Deck 2

Question 1

Giardiasis

Answer 1

prlonged GI illness watery diarrhea, wt loss, camping trip no running water - giardia cysts in water
large volume smelly stools
Dx: Giardia stool antigen
Tx:
Prev - boil water

O&P less sensitive

Modified acid staining - cryptosporiduium, isospora, cyclosproa

Question 2

Asymptomatic VSD as adult

Answer 2

small perimembranous defect
No pulm HTN, no chamber enlargment
close f/u and observation
No abx ppx
Dx: TTE
(if suboptima CMR)

Tx: iF Qp:Qs >2:1 and evidence of LV overload closure
If 1.5: 1 and net left to right then close

Question 3

Autoimmune bullous disease

Answer 3

Bullous pemphigoid
Tense subepidermal blisters
non-mucosal surfaces
aw RA, DM, SLE, thyrotitis
W/u: Skin bx with immunoflorescence

Question 4

Delirium in ICU

Answer 4

acute state of confusion - reduced conciouslness, cognititsion, emtional distrubance, , hyperactive, hypoactive

Acute CVA does not cause flucutaing conciousness

Opiods take some time to develop dependence and cause withdrwaal

Question 5

Risk factors for damaging veins in pts with CKD

Answer 5

If pt with bad CKD - don’t use PICC/central lines if avoidable - stenosis of central veins may make unsuitable for dialysis catheter or av fistula

Question 6

Limited stage small cell lung CA

No cure

Answer 6

rarely present early enough to have surgical resection
Dz limited to one hemithorax, with hilar and mediastinal adneopathy that can be encompassed in one tolerable radiofield
Tx: Chemo+chest radiation
If good response - ppx brain radiation done
Advaced dz - chemo along

Question 7

Small cell lung CA (early stage surgically treatable)

Answer 7

mediastinoscopy for staging for suitability for surgical cure

Question 8

Acute digit ischemia in systemic sclerosis

Answer 8

Warm environment
Pain control
**Vasodilating tx - IV epoprostenol (prostacyclin analgog)

sequelae = raynaud, ptting, ulceration, gangrene

Bosentan - preventing recurrences of digital ulcers
no benefit in treating acute digit ischemia

ACEi - sclerodermal renal crisis

Question 9

Colonoscopy with inadequate prep

Answer 9

re prep and repeat colonoscopy do not wait

q3yr colonoscopy for: 3-10 adenomas all <1cm) tubular adenoma, low grade dyplasia

q10yr - hyperplastic polyp or none

Question 10

Manage diabetic ketoacidosis

Answer 10

Admit to ICU - insulin, fluids, serial abd exams

No imaging or testing unless abd pain does not resolve with correction of met acidosis

Can cause elevated WBC, fever, elevated amylase

Question 11

Manage peripheral verigo

Answer 11

referral for vestibular rehab if epley maneuver fails

improves sx, balance and ADL

Question 12

Menieres dz

Answer 12

Tinnitis, hearing loss, vertigo - episodic vertigo, not positional

Question 13

Acute viral hepatitis

Answer 13

Marked jaundice - marked elevation of AST/ALT

short duration on sx (acute)

Question 14

Fulminant Hepatic failure

Answer 14

hepatic encephalopathy w/in 2 months of jaundice,

abnormal INR

Question 15

hemochromatosis

Answer 15

chronic liver dz muchlower LFT levels

Question 16

Primary biliary cirrhosis

Answer 16

chronic liver inflammation - lower LFTs, disproportionaly high alk phos

Question 17

Chorea gravidarum

Answer 17

self limited chorea during pregnancy
quick muscle jerks in random pattern
(DDX - huntingtons, HIV, encephalidies, poprhyoria etc, etoh, hyperglycem…

Huntington’s - hereditary progressive neurodeg d/o cogniftive decline with chorea - ataxia, dystonia, slurred speech,myoclonus - psych sx halluc, irrit agitation, dyphoria, disinhibition

Question 18

Tardive diskinsesa

Answer 18

2/2 mes that block dopamine rcts
twitching movememnts, abn postures
choreiform movmeemnt of face

Question 19

Takotsubo’s CM

Answer 19

Stress CM - transient ST elev, +CE normal coronaries with apical balooning, basal hypercontractility
catecholamine induced
Tx: BB, ACEi

Question 20

Pericarditis

Answer 20

PR seg depression
diffuse ST elev
Twave changes
CP postional

Question 21

HYperthyroid in pregnancy

Answer 21

Tx with PTU in 1st trimester -> methimazole after
presence of vilitigo, suggests automimmunte graves
r/o fetal growth retardation, miscarriage, prmature delivery, preeclampsia

Only thyroidectomy if toxic gointer, large malignant thyroid nodule, toxic adenoma

Question 22

**Hydroxurea cause of macrocytosis

Answer 22

decrease incidence of sickle cell crisis
RNA reductase inhibitor
dec’s DNA synthesis

Cobalamin def - high MCV, glossitis, wt loss, hypersg PMNs, takes years to manifest

Myelodyplastic syndrome =- infeff hematopoesis, transformationi to AML - need to be dificent in all cell lines

Question 23

Ankylosing spondylitis

Answer 23

Can occur in 20’s
Need radiographic evidence for dx
can be neg in xray
Pain/morning stiffness relieved with ACTIVITY

MRI sarcoilliac jnt - bone marrow edema, synovitis, erosions, CT can’t detect early bone edema (don’t MRI lumbar spine, affected LATER)

Tx: NSAIDS, tnf alpha, phys tx/surgery

Question 24

Rotator cuff tendonitis/impingement

Answer 24

pain in shoulder began after rpeitive activity
pain occurs in range of abduction only
neg drop arm test
+hawkins test

Question 25

Acromioclavicular joint degeneration

Answer 25

aw trauma or osteoarthritis - palpapbel osteophytes on xray with deg changes - pain with shouler movememnt up and down after 120 deg

Question 26

Adhesive capsulitis

Answer 26

thickening of capsule surrounded by glenohurmoral joint loss of both passive and active ROM multiple planes and stiffness slow in onset, near insertion of deltoid

Question 27

Rotator cuff tear

Answer 27

+drop arm test weakness, Loss of function wk external rotation

Question 28

Manage anemia in CKD pt

Answer 28

Start EPO CKD pt with Hg <10 r/o IDA, vit B12 def, GI blood loss, hemoglobinopathy target Hg 10-11

Question 29

Mild pulm Histoplasmosis

Answer 29

No tx needed in healthy host ohio river valley/misippi valley pulm infiltrates mild hilar LAD If tx needed: ie immunoompromised HIV Itraconazole more serious lipid amphotericin B (NO FLUCONAZOLE)

Question 30

Pulmonary embolism

Answer 30

Intermediate to high risk - get CTA chest lack of contraindication and str abn lung (no V/Q scan) Don't use D-dimer in intermed to high risk (only to r/o low risk patients) If contraindictation to CTA chest then get duplex LE US r/o DVT

Question 31

Mechanical heart valve and microangiopathic hemolytic anemia

Answer 31

elev LDH, dec'd haptoglobin, decreeased Hg, inc'd retics = evidence of microangiopathic hemolytic anemia + schistocytes on smear 10 year old valve with new murmur TTE to check for valve dysfxn TTP - adamts-13 assay - would have low plts and more acute course Not DIC - no signs of sepsis Direct coombs - warm or cold autoimmune hemo anemia - would show spherocytes Osmotic fragility test - hereditary spheroctyosis personal or family hx jaundice, splenomeg, gallstones, spherocytes on smear

Question 32

Cryptococcal meningitis

Answer 32

In pt with HIV and immune reconstitution inflammatory syndrome sweating diplopia, left gaze, somnolence immune response increases dramatically to fight crytococcus - (diss fungal infxn) - CSF (elev lymphocytes, inc'd protein low normal glucose) Check crytococcal antigen - Tx: IV amphotericin B then long term fluconazole CMV also OI in AIDS but with CD4<100, MRI multiple ring enhancing lesions, h/a mental status chagne, focal deficits

Question 33

Telogen effluvium

Answer 33

common cause of non-scarring hairloss common in young post partum women body brings lots of hair from anogen to telgoen phase under stress - hair loss diffuse No tx required (also cuase by sehorreic dermatiits, psoriasis, IDA, thyroid dz)

Question 34

Allopecia areata

Answer 34

patches of total hair loss no scarring - autoimmune

Question 35

Androgenta alopecia

Answer 35

chronic loss of hair in crown positon - male pattern baldness

Question 36

Lichen planpilaris

Answer 36

scarring alopeicia -

Question 37

Lupus

Answer 37

chornic cutaneous lupus - would have scaring with dyspigmentation

Question 38

REfractory temporal lobe epilepsy

Answer 38

Right temporal lobectomy Unlikely that addition of meds will help Corpus callosotomy palliateive surgery for kids with syptomatic generalized epilepsy or atonic seizures Vagal nerve stimulation doesn't put seizures into remission

Question 39

Eosinophllic esophagitis

Answer 39

slowly progressive solid food dysphagia in young person with asthma and allergies food impaction Mucosal bx with infiltration by EOS >15/hpf exclusion of GERD by ambulatory pH monitoring or non response to PPI trial proximal strictures on endoscpy Tx: swlalowed aersolized corticosteroids Achalasia - solid and liquid dyphagia aw CP and regurg (motiiity d/o not mech obstruction) Esophageal infection - in pts who use swallowed/aero corticosteroids - usually with oropharyngeal candidiasis Malignancy - less likely in young pt with no wt loss oropharyngeal dysphagia - difficulty swallowing phase/formation of food bolus

Question 40

Hypogonadism in pts with obesity

Answer 40

total testosterone >350 excludes hypogonadism <200 confirms hypogonadism 200-350 is grey zone Need free testosterone level - obesity can cause DECREASE in sex binding globulins so low total testosterone level can be normal in free testosterone then need to r/o other caueses ie meds karyotype not needed -normal FSH/LH (used to exlude klinefletsers) Pituitary MRI not needed because 2ndary hypogonadism not confirmed Sperm count not needed as pt with normal sperm count cna have low testoterone and vice versa

Question 41

Informed consent

Answer 41

1. understanding proposed tx 2. understanding alternatives 3. understanding risks and benfits of both tx and alternatives Applies to all health care decisions not just procedures

Question 42

Dx Glomerular hematuria

Answer 42

See dysmorphic erythrocytes (acanthocytes) on urine microscopy (eruthrocytes retain ring shape but have blebs of membrane protruding) - acanthocytes in blood have spikes not blebs) Then check urine protein-cr ratio - determine degree of proteinuria If + then check complement, hep panel, bctx, ANA, ANCA, anti basement membrane ab, anti streoptolysin ab, then kidney bx If microscopic hematuria non-glomerular then check kidney US UCtx not needed if U/A neg

Question 43

Amyloidosis in pt with heart failure

Answer 43

heart failure, hepatomegaly,proteinuria, bruising - low voltage on EKG despite LVH - infiltrative process Serum/urine spep/upep, fat pad bx -> amyloid Endomyocardidal bx for dx of myocardial amyloid

Question 44

Giant cell myocarditis

Answer 44

``` pw significant hf or cardiogenic shock high mortality rate refractory ventricular arrythmias may present over montsh or acutely NOT aw systemic sx ```

Question 45

Saroidosis

Answer 45

if inovlves heart - patchy areas of inflammation/fibrosis from granuloma formation - no low voltage (not infitrative) No pulm dz in this patient or skin fidings of sarcoid No proteinuria/bleeding abn in sarcoid

Question 46

Takayatsu arteritis

Answer 46

aorta and major branches young women low grde fever, wt loss, fatigue, myalgia, arthralgia, elevated ESR/CRP, mild anemia/thrombocytosis Fusiform narrowing of involved blood vessels Bruises -> pulse deficits -> organ/limb ischemia

Question 47

Adult onset STILLS dz

Answer 47

high eSR, CRP, high spiking fever, serositis, arthritis, RASH

Question 48

Microscopic polyangiitis

Answer 48

mononeuropathy, glomerulnephritis, pulm hemorrhage, p-ANCA(myeloperoxidase)

Question 49

Polyarteritis nodosa

Answer 49

aw Hep B | fever, myalgia, HTN, mononeuropathy, abd pain

Question 50

Polymyositis

Answer 50

elevated CK, prox muscle wk, myalgia, wt loss

Question 51

Pulmonary mets from Colonrectal CA

Answer 51

Stage II CRC - periodic H&P, exam, CEA Annual CT surveillance - colonoscopy Resection of primary mets to lung (limited to lung) No data on additional chemo/rad Nochemo/rad as primary tx for lung mets from CRC II

Question 52

Peripheral manifestations of psoriatric arthritis

Answer 52

Methotrexate - can treat both arthritis and peripheral manifestations of psoriasis Polyarticular, DIP, nail changes, arthritis mutilans, nail changes, dacylitis, Rituximab (CD20) may worsen psoriasis steroids may worsen psoriasis ibuprophen doesn't help

Question 53

sx Multiple myeloma

Answer 53

``` >10% plasma cells Need evidence of end organ damage 1. Kidney bx - myeloma cast neuroapthy 2. Hyper Ca+ 3. Anemia 4. Bone dz ``` Abd Fat pad aspiration - dx amyloid - nephrotic range proteinuria, peripheral sensomotor neuropathy, autonomic neuropathy, carpel tunnel, heart failure, macroglossia Chemotx only if end organ damage F/u M protein in 12 months only if <10% plasma cells

Question 54

Erythasma

Answer 54

well defined pink to brown patches, ofthen in moist skin folds, leisons floresce bright coral red under WOOD lamp Etio - coryneobacterium minitusimum - groin, axilla, intergluteal fold asx or mild pruritis,

Question 55

Cutaneous candidiasis

Answer 55

red itchy, inflamed skin, satelite pustules

Question 56

Inverse psoriasis

Answer 56

psoriasis in intertrignous areas (inguinal, perneienal, genital, axillary) ie not in extensors No scaling Tx: topical steroids

Question 57

Tinea

Answer 57

has ring with clearing center | KOH scraping branching hyphae

Question 58

Cushing syndrome - secondary cause of DM

Answer 58

DM, HTN, central obesity, hypokalemia, proximal muscle weakness CHeck 24 hr urine cortisol, overnight dexameth supp, Other secondary causes - meds, pancreatic dz, genetic conditions Causes of cushing - corticosteroid use, secrtion of ACTH by pituitary adenoma (cushing dz), hyperfxn adrenal adenoma Adrenal CT only if non- ACTH dep cushing Confirm autoimmune type I DM - glutamic acid decarboxylase Ab Type II DM high normal C-peptide from insulin resisitance Pancreatic imaging if jaundice, back pain, chronic diarrhea

Question 59

Screen for CKD in DM pts

Answer 59

CHeck spot albumin creatnine ratio annual testing Type I Dm - 5 years after dx Type II DM - immediately upon dx Microalbum 30-300 - need ACEi/ARB 24 hr urine protein too cumbersome (gold standard) Kidney US - once CKD dx

Question 60

Rumination syndrome

Answer 60

effortless regurgitation of undigested food and reswallowing of contents 30min to 1-2 hrs after meals Rome III criteria - persistent or recurrent regurgistation and swallow/spit, regurgitation not preeceded by wretching, 3-6 months Tx: deep breathing post prandial

Question 61

Cannaboid hyperemsis syndrome

Answer 61

h/o marijuana use with recurrent n/v abd pain - better with marijuana cessation or hot bath

Question 62

Cyclic vomiting syndrome

Answer 62

vomiting and feelin gwell between periods - (less than 1 week), fhx migraine

Question 63

Gastroparesis

Answer 63

n/v/bloating, postprandial fullness, early satiety, abd discomfort, DM >10 years

Question 64

Manage pressure ulcer

Answer 64

Stage III (full thickness no bone/tendon/muscle), Stage IV (Muscle/bone/tendon) Needs debridement Add abx as needed moiste wound environment No role for hyperbaric, EM or US therapy Neg pressure wound vac - not better than standard tx Surguical flaps only in refractory ulcers, vit c/zinc don't work.

