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MKSAP > Deck 1 > Flashcards

Deck 1 Flashcards

1
Q

Diffuse itching in absence of rash

A

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

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2
Q

Psoas sign

A

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

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3
Q

FHx of mucocutaneous bleeding, no prolonged PTT, on OCP

A

vW dz

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4
Q

Newly Dx DM2 - what to do to screen

A

Urine alb-Cr ratio now

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

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5
Q

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

A

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

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6
Q

COPD tx FEV<60%

A

1st recommendation - long acting broncodilator (tiotropium)

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

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7
Q

Depression screening

A

screen all adults as long as appropriate support available

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8
Q

Hep B screening

A

not routinely recommneded except pregnant women

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9
Q

Osteoporosis screening

A

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

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10
Q

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

A

ONLY H. Pylori serology

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11
Q

Cardiorenal syndrome

A

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

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12
Q

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

A

low dose vaginal estradiol/ring

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

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13
Q

Bacterial vaginosis

A

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

Tx: metronidazole

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14
Q

Yeast infections

A

thick white d/c, KOH + with hyphae

Tx: vaginal clomitrazole

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15
Q

Posterior mediastinal mass

A

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

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16
Q

Anterior mediastinal mass

A

thyroid, thymus, lymphomas

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17
Q

Middle mediastinal mass

A

broncogenic cysts, pericardial cysts, LAD

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18
Q

Allergic contact dermatitis

A

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

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19
Q

Ecthyma

A

saucer shaped ulcers, legs, feet -> strep

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20
Q

Nummular dermatitis

A

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

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21
Q

Pulmonary valve stenosis

A

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

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22
Q

ASD

A

fixed split S2,

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23
Q

Bicuspid aortic valve

A

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

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24
Q

MVP/regurg

A

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

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25
Q

VSD

A

holosystolic murmur at left lower sternal region

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26
Q

DISH - diffuse idiopathic skeletal hyperostosis

A

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

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27
Q

Ankylosing spondylitis

A

Younger patients
sarcoilitis
vertical bridging syndesmophytes

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28
Q

Lumbar spinal stenosis

A

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

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29
Q

Spondylolisthesis

A

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

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30
Q

Parkinson’s dz - wearing off syndrome

A

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

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31
Q

Functional hypothalamic ammenorrhea

A

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

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32
Q

PCOS

A

look for hyperandrogenism (hirsuitism)

PCOS has good estrogen levels so progestin challenge would cause withdrwawal bleeding

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33
Q

Primary ovarian insufficiency

A

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

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34
Q

Ceftaroline IV

A

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

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35
Q

Pregnant pt with VTE/PE

A

LMWH at least 6 months and 6 weeks post partum

NO WARFARIN - teratogenic

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36
Q

Polymyositis

A

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

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37
Q

Primary adrenal insufficiency

A

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

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38
Q

Calcium oxalate kidney stones

A

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

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39
Q

Hypercalciuria

A

Thiazide diuretics

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40
Q

Migraine with aura

A

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

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41
Q

Molluscum contagiosum

A

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

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42
Q

Bacterial folliculitis

A

pustules centered on hair follicles

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43
Q

Large esolphageal varices

A

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)

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44
Q

When to use TIPS

A

Varicieal bleeding - if no effect with endo ligation

Gastric bleeding - if balloon tamponade ineffective

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45
Q

Prevent surgical site infection

A

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

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46
Q

Prevention of neonatal GBS

A

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

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47
Q

hypoactive sexual disorder

A

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

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48
Q

Lofgren sydrome

A

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

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49
Q

STEMI

A 
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
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50
Q

Manage life sustaining care in critiaclly ill pt

A

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

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51
Q

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

A

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

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52
Q

Hyperandrogenism in pt with neoplasm

A

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

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53
Q

Hemolytic uremic syndrome

A

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)

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54
Q

Post strep glom nephr

A

weeks after strep/staph infxn - dec’d complement

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55
Q

Chemotx induced myeloblastic syndrome

A

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

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56
Q

ALL

A

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

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57
Q

Parvovirus B19

A

NOT A/W cytogenic changes

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58
Q

Recurrent Hodgkins lymphoma

A

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

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59
Q

Post infarct VSD

A

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

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60
Q

Acute aortic dissection

A

aw IWMI, asymmetric BPs, early diastolic murmur of AI

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61
Q

Rupture ventricular free wall

A 
electromech dissociation, hemopericardium
Risk factors
Female
First MI
Anterior infarct
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62
Q

RV infarct

A

hypotension, clear lung fields elevated JVP

not likely with AWMI

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63
Q

Acute ischemic MR

A

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

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64
Q

Acanthosis nigrans

A

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

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65
Q

Tinea corpis

A

scaling annular patches with erythema - pruritic

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66
Q

Lichen simplex chroicus

A

thickening of skin with exencuation of normal skin markings - pruritic

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67
Q

Inverse psoriasis

A

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

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68
Q

Allergic contact dermatitis

A

pruritis, erythematous, well demarkated border

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69
Q

Chronic thromboebolic pulm HTN (CTEPH)

