leydig and sertoli cell fxn)

Question 189

Young woman, mild nephritis, outpt setting

Answer 189

mild flank tenderness, +U/A, fever, dysuria Tx with floroquinolone ie cipro (no nitrofurantoin - not good in renal tissue)

Question 190

Step down therapy for asthma

Answer 190

If asthma sx stable with little need for rescue meds then try step down (ie stopping inhaled corticosteroid - use just rescue short acting B agonist)

Question 191

Drug induced myopathy

Answer 191

Recent increase in statin or drug that inc'd statin blood levels can cause myalgia (PI, azole anti fungals, macrolides)

Question 192

Polymyositis

Answer 192

prox muscle wk, elev CK, inflamm changes on muscle bx

Question 193

Drug reaction with eosinphils and systemic sx (DRESS)

Answer 193

Generalized papular eruption, facial edema, fever arthalgia, LAD, elev EOS, LFTS Anti-convulsants, sulfa, minocycline, allopurinol

Question 194

Acute generalized exathematous pustulosis (AGEP)

Answer 194

acute onset pusutules, fever, elev WBC poss EOS | B-lactam, ampicillin, floroquin, anti malarial agents, sulfa, terbafine, diltiazem

Question 195

Erythema Multiforme

Answer 195

acute recurrent mucocutaneous eruption following acute infection (recurrent herpres simplex), or could be drug related Erythematous plques with concentric rings of color

Question 196

Levido retiucularis

Answer 196

pink mottled netlike pattern | aw drug rxn to amantadinie, quinidine, warfarin, minocycline

Question 197

Pre-op Rheum Arthritis

Answer 197

Pt with longstanting RA need to rule out atlanto axial subluxation -> could cause paraplegia No need for pre-op spirometry If pt demonstrates 4 mets no need for stress test

Question 198

Manage GERD that does not respond to PPI trial

Answer 198

Pt failed PPI trial and has (wt loss, dyphagia, men >5 yrs sx, bleeding, anemia (no need for H2 blocker next) r/o eosinophilic esophagitis, mlaignancy, stricture, achalsia

Question 199

When to use ambulatory pH monitoring

Answer 199

After neg endoscopy and still with GERD sx

Question 200

Functional urinary incontinence

Answer 200

Pt's with cognitive decline may not be getting to toilet fast enough - prompted voiding

Question 201

Overflow incontinence

Answer 201

obstruction vs neurogenic bladder | Check residual urine

Question 202

Stress incontinence

Answer 202

pelvic floor muscle excercises

Question 203

Urge incontinence

Answer 203

anticholinergic ie tolterodine

Question 204

Inc'd risk of CV events in CKD pts

Answer 204

CKD pts may not have other risk factors but if symptoms occur then ACS should be ruled out

Question 205

Unstable angina in pt with contraindication to BB

Answer 205

Diltiazem (not nifedipine - can inc HR) contraindic to BB - sx brady, AV block (advanced), SBP<80, shock, pulm edema, sx reactive airway

Question 206

TCA overdose

Answer 206

can cause arrythmias blocks fast Na channels, -> VT/VF Sodium bicarb infusion - narrows QRS dec r/o arrythmia Procainamide contraindicated (also blocks sodium channel - makes arrythmia worse) Amio also bad - prolongues QT

Question 207

Sjogren's associated lymphoma

Answer 207

44 fold inc in incidence of lymphoma risk factors - dissappearance of RFactor, mixed monoclonal cryoglobulinemia, cutaneous vasculitis, LOW C4 Bx mass! Sjorens sx - dry mouth (pilocarpine), inflamm sx - arthritis, cytopenia, vasculitis (steroids), arthrisits - hydroxychloroquine

Question 208

Ectopic ACTH

Answer 208

Cushing syndrome - hypercortisolism, melanonchya) - signs of malignancy wt loss, temporal muscle wasting, new onset DM (excess mineralocorticoid), HTN, met alk, excessive urine K+ loss Ectopic ACTH secrtion from lung CA (small cell) NOT pituitary adenoma - ACTH levels lower

Question 209

Adrenal adenoma/CA

Answer 209

suppressed ACTH

Question 210

Autism spectrum d/o

Answer 210

impair communication, impaired social interaction, restrictive, repetitive stereotyped behaviors and interests learning disability or mental retardation, high functioning autism or Asberger variant

Question 211

Obsessive compulsant d/o

Answer 211

recurrent obsessions and compulsions at least 1 hr per day that cuase marked distres or functional impairment, peristnt idea, thoughts, impulses, images

Question 212

Schizophrenia

Answer 212

psychosis, delusions - hallucinations, disorganized speech, catatonic behavior At least 6 months of sx, 1 or more month of active sx (hallucination, delusion, d/o speech) and neg sx (flat affect)

Question 213

Social anxiety d/o

Answer 213

severe/persistent fear of social or performance situation

Question 214

Severity of acute pancreatitis

Answer 214

Dx: amylase/lipase | Predictiing severity : BUN

Question 215

Allergic contact dermatitis

Answer 215

Delayed type allegic rxn - red edematous, weepy, crusted Dx: Patch testing Pinprick and RAST only for immediate type hypersensitivity rxn

Question 216

Migraine without aura

Answer 216

``` Migraine 4-72hrs pulsatile unilateral mod - sev aggreva by activity ``` N/V or photophobia No neuroimaging if stable h/a sx for years Tx with triptan (sumatriptan)

Question 217

Locally advanced high risk cervical CA

Answer 217

Pelvic radiation with chemo Surgical resection then adjuvant chemo/radiation HPV now would not help Pelvics every 3-6 months for 2 years, then q6 m x 3 years then annually + serial CT scans

Question 218

Incidental high risk gallbladder polyp

Answer 218

High risk >10mm, gallstones >3cm, porceline gallbladder Cholecystectomy Risk factor for gallbladder CA, cholelithiasis, fhx gallbladder CA, If < 10mm then serial imaging

Question 219

Manage prostate CA screening

Answer 219

Start with informed discussion risks/benefits of prostate CA screening Screening would be DRE+PSA (after discussion)

Question 220

Tuberculous pericarditis

Answer 220

``` Treat TB (rifampin, INH, ethambutol, pyrazinamide) Add prednisone to decrease recurrence (indometh/colchisine only viral/idopathic pericarditis) if recurrent effsuinons then periocardial window or pericardectomy ```

Question 221

Dx obstructive lung dz in coal miner

Answer 221

Coal dust can activate inflammatory cascade Check PFTs first Asx patients should get imaging q5yrs

Question 222

Recurrent pericarditis

Answer 222

colchicine, ASA Pleurtic CP worse supine partially relieved leaning forward - pericardial friction rub, h/o acute pericarditis avoid corticosteroids (more recurrence) 3rd line azathroprine/cyclosporin CT Chest if suspect constrictive pericarditis (RHF JVD, pedal edema etc)

Question 223

Sickle cell pain episode

Answer 223

Treat iniitally with IVF, spirometry and IV morphine If stroke/acute chest -> erythrocyte exchange tx avoid if possible in this patient has multiple alloantibodies NO meperidine - low sz threshold, short half life

Question 224

Basic Calcium phosphate deposition dz

Answer 224

destructive inlfammaotory arthritis aw milwaukee shoudler Pain, large non-inflamm effusion after trauma destruction of articular cartilage ROM limited Dense Ca on Xray BCP crystals NOT seen under polazized light - only alizarin red staining

Question 225

Calciphylaxis

Answer 225

soft tissue calcium deposition - ESRD pts

Question 226

CPPD

Answer 226

see postivelty biregringent crystals (Gout neg birefringent crystals) OA fluid <2K WBCs

Question 227

Hep C associcated cryoglobulinemic vasculitis

Answer 227

HCV Viral load elev, Low serum C4, elevated RF Palpable purpura +cryoglobulins - cold precip immunoglob - tend to occur in periphery extrem Skin bx: leukoplastic vasculitis Can also aw CTD, waldenstogm, MM

Question 228

Henloch-schoen purpura

Answer 228

cutaneous small vessel vasculitsi (leukocytoclasic vasculitis) young children after strep infxn

Question 229

Porphorya Cutanea tarda

Answer 229

vessicles/bullae on sun exp skin - 50% aw HCV

Question 230

Necrolytic acral erythema

Answer 230

discrete erythematous to hyperpigmented plaques with scale/erosion in HCV pts, aw zinc def

Question 231

Hypokalemic metabolic alkalosis from Gentamycin

Answer 231

Diuretics, gastric fluid loss, gentamycin toxicity, gittleman/barrtler Gentamycin toxicity - barrtler like - mimick effect of LOOP diuretic Urine pot/cr ratio 50 -> c/w urine potassium losses 2/2 tubular dysfxn Without elevated BP, primary hyperaldo less likely If Urine potasium/Cr ratio < 15 then might be seroquel induced shift of K to intracellular space, no met alkalosis Vancomycin induced nephrotox -> aw HYPER K+