Question 65

Evaluate acute chest pain

Answer 65

``` Serious 6 ACS Pericarditis with tamponade PE PTX Aortic dissection Esophageal rupture diastolic murmur - poss dissection with aortic root rupture and AI ``` CHest CT for pt iwth widened mediastinum, CP, and difference in BP L vs R arm and diastolic murmur (not TTE - not good to assess ascending aortic aneursym) - TEE better for that Posterior EKG - dx of isolated posterior wall MI - would have +myoglibin No V/Q as pt does not have si sx PE

Question 66

Critical illness myopathy

Answer 66

Severely ill pt in ICU>7 days - inability to extubate, prox flaccid limb wk - elevated CK worse iwth use of steroids, hyperglyemia, NMJ agents Guillane barre similar but NO HIGH CK

Question 67

Corticosteroid myopathy

Answer 67

prox weakness - normal CK, only mild myopathic findings on EMG

Question 68

Myasthenia gravis

Answer 68

worse with activity post synaptic aceetylcholie rct ab pstosis, diplopia, slurred speech, weakeness incrases with repeated testing (on EMG)

Question 69

Prosthetic joint infection

Answer 69

prosthetic joint infection not loose and pt doesn't want replacement - lifelong abx suppression with bactrim (no sulfa allergy) (IDeally removal of hardware and abx therpay followed by replacement) Don't use rifampin - develops resistance quickly don't repeat abx regimen already used (IV) observation with sx relief but no abx will cause extension of local infection/systemic infxn

Question 70

Stage I rectal CA

Answer 70

Midrectal CA into mucosa but not trhough, no LN mets - surgery ALONE Low anterior resection - if further staging shows T3-4 or any postive nodes then chemorad/chemo needed Chemo, radiation or combination not shown to help stage I dz - RFA doesn't cure CRC primary tumors

Question 71

Asbestosis

Answer 71

b/l interstitial fiborsis of lung parenchyma 2/2 inhallation of asbestos fibers - latency 10-15 yrs Crackles on exam Work in shipyard without adequate respiratory protection CT with b/l peripheral and basal septal thickening with pleural thickening and calcified pleural plaques Breathlessness and restrictive pulmonary physiology Hypercapnic resp failure as lungs can't expand 2/2 stiff pleura Tob inc's risk of lung CA

Question 72

Hypersensitiveity Pneumonitis

Answer 72

acutely after exposure to antigen - fever, flulike sx, cough waxes and wanes with exposure Mid upper lung involvement (not basal) centrolobar nodules (not pleural plaques)

Question 73

IPF

Answer 73

pt with interstital lung dz | NO exposures

Question 74

Severe knee osteoarthritis

Answer 74

not responding to conservative mesures and have functional limitations - refer for total knee replacement No benefit from knee arthroplasty (is good with meniscal injury) Osteootomy for valgus/varus deformity or younger pts with unilateral Hyalronate injections only for mild to mod OA

Question 75

NSTEMI not candidate (or wants) angiography

Answer 75

BB, ASA, plavix, statin, LMWH - TIMI risk =4 would need angiogram but pt does not wish it Contraindication to LMWH - obesity, kidney dysfxn and need for invasive procedure Only use CCB when pt contraindicated for BB

Question 76

Glioblastoma Multiforme

Answer 76

MC and aggressive intraparenchymal brain tumor ring enhancing lesion with central necrosis and hemorrage Meningiomas - extraparenchymal / extradural - enhance diffusely with dural tail - slow growing, better prognosis thank gliobastoma MF Oligodendroglimoas - rare - intraparenchymal lesions - No enhancement, no necrosis/hemorrhage Schwanomma - tumors of nerve sheath - CN VIII, hearing loss, tinniis, enhancing lesion at cerebellopontine angle - better prognosis than gliomas

Question 77

Squamous cell CA

Answer 77

malignancy of lips/oral cavity Risk factors etoh, smoking, sun exposure red plaques/nodules - crust/erosions Need bx and excision

Question 78

Actinic chelitis

Answer 78

chronic erythema and scaling of lower lip - sun damage - PRECANCEROUS - SCC can evolve Tx: cryothrapy, topical 5FU, Laser ablation

Question 79

Herpes simplex (orolabial)

Answer 79

cold sores HSV 1 - found around vermillion of lip - prodrome tingling prior to onset of vesicles then crust over

Question 80

Impetigo

Answer 80

S aureus - yellow crusted surface - tx topical abx or systemic

Question 81

Lichen planus

Answer 81

lips and buccal mucosa - may ulcerate - Wichham striae - white lacy rash on buccal mucose - r/o evolving SCC

Question 82

Diffuse esophageal spasm

Answer 82

Chest pain Corkscrew esophagus on barium swallow (multiple simultaneous contractions on manometry) esophageal dysmotility dyphagia to solids/liquids both Tx: CCB Achalasia - birds beak esophagus - needs surgical myotomy Eosinophillic esophagitis - multiple rings/strictures - h/o asthma/atopy Schatzi ring - isolated ring in GE jnc - intermittent dysphagia no CP

Question 83

IgA nephropathy

Answer 83

gross hematuria, h/o resp/GI illness (recent) and normal complement Infections precipitate production of Ab - IgA depostis in glomeruli causing injury and bleeding (ATN from tubular congestion) Glomerular cresents on kidney bx bad prognosis

Question 84

Analgesic nephropathy

Answer 84

NOT DUE TO Glomerular damage (chornic interstitial nephritis, renal papillary necrosis)

Question 85

Post infectious glomerulonephritis

Answer 85

Preceding GI/resp infection weeks before (strep/staph) Decreased complement elevated anti steptolycin O ab

Question 86

Rhabdomyolysis

Answer 86

pigment induced nephropathy muscle injury releases CK/myoglobin elevated CK, elevated urine myoglobin

Question 87

ACEi induced cough

Answer 87

non productive cough after starting ACEi - normal CXR d/c ACEi (cough from bradykinin) Substitute ARB + smoking cessation + re-eval in 4 wks (can consider GERD, asthma, upper airway cough syndorme (post nasal drip))

Question 88

Babesia

Answer 88

``` Camping trip new england Tick borne dz Ioxides tick 1. Lyme (borriella burgdorferi) 2. Babeesiosis (Babesia microti) 3. Human granulocytic Anaplasmosis (anaplasma phagoctyophilium) ``` Only Babesiosis have HEMATURIA Tx: atovaquone or azithro severe - exch tx RMSF - rash no hematuria - blanching erythematous macuoles wrists and ankels -> petechiae West Nile virus - fever, CNS SX not HEMATURIA

Question 89

Cardiac sarcoid

Answer 89

Dx with cardiac MR Echo findings suggestive - restrictive filling, biatrial enlargement, MR would show delayed gadoinium enhancement in atypical distribtuions for coronary artery disease MR also looks at pericardial thickness r/o constrictive pericarditis IF cardiac sarcoid confirmed -> ICD ENdomyocardial bx warranted if MR neg TEE only if TTE inadequate

Question 90

High grade dysplasia in pt with barretts

Answer 90

Pt with Barrett esophagus High grade dysplasia Tx: Esophagectomy if surgical candidate Endoscopic ablation (ie bad heart failure) - alternative If no precedure - endoscopic surveillance q3m - adenoCA then surgery (high grade-> adeno 6%/yr)

Question 91

Macroprolactinoma

Answer 91

``` Dopamin agonist (carbergoline better tolerated than bromocriptine) if no sx (no visual field changes despite being on optic chiasm) will decrease tumor size OCP do not use - may increase tumor size Surgery only with intolerance of dopamine agonist, unstable vision changes Radiation last resort tx ```

Question 92

External spinal cord compression by epidural hematoma on warfarin

Answer 92

Pt on warfarin with INR 3 Discontinue warfarin reverse A/C in prep for surgical decompression Cauda equina syndrome form cauda equa compression 2/2 epidural hematoma Do not lumbar puncture prior to AC reversal Without fever and WBC elev, epidural abscess unlikely so no abx If no signs of inflammaotry process then no need for high dose solumedrol

Question 93

Staph aureus infection

Answer 93

G+ organisms MCC infectious arthritis monarticular usually affect large joints, rapid (1-2 hrs) Otherwise healthy patient with skin breakdown in trauma Fever, swollen knee with effusion -> stayph aureus septic arthritis hematogenous spread of skin infection to knee Gout rare in healthy young women Onset of chronic lyme gradual

Question 94

Patient hospital dispostion options

Answer 94

Skilled nurinsing facility - IV meds, low level rehab - when gets better can reassess for better dispo Inpatient rehab - intensive physical and occupation therapy - need to be medically stable and able to participate in 3 hrs /day at least Long term acute care hospital - will need hospital based interventions - need for significant medical monitoring>25 days - overseen by physicians Hospice care - prognosis < 6 months

Question 95

Hematuria - low risk patient

Answer 95

Risk factors >40, h/o uro d/o, analgesic abuse, pelvic irrad, UTI, smoking, occupational exposure chem/dyes (FHx does not increase risk) Repeat U/A if + Glomerular - dymorphic erythrocytes (acanthocytes) on urine microscopy, erythrocyte casts Non-glomerular - isomorphic/normal RBCs on urine microscopy (UTI, bladder/renal CA) Dx: Upper urinary tract imaging - CT, US, IV uropgraphy (CT Urography best) ->cytoscopy / urine cytology No Uctx if no WBC no dyuria

Question 96

Vocal cord dysfxn

Answer 96

inspir and exp wheezing respiratory distress, anxiety difficult to distinguish from asthma during exacerbation Clues: sudden onset and abrupt termination of attacks - lack of response to asthma tx, promient neck discomfort, lack of hypoxemia, lack of hyperinflation FLow volume loop: Inspiratory (lower) limb cut off 2/2 extrathoracic obstruction - vocal cord - expiratory (upper limb) prserved TX: speech therapy, relaxation techniques, tx of anxity, post nasal drip, gastroesophageal reflux

Question 97

Acute asthma

Answer 97

cxr not needed unless doesn't respond to asthma therapy or evidence of concurrent condition (PNA< HF, PTX)

Question 98

Bullous pemphigoid

Answer 98

autoimmune bullous disorder Tx: prednisone initially then transition to steroid sparing ageng (azathroprine, mycophenolate motif) Dx: skin bx (infection, contact dermatitis, allerigc, drug reaction) Monitor skin for signs of superinfection (antihistoamien hydroxazien may not help

Question 99

Manage GI Bleed in patient taking warfarin

Answer 99

Upper endoscopy to be performed right away in pts with UGIB with INR <3 Gnawing pain and characteristic coffee ground emesis = pepcid ulcer dz Weigh risk of thrombosis from A/C rev against riks of bleeding - in pt with prosthetic valve and recent TIA should NOT reverse or sthop A/C (pt HD stable) If need to reverse - FFP immediate, oral or IV vit K delayed

Question 100

Profound hypoglycemia in older patients

Answer 100

Sulfonyureas with longer half lives in older pts prolonged hypoglycemia focal neuro signs(coma, hemiplegia), sweating (A1c level HCT if + and within window consider TPA

Question 101

Prevent varicella zoster in pt with leukemia

Answer 101

Give varicella IgG (VZIG) or IVIG if not available for ppx w/in 96hrs No varicella vaccine (live vaccine) in leukemia immunocompromized pt (under therapy) Acyclovir not proven to help for post exp ppx

Question 102

HTN in pt with DM2

Answer 102

keep < 130/80 - already on arb (irbesartan), HCTZ - add BB or CCB If GFR <30 and need better diuresis change HCTZ to loop diuretic Only add spironolactone as 4th drug if 3 drugs already on board at optimal doses

Question 103

Paroxysmal nocturnal hemoglobinuria

Answer 103

Unprovoked vein thrombosis unusual location (splenic vein) Hemolytic anemia mild to mod pancytopenia Dx: flow cytometry CD55, 59 Direct coombs - to evaluate autoimmune hemolysis, splenomegaly, spherocytosis, reticulocytosis, elevated unconjugated bili, elev LDH, dec'd haptoglobin Factor V Leiden - thrombophilia Antiphospholipid syndrome - inc'd risk of arterial and venous TE - correlation to pregnancy loss

Question 104

dermatitis herpetiformis

Answer 104

aw celiac dz!!! autoimmune bullous dz intensly itchy small papulovesicles on scalp, elbows, knees, back buttocks Skin bx: deposition of granular IgA in dermal papillary tips Tx: gluten free diet (Dapsone for skin lesions only) follow TTG ab will improve anemia Sarcoid - skin - maculopapular eruption, waxy nodule, erythema nodosum

Question 105

manage epistaxis

Answer 105

apply uninterupted pressure x 15-30 minutes then avoid blowing nose, stop nasal steroids Etio (viral/bact rhinositis, nose pickign, dry air, intranasal steroids) No need for blood count or coags Cauterization/nasal packing or nasal artery emboliz for sevre cases not responsing to pressure Only posterior nasal bleeds need ENT

Question 106

Acute ischemic stroke treatment

Answer 106

Tx with ASA at least 160mg daily | dpeending on size of stroke transition to warfarin

Question 107

Obesity hypoventillation syndrome

Answer 107

``` Daytime hypercapnia PCO2>45 (dimineshd ventilaotry drive 2/2 obesity) Pulmonary HTN, polycythemia OSA Sleep study to determine CPAP vs bipap Tx: weight loss ``` Cheyne stokes breathing - central sleep apena - cresencdo decresendo pattern men with advanced LV dysfxn COPD long standing - carbon dioxide retnetion and hypercapnia

Question 108

Treat aortic disease in patient with bicuspid aortic valve

Answer 108

Sx aortic regurg -> already indicated for AVR regardless of LV fxn if aorta > 45mm then repair at time of AVR indicated Bicuspid aortic valve aw ascending aortic dilation - Don't wait on intervention (BB can slow progression of aortic dilation in marfans)

Question 109

Tennis elbow/lateral epicondylitis

Answer 109

Periarthritic d/o pain at elbow-> forewarm repetitive motion of forearm injury and inflammation of the tendon - carrying/lifting/grasping objects (overuse syndrome) Pain on lateral elbow Tx: counterbrace

Question 110

Cervical radiuclopathy

Answer 110

pain-> forarm but also aw numbness, tingling, wk | Sx reproduced by bending neck

Question 111

Olecron bursitis

Answer 111

Pain at the olecron process at tip of elbow aw bursa swellign etio - trauma, septic (staph aur), gouty Tx: aspiration

Question 112

OA of elbow

Answer 112

rare - occurs with prior injury to elbow - pain localized to elbow joint only

Question 113

Tx Younger pt with AML with high risk features

Answer 113

High risk AML=complex karyotype, 5q deletion Best tx: allogenic stem cell tx (no advantage with autologous stem cell tx) (Azacitindine - high risk MDS) Favorable young patients - t(8;21), inv 16 - chemo/cytarabine

Question 114

Radiation induced aortic valve regurgitation

Answer 114

Common in post radiation patients (10-25years) - r/o valve fibrosis Corrugan pulse (rapid carotid upstroke, rapid decline) high pitched blowing diastolic decrescendo murmur heard to left of sternum at 3rd ICS Displaced PMI Widended pulse pressure (155/43) Dypnea from inc'd LVEDP from AR CP from low coronary filling pressures low diastolic aortic pressure

Question 115

Constrictive pericarditis

Answer 115

prior radiation with DOE | findings of RV failure (JVD, peripheral edema)