A

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

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70
Q

Rheumatoid arthrtis

A

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)

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71
Q

Renovascular HTN w/u

A

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)

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72
Q

Restrictive CM

A

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

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73
Q

Cardiac hemochormatosis

A

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

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74
Q

Constrictive pericarditis

A

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

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75
Q

Male hypogonadism

A

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)

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76
Q

Subacute cuteanous Lupus erythematosis

A

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

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77
Q

Levido reticularis

A

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

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78
Q

Colonoscopy screening UC pts

A

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

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79
Q

Colonoscopy screening normal

A

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

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80
Q

Extrapulmonary blastomycosis

A

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

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81
Q

Suspected melanoma

A 
ABCDE
Asymetry
borders irregular
Color varied
Diameter >6mm
Evolving
Dx: Excisional bx - breslow depth analysis
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82
Q

Prevent pressure ulcers in elderly

A

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

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83
Q

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

A

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

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84
Q

DVT dx

A

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

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85
Q

Non-dermatophyte (fungus) onchymycosis

A

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

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86
Q

Aplastic anemia in young patient

A

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

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87
Q

High risk NSTEMI

A

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

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88
Q

Respiratory failure in pt with COPD

A

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

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89
Q

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

A

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)

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90
Q

Diagnose secondary h/a

A

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

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91
Q

Evaluate pt with high BP

A

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

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92
Q

Chronic pelvic pain - interstitial cystitis

A

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)

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93
Q

Type I cryoglobulinemic vasculitis

A

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

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94
Q

Microscopic polyangiitis

A

p-ANCA
No immune depostis
L

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95
Q

Lupus associated Glom nephritis

A

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

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96
Q

Type II cryoglobulinemic vaculitis

A

active Hep C (RNA +)

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97
Q

Painful DM neuropathy

A 
better glucose control+
TCA (Desipramine) + capsacin cream
Remyelination can occur with better glucose control
NO SSRI
Nerve conduction studies NOT needed
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98
Q

Acute stroke

A

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

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99
Q

Post Roux en Y gastric bypass abn CBC elev MCV

A

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

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100
Q

Excercise induced broncospasm

A

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

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101
Q

Inhaled corticosteroids

A

> twice daily sx, weekly nightime sx

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102
Q

Type A acute aortic dissection

A

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

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103
Q

Histoplasmosis

A 
Bat droppings
Ohio river valley
Hilar LAD with infiltrates
SE US/ohio river valley bird/bat droppings
Asx, or flu like sx, dyspnea
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104
Q

Blastomycosis

A

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

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105
Q

Coccoidomycosis

A

SW US

Acute pulmonary, erythema nodosum, joint pain

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106
Q

Flat warts

A

HPV
autoinnoculation from shaving
flat, flesh colored

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107
Q

Actinic keratosis

A

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

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108
Q

Lichenoid keratosis

A

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

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109
Q

Dermatofibromas

A

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

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110
Q

Hypoparathyroidism

A

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

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111
Q

Treat pt with kidney stone

A

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

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112
Q

Cancer of unknown primary site

A

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)

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113
Q

Manage carpel tunnel

A

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

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114
Q

Tx pt with recurrent chemo sensitive diffuse b cell lymphoma

A

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

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115
Q

Hypercalciuric patient with nephrolithiasis

A

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)

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116
Q

CAP in outpt

A

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

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117
Q

Pt with advanced HF

A

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

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118
Q

Pusatile tinnitis

A

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

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119
Q

Pull test

A

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

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120
Q

Dix Halpike

A

peripheral vs central verigo

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121
Q

Abnormal proprioception

A

do not fall backward - have abnormal gait

loss of proprioception - peripheral neuropathy, spinal cord dz, severe hemicranial cortex dz

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122
Q

Rhomberg test

A

ataxia and proprioception loss - cerebellum, cerebellar, vestibular issue

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123
Q

Utricarial Vasculitis

A

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)

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124
Q

Malignant pleural effusion

A

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

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125
Q

Evaluate GIB with endoscopy

A 
Neg NGT does NOT r/o UGIB
First resucitate
then EGD (first)
if neg then colonoscopy
then tagged RBC scan
then video capsule
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126
Q

PCOS

A

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

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127
Q

Prolactinoma

A

tx’d with bromocriptine

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128
Q

Congential adrenal hyperplasia

A

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

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129
Q

Non-purulent cellulitis - B hemolyitic strep

A

B lactam agent - Cephalexin

CAMRSA (doxy/bactrim)

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130
Q

Apraxia

A

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)

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131
Q

Hemiparkinsonianism

A 
asymmetric rigidity, bradykinesia, dystonia
Corticobailiar degeneration (hemiparkinson combined with hand moving independent of voluntary control = alien hand syndrome)
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132
Q