Question 232

Acute exacerbation of multiple sclerosis

Answer 232

High dose IV methylprednisolone (NOT PO) If refractory - plasmaphereiss Phyical/occup/speech therapy

Question 233

Dermatomyositis (can occur without myalgia)

Answer 233

Need age appropriate cancer screening poikilodermatous erythema inc'd abd girth, fhx ovarian CA - need TVUS only bx if has myalgia - blind bx low yield

Question 234

Patient presenting late with STEMI

Answer 234

``` Primary PCI (NOT EMERGENCY CABG) No thrombolytics >12hrs STEMI ```

Question 235

Fundic gland polyps

Answer 235

Need colorectal eval for Familial Adenomatous polyposis | Multiple small 1cm

Question 236

COPD pt immunizations

Answer 236

Can have both influenza and pneumococcal vaccines same visit diffierent sites Pneumococcal vaccine in routine pts >65yo At any age if COPD, asthma, DM, liver dz (chronic), etoh, fxn/antomic asplenia, immunocomprimizing conditions, smokers, NH One time revaccination for those vacc >5ya or <65 at time of vacc Only influenza vacc aw decrease in mortality

Question 237

Antiepileptic in pt who wants to get pregnant

Answer 237

Carbamazepine, lamotrigine, levetiricem | No VPA, phenobarb or phenytoin

Question 238

Risk factors for RA

Answer 238

Smoking increases risk of developing RA No change with etoh, obesity, excercise Dec'd risk with OCP

Question 239

NSAID induced nephropathy in MM patient

Answer 239

MM pts particularly vulnurable to nephrotoxic meds ie NSAIDs, IV dye Pt's particulary vul baseline CKD, vol depletion, hyper Ca Cast nephropathy - filtered light chains intratubular obstruction/precipitation - unlikely if severe AKI but improved cast burden Palmidronate AKI - low indcidnece Focal segmental glomerular sclerosis +proteinuria Renal amyloidosis - highly unlikely as would have significant non-selective proteinuria

Question 240

Nonpurulent cellulitis outpt therapy with systemic symptoms

Answer 240

Clindamycin active against CA MRSA and B hem strep risk factors for le cellulitis - DM, leg ulcers, tinea pedis, obesity, phlebitis Doxy/bactrim NO B hem strep coverage - if used need amoxicillin No rifampin - lots of resistance

Question 241

Minimal change glomerulonephropathy

Answer 241

aw lithium use - fusion of podocytes on EM, no immune depostis, massive proteinuria aw mono, malignancies, NSAIDs, lithium rifampin Hep C ass glomeruloneph, lupus nephr, membran glomeruplopneph - > immune deposits

Question 242

Benign positional vertigo

Answer 242

breif severe vertigo with position change episodes 1min and VERTICAL (not horizontal) Menieres - vertigo (nonpostional), unlateral hearing loss, tinitis Vestibular neurontis - aw viral infxn, more extended sx

Question 243

Pustular psoriasis

Answer 243

pinpoint pustules coalescing into lakes of PUS h/o psoriasis Fever sheets of pustules Erythroderma - generalized erythema >90% skin - drug eruptions, psoriasis, atopic dermattis, cutaneous T cell lymphoma (high risk psoriasis tx by corticosteroids) Tx: underlying dz, general supportive care

Question 244

Candida

Answer 244

localized in immunocompromized | erytmmatous base with white stuff

Question 245

Sweet syndrome

Answer 245

acute febrile neutrophillic dermatosis (neutrophil granulocytes on histo) +arthralgia, myalgia Edematous red-purple plaques in trunk/extremites Can be aw AML Tx: corticosteroids Reactive syndrome preeceding viral syndrome (resp/GI)

Question 246

Toxic shock syndrome

Answer 246

diffuse erythroderma resembling sunburn | Nasal packs, wound care

Question 247

Dx Celiac dz with IDA

Answer 247

if upper/lower endoscopy neg and pt still anemic (pt with down syndrome) even if TTG neg - repeat endoscopy with small bowel bx r/o celiac dz, capsule endoscopy if neg Meckel diverticulum - pw acute bleeding, ft's of obstruction,

Question 248

Normotensive acute ischemic kidney injury (ATN)

Answer 248

Pt with vascular risk factors and HTN now with lower than normal BP - renal hypoperfusion Elevated FENA, granular casts on u/a, normal kidney US

Question 249

Acute intersitial nephritis

Answer 249

1 week after offending drug hypersensitity rxn rash WBC, erythrocytes in U/A

Question 250

Cholesterol emboli syndrome

Answer 250

after conoary angio | bland urine sediment

Question 251

Pre-renal azotemia

Answer 251

h/o fluid losses, dec'd fluid intake FENA >2% FE uria >50%

Question 252

Osteoarthritis

Answer 252

subchondral sclerosis, asym joint space narrowing, osteophytes No h/o inflamm attacks - not gout RA would have symmetric joint space narrowing, no subchonral sclerosis or osteophytes

Question 253

Calcium pyrophosphate deposition dz

Answer 253

chondrocalcinosis - in fibrocartillage (menisci)

Question 254

Agitation and confusion in pt with alzheimers

Answer 254

r/o occult infextion, head trauma, CVA, meta abnormality If w/u neg D/c sedatives/anticholinergics don't need risperodone yet (not indicated for delirium) Donezepil , acetycholinesterase inhib, rivasstigmine - tx alzhemiers but not delierum

Question 255

Hyperprolinemia

Answer 255

pt with h/a and low libido-pituitary MRI r/o mass (Sellar) Eventual tx with cabergoline (dopamin agonist) No need for testosterone tx - secondary hypogonadism

Question 256

Acute cervical radiculopathy

Answer 256

without evidence of weakness or myelopathy - conservative tx with analgesics and avoidance of triggering activity ok (neck collars, corticosteroids, cervical traction don't show any superiority) EMG only if surgery being considered to pinpoint what nerve If wk/hyporeflexia then CT/MR myelograpy needed

Question 257

Malaria -

Answer 257

``` Plasmodium falicparum - most malaria cases Can be from resistance or non-compliance fever, cyclical every 48-72hrs Giemsia blood smear Banana shaped gametocytes, ring forms ```

Question 258

Plamodium Maraliae

Answer 258

fevers q72hrs | band form - trophozite

Question 259

Plasmodium ovale, vivax

Answer 259

trophozoit, schizont forms - Shuffer dots inside enlarged RBCs

Question 260

COPD exacerbation with NIPPV

Answer 260

reduces mortality, need for intubation (if has mental status or risk of aspiration) if RR<88%

Question 261

Evaluate asx heart murmur

Answer 261

check TTE for any systolic lout (3 or >/6, any diastolic or continuous MVP (click) - reduction in LV volume, valsava prolongs murmur, shortens S1 to click inc in LV vol and preload by squatting dec's murumur, delays systolic click

Question 262

Calciphylaxis

Answer 262

ESRD patients on HD elevated serum Ca, Phos Elev PTH Purpuric non-blanching patches associated soft tissue nodules -> bullae->ulcerate->escar From metastic calcium deposit in skin, vesicular CA - skin necrosis

Question 263

Nephrogenic systemic fibrosis

Answer 263

yellowish thickened papules, and nodules, progressive skin tightening and sclerosis - pt with ESRD on HD exposed to GADOLINIUM

Question 264

Polyarteritis nodosa

Answer 264

reticuloform purpura and SQ nodules - not aw ESRD

Question 265

Pyoderma granulosum

Answer 265

p/w ulceration no SQ nodules, violacious, overlying edge, NOT AW ESRD

Question 266

Inaccurate HgA1c

Answer 266

may be postprandial hyperglyemia if all preprandial and fasting FBS are normal and HgA1c elevated HgA1c falsely high with inc'd survival of RBC - untreated iron, B12, folate deficiency HgA1c falsely low survival of RBC (shorter) - hemolytic anemai, tx'd for B12, iron or folate def

Question 267

Manage giant cell temporal arteritis

Answer 267

IF suspected GCA with neg bx on one artery - repeat bx on other side needed Don't use MRI with GAD in pt with CKD - npehrogenic systemic fibrosis

Question 268

Cough variant asthma

Answer 268

Chronic cough - cough triggered by cold air and excercise Bronchial challange can exclude asthma if neg Pertussis - tx with macrolide/floroquinolone

Question 269

HFPEF

Answer 269

preseved EF with HF sx LVH on ekg Tx: diuretics and ARB (candesartan) - reduced hospitalizations No digoxin in HFPEF