Question 116

Restrictive CM

Answer 116

signs of RV prossure overload

Question 117

Tricuspid regurg

Answer 117

large retrograde V waves/hepatojugualar reflux | systolic murmur

Question 118

Manage non-cardiac chest pain

Answer 118

2wice daily PPI x 8 to 10 weeks if no alarms sx (if so then directly to EGD) Pt with non-anginal CP with neg stress and neg echo ``` If PPI unsucessful then endoscopy (r/o erosive esophagitis, achalaisa or manometry (DES/esoph motilitly d/o) ambulatory pH monitoring ``` MSK CP - focal, sharp localized to one area

Question 119

Multiple sclerosis

Answer 119

partial demyelinnating myeltis Cervical cord Electrical sensation with neck movment (Lhermmete sign) Prior eposide of vision loss (optic neurtis) daytime fatigue Dx: MRI brain ovoid white matter lesions from MS Not cardioembolic CVA - no language deficit in setting of large motor def/sens def Not migraine - would have h/a, would caurse subtle neuro deficits only

Question 120

CVID

Answer 120

h/o recurrent respiratory tract infections with encapsulated bugs, H flu, S.pneumoniae, giardiasis autoimmunie hemolytic anemia, pernicious anemia (high MCV), RA, d/o of GI tract -> malaborption r.o sinopulm d/o, lymphoma, If titers low, check response to protein/protein sacc vacines If very low then then vaccine response unnecessary

Question 121

Low total hemolytic complement

Answer 121

complement def Early compoent of complement - SLE (recurrent infxn wtih encapsulated bugs or diss neissria Def in terminal complement - recurrent neisserial infxn, ie meningitis and DIG

Question 122

NNT

Answer 122

Absolute risk=pt with event in one group/total pt's in group ARR=AR1-AR2 NNT= 1/ARR

Question 123

Primary hyperparathyroidism

Answer 123

h/o fragility fx inappropriately high PTH in setting of hyperCa+ Need PTHectomy Indications for PTHectomy 1. Sx hyperCa (arrtymias, nephrolithiasis) 2. Cr Cl < -2.5 4. Ca+ > 1mEq abov normal 5. age< 50 6. Fragility fx Bisphosp only if pt refuses surgery No bone scan, no PTHrP needed

Question 124

Actinic keratosis

Answer 124

sun exposed areas in older people Premalignant -> SCC erythematous scaley macules Cryotx, 5FU, photodynamic tx Easier to papate and dx

Question 125

Basal cell CA

Answer 125

pearly, waxy - fair skin, sun exposure

Question 126

Sebhorriec kearatosis

Answer 126

brown, warty waxy plaques - stuck on appearance - benign

Question 127

Solar lengintes

Answer 127

brown macular patches in fair skined with sund damage - benign but could be hiding cancer underneath

Question 128

Porphorya cutanea tarda

Answer 128

blistering d/o - def o enzyme uroporphyingen decarbox - bullae on dorsum of hands after sun exposre - dyspigmentation, scaring, tender

Question 129

End stage kidney dz and alport syndrome

Answer 129

GFR 13 - Xlinked dz collagen synthesis sensoneural hearing loss, ocular abn, fhx kidney dz and deafness Kidney tx is only therapy - dz does not recur in tx (ACE/ARB can slow decline, not tx)

Question 130

Manage CVD risk in pt with CKD

Answer 130

LDL target in pts with CKD not on HD is < 70 Increase lipitor dose Lowering PTH in CKD patients not aw dec'd mortality Keep bicarb >23

Question 131

Corticosteroid refractory idiopathic tranverse myelitis

Answer 131

Plasmapheresis PE: bl leg wk, loss of sensation below umbilicus, hyperreflexia LE, leukocytosis in CSF, inflammation in MRI, Probably autoimmune transverse myelitis First line tx: high dose steroids 2nd line: plasmapheresis or cyclophosphamide (NOT MTX) Glatiramer acetate - Disease mod agent in tx of MS - reducees immune resposes that exacerbate MS

Question 132

Treat multinodular goiter

Answer 132

``` thyroidectomy if impinging partially solid and cystic nodules Goiter grows over time FNA rules in or out CA If no CA Growing goiter can compress trachea, esophagus, laryngeal nerve ``` Ext beam radiation doesn't work synthroid will make pt thyrotoxic No need for PTU/methimazole Radioactive iodine only used in pts with MN goiter with autonomous fxn

Question 133

Metastic melanoma

Answer 133

sx brain mets If symptomatic - resect brain mets or stereotactic surgery chemo and/or radiation won't work without surgery Melanoma relatively radio resistant

Question 134

Schizophrenia

Answer 134

Neg sx: withdrawal, flat affect, lack of interest Pos sx: paranoia, hearing voices Sig/sx at least 1 month Fhx schzophrenia inc's risk

Question 135

Sebhorreic keratosis

Answer 135

flesh colored to yellow, tan, irregularly pigmented waxy/veruncous intexture BENIGN - no premalignant potential

Question 136

Atypical nevi

Answer 136

located on torso more macular (ie flat), lack verruncous texture of seborrhic keratosis

Question 137

Melanomas

Answer 137

irreg borders, darkly pigmented black lesion

Question 138

Solar lentignes

Answer 138

completely flat in areas of sun exposure

Question 139

Dx amiodarone induced pulm toxicity

Answer 139

HRCT chronic dypnea, dry cough, restrictive lung physiology temporaly related to start of amiodarone Chroic intersticital pneumonits, organizing PNA, ARDS, pulm mass, Risk - inc'd age, dose, duration of tx, pre-existing lung dz

Question 140

Psoriatric arthritis

Answer 140

various pattern of joint/nail involvement DIP, enthesitis, dactylitis, tenosynovitis, nail pitting, symmetric polyarthritsi - arthrtiis mutilans, spondylitis - onchymyolysis

Question 141

Lyme arthritis

Answer 141

med or large joints - NO NAIL CHANGES

Question 142

OA

Answer 142

DIP no nail findings

Question 143

RA

Answer 143

usually symmetric - PIP, MCP, NO NAIL CHANGES

Question 144

Tuberculin skin testing

Answer 144

>10mm - IVDA, persons from countries with high prev < 5ya, employees of NH, hospit, homeless shelter, mycobacterium lab, ppl with inc'd risk of TB (DM, CKD, siolosis, cancer of head/neck, gastric bypass >5mm - recent contact with active TB pt, HIV, fibrotic changes on prior CXR c/w old healed TB, organ tx or other immunocomprimised Asx person of both groups if cxr neg then need latent TB tx

Question 145

Afib in setting of HF after MI

Answer 145

Amiodarone One of few agents safe for sx afib with LV dysfxn (alternate= dofetilide - ok with afib and HF - monitor QT) No flecanid - inc'd r/o polymorphic VT NO disopyramide - neg ionotrope No dronedarone - inc'd mortality in NYHA III, IV No soltolol - more BB than amio, bad in HF

Question 146

Proliferative glomerulonephritis

Answer 146

active SLE and abn urine new onset HTN/edema +ANA, dec'd complement, proteinuria, hematuria Need prompt bx - wil lthen start on high dose corticosteroids + immunosupp agent (cyclophos or mycophenilate moteifil)

Question 147

Severe COPD

Answer 147

Pulmonary rehab for... Sx COPD with FEV1t walk, recent MI or UA) Morphine only for pt with severe dypnea at rest for palliation O2 only for 88% or lower Steroids only for acute exacerbation - change in baseline cough, sputum

Question 148

Cryptococcal meningitis in pt with AIDs

Answer 148

Disseminated cryptococcus - with meningitis Tx: conventional amphoteriicin B and flucytosine h/a, skin lesions (molloscum like) - CSF paucity If pressure>250 then drainage needed 1: induction - amphoter B + fluctyocine 2: consolidation - oral fluconazole x 8 wks 3: maintenanc/suppression (lipid amphoter for kidney dz pts) no echiochinocandins - (caspofungin) as no activity against crypto and no CSF penetration (also amphot B+ fluconazole, flucon along, fluc + flucytocine)

Question 149

Sx pulmonary valve stenosis

Answer 149

Contraindications to pulm baloon valvulopastic Sub or supra pulm valvular stenosis Severe PR hypoplastic pulm annulus going in anyway for other cardiac dz - fix valve while in there (need pulm valve replacement) Sx patients with >50mm instant grad (30mm mean) Asx pt with >60mm/40mm mean wihtout mod or greater PR Pulm vasodilator therapy for PAH

Question 150

Atypical parkinson's dz

Answer 150

typical parkinson's responds to high dose levodopa Sx: resting tremor, bradykinesia, rigidiy, postural instability absense of olfaction w/o response to levodopa - more extensive dz Tremor absent in 30% Most parkinson's patients have autonomic dysfxn

Question 151

Manage pt with secondary iron overload from B thal minor

Answer 151

Hct 25% - can't do phlebtomy - need iron chelation (deferasirox) B thal major with iron overload from excessive tx and inefective EPpoesis elev ferritin and transferrin saturation indication for tx Complications from second iron overload - HF, liver failrue, arthraligia, pitutiary, islet cell dysfxn

Question 152

Chronic neuropathic pain

Answer 152

mod to severe if did not respond to non-opiod meds transition to sustained release morphine don't use tramadol for chronic pain - weak opiod don't use methadone in pt with ischemic CM and conduction dz (can cause long QT -> VT)

Question 153

HTN in black patient with CKD

Answer 153

Stage 3 CKD - add ramipril blacks with more end organ damage from HTN at any level than other groups Absense of end organ damage goal < 135/85 +end organ damage - ing diuretic will improve bp but not proetinuria and kidney dz progression)

Question 154

Tx superficial lacerations in elderly adult

Answer 154

Non-adherent dressing over plain petrolium - cheap and good ``` Atopic skin (Polymyalgia rheumatica - pain in neck,shoulder, hip aw temporal arteritis - tx with low dose prednisone) Minimize risk of damage to skin with adherent tapes ``` (no need for hydrocolloid, hydrogel, calcium angonate, foam dressings) No need for topical abx - risk of allergic contact dermatitis and drug resistance Don't leave wound open - escar can form - prolong healing time

Question 155

Evaluate diarrhea not meeting criteria for irritable bowel syndrome

Answer 155

IBS - abd pain, diarrhea, imporovment with defecation, onset with change in stool frequency, Dx: flex sig with bx - r/o microscopic colitis thickened subepithelial collagen band (collangenous colitis) or subepithelial lymophcytic infiltrate (lymphocytic colitis) Don't use antispasmotic agents - dicyclomine - GI smooth muscle relaxants - Pt with normal IgA unlikely to have celiac dz If needed to use TTG NOT antigliaden ab to dx celiac dz Don't give loperimdie without dx

Question 156

Small intestinal bowel overgrowth

Answer 156

``` diarrhea, bloating, weight loss Macrocytic anemia 2/2 B12 def Elevated folate (bacteria consume B12, synthesize folate) Pt with sclerosis high risk for SIBO 2/2 intestinal dysmotility Risk factors - altered gastric acid (gastrectomy, achlorohydria, str abn (strictures/diverticula blind loops), intestinal dysmotility (DM, NM d/o) Dx: hydrogen breath test, upper endo with ctx ``` Celiac dz unlikely with normal TTG Microscopic colitis - chagnes ONLY in colon so fat absorption should not be affected, vit def not present

Question 157

Acute sinusitis

Answer 157

tx with anti histamine for mild case, no abx usually resolves 7-10 days Abx only for worsening sx and HIGH fever No need for nasal ctx No need for imaging - not very sensitive role of nasal steroids unclear

Question 158

Hypothyroid in critically ill adult

Answer 158

High TSH, low T3, T4 in ICU pt with PNA amiodarone also causes hypothyroid start treating hypothyroid Adrenal insuff - Nonthyroidal illness causing hypothyroid - euthyroid sick syndrome - from cytokine inc - TSH shouldn't be above 10, TSH secreting tumor inc'd TSH and T3/4

Question 159

Folliculitis

Answer 159

``` pustules caused by bacteria around follicles topcial abx (clinda, benzoyl peroxide) or doxy ``` Acne would have comedones - pustule of acne usually sterile Miliria - heat rash - erythematous papules occulsion of sweat ducts, no pustules Rosacea - papules and pustules - central face only!

Question 160

Acute disseminated encephalomyelitis

Answer 160

inflammatory demyelating d/o young adults post infectious phenomenon simultaneous demyelinateing in multiple areas h/a, fever, ENCEPHALOPATHY (not c/w MS) lymphocytic prolif in CSF (not c/w MS) usually SELF limited

Question 161

CKD patient with HTN

Answer 161

Sodium restriction, keep BP <130/80 Start with CE in CKD patients with proteinuria nonproteinuric CKD - focus on BP control not specific agent Nabicarb in pt with CKD and bicarb 15-20 No need to tx mild elev PTH with normal Ca+/Phos

Question 162

Sarcoidosis

Answer 162

Idiopathic d/o with UPPER LUNG infiltrates (better seen in lateral view) Non-necrotizing granulomatous infection Dx requires tissue Asbestosis, organizing pna iPF all lower lobe predominant

Question 163

Gestational anemia

Answer 163

red cell mass increases (inc'd EPO) inc'd plasma HELLP (hemolysis, elevated liver ezymes, low plts) - RUQ pain, elev LFTs, pre-eclampsia, Abn blood smear with throbocytopenia, fragmented erythrocytes No signs sx of IDA, normal smear, normal MCV not IDA EPO inc'd during preg

Question 164

Intercritical gout, hyperuremcemia

Answer 164

HCTZ INCREASES serum uric acid levels, inc's risk of gout change to urate neurtral or lowering anti HTN agen Low fat dairy dec's urate Fruit inc'd urate, wine is the least gout precip etoh

Question 165

Pt with HIV exposed to active TB

Answer 165

should get INH/pyridimine regardless of inf gamma/TST testing results/CXR need pyraxidine with DM, HIV, uremia, etoh, malnutrition, sz d/o, pregnant women Don't use rifampin and pryridmime together - hepatoxicity

Question 166

doxorubicin induced dilated CM

Answer 166

decompensated HF - S3 gallop, pulm crackles years to decades after chemo cumulative dose >550 risk factors age >70, other cardiotoxic agent (cyclophosphamide) Radiation tx to thorax No cardiac tamponade without JVD, or pulsus >10 No COPD exacerbation without cough/sputum Radiation induced constrictive pericarditis -RHF signs, relatively normal BNP

Question 167

potential cardiotoxicity in breast CA requiring trastuzumab tx

Answer 167

HER2+ Check LVEF before initiating for baseline and during tx No Exc stress test prior to radiation radiation can lead to premature CAD, valve fibrosis, abn in LV fxn/mass

Question 168

Dermatomyositis

Answer 168

``` Elev CK prox muscle wk heliotrope(violacious color eyelids with periorbital edema), shawl sign, V sign, gottron papules (violacious to pink plques with scalling over extensor surfaces of hand joints, knees, elbows Raynauds, perungal erythema, arthritis, pulm/GI involvement +ANA ``` SLE - discoid, malar rash Polymyositis - no rash MCTD - overlap systemic sclerosis, SLE, myositis Inclusion body myositis - older pts, both prox and distal wk

Question 169

SCC in kidney tx patients

Answer 169

immunosupp agents increase r/o cancer SKin CA, melanoma, SCC, basal cell CA, Kaposi's Occur at younger age, more met potential Thick adherent scale and eroded areas