Asomatognosia

A

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

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133
Q

Routine f/u in breast CA survivor

A

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

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134
Q

Humoral hyperCa of malignancy

A

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

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135
Q

Sx PAD tx

A

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

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136
Q

Miliaria

A

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

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137
Q

Fibromuscular dysplasia

A 
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
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138
Q

Obese patient needing weight loss

A

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)

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139
Q

Manage acute PE

A

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)

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140
Q

Dyspepsia

A

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

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141
Q

If H. pyori

A

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)

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142
Q

Thiamine deficiency s/p gastric bypass

A

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

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143
Q

CMV after kidney tx

A

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

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144
Q

Polyoma BK virus post tx

A

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

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145
Q

Listeria mono post tx

A

usually causes meningitis, h/a, MS change

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146
Q

EBV post tx

A

usually pw LAD

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147
Q

hemodynamically stable WC tachycardia

A

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

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148
Q

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

A

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

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149
Q

Axial spondyloarthritis

A

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

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150
Q

Centor criteria

A

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)

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151
Q

Plasma osmolality

A

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 -

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152
Q

Delayed hypoglycemia in pt with Type I DM

A

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)

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153
Q

Lichen planus

A

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

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154
Q

Candidiasis

A

Usually immunocompromised or corticosteroid use

scrapes off

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155
Q

Oral hairy leukoplakia

A

aw HIV

lateral tongue - adherent doesn’t remove from scraping - no ulceration

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156
Q

MAP

A

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

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157
Q

Invasive aspergillosis in pt with leukemia after chemo

A 
halo sign on CT
galactomannan antigen immunoassay +
BAL or TT percutaneous bx, VATS
Tx:
Voriconazole
Salvage Tx: amphotericin, itraconazole, caspofungin/micofungin (echinocandin)
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158
Q

Toxic epidermal necrolysis

A

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)

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159
Q

A/C preg pt with mechanical MVR

A

Warfarin - despite teratogenicity

or LMWH or UFH

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160
Q

VTE after intracranial hemorrhage stroke

A

UFH low dose or LMWH after day 4 if no ongoing bleeding

IVC filter only if absolute contraindication to heparin

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161
Q

Axial Spondyloarthritis

A

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

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162
Q

Evaluate obscure GIB

A

If pan endoscopy neg - repeat EGD (or colon) whichever more likely source

If neg then other modality (wireless capsule, single balloon enteroscopy)

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163
Q

Asess for recurrent PE

A

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

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164
Q

Manage hyperparathyroid in CKD

A

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)

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165
Q

Febrile neutropenia

A

Begin broad spectrum abx (zosyn, cefepime) - G pos and neg coverage

Only start antifungals after 4-7 days of no response to zosyn cefepime

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166
Q

Chronic pain in elderly

A

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

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167
Q

Metabolic syndrome

A 
3 of 5
Waist circumference >40 men, >35 F
SBP >130>85
HDL< 50 F
TG>150
Fasting glucose>110
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168
Q

Tx for severe etoh hepatitis

A

Should add corticosteroid unless contraindictated
(GIB, kidney failure, active infection (has this - SBP))

Maddrey discriminant score >32
Add pentoxyfyline

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169
Q

Reactive arthrtiis

A

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

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170
Q

Infection control in pt with strep pyogenes (invasive)

A

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)

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171
Q

Airborne precautions

A

TB, avian influenza, disseminated zoster, smallpox

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172
Q

Droplet precaustions

A

> 5micrometer droplets 3 to 10 feet

Neiserria meningitidus, pneumonic plague, diptheria, H flu b, pertussus, influenza, mumps, parvo b19

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173
Q

Erythema Multiforme

A 
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)
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174
Q

Erythema migrans

A 
hallmark cutaneous lesion of lyme
centrifical spreading ring - bullseye
much bigger than erythema multiforme
lack of mucosal invovlement
amoxicillin or doxy
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175
Q

Erythema nodosum

A

strep infection

PCN tx

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176
Q

Recurrent breast CA with possible bony mets

A

first bx bone to see HER2neu and hormone status

Tx: IV bisphosphonate -

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177
Q

Hypothyroid during pregnancy

A

thyroid supp requirement inc’d by 30-50%

Goal first trimester <2.5 TSH (less fetal complications)

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178
Q

AL Amyloidosis

A 
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
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179
Q

Polyarteritis nodosa

A

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

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180
Q

Occupational lung dz

A

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

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181
Q

Cardiovascular risk in elderly women

A

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

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182
Q

Stroke risk reduction

A

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

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183
Q

Myopericarditis

A

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

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184
Q

Cardiac tamponade

A

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

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185
Q

Post myocardial infarction syndrome

A

Pericardidits preceeded by cardiac injury (ST e MI)

Does not usually cause HF

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186
Q

Takutsubo’s CM

A

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

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187
Q

Concurrent primary cancers - cancerization field effect

A

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

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188
Q

Dx Male infertility

A

1st step: Semen analysis (abstain 2-3 days)

2nd step: if semen analysis abn - FH, LSH, total testosteroine (asess leydig and sertoli cell fxn)