Question 270

Normal Pressure hydrocephalus

Answer 270

gait shuffling, urinary incontinence, cognitive change | -check Brain MRI - look for ventriculomegaly

Question 271

Hormone Rct + breast CA pre-menopausal

Answer 271

Tamoxifen x 5 years if ER/PR + in PRE-menopausal S/E endometrial CA, , VTE, hot flashes, cataracts Aromatase inhibitors if hormone + POST=menopausal woemn (anastrazole, letrozole) DCIS - no chemo needed Raloxifene - no study indicating for adjuvant tx - just prevention of cancer in pt with high risk/osteoporosis

Question 272

HTN in women of childbearing age

Answer 272

``` d/c lisinopril - > start labetolol No spironolocatone(anti androgenic) and does need SOME antiHTN med ``` ACEi-> cardiac abn, kidney abn, death

Question 273

Short bowel syndrome

Answer 273

surge of gastric acid after small bowel resection - incactivaes pancreatic lipase - > diarrhea Need suppressive PPI tx No cholestyramine - will worsen diarrhea by binding remaining bile salts

Question 274

Palliative care discussion

Answer 274

Early referral preferred, emphasize NOT withdrawal of care, just improving quality of life Longer mean survival in study in patients with SCLC

Question 275

Hypoactive sexual desire d/o

Answer 275

persistent lack of sexual desire/thoughts Tx: sex therapy Tx: post menopausal dryness vaginal estradiol Dysparenunia - infx, cystitis, pelvic adhesions, endometriosis, Sexual Aversion d/o - aversive response to any genital contact, nausea, SOB, Vaginismus - involutary spasm of vagina

Question 276

Beau lines

Answer 276

transverse lines on nails in setting of systemic stress ie chemo or sepsis (disruption of nail natrix prodxn)

Question 277

Lichen planus

Answer 277

pitting, onchyolysis, longitiudinal ridging

Question 278

Median nail dystophy

Answer 278

longitudinal (not transverse) depression in center of nail and traverses whole length of nail - one or two nails - trauma

Question 279

Psoriasis

Answer 279

Nail changes like pitting, oncylolysis

Question 280

Concussion management

Answer 280

Grade 1 - Amensia/MS change < 15 min no LOC - may return to competetion if ok same day Grade 2 - Amnesia/MS change >15 min no LOC - remove from competition that day Grade 3 - Brief LOC - remove from competition and for 1 week asymoptomatic CT for grade 2 or 3 if sx return within week Hospitalization if traumatic findings on neuroimaging or persistent abn on physical exam

Question 281

GERD

Answer 281

If no alarm sx (weight loss, dysphagia, bleeding, melena, anemia) then PPI trial first for GERD inc'd r/o GERD with obesity, tob use, OSA Reassss in 6-12 wks Ambulatory pH monitoring if fail PPI trial and neg EGD to confirm dx GERD Fundoplication if still GERD after PPI trial and neg EGD

Question 282

Smallpox

Answer 282

Variola - respiratory tract infxn initially - high fever, vomiting, buccal/pharyngeal mucosa (Kolip spots) - > hands/face same stage maturation - contagious till all scabs crusted/shed Give smallpox vaccine for exposure of health worker CHicken pox - lesions in crops Cidofovir - outbreak of smallpox

Question 283

NSTEMI/UA pt

Answer 283

If no stent - ASA + plavix x 1 month to 1 year (ideally) aw OMT

Question 284

Severe asthma exacerbation

Answer 284

ICU - PCO2>42, FEV1<40% despite broncodilator

Question 285

TSH secreting tumor

Answer 285

``` Hyperthyroid - elevated radio iodide uptake - Thyrotoxicosis with inappropriately elevated TSH -> TSH secreting tumor -> pituitary MRI needed NSx resection No thyroiectomy, methimazole, PTU ```

Question 286

HTN pregnant pt

Answer 286

HTN before 20 weeks - presence of chronic HTN NOT HTN aw pregnancy Cr usually falls during pregnancy so does BP Gestational HTN - after 20 wks no proteinuria Pre eclampsia - HTN and proteinuria after 20 weeks

Question 287

G6PD

Answer 287

Acute hemolytic anemia after oxidative drug (Bactrim) Bite cells on smear also dapsone and primaquin Cold agluten dz - high MCV - agglutination of erythrocytes Hereditary spherocytosis - no central pallor spherical on smear Thallesemia - target cells on smear

Question 288

Older pt with seizures

Answer 288

Lamotrigine best tolerated Complex partial seizures/generaized Don't use carbamazepine (hyponatremia) phenytoin (dizzinesslethargy gait instability)

Question 289

Selective IgA deficiency

Answer 289

Chronic/recurrent resp tract infections Atopic disorders (eczema) autoimmune dz (RA, SLE) Anaphylaxic rxn to blood products/immunoglobulin - > ab vs IgA

Question 290

C1 Inhibitor def

Answer 290

Hereditary angioedema | fhx angioedema - subcut edema

Question 291

Terminal complement deficiency

Answer 291

susceptible to neiserrial dz - meningiococcal

Question 292

Uninterpretable ABI

Answer 292

ABI 1.4 - uninterpretable - | need great toe pressure or <0.7 = PAD

Question 293

Spinal stenosis

Answer 293

leg discomfort with walking relieved lying down or waist flexion

Question 294

Kawasaki dz

Answer 294

LN syndrome particularly with HIV infxn fever, nonexud conjunctivitis, desquamanting erythematous rash, mucositis, LAD - vasculitis of med vessles Tx: Immunoglobulin + salicylates - > corticosteroids

Question 295

TSS

Answer 295

bacterial toxins - septic shock | hypotensive, fevrile, diffuse malar rash, severe myalgia, elevated CPK, hyperemia, AKI, acute liver injury

Question 296

Newly dx breast CA with risk of BRCA

Answer 296

Counseling and genetic testing Pt with h/o ovarian and breast CA decide on local surgery vs ppx mastectomy/BLSO

Question 297

Keloid tx

Answer 297

``` Intralesional triamincolone (several injections over weeks) claw like beyond confine of area of trauma - tender or itchy, do not resolve on own - nodule like laser excision/radiation if recalcitrant ``` No abx, oral steroids don't work, topical steroids don't work Hypertrophic scars at surgery site/trauma - flatten out and resolve over 2 years

Question 298

Hypothyroid after central hypopituitarsim from surgery/radidation

Answer 298

Fatigue and wt gain - suspect hypothyroid, check free T4 with central hypothyroid - have low TSH since it is produced in pituitary Tx: levothyroxin Morning cortisol will be low because pt taking glucocorticoid replacement OCP will lower LH /gonadotropin levels Check IGF-1 to assess GH deficiency (GH directly measure is bad - GH is surge hormone)

Question 299

Hyperkalemia in setting CKD worsening

Answer 299

Hyperkalmemia - tx with gluc/insulin, calcium carbonate, If peaked twaves or other signs of cardiac conduction abn in setting of hyper K -> needs emergent HD Don't use lasix in setting of AKI and low UOP Pt with hyperkalmeia, hypovolemia and met acidosis -> sodium bicarb No kayexalate with recent bowel surgery risk of interstitial necrosis

Question 300

Recently resolved acute diverticulitis

Answer 300

AFter therapy with abx and settling period of few weeks-> Colonoscopy - r/o crohns/adenoCA Elective colon resection not warranted with one attack of diverticuosis

Question 301

Acute Angle closure glaucoma

Answer 301

narrowing or closure of anterior chamber angle - impedes trabecular drainage - elevated IOP/ optic nerve damage Ophthalmic emergency Sx: halo eyesite, decreased visiual acuity, pain on eye, n/v, sluggish mid range pupil, corneal cloudiness, cupping of optic nerve Tx: Topical B adrnergic agents, pilocarpine, carbonic anhydrase inhibitor

Question 302

Central rentinal artery occulsions

Answer 302

50-70yo painless unilateral vision loss embolic/thrombotic event afib (No red eye, pain, n/v)

Question 303

Occular migraine

Answer 303

Fhx/pmhx migraine flahsing lights, visual blurring/unilateral vision loss <40yo

Question 304

Temporal arteritis

Answer 304

Pt older than 50 severe new h/a visual loss PAINLESS (no red eye, n/v)

Question 305

Chronic severe MR

Answer 305

Surgical indications preserved LVEF with New onset afib concurrent maze/PVI +warfarin for afib (Rhythm control with amio, DCCV, not likely to work)

Question 306

OSA therapy

Answer 306

Apnea/hypopnia index 5-15 = mild 16-30 = mod >30=severe CPAP for anyone with OSA + sx (daytime somnolensce) Mild to mod can use oral device (not as effective) Surgery if nasal sept dev, polyps, tonsillar enlargement, retrognathia (not willing to do CPAP)

Question 307

Acute pseduogout

Answer 307

Positively biregfringent - rhomboid shaped crystals linear calcium dep in cartilage (chondroCA) Pt with DM, CKD, PUD Tx: best= intraarticular steroids don't want oral steroids 2/2 DM, don't want NSAIDS 2/2 PUD No abx as infection not likely (neg gram stain, low wbc in synovial fluid)

Question 308

Drug induced erythema nodosum

Answer 308

Non-specific inflammatory cutaneous rxn - inflamm in fat pads - septal panniculitis - red brown nodules in anterior shins Etio - infections (Hep C, TB, EBV, cat scratch), drugs (OCP, PCN, sulfa), systemic dz's (IBD, behchets, sarcoid, NHL Tx: D/c OCP Tx infection

Question 309

Wilson's dz in young pt

Answer 309