Question 170

Fixed drug eruptions

Answer 170

repeated exposure to same agents | rash recurrening at same areas each day

Question 171

Nummular eczema

Answer 171

circular/coin shaped eczema

Question 172

Psoriasis

Answer 172

think pink plaque, silvery scale | elbows, gluteal cleft

Question 173

Tinea corporis

Answer 173

pruritic, annular patch, thin plaque fine scaling

Question 174

Post hypoxic myoclonus

Answer 174

``` prolongued cerebral hypoxia/anoxia syndrome of generalized myoclonus shokclike muscle jerks negative myoclonus Cariac arrest with delayed resucitation cortex hyperexcitable after hypoxic injury VPA, levecitram, clonezepam ```

Question 175

Cerebellar degeneration

Answer 175

spinocerebellar ataxia autosomal dominent 40's gait unstadiness, uncoordination

Question 176

Myoclonic epilepsy

Answer 176

generalized tonic-clonic seizures

Question 177

Wernickes encephalopathy

Answer 177

ataxia, opthalmoplegia, confusion, peripheral neuropathy, seizures Thiamine def Etoh abuse, bariatric surgery, fasting, vomiting, TPN without vitamins

Question 178

Cocaine associated CP

Answer 178

No BB - unopposed alpha Tx with CCB and lorezepam (benzos) lower HR, BP and myocardial demand No thrombolytics if no ST elevation No nitroprusside - no reason to acutely lower BP

Question 179

Palliative care

Answer 179

focuses on maintining quality of life not limited to terminal illness Non-hopsice palliative care DOES NOT exclude tx (just ensure they are what patient wants) Morphine only with severe dsypnea at rest without reversible cause

Question 180

Asx hyponatremia

Answer 180

absence of neurofindings chronic - rapid correction undesired 1st fluid restriction 3% NS if menstal sattus hcange and Na d r/o variceal bleeding SIADH - (would have high urine Na), use demecyclocine

Question 181

Secondary hypogonadism

Answer 181

Central hypogonadism - low serum testosterone, FSH, LH r/o prolactinoma r/o hemochromatosis - iron/ferritin levels (h/o OA, inc'd LFT) Reason to suspect inc'd sex biding globulin (obesity, DM, older age) Karyoytpe and testiuclar US in pt with primary hypogonadism (inc'd gonadotrpin level (inc'd LH/FSH)

Question 182

Dyspepsia without alarm sx from developing country

Answer 182

Young pt with dypepsia from endemic area for h pylori without alarm sx (wt loss, anemia, dyphagia, fhh/o UGI malig) Test and treat h pylori stool antigen - if + then tx h pylori if neg trial PPI EGD for pt's that do not respond to H pylori tx and PPI or pt's pw alarm sx

Question 183

Manage adrenal fxn during critical illness

Answer 183

Need stress dose steroids if appropriate abx not solving fever, hypotension (repeated steroid injections probably mad adrenally insufficient) Cortisol level though normal inappropriately low for stress condition ie sepsis Don't wait for ACTH stim, don't add vasopressors before giving steroids

Question 184

Patient with hypokalemic met alkalosis

Answer 184

net loss of acid or retention of bicarb Saline responsive hypokalemic met alkalosis - hypovolemic - corrects with saline UClt correct with Saline active diuresis or gnetic tubular d/o - bartter or gitelman Pirmary hyperaldo - aldo renin ratio 20 to 30 Mineralocorticoid excess - both renin and aldo suppressed Plasma aldo and renin levels elevated in patients with malignant HTN, renin secreting tumores and renovasc htn UOsm gap - used in estimating ammonium excretion

Question 185

Brachioradial pruritis

Answer 185

neuropathic itch inflammation in cervical spine causes recurrent itching in upper extrem Response only to cold pack Skin bx neg - NO RASH Not histamine related so antihistamine creams don't help Tx: gabapentin/pregabalin Polymorphous light eruption - skin lesion after light exposure - wheals, papules, plaques vesicles Skin lesions + itch Prurigo nodularis - itchy skin, licenified nodules where been repeatedly scratched (pickers nodules) Solar utricaria - sunlight hives

Question 186

OSA in post op period

Answer 186

pts with mild risk of OSA should be screened pre-op - (Snoring, tired, observed stop breathing during sleep, big neck, BMI>35, male Pushed over edge by anesthesia and narcotics

Question 187

Acute severe pancreatitis

Answer 187

Aggressive hydration by IVF - acute necrotizing pancreastitis - avoids end organ damage No need for broad spectrum abx even with necrosis no benefit for ppx either Only abx if pancreatic infection noted with sample ERCP only if gallstone lodged in pancrease

Question 188

Post concussion syndrome

Answer 188

somatic, neurologic and psychatric sx after head injury - h/a fatigue, sleep distrubances, diff concentration and memory - depression, anxiety irritability, dizziness, tinnitis abn on fxn neuroimaging,

Question 189

Meniere dz

Answer 189

tinnitis, vertigo, hearing loss

Question 190

Post traumatic stress d/o

Answer 190

cognitive and emotional sx, memory loss, irritabliity, h/a flahsbacks of events

Question 191

Manage inadequately observed asthma 2/2 improper inhaler technique

Answer 191

Observe pt using inhaler on observed inhaler sx PFTs improve reduce sx of oral thrush and dysphagia Add leukotriene rct antag if using inhaler properly (corticosteroids and long acting beta agonist) Prednisone therapy only if lung fxn not improved after proper inhaler technique - lots of systemic s/e don't use if topical/inhaled meds work Peak flow diary can document loss of asthma control prior to onset of sx

Question 192

DM related osteomyelitis

Answer 192

vancomycin/meropenum septic syndrome with limb threatening foot infection spreading cellulitis far beyond wound/ulcer staph, strep enteric g neg,pseudomonas, anaeroboes Bx of deep bone ideal Need surgical debridement NOT aztreonma/flagyl - no cov vs step/staph No cefazolin - no coverage of MRSA No gentamycin/aminoglycosides - very toxic, little activity in necrotic aorobic environtmnet

Question 193

Treatment of mild systolic HF (LVF) in black pt

Answer 193

Needs BB and ACEi - NYHA I-II mild HF sx resolved with diuresis No need for CCB 1st gen CCB inc'd r/o HF Hydralazine and nitrate only added to all patients intoleratnt of ACEi/ARB - also blacks with NYHA III/IV HF - addition of these two to ACEi reduces mortality Spironolactone for severe SHF NYHA III/IV added to BB/ACEi - if pt has only mild sx no need for spironolactone

Question 194

Iron defiicency anemia with anisopoikilocytosis

Answer 194

variation in RBC size and shape (anisopoikilocytossi) inc'd RDW, inc'd central pallor Iron def anemia (throbocytosis as well) DOE/chest pain from dec'd O2 carrying capacity of blood G6PD def - bite or blister cells - MCV normal eccentricaly located hemoglobin to one side of cell - MCV normal or slightly high 2/2 inc'd recitulocytosis 2/2 G6PD mediated hemolysis Myelofiboriss - sign sx anemia + night sweats, wt loss - leukoerythroblastic picture - nucleated eruthrocytes and left shift in leukocytes - TEARDROP CELLS, MEGATHROMBOCYTES. TTP - fragmented erythrocytes (schistocytes) + AKI + MS changes + ecchymoses

Question 195

Treat chronic HCV infection

Answer 195

Pt with chronic HCV and advanced bridging fibrosis and no cirrhosis Start peginferon and ribavirin can progress to HCC (If Genotyope I HCV - NS3/4A protease inhib) Candidates for thearpy - detectable virus - some indication of hepatic inflamm - elev LFTs, inhflamming/bridging fibrosis on bx, NO CONTRAINDICATON to therapy - decompensated liver dz (ascietes, hpe encep, jaundice)preg, psych dz, cytopenia Goal therapy to sustain response - non-detectable virus w/in 6 months - lot of morbidity from tx Corticosteroid tx for extrahep manifestations of HCV - mixed cryoglobulinemia, lymphoma, skin dz, autoimmune dz (thyroididits), don't give unless indicated otherwise worsens HCV (inc's replication) Liver tx for HCV pt with DECOMPENSATED cirrhosis, - No reason to wait - should not reeval in 6 montsh - treat now!

Question 196

ARDS mechanical ventillation

Answer 196

hypoxemia corrected with mech ventillation, suppleemntal O2 and PEEP - limit barotrauma by ventilating 6mL/kg IDEAL body weight prevent ventilator associated lung injury then stepwise dec till pleateau pressure <0.6 IBW= 50Kg +2.3Kg for men each inch over 60 (45.5+2.3 women)

Question 197

Interpret thyroid fxn test in older pt

Answer 197

observe with TSH 6.5 and low normal T4 (free) monitor for signs of hypothyroid Repeat test over months to ensure stability In pts over 80 elevated TSH no aw adverse outcomes (depression, impaired cognition), Normal reference TSH 1-7 Don't give older pts levothyroxine just for mildly elevated TSH without other clinical sx TPO normal and exam normal except mild fatigue No advantage of liothyroxine (T3) over levothyroine (T4)

Question 198

Pyoderma granulosum

Answer 198

uncommon, neutrophilic, ulcerative skin dz - multiple lesions - begin as tender papules/pustules or vesicles -> spontaneously ulcerate to painful ulcers with purulent base with ragged violacious borders Sharp cliff cutoff face compared to normal skin Etio - inflamm bowel dz, -> RA, seroneg spondlyloarthritsi, hematologic dz/malignancy - AML

Question 199

Caliphylaxis

Answer 199

ectopic Ca of arteries feedign skin - always in pts with ESRD on HD in setting of high Ca+/Phos products, - reticulous dusky erthema that then ulcerates from cutaenous ischemia

Question 200

Ecthyma gangrenosum

Answer 200

perivascular bacterial infection of blood vessel walls with secondary ischemic necrosis, - multple lesions in diff stages of dev - infecting agent psedomonas - in immunocompromised patients that are ill

Question 201

Necrotizing fasciitis

Answer 201

rapidly progressive infxn of SQ tissue - strep or poly microbial bacteria - pts are critically ill - progresses over HOURS (not days or weeks) - pale dusky skin with creptus - sepsis

Question 202

Evaluate pt with metastatic non small cell lung CA

Answer 202

Pt with metastatic adenoCA and NO SMOKING HX - Need Epidermal growth factor rct analysis - can benefit from biologic agents targeting this gene factor Chemotx + erlotineb/gefitinib (EGFR ab) - sruvival 8-10 months longer than standard chemo Bx of liver not recommended with multiple mets (only if soltiary lesion because if you can resect can change STAGE of dz) Medistinoscopy with bx of LN in pts with potentially resectable non-small cell lung cA (not if pt has multiple mets) Serum chromografin levels in pt with neuroendocrine tumors (carcinod) or small cell lung CA

Question 203

Manage side effects of corticosteroid use

Answer 203

Alendronate indicated for pts being tx for giant cell arteritis with corticosteroids - if tx >3months >7.5mg/day Ca+, vit D No HRT (estrogen or estrog+prog) for prev of chronic dz like osteoporisis in post menopausal woemn - r/o VTE, CAD, CVA

Question 204

Epididymitis

Answer 204

Pain in superior and posterior aspect of testicle dysuria, urgency, frequency, gradual onset of pain fever, leukocytosis Risk factors - rec sexual activity, heavy exertion, bike riding 55/MSM - ecohli, pseduomonas Orchitis - direct palpation of testicle gives pain, testicuular enlargmemnt Acute prostatitis - pelvic pain, lower UTI sx - fever, WBC - TENDER PROSTATE Indirect hernia - discomfort and fullness in scrotum, unlateral - scrotal mass - NO FEVER OR WBC Testicuular torision - testicle twists on spermatic cord - acute pain - cut off blood supply - SURGICAL EMERGENCY - n/v high riding testicle

Question 205

HIV in pregnancy

Answer 205

Zidovudine, lamivudine, lopinavir-rotinavir NOW when HIV detected lowers transmission to 2% NO EFAVIRENZ - teratogenicity Do not withhold tx till CD4<500

Question 206

Postinfectious glomerulonephritis

Answer 206

weeks after staph infection decreased complement (C3 and 4) - activate classic and alt pathways acute nephrotic syndrome, edema, HTN, oliguria, erythrocyte casts

Question 207

Diabetic nephropathy

Answer 207

steady decline of GFR not sudden

Question 208

IgA nephropathy

Answer 208

normal complement AKI macro/micro hematuria within days of staph/strep infxn

Question 209

Primary membranous glomerulpathy

Answer 209

``` nephrotic syndrome hypoalbumin NORMAL COMPLEMENT HLD asx protienuria erythrocyes and granular casts NO ERYTHROCYTE CASTs ```

Question 210

Acute Severe MR

Answer 210

ruptured mitral valve cord flail leaflet, severe MR pulm edema - sx urgent surgery MVR BRIDGE could be IABP, IV vasodilator tx NOT ORAL afterload reducer (captopril)!! NO BB - tachy is compensatory and maintaining CO No sign's/sx endocarditis so NO ABX

Question 211

Bacterial meningitis s/p NSx

Answer 211

Empiric tx for NOSOCOMIAL bacterial meningitis Vanc + agent that penetrates CSF well MEROPENUM (for g neg bacteria/pseduomonas) CFtx and bactrim NO EFFECT vs pseudomonas Gentacmycin doesn't get into CSF Flagyl only vs anaorobes

Question 212

Hypokalmeic distal RTA I

Answer 212

Normal AG with nephorcalincosis metabolic acidosis and hypokalmeia can't acidify urine - > pH alkalotic (>5.5) Etio: SLE, Sjogrens, RA, lithium, , amphotericin B hypercalciuria, hyperglobulinemia Inc'd pH increase r/o kidney stones

Question 213

Gitleman's syndrome

Answer 213

hypokalemic met alkalosis BP low to normal defect in thiazide channel ie acts like thiazide

Question 214

Laxative abuse

Answer 214

hypokalmeic normal AG met acidosis inc'd GI losses - compensted by kidney by urine ammonium prodxn - acid secrition by kidney Urine amm estimated by UCl gap 15 - decreased acid secrtion

Question 215

Proximal RTA II

Answer 215

defect regenerating bicarb in prox tubule normal AG met acidosis hypokalemia glycosuria in setting of normal blood sugar renal phosphate wasting LMW proteinuria Distal acidification is intact so pH urine <5.5 No kidney stones

Question 216

Manage menopausal sx in pt on tamoxifen therapy

Answer 216

Venlafaxine and gabapentin hot flushes, ameorrhea NO fluoxetine or paroxeteine (inhibits liver enzymes) Hormone RT contraindicated in pts with hormone rct + breast CA No evidence that excerise or herbal meds help

Question 217

Lambert eaton

Answer 217

progressive proximal muscle wk depressed dTRs improve with repeated excercise Autonomic dysfxn P/Q Calcium voltage gated ioin channel Ab Dx: motor nerve conduction studies - inc of potential after stimulation