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189
Q

Young woman, mild nephritis, outpt setting

A

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

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190
Q

Step down therapy for asthma

A

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)

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191
Q

Drug induced myopathy

A

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

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192
Q

Polymyositis

A

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

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193
Q

Drug reaction with eosinphils and systemic sx (DRESS)

A

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

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194
Q

Acute generalized exathematous pustulosis (AGEP)

A

acute onset pusutules, fever, elev WBC poss EOS

B-lactam, ampicillin, floroquin, anti malarial agents, sulfa, terbafine, diltiazem

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195
Q

Erythema Multiforme

A

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

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196
Q

Levido retiucularis

A

pink mottled netlike pattern

aw drug rxn to amantadinie, quinidine, warfarin, minocycline

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197
Q

Pre-op Rheum Arthritis

A

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

198
Q

Manage GERD that does not respond to PPI trial

A

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

199
Q

When to use ambulatory pH monitoring

A

After neg endoscopy and still with GERD sx

200
Q

Functional urinary incontinence

A

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

201
Q

Overflow incontinence

A

obstruction vs neurogenic bladder

Check residual urine

202
Q

Stress incontinence

A

pelvic floor muscle excercises

203
Q

Urge incontinence

A

anticholinergic ie tolterodine

204
Q

Inc’d risk of CV events in CKD pts

A

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

205
Q

Unstable angina in pt with contraindication to BB

A

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

206
Q

TCA overdose

A

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

207
Q

Sjogren’s associated lymphoma

A

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

208
Q

Ectopic ACTH

A

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

209
Q

Adrenal adenoma/CA

A

suppressed ACTH

210
Q

Autism spectrum d/o

A

impair communication, impaired social interaction, restrictive, repetitive stereotyped behaviors and interests

learning disability or mental retardation, high functioning autism or Asberger variant

211
Q

Obsessive compulsant d/o

A

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

212
Q

Schizophrenia

A

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)

213
Q

Social anxiety d/o

A

severe/persistent fear of social or performance situation

214
Q

Severity of acute pancreatitis

A

Dx: amylase/lipase

Predictiing severity : BUN

215
Q

Allergic contact dermatitis

A

Delayed type allegic rxn - red edematous, weepy, crusted
Dx: Patch testing

Pinprick and RAST only for immediate type hypersensitivity rxn

216
Q

Migraine without aura

A 
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)

217
Q

Locally advanced high risk cervical CA

A

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

218
Q

Incidental high risk gallbladder polyp

A

High risk >10mm, gallstones >3cm, porceline gallbladder
Cholecystectomy
Risk factor for gallbladder CA, cholelithiasis, fhx gallbladder CA,

If < 10mm then serial imaging

219
Q

Manage prostate CA screening

A

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

220
Q

Tuberculous pericarditis

A 
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
221
Q

Dx obstructive lung dz in coal miner

A

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

222
Q

Recurrent pericarditis

A

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)

223
Q

Sickle cell pain episode

A

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

224
Q

Basic Calcium phosphate deposition dz

A

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

225
Q

Calciphylaxis

A

soft tissue calcium deposition - ESRD pts

226
Q

CPPD

A

see postivelty biregringent crystals

(Gout neg birefringent crystals)

OA fluid <2K WBCs

227
Q

Hep C associcated cryoglobulinemic vasculitis

A

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

228
Q

Henloch-schoen purpura

A

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

229
Q

Porphorya Cutanea tarda

A

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

230
Q

Necrolytic acral erythema

A

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

231
Q

Hypokalemic metabolic alkalosis from Gentamycin

A

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+

232
Q

Acute exacerbation of multiple sclerosis

A

High dose IV methylprednisolone (NOT PO)

If refractory - plasmaphereiss
Phyical/occup/speech therapy

233
Q

Dermatomyositis (can occur without myalgia)

A

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

234
Q

Patient presenting late with STEMI

A 
Primary PCI (NOT EMERGENCY CABG)
No thrombolytics >12hrs STEMI
235
Q

Fundic gland polyps

A

Need colorectal eval for Familial Adenomatous polyposis

Multiple small 1cm

236
Q

COPD pt immunizations

A

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

237
Q

Antiepileptic in pt who wants to get pregnant

A

Carbamazepine, lamotrigine, levetiricem

No VPA, phenobarb or phenytoin

238
Q

Risk factors for RA

A

Smoking increases risk of developing RA

No change with etoh, obesity, excercise
Dec’d risk with OCP

239
Q

NSAID induced nephropathy in MM patient

A

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

240
Q

Nonpurulent cellulitis outpt therapy with systemic symptoms

A

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

241
Q

Minimal change glomerulonephropathy

A

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

242
Q

Benign positional vertigo

A

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

243
Q

Pustular psoriasis

A

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

244
Q

Candida

A

localized in immunocompromized

erytmmatous base with white stuff

245
Q

Sweet syndrome

A

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)

246
Q

Toxic shock syndrome

A

diffuse erythroderma resembling sunburn

Nasal packs, wound care

247
Q

Dx Celiac dz with IDA

A

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,

248
Q

Normotensive acute ischemic kidney injury (ATN)