``` Presents with parkinson's rigidity, bradykinesia cramped handwrited, masked faces psycomotor retardation, depression Dx: CHeck serum ceruloplasmin Slit lamp exam kleiser fliester rings ``` Other causes parkinsonianism in young ppl CO poisoning, trauma, brain tumor, hydrocephalus

Question 310

Pt with breast CA and h/o VTE

Answer 310

Pt with hormone rct + breast CA but contraindication for aromatase inhibitor (h/o VTE) Tx: Ovarian ablation ONly use trantuzumab in HER2Neu + patients

Question 311

Thyroid storm

Answer 311

temp elevation, tachycardia, HF, abd pain, diarrhea, n/v, jaundice Can be from non-compliance with anti-thyroid meds or precip by surgery, truama or radiocontrast Tx: PTU/methimazole, BB, iodine solution Myxedema coma - hypothyroid - hyponatremia, hypoventillation how T3, T4

Question 312

Subacute (de Quervain) thyroiditis

Answer 312

transient destructiono f thyroid tissue - release of pre-formed T3/T4 - initially hyperthyroid then hypotheyroid s/p viral infct, tender thyroid

Question 313

Budd Chiari syndrome

Answer 313

``` hepatic vein thrombosis risk factor PCVera (also have TIA, MI/CVA, erythromyalgia Dx: Doppler US check for hepatic flow Tx: A/C - oral diuretics if not fully controlled - TIPS -> liver tx ``` Splenic vein thrombosis - isolated gastri varices no tender Hepatomegaly or ascites

Question 314

HTN in pt with CKD

Answer 314

Thiazide diuretics less effective than loop diureteics if GFR < 30 (resistent HTN - 3 agents diff classes including diuretic) Change HCTZ-> loop

Question 315

Dx Acute retroviral syndrome

Answer 315

Pt with high risk features for HIV HIV test neg, strep and mono neg Check HIV RNA to dx HIV

Question 316

Manage AC for pt with mech AVR preop

Answer 316

Short term risk small D/C warfarin 3 days before surgery and restart evening of surgery Risk factors = afib, more than one valve, valve position, hypercoag state, LVEF<2, stop 4 hrs prior to surgery then restart after with warfarin until INR therpautic If needs emergent surgery then use FFP to reverse coumadin

Question 317

Henloch Schloen purpura

Answer 317

Palpable purpura of legs after strep pharyngitis (raised violacious non-blanching papules) Cutaneous small vessel vasculitis elevated risk of kidney dz

Question 318

Disseminated gonnococcal infxn

Answer 318

fevers, tenosynovitis, arthritis, skin lesions - hmorrhagic pustules -

Question 319

Sweet syndrome

Answer 319

neutrophillic dermatosis - bright erythematous well demarcated papules Idiopathic or aw underlying dz (hem malignancies)

Question 320

Treat carpel tunnel syndrome

Answer 320

avoid repetitive wrist motions start wrist splinting Local corticosteroid inj for 3 months releif not durable ->contraindicated with thenar hypertrophy, lot of sensory loss, acute carpel tunnel NSAIDS not effective Surgical intervention if medical/nonpharm tx fails - progresive sensory and motor defects, severe EMG findings

Question 321

Manage sellar mass

Answer 321

Incidental sellar mass Check for hormone hypersecretion IGF-1(to measure GH fxn), morning cortisol AND prolactin IF inc'd prolactin - > dopamine agonist tx

Question 322

DMSupp

Answer 322

used to locate tumor in ACTH dependent cushings

Question 323

SIADH

Answer 323

check serum and urine sodium

Question 324

Acute ischemic stroke with HTN

Answer 324

initial stroke >3-4.5 hrs out - no Tpa no end organ damage (no LVH, ACS, kidney dz, encephalopathy, preeclmapsia, CHF, aortic dissection keep BP<220/120 No oral meds (dysphagia risk)

Question 325

Inpt with risk for VTE

Answer 325

immobilized and two risk factors for VTE low dose HSQ (not ASA, warfarin 1mg) - don't use SCDs unless contraindication for HSQ

Question 326

Complicated parapneumonic effusion

Answer 326

pleural fluid cw exudate | Complicated = large effusion, loculation, +pleural fluid g stain, pleural fluid glucose < 60, pH tube thoracostomy)

Question 327

Esophageal candidasis

Answer 327

Oral fluconazole plaques in mouth and dysphagia Nystatin swish/swallow only in pt with oral dz and NO dysphagia (indicating esophageal inovlvment) Do not d/c inhaled steroids yet - tx candidasis

Question 328

Kidney bx contraindication

Answer 328

``` Uncontrolled HTN (r/o post bx hemorrhage) <160/95 (take all antiHTN preprocedure - short acting BB/clonidine during procedure also mild sedative (lorezepam) ``` Other contraindication - coagulaopathy, low plt, hydronephrosis, atroptic kidney, kid cyst, acute pyelo

Question 329

Hereditary hemochormatosis

Answer 329

C282Y mutation - risk factors ferritin >1000, age>40 r/o cirrhosis - if dx then liver bx to r/o cirrhosis -> r/o HCC If cirrhosis - > EGD r/o varices, HCC Tx: phlebotomy Observation only if ferritin low <50, no end organ damage Yearly checkups for iron level and labs If genetic hemochormatosis with iron overload wihtout end organ damage still needs phlebotomy

Question 330

Reactivation of HSV by UV radiation

Answer 330

latent HSV in trigeminal nerve activated by sunlight UV - immunosupp by UV localized cluster of vesicles on vermillion border of lip - vesicles rupture and heal tx: oral acyclovir, lip balm with sunblock

Question 331

Actinic chelitis

Answer 331

premalignant in people with significant sun exposure | on lip - ulcers, vermillion border

Question 332

Contact dermatitis

Answer 332

from lip balm usually pruritic

Question 333

Coxsackie

Answer 333

``` hand foot mouth dz intraoral, palmar, plantar lesions oval flesh colored papules with erythema rim fever/sore throat Spare lips - different than HSV ```

Question 334

HLD tx in pt wants to get pregnant

Answer 334

colesevelam (welchol) bile acid sequestrant - dec CV mortality Risk factors for CVD - DM, HTN, HLD, FHx MI s/e constipation - binding and dec absorbtion of other drugs ``` No ezetimeibe (doesn't dec mortality and preg cat X) Gemfibrozil not efficiacious enough No statins (cat x) ```

Question 335

Clinical manifestation of sickle cell TRAIT

Answer 335

Only hematuria, risk fo splenic rupture high altidute, VTE, sudden death during extremem condidtions, renal medually CA Hematuria - renal papillary necrosis (local microinfarcitons) - painless gross hematuria Need well hydration during strenous excercise r/o stones/urinary tract neoplasms Pt with SC trait don't get acute chest, bone/joint sx, LE swelling

Question 336

Treatment of Tic d/o

Answer 336

If no effect on social /academic or occupational fxn no need to treat Tourette's syndrome No ADHD or O/C d/o If does disrupt ADL - block dopamine with clonidine, pimozole, haldol

Question 337

Lymphangiolyomyomatosis (LAM)

Answer 337

``` rare cystic lung dz rare in women of childbearing age aw tuberous sclerosis Spontaneous PTX/chylothorax Young woman with dyspnea and chest CT with cystic findings/hyperinflation on CT Diffuse think walled cysts Etio - smooth muscle cells in lung infiltrating lung with inactivating TS gene tx: sirolimus ```

Question 338

Organizing PNA

Answer 338

sx over 4-6 wks no more than 6 months | patchy airspace dz, ground glass, consoidation (no cysts)

Question 339

Repsiratory bronciolitis associated ILD

Answer 339

smokers | centroloar nodules, air trapping scatterd gound glass

Question 340

Sarcoidosis

Answer 340

reticulonodular abn in central distribution along lymphatics b/l hilar and mediastinal LAD