Question 218

Myastenia gravis

Answer 218

``` Acetylcohlinesterase Ab Post synaptic Muscle use and stimuulation WORSENS strength NO AUTONOMIC dysfxn normal DTR ```

Question 219

Chronic inflammatory demyelinating polyneuropathy

Answer 219

elevated protein level progressive prox muscle weakness and hyporeflexia No autonomic dysfxn

Question 220

Tx SBP with significant hepatic and kidney injury

Answer 220

+ascitic fluid with >250PMN Cefotaxime If Cr >1.5 then also ALBUMIN If advanced liver dz then also ALBUMIN DOn't use diureteic or large volume paracentesis - worsen kidney fxn

Question 221

Evaluate rheum arthritis

Answer 221

AFter therapy with MTX/biologics get XR of hands and wrists to reevaluate erosive changes Don't use anti CCP for monitoring RA (just to dx) Only do TB screening yearly

Question 222

Secondary causes of HLD

Answer 222

LDL and TC really elevated despite statin statins ineffective in setting of hypothyroid Check TSH (sx fatigue, constipation, dry skin) Also check for DM, obstructive liver dyfxn, nephrotic syndrome don't add gemfibrozil to statin unless needed - inc'd conc of statin and inc's r/o statin induced myopathy Don't ever give zocor 80 - change to lipitor or rosuvastatin instead If fasting glucose and TG normal - don't need to check HgA1c for now.

Question 223

Body areas

Answer 223

leg 18%, arm 18%, front torso 18%, back torso 18%, head 9% | Need 30gm topical med to cover body in 70kg person

Question 224

Tx Myedema coma

Answer 224

IV levothyroxin and IV hydrocortisone Non-responsive, hypotension, hypoglycemic, hypothermic, bradycardic tx of sepsis - /PNA - ventillation tx of cardiac issues With severe hypothyroid also hypopituitarism - need IV hydrocortisone(glucocorticoid) replacement also Check for adrenal insufficinecy as tx occurs Don't use liothyroxine (T3)

Question 225

Hypotension in pt with Hypertorpic CM

Answer 225

Stop dopamine cw IVF START PHENYEPHRINE LVOT obstruction from SAM Worsen with ionotropic agens (dob/dopamine) WOrse with volume depletion, vasodilators, sustained atrial arrythmia and sinus tach Worse with withdrawwal of BB, CCB Phenylephrine alpha agonist - raises afterload by peripheral vasoconstriction Esmolol decrases dynamic outflow tract obstruction raising SBP DOn't use milronone - vasodilator effect worsens obstruction of LVOT

Question 226

Treat central sleep apnea in pt with HF

Answer 226

Cheyne stokes breathing/Central sleep apnea 2/2 HF Needs diuresis improvement in cardiac fxn 2/2 dieuresis improves CSA If CSA persists after medical optimization of HF - adaptive seroventillation (ASV) CPAP only if obstructive element to sleep apnea If O2 low then supplement only Oral appliances only with obstructive sleep apnea element

Question 227

Dx SLE

Answer 227

Anti- DSDNA Ab ``` +ANA arthritis ulcer photosensitive rash livido reticularis - antiphopholipid Ab ``` ANti ro/SSA, anti la/SSB - Sjogrens, slcerosis , RA Anti U1-ribonucoprotien (RNP) - MCTD - features of systemic slcerosis, polymyositis, SLE c-ANCA (antiprotienase 3 ) - granulomatosis weith polyangiitis (wegeners) necrotizing vasculitis lungs and kidneys

Question 228

Tx pt with acute VTE

Answer 228

LMWH 5 days overlapped with warfarin INR 2 or more x 24hrs or risk of recurrent thromboembolism

Question 229

cellulitis

Answer 229

rapidly spreading subcutaneous infection warmth, swelling, tenderness, erythema, fever chills Strep Never b/l Risk factors - h/o cellulitsi, chronic leg ulceration, varicose veins, DM, thrombophlebitis, lymphedema, obesity, tinea pedis, onchymycosis Bullous tiniea - inflammatory and erthematous scales in mocassin distriubtion localized to foot -> ankle Contact dermatitis - swelling erythema, warmth - also PRURITIS, - can get secondarily infected Stasis dermatitis - usually b/l NOT TENDER

Question 230

Suspected SAH

Answer 230

sudden onset severe h/a Neg HCT Need LP to dectect xanthochromia No use for MRI, MRA, repeat HCT with contrast (if mass lesion large enougth for headache would have shown up without contrast)

Question 231

Primary biliary cirrhosis

Answer 231

Tx: ursodeoxycholic acid women >25yo cholestatic liver enzymes - alk phos 1.5x, AST/ALT 1:40 (bigger is more +) Tx: monitor with alk phos reduction don't give ursodeoxycholic acid with bile binders (cholestyramein)

Question 232

Screen for HIV infection

Answer 232

HIV ab enzyme immunoassay HIV screening for all those 13 to 64 once with risk factors annually confirm + with HIV western blot (if EIA is +) (don't use HIV wetern blot as initial screen) If acute sx and suspect in window phase -> HIV nucliec acid amplication (PCR)

Question 233

Graves opthalmopathy

Answer 233

Thyroidectomy + local measures,/steroids proptosis, diplopia, chemosis, conjuntival injection - optic nerve compresssion can cause blindness WIth graves dz - surgery for those severe allergy or intol of anti-thyrod drugs (methimazole, PTU, iodine), large obstr goiters or opthalmopathy If oral iodine taken reduces TFTs but without antithroid drug will cause hyperthryoid Don't use PTU if adverse rxn to methimazole **Don't use radioactive iodine for graves -> worsens!!

Question 234

Dronedarone

Answer 234

increases Cr BUT DOES NOT DECREASE GFR (partial inhibition of tubular tx of creatinine itself) measured value shoudl be new baseline on dronedarone DO NOT USE DRONEDAREONE with CHF NYHA IV or NYHA II-III with recent decompensation and hospitalization

Question 235

de Quervain tenosynovitis

Answer 235

swelling/stenosis of abductor pollicus longus/brevis tendons at level of wrist Etio - repetive motion of thumb Pain and swelling over radial syloid Pain with resisted thumb flexion and extension Finklestein + Carpometacarpal arthritsi - pain at base of thumb during gripping - tenderness on doral and palmar joint surface loss of ROM/joint stiffness Older patients Ganglion cyst - in tendon shealth from inflammation following TRAUMA Scaphoid fx - h/o injury with wrist dorsiflexion

Question 236

Dx type II DM

Answer 236

HgA1c dx of DM, FBS not - so recheck test dx of dm - ie HgA1c (has risk factors - fhx CAD, DM, obesity) If both tests dx'd DM then no reason to repeat either

Question 237

Manage influenza during outbreak in community

Answer 237

Mild illness otherwise healthy - does not need tx Those at high risk for influenza - CVD, active CA, CKD, chronic liver dz, hemoglobinopathy, immunocompromise - neurologic dz impairing handling of resp secrtions - ] Agents should be given with 48hrs (Oselamavir, zanamivir) Don't use amatadine, rimanitidine (high reistance)

Question 238

Dermatomyositis

Answer 238

heliotrope rash - erythema of malar area, nasolabial fold, periorbiatl skin gottron sign - erythema over extensor joint spaces Gottron papules - pink t skin colored papules DIP/PIP, lacy or reticulate erythema of v-neck - shawl sign Exacerbated by sun Psoriasis -pink papules, silvery scale - elbows/face improved withsun exposure RA - a/w rheum nodules - SQ nodules over ext joints - no muscle weakness SLE - malar rash - NO MUSCLE weaknes, no guttron papules

Question 239

Tardive dystonia

Answer 239

facial grimacing, akasthesia(restlessness) induced by dopamine rct agoneists - (metocloproamide) and antipsych drugs Tx: slowly taper off offending agent, antichol or dopamine rpeleting agen and botox injections Huntington - familial d/o - generalized chorea, dementia, behavioral changes Juvenile parkinsons - in child

Question 240

Wilson's dz

Answer 240

copper accum in basal ganglia and liver - progressive parkinsons or dystonia. onset in teens - keisher flyscher rings

Question 241

Stage IIB lung CA

Answer 241

Surgical candidate - isolated, growing nodule Calculating lung fxn post op - take percentage of lung removed and multiple by FEV1 and DLCO if >40% then ok neoadjuvant chemo good too No need to bx as high probability that patient has malignancy

Question 242

Pt with BRCA gene and inc'd risk for ovarian CA - sister ovarian CA young

Answer 242

b/l salpingoooprhectomy and ppx b/l mastectomy (multiparity and OCP protective against ovarian CA) (Pelvic exams, CA125 screening only in pts declining surgery)

Question 243

Hepatic encephalopathy

Answer 243

neuropsych d/o (minmal MS change to coma/confusion) Oral lactulose was stnadard tx Rifaxamin equiv or superior to lactusose (infection, dehydration, electrolyte disturbances, GI bleeding, constipation and use of narcotics) No dose adjustement for kidney needed DO NOT PROTEIN RESTRICT - causes malnurtrition and further infxn

Question 244

Kidney fxn decline in pt with HTN

Answer 244

ARB/ACEi may lead to inc'd serum cr and uncover previously undx kidney dz - Pt had kidney dz when started ACE/ARB but treatment decrease GFR from efferent vasodilation - inc's serum Cr (renal perfusion pressure maintained by inc'd angiotensin)

Question 245

Peripheral manifestations of inflammatory bowel dz (UC/Crohns)

Answer 245

IBD arthritritis 1st NSAIDs Can't use NSAIDs 2/2 GIB first line = sulfasalazien (also treats diarrhea, tenesmus) 2nd line if sulfasalazine does not work: MTX 3rd line - biologic (TNF alpha - etanercept, infliximab adulimabib) No corticosteroid for long term...

Question 246

Premature CAD in CA survivor s/p radiation therapy

Answer 246

typically in ostial/prox sites - fibrous intimal prolif poor candidates for PCI 2/2 fibrous nature Antiphospholipid syndrome - prolonged aPTT - inc'd r/o VTE/arterial thromboembolism and preg loss - aw SLE Cocaine induced vasospasm - more likely ST elevation and only in case of +cocine labs Kawasaki dz - fever, conjunctivitis - eyrthema oral mucosal mem, ertyma of LE, cervial LAD, coronary aneurysm /throbmosis of Coronaries- childhood

Question 247

MS related fatigue

Answer 247

Amantadine or modafnil exacerbated by hot weather need to exclude anemia, sleep d/o, hypothyroid, depression, Adeuqte rest and physical exc importnat too DON"T USE MEMANTIDINE only change therapy to INFN beta if relapse (fatigue is not relapse)

Question 248

Dx acute kidney injury

Answer 248

If BPH with suprapubic illness - suspect obstructive uropathy and get kidney US h/o irradiation, pelvic tumors, congential urinary abn, prostate enlargment all inc risk Don't rely on U/A - FENA may be variable (low in early obst but high later on with tubular damage) - can cuase hyperkalmic metabolic acidosis - Kidney bx only for kidney injury of unknown cuase Rhabdo can cuase AKI but need h/o crush injury, muscle pain, meds that cause rhabdo etc

Question 249

Aortic coarctation

Answer 249

discrete aortic narrowing distal to subclavian artery - discrpance in UE & LE BP - UE HTN, delayed/diminished femoral pulses - AW bicuspid aortic valve - early systolic click 2/6 murmur RUSB - pt can also have aortic regurg with diastolic murmur

Question 250

ASD

Answer 250

Fixed split S2 (inc'd L->R R vol overload, pulm HTN) | holosystolic murmur with flow across TV (TR)

Question 251

Mitral valve prolapse

Answer 251

midsystolic clikc - late systolic murmur DECREASE with squat - if regurg with LVH - displaced PMI

Question 252

VSD

Answer 252

harsh holosystolic murmur inc's with isometric exc (inc'd afterload) +thrill

Question 253

Inflammmatory muscle/joint pain aw systemic sclerosis

Answer 253

Methotrexate systemic digit swelling in pt with GERD, systemic sclerosis, dilated nailfold capillaries pruritis/skin induration - scl-70 MSK features - dcSSc - symmetric synovitis - peripheral joints, tendon sheaths, mild inflamm myopathy Cyclophosphamide - alveolitsi (low DLCO) aw dcSSc Hydroxychloroquine - tx SLE - need to be dx with anti DS DNA ab or anti smith - NSAIDs - no effect with inflammatory myopathy or dermal inflammation

Question 254

Manage constipation with alarm sx

Answer 254

Colonoscopy change in bowel habits with recent blood in stool or wt loss, Fhx colon CA or age of onset >50yo Fiber supplement for uncomplicated constipation without alarm features Don't check TSH if TSH already normal Anorectal mamometry - suspected pelvic floor dyfxn (sensative of blockage in anorectal region), paradoxical contraction of anal sphincter) No stool guiac if blood on finger...

Question 255

Chronic Fatigue Syndrome

Answer 255

medically unexplained fatigue that persists for 6 months or greater - subjective memory impairment, sore throat, tender LN, muscle or joint pain, h/a, unrefreshing sleep, post excercise malaise>24hrs No dx test for CFS - check sleep hx, r/o OSA, frequent limb movements during sleep (restless leg syndrome) - check for depression, check for hypothyroid (if dx of hypothyroid) - CBC r/o anemia/lymphoma, r/o DM, CKD Don't test for EBV, parvo B19

Question 256

Pitted keratolysis

Answer 256

``` caused by kytococcus sedenarius in ppl with hyperhidrosis warmth, moisture, occlusion Malodor, smelliness of skin Pressure bearing areas (balls of feet) ```

Question 257

Ecthyma

Answer 257

Superficial sausage ulcers with overlying crusts legs and feet Staph aureus - IVDA and HIV pts at higher risk

Question 258

Tinea pedis

Answer 258

silvery scale and dull erythema of whole foot, interdigit scaling and maceration

Question 259

Kertadoerma blenorrhagia

Answer 259

hyperkeratotic skin lesions on palms and soles | aw reactive arthritis

Question 260

Murcomycosis in pt with DKA

Answer 260

rhino-orbital murcomycosis - emergency surgical debridement and amphotericin B Posaconazole as steop down to ampho B (or salvage) Inhalation of spores - can proceed rapidly from orbit to brain - high mortality rate if not treated Periorbital edema with escar in nasal turbinate Rhino orbtial or rhino cerebral infxn DO NOT USE zosyn (no fungal activity)

Question 261

High altitude periodic breathing

Answer 261

cyclic central sleep apneas and hyperapenas during sleep aw ascention to high altitude hypoxemia stiulates ventillation resolves with acclimatization >2500m dyspnea, waking from sleep, poor sleep quality Not asthma - no cough or wheeze HIgh altitude cerebral edema - exterme of high altidudie sickness - encephalopathy in response to brain swelling High altitude pulm edema - capillary leak in response to hypoxia - no cough or signs of pulm edema

Question 262

Chronic myeloid leukemia

Answer 262

Sx: fatigue, night sweats, wt loss, early satiety BASOPHILIA on smear -> CML Dx: t(9,22) in situ hybridization

Question 263

Flow cytometry

Answer 263

good for dx malignancy with homogenous cell population ALL, CLL, NHL, AML Check for specific CD markers

Question 264

Heterophile ab test

Answer 264

infectious mono | check for pharyngitis, LAD

Question 265

JAK2 Mutation

Answer 265

95% P Vera | 60% essential thombocytosis, primary myelobfibrosis (tear drop cells, nucleated cells)

Question 266

End stage COPD

Answer 266

``` Palliative/hospice care Dypsnea - Etio PE, PNA, lung mets continue broncodilators if on them MORPHINE for relief of dypnea ``` Transfusion only severely anemic Benzos only for anxiety Oxygen for pts with hypoxemia

Question 267

Acute UNCOMPLICATED diverticulitis

Answer 267

Oral abx - cipro and flagyl (if able to tolerate oral intake) obstruction of diverticula neck with fecal matter mucous/bacterial overgrowth LLQ pain, n/v inc'd WBC, mild fever tachy DO NOT DO COLONOSCOPY RIGHT AWAY - r/o malignancy in 6 weeks CT guided percutanous bx if peridivertiucular abscess >4cm Hospitalization and IV abx only with peritonitis or significant comorbidies or no oral intake tolerating Surgical consultation if unresponsive to abx therapy or COMPLICATED - abscess, fistula, obstrction, peritonitis/stricture

Question 268

Dural sinus venous thormbosis

Answer 268

Magnetic resonance venography h/a worse in AM and valsalva, c/w inc'd ICP h/a, papiledema, visual problems, focal neruo, MS changes, Sz NOrmal MRI, h/o tobacco and OCP use -> dural sinus venous thrombosis Tx: d/c OCP, tob and systemic A/C x 6 months No lupus A/C if coag panel normal

Question 269

Adverse effects of glaucoma drugs

Answer 269

``` Pt brady and low energy/libido inc'd IOP Timolol should be d/c'd decreases inflow of aqueous humor and generally well tolerated - broncospam, depression, mood swings ``` Amlodipine - s/e hypotension, peripheral edema, dizziness, h/a, Carbonic anhydrase (Dorlozamine) - acidosis, malaise, diarrhea, hirsuitism, bloody dyscrasia lantoprost - flu like sx ACEi - cough hyperkalemia, kidney failure.