A

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

249
Q

Acute intersitial nephritis

A

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

250
Q

Cholesterol emboli syndrome

A

after conoary angio

bland urine sediment

251
Q

Pre-renal azotemia

A

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

252
Q

Osteoarthritis

A

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

253
Q

Calcium pyrophosphate deposition dz

A

chondrocalcinosis - in fibrocartillage (menisci)

254
Q

Agitation and confusion in pt with alzheimers

A

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

255
Q

Hyperprolinemia

A

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

256
Q

Acute cervical radiculopathy

A

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

257
Q

Malaria -

A 
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
258
Q

Plamodium Maraliae

A

fevers q72hrs

band form - trophozite

259
Q

Plasmodium ovale, vivax

A

trophozoit, schizont forms - Shuffer dots inside enlarged RBCs

260
Q

COPD exacerbation with NIPPV

A

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

261
Q

Evaluate asx heart murmur

A

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

262
Q

Calciphylaxis

A

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

263
Q

Nephrogenic systemic fibrosis

A

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

264
Q

Polyarteritis nodosa

A

reticuloform purpura and SQ nodules - not aw ESRD

265
Q

Pyoderma granulosum

A

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

266
Q

Inaccurate HgA1c

A

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

267
Q

Manage giant cell temporal arteritis

A

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

268
Q

Cough variant asthma

A

Chronic cough - cough triggered by cold air and excercise
Bronchial challange can exclude asthma if neg

Pertussis - tx with macrolide/floroquinolone

269
Q

HFPEF

A

preseved EF with HF sx
LVH on ekg
Tx: diuretics and ARB (candesartan) - reduced hospitalizations

No digoxin in HFPEF

270
Q

Normal Pressure hydrocephalus

A

gait shuffling, urinary incontinence, cognitive change

-check Brain MRI - look for ventriculomegaly

271
Q

Hormone Rct + breast CA pre-menopausal

A

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

272
Q

HTN in women of childbearing age

A 
d/c lisinopril - > start labetolol
No spironolocatone(anti androgenic) and does need SOME antiHTN med

ACEi-> cardiac abn, kidney abn, death

273
Q

Short bowel syndrome

A

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

274
Q

Palliative care discussion

A

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

275
Q

Hypoactive sexual desire d/o

A

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

276
Q

Beau lines

A

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

277
Q

Lichen planus

A

pitting, onchyolysis, longitiudinal ridging

278
Q

Median nail dystophy

A

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

279
Q

Psoriasis

A

Nail changes like pitting, oncylolysis

280
Q

Concussion management

A

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

281
Q

GERD

A

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

282
Q

Smallpox

A

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

283
Q

NSTEMI/UA pt

A

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

284
Q

Severe asthma exacerbation

A

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

285
Q

TSH secreting tumor

A 
Hyperthyroid -
elevated radio iodide uptake - 
Thyrotoxicosis with inappropriately elevated TSH -> TSH secreting tumor -> pituitary MRI needed
NSx resection
No thyroiectomy, methimazole, PTU
286
Q

HTN pregnant pt

A

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

287
Q

G6PD

A

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

288
Q

Older pt with seizures

A

Lamotrigine best tolerated

Complex partial seizures/generaized

Don’t use carbamazepine (hyponatremia) phenytoin (dizzinesslethargy gait instability)

289
Q

Selective IgA deficiency

A

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

290
Q

C1 Inhibitor def

A

Hereditary angioedema

fhx angioedema - subcut edema

291
Q

Terminal complement deficiency

A

susceptible to neiserrial dz - meningiococcal

292
Q

Uninterpretable ABI

A

ABI 1.4 - uninterpretable -

need great toe pressure or <0.7 = PAD

293
Q

Spinal stenosis

A

leg discomfort with walking relieved lying down or waist flexion

294
Q

Kawasaki dz

A

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

295
Q

TSS

A

bacterial toxins - septic shock

hypotensive, fevrile, diffuse malar rash, severe myalgia, elevated CPK, hyperemia, AKI, acute liver injury

296
Q

Newly dx breast CA with risk of BRCA

A

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

297
Q

Keloid tx

A 
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

298
Q

Hypothyroid after central hypopituitarsim from surgery/radidation

A

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)

299
Q

Hyperkalemia in setting CKD worsening

A

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

300
Q

Recently resolved acute diverticulitis

A

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

301
Q

Acute Angle closure glaucoma

A

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

302
Q

Central rentinal artery occulsions

A

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

303
Q

Occular migraine

A

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

304
Q

Temporal arteritis

A

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

305
Q

Chronic severe MR

A

Surgical indications
preserved LVEF with New onset afib
concurrent maze/PVI
+warfarin for afib

(Rhythm control with amio, DCCV, not likely to work)

306
Q

OSA therapy

A

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)

307
Q

Acute pseduogout

A

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)