Question 341

Padget's dz of bone

Answer 341

osetitis deformans focal abn of bone metabolism - compromoised bone integrity Dx: confirmed by plain Xray - coarsened bone trabeculae elev alk phos (bone isoform) traumatic / pathoogic fx, hearing loss impringemneet CN VIII, bone bx, audiology after confirmation or denial of padgets

Question 342

Diffuse cutaneous systemic sclerosis

Answer 342

Pt's w/ SCL70 - antitopoisomerase + high risk of ILD - check HRCT chest (low dlco, restrictive pattern (low FEV1)) ILD w or w/o alveolitis No risk factors for PE, no RH strain No RHC if normal TTE

Question 343

Achalasia

Answer 343

Tapering esophagus - birds beak surgical myotomy No endoscopic dilation in young pt (recurs and r/o rupture) No botox injection - only temp relief - only if not candidate for surgery or endo dilation No medical tx - no consistent results

Question 344

Cardiac monitoring for INFREQUENT arrythmia episodes

Answer 344

Implantable loop recorder concern for arrythmia given occupation Up to 3 years when shorter duration monitors non-dx

Question 345

Lead nephrotoxicity

Answer 345

Pt with normal lead levels but still suspect lead poisoning Use chelation mobilization testing - measure in urine Lead nephrotoxicity - chronic intersititial nephorlithiasis - low grade proteinuria, - Fanconi like syndrome - glycosuria in normal glucose, hyperurecemia, hypophosphatemia, aminoaciduria Erythrocyte protoporphy measurement - acute lead exposure Lead lines - long bone radiography - only in kids Basophilic stippling in peripheral smear - non-specific

Question 346

Colonscopy screening ulcerative procitis

Answer 346

if confined to colon then like general population (q10yr)

Question 347

Coccoidomycosis

Answer 347

SW US/S/Central america | Pulmonary infxn, joint pain, erythema nodosum

Question 348

Blastomycosis

Answer 348

Mississipi/Ohio river valley, great lakes

Question 349

Histoplasmosis

Answer 349

ohio river valley Hilar LAD with pulm infiltrates Bird/bat droppings

Question 350

Sporotrochosis

Answer 350

rare cuase of PNA - can have erythema nodosum, cavitations, lung nodules, hilar LAD

Question 351

Ischemic stroke treatment

Answer 351

Contraindication for TPA - DM, ischemic stroke hx Tx: not candidate for tPA (keep BP < 220/120) Use high dose statin

Question 352

Adrenal fxn during critical illness

Answer 352

Random cortisol >12 makes adrenal insuff unlikely in pt with hypoalbumin/ critically ill continue current therapy abx/IVF Cosyntropin stim not useful in setting of sepsis (stressful arleady) No reason for morning cortisol in pt with sepsis as maximally stimulated all day No need for hydrocortisol

Question 353

Lentigo malina

Answer 353

Melanoma in situ uniformly pigmented light brown patch in area of sun exp skin grows slowly over years Broad shave biospy Not an excisional bx because lesion is large and likely lentigo maligna and NOT melanoma so likely minimally invasive

Question 354

High risk myelodyplastic syndrome

Answer 354

Refractory anemia with excess blasts 10-19% tx with azacitidine (nucleoside analogue) Abnormal cytogenetics

Question 355

TTP

Answer 355

``` thombocytopenia microangipathic hemolytic anemia fever kidney impairment neurologic deficits +schistocytes on smear ```

Question 356

MM and AKI

Answer 356

MM - production of abnormal immunoglobulin (paraprotein) Pw bone pain, hyperCa, anemia, AKI - precipitation of paraproteins in kidney Clue: Urine dipstick low protein (only measures albumen) Total protein HIGH Use SPEP/UPEP to dx MM If was ANCA vasculitis then u/a would be active

Question 357

Disseminated gonnoccocal infection

Answer 357

Young, sexually active adults prodrome tenosynovitis, polyarthralgia Cutaneous lesions papule/macule -> pustule, frank arthritis, gram stain/ctx usually neg tendinitis, PAPULOPUSTULAR skin lesions

Question 358

Staph arthritis

Answer 358

usually monoarhritiss | no tenosynovitis or skin findings

Question 359

Thromboembolic ppx after afib ablation

Answer 359

First 2-3 months ALL pts take warfarin AFter that period give according to CHADS2 (don't know if pt having asx pAF) NOAC not studied in post afib ablation setting

Question 360

Symptomatic BPH

Answer 360

combination therapy with alpha blocker (tamsulosin, doxazosin, terazosin) and 5 alpha reductase inhib (finasteride) - shrink prostate takes time (no reason to change 5 alpha red i, or for abx

Question 361

Meralgia paresthetica

Answer 361

Nerve entrapment of lateral femoral CUTANEOUS nerve BURNING, numbness - anterolateral thigh PURELY sensory DM, obesity, wearing of tight fitting pants/belts dysthesia/hypothesia in distribution of lateral thigh No tenderness to palpation

Question 362

Greater trochanteric bursitis

Answer 362

Pain in region of greater trochanter worse on affected side | Pain to palpation

Question 363

Illiotibial band syndrome

Answer 363

pain in anterolateral knee worse with running/cycling absent in rest pain to palpation of femoral lateral epicondyl

Question 364

L5 radiculopathy

Answer 364

back pain -> lateral thigh weakness in foot all three (eversion, inversion, dorsiflexion) +straight leg test

Question 365

Dopamine agonist induced COMPULSIVE behavior

Answer 365

excessive repetive tasks 2/2 dopamine agonist meds dysregulation of brains dopamine rewards system Tx: reduce dopamine agonists

Question 366

Demntia with lewy bodies

Answer 366

80% parkinson's pt affected cognitive decline, parkinsons Bizarre visual hallucinations

Question 367

Frontotemporal dementia

Answer 367

apathy, impulsivity, hoarding, disinhitibtion | obsessionality

Question 368

Prevent ventillator associated PNA

Answer 368

48-72 hrs after intubation maintain head of bed 30 deg daily wheening assessment chorohexadine mouth washes No need for early trach, chorlox baths,

Question 369

Symptomatic rapid afib

Answer 369

hemodynamically unstable -> DCCV (hypotension, pulm edema, - loss of atrial kick dec's BP and CO) - recent sx development - no A/C needed Adenosive to dx SVT Amiodarone only for cardioversion of stable afib pt or long term afib prevention No metoprolol or diltiazem in setting of acute HF and unstable afib

Question 370

Lofgren syndrome

Answer 370

anterior uvietic, fever, acute lower extrem arthritis, erythema nodosum, -> check for hilar LAD on CXR to confirm Lofgren without tissues bx

Question 371

Granulomatosis with polyangiitis

Answer 371

Wegeners - arthritsi, uveitis, pw URI - glomerulonephritis and mononeuritis multiplex,

Question 372

Disseminated gonnococcus

Answer 372

fever, tenosynovitis - usually no uveitis | No erytema nodosum

Question 373

Pityriasis rosea

Answer 373

young ppl single pink oval shaped plaque (herald patch) -> surrounded later by smaller lesions (christmas tree pattern) Pruruits Tx: none - self limited (only mild low dose topical steroids if pruritic)

Question 374

Fungal

Answer 374

Expanding ring like lesion central clearing | scrape and KOH lesions

Question 375

Treat vent failure 2/2 opiods

Answer 375

Non-focal neuro exam, pinpoint pupils, RR < 12, - needs escalating doses of naloxone Stroke less likely given non-focal findings

Question 376

Hepatorenal syndrome

Answer 376

``` Setting of SBP doubling of Cr Cirrhosis with ascites No concurrent nephrotoxic drugs Tx: Albumin ``` (no benefit of octreotide or vassopressin)

Question 377

Diabetes inspidis

Answer 377

Central DI: Urine Osm < 200 in setting of hypernatremia Response to ADH/despmospressin UOsm>600 CMV Nephrogenic DI: foscarnet tx, lithium Desmopressin does not inc UOsm

Question 378

Cerebral salt wasting

Answer 378

HYPOnatremia, HYPOvolemia

Question 379

Pt with DVT and cancer

Answer 379

LMWH (not coumadin, not UFH (needs labs)) No IVC (no contraindic for A/C or failed A/C)

Question 380

Acute utricaria likely 2/2 levofloxacin

Answer 380

cetirzizine, ranitidine, diphenylhydramine (h1, h2 tx) No concerning features (stridor, eyelid swelling, breathing comfortably - these would warrant admission to hospital) Topical corticosteroid impractical NO NSAID - mast cell degranulation - worsen utricaria

Question 381

Spasmodic torticollis

Answer 381

focal dystonia of neck occupational overuse syndrome characterized by directionality Tx: botox injection

Question 382

Elevated chol in pt with DM

Answer 382

With DM - LDL goal LDL<70 To dec LDL always try to inc statin if possible (other drugs do not dec mortality)