Question 270

Low solute intake

Answer 270

h/o anorexia/wt loss clinical eurvolemia low plasma AND urine Na/osmolarity hypotonic hyponatremia NOT hypovolemia - no postural chagnes - if hypovolemia, urine OSM would be high as ADH would decrease free water diuresis

Question 271

Pseduohyponatremia

Answer 271

low serum sodium due to measurement in falsely large volume - Inc'd LIPIDS and PARAPROTEINS shows lower than real measure of serum sodium If no osmal gap then no pseuodohyponatremia

Question 272

Hyponatremia with primary adrenal insuff

Answer 272

mineralocorticoid and inc'd vasopressin | hypotension, hypovolemia, hyperkalemia, low morning cortisol

Question 273

Sx Severe TR

Answer 273

Tricuspid valve replacement either sx or signs of RV overload dilation, reduced fxn Severe RH failure - dyspnea Pulm HTN Don't cardiovert as TC annullar dilation will preceipate flutter Don't treat RHF with digoxin Don't treat with abx for endocarditis - no fever wbc etc

Question 274

Tx chronic venous insufficiency

Answer 274

Knee high compression stockings 20-40mmHg/leg elevation persistent venous HTN caused by venous incompetence or occlusion Edema, hyperpigmentation, stasis dermatitis, varicose veins, cellulitis,ulceration avoid bx (non-healing wound) Etio also meds CCB/thiaziediones -> dependent edema Elevation of leg and comrpession avoid compression with PAD, decompensated HF Abx only if signs of infection Diuretics only if systemic signs of volume overload Patch testing only if allergic contact dermatitis (disrupted skin barrier or use of multiple topical meds)

Question 275

Immunizations prior to administration of biologic anti-inflammatory therapy

Answer 275

Rituximab Give IM flu shot prior No live attenuated in immunocompromised, pregnant women, chornic met dz, DM, kidney dysfxn, hg opathy prolbem with respiratory secretion handling Biologics may blunt dendritic or b cell fxn in terms of vaccine response (antigen presentation or ab formation) Only contraindication is egg allergy, vaccine intolerance Anti flu tx (oseltamavir, zanamavir) - bridge to therapy with vaccine in immunocompromised Assistd living during outbreak, close household contact, heathcare works

Question 276

Delayed hemolytic reaction

Answer 276

Sickle cell anemia pt Blood tx 1 week ago jaundice, inc'd indirect bili, lower Hg - worsening pain crisis If pt with new alloantibody then at risk to develop more 5-10 days later (not IgA - would have had anaphylaxis)

Question 277

Tranfusion related acute lung injury (TRALI)

Answer 277

pulm edema/infiltrates antibodies against neurtrophils in donor plasma fever/hypotension

Question 278

HLA alloimmunization

Answer 278

rxn from plt exposure | new plt tx doesnt inc level appropriately

Question 279

Pt with adrenal insufficiency with mild illness

Answer 279

increase hydrocortisone dose to avoid addison crisis x 3 days Hospitalization only if hypotensive and not taking oral meds/fluids Don't need mineralocorticoid (flucortisone)

Question 280

Manage implanted cardiac device infection

Answer 280

PPM generator eroded thru skin extraction PPM and leads needed EVEN WITH NO SIGNS OF INFECTION visible generator means entire PPM system infected (microbes track down leads) temp wire if ppm dep abx for at least 72hrs Neg BCx followed by 7-14 days abx directed by cultures from PPM pocket coagulase neg staph, staph aureus MCC With endocarditis or bacteremia better to wait longer b4 replant (extend abx therapy) Prior to explant abx may be used to limit systemic spread of infection but still need explant In pts with localized pocket inflammation but no erosion DO NOT ASPIRATE could spread infxn TEE if bacteremia present check for lead or valvular veg DO NOT JUST CLOSE EROSION

Question 281

Early stage ductal breast CA - breast conservation tx

Answer 281

Excision of primary tumor, sentinal LN bx, radiation overall survival same with lumpectomy vs mastectomy but better cosmetic results Sentinel = first LN draining after cancer site (inject blue dye and radioactive colloid into tumor) If sentinel LN neg then further nodes likely no mets NO FURTHER SURGERY If sentinel LN + then axillary node dissection done to determine number of LN involved If pt with scleroderma, prior chest wall radiation - can't have breast conservation tx - NEED MASTECTOMY and LN bx/radiation Always do sentinel LN bx not just surgery - for decision on adjuvant chemo Most pts undergoing mastectomy don't need radiation therapy unless large tumors (>5cm)

Question 282

Validity of medical study

Answer 282

Primary threat to validity in CASE SERIES is NO CONTROL GROUP to compare tested intervention to... Also randomization not possible

Question 283

Balkan nephropathy

Answer 283

chornic tubulointerstitial condition of unclear cause in patients of southeastern european origen (Balkan region) ?aristolocholic acid - plant alkaloid from region etio? Dec'd GFR, urine protein <1gm /day, relative with same dz CKD, minimal proteinuria, benign urine sediment Analgestic nephrophathy - h/o analgestic heavy use over years HTN nephrophathy - long h/o poorly controlled HTN IgA nephoropathy at later stage of kidney dz should have hematuria and more proteinuria

Question 284

Venous stasis ulcers

Answer 284

provide compression, minimze vascular HTN, minimize edema -> promote healing (Unna boot) medial maleolus classical area surrounding skin thickened with hemisderin deposition venous stasis dermatitis No arterial vasc - not PAD (ABI 0.9) - arterial ulcers at LE affected limb cool with poor cap refill, pulses may not be palpable - over bony prominances or post calf contact casing - redistribute pressure in neuropathic feet cellulitis should have fever/ inc WBC and should respond to abx

Question 285

Hyperaldosteronism diagnosis

Answer 285

Biochemical evidence of hyperaldo: HTN, hypokalemia No cushings featers (so not cushing syndrome) so no dexamethasone suppression or 24 hr urine cortisol No CAH features (no hirsuitism, amenorrhea) - No pheo sx so no plasma catecholamines DX: check aldo to renin ratio (except if on spirono/eplero) (should be inc'd aldo, suppressed renin No need for imaging yet

Question 286

Behcet's dz

Answer 286

``` vasculitis in multiple organs mucous membrane ulcerations occular involvement GI, pulm, neuro manifestations erythema nodosum, arthritis, pan uveitis, retinal vasculitis, pulm artery aneurysm ```

Question 287

Granulomatosis with polyangiitis (Wegeners)

Answer 287

small blood vessel involvememnt NO aneursyms h/o upper airway dz (sinusitis, epistaxis) and glomerulonephritis

Question 288

Polyarteritis nodosa

Answer 288

medicum size vessel vasculitis mesenteric/renal arteries - intestinal ischemia and renovasc HTN aw Hep B

Question 289

Sarcoidosis

Answer 289

arthritsi/uveitis CXR hilar LAD no aneurysm

Question 290

Pt on multiple NSAIDS wtd?

Answer 290

put on PPI h/o PUD >65, high dose NSAID, use of ASA also, AC or steroids Enteric coated ASA doesn't really help GI ppx Don't d/c ASA in CAD pt s/p MI

Question 291

Subdural hematoma

Answer 291

Pt with recent head/neck trauma SDH (unlike epidural hematoma) require only mild injuries to cervical spine or head Disruption of bridging veins - sx incidious in onset Older pts, use of AC (mental cloudiness, dizziness, ataxia, h/a) IMAGE HEAD (HCT) cyclobenzaprine only helps with neck spasms Meclizine - only helps dizziness of vestibular origin

Question 292

Flu ppx in pregnant pt

Answer 292

use inactivated trivalent flu vaccine dont give if allergy to eggs or h/o guillan barre osetlamavir zanamavir and amantadines only effetive in prev after exposure in close contacts Can use osteltamavir or zanamavir in pregnancy if confirmed flu infection NO LIVE flu vaccine for preg women or chornic met dz, DM, Hg opathy, immunosupp, CKD

Question 293

Manage patients with etoh abuse

Answer 293

``` connect drinking with negative consquences physical or psychosocial harm serious illness, DWI needs f/u and reassessment identify barriers ``` Adjunct - disulfuram, AA, pscyh Etoh abuse >14 drinks/wk, 4 drinks per occasion (3 for women)

Question 294

Suspected advanced stage testicular CA

Answer 294

orchiectomy and chemo (platnum based good with germ cell tumors and mets) Lung mass and pleural effusion in young pt with testicular tumor is likely mets High AFP/HCG= nonseminoma Platnum, etopside, bleomycin do chemo before resecting mets

Question 295

Churg Strauss

Answer 295

+eos, migratory pulm infiltrates, purpuric skin rash, mononeuritis multiplex, glomerular nephritis, alveolar hemmorrage Antecedent asthma, allergic rhinitis, sinusitis pANCA (MPO) fever, arthralgia, myalgia

Question 296

Granulomatosis with polyangiitis

Answer 296

``` Wegeners c-anca (antiproteinase 3) necrotizing vasculitis resp/kidney inflitrates/nodules CXR, pulm hemorr No eos, no antecedent asthma/allergic rhinitis/sinusitis ```

Question 297

Microscopic polyangiits

Answer 297

necrotizing vasculitis lungs/kidney RPGN pulm hmorrhage No eos, no antecedent asthma/allergic rhinitis/sinusitis

Question 298

Polyarteritis nodosa

Answer 298

``` Hep B fever abd pain, arthralgia, wt loss mononeurtiis multiplex nodules, ulcers, purpura, erythema nodosum No lung invovlemnt ANCA NEGATIVE ```

Question 299

Exclude PE with d-dimer

Answer 299

low risk patietn neg D-dimer no need for further testing strong h/o asthma - may have come back check peak flow No physical signs of abd issue so no need for CT abd

Question 300

Systolic HF tx with BB

Answer 300

Can start with systolic HF DO NOT START IF IN ACUTE Decompented HF B1 selectives (metoprolol, biosprolol) Don't replace MV if 2/2 to dilated CM in decompensated HF Epleronone should replace spironolactone if +gynecomatia BIVI ICD upgrade - NYHA III/IV, EF120

Question 301

Malaria ppx pregnant pt

Answer 301

NO DOXY during pregnancy Mefloquin better in africa (chloroquin resistant strains) No atovaquin-proguain in pregnant women

Question 302

Dx Nephrolithiasis

Answer 302

Non contrast helical CT sx of renal colic pain rad to testicle or labia majora Can ID all stones KUB only with Ca containing stones follow stone burden or pre-op planning No further use for IV pyelography with non contrast helical CT Testicular US if abn of testicle, turmor hernia abscess

Question 303

Grover dz (acantolytic dermatosis)

Answer 303

transient rash self limiting, waxing and waning chronic 50yo pruritis when hot and sweaty bx acantholysis - dissociation of keartinocytes in epidermis Tx: reassurance, cooling measures, mild topical steroids,

Question 304

Miliaria

Answer 304

red papules on skin without scales - occlued and hot such as neonates and hospitalized patients - eruption can be asx, pruritic, burning, stinging - self limited and would not persist

Question 305

Pityriasis rosa

Answer 305

spring/fall pink oval shaped plaque - thin collarette of scale (herald patch) christmas tree pattern of smaller plaques asx/mildly itchy 4-10 weeks

Question 306

Tinea versicolor

Answer 306

Malasezzar Furur | scaly slightly hyperpigmented or hypopig macules on trunk/ torso, don't itch typically don't itch

Question 307

Dx complications after SAH/repair

Answer 307

CT angiography urgent Early complications - aneursymal re-rupture, hydrocephalus Late complications (5+ days) - cerebral artery vasospams - decline in neuro exam, - cerebral infarction - CT Angio can show cerebral vasospam -tx with intraarterial CCB or angioplasty of spasm vessel EEG if CT angio net - r/o status epilecticus (conv/non-conv) Lumbar pct to measure ICP or r/o post surgery meningitis but neuroimaging first to r/o mass effect (don't want cerebral herniation) MRI - cerebral infarction - less accurate for vasospasm AND slow...

Question 308

Pituitary tumor apoplexy

Answer 308

Bleeding into tumor in pituitary - ie pt on A/C for afib - high risk Need to give glucocortocoid supp immediately (acute ACTH def) (hypotensive) and surgery to remove tumor Pan hypopit hx - wt gain, ED, hyponatremia Acute h/a, neck stiffness - hemmorage Insulin tolerance test - adrenal insuff, GH insuff Prolactin - r/o proloactinoma Lumbar pct - meningitis or SAH for xanthochromia

Question 309

Arrythmogenic RV dysplasia (ARVD) with syncope

Answer 309

``` disorder of desmosome fibrofatty infiltrate of myocardium syncope 2/2 monomorphic VT from RV Syncope=ICD placment!! discourage competitive sports - increase in sudden death from mech stress on RV, inc'd sympathetic tone - RV strech progresses dz RV failure/LV failure eventually ``` No need for pre-icd EPS but VT ablation option to decrease indicdence of VT Ambulatory holter - >500 PVCs in 24 hrs = ARVD no need if already dx'd Can use BB (sotolol) to reduced VT and ICD shocks but still need ICD

Question 310

Advanced symptomatic follicular lymphoma

Answer 310

chemo - rituximab, vincristine, dobxorubcin, prednisone- > reituximab maintenance If relapse - hemtopoetic stem cell tx

Question 311

Acute adrenal insufficiency

Answer 311

``` hemorrhage - trauma, A/C, emboli (afib) sepsis Sx: b/l flank pain, hypotension, fever, n/v - hyponatremia, hypokalemia low hct Tx: IVF, hydrocortisone replacement - Abd CT confirm dx ```

Question 312

TB Drug s/e

Answer 312

Pyrazinamide - hyperurecemia/gout (inhibits tubular excretion of urate), hep, rash, GI upset Norvasc - peripheral edema, muscle pain, nausea, palpitations, dizziness INH - hep, rash, peripheral neuropathy, lupus like syndorme Rifampin - rash, hepatitis, GI upset, ORANGE BODY FLUIDS, - enhances renal excretion of urate

Question 313

Isolated triglyceridemia

Answer 313

very high >500 fenofibrates Non-HD chol=total chol - HDL chol Covelesam - ok for preg pts can raise TG nicotinic acid - red tg and inc HDL -precip gout Omega 3 fatty acid - lower TG - reduce hepatic secrtion -

Question 314

Tuberculous arthritis of spine

Answer 314

immunosupp'd pt (HIV no meds) area where TB endemic Vertibral bx to dx can have normal CXR CT Mycelography - only for demonstrating compression after dx made Tn 99 bone scan - areas of inflamm no microbiail dx - TsT too slow