308
Q

Drug induced erythema nodosum

A

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

309
Q

Wilson’s dz in young pt

A 
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

310
Q

Pt with breast CA and h/o VTE

A

Pt with hormone rct + breast CA but contraindication for aromatase inhibitor (h/o VTE)
Tx: Ovarian ablation

ONly use trantuzumab in HER2Neu + patients

311
Q

Thyroid storm

A

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

312
Q

Subacute (de Quervain) thyroiditis

A

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

313
Q

Budd Chiari syndrome

A 
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

314
Q

HTN in pt with CKD

A

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

315
Q

Dx Acute retroviral syndrome

A

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

316
Q

Manage AC for pt with mech AVR preop

A

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

317
Q

Henloch Schloen purpura

A

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

318
Q

Disseminated gonnococcal infxn

A

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

319
Q

Sweet syndrome

A

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

320
Q

Treat carpel tunnel syndrome

A

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

321
Q

Manage sellar mass

A

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

322
Q

DMSupp

A

used to locate tumor in ACTH dependent cushings

323
Q

SIADH

A

check serum and urine sodium

324
Q

Acute ischemic stroke with HTN

A

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)

325
Q

Inpt with risk for VTE

A

immobilized and two risk factors for VTE
low dose HSQ

(not ASA, warfarin 1mg) - don’t use SCDs unless contraindication for HSQ

326
Q

Complicated parapneumonic effusion

A

pleural fluid cw exudate

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

327
Q

Esophageal candidasis

A

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

328
Q

Kidney bx contraindication

A 
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

329
Q

Hereditary hemochormatosis

A

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

330
Q

Reactivation of HSV by UV radiation

A

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

331
Q

Actinic chelitis

A

premalignant in people with significant sun exposure

on lip - ulcers, vermillion border

332
Q

Contact dermatitis

A

from lip balm usually pruritic

333
Q

Coxsackie

A 
hand foot mouth dz
intraoral, palmar, plantar lesions
oval flesh colored papules with erythema rim
fever/sore throat
Spare lips - different than HSV
334
Q

HLD tx in pt wants to get pregnant

A

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)
335
Q

Clinical manifestation of sickle cell TRAIT

A

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

336
Q

Treatment of Tic d/o

A

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

337
Q

Lymphangiolyomyomatosis (LAM)

A 
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
338
Q

Organizing PNA

A

sx over 4-6 wks no more than 6 months

patchy airspace dz, ground glass, consoidation (no cysts)

339
Q

Repsiratory bronciolitis associated ILD

A

smokers

centroloar nodules, air trapping scatterd gound glass

340
Q

Sarcoidosis

A

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

341
Q

Padget’s dz of bone

A

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

342
Q

Diffuse cutaneous systemic sclerosis

A

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

343
Q

Achalasia

A

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

344
Q

Cardiac monitoring for INFREQUENT arrythmia episodes

A

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

345
Q

Lead nephrotoxicity

A

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

346
Q

Colonscopy screening ulcerative procitis

A

if confined to colon then like general population (q10yr)

347
Q

Coccoidomycosis

A

SW US/S/Central america

Pulmonary infxn, joint pain, erythema nodosum

348
Q

Blastomycosis

A

Mississipi/Ohio river valley, great lakes

349
Q

Histoplasmosis

A

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

350
Q

Sporotrochosis

A

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

351
Q

Ischemic stroke treatment

A

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

352
Q

Adrenal fxn during critical illness

A

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

353
Q

Lentigo malina

A

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

354
Q

High risk myelodyplastic syndrome

A

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

355
Q

TTP

A 
thombocytopenia
microangipathic hemolytic anemia
fever
kidney impairment
neurologic deficits
\+schistocytes on smear
356
Q

MM and AKI

A

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

357
Q

Disseminated gonnoccocal infection

A

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

358
Q

Staph arthritis

A

usually monoarhritiss

no tenosynovitis or skin findings

359
Q

Thromboembolic ppx after afib ablation

A

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

360
Q

Symptomatic BPH

A

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

361
Q

Meralgia paresthetica

A

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

362
Q

Greater trochanteric bursitis

A

Pain in region of greater trochanter worse on affected side

Pain to palpation

363
Q

Illiotibial band syndrome

A

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

364
Q

L5 radiculopathy

A

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

365
Q

Dopamine agonist induced COMPULSIVE behavior

A

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

366
Q

Demntia with lewy bodies

A

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

367
Q

Frontotemporal dementia

A

apathy, impulsivity, hoarding, disinhitibtion

obsessionality

368
Q

Prevent ventillator associated PNA

A

48-72 hrs after intubation
maintain head of bed 30 deg
daily wheening assessment
chorohexadine mouth washes

No need for early trach, chorlox baths,

369
Q

Symptomatic rapid afib

A

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

370
Q

Lofgren syndrome

A

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

371
Q

Granulomatosis with polyangiitis

A

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

372
Q

Disseminated gonnococcus

A

fever, tenosynovitis - usually no uveitis

No erytema nodosum

373
Q

Pityriasis rosea

A

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)