Question 383

Mild congential asymptomatic neutropenia

Answer 383

ANC 1000-1500 common among certain groups able to do ADL NOT aw inc'd infections No tx needed, repeat CBC in 2 months (If need to r/o autoimmune neutropenia then antineutrophil Ab assay) BM aspirate if neutropenia worsesns (Flow cytometry only in lymphoprolif d/o)

Question 384

Tb tx

Answer 384

With meningitis - 9-12 months 4 drug regimen (meningeal involvement on CT) CSF lymphocytic pleocytosis, dec'd glucose Regular pulm/extrapulm TB - 6 to 9 months INH, rifampin, ethambutol, pyrazinamide 2 months of all 4 then 4 or 7 more months depending on pyrazinamide or not during first 2 months >12 months for drug resistance

Question 385

Non etoh steatohepatosis

Answer 385

Wt loss, excercise, agressive control of lipids, BP, glucose

Question 386

Nodular lung infiltrates suspected vasculitis

Answer 386

lung infiltrates with hemoptysis, p and c ANCA + rapidly progressive GN Need lung bx for dx (nasal/rhin tissue dx insufficient, no indication for kidney bx if no protein in urine)

Question 387

Secondary Osteoporosis

Answer 387

Fragility fx r/o causes of osteopenia Check for hypogonadism, vit D def, pirmary PTH, Ca malabsorbtion, Ca+ malaborb, MM H/o IDA with low urine Ca - possible celiac dz start bisphosphonates when dx certain

Question 388

Upper airway obstruction 2/2 angioedema from ACEi

Answer 388

No signs and sx of anaphylaxis or allergic rxn (no role for steroids or epinephrine) Need intubation

Question 389

Generalized anxiety d/o

Answer 389

excessive anxiety and worry about Variety of events on most days for at least 6 months fatigue, irritability, restlessnes, insomnia SOmatoform sx (high utilizer of heathcare)

Question 390

Major depressive d/o

Answer 390

5 or more depressive sx in 2 week period

Question 391

Bipolar d/o

Answer 391

manic or hypomanic mood epsisodes and depressive ones (manic = delusions of granduer, elevatd mood, dec need for sleep,, hypersexual, spending sprees)

Question 392

ADHD

Answer 392

inattention in childhood, hyperactivity, impulsivity in work/home/school (2)

Question 393

Chronic stable angina

Answer 393

despite optimal medical therapy and no options for revascularization (already on BB, nitrate, CCB) Ranolazine (don't give to long QT pt, inhibits met of dig/zocor, dose ajust with Kidney dz, )

Question 394

Primary glomerulous nephropathy

Answer 394

Nephrotic syndrome Microscopic hematuria, no erythrocyte casts HBC, HCV, SLE, malaria, syphillus, malignancies (breast, lung, kidney, stomach, colon, NSAIDS, ACEi, RA, DM Kidney bx: LM: diffuse glomerular thickening, no inc'd cellularity Immuno: granular IgG C3 deposits along capillary loops EM: mod foot process effacement

Question 395

Asymptomatic gallstones

Answer 395

Observation unless symptomatic (or undergoing procedure that will make syptomatic) Most asx gallstones benign course

Question 396

Superior vena cava syndrome

Answer 396

Need tissue dx - mediastinoscopy and bx can be caused by lymphoma, mediastinal germ cell tumors, lots of pt with malignancy have this as presentring syndrome Progressive dyspnea, facial swelling, distention of neck/veins, facial edema, mediastinal widening, pleur eff

Question 397

Dx Vit D deficiency

Answer 397

Pt with osteoporosis, high PTH, low Ca+ and Phos -> secondary hyper PTH 2/2 vit D deficiency Check 25OHD3

Question 398

Chronic fatigue syndrome

Answer 398

unexplained fatigue that lasts more than 6 months - subj memory impairment, sore throat, tender LN, h/a, unrefreshing sleep tx: CBT, graded exc, sleep hygene,

Question 399

Osteomyelitis

Answer 399

Deep bone bx cultures more accurate | Sinus tract drainiage could be contaminated from surface

Question 400

Discoid lupus

Answer 400

dyspigmented atrpohic patches on scalp/ears, black women, hair loss, leave scars usually no systmeic SLE

Question 401

Allopeica areata

Answer 401

NON-scarring process - no skin changes in ears

Question 402

Tension headaches

Answer 402

``` Non disabling h/a 30 min to 7days Need brain imaging - done, net b/l steady, unaffeted by physical activity, no photopobhia, n/v Tx: NSAID> ASA or tylenol (no role for TCA, cyclobenzaprien, ```

Question 403

Early Rheum arthritis

Answer 403

CRP, +CCP, +RF, lots of joints, early morning stiffness >60min, Tx: DMARD (MTX) (NSAIDs, shoe inserts and colchicine NOT better)

Question 404

Adult with repaired tetralogy of fallot (pulmonary infundibular stenosis, Overrding aorta (AV connected to both L&R Ventricle), VSD, RVH) pw sx afib

Answer 404

Pulm valve replacement, TV repair, Maze procedure (afib) MC post op problem - afib from severe PV Regurg 2/2 patch over RVOT - well tolerated for years but causes RVH, TV annular dilation, TR, dilation of RA causing afib RFA/DCCV won't work without fixing PV/TV Tx onlywith biventricular failure

Question 405

Treat anaphylaxis

Answer 405

IM/SQ epi for anaphylaxis and inhaled albuterol for wheezing need high flow o2, cardiac monitor, IV access, No IV epi - only treats hypotension (r/o MI, HTN, CVA, r/o arrhythmia) Antihistamines or corticosteroids won't help anaphylaxis Mechanical ventillation only in drooling, stridor, facial/tongue swelling, inability to talk

Question 406

Nephrogenic systeic fibrosis

Answer 406

(nephrogenic fibrosing dermopathy, scleromyxedema like illness of renal dz) Seen in some pts with ESRD on HD after MRI with GAD, Progressive tightening and thickening of skin, fleshy/yellow plaques/papules, pruritis, Skin bx CD34, dermal fibroblasts

Question 407

Lipodermatosclerosis

Answer 407

Significant venous insufficiency darkly pgimented indurated skin +venous ulcers, dependent edema

Question 408

Scleroderma

Answer 408

should be in face, periooral, fingers, +SCL70, +anticentromere Ab

Question 409

Scleromyxedema

Answer 409

widespread ertyemaouts, indurinated skin with fleshy papules, face, fingers, extremities, aw serum paraprotein seen on SPEP

Question 410

Parapneumonic effusions

Answer 410

Pt's with CAP and large pleural effusion (>1/2 hemithroac or 1cm lying) - should undergo prompto thoracentesis, exclude complicated parapneumonic eeff (pH<60, G stain +) Delay may cause loculation and need for VATs Small pleural effusions do not require drainage

Question 411

Cancer of unknown primary

Answer 411

symmetric around midline mediastinum and retroperitonium - poorly diff CA LIKELY Extragonodal GERM CELL TUMOR (given young man) Check AFP, HCG Tx: Cisplatin chemo

Question 412

Palliative care discussion with family of cancer pt

Answer 412

Communicate with family to assess understanding of patient's condition Don't start with advanced directives Don't say cure intent is futile

Question 413

Overcorrection of hypotonic hyponatremia

Answer 413

Correct 4-6 meq in 24hrs if more then need to correct backward with 5% dextrose (high UOP suggests rapid water diuresis which will worsen correction) Tolvaptan would also block ADH which would make overcorrction worse (same with fluid restriction, NS) - cells shrink, water out, central pontine myelolysis

Question 414

Generalized convulsive status epilepticus | jerking all 4 extremities tonic clonic >5 min

Answer 414

First Lorazepam (benzo) Then Phenytoin/fosphenytoin Acute complication - rhabdo, hypoxia, met acidosis Chronic - cognficitve defects, future seizures CTH needed levecitram (keppra) not used in general convulsive status epilepticus

Question 415

Fungal arthritis

Answer 415

In immunocompromised (ie DM) subacute monoarthritis gardener scraping knees (sporothorax) Synovial fluid culture, synovial bx

Question 416

Basic calium Phophate dz

Answer 416

usually chronic crystals invisible in polarized light alizen red stains them should have Ca+ seen on xrays

Question 417

Fasting hypoglycemia in pt without DM

Answer 417

Pt with lab documented HYPOglycemia inappropriately high insulin level (without inappropriately high C-peptide) -> hypoglyemia due to EXOGENOUS insulin injection -> needs PSYCH eval also r/o sulfonyurea If suspect insulinoma - abd CT Gastric emptying delay rarely causes SEVERE hypoglycemia (also with h/o altered Gastric anatomy ie bypass) - no need for gastric emptying study

Question 418

Pt with active TB that discontinued all meds on 2 month initial regimen

Answer 418

If meds d/c'd more than 2 or more weeks in initial 2 month tx then restart from beginning with SAME meds If < 2 weeks missed then continue regimen as long as all planned doses taken within 3 months REgardless if sputums neg pt needs initial 2 month phase followed by 4 month continuation phase SInce all meds dc'd at once no reason to change meds suspecting resistance

Question 419

Acute exacerbation of IPF

Answer 419

Some patients with IPF develop acute exacerbation Dx criteria - unexplanined worsening of dyspnea in < 30 days, CT new GG appearance, consoldation Only intervention = lung tx Diffuse alveolar damage on bx - pt age and lack of comorbid condition - good tx candidate Diffuse alveolar hemorrage can show as ground glass on CT however would show blood in BAL PJP PNA - would show organisms on BAL, pt should be immunocompromised Pulm edema 2/2 tachy - would have S3, elevated BNP, JVD

Question 420

Myasthenia gravis

Answer 420