Question 315

Space occupying cerebral infarction

Answer 315

``` surgical decompression (mannitol could be first) w/in 48hrs of stroke ``` No ASA Dexamethoasone and steroids could help with mass effect of tumores and inffection ICP monitoring after surgery No lumbarpnct in pt with mass effect

Question 316

Constipation predominant irritable bowel sydrome

Answer 316

First laxatives and fiber Lubiprostone - Cl Ch acitivator - secretes salt water into intestine Hycoscyamine - IBS as antisposmotic blocks acetylcholine at GI smooth muscle - CAN WORSEN constripation TCA for abd pain in IBS but anticholilnergic effects worsen constipation Metochorlproamide - only for gastropariesis

Question 317

HTN emergency

Answer 317

ENd organ damage - encephalaopathy, AKI, retinal hemorrhage, exudates, papiledema, Decrase BP 25% in 1st hour

Question 318

Lentigo maligna

Answer 318

slow growing melanoma pt with signfiicant sun exposure prolonged radial growth phase - can be present for many years before vertical invasive phase

Question 319

Actinic Purpura

Answer 319

well demarcated smooth violacious red patches in elderly pt with sun damaged skin - skin fragility - arise from trauma - may heal with post inflamm hyperpigmentation

Question 320

Actinic keratosis

Answer 320

PREMALIGNANT in sun damdaged areas may be pigmented and be mistaken for lentigo malgna progreses to SCC

Question 321

Sebhorreic keratosis

Answer 321

barnicles of the old Benign brown scaly waxy

Question 322

Solar lentignes

Answer 322

brown macules and patches occur in elderly pts sun damaged areas - more homogenous pigmentation and lighter color than lentigo malgna

Question 323

Acromegaly after transspenoid surgery

Answer 323

elevated IGF-1 and sx of acromegaly Octreotide Don't just observe

Question 324

Reactive arthrtis

Answer 324

Tx: sulfasalazine (after NSAIDs/steroids fail) inflamm arthritis that occus within 2 months of bacterial gastroenteritis or non-gonoccoal urethriis or cervicitis arthritis, uveitis, conjunctivitis Usually self limited - 25% develop chronic arthrtiis (refractory to NSAIDS or steroids) Sulfasalazine also useful in peripheral arthritis forms of IBS associated arthrtis, psoriatic arthritis, ankylosing spondylitis No colchicine - only for crystal arthropathies No glucosamine - OA No role for abx

Question 325

Carcinoid tumor

Answer 325

``` low grade malignancy Young, never smokers evidence of bronchial obstruction recurrent PNA tx: surgical resection ``` AdenoCA is most frequent CA in non-smokers but INFREQUETN cause of endobrochial obstrution Small cell and SCC do cause endobronchial obstruction but rare in young non-smokers

Question 326

Cat Scratch Dz

Answer 326

Bartonella Henslae red papules then tender LAD near site of scratch AZITHROMYCIN (or doxy, rifampin, clarithro, bactrim, cipro) Linezold/dicloacillin - G+ activity - not good again gram neg Sporotrochosis - itraconazole is tx

Question 327

Chronic stable angina

Answer 327

If BP and HR can tolerate increased BB then increase CCB - 1st line antianginal if contraindication to BB can be added if maximal at optimal dose of BB/nitrates Ranolazine added if optimal doses of BB, CCB, nitrates don't give with hepatic impairment, baseline long QT, Don't cath if not medically optimiezed

Question 328

Bed bug bites

Answer 328

itchy - topical steroids/antihistamines | grouping in linear pattern, don't need ivermectin or topical permethrin or doxy as dont infest skin..

Question 329

Manage pt with asymptomatic advanced follicular lymphoma

Answer 329

NHL - if asx and normal blood counts then watchful waiting If sx develop - rituximab, chemo, prednisone No LN radiation (just circulate and come back)

Question 330

diarrhea predomiant IBS

Answer 330

Test for celiac dz | also correlation between celiac, DM1, autoimmune thryoitiis

Question 331

Smoking cessation

Answer 331

If pt needs nicotine replacement and failed one form then try another form Can add bupriprion BUT NOT WITH SEIZURE HISTORY No need for benzoes - need nicotine replacement

Question 332

Acute bell's palsy

Answer 332

could be 2/2 human herpes virus type I Upper and Lower face - inability to close mouth AND raise eyebrows antecedent viral infection dry mouth, impaired taste, pain/numbness in ear abrupt onset over 1-2 days Tx: PREDNISONE within 72 hrs No role for acyclovir High dose IV steroids for MS not bell's (if this was MS would have history of recurrent neurologic epsisodes) Migraine associated weakness upper face spared...

Question 333

Tx pt with resistent HTN and systolic HF

Answer 333

Pt already on ACE, BB, diuretic and HR 50 Add norvasc (doesn't lower HR) not 1st line as neutral in mortality effect for HF (but other CCB - diltiaem, nifedipine, verapamil are neg ioniotrpes so worsen mortality) So norvasc/feldopine only used for HTN or angina in pts with systolic HF when pt already optimized on ACE/BB

Question 334

Post op VTE ppx in high risk patients (cervical Ca hyster)

Answer 334

5 weeks enoxaparin High risk = prior VTE, orothopedic surgery, cancer (esp gyn malig) - extended ppx Non-pharm therapy - in all post surgical pts (early ambulation, compression stockings, SCDs) - only when very low risk (outpt surgery) or bleeding risk (neuroscurgery) IVC in high risk patients with known VTE or who can't get ppx 2/2 bleeding risk SQH is ok but in high risk pt LMWH better and needs to be after d/c also warfarin only in perioperateive stting in ortho pts

Question 335

Hirenadrnous suppurativa

Answer 335

(acne inversa) Painful, recurrent chronic sterile abscesses - sinus tract formation, scarring of axilla/inguina, perianal, inframmammory area Tender SQ nodules tha tcoalesce and rupture - deep dermal abscesses - can become secondarily infected AW smoking and obesity Not acne - double comedones and sinus tracts No pyogenic gangrenosum - bright red friable papules - resulting from capillary proliferation and NOT infection Sweet syndrome - acute febrile neutropenic dermatosis - middle aged women after URI fever arthraliga, myalgia and cutanous lesion - salmon colored papules/plaque trunk, neck extremities

Question 336

Intrahepatic cholestasis of pregnancy

Answer 336

2nd or 3rd trimester mildly elev bili and alk phos (maybe ast/alt) generalized prurutis sex hormone induced inhibition of bile salt export from hepatocytes tx: Ursodeoxycholic Acid Acute fatty liver of pregnancy - 3rd trimester - need early delivery - liver failure adn coagulaopathy HELLP - microangiopathic hemolytic anemia, elevated liver enzymes and low plt - 3rd trimester - early delivery

Question 337

Hyperemesis gravidum

Answer 337

1st trim - unrelenting n/v - elev LFTs but resolve when sx abate

Question 338

Travelors diarrhea

Answer 338

enterotoxogenic e coli - self limited, mild diarrheal illness Sx treatment, no testing from eathing fruits - ingestion of unprocessed water Stool ctx only if diarrhea >72hrs (esp if tenesmus, fever, blood instool) Ova & Parasite dx - if >7 days sx No role for fecal leukocytes

Question 339

Opiate induced secondary hypogonadism ie methadone

Answer 339

Downregulates GnRH, low FSH, LH, decreased testosterone Anabolic steroid use pts typically c/o infertility - may have pusutular acne and are big not thin Citalopram cuases low libido but DOSE NOT DECREASE TESTOSTERONE levels

Question 340

Spinal cord compression in pt with parkinsons

Answer 340

Compressive cervical myelopathy MRI cervical spine acute onset of leg weakness in pt previously able to walk, ankle clonus HYPER reflexia,upgoing toes, leg weakness (arm strength normal) -> suggest spinal cord compression Not CT myelography - harder to perform, worse images No inc'd carvidopa/levodopa

Question 341

Acute interstitial nephritis

Answer 341

``` hypersensitivity to a medication presentation variable - dependent on type of med - Fever, rash eosinophilia 10% only leukocytes or leukocyte casts on U/A PPI induced AIN is subacute ``` Bisphosphonats - ATN - muddy brown casts, no leukocytes Glomerulonephritis - dysmorphic erythrocytes, erythrocyte casts, proteinuria TTP - cancer/chemotx agents - cyclosporin, tacrolimus, quinidine - ticlodipine, quinine AKI can happend but with hemolytic anemia and low plts, elev LDH

Question 342

Inflammatory anemia

Answer 342

normal or low normal iron, low TIBC, ELEVATED FERRITIN - microcytic hypochromic anemia Elevated hepcidin in response to inflamm cytokines from inflamm dz (SLE, Tb, OM, malignancy, colagen vasc dz) Tx: Treat underlying condition Warm antibody mediated hemolysis - small spherecytes Microcangiopathic hemolytic anemia - schistocytes

Question 343

Suspected osteoporotic fracture - young pt on steroids

Answer 343

SLE/steroids - high risk for osteoporosis and fx avoidane of sun Even if XR neg -> CT thoracic spine r/o fx Tylenol and NSAID for pain PT after fracture r/o and pain controlled NO BEDREST DOn't continue cyclobenzaprine - can cause dependence

Question 344

Cutaneous T cell lymphoma (indolent course)

Answer 344

erythematous eruption >90% body= ERYTHRODERMA etio: drug eruptions, psoriasis, atopic dermatidis, cutaneous t-cell lymphoma Patches, plaques, tumors, allopecia, nail dystrophy, thickening palms and soles Bx skin Drug hypersensitivity - usually acute in onset 3-6 weeks, MCC allopurinol, anticonvulsants, dapsone, NSAIDs, sulfonamides, - also facial edema, LAD, HSM Pustular psoriasis - h/o psoriasis tx'd with steroids - erythrodermic flarie days to weeks after d/cing steroids SSSS - children or adults with immunosupp, AKI - have peiroral crusting, fissuring - confirm with isolation of staphy (dx clinical)

Question 345

Serologic testing for lyme (borreilia burgdorferi)

Answer 345

vague constitutaional sx of several months duration - non-focal, nonsp - not suggestive of lyme Initiate further eval for faigue and weakness Lyme +IgM, neg IgG - clinical correlation If findings <1 month after sx then delayed seroconversion - repeat testing in one month Do not treat for lyme

Question 346

OMT for severe HF

Answer 346

SHF 2/2 peripartum CM - during preg start BB, digoxin, diuretics Start acei after delivery Also with severe sx will also need spironolactone If after OMT and is euvolemic still with symptoms - and LVEF < 35%, QRS>120 - Cardiac resyncronization tx Can't titrate BB up if HR low Endomyocardial bx only if suspect infiltrative process (amyloid, hemochromatosis, sarcoid) - no LVH, no low voltage

Question 347

New onset crohns dz

Answer 347

mod to severly active crohns (transmural) weight loss and significant sx Treat aggressively with Anti-TNF (infliximab) with or without immunomodulator (azathropine or 6MP) Abx only if associated abscesses/wound infections 5ASA (mesalamine) more effective in UC (mucosal) than in crohsns (transmural) - used in mild dz for crohns DOn't just use corticosteroids - may improve some sx but most pts need maintenance Surgical eval only if performation, abcess, obstruction or medically refractory dz

Question 348

Cryptogenic ischemic stroke

Answer 348

when infarct appear embolic suspect pAF will need prolonged cardiac monitoring 25% cryptogenic ischemic stroke have pAF No reason to close PFO - no diff in stroke risk vs OMT (ASA) Warfarin only if pt in pAF

Question 349

Estimate GFR in low risk healthy person

Answer 349

Use chronic kidney disease epidemiology collaboration equation - MDRD UNDERESTIMATES GFR at higher (normal) values (especially with patients of normal or higher muscle mass) Crockfeld gault ALSO UNDERESTIMATES GFR at normal values Only need 24 hr Cr urine collection or radionuclide kidney clearance scanning when evaluating living kidney donor candidates

Question 350

Hypoglycemic unawareness

Answer 350

Reduce insulin dosages HgA1c below target adrenergic response blunted after hypoglyemic episode for 2-3 days - inc'd likelihood of 2nd hypoglyemic episode Don't increase carbs - on healthy diet, wants toget pregnant and could cause weight gain Alpha lipoic acid helps with painful Dm nephropathy no effect on hypoglycemic awareness Pramlintide - analogy of amylyn decrases stomach emphyting speed - promotes satiety - inc'd r/o hypoglycemia

Question 351

Treat dypnea at end of life

Answer 351

end of life dypnea common cardiopulm pathology - ie pleural eff, HF, COPD, PE, PNA, lung mets If underlying lung dz on broncodilator - c/w those and ADD MORPHINE Abx and steroids won't immediately help - not c/w comfort only measures Benzos don't always help

Question 352

Diagnose Rheum Arthritis

Answer 352

Anti-CCP - dx 40-60% RA including pt with neg RF 95% specific for RA Synovitis >1hr in AM

Question 353

Anti mitox ab

Answer 353

autoimmune hepatitis - can have arthralgia but also with LFT abnormalities

Question 354

ANCA+

Answer 354

granulomatosis with polyangiitis (wegers), microscopic polyangiitis, Churg strauss, drug induced vasculitis - woul dhave some other systemic involvement

Question 355

ANA

Answer 355

suspicion for autoimmune dz ie SLE | women of child bearing age,

Question 356

Respiratory muscle weakness

Answer 356

NM dz - reduced TLC - increased residual volume due to inability to fully exhale Restrictive pattern, no obstruction increased RESIDUAL VOLUME - Dypnea as presenting sx for NM dz COPD - would have increased residual volume but also inc'd TLC, HF - no JVD, no edema, abn cardiac exam ILD - reduction in both TLC and residual volume

Question 357

Diagnose brain death

Answer 357

Apnea test only test required to dx brain death Cerebral hemorrhage coma, absense of motor response, pupillary resonse, corneal reflex, jaw jerk, gag reflex, rxn to pain, cough while suctioning trach, suckign or rooting reflex Initiate apnea test when PCO2 40-60, pt normothermic and off sedation Pt off vent to obtain baseline PCO2, O2 supp by other methods, serial blood gasses and observe spontaneous resp POSITIVE APNEA TEST: if pCO2 inc'd by >20 without spontaneous respiration No CT angio when brain death dx - even if find hematoma expansion no reason to tx with severe neuro damage EEG/Transcranial doppler - not required unless apnea test tolerated

Question 358

Manage asx ostium secondum ASD defect

Answer 358

ASD closure in asx pt (TTE 2/2 murmur) indicated with R side chamber enlargement, no evidence of pulm HTN Also if sx attributable to ASD - afib, paradox embolism, cyanosis (L-> R shunt) - pt also has mild inc in RV pressure Device vs surgical ussualy physician preference but if no associated CV dz device closure better tolerated, faster recovery ASA can be used to prevent paradox embolism in pt with PFO or ASD (Small) No warfarin unless pt has afib or has paradoxical embolism Don't just observe - needs closure - pt already has enlarged right sided chambers - inc'd risk of complications (arrhythmias)

Question 359

Preop care of pt with COPD and intermedicate risk procedure

Answer 359

Incentive spirometry - reduces risk of peri op pulm complications (or deep breathing) begin pre op Risk factors chornic lung dz, older age, spinal or general anesthesia, surgery arond diaphragm Positive airway pressure only for pts who can't do incentive spirometry (MSK or NM limitations) CXR pre or post op without any clinical suspsicon of lung issues does not help PFTs only when cause of dypnea unknown (pt known to have COPD)

Question 360

Manage newly dx HIV

Answer 360

combination HAART now (tenofovir, emtricitabine, efavirenz) since CD4< 500, HIV nephropathy, co-infct HBV, pregnancy, CV dz or Hep C No Viral load indications (just CD4)

Question 361

Hypercalcemia Tx

Answer 361

Severely sx hyperCa in setting of metastatic breast CA polyuria, polydipsia, dry MM, low bp, tachy- dehydration - START normal saline High Ca impairs nephorons to concentrate urine - need to restore euvolemia with saline diuresis - aids in delivery of calcium to distal tubule which will excrete excess Ca with excess Na from NS HyperCa of malignancy induces skeletal resorbtion - liver mets likely secreting PTHrP - need control of tumor with chemo Bisphosphonate may be needed if hyperCa+ after normal saline - also IV lasix may also be needed after euvolemic Glucocorticoid also can lower Ca if bisphosph don't work.

Question 362

Drug induced SLE

Answer 362

d/c offending agent (HCTZ) drug or light induced HCTZ commonly implicated drug in SLE anti histone Ab+ ANA titer + Anti Ro/SSA, Anti La/SSB (photosensitive conditions) onset of rash after drug starts annnualar polycyclic erutyenatous scaling patches in sun exposed areas with sharp cutoff at clothes No MTX as drug induced lupus usually not systemic - normal other labs CK and aldolase not needed as pt does not have signs of polymyositis or dermatomyositis (heliotrope rash - violacious dusky erythem rash periorobial with or without edema , goutrrons papules - violacious scaley papules over bony prominances MCP, PIP, DIP , prox muscle wk) Topical terbinafine - KOH neg not fungal - only needed if tinea corporis

Question 363

Laxative abuse

Answer 363

normal anion gap metabolic acidosis kidney ability to exrete acid correlates with urine ammonium (hard to measure) Urine anion gap estimates ammonium excretion Urine amm=UAG/2 UOsm= 2x UNa + UK+ + Uurea/2.8+ Ugluc/18=176(no gluc) UAG=176, UAmmonium = 88 UAm >80 = extrarenal losses of bicarb UAm < 30 = primary kidney losses of bicarb ( Chronic diarrhea from laxative abuse dumps bicarb - causing systemic acidemia - kidneys try to dump extra acid by making ammonium so ammonium levels increase, increasing UAG Diuretic abuse and surrepticious vomiting are metabolic alkaosis - Vomitting is cloride resopnsive - so UCl- < 10 Diuretic abuse is chloride unresponsive so UCl>20 Hypokalemic RTA (distal type I) - renal tubular acidosis - impairment of urine ammonium excretion (can't acidfy urine) pH>6, urine ammonium levels >30

Question 364

Long term f/u for Stage III colon CA

Answer 364

Physical exam, CEA monitoring q3-6 months Annual CT for 3-5 years (dx relapse tha tis potentially curable) Colonoscopy 1 year after resection and then q3-5 years PET only if abn seen on CT

Question 365

Inclusion body myositis

Answer 365

MC form of myositis >60yo proximal AND distal muscle wk (can be assymetric) quads, wrist, finger flexor muscles incidious onset, modest CK elevation (<1000) No autoAb (ANA neg) Dermatomyositis - symmetric prox muscle wk, +autoab and rash (gottrons papules, heliotrope rash), shawl sign Polymyositis - younger pts, MC women, + autoab/+ANA symmetric prox muscle wk - extramusc manifestations (fever, pulm inovlvmenet) Statin induced myalgia - asx CK elevation or myalgia, rhabdo - ONset of muscle pain tenderness/cramping - withini 6 months of starting statin, resolve 2 months after stopping - dose related

Question 366

Evaluate 2cm calcified lung nodule in smoker

Answer 366

Smooth bordered, centrally calcified - c/w granuloma Benign : nodules with smooth borders, popcorn, lamellar, cetral and diffuse Ca Malignant: spiculated borders - ecentric/off center CA - needs further w/u Bronchial carcinoid tumor - low grade neuroendocrine neoplasm - pw hemoptysis - bronchial obstruction or asx Central airway location SMOOTH BORDER, not calcified Lung mets - breat, head/neck, colon, thyroid, kidney Usually multiple and smoothly bordered - NOT calificied NSCLC - Calcium within nodule unusual - if there would be eccentric

Question 367

Chronic tubulointerstitis nephritis 2/2 lithium use

Answer 367

Ideally change lithium to other agent If not possible then add amiloride - decreaes lithium uptake in renal tubule cells decreasing damage Lithium - decreased GFR - distal renal tubular acidosis - partial nephorgenic DI - high urine output inability to concentrate urine - lithium is uptaken in renal cells along with sodium so concentrates and causes damage DO not fluid restrict - will make hypernatremia worse in lithium Nephorgenic DI Prednisone only if tubulointersitial nephritis not improved by dc ing offending agent or adding amiloride Tolvaptan - hypervol or euvolemic HYPOnatremia -in chronic HF, cirrhosis, SIADH - blocks effect of ADH and causes free water diuresis

Question 368

Basal cell CA

Answer 368

MC type cutaneous malignancy Head and neck of older ppl Sun exposed areas Smooth, pearly, asx telecangiectatic papules - grow slowly but cause siginficant tissue destruction if not removed - rarely metastasize - bleed when traumatized ``` Actinic keratosis - PRECANCEROUS sun damdaged skin - large numbers -> SCC flat with prominent scale easier to plpate than see ``` Epidermal inclusion cyst firm SQ nodules with prominent central punctum copious amount of keratinaceous material - malodoorous when extruded Melanoma - malignancy of pigment producing cells of epidermis - darkly pigmented - ABCDE (assymetric, irreg border, color variation, diameter >6mm, evolution/enlargment) ``` SCC - scalier, grow radipidly, tender lack pearliness/teleangietatic features areas of sun damage but cna co=exist with BCC lots in immunosuppressed Higher tendency to metastasize ```

Question 369

Manage impending respiratory failure in patient with asthma with intubation

Answer 369

Life threatening asthma exacerbation despite aggressive B2 agonist (16 puffs) - pulse 132, RR 32, accessory muscle use - only speak 1 word at a time, reduced breath sounds Intubate to avoid respiratory arrest Continuous nebs only with MODERATE broncospam Not just IV steroids - will take 4-6 hours to fully work- still need intubation Don't use lorezepam - will likely exacerbate respiratory acidosis

Question 370

Treat PFO

Answer 370