374
Q

Fungal

A

Expanding ring like lesion central clearing

scrape and KOH lesions

375
Q

Treat vent failure 2/2 opiods

A

Non-focal neuro exam, pinpoint pupils, RR < 12, - needs escalating doses of naloxone

Stroke less likely given non-focal findings

376
Q

Hepatorenal syndrome

A 
Setting of SBP
doubling of Cr
Cirrhosis with ascites
No concurrent nephrotoxic drugs
Tx: Albumin

(no benefit of octreotide or vassopressin)

377
Q

Diabetes inspidis

A

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

378
Q

Cerebral salt wasting

A

HYPOnatremia, HYPOvolemia

379
Q

Pt with DVT and cancer

A

LMWH (not coumadin, not UFH (needs labs))

No IVC (no contraindic for A/C or failed A/C)

380
Q

Acute utricaria likely 2/2 levofloxacin

A

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

381
Q

Spasmodic torticollis

A

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

382
Q

Elevated chol in pt with DM

A

With DM - LDL goal LDL<70

To dec LDL always try to inc statin if possible (other drugs do not dec mortality)

383
Q

Mild congential asymptomatic neutropenia

A

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)

384
Q

Tb tx

A

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

385
Q

Non etoh steatohepatosis

A

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

386
Q

Nodular lung infiltrates suspected vasculitis

A

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)

387
Q

Secondary Osteoporosis

A

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

388
Q

Upper airway obstruction 2/2 angioedema from ACEi

A

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

Need intubation

389
Q

Generalized anxiety d/o

A

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)

390
Q

Major depressive d/o

A

5 or more depressive sx in 2 week period

391
Q

Bipolar d/o

A

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

392
Q

ADHD

A

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

393
Q

Chronic stable angina

A

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, )

394
Q

Primary glomerulous nephropathy

A

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

395
Q

Asymptomatic gallstones

A

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

396
Q

Superior vena cava syndrome

A

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

397
Q

Dx Vit D deficiency

A

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

398
Q

Chronic fatigue syndrome

A

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,

399
Q

Osteomyelitis

A

Deep bone bx cultures more accurate

Sinus tract drainiage could be contaminated from surface

400
Q

Discoid lupus

A

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

401
Q

Allopeica areata

A

NON-scarring process - no skin changes in ears

402
Q

Tension headaches

A 
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,
403
Q

Early Rheum arthritis

A

CRP, +CCP, +RF, lots of joints, early morning stiffness >60min,

Tx: DMARD (MTX)
(NSAIDs, shoe inserts and colchicine NOT better)

404
Q

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

A

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

405
Q

Treat anaphylaxis

A

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

406
Q

Nephrogenic systeic fibrosis

A

(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

407
Q

Lipodermatosclerosis

A

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

408
Q

Scleroderma

A

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

409
Q

Scleromyxedema

A

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

410
Q

Parapneumonic effusions

A

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

411
Q

Cancer of unknown primary

A

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

412
Q

Palliative care discussion with family of cancer pt

A

Communicate with family to assess understanding of patient’s condition

Don’t start with advanced directives
Don’t say cure intent is futile

413
Q

Overcorrection of hypotonic hyponatremia

A

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

414
Q

Generalized convulsive status epilepticus

jerking all 4 extremities tonic clonic >5 min

A

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

415
Q

Fungal arthritis

A

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

416
Q

Basic calium Phophate dz

A

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

417
Q

Fasting hypoglycemia in pt without DM

A

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

418
Q

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

A

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

419
Q

Acute exacerbation of IPF

A

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

420
Q

Myasthenia gravis

A 
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

421
Q

Manage white coat HTN

A

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

422
Q

Nocturnal hypoglycemia

A

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

423
Q

Dawn phenomenon

A

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

424
Q

Somogyi phenomenon

A

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

425
Q

Risk of death for women

A

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

426
Q

Tinea corporis

A 
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
427
Q

Atopic dermatitis

A

would not be worse when cream d/c’d

FHx atopy - eczema, asthma, seasonal allergies, atopic deramatisi - on flexor areas

428
Q

Nummular Dermatitis

A

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

429
Q

Psoriasis

A

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

430
Q

Sclerodermal renal crisis

A

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

431
Q

Sycope in elderly male

A

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

432
Q

Risk of ampullatory adenoCA in pt with FAP or Peutz Jehurers

A

Need regular upper endoscopy even after colon resection r/o ampullary CA

Tx: whipple

DOn’t just monitor LFTS - when elevated likely too late!