``` immune attack on post-synaptic nm jnc Ab vs acetylcholin rect Muscle spectific tyrokinase rect ab CT chest r/o thymoma - needs surgical resection Tx: plasma exchange or immunosuppression ``` If muscle sp tyros kinase Ab + then less responseive to pyrostigmine Ephodrium - check if clear cut muslce strengthening after injection -> dx MG not good with just opthalmic and mild limb weakness

Question 421

Manage white coat HTN

Answer 421

White coat HTN with no evidence of end organ damage (no LVH on EKG, normal Cr/labs) Dx: 3 sep office measurement above 140/90 and two at home below f/u q6month, continue HOME measurements - still at risk for sustained HTN No benefit to pharm tx of white coat HTN Normal labs, normal ekg no need for TTE or urine studies

Question 422

Nocturnal hypoglycemia

Answer 422

HgA1c lower than avg blood sugars measured - so i hypoglycemic at unmeasured times of day 70/30 insulin peaks 6-8 hrs h/a, morning fatigue, sweating in DM I pts

Question 423

Dawn phenomenon

Answer 423

Elevated glucose 4-8am with morning cortisol surge (co release with GH) - dx with perisistent hyperglycemic morning readings

Question 424

Somogyi phenomenon

Answer 424

the lower the glucose at night, the higher the rebound hyperglycemia in AM

Question 425

Risk of death for women

Answer 425

Greatest problem is cardiovascular dz more than all other cuases (ie cancer) combined Post menopausal, HTN, obseity, inc'd waist circumference, (CAD, PAD, CVA) Even women with DM will diet of CAD or CVA not DM

Question 426

Tinea corporis

Answer 426

``` asx or puritis/burning Often annual growing circumferentially Topical steroids reduce temporatily but do not tx condition and will recur dx: KOH skin scraping Tx: topical antifungals ```

Question 427

Atopic dermatitis

Answer 427

would not be worse when cream d/c'd | FHx atopy - eczema, asthma, seasonal allergies, atopic deramatisi - on flexor areas

Question 428

Nummular Dermatitis

Answer 428

coin shaped eczematous lesions - pruritic - well demarkaced - can be acutely inflammed and weeping - dx by skin bx if needed

Question 429

Psoriasis

Answer 429

round scaled lesions thicker scale - removal causes pinpoint bleeding (Auspitz sign)

Question 430

Sclerodermal renal crisis

Answer 430

setting of diffuse cutaneous systemic sclerosis etio - acute HTN, AKI - microangiopathic hemolytic anemia Tx: ACEi Bosentan - tx pulm HTN or digital ulcers in pt wit syst sclerosis Plasma exchange for TTP, HUS Sildenafil - PDE inhib, Pulm HTN/ raynauds

Question 431

Sycope in elderly male

Answer 431

Cardiac causes of syncope have high mortality - inpt cardiac monitoring needed likely with prodrome of palpitations and immediate recovery Neuro etio of syncope rare - no need for HCT or carotids NO TTE unless suspect structural heart dz

Question 432

Risk of ampullatory adenoCA in pt with FAP or Peutz Jehurers

Answer 432

Need regular upper endoscopy even after colon resection r/o ampullary CA Tx: whipple DOn't just monitor LFTS - when elevated likely too late!

Question 433

Manage early septic shock

Answer 433

Empiric abx therapy - within 1 hr of dx sepsis (after cultures obtained) crystalloids to maintain preload O2 to prevent hypoxia Vasoactive agents if persistent hypotension after IVF - go with epi first Tx of PRBC if needed (if Hct < 30 or CVO2<70%

Question 434

Salicylate toxicity

Answer 434

respiratory alkalsosis tinnitis, tachpnea, confusion, fever AG met acidosis (salicylate anion and lactic acid/ketoacid) Alk of serum pH to decrease cellular uptake of salicylate IV glucose to stop salicylcate induced neuroglycopenia correct hypokalmeia to prevent salicylate absorption in distal tubule Don't use acetazolamide - decreases serum pH which increases cellular uptake of salicylate/toxicity HD if salicylate >80, AMS, AKI, pulm edema, Avoid mech ventillation if possible - decreases serum pH increasing salicylate tox/uptake

Question 435

Dx Scabies

Answer 435

confirm with scraping and microscopy mites, eggs, feces KOH/oil unexplained itching and rash finger web spaces, wrist, nipples, axilla, small excoriated papules, vesicles, linear burrows EOS is non specific Serum TTG - r/o dermatitis herpetiforms aw celiac dz No need for skin bx

Question 436

MEN I

Answer 436

Parathyroid, Pituitary, pancrease - genetic | (gatrin secreting pancreasic neuroendocrine tumor

Question 437

Autoimmune polyglandular syndorme

Answer 437

chronic mucocutaneous candidiasis, autoimmune hypoPTH, adrenal insufficiency

Question 438

MEN II

Answer 438

parathyroid, Pheo, medullary thyroid CA

Question 439

Convulsive syncope

Answer 439

cardiogenic/vasovagal syncope similar events in past - prodrome during blood draw Reassurance - no tx needed No anti epileptic drugs needed Even if seizures - only if has risk factors or focal findings on EEG/MRI

Question 440

Acute chest syndrome in Sickle cell dz

Answer 440

New pulmonary infiltrates on CXR CP temp t use lasix - can increase sickling Hydroxyurea only for prevention of acute chest not tx

Question 441

Risk factor management in pt with CAD

Answer 441

Smoking cessation best risk factor modification approach non-smoker status after 3 years excercise at least 3x/wk 20min/day <70 if CAD+DM

Question 442

Botulism

Answer 442

symmetric descending flaccid paralysis with bulbar palsies, (diplopia, dyarthria, dyphagia), normal body temp, clear sensorium ``` Injestion of botulism toxin from home canned foods, wound contamination 1-5 days of ingestion respiratory dysfxn (Diaphragmatic wk) Detect toxin in stool, serum No abx needed ```

Question 443

Guillane barre

Answer 443

oculomotor dysfxn - h/o antecedent infection (GI illness from campylobacter), ASCENDING paralysis, paresthesia,

Question 444

Paralytic shellfish poisoning

Answer 444

ingestion of filter feeeders clams, oysters... sx few minutes to hours Tingling lips, paraesthia hand/feet, loss of contrl of arms/legs

Question 445

Tick paralysis

Answer 445

ASCENDING paralysis, large muscles

Question 446

Colonoscopy screening

Answer 446

Nonsyndromic colon CA 1st deg relative with colon CA age 54 Get screened age 40 or 10 years prior to 1st deg relative dx (whichever earlier) - ie 40

Question 447

Manage ADHD inadult

Answer 447

not paying attendtion, impulsivity, motor restlessness manifest social/academic dysfxn at least in 2 settings If few sx then drug holiday q2yr for reassessment warranted If needs drug after holiday - atomoxidene warranted other SSRI not shown to help

Question 448

Guillane barre

Answer 448

Plasma exchange and IVIG to prevent respiratory failure acute inflammatory demyelnating polyneuropathy Not phrenic nerve pacing (only with high C spinal injuries) No cpap - bulbar dyfxn r/o aspiration No benefit with steroids

Question 449

Thyroid lymphoma

Answer 449

older pts h/o hashimotos presents as enlarging neck mass Local , systemic sx Local compression (dyphagia, stridor, JVD, facial edema) B symptoms Bleeding of thyroidd would show cystic mass no h/o trauma Thyroid CAs grow slowly

Question 450

Atopic hand dermatitis

Answer 450

``` pts with atopic eczema prolongued contact water/harsh substances pruritic skin conditioin intermittent flares skin bx non sp ```

Question 451

Keratoderma blenorrhagica

Answer 451

hyperkeratotic skin condition | erythem scaley plaque palms and soles aw sponyloarthropathy