``` Platypnea-orthodeoxia - positional sx cyanosis/dypnea when patient sitting up - resolve when sitting down Sitting up changes shunt to R->L when sitting up 2/2 deformation of atrial septum and redirection of shunt - all 2/2 pneumonectomy CLOSE PFO (is an indication) ``` Ambulatory O2 may relieve sx but won't fix problem Warfarin not indicated as pt has not has paradox embolism (even if he did -> ASA then PFO closure if recurs) No diuresis as no signs of volume overload

Question 371

Capgrass syndrome - delusional thinking as primary sx of dementia

Answer 371

Capgrass syndrome - bleieves daughter is imposter replaced by imposter, delusions fixed, false ideas, paranoid aspect, delusional misidentifiaction, believe home is not really his house Right hemisphere lesion = role in recognition and emotioinal familiarity Can also occur in alzhimers with diffuse neurogeneration Tx: antipsychotics (reassuance wont work) Anosognosia - hemiplegia or vision Confabulation - disortorded or invented statements WITHOUT intent to deceive (brain fills in detials at random) - retrograde amnesia Etio - etoh induced korsakoff Reproductive paramnesia - opposite of capgrass - delusion of familiarity in which pt in hospital bed insists they are at home

Question 372

Evaluate patient with osteomyeltis and contraindication to MRI

Answer 372

USE CT SCAN if +ICD (MRI would be ideal) when xray normal but still suspicious of OM local pain/fever, h/o trauma If xray neg and still suspicious -> MRI or CT Nuclear imaging ok but can have false + from bone healing, inflammation from non-infx cuases ie trauma, neoplasm, deg bone dz, Gallium scans stick to neurtrophils and goto site of inflammation or infection Three phase bone scan not as good as MRI or CT

Question 373

Primary ovarian insufficiency

Answer 373

Must exclude turner syndrome - pt has elevated FSH and no period Check karyotype if + r/o AV dz, aoritic dilation, coarct, renal malformation(horseshoe kidney), autoimmune d/o, thyroid dz, Short stature, stocky build, square chest, webbed neck Pelvic US not needed yet - elevated FSH indicates low estradiol prodxn from ovaries No progesterone challenge - only when ammenorrhea in normal estrogen state (pt is low estrogen) Don't need to measure estadiol as elevated FSH already shows that pt is low estrogen state

Question 374

Avoid NSAIDS with CV toxicity in pt with OA

Answer 374

1st line is tylenol 2nd line tramadol - low addictive poteintial opiate and does not cuase constipation don't use COX-2 - inc'd CV risk (pt already has PAD) Don't use indomethacin - HTN/kidney dz induction - r/o CVD Don't use oral prendisone (inejctions ok for temporary releif) No colchisine (potent anti inflamm for gout or fam med fever)

Question 375

Decompensated cirrhosis

Answer 375

``` Refer for liver tx if: acute liver failure hepatic decompensation due to chronic liver dz primary liver cA inborn errors of metabolism HCV, cirrhosis from NASH, etoh liver dz ``` If patient has manifestation of etoh liver cirrohosi (ascietes, encephaloptahy, gastroesophagela variceal hemorrhage )-> refer for liver tx - 50% 2 year mortality abstain from etoh x 2 years Nonselective BB (propranol, nadolol) for medium or large varicies - DO NOT NEED IF NO VARICES Protein restriction only if encephalopathy not managed with lactulose alone

Question 376

Older patient with cobalamin (vit B12) def

Answer 376

Vit B12/cobalamin def = elevated homocystine AND MMA oval macrocytes, basophilic stippling, hypersegmented neutrophils (>5 lobes), elev LDH, bili, megaloblastic anemia, loss of vibratory sense, parastheisia, loss of position sense, wk spasiticity, paraplegia, bladder incontinence, MCC - malabsorbtpion Best way to supplement = oral (less expensive and easier that shots) Folate def = elevated HOMOcystine ONLY same peripheral smear as B12 def No neurologic findings If deficient replace ORALLY

Question 377

Hypopituitarism aw Sheehan syndrome

Answer 377

Adrenal insufficiency Immediate hydrocortisone replacement low morning cortisol Sheehan syndrome - pitutary infarct/hemorrhage in setting of complicated delivery with significant blood loss and hypotension Will need brain imaging to r/o sellar mass (though no prior sx suggestive of pre-exisiting pitutiary lesion) Subacute progressive hypopituitarism - inability to lactate 2/2 prolactin def, ammenorrhea DI rare in sheehan syndrome so argine vasopressin (ADH) replacement not needed Hyponatremia should correct with replacement of pituitary hormones - don't neeed hypertonic saline No need for synthroid unless free thyroxine low (not urgent as no signs of hypothyroid

Question 378

Reduce risk of lung cancer with smoking cessation

Answer 378

risk down by 1/2 with quitting smoking compleletly No mortality benefit in CXR surveillence No decrease in mortality with B carotein suppleemtation Isotreetioin supp does not decrease mortality in smokers

Question 379

Treat erythema nodosum aw UC

Answer 379

Intensify therapy for UC to treat erythema nodosum follicular non-infectious panniculitis of SQ tissue one or more tender, erythematous nodules on anterior shin easily palpated and visualized Prodrome of fever, malaise, arthralgia Lot of cases are idiopathic others: infectious, drugs, systemic dz (inflamm d/o UC, sarcoid) Self limited with tx of underlying d/o Recurrent may require corticosteroids or immunosupp's Don't tx EN with abx unless underlying cuase is infectious NSAIDs only if idiopathic - don't use NSAIDS with inflamm bowel dz - can exacerbate and cause flare No role for TOPICAL steroids - doens't treat underlying cause

Question 380

Manage tick borne ricksettial infxn

Answer 380

Start empiric doxycycline now serologic testing for any tick borne ricksettial infxn often neg in acute phase - high suspeicion with multiple tick bites requires tx - inc'd morbiidity if wait Human granulocytic Analplasmosis - few get rash Human monocytic erylichosis - few get rash Rocky Mtn spotted fever - has rash (blanching erythematous macules start at wrist and ankles, spread centripetally and becaome petechial) Initiate tx empirically as 2/3 won't get rash (HME, HGA) All non-focal febrile illenss with cytopneia and elev LFTs Tick vector for HGA is same as one for lyme dz - in NE US/great lakes , tick vector for HME in south central US, RMSF througout US (continental) Amoxicillin doesn't treat these tick dz's

Question 381

Diagnose resistant HTN

Answer 381

blood pressure above goal with 3 classes of anti HTN meds including diuretic Need to document real resistent HTN with ambulatory BP monitoring (older age, high BMI, high baseline BP, DM, blacks) If still high then search for secondary cuases, - salt intake,, use o fNSAIDs, OSA No TTE needed for HTN w/u Onlly add another med if resistant HTN confirmed with montioring Only look for secondary caues (r/o pheo) if resistent HTN confirmed

Question 382

Chronic paroxysmal hemicrania

Answer 382

trigeminal nerve related pain - ipsilateral automonic features, lacrimation, ptosis, injection, nasla congestion, rhinorrhea Cluster h/a last 15-80 min, 1-8x/day Chronic paroxymal hemicrania - 15 min 8-40x/day tx: INDOMETHACIN Carbamazepine - Trigeminal neuralgia - severe pain along distribution of Trigeminal nerve Pain paroxymal, lasting seconds, volley/jabs of sharp pain trigger zones around mouth/nostrills 2nd and 3rd branches of CN V no autonomic fts Not prednisone - not giant cell arteritis given pattern and timing of pain and normal ESR Topiramte for migrain ppx - no use in cluster/Chro Parox Hemicrainia Verapamil - for cluster h/a not chronic paroxymal hemicrania

Question 383

Eisenmenger's syndrome in adult

Answer 383

Eisengener's - aw Down syndrome EKG RAD with RAE RVH with strain CXR central pulm artery enlargement, reduced pulm vasc Longstanding cardiac shunt with eventual reversal of shunt - Eisenmenger's physiology - digital clubbing, cyanosis, RV hypertrophy, dec'd pulm vascularity Downs - half have congential HDz - AV septal defect - develop pulm HTN, reversal of shunt -> eisenmengers

Question 384

Aortic Coarctation

Answer 384

HTN in upper extrem, systolic murmur or continuous murmur in left infraclavicular area, LE pulses reduced, radiofemoral pulse delay, LVH on EKG, CXR 3 sign - aortic narrowing with rib notching

Question 385

Ebstein anomaly

Answer 385

``` RV enlargement, Tricusupid regurg ASD or PFO - cyanosis Tall peaked p waves (himalyan waves) QRS prolonged, RBBB, pre-excitation CXR - RH enlargement, clear lungs ```

Question 386

Tetralogy of Fallot

Answer 386

cyanosis/clubbing | loud systolic murmur - severe RVOT obstruction

Question 387

Association of Herpses Simplex virus with erythema Multiforme

Answer 387

recurrent mucocutaneous eruption that follows acute infection HSV infection erythematous plaques with concentric rings of color - dusky center might become necrotic and can blister or eschar Few to hundreds of lesions - extensor surfaces of extremiteis (hands/feet) - Mucosal lesions - lips, gingival sulcus, sides of tongue painful erosions or bullae 1-2 weeks - can have residual hyperpigmentation Recurrences common systemic corticosteroids can provide relief but Abx only if identified bacterial cuase If 2/2 new drug - d/c drug EM not caused by staph but abx used to treat can cuase it EM not caused by Parvo B19 ,or varicella zoster

Question 388

Prevent medication errors from occuring

Answer 388

Pt need specific instructions on increase in pre-hospital meds Need to communicate with PCPs on changes Need list of medication at d/c with med changes, discontinuation and addition Diuretic resistance uncommon, highly unlikely as pt inc'd pre admission lasix and added spironolactone Hosptial f/u for CHF exacerbation - 1 week Spironolactone won't cause CHF exacerbation (decreases mortality in patients with Systolic HF)

Question 389

Warm autoimmune hemolytic anemia

Answer 389

incidious sx of anemia, jaundice, splenomegaly, peripheral blood smear with spherocytes (erythrocytes losing central pallor) Strong + coombs for IgG, weak for C3

Question 390

COLD agglutin dz

Answer 390

Coombs test IgG neg + complement - pathogenic IgM ab

Question 391

G6PD def

Answer 391

peripheral smear shows BITE CELLS eccentrically located hemoglobin NO SPHEROCYTES No + direct coombs

Question 392

Hereditary spherocytosis

Answer 392

fhx anemia, jaundice, splenomegaly, gallstones Spherocytes on smear NEGATIVE direct coombs would always have abnormal CBC (spherocytes)

Question 393

TTP

Answer 393

microangiopathic hemolytic anemia schistocytes on smear inc'd LDH thrombocytopenia