433
Q

Manage early septic shock

A

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%

434
Q

Salicylate toxicity

A

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

435
Q

Dx Scabies

A

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

436
Q

MEN I

A

Parathyroid, Pituitary, pancrease - genetic

(gatrin secreting pancreasic neuroendocrine tumor

437
Q

Autoimmune polyglandular syndorme

A

chronic mucocutaneous candidiasis, autoimmune hypoPTH, adrenal insufficiency

438
Q

MEN II

A

parathyroid, Pheo, medullary thyroid CA

439
Q

Convulsive syncope

A

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

440
Q

Acute chest syndrome in Sickle cell dz

A

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

441
Q

Risk factor management in pt with CAD

A

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

442
Q

Botulism

A

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
443
Q

Guillane barre

A

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

444
Q

Paralytic shellfish poisoning

A

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

445
Q

Tick paralysis

A

ASCENDING paralysis, large muscles

446
Q

Colonoscopy screening

A

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

447
Q

Manage ADHD inadult

A

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

448
Q

Guillane barre

A

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

449
Q

Thyroid lymphoma

A

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

450
Q

Atopic hand dermatitis

A 
pts with atopic eczema
prolongued contact water/harsh substances
pruritic skin conditioin
intermittent flares
skin bx non sp
451
Q

Keratoderma blenorrhagica

A

hyperkeratotic skin condition

erythem scaley plaque palms and soles aw sponyloarthropathy

452
Q

Scabies

A

intnese itching

burrows interdigital web space, wrist, nipples

453
Q

Tineas Mannum

A

infect stratum corneum (epidermis)

454
Q

Pigment nephropathy from rhabdo

A

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

455
Q

Ambulatory arrythmia monitoring

A

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

456
Q

Creutzfeld Jacob rapidly progressive dementia

A 
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

457
Q

Henloch scholen purpura

A 
Purpuric rash
lower extrem
arthritis, abd pain, hematuria
Skin bx: Iga Depostis, leukocytoclasic vasculitis
aw solid tumors or MDS
458
Q

Churg Strauss

A

vasculitis - h/o asthma
peripheral EOS
p-ANCA

459
Q

Microscopic polyangiitis

A

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

460
Q

Polyarteritis nodosa

A

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

461
Q

Subacute cutaneous lupus

A

maculopapular rash,
anti ro/SSA
no glomerulonephritis

462
Q

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

A

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

463
Q

Periop risk assessment

A

3 or more cardiac risk factors (Revised Cardiac Risk index)
unable to achieve 4 mets

If above met - proceed to surgery

464
Q

Dx severe CAP

A

Urine antigen for S pneumo and legionella

465
Q

Treat hospitalized patient with DM and basal insulin

A

Type I DM should have basal insulin + premeal (aspartate)

Don’t resume pre-mixed 70/30 basal /bolus

466
Q

Manage patietn with rhabdo

A

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

467
Q

Manage pt with Vfib arrest

A

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

468
Q

Manage meds in pt who MAY become pregnant

A 
Metformin ok for DM (class B)
IF becomes preg then prossibly change to insulin

No ASA, ACEi, zocor (ACEi/statin class X)

469
Q

Localized impetigo

A

Bullous impetigo = staph aurueus
-use mupirocin if not systemic

If systemic use cephalexin

470
Q

Complex liver cyst

A

Complex=irregular, septations
REfer for surgical resction (r/o malignant transformation)
heaptic cystadenoCA

Cyst asp not appropriate
Do not just observe or repeat US

471
Q

Asx hyperurecemia

A

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

472
Q

Gout drugs

A

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

473
Q

Treat elevated BP after IC hemorrhage

A

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

474
Q

Idiopathic pulmonary fibrosis (IPF)

A

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

475
Q

Hypersensitity pneumonitis

A

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

476
Q

Clenched fist injury pt allergic to PCN

A

Person bite
Augmentin if NOT PCN allergic
Clindamycin/moxifloxacin if PCN allergy

Alt is bactrim with flagyl

477
Q

ethylene glycol intoxication

A

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)

478
Q

psychogenic nonepileptic seizures

A

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

479
Q

Patient with cyanotic heart disease and anemia

A

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

480
Q

Advanced stage ovarian CA in complete remission after initial adjuvant chemo

A

H&P, pelvic and CA125 q4month x 2 years -> restart chemo if relapse

No role for surveillence CT

481
Q

Fuliminant liver failure

A

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

482
Q

Pulmonary artery HTN in pt with MCTD

A 
MCTD - sx of SLE,  high ANA and RNP ab
PAH occurs
\+Raynauds
Isolated low DLCO
Elev PAP on TTE
Needs RHC
483
Q

CA-MRSA skin infection

A

Bactrim
Large pustular abscess with purulencea nd drainage

Azithro, augmentin no activ vs MRSA
Rifampin - rapid resistance

484
Q

Prevent DM2 in overweight pt

A

Weight loss, excercise

impaired fasting glucose 100-125

485
Q

Acute HIV infection

A

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

486
Q

Typhoid fever

A

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

487
Q

EBV

A

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

488
Q

parvovirus B19

A

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

489
Q

Lymphocytic Hypophysitis

A

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

490
Q

Craniopharygioma

A

rare mixed solid cystic lesion WITH CALCIFICATION

aw panhypopit and DI

491
Q

Sheehan syndrome

A

pituitary infarction in setting of hemorrhage during complicated delivery

492
Q

Prolactinoma

A

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

MKSAP (4 decks)

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