Question 452

Scabies

Answer 452

intnese itching | burrows interdigital web space, wrist, nipples

Question 453

Tineas Mannum

Answer 453

infect stratum corneum (epidermis)

Question 454

Pigment nephropathy from rhabdo

Answer 454

CK>5000 heme + urine, few RBCs (dipstick detects myoglobin) High urine sodium High FENa/granular casts suggests intrinsic renal damage Hx suggestive of muscle damage Acute interstitial nephritis - suspicious mediciine exposure Hepatorenal - liver dz, low urine sodium Intrabd compartment - surgery or massive fluid rescuitation

Question 455

Ambulatory arrythmia monitoring

Answer 455

Presyncope few times a month Looping event recorder - will record pre-sx rthym but store when pt indicates feeling sx Holter (continueous 24 hr) - good for frequent asx arrythmia Post symptoms event recorder - No preeceeding rhtym - takes a while to place and record

Question 456

Creutzfeld Jacob rapidly progressive dementia

Answer 456

``` progressive dementia aw myoclonus rapdi deterioration of mental status no trauma, infxn, fever Prion d/o Spongioform incephalopathy without inflammaotry signs - neg neuro imaging ``` Frontotemporal dementia time course longer herpes simplex encephalitis - fever, hemicranial h/a, memory impairment, seizures - neuro imaging with edema, hemorrhage in temporal lobes b/l temporal involvmenet -> pathomnemoic for HSV enceph

Question 457

Henloch scholen purpura

Answer 457

``` Purpuric rash lower extrem arthritis, abd pain, hematuria Skin bx: Iga Depostis, leukocytoclasic vasculitis aw solid tumors or MDS ```

Question 458

Churg Strauss

Answer 458

vasculitis - h/o asthma peripheral EOS p-ANCA

Question 459

Microscopic polyangiitis

Answer 459

small arterioles glomerulonephritis and purpuric skin lesions NO IMMUNE deposits +ANCA

Question 460

Polyarteritis nodosa

Answer 460

small to med vessel vasculitis renal artery involvement and HTN No immune depostis

Question 461

Subacute cutaneous lupus

Answer 461

maculopapular rash, anti ro/SSA no glomerulonephritis

Question 462

Preg pt with VTE and aquired protein S deficiency (anticoagulant)

Answer 462

dec'd protein S activity dec'd free protein S Ag normal TOTAL protein S antigen During preg (or warfarin use) conc of C4b binding protein inc's - binding free protein S Ag - dec'ing protien S activity -> hypercoag state - > more VTE Congneital protein S def shows just dec in protein S activity

Question 463

Periop risk assessment

Answer 463

3 or more cardiac risk factors (Revised Cardiac Risk index) unable to achieve 4 mets If above met - proceed to surgery

Question 464

Dx severe CAP

Answer 464

Urine antigen for S pneumo and legionella

Question 465

Treat hospitalized patient with DM and basal insulin

Answer 465

Type I DM should have basal insulin + premeal (aspartate) | Don't resume pre-mixed 70/30 basal /bolus

Question 466

Manage patietn with rhabdo

Answer 466

First trial of NS (rapid infusion) Inc'd sodium delivery to tubules will also excrere K+ No immediate need for HD as no EKG changes

Question 467

Manage pt with Vfib arrest

Answer 467

after defib shock - CPR x 2 min - 5 cycles of 30 then 2 breaths then rnythem check CPR @ 100/min IV epi, after 2nd dose then IV vassopressin If multiple shocks then amio /lido considered offer ICD if survives arrest

Question 468

Manage meds in pt who MAY become pregnant

Answer 468

``` Metformin ok for DM (class B) IF becomes preg then prossibly change to insulin ``` No ASA, ACEi, zocor (ACEi/statin class X)

Question 469

Localized impetigo

Answer 469

Bullous impetigo = staph aurueus -use mupirocin if not systemic If systemic use cephalexin

Question 470

Complex liver cyst

Answer 470

Complex=irregular, septations REfer for surgical resction (r/o malignant transformation) heaptic cystadenoCA Cyst asp not appropriate Do not just observe or repeat US

Question 471

Asx hyperurecemia

Answer 471

mod elev serum urate NO sx Dietary/lifestyle mod only (avoid meat, shellfish, etoh) inc dairy, wt loss Don't use HCTZ - inc'd reabsorp urate, inc's r/o gout

Question 472

Gout drugs

Answer 472

Allopurinol XO inhib - urate lowering Probeneicid - inc'd urate excetion Colchicine - anti-inflamm

Question 473

Treat elevated BP after IC hemorrhage

Answer 473

IC hemorrhage after HTN, cocaine and ASA BP goal with IC hemorrhage - 160/90 (if ICP elev <140/90) Pt on cocaine so IV labetolol (not lopressor) IF unconcous or AMS - ventricular drain

Question 474

Idiopathic pulmonary fibrosis (IPF)

Answer 474

Progressive dypnea with worsening dry cough >6mo smoking hx, inspiratory crackles dust exposure (ie wood) CT septal thickening, honeycombing, traction bronciectasis No COPD - normal FEV1/FVC

Question 475

Hypersensitity pneumonitis

Answer 475

allergic inflamm lung dz exp to airborne antigens sx w/in 4-12 hrs

Question 476

Clenched fist injury pt allergic to PCN

Answer 476

Person bite Augmentin if NOT PCN allergic Clindamycin/moxifloxacin if PCN allergy Alt is bactrim with flagyl

Question 477

ethylene glycol intoxication

Answer 477

envelope shaped crystal (Ca Ox) flank pain, kidney failure, coma, seizures, noncardio pulm edema, Tx: fomipezole (competitive inhib of etoh dehydrogenase - presents converstion to more toxic compount) and hemodialysis to REMOVE present toxic compounds Metabolic acidosis (AG) with resp alkalosis and met alk (vomiting)

Question 478

psychogenic nonepileptic seizures

Answer 478

Dx with inpt EEG video monitoring 2-7 days - continuous monitoring Antiepileptic drugs withdrwan

Question 479

Patient with cyanotic heart disease and anemia

Answer 479

With cyanotic HD - goal Hg 60-65% In this pt Hct 52 but ferritin low Iron therapy needed Atrial septostomy - ES pulm htn tx without intracardiac shunt Pulm vasodilator tx if still sx after iron therapy

Question 480

Advanced stage ovarian CA in complete remission after initial adjuvant chemo

Answer 480

H&P, pelvic and CA125 q4month x 2 years -> restart chemo if relapse No role for surveillence CT

Question 481

Fuliminant liver failure

Answer 481

Refer for liver tx hepatic encephalopathy in setting of jaundice without pre-existing liver dz MCC FLF - medication (esp tylenol), viral infxn No need for FFP unless bleeding No ERCP - bile ducts NOT dilated

Question 482

Pulmonary artery HTN in pt with MCTD

Answer 482

``` MCTD - sx of SLE, high ANA and RNP ab PAH occurs +Raynauds Isolated low DLCO Elev PAP on TTE Needs RHC ```

Question 483

CA-MRSA skin infection

Answer 483

Bactrim Large pustular abscess with purulencea nd drainage Azithro, augmentin no activ vs MRSA Rifampin - rapid resistance

Question 484

Prevent DM2 in overweight pt

Answer 484

Weight loss, excercise | impaired fasting glucose 100-125

Question 485

Acute HIV infection

Answer 485

nonspecific consitutuional sx non specifici morbiliform exanthum/rash trunk/prox exttrem oral ulcers

Question 486

Typhoid fever

Answer 486

fever, constitutional sx 1 -3 weeks afgter ingesting contaminated food/water faint salmon colored rash diarrhea, abd pain Dx: salmonella typhi in blood, urine

Question 487

EBV

Answer 487

heterophile Ab test pharyngitis and LAB (cerv) mailaise, h/a Rash RARE

Question 488

parvovirus B19

Answer 488

Flu like sx, rash/arthralgia, slapped cheeck rash, No oral ulcers or gen LAD Parvoviurs B19 ab titers

Question 489

Lymphocytic Hypophysitis

Answer 489

uncommon autoimmune d/o enlargment of sellar contents central adrenal insuff (low ACTH), central hypothyroid, central hypogonadism Tx: glucocorticoid replacement - mass should decrease surgery if visiual field defect

Question 490

Craniopharygioma

Answer 490

rare mixed solid cystic lesion WITH CALCIFICATION | aw panhypopit and DI

Question 491

Sheehan syndrome

Answer 491

pituitary infarction in setting of hemorrhage during complicated delivery

Question 492

Prolactinoma

Answer 492

with such large lesion likely would have much higher prolactin =- inc'd size pituitary in preg does not cause sx or mass effects